Current through Register Vol. 43, No. 02, November 27, 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.
(2) If any of the events set forth
in subsections (1)(a)-(e) occur, the Medicaid Agency may, in its sole
discretion, offer any RCO, which it judges could successfully provide services
in its initial region and an additional region or regions (Additional Region),
the opportunity to serve Medicaid beneficiaries in both regions. In any of such
events, the Medicaid Agency will send a notice of opportunity to serve Medicaid
beneficiaries in the Additional Region (Notice of Opportunity) to all remaining
RCOs in any region. The Notice of Opportunity shall include, at a minimum:
(a) Identification of the Medicaid region in
which the vacancy exists;
(b) The
Agency's anticipated timeline for implementation;
(c) The deadline for notice to be sent to the
Agency in writing of a RCO's interest in sponsoring an entity to serve
beneficiaries in the Additional Region (Sponsor RCO);
(d) The date of the proposed planning meeting
described in section (3) below; and,
(e) Any other items or factors the Agency
deems relevant.
(3) The
Medicaid Agency shall schedule a planning meeting to discuss the Notice of
Opportunity with all RCOs that notify the Agency in writing of an interest in
serving beneficiaries in the Additional Region. At the planning meeting, the
Medicaid Agency shall discuss the Agency's proposed Eligible Responder
criteria, described in section (4) below, and Application Process criteria,
described in section (6) below.
(4)
In order to participate in the Application process described in section (6)
below, an entity must be an Eligible Responder. In order to be an Eligible
Responder, an entity must meet the following criteria:
(a) Demonstrate to the Medicaid Agency's
satisfaction that the Sponsor RCO has the ability to successfully provide
services in both its initial region and the Additional Region. In evaluating
the demonstration, the Medicaid Agency shall take into consideration:
(i) The Sponsor RCO's historic performance in
operating and/or establishing an organization with probationary or full
certification;
(ii) The stability
of the Sponsor RCO's current or proposed program, including, but not limited to
the RCO's financial solvency and the operation of a health home program, if
applicable;
(iii) The Sponsor RCO's
compliance with reporting requirements, corrective action plans, and state or
federal laws and regulations, including any sanctions issued for noncompliance;
and,
(iv) Any other facts or
circumstances the Medicaid Agency deems relevant to its
consideration;
(b)
Attend the planning meeting and all other meetings deemed by the Medicaid
Agency, in writing, as mandatory for Eligible Responders;
(c) Obtain a Certificate to Collaborate in
accordance with Alabama Medicaid Administrative Code Rule
560-X-62-.01;
(d) Establish a separate legal entity in the
Additional Region with a corporate and governance structure approved by the
Medicaid Agency. This structure, at a minimum, must include:
(i) An organization incorporated as a
nonprofit corporation under Alabama law. The Certificate of Formation of the
organization shall mandate that:
(I) 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
(II) More than 80% of
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.
(ii) A Governing Board of Directors which
shall be responsible for the establishment and oversight of the organization's
business and affairs. The Medicaid Agency shall have the power to approve the
members of the Governing Board of Directors of the organization and the board's
structure, powers, bylaws, or other rules of procedure, as well as all
amendments thereto. The Governing Board of Directors shall be composed of the
following members:
(I) Six risk-bearing
members who are "primary medical providers," "core specialists" and/or
"facilities" as defined in Alabama Medicaid Administrative Code Rule
560-X-62-.12(1)(a)
-(c), or representatives thereof, who treat Medicaid beneficiaries in the
Additional Region to be served by the organization;
(II) Six risk-bearing members who are
risk-bearing members of the Sponsor RCO (any risk-bearing member that could
qualify under both subsection (I) and (II) will be counted in this subsection
(II) only); and,
(III) Eight non
risk-bearing members in accordance with Section
22-6-151(c)(1)(b)
-(c) of the Alabama Code and Alabama Medicaid Administrative Code Rule
560-X-62-.03(1)(b)(i)
-(ii) or a timeline, acceptable to the Medicaid Agency, for obtaining the eight
non risk-bearing members;
(iii) A Citizens' Advisory Committee in
accordance with Section
22-6-151(d) of
the Alabama Code and Alabama Medicaid Administrative Code Rule
560-X-62-.04 or a timeline,
acceptable to the Medicaid Agency, for forming the Citizens' Advisory
Committee;
(iv) A Provider
Standards Committee in accordance with Section
22-6-151(h) of
the Alabama Code and Alabama Medicaid Administrative Code Rule
560-X-62-.09 or a timeline,
acceptable to the Medicaid Agency, for forming the Provider Standards
Committee;
(v) A conflict of
interest policy consistent with Alabama Medicaid Administrative Code Rule
560-X-62-.08;
(e) Demonstrate that the
organization will be able to meet the minimum solvency and financial
requirements of Section
22-6-151(e) of
the Alabama Code and Alabama Medicaid Administrative Code Rule
560-X-62-.16, notwithstanding the
timing requirements contained therein; and
(f) Any other requirements established by the
Medicaid Agency.
(5) On
or before a date established by the Medicaid Agency, all interested entities
must have completed and submitted to the Agency evidence of compliance with the
required criteria for Eligible Responders. The Medicaid Agency, in its sole
discretion, may deem one or more, if any, organization(s) meeting the criteria
established in section (4) above as Eligible Responders that shall be permitted
to participate in the Application Process described in section (6)
below.
(6) Only organizations
designated as Eligible Responders may participate in the Application Process
established by the Medicaid Agency. This process shall include:
(i) A readiness assessment process consistent
with Alabama Medicaid Administrative Code Rule
560-X-62-.22, notwithstanding the
timing requirements contained therein;
(ii) Active supervision reporting on a
periodic basis as specified in the Application Process, consistent with Alabama
Medicaid Administrative Code Rule
560-X-62-.26;
(iii) Meet the minimum solvency and financial
requirements of Section
22-6-151(e) of
the Alabama Code and Alabama Medicaid Administrative Code Rule
560-X-62-.16, notwithstanding the
timing requirements contained therein;
(iv) Demonstration of an adequate service
delivery network as outlined in Alabama Administrative Code Rule
560-X-62-.12 notwithstanding the
timing requirements contained therein;
(v) Obtaining full certification consistent
with Alabama Administrative Code Rule
560-X-62-.19, notwithstanding the
timing requirements contained therein; and,
(vi) Any other criteria established by the
Medicaid Agency.
(7) On
or about the date specified in the Application Process, the Medicaid Agency, in
its sole discretion, may offer to one or more Eligible Responders the
opportunity to serve Medicaid beneficiaries in the Additional Region. The
Medicaid Agency's determination shall be based on the organization(s)'s
performance during the Eligible Responder period and Application Process and
compliance with all established benchmarks, reporting requirements, and other
mandatory elements. The Medicaid Agency may, within its discretion, contract
with one or more RCOs that meet the requirements of this Rule and other
applicable RCO laws if the Agency determines the contract to be in the best
interest of the State and Medicaid beneficiaries.
(8) No legal or equitable rights or interests
are created by a RCO attending the planning meeting, pursuing Eligible
Responder status, participating in the Application Process, or otherwise
engaging in the process described herein. Any RCO dissatisfied with a
determination of the Medicaid Agency during any step of the process described
herein may file a written request for reconsideration to the Agency within five
business days of the determination for which reconsideration is requested. The
Medicaid Agency shall respond to the request for reconsideration within a
reasonable time period.
Author: Stephanie Lindsay, Administrator,
Administrative Procedures Office
Statutory Authority:
Code of Ala.
1975, §§
22-6-150 et
seq.