Current through Register Vol. 43, No. 02, November 27, 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.
(2) The committee shall identify objective
outcome and quality measures, including measures of outcome and quality for
ambulatory care, inpatient care, chemical dependency and mental health
treatment, oral health care, and all other health services provided by regional
care organizations.
(3) Quality
measures adopted by the committee shall be consistent with existing state and
national quality measures.
(4) The
Medicaid Commissioner shall incorporate outcome and quality measures into
regional care organization contracts to hold the organizations accountable for
performance and customer satisfaction requirements.
(a) The committee shall adopt outcome and
quality measures annually and adjust the measures to reflect the following:
1. The amount of the global budget for a
regional care organization.
2.
Changes in membership (RCO enrolled population) of the organization.
3. The organization's costs for implementing
outcome and quality measures.
4.
The community health assessment and the costs of the community health
assessment conducted by the organization.
(5) The Medicaid Agency shall continuously
evaluate the outcome and quality measures adopted by the committee.
(6) The Medicaid Agency shall utilize
available data systems for reporting outcome and quality measures adopted by
the committee and take actions to eliminate any redundant reporting or
reporting of limited value.
(7) The
Medicaid Agency shall publish the information collected under this section at
aggregate levels that does not disclose information otherwise protected by law.
The information published shall report, by regional care organizations, all of
the following:
(d) Other information, as specified by the
contract between the regional care organization and the Medicaid Agency, that
is necessary for the Medicaid Agency to evaluate the value of health services
delivered by a regional care organization.
(8) Except as otherwise provided in rules
promulgated by the Medicaid Agency, the Medicaid Quality Assurance Committee
shall not participate in the data validation or performance evaluation of
regional care organizations by the Medicaid Agency.
(9) The Medicaid Quality Assurance Committee
shall select a Committee Chair and a Committee Co-Chair, who shall each reside
in different regions.
(10) The
Medicaid Quality Assurance Committee shall meet at least annually to approve
the regional care organization outcome and quality measure set for the upcoming
calendar year.
(a) A quorum of at least
fifteen (15) Medicaid Quality Assurance Committee members (or their selected
alternates) shall be required to take such action on behalf of the
Committee.
(b) The Committee shall
approve or disapprove outcome and quality measures based on a simple majority
vote (50 percent +1 member) of those present and eligible to vote.
(c) If approved by the Committee Chair, a
committee member may participate and/or vote in a meeting of the committee by
means of telephone conference, videoconference, or similar communications
equipment by means of which all persons participating in the meeting may hear
each other at the same time. Participation by such means shall constitute
presence in person at a meeting for all purposes, including the establishment
of a quorum.
(d) In the event that
a Medicaid Quality Assurance Committee member is unable to participate in a
Medicaid Quality Assurance Committee meeting, the Committee Chair shall, upon
receipt of advance written, facsimile or email request from the member
explaining the reason for the member's absence, permit the alternate member
selected by the Medicaid Commissioner pursuant to subsection 1(d) of this rule
to participate and/or vote in the member's place.
(11) The performance standards and quality
measures reviewed or developed by a regional care organization's Provider
Standards Committee shall be subject to the approval of the Quality Assurance
Committee in accordance with Section
22-6-151(h) and
the procedures set forth in Rule No.
560-X-62-.09.
(a) No member of the Medicaid Quality
Assurance Committee who also served on a provider standards committee which
developed a performance standard or quality measure that is at issue shall vote
or participate in the Medicaid Quality Assurance Committee's review of that
performance standard or quality measure.
(b) A quorum of at least fifteen (15)
Medicaid Quality Assurance Committee members (or their selected alternates)
shall be required to take such action on behalf of the Committee.
(c) The Committee shall approve or disapprove
outcome and quality measures based on a simple majority vote (50 percent +1
member) of those present and eligible to vote
(d) If approved by the Committee Chair, a
committee member may participate in a meeting of the committee by means of
telephone conference, videoconference, or similar communications equipment by
means of which all persons participating in the meeting may hear each other at
the same time. Participation by such means shall constitute presence in person
at a meeting for all purposes, including the establishment of a
quorum.
(e) In the event that a
Medicaid Quality Assurance Committee member is unable to participate in a
Medicaid Quality Assurance Committee meeting, the Committee Chair shall, upon
receipt of advance written, facsimile or email request from the member
explaining the reason for the member's absence, permit the alternate member
selected by the Medicaid Commissioner pursuant to subsection 1(d) of this rule
to participate and/or vote in the member's place.
Author: Sharon Weaver, Administrator,
Administrative Procedures Office
Statutory Authority:
Code of Ala.
1975, §§
22-6-150 et seq; 42 CFR Part
438.