reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
Children's Specialty Clinic Services are specialty-oriented
				services that are provided by an interdisciplinary team to children who are
				eligible for EPSDT services and are experiencing developmental problems.
				Children's Specialty Clinic Services means preventive, diagnostic, therapeutic,
				rehabilitative, or palliative services that are provided in a clinic setting
				that is not part of a hospital, but is organized and operated to provide
				medical care to patients according to recognized standards of care for children
				with special health care needs.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §440.90.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.02 - Provider Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Eligible persons may receive Children's Specialty Clinic Services through
			 providers who are under contractual agreement with Medicaid to provide services
			 to children eligible for EPSDT services.
(2) Providers under this section are clinics
			 that are organized apart from any hospital and operate to provide an integrated
			 multidisciplinary medical/rehabilitation program designed to upgrade the
			 physical functioning of handicapped disabled individuals by bringing
			 specialized staff together to perform as a team.
(a) Clinics must meet recognized standards of
			 care for children with special health care needs and employ on staff the
			 following practitioners:
1. Specialty
			 physicians
2. Nurses
3. Social workers/service
			 coordinators
4. Physical
			 therapists
5.
			 Audiologists
6.
			 Nutritionists
7. Speech/language
			 pathologists
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.03 - Recipient Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 persons under twenty-one (21) years of age who have been certified as being
			 eligible for Medicaid, who are eligible for EPSDT services, and are
			 experiencing developmental problems are eligible for Children's Specialty
			 Clinic Services.
(2) Alabama
			 Medicaid Agency Administrative Code, Chapter One, General, contains information
			 about the identification of Medicaid recipients.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §440.90.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.04 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Children's Specialty Clinic Services do not include services that have been
			 rendered under other Medicaid programs.
(2) Children's Specialty Clinic Services are
			 covered when provided by a Medicaid enrolled children's specialty clinic
			 provider.
(3) Covered children's
			 specialty clinic services include preventive, diagnostic, therapeutic,
			 rehabilitative, and/or palliative items or services provided by a Medicaid
			 approved provider who meets the requirements described in Section
			 560-X-61-.02. Specific types of
			 services provided in Children's Specialty Clinics include: diagnosis of medical
			 conditions, multidisciplinary evaluations, completion of durable medical
			 equipment assessments, therapy services, nutrition services, case management
			 services, orthotic and prosthetic services, vision and hearing services, and
			 dental services for children experiencing developmental problems. For details
			 of dental services covered in children's specialty clinics see Rule No.
			 560-X-15-.06(3)
			 of the State of Alabama Administrative Code.
(4) A patient care plan is required for each
			 child and a service coordinator is responsible for arranging specialty and
			 needed social services for the family.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §440.90.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.05 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Children's
			 Specialty Clinics will be reimbursed by as follows:
(a) Governmental providers will be reimbursed
			 by an encounter rate based on reasonable allowable costs, as defined by OMB
			 Circular A-87, and established by the Medicaid Agency based on completion of
			 the required cost report documentation.
(b) Nongovernmental providers will be
			 reimbursed by a rate established by Medicaid based on usual, customary, and
			 reasonable charges.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.06 - Copayment (Cost Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid recipients shall not be required to pay and providers may not collect
			 a copayment for any of these services. Refer to Rule No. 560-1-X-.25(3) for
			 copay information.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42
				  C.F.R. §440.130.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.07 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Eligible Medicaid recipients are not to be billed for covered services once the
			 recipient has been accepted as a Medicaid patient.
(2) The provider is responsible for any
			 follow-up with the fiscal agent or Medicaid on denied claims.
(3) The recipient is not responsible for any
			 difference between billed charges and Medicaid allowed charges.
(4) The recipient may be billed for
			 non-covered services.
(5)
			 Children's Specialty Clinic Services shall be billed utilizing the standard
			 HCFA-1500 claim format and locally assigned procedure codes. The appropriate
			 ICD-9-CM diagnosis code shall be required.
(6) Claims submitted for which there is no
			 documentation, or for charges in excess or in violation of the provider's
			 contractual agreement, are subject to recoupment by the Agency, and to referral
			 for investigation and possible prosecution for fraud.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §447.15.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.08 - Confidentiality

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The provider
			 shall not disclose, except to duly authorized representatives of federal or
			 state agencies, any information concerning an eligible recipient except upon
			 written consent of the recipient, his attorney, or his/her guardian, or upon
			 subpoena from a court of appropriate jurisdiction. See Rule
			 560-X-20-.05, Third Party, for
			 additional requirements regarding release of information.
(2) The provider must safeguard clinical
			 records against loss, destruction, and/or unauthorized use.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; State Plan;
				  42 C.F.R.
				  §431.306.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-61 - CHILDREN'S SPECIALTY CLINIC SERVICES › Section 560-X-61-.09 - Maintenance Of Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 provider shall make available to the Alabama Medicaid Agency at no charge all
			 information regarding claims for services provided to eligible recipients. The
			 provider shall permit access to all records and facilities for the purpose of
			 claim audit, program monitoring, and utilization review by duly authorized
			 representatives of federal and state agencies. Complete and accurate fiscal
			 records which fully disclose the extent and cost of services shall be
			 maintained by the provider.
(2) The
			 provider shall maintain documentation of Medicaid client's signatures. These
			 signatures may be entered on a sign-in log, service receipt, or any other
			 record that can be used to indicate the clients' signatures and dates of
			 services.
(3) All records shall be
			 maintained for a period of at least three (3) years plus the current fiscal
			 year. If audit, litigation, or other legal action by or on behalf of the state
			 or federal government has begun but is not completed at the end of the three
			 (3)-year period, the records shall be retained until resolution and finality
			 thereof. Such records shall be kept in a form that will facilitate the
			 establishment of a complete audit trail in the event such items are audited.
Author:
Statutory Authority:
State Plan for Medical
				  Assistance; Title XIX, Social Security Act;
				  42 C.F.R.
				  §431.17 and
				  433.32.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.02 - Active Supervision Of Collaboration

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid Agency shall actively
			 monitor and supervise the collective negotiations, bargaining, and cooperation
			 among Collaborators that have been issued Certificates to Collaborate by the
			 Medicaid Agency and Regional Care Organizations (RCOs) in accordance with
			 Sections 22-6-150, et seq. of the
Code of Ala. 1975
. Each Collaborator issued a
			 Certificate to Collaborate shall submit an on-line periodic report to the
			 Medicaid Agency no later than March 1 and September 1 of each year in which the
			 Collaborator holds a Certificate to Collaborate.
(2) Each periodic report must contain the
			 information requested by the Medicaid Agency in order to allow the Medicaid
			 Agency to engage in appropriate state supervision in accordance with Section
			 22-6-163 of the
Code
			 of Ala. 1975
, including the following information:
(a) A description of the Collaborator's
			 activities during the reporting period conducted pursuant to the Certificate to
			 Collaborate, including a description of what entities and persons with whom the
			 Collaborator engaged in collective negotiations, bargaining, or cooperation
			 during the reporting period;
(b) A
			 description of any progress the Collaborator has made during the reporting
			 period in helping establish or develop a RCO or enrolling as a provider with a
			 RCO;
(c) A description of any
			 concerns or problems encountered in the collaborative process during the
			 reporting period;
(d) A description
			 of the nature and scope of expected future activities pursuant to the
			 Certificate to Collaborate; and
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.03 - Governing Board Of Directors

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A regional care organization and an
			 organization with probationary regional care organization certification shall
			 have a governing board of directors composed of the following members:
(a) Twelve members shall be persons
			 representing risk-bearing participants in the regional care organization or
			 organization with probationary certification. A participant bears risk by
			 contributing cash, capital, or other assets to the regional care organization.
			 A participant also bears risk by contracting with the regional care
			 organization to treat Medicaid beneficiaries at a capitated rate per
			 beneficiary or to treat Medicaid beneficiaries even if the regional care
			 organization does not reimburse the participant. To be a risk-bearing board
			 member, the capitated contract and/or contribution of cash, capital or other
			 assets contributed by the risk-bearing participant must be meaningful as
			 determined in the sole discretion of the Medicaid Agency.
(b) Eight members shall be persons who do not
			 represent a risk-bearing participant in the regional care organization.
1. Five members shall be medical
			 professionals who provide care to Medicaid beneficiaries in the region.
Three of these members shall be primary care physicians, one
				optometrist, and one a pharmacist. One primary care physician shall be from a
				Federally Qualified Health Center appointed jointly by the Alabama Primary
				Health Care Association and the Alabama Chapter of the National Medical
				Association and the other two primary care physicians shall be appointed by the
				Medical Association of the State of Alabama, or its successor organization. The
				optometrist shall be appointed by the Alabama Optometric Association, or its
				successor organization. The pharmacist shall be appointed by the Alabama
				Pharmacy Association, or its successor organization. All five medical
				professionals shall work in the region served by the regional care
				organization. None of these members shall be a risk-bearing participant in the
				regional care organization or be an employee of a risk-bearing participant, but
				these members may contract with the regional care organization on a
				fee-for-service basis.
2.
			 Three of the eight members shall be community representatives and may not be
			 risk-bearing participants in the regional care organization or employees of a
			 risk-bearing participant. They are comprised as follows:
(i) The chair of the citizen's advisory
			 committee established pursuant to the Medicaid Administrative Code.
(ii) A citizen's advisory committee member,
			 elected by the committee, who is a representative of an organization that is
			 part of the Disabilities Leadership Coalition of Alabama or Alabama Arise, or
			 their successor organizations.
(iii) A business executive, nominated by a
			 chamber of commerce in the region, who works in the region.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.04 - Citizens' Advisory Committee

Current through Register Vol. 42, No. 9, June 28, 2024
A citizens' advisory committee shall advise the organization
				on ways the organization may be more efficient in providing quality care to
				Medicaid beneficiaries. In addition, an advisory committee shall carry out
				other functions and duties assigned to it by a regional care organization and
				approved by the Medicaid Agency. Each regional care organization shall have a
				citizens' advisory committee, as shall an organization seeking to become a
				regional care organization, which membership shall be inclusive and reflect the
				racial, gender, geographic, urban/rural, and economic diversity of the state.
				The committee shall meet all of the following criteria:
(1) Be selected in a method established by
			 the organization seeking to become a regional care organization, or established
			 by the regional care organization, and approved by the Medicaid
			 Agency.
(2) At least 20 percent of
			 its members shall be Medicaid beneficiaries or, if the organization has been
			 certified as a regional care organization, at least 20 percent of its members
			 shall be Medicaid beneficiaries enrolled in the regional care organization. It
			 shall be applicant's sole responsibility to obtain all necessary approvals,
			 consents or waivers from Medicaid beneficiaries and to comply with all
			 applicable laws regarding privacy and confidentiality related to such
			 information before providing it to the Medicaid Agency.
(3) Include members who are representatives
			 of organizations that are part of the Disabilities Leadership Coalition of
			 Alabama or Alabama Arise, or their successor organizations.
(4) Include only persons who live in the
			 Medicaid region the organization plans to serve; or if the organization has
			 become a regional care organization, include only persons who live in the
			 Medicaid region served by the regional care organization. The membership of the
			 committee shall be inclusive and reflect the racial, gender, geographic,
			 urban/rural, and economic diversity of the region.
(5) Elect a chair.
(6) Meet at least every three
			 months.
Author:
Sharon Weaver, Administrator,
				  Administrative Procedures Office
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-6-150 et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.05 - Probationary Certification Of Organizations Seeking To Become Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 organization may receive probationary certification as a regional care
			 organization (Probationary Certification) upon submission of an application to
			 the Medicaid Agency that satisfies the requirements of the Medicaid
			 Administrative Code and Sections
			 22-6-150, et seq.,
Code of Ala. 1975
.
(2) An organization seeking Probationary
			 Certification shall be incorporated as a nonprofit corporation under Alabama
			 law. The Certificate of Formation of the organization shall mandate that:
(a) no part of the organization's net
			 earnings shall inure to the benefit of any private shareholder or individual,
			 no substantial part of the activities of the organization shall include
			 carrying on propaganda, or otherwise attempting, to influence legislation
			 (except as otherwise provided in section 501(h) of the Internal Revenue Code of
			 1986), and the organization shall not participate in, or intervene in
			 (including the publishing or distributing of statements), any political
			 campaign on behalf of (or in opposition to) any candidate for public office;
			 and
(b) all of the gross revenues
			 of the organization shall be received from government programs that target
			 low-income, elderly, or disabled populations under titles XVIII, XIX, and XXI
			 of the Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.06 - Active Supervision of Organizations with Probationary Certification

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid
			 Agency shall actively monitor and supervise the collective negotiations,
			 bargaining, and cooperation among Collaborators as defined in Section
			 22-6-150(4) of
			 the
Code of Ala. 1975
, and each organization that
			 receives probationary certification as a regional care organization
			 ("Probationary Organization") in accordance with Sections
			 22-6-150, et seq. of the
Code of Ala. 1975
. Each Probationary Organization
			 shall submit an on-line periodic report to the Medicaid Agency quarterly on the
			 last day of the month following the end of each full quarter (January 31, April
			 30, July 31 and October 31) in which the Probationary Organization is
			 certified.
(2) Each periodic report
			 must contain the information requested by the Medicaid Agency in order to allow
			 the Medicaid Agency to engage in appropriate state supervision in accordance
			 with Section
			 22-6-163 of the
Code
			 of Ala. 1975
, including the following information:
(a) A description of the Probationary
			 Organization's activities during the reporting period, including a description
			 of what entities and persons with whom the Probationary Organization engaged in
			 collective negotiations, bargaining, or cooperation during the reporting
			 period;
(b) A description of
			 progress the Probationary Organization has made during the reporting period
			 establishing or developing a regional care organization (RCO) that may gain
			 full RCO certification on or before October 1, 2016;
(c) A description of any concerns or problems
			 encountered in the collaborative process during the reporting period;
			 and
(d) A description of the nature
			 and scope of expected future activities of the Probationary
			 Organization.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.07 - Contract For Case-Management Services With Organization With Probationary Certification

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Medicaid Agency may contract for specific case-management services with an
			 organization that the Medicaid Agency has granted probationary regional care
			 organization certification on such terms and conditions required by the
			 Medicaid Agency.
(2) Probationary
			 certified regional care organizations desiring to contract for specific case
			 management services with the Medicaid Agency must submit a Response to a
			 Medicaid Request for Proposal. The Request for Proposal and/or Contract shall
			 set forth terms and conditions required by the Medicaid Agency to perform case
			 management services. Requests for Proposals and/or Contracts for specific
			 case-management services in each Medicaid region shall be issued and available
			 for inspection on the Medicaid Agency's website. Requests for Proposals and/or
			 Contracts shall set forth the scope of work, pricing, general information,
			 entity qualifications and references, submission requirements, evaluation and
			 selection process, any requirements for establishing an adequate medical
			 service delivery network, any solvency and financial requirements, general
			 terms and conditions, and other provisions for case-management services. Any
			 organization that the Medicaid Agency has granted probationary regional care
			 organization certification by October 1, 2014 shall be eligible to submit a
			 proposal to provide case-management services in the Medicaid region(s) for
			 which it has received probationary certification. The Medicaid Agency may, in
			 its discretion, allow one or more organizations granted probationary regional
			 care organization certification after October 1, 2014 to submit proposals to
			 provide case-management services. The Medicaid Agency may contract for specific
			 case-management services with one or more organizations with probationary
			 certification.
(3) Pursuant to
			 Section 22-6-162 of the
Code
			 of Ala. 1975
, if any organization that has contracted with the
			 Medicaid Agency for case-management services has failed to gain full regional
			 care organization certification or has had its probationary certification
			 terminated or revoked, then the contract for case-management services shall be
			 terminated and that organization shall refund half the payments, made by the
			 Medicaid Agency to the organization for case-management services, paid over the
			 previous 12 months.
Author:
Sharon Weaver, Administrator,
				  Administrative Procedures Office
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-6-150 et
				  seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.08 - Conflict Of Interest Policy For Directors And Officers Of Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 regional care organization (RCO) and an organization with probationary RCO
			 certification shall adopt a conflict of interest policy for directors and
			 officers. The conflict of interest policy shall require all directors and
			 officers of conduct their activities as directors or officers so that they do
			 not advance or protect their own interests, or the interest of others with whom
			 they have a private or professional relationship, in a way that is detrimental
			 to the interests of, or to, the RCO or organization with probationary RCO
			 certification, and the conflict of interest policy shall provide for the
			 removal of any director or officer whose conduct violates such policy, unless a
			 remedial action shall be sufficient to bring the director or officer into
			 compliance with the policy. The conflict of interest policy shall require each
			 director and officer to disclose in a written statement all employments,
			 associations, commitments and financial interests within the preceding two
			 years on the part of the director or officer, or his or her immediate family
			 member, including spouse, dependents, adult children and their spouses,
			 parents, spouse's parents, siblings and their spouses, that could reasonably be
			 perceived, directly or indirectly, as a conflict of interest with the RCO or
			 organization with probationary RCO certification. The statement shall also
			 disclose whether the director or officer or his or her immediate family member
			 as described in the preceding sentence is a current or former employee of,
			 consultant with, or lobbyist for the Medicaid Agency. Each director and officer
			 shall file such disclosure statement with the RCO's or organization's board of
			 directors and the Medicaid Agency on an annual basis.
(2) The conflict of interest policy must
			 also:
(a) Require each director or officer to
			 disclose relevant financial interests;
(b) Provide a procedure to determine whether
			 a conflict of interest exists and set forth a process to address any conflicts
			 that arise; and
(c) Address
			 remedial action for directors or officers that fail to comply with the
			 policy.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.10 - Minimum Fee-For-Service Reimbursement Rates

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In accordance with Section
			 22-6-153(c) of
			 the Alabama Code, the minimum fee-for-service reimbursement rates that a
			 regional care organization shall pay providers for applicable Medicaid services
			 provided to a Medicaid beneficiary shall be the prevailing Medicaid
			 fee-for-service payment schedule, unless otherwise jointly agreed to by a
			 provider and a regional care organization through a contract or mandated by
			 federal law.
(2) The minimum
			 provider reimbursements shall be incorporated into the actuarially sound rate
			 development methodology for each regional care organization. The Medicaid
			 Agency shall submit the methodology and resulting rates to the Centers for
			 Medicare and Medicaid Services for approval.
Author:
Sharon Weaver, Administrator,
				  Administrative Procedures Office
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-6-150
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.11 - Provider Contract Disputes

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All provider contracts of an organization
			 granted probationary or final certification as a regional care organization
			 shall be subject to review and/or approval of the Medicaid Agency.
(2) Any Medicaid provider who is dissatisfied
			 with any term or provision of the agreement or contract offered by or with a
			 regional care organization shall first seek redress by filing a grievance with
			 the regional care organization. The Medicaid provider may contest any terms or
			 provisions of the agreement or contract offered by or with the regional care
			 organization other than (a) terms or provisions required by the Medicaid Agency
			 or the Centers for Medicare and Medicaid Services and (b) terms or provisions
			 identifying performance standards or quality measures subject to review by a
			 provider standards committee under Rule No.
			 560-X-62-.09. The contractual
			 application of the provider standards committee standards and measures shall be
			 subject to review but not the performance standards or quality measures
			 themselves.
(3) In providing
			 redress, the regional care organization shall afford the Medicaid provider
			 within 5 business days of the filing of the grievance, a review and final
			 decision by a panel composed of the following:
(a) A representative of the regional care
			 organization.
(b) The same type of
			 provider.
(c) A representative of
			 the citizen's advisory board appointed by the chairperson of the citizen's
			 advisory board.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.12 - Service Delivery Network Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Definitions - As referenced in this
			 Chapter of the Alabama Medicaid Administrative Code the following terms shall
			 be defined as follows:
(a)
Primary
			 medical provider
(PMP) is defined as one of the following:
1. Family practitioner
2. Federally Qualified Health
			 Center
3. General
			 Practitioner
4. Internist
5. Pediatrician
6. Obstetrician or Gynecologist
7. Rural Health Clinic
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.13 - Quality Assurance Committee

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Pursuant to Section
			 22-6-154,
Code of Ala.
			 1975
, the Medicaid Agency shall have a quality assurance committee
			 appointed by the Medicaid Commissioner.
(a)
			 The members of the committee shall serve two-year terms.
(b) At least 60 percent of the members shall
			 be physicians who provide care to Medicaid beneficiaries served by a regional
			 care organization.
(c) In making
			 appointments to the committee, the Medicaid Commissioner shall seek input from
			 the appropriate professional associations.
(d) The Medicaid Commissioner shall also
			 select an alternate to each appointed committee member who shall be permitted
			 by the Committee Chair to participate and/or vote in the event of an appointed
			 member's absence pursuant to subsections 10(d) and 11(e) of this rule. The
			 alternate shall be of the same profession as the absent member for whom the
			 alternate is selected.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.14 - Quality Assurance Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid Agency shall have a regional
			 care organization performance monitoring and improvement process that includes
			 at a minimum:
(a) The review of monthly,
			 quarterly and annually-reported quality and performance data, including
			 outcomes and quality measures adopted by the Medicaid Quality Assurance
			 Committee, regional care organization operational and administrative measures,
			 CMS-required performance standards and other measures as deemed necessary by
			 the Medicaid Agency in its contract with a regional care organization and/or in
			 rules promulgated by the Medicaid Agency to manage the regional care
			 organization program.
(b) At least
			 quarterly, a meeting with the executive director, medical director and others
			 as determined by the Medicaid Agency from each regional care organization to
			 share performance results, discuss performance successes and challenges and
			 determine the effectiveness of quality improvement activities
(c) At least annually, a meeting with the
			 Medicaid Quality Assurance Committee to adopt the recommended regional care
			 organization outcome and quality measure set for the upcoming calendar year.
			 Prior to the annual meeting, the Medicaid Agency shall distribute performance
			 reports and other materials, as necessary, to assist Committee members with
			 evaluating the effectiveness of outcome and quality measures and determining
			 whether to change the regional care organization outcome and quality measure
			 set. The Medicaid Agency shall also conduct telephonic, webinar or in-person
			 meetings with the Medicaid Quality Assurance Committee, as necessary, to
			 discuss performance results.
(d) At
			 least annually, a meeting with each regional care organization's provider
			 standards committee to share that regional care organization's performance
			 results for the purpose of determining the effectiveness of provider
			 performance standards and quality measures. This meeting may be conducted by
			 telephonic, webinar or in-person means.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.15 - Right To Terminate Certificates Of Probationary And Fully Certified Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 certificate of an organization as a probationary regional care organization or
			 as a full regional care organization (referred to collectively hereafter in
			 this rule as "certificate") may be terminated by the Medicaid Agency, in its
			 sole discretion, for nonperformance of contractual duty or for failure to meet
			 or maintain benchmarks, standards, or requirements provided by Sections
			 22-6-150, et seq., of the Alabama
			 Code or rules promulgated by the Medicaid Agency.
(2) In the event of termination by the
			 Medicaid Agency, a written notice of termination shall be sent to the
			 organization.
(3) The Medicaid
			 Agency may terminate a certificate based on an organization's failure to timely
			 file required reports and updated information as required by Rules
			 560-X-62-.05(20)
			 and 560-X-62-.06(9)
			 or otherwise required by the Medicaid Agency after reasonable written notice
			 with an opportunity to cure is provided by the Medicaid Agency.
(4) The Medicaid Agency may terminate a
			 certificate based on material misrepresentations and/or omissions in
			 applications and reports required of the organization pursuant to Medicaid
			 rules and any contract between the organization and the Medicaid
			 Agency.
(5) The Medicaid Agency may
			 terminate a certificate for the failure on the part of the organization to meet
			 and/or maintain the solvency and other financial requirements set forth in
			 Section 22-6-151,
Code of Ala.
			 1975
, and rules promulgated by the Medicaid Agency.
(6) The Medicaid Agency may terminate a
			 certificate should it reasonably determine that the continued operation of the
			 organization is hazardous to Medicaid beneficiaries or to the state after
			 reasonable notice of the hazardous condition and an opportunity to cure is
			 provided by the Medicaid Agency to the organization.
(7) Notwithstanding any provisions of this
			 rule, the Medicaid Agency may terminate an organization's certificate for
			 violations of state or federal law related to acts or omissions that could
			 reasonably affect the delivery of care to Medicaid beneficiaries, committed by
			 the organization and/or any of its officers and directors.
(8) The organization may request a fair
			 hearing in writing if it is not satisfied with the termination
			 action.
(9) A written request for a
			 fair hearing must be received by the Medicaid Agency within 30 days from the
			 date the notice of termination is mailed. The Medicaid Agency will not accept
			 requests for fair hearings which are outside the 30 day limit.
Author:
Sharon Weaver, Administrator,
				  Administrative Procedures Office
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-6-150 et seq; 42 CFR Part
				  438.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.16 - Solvency And Financial Requirements For Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Subject to
			 Section 22-6-159(c),
Code of Ala. 1975
, each organization with probationary
			 regional care organization certification ("probationary RCO") shall, not later
			 than October 1, 2015, have demonstrated to the Medicaid Agency's approval that
			 it has met or will meet the solvency and financial requirements for a regional
			 care organization ("RCO") as outlined in section (2) of this rule.
(a) A probationary RCO shall be deemed to
			 have met such requirements if the Medicaid Agency has in its discretion
			 approved one or more of the following:
(i)
			 irrevocable letters of commitment to provide the required capital or surplus
			 and restricted reserves from one or more risk bearing participants with a
			 demonstrated ability (as determined by the Agency in its sole discretion) to
			 provide the required funds,
(ii) a
			 commitment letter from a qualified insurer to issue a performance bond
			 complying with section (3) of this rule,
(iii) evidence satisfactory to the Medicaid
			 Agency demonstrating that the probationary RCO has adequately funded a
			 restricted reserve account in accordance with section (4) of this rule and has
			 satisfied the capital or surplus requirement,
(iv) the probationary RCO's most recent
			 audited financial statements reflecting the required capital or surplus and
			 restricted reserves, or
(v) some
			 combination of (i) through (iv) satisfactory to the Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.19 - Requirements For Full Certification Of Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An organization
			 seeking full certification as a regional care organization (referred to herein
			 also as "applicant") shall be incorporated as a nonprofit corporation under
			 Alabama law. The certificate of formation of the organization shall mandate
			 that:
(a) No part of the organization's net
			 earnings shall inure to the benefit of any private shareholder or individual,
			 no substantial part of the activities of the organization shall include
			 carrying on propaganda, or otherwise attempting, to influence legislation
			 (except as otherwise provided in section 501(h) of the Internal Revenue Code of
			 1986), and the organization shall not participate in, or intervene in
			 (including the publishing or distributing of statements), any political
			 campaign on behalf of (or in opposition to) any candidate for public office;
			 and
(b) More than 80 percent of the
			 gross revenues of the organization shall be received from government programs
			 that target low-income, elderly, or disabled populations under titles XVIII,
			 XIX and XXI of the Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.22 - Readiness Assessment Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Each organization that intends to enter
			 into a risk contract with the Medicaid Agency shall be subject to a readiness
			 assessment period. The readiness assessment period shall commence on January 1,
			 2015 and shall conclude with the Medicaid Agency's award or denial of full
			 regional care organization certification to the organization.
(2) The Medicaid Agency will provide draft(s)
			 of a risk contract to any organization seeking full regional care organization
			 certification. Upon the Medicaid Agency's request, the organization will have
			 forty-five (45) days to submit a written plan and other necessary documentation
			 describing the organization's readiness to satisfy requirements of the Medicaid
			 Agency in the areas set forth below and as may otherwise be required by Section
			 22-6-150,
et seq
.
			 and rules promulgated thereunder:
(a) April
			 1, 2015 - Demonstrate the ability to establish an adequate medical service
			 delivery network.
(b) October 1,
			 2015 - Demonstrate compliance with the solvency and financial requirements for
			 a regional care organization
(c)
			 May 1, 2016 - Demonstrate ability to provide services pursuant to a risk
			 contract to be effective October 1, 2016 including development and readiness to
			 operate:
1. Key Staffing
2. Governance
3. Provider Services and Materials
4. Network Adequacy
5. Claims Processing and Payment
6. Solvency and Audit
7. Financial
8. Care Coordination
9. Quality Management
10. Grievance and Appeals
11. Requirements Related to Enrollees
(i) Enrollment
(I) Disenrollment
(II) Enrollee Services
(III) Information Requirements
(ii) Marketing, Outreach and Member
			 Materials
12.
			 Administrative Support
13.
			 Technical Infrastructure
(i) Management
			 Information Systems (MIS)
14. Utilization Management
15. Compliance and Oversight
16. Other Requirements as requested by the
			 Medicaid Agency pursuant to final RCO Contract
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.24 - Sanctions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Bases for
			 Imposition of Sanctions on RCOs. The Medicaid Agency may impose sanctions on a
			 regional care organization ("RCO") if the Medicaid Agency determines in its
			 sole discretion that the RCO has violated an applicable federal or state law or
			 regulation, the Alabama Medicaid State Plan, the risk contract between the
			 Medicaid Agency and the RCO and the exhibits thereto (the "risk contract"), any
			 policies, procedures, written interpretations, or other guidance of the
			 Medicaid Agency, or for any other applicable reason described in 42 C.F.R. Part
			 438, Subpart I or the risk contract, including but not limited to a
			 determination by the Medicaid Agency that an RCO acts or fails to act as
			 follows:
(a) fails substantially to provide
			 medically necessary services that the RCO is required to provide, under law or
			 under its risk contract, to an enrollee covered under the risk
			 contract;
(b) imposes on enrollees
			 premiums or charges that are in excess of the premiums or charges permitted
			 under the Alabama Medicaid program;
(c) acts to discriminate among enrollees on
			 the basis of their health status or need for health care services (including
			 termination of enrollment or refusal to reenroll a recipient, except as
			 permitted under the Alabama Medicaid program, or any practice that would
			 reasonably be expected to discourage enrollment by recipients whose medical
			 condition or history indicates probable need for substantial future medical
			 services);
(d) misrepresents or
			 falsifies information that it furnishes to the Medicaid Agency or to the
			 Centers for Medicare and Medicaid Services (CMS);
(e) misrepresents or falsifies information
			 that it furnishes to an enrollee, potential enrollee, or health care
			 provider;
(f) distributes directly,
			 or indirectly through any agent or independent contractor, marketing materials
			 that have not been approved in writing by the Medicaid Agency or that contain
			 false or materially misleading information;
(g) fails submit a corrective action plan
			 that is acceptable to the Medicaid Agency within the time period specified by
			 the Medicaid Agency's written notice or does not implement or complete the
			 corrective action within the established time period;
(h) violates, as determined by the Medicaid
			 Agency, any requirement of sections 1903(m) or 1932 of the Social Security Act
			 or any implementing regulations; or
(i) violates, as determined by the Medicaid
			 Agency, any requirement of Sections
			 22-6-150,
et seq
.
			 of the Alabama Code or the rules promulgated thereunder.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.27 - Contracts With Additional Regional Care Organizations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid Agency shall follow the
			 procedures outlined in this Rule in the event any of the following occurs:
(a) A regional care organization with
			 probationary or full certification (collectively referred to as RCOs) has its
			 certification terminated in a Medicaid region;
(b) No organization had been awarded full
			 certification in a Medicaid region by the date stablished by the Medicaid
			 Agency;
(c) The Agency could not
			 award a contract to a RCO in a Medicaid Region under the terms of Section
			 22-6-153 of the
Code
			 of Ala. 1975
;
(d) A
			 RCO failed to provide adequate service in a Medicaid Region pursuant to its
			 risk contract with the Agency; or,
(e) The Agency and a RCO have initiated
			 termination procedures under the terms of the risk contract.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-63 - VENTILATOR-DEPENDENT AND QUALIFIED TRACHEOSTOMY CARE › Section 560-X-63-.01 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nursing
			 Facility - An institution which is licensed by the Alabama State Board of
			 Health as a nursing facility and is primarily engaged in providing nursing care
			 and related services for residents who require medical and nursing care,
			 rehabilitation services for the rehabilitation of injured, disabled or sick
			 persons, or on a regular basis health related care and services to individuals
			 who because of their mental or physical condition require care and services
			 which may be made available to them only through institutional facilities. A
			 facility may not include any institution that primarily is dedicated to the
			 care and treatment of mental disease.
(2) Qualified Ventilator-Dependent and/or
			 Tracheostomy Care Resident - A resident that is either determined to be:
(a) Ventilator-Dependent Resident - A
			 resident who is on mechanical ventilation necessary to sustain life and who
			 requires the care by and monitoring of a Registered Nurse or Licensed Practical
			 Nurse 24 hours a day and routine interventions by a duly licensed respiratory
			 therapist; or
(b) Qualified
			 Tracheostomy Resident - A resident who (i) has a tracheostomy, (ii) receives
			 oxygen therapy, and (iii) requires the care and monitoring of a Registered
			 Nurse or Licensed Practical Nurse 24 hours a day and routine interventions by a
			 duly licensed respiratory therapist. This definition does not cover a resident
			 with a tracheostomy who receives only PRN monitoring or suctioning.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-63 - VENTILATOR-DEPENDENT AND QUALIFIED TRACHEOSTOMY CARE › Section 560-X-63-.02 - Introduction

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A supplemental
			 fee-for-service payment will be paid to Medicaid-certified nursing facilities
			 that provide care to Medicaid eligible ventilator-dependents- and/or qualified
			 tracheostomy residents.
(2) The
			 supplemental fee-for-service payment will promote quality care and ensure the
			 health and safety of Medicaid recipients who are ventilator-dependent and/or a
			 qualified tracheostomy resident.
Author:
Marilyn F. Chappelle, Director, Long
				  Term Care Division
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-2.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-63 - VENTILATOR-DEPENDENT AND QUALIFIED TRACHEOSTOMY CARE › Section 560-X-63-.03 - Authority

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
(1) The Medical Assistance (Title XIX) Plan
			 for Alabama provides for medically necessary nursing facility services,
			 rendered in a facility which meet the licensure requirements of the department
			 of Public Health and the certification requirements of Title XIX and XVIIII of
			 the Social Security Act and complies with all other applicable state and
			 federal laws and regulations and with accepted professional standards and
			 principles that apply to professionals providing services.
(2) Nursing facilities must meet and comply
			 with all of the requirements as delineated in Alabama Medicaid Agency
			 Administrative Code Chapter10,
Long Term Care and Chapter 22 Nursing
			 Facility Reimbursement
.
Author:
Marilyn F. Chappelle, Director, Long
				  Term Care Division
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; and
				  42 CFR
				  Section 431.1, et seq., Section
				  483.75.