Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.05 - Medicare Health Maintenance Organizations (MHMOs) And Competitive Medical Plans. (CMPs)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A Medicare
			 Health Maintenance Organizations (MHMO) and Competitive Medical Plans (CMP) are
			 organizations which may contract with the Health Care Financing Administration
			 (HCFA) to enroll Medicare beneficiaries and other individuals and groups to
			 deliver a specified comprehensive range of high quality services efficiently,
			 effectively, and economically to its Medicare enrollees. An HMO or CMP must be
			 organized under the laws of the State and must meet HCFA's qualifying criteria,
			 as specified in 42 C.F.R.
			 §
									417.410 -.418, in order to enter into
			 a contract with HCFA to enroll Medicare beneficiaries.
A Competitive Medical Plan, as defined in
				42 C.F.R. §
										417.407(c), is a legal
				entity, which provides to its enrollees at least the following services:
				services performed by physicians; laboratory, x-ray, emergency, and preventive
				services; out-of-area coverage; and inpatient hospital services. The entity
				receives compensation by Medicaid for the health care services it provides to
				enrollees on a periodic, prepaid capitation basic regardless of the frequency,
				extent, or kind of services provided to any enrollee. The entity provides
				physician services primarily through physicians who are employees or partners
				of the entity or physicians or groups of physicians (organized on a group or
				individual practice basis) under contract with the entity to provide physician
				services. The entity assumes full financial risk on a prospective basis for
				provision of health care services, but may obtain insurance or make other
				arrangements as specified in 42 C.F.R. §
										417.120 and .407.
				The entity must provide adequately against the risk of insolvency by meeting
				the fiscal and administrative requirements of
				42 C.F.R. §
										417.120(a)(1)(i) through
				(a)(1)(iv) and
				417.122(a).
(2) The Alabama Medicaid Agency
			 may reimburse a fixed per member per month (PMPM) capitated payment established
			 by Medicaid to HMOs and CMPs which have an approved Medicare risk contract with
			 the Health Care Financing Administration for beneficiaries who enroll in a
			 Medicare HMO or CMP for which Medicaid is responsible for payment of medical
			 cost sharing. Medicare beneficiaries must receive Part A or Parts A&B
			 coverage to be eligible for this program. This PMPM payment will cover, in
			 full, any premiums or cost sharing required from the Medicare Plan. The PMPM
			 payment will be established based on historical costs and
			 negotiations.
(3) Medicare HMOs and
			 CMPs may enroll with the Medicaid Agency to receive capitated payments for
			 beneficiary premiums and cost sharing by executing a Memorandum of
			 Understanding with the Medicaid Agency. To enroll the following must be
			 submitted to Medicaid:
(a) A copy of HCFA
			 approval for a Medicare risk contract to enroll Medicare
			 beneficiaries;
(b) A copy of the
			 HMO or the CMP's member services handbook; and
(c) A copy of Certificate of Authority (COA)
			 from the Alabama Insurance Department and appropriate approvals for a material
			 modification to a COA.