Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-64 - INTEGRATED CARE NETWORKS
Section 560-X-64-.18 - Sanctions
Current through Register Vol. 43, No. 02, November 27, 2024
(1) Bases for Imposition of Sanctions on ICNs. The Medicaid Agency may impose sanctions on an integrated care network ("ICN") if the Medicaid Agency determines in its sole discretion that the ICN has violated any applicable federal or state law or regulation, the Alabama Medicaid State Plan, the risk contract between the Medicaid Agency and the ICN 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 ICN acts or fails to act as follows:
(2) Types of Sanctions that May be Imposed on ICNs. The sanctions imposed by the Medicaid Agency against an ICN are as follows:
Activity |
Sanction |
* Distribution of unapproved material, distribution of materials that contain false or materially misleading information, or materials that otherwise violate Rule No. 560-X-64-.09. |
* Up to $25,000 for each determination |
* Untimely, as defined in the ICN's contract with the Medicaid Agency, payment to a Case Management Organization, through the Alabama Department of Senior Services for Home and Community Based Services Case Management. |
* Up to $5,000 for the first quarter that Claims performance percentages by claim type fall below the performance standards * Up to $25,000 per quarter for each additional quarter that the Claims performance percentages by claim type fall below the performance standards |
* Failure to report, as required by the ICN's contract with the Medicaid Agency, suspected Enrollee abuse, neglect, or exploitation. |
* Up to $25,000 for each determination |
* Approved Encounters, as defined in the ICN's contract with the Medicaid Agency, less than 98%. |
* 0.25% of the Per Member Per Month Payment for each percentage point below 98% |
* Misrepresents or falsifies information furnished to the Agency or CMS. |
* Up to $100,000 for each determination |
(3) Notice of Sanction. Before the Medicaid Agency imposes a sanction under this rule, it will give the affected organization timely written notice explaining (a) the basis and nature of the sanction, (b) if applicable, the organization's right to request a fair hearing under Rule No. 560-X-64-.15, and (c) any other due process protections the Medicaid Agency elects to provide.
(4) Waiver of Fair Hearing and Reduction of Sanction. Except as otherwise required by applicable law, in the event of an imposed sanction in the form of a civil monetary penalty according to this rule and/or the risk contract and exhibits thereto, the amount of the sanction imposed will be reduced by thirty five percent (35%) if the ICN waives, in writing, its right to a fair hearing within thirty (30) calendar days from the date of notice imposing the sanction. The reduction under this section only applies to sanctions that could be appealed under Rule No. 560-X-64-.15 and not to any other outstanding sanctions imposed on the ICN by the Medicaid Agency.
(5) Pre-termination Hearing. Before terminating the contract as a sanction under this rule and 42 C.F.R. § 438.708, the Medicaid Agency will provide the ICN with a pre-termination hearing to be conducted in accordance with the procedures for fair hearings set forth in Rule No. 560-X-64-.15. Prior to such pre-termination hearing, the Medicaid Agency will, in accordance with 42 C.F.R. § 438.710:
(6) Sanctions Not Exclusive. The imposition of a single sanction by the Medicaid Agency does not preclude the imposition of any other sanction or combination of sanctions or any remedy authorized under the risk contract for the same deficiency. The Medicaid Agency may impose sanctions under this rule in addition to or in lieu of exercising any other right, remedy, or authority that the Medicaid Agency may exercise under other rules promulgated by the Medicaid Agency, other applicable state and federal laws and regulations, or any contract between the Medicaid Agency and an ICN. Nothing in this rule shall restrict or prevent the Medicaid Agency or the State of Alabama from obtaining declaratory, injunctive or equitable relief, or from recovering damages from an ICN and/or any other person or entity for breach of contract or any other cause of action.
Author: Stephanie Lindsay, Administrator, Administrative Procedures Office
Statutory Authority: Code of Ala. 1975, §§ 22-6-220 et seq.