Ala. Admin. Code r. 560-X-64-.07

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

Section 560-X-64-.07 - Service Delivery Network Requirements For Integrated Care Networks

(1) Definitions - As referenced in this Chapter of the Alabama Medicaid Administrative Code the following terms shall be defined as follows:

(a)Care Management Organization (CMO) is defined as an organization providing case management for the 1915(c) waivers enrolled in the ICN program in accordance with Rule 560-X-64-.17 (e.g. AAAs and other agencies currently providing HCBS Case Management.)

(b)Nursing Facility as defined in Rule 560-X-10-.01.

(c)Service Delivery Network is defined as one that ensures enrollees have access to a network of appropriate providers that is sufficient to provide adequate access to all enrollees of the ICN.

1. The ICN must establish prior to the ICN Program implementation and maintain thereafter an adequate amount and appropriate geographic distribution of Nursing Facilities and CMOs, as required to appropriately service its enrollees, provide choice of providers to enrollees, and facilitate timely and effective care transitions and community participation. To satisfy this adequacy requirement, the ICN must have:

(i) Coordination agreements with at least fifty percent (50%) of the Medicaid Nursing Facilities' total licensed beds in the State.

(ii) Contracts with at least seventy-five percent (75%) of the CMOs in the State.

2. The ICN must establish agreements with the Alabama Department of Mental Health (ADMH) to ensure that each ICN establishes and maintains a collaboration to address the needs of enrollees who have mental illnesses and substance abuse disorders.

3. The ICN must establish agreements with the Alabama Department of Human Resources (ADHR) to ensure that each ICN establishes and maintains a collaboration to assist with prevention, reporting, and investigation activities of Adult Protection Services.

4. The ICN must establish agreements with the Alabama Department of Senior Services (ADSS) to ensure that each ICN establishes and maintains an adequate network for HCBS Waiver Case Management activities.

(2) Each ICN must demonstrate to the satisfaction of the Medicaid Agency that its Service Delivery Network meets the requirements of this rule based on the timelines established by the Medicaid Agency.

(3) Each ICN 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.

(4) 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.

(5) Notwithstanding any provisions of this rule to the contrary, any ICN 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.

Ala. Admin. Code r. 560-X-64-.07

Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 09, June 30, 2017, eff. 7/24/2017.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 09, June 29, 2018, eff. 7/26/2018.

Author: Stephanie Lindsay, Administrator, Administrative Procedures Office.

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. Part 438.