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. 43, No. 02, November 27, 2024
(1) Definitions - As referenced in this Chapter of the Alabama Medicaid Administrative Code the following terms shall be defined as follows:
Life-Threatening Emergency Care |
Immediate |
Urgent Care |
24 hours |
Routine Sick Care - PMP |
3 calendar days of presentation or notification excluding legal holidays |
Routine Sick Care - Core Specialist |
30 calendar days of presentation or notification excluding legal holidays |
Routine Well Care |
90 calendar days (15 calendar days if pregnant) |
Non-Life-Threatening Emergency |
6 hours |
Urgent Care |
48 hours |
Routine Visits |
30 calendar days |
Phone Access |
24 hours |
Appointment with behavioral health provider following a discharge from hospital |
72 hours |
Walk-Ins |
2 hours or schedule an appointment within the standards of appointment availability |
Scheduled Appointment |
1 hour |
Life-Threatening Emergency |
Immediate |
PMPs excluding Pediatricians and Delivering Healthcare Providers |
1.5 per 1,000 enrollees, with a minimum of two |
50 miles from each enrollee's residence |
Core Specialists (for each of the types identified in section (1)(b) of this rule) |
0.2 per 1,000 enrollees |
50 miles from each enrollee's residence |
Pediatricians |
1.5 per 1,000 enrollees under the age of 21, with a minimum of two |
50 miles from each enrollee's residence |
Obstetricians and Gynecologists |
No requirement |
50 miles from each enrollee's residence |
Facilities (for each of the types identified in section (1)(c) of this rule) |
No requirement |
50 miles from each enrollee's residence |
The distance requirement for each provider type listed above is limited to 30 miles from the state line border for out-of-state providers.
(2) Each entity with probationary regional care certification must demonstrate to the satisfaction of the Medicaid Agency that its Service Delivery Network meets the requirements of this rule. An exception from the requirements of Service Delivery Network requirements as defined in this rule may be made, within the sole discretion of the Medicaid Agency, upon the request of an entity using an Agency approved form, or as otherwise deemed appropriate by the Medicaid Agency.
(3) Notwithstanding the minimum network requirements of this rule, Medicaid enrollees shall have the option to be treated at the nearest hospital, NICU, or other facility able to provide the most appropriate medically necessary level of care in cases of medical emergency or necessity and/or when the treatment of a Medicaid enrollee elsewhere could pose an unreasonable risk of harm. For the purposes of this Subsection, medical emergency or necessity is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part. A medical emergency or necessity is determined based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a health care professional) and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results described in the previous sentence.
(4) Each entity must ensure compliance with all requirements for the furnishing of Medicaid services in accordance with this rule, applicable laws and medical standards as well as the needs of Medicaid enrollees.
(5) The Medicaid Agency may inspect or request additional documentation and information relating to the documentation submitted pursuant to this rule at any time to verify the information contained therein.
(6) Notwithstanding any provisions of this rule to the contrary, any probationary regional care organization, final regional care organization or alternate care provider shall be governed by federal access standards which may be found in their entirety in 42 C.F.R. §§ 438.206- 438.210 and which are hereby incorporated by reference and made a part of this rule as if set out in full and all provisions thereof are adopted as rules of the Medicaid Agency.
Author: Stephanie Lindsay, Administrator, Administrative Procedures Office
Statutory Authority: Code of Ala. 1975, §§ 22-6-150 et seq; 42 C.F.R. § 483.68 ; 42 C.F.R. §§483.06 - 438.210.