Title 22

In the event a hospital or hospital system transfers funds to the Medicaid Agency and certifies that the funds transferred are in compliance with Section 22-6-93, but subsequently it is determined that the transfer was not in compliance, the Medicaid Agency shall return the trans…

The Commissioner of the Medicaid Agency may adopt and implement regulations as necessary to ensure compliance with this article. (Act 2002-410, p. 1031, §9.)

The Legislature finds the following: (1) The availability of appropriate pharmaceutical benefits to every Alabama citizen is a critical component to the overall health of its population. (2) Alabama should strive to provide appropriate, safe, effective, and cost-efficient pharmac…

(a) The Alabama Medicaid Agency shall utilize a Medicaid Pharmacy and Therapeutics Committee within the agency for the purpose of advising and assisting Medicaid in the development of a preferred drug plan pursuant to 42 U.S.C. §1396r-8. (b) The Medicaid Pharmacy and Therapeutics…

(a) The Medicaid Pharmacy and Therapeutics Committee shall review and recommend classes of drugs to the Medicaid Commissioner for inclusion in the Medicaid Preferred Drug Plan. Class means a therapeutic group of pharmaceutical agents approved by the FDA as defined by the American…

(a) Drugs will be considered for the Medicaid preferred drug list based on clinical efficacy, side effect profiles, appropriate usage, and cost effectiveness. (b) The Medicaid Pharmacy and Therapeutics Committee shall perform a thorough review of relevant clinical and medical con…

Notwithstanding any other law to the contrary, all information and documents containing trade secrets, proprietary information, rebate amounts for individual drugs or individual manufacturers, percentage of rebates for individual drugs or manufacturers, and manufacturer’s pricing…

For the purposes of this article, the following words shall have the following meanings: (1) ALTERNATE CARE PROVIDER. A contractor, other than a regional care organization, that agrees to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined …

(a) A regional care organization shall serve only Medicaid beneficiaries in providing medical care and services. (b) Notwithstanding any other provision of law, a regional care organization shall not be deemed an insurance company under state law. (c)(1) A regional care organizat…

The Medicaid Agency shall establish by rule geographic Medicaid regions in which a regional care organization or alternate care provider may operate, which together shall cover the entire state. Each Medicaid region, according to an actuary working for Medicaid, shall be capable …

(a) Subject to approval of the federal Centers for Medicare and Medicaid Services, the Medicaid Agency shall enter into a contract in each Medicaid region for at least one fully certified regional care organization to provide, pursuant to a risk contract under which the Medicaid …

(a) The Medicaid Agency shall create a quality assurance committee appointed by the Medicaid Commissioner. The members of the committee shall serve two-year terms. At least 60 percent of the members shall be physicians who provide care to Medicaid beneficiaries served by a region…

An initial contract between the Medicaid Agency and a regional care organization shall be for three years, with the option for the Medicaid Agency to renew the contract for not more than two additional one-year periods. The Medicaid Agency shall obtain provider input and an indep…

The Medicaid Agency may contract with an alternate care provider in a Medicaid region only under the terms of this section: (1) If a regional care organization failed to provide adequate service pursuant to its contract, or had its certification terminated, or if the Medicaid Age…

(a) The Medicaid Agency shall establish by rule the procedure for the termination of a regional care organization certification or probationary regional care organization certification for non-performance of contractual duty or for failure to meet or maintain benchmarks, standard…

A regional care organization shall contract with any willing hospital, doctor, or other provider to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered comparable providers. Any provider shall meet licensing requirements set b…

(a) The following is the timeline for implementation of this article: (1) Not later than October 1, 2013, the Medicaid Agency shall establish Medicaid regions. (2) Not later than October 1, 2014, an organization seeking to become a regional care organization shall have establishe…

The Medicaid Agency shall decide which groups of Medicaid beneficiaries to include for coverage by a regional care organization or alternate care provider. The Medicaid Agency, without the approval of the Governor, shall not make a coverage decision that would affect Medicaid ben…

(a) The Medicaid Agency, with input from dental care providers, shall conduct an evaluation of the existing dental care program for Medicaid beneficiaries and, on October 1, 2015, shall report the findings of the evaluation to the Legislature and Governor. (b) Notwithstanding the…

The Medicaid Agency may contract for case-management services with an organization that has been granted by the Medicaid Agency a probationary regional care organization certification. If the agency has contracted with such an organization, and that organization on or before Octo…

(a) The Legislature declares that collaboration among public payers, private health carriers, third party purchasers, and providers to identify appropriate service delivery systems and reimbursement methods in order to align incentives in support of integrated and coordinated hea…

The Medicaid Agency may adopt rules necessary to implement this article and to administer the Alabama Medicaid Program in a manner consistent with state and federal law, as well as any state plan approved by the Centers for Medicare and Medicaid Services. (Act 2013-261, p. 686, §…

Any provision of law to the contrary notwithstanding, regional care organizations, as defined in Section 22-6-150, are exempt from the payment of any and all state, county, and municipal license fees, including any business privilege or license tax heretofore or hereafter levied …

This article shall apply only in a Class 2 municipality and would provide for a federal Program for All Inclusive Care for the Elderly (PACE program) with its principal place of business in a Class 2 municipality to contribute to the Alabama Health Care Trust Fund. (Act 2014-126,…

The intent of this article is to allow the only PACE provider in the State of Alabama to continue to provide services to nursing home eligible patients as the PACE program provides treatment to patients for fewer federal and state taxpayer dollars than other programs existing in …

For the purposes of this article, the following words have the following meanings: (1) DEPARTMENT. The State Department of Revenue. (2) FISCAL YEAR. An accounting period of 12 months beginning on the first day of the first month of the state fiscal year. (3) MEDICAID PROGRAM. The…

Each PACE provider providing services in a Class 2 municipality shall be licensed by the Department of Public Health which shall, from time to time, as it deems desirable, promulgate such reasonable rules as necessary to provide for the delivery of health care by the PACE provide…

To provide further for the availability of indigent health care in a Class 2 municipality, there is levied and shall be collected as provided in this article a privilege assessment on the business activities of each provider of a PACE program with its principal place of business …

(a) The assessment imposed by this article shall be due and payable to the department on or before the twentieth day of the month next succeeding the month in which the assessment accrues and, when collected, shall be paid by the department into the State Treasury. Payment by Uni…

Any PACE provider that fails to pay the assessment levied by this article within the time required by this article shall pay, in addition to the assessment, a penalty of 10 percent of the amount of assessment due, together with interest thereon at the rate prescribed by Section 4…

(a) It shall be the duty of each PACE provider subject to this article to keep and preserve suitable books and records as may be necessary to determine the amount of assessment for which it is liable under this article. The books and records shall be kept and preserved for a peri…

(a) The Medicaid Agency shall use the revenues from the assessment levied by this article in furtherance of the purposes of this article, provided that the uses shall be limited to those for which federal financial participation under Title XIX of the Social Security Act is avail…

No revenues resulting from the assessment established by this article and applied to increases in covered services or reimbursement levels or other enhancements of the Medicaid program adopted by the Medicaid Agency as a result of revenues made available under the assessment levi…

This article shall be of no effect if federal financial participation under Title XIX of the Social Security Act is not available to the Medicaid program for the purposes of this article at the approved federal medical assistance percentage, established under Section 1905 of the …

For the purposes of this article, the following words shall have the following meanings: (1) CAPITATION PAYMENT. A payment the state Medicaid Agency makes periodically to the integrated care network on behalf of each recipient enrolled under a contract for the provision of medica…

(a) An integrated care network shall serve only Medicaid beneficiaries in providing medical care and services. For the purposes of this article, a beneficiary cannot be a member of both an integrated care network and a regional care organization. (b) An integrated care network sh…

There shall be a citizens’ advisory committee constituted to advise the integrated care network on ways the integrated care network may be more efficient in providing quality care to Medicaid beneficiaries. In addition, the advisory committee shall carry out other functions and d…

(a) An integrated care network shall meet minimum solvency and financial requirements as provided by the Medicaid Agency. The Medicaid Agency shall require the integrated care network, as a condition of certification or continued certification, to maintain minimum solvency and fi…

(a) Subject to approval of the federal Centers for Medicare and Medicaid Services, the Medicaid Agency shall enter into contracts with one or more integrated care networks to provide, pursuant to a risk contract under which the Medicaid Agency makes a capitated payment, medical c…

(a) The Medicaid Agency shall establish by rule procedures for safeguarding against wrongful denial of claims and addressing grievances of enrollees in an integrated care network. (b) If a patient or the provider is dissatisfied with the decision of an integrated care network, th…

(a) All provider contracts of an organization granted final certification as an integrated care network shall be subject to review and approval of the Medicaid Agency. (b)(1) If a provider is dissatisfied with any term or provision of the agreement or contract offered by an integ…

(a) The Medicaid Agency shall create a quality assurance committee appointed by the Medicaid Commissioner to review the care rendered through the integrated care networks. The members of the committee shall serve two-year terms. The Medicaid Agency shall promulgate a rule establi…

A risk contract between the Medicaid Agency and an integrated care network shall be for two years, with the option for Medicaid to renew the contract for not more than three additional one-year periods. The Medicaid Agency shall obtain provider input and an independent evaluation…

(a) The Medicaid Agency shall establish by rule the procedure for the termination of an integrated care network certification for non-performance of contractual duty or for failure to meet or maintain standards or requirements provided by this article or established by the Medica…

An integrated care network shall contract with any willing nursing home, doctor, home and community waiver program, or other provider to provide services through an integrated care network if the provider is willing to accept the payments and terms offered comparable providers, w…

(a) The following timeline applies to implementation of this article: (1) Not later than April 1, 2017, the Medicaid Agency shall establish integrated care network rules setting forth solvency, governing board, network, and active supervision requirements, as well as other requir…