Ala. Admin. Code r. 560-X-64-.17

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

Section 560-X-64-.17 - ICN Covered Services

(1) The following services must be covered for Medicaid recipients who are enrolled in an integrated care network (ICN):

(a) Direct Home and Community-Based Service Case Management for the Alabama Community Transition (ACT) Waiver in accordance with Alabama Medicaid Administrative Code Rule 560-X-44-.04;

(b) Direct Home and Community-Based Service Case Management for the Elderly and Disabled in accordance with Alabama Medicaid Administrative Code Rule 560-X-36-.04; and

(c) Primary care case management services, which include the location, coordination, and monitory of primary health care services, in addition to one or more of the following, as specified by the Medicaid Agency:

1. Provision of intensive telephonic or face-to-face case management, including operation of a nurse triage advice line.

2. Development of enrollee care plans.

3. Execution of contracts with and/or oversight responsibilities for the activities of FFS providers in the FFS program.

4. Provision of payments to FFS providers on behalf of the State.

5. Provision of enrollee outreach and education activities.

6. Operation of a customer service call center.

7. Review of provider claims, utilization and practice patterns to conduct provider profiling and/or practice improvement.

8. Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers.

9. Coordination with behavioral health systems/ providers.

10. Coordination with long-term services and supports systems/providers.

(2) Only those services identified in paragraph (1) above will be used in calculating an ICN's Per Member, Per Month (PMPM) payment amount; however, nothing in this rule shall preclude an ICN from providing services not identified in paragraph (1), subject to the approval of the Medicaid Agency, at its own expense.

Ala. Admin. Code r. 560-X-64-.17

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 01, October 31, 2017, eff. 11/28/2017.

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.