Ala. Admin. Code r. 560-X-37-.01

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-37-.01 - General

(1) The Medicaid Agency may, at its discretion, and in consultation with local communities, organize and develop area specific systems as part of an overall managed care system.

(a) Flexibility. Since community needs and resources differ from area to area, the Medicaid Agency will maintain the flexibility to design plans which are consistent with local needs and resources.

(b) Waiver Programs. Plans may be either voluntary or mandatory pursuant to waiver(s) granted by the Centers for Medicare and Medicaid Services (CMS). Some plans may start as voluntary and subsequently become mandatory. All required federal waivers and/or approvals must be obtained by the Medicaid Agency before any system or contract can become effective.

(c) State Plan Programs. Amendments to the state plan must be approved by CMS before any system or contract can become effective.

(d) Models. The Medicaid Agency may utilize one or more managed care systems established in 42 C.F.R. Part 438 or approved by CMS, including but not limited to, health maintenance organizations (HMO), managed care organizations (MCO), prepaid ambulatory health plans (PAHPs), prepaid Inpatient health plans (PIHP), primary care case management systems (PCCM), and/or primary care case management entities (PCCM entity).

(e) Purpose. The purposes of managed care are to:

(i) Ensure needed access to health care;

(ii) Provide health education;

(iii) Promote continuity of care;

(iv) Strengthen the patient/physician relationship; and

(v) Achieve cost efficiencies.

(2) Any established managed care system shall comply with the following:

(a) the Alabama Medicaid State Plan and any award letters, waivers or other directives or permissions approved by CMS for operation of the managed care system;

(b) the Federal Medicaid Act, Title XIX of the Social Security Act, the Children's Health Insurance Program (CHIP), established by Title XXI of the Social Security Act, and the Affordable Care Act, and their implementing regulations published in the Code of Federal Regulations (CFR), except as waived by CMS, including, but not limited to, 42 C.F.R. Parts 430, 432, 434, 438, 440, and 447, and as may be subsequently amended;

(c) any state law implementing or directing the implementation of the managed care system;

(d) Alabama Medicaid Administrative Code;

(e) the Alabama Medicaid Provider Manual and/or operational protocols, any Agency written policy, written procedure, written interpretation or other written guidance, including operational memos, manuals, interpretations, and Agency written communications; and

(f) all other applicable state and federal laws and regulations.

(3) Any managed care system or respective network provider shall comply with all applicable federal and state laws, rules, and regulations, including, but not limited to:

(a) Age Discrimination Act of 1975, as amended, 42 U.S.C. § 6101, et seq.;

(b) Age Discrimination in Employment Act of 1967, 29 U.S.C. §§ 621- 634;

(c) Americans with Disabilities Act of 1990 (ADA), 42 U.S.C. § 12101, et seq. ;

(d) Byrd Anti-Lobbying Amendment, 31 U.S.C. § 1352, 45 C.F.R. §2 54 3.8 7 ;

(e) Clean Air Act, 42 U.S.C. § 7401, et seq.;

(f) Debarment and Suspension 45 CFR § 74 Appendix A (8) and Executive Order (E.O.) 12549 and 12689;

(g) Equal Employment Opportunity, E.O. 11246, as amended by E.O. 11375, amending E.O. 11246 and as supplemented by 41 C.F.R., Part 60 ;

(h) Equal Pay Act of 1963, 29 USC § 206(d);

(i) Federal Water Pollution Control Act, as amended, 33 U.S.C. § 1251, et seq.;

(j) Immigration Reform and Control Act of 1986, 8 U.S.C. § 1324b;

(k) Rights to inventions made under a contract or agreement, 45 C.F.R. § 2543.85 ;

(l) Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794;

(m) Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. § 2000d, et seq.;

(n) Title VII of the Civil Rights Act of 1964, 42 U.S.C. § 2000e;

(o) Title IX of the Education Amendments of 1972, as amended, 2 0 U.S.C. § 1681 ; and

(p) Section 1557 of the Patient Protection and Affordable Care Act.

(4) The Medicaid Agency's contract with the managed care system must, at a minimum:

(a) include the applicable standard contract provisions of 42 C.F.R. § 438.3;

(b) include all applicable provisions required by 42 C.F.R. Part 438;

(c) include any provisions required by state or federal laws or regulations;

(d) be approved by CMS in accordance with to 42 C.F.R. § 438.3(a).

(5) Each managed care system must comply with the information requirements contained in 42 C.F.R. § 438.10. Unless otherwise specified in the manage care system contract or elsewhere by the Medicaid Agency, Prevalent Languages shall mean the fifteen (15) most spoken languages in the state as determined by the most recent United States Census.

(6) The Medicaid Agency must have policies and procedures in place to ensure that its obligations under 42 C.F.R. § 438 Subpart B are met. Further, Medicaid Agency employees must comply with the state ethics laws including, but not limited to, Code of Alabama (1975), Sections 36-25-5, -7, -8, -11, -12, and -13.

(7) Every managed care system must establish policies and procedures, which shall be subject to the Medicaid Agency's sole approval, to ensure that its obligations under its contract with the Medicaid Agency and 42 C.F.R. Subparts D and E are met. In addition, the Medicaid Agency must establish policies and procedures to monitor the managed care system's performance of its obligations.

(8) Every managed care system must establish, subject to the Medicaid Agency's sole approval, a grievance system. Such grievance system must, at a minimum:

(a) comply with the applicable provisions of 42 C.F.R. § 438 Subpart F; and

(b) comply with any other applicable state or federal laws and regulations.

Ala. Admin. Code r. 560-X-37-.01

Amended: May 15, 1991; April 15, 1992. Amended: Filed April 6, 1994; effective May 13, 1994. Amended: Filed August 12, 1994; effective September 17, 1994. Amended: Filed July 6, 1995; effective August 12, 1995. Repealed and Replaced: Filed June 6, 1996; effective July 12, 1996. Amended: Filed November 8, 2001; effective December 13, 2001. Amended: Filed May 12, 2003; effective June 16, 2003.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 05, February 28, 2018, eff. 3/26/2018.

Author: Jerri Jackson, Director, Managed Care Divsion

Statutory Authority: Alabama State Plan for Medical Assistance (hereinafter State Plan), Section 2.1(c), attachment 2.1-A; Social Security Act, Title XIX, Section 1903(m)(2)(B); 42 C.F.R. Section 434.26, Section 434.6; Civil Rights Act of 1964, Titles VI and VII, as amended. The Federal Age Discrimination Act, Rehabilitative Act of 1973. The Americans with Disabilities Act of 1990.