ALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-64 INTEGRATED CARE NETWORKS TABLE OF CONTENTS

Transcription

1 Medicaid Chapter 560-X-64 ALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-64 INTEGRATED CARE NETWORKS TABLE OF CONTENTS 560-X X X X X X X X X X X X X X X X X X X Certificate In Order To Collaborate With Other Entities, Individuals, Or Integrated Care Networks Active Supervision Of Collaborations Governing Board Of Directors Citizen s Advisory Committee ICN Quality Assurance Committee Solvency And Financial Requirements For Integrated Care Networks Service Delivery Network Requirements For Integrated Care Networks Active Supervision Of Organizations With Probationary Certification Qualification Criteria For Participation In The Mandated Competitive Procurement For Integrated Care Networks Financial Reporting And Audit Requirements Hazardous Financial Condition And Insolvency Probationary Certification Of Organizations Seeking To Become Integrated Care Networks Conflict Of Interest Policy For Directors And Officers Of Integrated Care Networks Right To Terminate Certificates Of Probationary And Fully Certified Integrated Care Networks Grievances And Fair Hearings Of Integrated Care Networks ICN Covered Population ICN Covered Services Sanctions Readiness Assessment Requirements Supp. 12/31/

2 Chapter 560-X-64 Medicaid 560-X Certificate In Order To Collaborate With Other Entities, Individuals, Or Integrated Care Networks. (1) Every person or entity who is operating or may operate as a Collaborator shall possess a certificate (Certificate to Collaborate) issued by the Medicaid Agency qualifying such person or entity to collaborate as set forth in Section , Code of Ala A Collaborator is defined in Section (2), Code of Ala as: A private health carrier, third party purchaser, provider, health care center, health care facility, state and local governmental entity, or other public payers, corporations, individuals, and consumers who are expecting to collectively cooperate, negotiate, or contract with another collaborator or integrated care network in the health care system. (2) Every person or entity seeking a Certificate to Collaborate shall submit an on-line application with the Medicaid Agency and must include the following information in the application: (a) The applicant s name, business, occupation or medical specialty, principal address and the name, mailing address, address, and telephone number of each person authorized to receive notices and communications relating to the application; (b) As applicable, the applicant s National Provider Identifier (NPI) number(s), Medicaid ID number(s), Taxpayer Identification Number(s) (TIN), Social Security Number (SSN) and any state professional or facility license number(s); (c) The name and address of each individual who the applicant authorizes to collaborate on its behalf with other entities, persons, Integrated Care Networks (ICNs), or Regional Care Organizations (RCOs); (d) Background information relating to the applicant and each individual authorized to collaborate on its behalf, including: 1. whether the applicant or any individual authorized to collaborate on its behalf is currently excluded or suspended from the Medicare, Medicaid, or the Title XX services program; Supp. 12/31/

3 Medicaid Chapter 560-X whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty to or been convicted of a criminal offense related to the applicant s or the individual s involvement in any program under Medicare, Medicaid, or the Title XX services program; 3. whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty, been convicted, or found liable in a criminal or civil proceeding of engaging in any form of health care fraud or abuse; 4. whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty, been convicted, or found liable in a criminal or civil proceeding of engaging in any form of anti-competitive conduct or other anti-trust violation; 5. whether the professional license or certification of the applicant or any individual authorized to collaborate on its behalf is currently suspended or revoked; and 6. whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty or been convicted of a violation of the state or federal securities or insurance laws. (e) Information whether the applicant intends to help establish or develop an ICN, to enroll as a provider with an ICN, or to engage in other activity. (f) Description of what entities and persons with whom the applicant intends on collaborating or negotiating; (g) Description of the expected effects of the negotiated contract, including whether the negotiated contract is expected to: 1. result in improved quality of health care services and/or Long-Term Care Services, as defined in Section (5), Code of Ala. 1975, to Medicaid beneficiaries; 2. result in cost containment in providing health care services and/or Long-Term Care Services; 3. result in enhancements in technology; and Supp. 12/31/

4 Chapter 560-X-64 Medicaid 4. maintain competition in the health care services market and/or the Long-Term Care Services market. (h) Certification by the applicant that all information entered on the application is true, to the best of the applicant s knowledge, and (1) that the applicant will bargain in good faith as contemplated in Section , Code of Ala. 1975, (2) that such bargaining is necessary to identify appropriate service delivery systems and reimbursement methods in order to align incentives in support of integrated and coordinated long-term healthcare delivery, and (3) that such bargaining is necessary to provide quality health care to Alabama citizens who are Medicaid eligible at the lowest possible cost. (3) The Medicaid Agency may inspect or request additional documentation and information from an applicant as the Medicaid Agency deems appropriate before issuance of a Certificate to Collaborate or at any other time to verify that the Medicaid laws are implemented in accordance with the legislative intent. (4)(a) The Medicaid Agency shall review the application and any additional documentation and information and, if the Medicaid Agency determines that the applicant has made a sufficient showing that the collaboration is in order to facilitate the development and establishment of the ICN or long-term health care payment reforms, the Medicaid Agency shall issue a Certificate to Collaborate. (b) Certificates to Collaborate issued by the Medicaid Agency pursuant to this rule and Section , Code of Ala. 1975, shall be issued to allow collective negotiations, bargaining, and cooperation among Collaborators and ICNs in accordance with Sections , et seq., Code of Ala (c) A Certificate to Collaborate shall be effective immediately upon issuance by the Medicaid Agency and shall expire on October 1, The Medicaid Agency may implement rules for renewals of Certificates to Collaborate. (d) The holder of a Certificate to Collaborate (Certificate Holder) shall promptly notify the Medicaid Agency online of any substantial or material corrections or updates to the information provided in the Certificate Holder s application. Supp. 12/31/

5 Medicaid Chapter 560-X-64 (5) All applications submitted pursuant to this rule, all Certificates to Collaborate, and the names and addresses of all persons and entities to whom the Medicaid Agency issues Certificates to Collaborate shall be public records and shall be subject to disclosure. The names and addresses of all Certificate Holders and all individuals authorized to collaborate on behalf of Certificate Holders shall be posted on the Medicaid Agency s website for review. (6) The Medicaid Agency shall actively monitor and supervise collective negotiations, bargaining, contracting, and cooperation among Collaborators and ICNs in accordance with Sections , et seq., Code of Ala As part of its monitoring and supervision, the Medicaid Agency shall, as it deems appropriate, request periodic reports and additional information regarding the status, progress being made and problems encountered in the collaborative process, and the status of efforts to create integrated networks intended to provide for the delivery of a coordinated system of long-term healthcare. Failure to file a periodic report or to provide information or documents requested by the Medicaid Agency is grounds for revocation of a Certificate to Collaborate. (7) Any person or entity may notify the Medicaid Agency of conduct of a Certificate Holder that is alleged to violate any of the certifications by the Certificate Holder pursuant to Section (c), Code of Ala. 1975, and subsection 2(h) of this rule. The notice must be signed, in writing and include a statement of facts supporting the allegation of a violation. Upon receipt of such notice or upon receipt of such information obtained by Medicaid on its own, the Medicaid Agency shall review the notice and conduct any inquiry it finds appropriate and may refer the allegation of a violation to the State of Alabama Attorney General. The Medicaid Agency may revoke a Certificate to Collaborate upon finding that the Certificate Holder has violated any of the certifications by the Certificate Holder pursuant to Section (c), Code of Ala. 1975, and subsection 2(h) of this rule or it may in its discretion impose additional terms and conditions determined necessary to effectuate the objectives of the Certificate to Collaborate. (8) Should Collaborators or an ICN be unable to reach an agreement, they may request that the Medicaid Agency intervene and facilitate negotiations. Supp. 12/31/

6 Chapter 560-X-64 Medicaid (9) The Medicaid Commissioner or the Medicaid Commissioner s designee(s) may enter into discussions with, meet with, or convene Collaborators and ICNs to facilitate the development and establishments of the ICNs and long-term health care payment reforms and discuss questions, concerns, or complaints related thereto. (10) Given the important governmental and public interest to ensure that state action immunity is not conferred upon persons or entities who fail to sufficiently show that their collaboration is in furtherance of the goals of Section et seq., Code of Ala. 1975, all decisions to grant, deny, or revoke, a Certificate to Collaborate shall serve as the final decision of the Medicaid Agency and shall be appealable immediately to circuit court. Notwithstanding this rule, a holder of a Certificate to Collaborate that is revoked for failure to provide a timely periodic report or other requested information or documents, may apply for reinstatement of the Certificate to Collaborate no more than two times (which number may be expanded by the Medicaid Agency for special circumstances as determined in the Medicaid Agency s sole discretion) upon submission of the delinquent periodic report or information, an explanation for failure to provide a timely periodic report or other requested information, and any other information deemed necessary by the Medicaid Agency. Author: Stephanie Lindsay, Administrator, Administrative Procedures Office Statutory Authority: Code of Ala. 1975, Section et seq. History: New Rule: Filed June 10, 2016; effective July 25, X Active Supervision Of Collaborations. (1) The Medicaid Agency shall actively monitor and supervise the collective negotiations, bargaining, contracting, and cooperation among Collaborators that have been issued Certificates to Collaborate by the Medicaid Agency and Integrated Care Networks (ICNs) in accordance with Sections , et seq., Code of Ala Each Collaborator issued a Certificate to Collaborate shall submit an on-line periodic report to the Medicaid Agency no later than June 1 and December 1 of each year in which the Collaborator holds a Certificate to Collaborate. Supp. 12/31/

7 Medicaid Chapter 560-X-64 (2) Each periodic report must contain the information requested by the Medicaid Agency in order to allow the Medicaid Agency to engage in appropriate state supervision in accordance with Section , Code of Ala. 1975, including the following information: (a) A description of the Collaborator s activities during the reporting period conducted pursuant to the Certificate to Collaborate, including a description of what entities and persons with whom the Collaborator engaged in collective negotiations, bargaining, or cooperation during the reporting period; (b) A description of any progress the Collaborator has made during the reporting period in helping establish or develop an ICN or enrolling as a provider with an ICN; (c) A description of any concerns or problems encountered in the collaborative process during the reporting period; (d) A description of the nature and scope of expected future activities pursuant to the Certificate to Collaborate; and (3) Each periodic report submitted by a Collaborator who intends to help establish or develop an ICN must include additional information concerning whether the ICN is expected to: (a) result in improved quality of health care services and/or Long-Term Care Services, as defined in Section (5), Code of Ala. 1975, to Medicaid beneficiaries; (b) result in cost-containment in providing health care services and/or Long-Term Care Services; (c) result in enhancements in technology; (d) maintain competition in the health care services market and/or the Long-Term Care Services market; and (e) identify appropriate service delivery systems and reimbursement methods in order to align incentives in support of integrated and coordinated health care delivery and/or Long-Term Care Services delivery. Supp. 12/31/

8 Chapter 560-X-64 Medicaid (4) The Collaborator shall certify in each periodic report that the bargaining during the reporting period was in good faith and necessary to meet the legislative intent expressed in Section , Code of Ala (5) The Medicaid Agency may inspect or request additional information, inspect or request documentation, and may convene meetings, make inquiries, and have such discussions with entities and persons it deems appropriate. (6) Failure to file a periodic report required by this rule and failure to provide information or documents requested by the Medicaid Agency are each grounds for revocation of a Certificate to Collaborate pursuant to Rule 560-X (10). A holder of a Certificate to Collaborate that is revoked for failure to provide a timely periodic report or other requested information or documents may apply for reinstatement of the Certificate to Collaborate no more than two times (which number may be expanded by the Medicaid Agency for special circumstances as determined in the Medicaid Agency s sole discretion) upon submission of the delinquent periodic report or information, an explanation for failure to provide a timely periodic report, and any other information deemed necessary by the Medicaid Agency. Author: Stephanie Lindsay, Administrator, Administrative Procedures Office Statutory Authority: Code of Ala. 1975, et seq. History: New Rule: Filed June 10, 2016; effective July 25, X Governing Board Of Directors. (1) An integrated care network shall have a governing board of directors composed of the following twenty members: (a) Twelve members shall be persons representing risk-bearing participants in the integrated care network. A participant bears risk by contributing cash, capital, or other assets to the integrated care network. 1. Six of the twelve risk-bearing participants shall be long-term health care or medical providers, or representatives thereof, who serve or will serve Medicaid beneficiaries enrolled in the integrated care network. Supp. 12/31/

9 Medicaid Chapter 560-X The long-term health care or medical providers must collectively contribute cash, capital, or other assets approved by the Agency to satisfy at least fifty percent of the capital and surplus requirements of Alabama Medicaid Administrative Code Chapter 560-X-64. (b) Eight members shall be persons who do not represent a risk-bearing participant in the integrated care network and are not employed by a risk bearing participant. At least four of these members must be long-term health care or medical providers who serve or will serve Medicaid beneficiaries enrolled in the integrated care network. 1. Two members shall be appointed by the Medical Association of the State of Alabama, or its successor organization; 2. One member shall be appointed by the Alabama Hospice and Palliative Care Organization, or its successor organization; 3. One member shall be a representative of an organization that is part of the Disabilities Leadership Coalition of Alabama or Alabama Arise, or their successor organizations; 4. One member shall be a representative of the Alabama chapter of AARP or the Alabama Disabilities Advocacy Program, or their successor organizations; 5. One member shall be a representative of the Disability Rights and Resources or the Arc of Alabama, or their successor organizations; 6. The chair of the citizen s advisory committee established pursuant to Alabama Medicaid Administrative Code Rule 560-X ; and, 7. One members shall be a community representatives. (2) A majority of the members of the board may not represent a single provider. Any provider shall meet licensing requirements set by law, shall have a valid Medicaid provider number, and shall not be otherwise disqualified from participating in Medicare or Medicaid. Supp. 12/31/

10 Chapter 560-X-64 Medicaid (3) Medicaid shall have the power to approve the members of the governing board and the board's structure, powers, bylaws, or other rules of procedure. No organization shall be granted integrated care network certification without approval. (4) Any vacancy on the governing board of directors in connection with non-risk bearing members appointed as described in Section (d)(1) shall be filled by the appropriate authority. A vacancy in a board of directors seat held by a representative of a risk-bearing participant as defined in Section (d)(1)(a) shall be filled by a majority vote of the remaining directors of the integrated care network. Notwithstanding other provisions of this rule, the Medicaid Commissioner shall fill a board seat left vacant for more than three months. (5) The governing board may, by resolution adopt by a majority of the directors, appoint an executive committee, which shall consist of two or more directors, who may have such authority and take such action as authorized by the governing board and consistent with state law; provided, however, any at-risk provider type shall be represented on the executive committee. For purposes of this subsection, a legal entity shall be considered the same provider type of the majority owner(s), principal(s) or member(s) of that entity. The governing board shall set policy and direction for the integrated care network and the executive committee shall execute the policies established by the governing board. The governing board may also appoint such other committees as are consistent with Alabama law. All actions of the executive committee and all other committees shall be reported to the governing board. At least one member of an executive committee and any other committee shall be one of the members appointed to the board by the Medical Association of the State of Alabama. (6) The governing board shall meet at least quarterly. If provided for in the ICN s bylaws, a member may participate and/or vote in a meeting of the governing board of directors by means of telephone conference, videoconference, or similar communications equipment only if: (a) All persons participating in the meeting may hear each other at the same time. (b) The meeting of the governing board of directors is conducted at a physical location whereby members have the Supp. 12/31/

11 Medicaid Chapter 560-X-64 option to attend the meeting in-person. Participation by such means shall constitute presence in person at a meeting for all purposes, including the establishment of a quorum. (7) All appointing authorities for the governing board and the executive committee shall coordinate their appointments so that diversity of gender, race, and geographical areas is reflective of the makeup of the population served. Author: Stephanie Lindsay, Administrator, Administrative Procedures Office Statutory Authority: Code of Ala. 1975, et seq. History: New Rule: Filed December 12, 2016; effective January 26, X Citizens Advisory Committee. (1) A citizens advisory committee (CAC) shall advise an integrated care network (ICN) on ways it may be more efficient in providing quality care to Medicaid beneficiaries. In addition, a CAC shall carry out other functions and duties assigned to it by the ICN and approved by the Medicaid Agency. Each ICN shall have a CAC, which membership shall be inclusive and reflect the racial, gender, geographic, urban/rural, and economic diversity of the population served. The committee shall meet all of the following criteria: (a) Be selected in a method established by the ICN and approved by the Medicaid Agency. (b) At least 20 percent of its members shall be Medicaid beneficiaries or sponsors of Medicaid beneficiaries or, if the ICN has been certified as an integrated care network, at least 20 percent of its members shall be Medicaid beneficiaries enrolled in the integrated care network, or the Medicaid beneficiary s sponsor. It shall be the ICN s sole responsibility to obtain all necessary approvals, consents or waivers from Medicaid beneficiaries and to comply with all applicable laws regarding privacy and confidentiality related to such information before providing it to the Medicaid Agency. (c) Include members who are representatives of organizations that are part of the Disabilities Leadership Coalition of Alabama or Alabama Arise, or their successor organizations, the Alabama chapter of AARP, the Alabama Disabilities Advocacy Program, the Disability Rights and Supp. 12/31/

12 Chapter 560-X-64 Medicaid Resources, the Arc of Alabama, and also include members who are non-at-risk providers that provider services to Medicaid beneficiaries through the integrated care network. (d) (e) Elect a chair. Meet at least every three months. (2) A member may participate and/or vote in a meeting of the CAC by means of telephone conference, videoconference, or similar communications equipment. Participation by such means shall constitute presence in person at a meeting for all purposes, including the establishment of a quorum. Such participation is permitted only if: (a) All persons participating in the meeting may hear each other at the same time; (b) The equipment necessary to participate in the meeting is readily available to all members of the committee; and (c) The meeting of the CAC is conducted at a physical location whereby members have the option to attend the meeting in-person. Author: Stephanie Lindsay, Administrator, Administrative Procedures Office Statutory Authority: Code of Ala. 1975, et seq. History: New Rule: Filed December 12, 2016; effective January 26, X ICN Quality Assurance Committee. (1) Pursuant to Section of the Code of Ala. 1975, the Medicaid Agency ( Agency ) shall have an integrated care network (ICN) quality assurance committee ( Committee ) appointed by the Medicaid Commissioner. (a) terms. The members of the Committee shall serve two-year (b) At least 60 percent of the members shall be long-term health and medical care providers who provide care to Medicaid beneficiaries served by an ICN. Supp. 12/31/

13 Medicaid Chapter 560-X-64 (c) In making appointments to the Committee, the Medicaid Commissioner shall seek input from the appropriate stakeholders and professional associations. (d) The Medicaid Commissioner shall also select an alternate to each appointed committee member who shall be permitted by the Committee Chair to participate and/or vote in the event of an appointed member s absence pursuant to subsection (4)(d) of this rule. The alternate shall meet the same appointment criteria as the absent member for whom the alternate is selected. (e) The Medicaid Commissioner may also appoint Ex Officio members to the Committee. Ex Officio members are not counted for quorum purposes or for the composition requirement of subsection (1)(b) above, and are exempt from the alternate member rule in subsection (1)(d) above. (2) The Committee shall identify objective outcome and quality measures for nursing facility services, home-based and community-based support services, and any other such long-term health and medical care services the Agency requires to be provided by an ICN. These measures should include, but not be limited to: (a) identifying individuals needing Long Term Service Supports (LTSS); (b) (c) (d) services. delivering person centered planning; providing adequate access to services; and, progressing toward rebalancing in the delivery of (3) Quality measures adopted by the Committee shall not conflict with existing state and national quality measures. (4) The Committee shall meet at least bi-annually to review quality, performance and outcomes measures and make recommendations to the Agency for modifications to measures for the upcoming calendar year. (a) A quorum of a simple majority (50 percent +1 member) of the Committee members (or their selected alternates) shall be required to take such action on behalf of the Committee. Supp. 12/31/

14 Chapter 560-X-64 Medicaid (b) The Committee shall approve or disapprove outcome and quality measures based on a simple majority vote of those present and eligible to vote. (c) If approved by the Committee Chair, a Committee member may participate in a meeting of the Committee by means of telephone conference, videoconference, or similar communications equipment by means of which all persons participating in the meeting may hear each other at the same time. Participation by such means shall not constitute presence in person at a meeting for all purposes, including the establishment of a quorum. (d) In the event that a Committee member is unable to participate in a Committee meeting, the Committee Chair shall, upon receipt of advance written, facsimile or request from the member explaining the reason for the member s absence, permit the alternate member selected by the Medicaid Commissioner pursuant to subsection (1)(d) of this rule to participate and/or vote in the member s place. (5) The Committee shall recommend quality measures to the Agency to include in the ICN Quality Assessment and Performance Improvement program which will be included in contractual agreement(s). (6) The Quality Assessment and Performance Improvement Plans developed by ICNs shall consult with the Committee prior to approval by the Agency. (7) Outcome and quality measures, established in accordance with this Rule, shall be used to review the care rendered through an ICN. (a) The Committee shall adopt outcome and quality measures annually and adjust the measures to reflect the following: 1. Shifts and changes in utilization that reflect rebalancing and enhancements in the delivery of services. 2. Changes in membership (ICN enrolled population) of the organization. 3. A community health assessment conducted by a state agency. Supp. 12/31/

15 Medicaid Chapter 560-X Percentage of population served in a community setting. (b) The Agency shall continuously evaluate the outcome and quality measures adopted by the Committee and make adjustments to the outcome and quality measures as necessary. (c) The Medicaid Commissioner shall, where appropriate, incorporate outcome and quality measures established by the Committee into each ICN contract to hold the organizations accountable for their performance and consumer satisfaction evaluation measures. (8) The Agency shall require each ICN to provide electronic encounter, assessment data, claims management, and all other relevant information on all applicable beneficiaries in a format approved by the Agency. Information shall include, but is not limited to: (a) Diagnosis, Setting of Care, Committee approved quality measures, hospitalization, coordination of care and outcomes. (b) Any other information, as specified by the contract between an ICN and the Agency, or data required by CMS, that is necessary for the Agency to evaluate the performance and outcomes achieved through the coordination of LTSS by an ICN. (9) The Agency shall utilize available data systems for reporting outcome and quality measures adopted by the Committee and take actions to eliminate any redundant reporting or reporting of limited value. (10) The Medicaid Agency shall publish the information collected under this section at aggregate levels that do not disclose information otherwise protected by law. The information published shall report, by ICN, all of the following: (a) (b) (c) Quality measures; Costs and financial performance; Outcomes; and, (d) And other information, as specified by the contract between an ICN and the Agency, that is necessary for Supp. 12/31/

16 Chapter 560-X-64 Medicaid the Agency to evaluate the value of health services delivered by an ICN. (11) Except as otherwise provided in rules promulgated by the Agency, the Committee shall not participate in the data validation or performance evaluation of an ICN by the Agency. (12) Each ICN shall create a provider standards committee which shall review and develop the performance standards and quality measures required of a provider by the ICN. The performance standards and quality measures shall be subject to the approval of the Committee. (13) No member of the Committee, including Ex Officio members, who has a potential conflict of interest with a particular quality measure or performance standard shall vote or participate in the Committee s review of that performance standard or quality measure. Author: Stephanie Lindsay, Administrator, Administrative Procedures Office Statutory Authority: Code of Ala. 1975, ; 42 CFR Part 438. History: New Rule: Filed December 12, 2016; effective January 26, X Solvency And Financial Requirements For Integrated Care Networks. (1) Each integrated care network (ICN), as a condition of final certification or continued final certification, and as a condition to the risk contract between the Medicaid Agency and the ICN, shall maintain minimum financial reserves and capital or surplus at the following levels: (a) Restricted reserves in an amount equal to 20 percent of the ICN's average monthly total capitation payment (as defined in section 4 of this rule); and (b) Capital or surplus, or any combination thereof, of four million dollars ($4,000,000), which shall not be satisfied by an irrevocable letter of credit provided pursuant to section 2 of this rule. Supp. 12/31/

17 Medicaid Chapter 560-X-64 (2) The Medicaid Agency may, in its sole discretion, add to, reduce, or otherwise alter, amend, adjust, or modify the minimum financial reserves and capital or surplus described in section (1) of this rule to account for the level of financial and/or other risk the ICN bears with regard to the populations to be served or the services to be provided by the ICN, or any other factor the Agency considers relevant to the financial solvency of the ICN. (3) Instead of maintaining the restricted reserves required by subsection 1(a) of this rule, an ICN may submit to the Medicaid Agency an irrevocable letter of credit in an amount equal to the aggregate restricted reserves that would otherwise be required of the ICN under subsection 1(a), to guarantee the performance of the provisions of the risk contract, satisfying the following requirements: (a) The irrevocable letter of credit shall be issued by a federally or State of Alabama chartered banking institution with assets in excess of four billion dollars ($4,000,000,000) authorized to do business in the State of Alabama and approved by the Medicaid Agency. (b) No assets of the ICN shall be pledged or otherwise encumbered in connection with the irrevocable letter of credit. (c) The irrevocable letter of credit by its terms shall be effective through the date that is 30 days after the latest date that the ICN s risk contract could expire, in accordance with its terms, including any extension periods. (d) The irrevocable letter of credit shall be approved by the Medicaid Agency as to form and content and shall be payable to the Medicaid Agency within five (5) calendar days of the Medicaid Agency's presentation of a notice to the issuing bank stating that the Medicaid Agency has determined in its sole discretion that the ICN is in breach or default under the risk contract. No proof of breach or default shall be required. (e) In addition to the foregoing and such other terms and conditions as shall be required by the Medicaid Agency, the irrevocable letter of credit shall require that the bank notify the Medicaid Agency in writing within ten business days after the occurrence of any delinquency in payment of any fee by the ICN or giving of notice of default to the ICN by the bank. The irrevocable letter of credit shall also require that the bank Supp. 12/31/

18 Chapter 560-X-64 Medicaid give the Medicaid Agency 30 calendar days advance written notice prior to termination or nonrenewal of the irrevocable letter of credit or any other material adverse action to be taken by the bank with respect to the irrevocable letter of credit. (4) Each ICN other than ICNs satisfying their restricted reserve requirements with an irrevocable letter of credit shall, using a model depository agreement provided by the Medicaid Agency, establish a restricted reserve account with a third party financial institution that is authorized to do business in the State of Alabama and is satisfactory to the Medicaid Agency for the purpose of holding the ICN s restricted reserve funds required pursuant to subsection 1(a) of this rule. (a) Restricted reserves shall be held for the exclusive purpose of making payments to providers in the event of a determination by the Medicaid Agency pursuant to Rule No. 560-X that the ICN is insolvent, is in a hazardous financial condition, or is otherwise in breach or default under the risk contract. (b) Each ICN shall provide a copy of its executed model depository agreement to the Medicaid Agency as a condition of final certification or continued final certification, and as a condition to the risk contract between the Medicaid Agency and the ICN and such model depository agreement shall remain in effect throughout the term of the risk contract, including any renewals thereof, unless and until the ICN provides an irrevocable letter of credit in compliance with section 2 of this rule. (c) The following are considered eligible deposits for the purposes of the restricted reserve requirements: 1. Cash; 2. Certificates of deposit satisfying standards approved by the Medicaid Agency; and 3. Bonds, notes, warrants, debentures, and other evidences of indebtedness which are direct obligations of the United States of America for which the full faith and credit of the United States of America is pledged for the payment of principal and interest. Supp. 12/31/

19 Medicaid Chapter 560-X-64 (5) For purposes of calculating an ICN's required restricted reserves pursuant to subsection 1(a) of this rule, average monthly total capitation payment means the mathematical average of the total capitation payment pursuant to the risk contract for each of the three months during the preceding calendar quarter. Within 30 calendar days after the end of each calendar quarter, each ICN s required restricted reserves shall be adjusted based on the average monthly total capitation payment for such preceding quarter. Until an ICN has completed a full calendar quarter of its risk contract, the ICN s projected average monthly total capitation payment shall be determined by the Medicaid Agency, based on a projection of the capitation payment to be paid to the ICN if the Medicaid Agency enters into a risk contract with the ICN. Such projected average monthly expenditures may be adjusted by the Medicaid Agency from time-to-time through the completion of the first full calendar quarter of the ICN s risk contract, based upon changes in the projected or the actual capitation payment under the risk contract. (6) For purposes of subsection 1(b) of this rule and Section of the Alabama Code, an ICN's capital and surplus is the difference between the admitted assets of the ICN and the liabilities of the ICN, determined as follows: (a) The classification and value of the ICN's assets and liabilities shall be determined in accordance with Generally Accepted Accounting Principles (GAAP) and Generally Accepted Auditing Standards (GAAS), as modified by the provisions of this section 5. (b) For purposes of this rule, "admitted assets" means only assets owned exclusively by the ICN consisting of: 1. Cash, including the true balance of deposits in solvent banks and trust companies; 2. Bonds, notes, warrants, debentures, and other evidences of indebtedness which are direct obligations of the United States of America for which the full faith and credit of the United States of America is pledged for the payment of principal and interest ("U.S. Treasury Securities"); 3. Investment grade bonds or other evidences of indebtedness other than U.S. Treasury Securities, satisfying standards approved by the Medicaid Agency; Supp. 12/31/

20 Chapter 560-X-64 Medicaid 4. Marketable equity securities, satisfying standards approved by the Medicaid Agency; 5. Due or deferred capitation payments pursuant to the risk contract between the ICN and the Medicaid Agency; 6. The acquisition cost of land and depreciated cost of improvements thereon owned by the ICN and used in connection with the performance of the risk contract, in excess of any liabilities secured by encumbrances on such assets, in an aggregate amount not greater than 50 percent of the required minimum capital and surplus of the ICN; and 7. Such other assets as may be approved by the Medicaid Agency. (c) In addition to assets not described in subsection 5(b) of this rule, an ICN's admitted assets shall not include: 1. Any single investment or asset, or any combination of investments in or secured by the securities, obligations, and/or property of one person, entity, or governmental unit, to the extent any such investment or combination of investments would exceed 20 percent of the ICN's admitted assets, provided that the foregoing restriction shall not apply to U.S. Treasury Securities or cash; or 2. Goodwill and other intangible assets. (d) In any determination of the capital and surplus of an ICN, liabilities to be charged against the ICN's admitted assets shall include, in addition to other liabilities chargeable in accordance with GAAP and GAAS: 1. The amount necessary to pay all of the ICN's unpaid losses and claims incurred on or prior to the date of the statement, together with the expenses of adjustment or settlement thereof; 2. Federal, state, and local taxes, expenses and other obligations due or accrued at the date of the statement; 3. The restricted reserves required by subsection 1(a) of this rule, if applicable; and 4. Any additional reserves for asset valuation contingencies or loss contingencies required by the Medicaid Supp. 12/31/

21 Medicaid Chapter 560-X-64 Agency pursuant to Alabama Medicaid Administrative Code Rule 560-X or otherwise required by applicable law. (7) No ICN shall reduce its combined capital and surplus, by distribution of its assets to the members, owners, or risk-bearing participants of the ICN or otherwise, below the ICN's required capital and surplus under the rules of the Medicaid Agency. (8) Each ICN shall at its expense procure and maintain, throughout the term of the risk contract between the Medicaid Agency and the ICN, professional and general liability insurance, directors' and officers' liability insurance, errors and omissions liability insurance, and, if the ICN provides Medicaid services to enrollees directly, medical malpractice insurance, in such amounts and including such coverage as set forth in the risk contract. Author: Stephanie Lindsay, Administrator, Administrative Procedures Office Statutory Authority: Code of Ala. 1975, et seq. History: New Rule: Filed June 9, 2017; effective July 24, X 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) Primary medical provider (PMP) is defined as one of the following: 1. Family Practitioner 2. Federally Qualified Health Center 3. General Practitioner 4. Internist 5. Geriatrician 6. Obstetrician or Gynecologist Supp. 12/31/

22 Chapter 560-X-64 Medicaid 7. Pediatrician 8. Rural Health Clinic (b) following: Core Specialist is defined as each of the 1. Anesthesiologist 2. Cardiologist 3. Cardiovascular Surgeon 4. Endocrinologist 5. Gastroenterologist 6. General Surgeon 7. Nephrologist 8. Neurologist 9. Oncologist 10. Ophthalmologist 11. Optometrist 12. Orthopedic surgeon 13. Psychiatrist 14. Pulmonologist 15. Rheumatologist 16. Urologist (c) Facility is defined as each of the following: 1. Hospitals as defined in Rule 560-X Over 2. Psychiatric Facilities for Individuals 65 and 3. Outpatient Mental Health Center Supp. 12/31/

23 Medicaid Chapter 560-X Nursing Facility as defined in Rule 560-X (d) Hospice Provider is defined in accordance with Rule 560-X (1) and which meets the requirements in Rule 560-X (e) Home and Community Based Service Site-Based Services Provider is defined as a provider of a 1915(c) waiver approved service to whom an enrollee must travel, in order to receive services. (f) Home and Community Based Service In-Home Services Provider is defined as a provider of a 1915(c) waiver approved service who travels to an enrollee s home, in order to provide services. (g) Non-Core Specialist is defined as any medical provider type not listed above which is needed to appropriately service the Integrated Care Network ( ICN ) enrollees and provide care delivery for all of the services and benefits covered by the ICN program. (h) Urban and Rural Counties are defined in accordance with the Code of Federal Regulations 42 C.F.R (b)(3), which defines a rural area as any county designated as micro, rural, or County with Extreme Access Considerations (CEAC) in the Medicare Advantage Health Services Delivery (HSD) Reference file for the applicable calendar year. (i) Service Delivery Network is defined as one that meets and maintains each of the following: 1. Makes available and accessible all non-excluded services that are required under the State Plan and 1915(c) waiver(s) included in the ICN program, including those Covered Services identified by rule in the Alabama Medicaid Administrative Code and in the risk contract between the Medicaid Agency and the ICN. 2. Consists of a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all enrollees of the ICN. The following factors shall be considered in determining an appropriate provider network. Supp. 12/31/

24 Chapter 560-X-64 Medicaid (i) The anticipated Medicaid enrollment in accordance with the state's standards for access to care; (ii) The expected utilization of services, taking into account the characteristics and health care needs of specific Medicaid populations represented in the particular ICN; (iii) The numbers and types of providers (in terms of training, experience, and specialization) required to furnish the contracted Medicaid services; (iv) The number of network providers who are not accepting new Medicaid patients; (v) The geographic location of providers and Medicaid enrollees, considering distance, travel time, and the means of transportation ordinarily used by Medicaid enrollees; (vi) The ability of Home and Community Based Service In-Home Services Providers to provide in-home services outside of standard business hours, defined as Monday-Friday (excluding legal holidays), from 8AM to 5PM; (vii) The ability of network providers to communicate with limited English proficient enrollees in their preferred language; (viii) The ability of network providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment for Medicaid enrollees with physical or mental disabilities; (ix) The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions; (x) The ability of network providers to provide the delivery of services in a culturally competent manner to all Medicaid enrollees in accordance with 42 C.F.R (c)(2). (xi) The ability of network providers to offer self-directed service options for enrollees who wish to self-direct eligible services, as defined by an approved 1915(j) waiver. (iii) Provides female enrollees with direct access to a women s health specialist within the network for covered care Supp. 12/31/

25 Medicaid Chapter 560-X-64 necessary to provide women s routine and preventive health care services. (iv) Provides for a second opinion from a qualified health care professional within the network, or arranges for the enrollee to obtain one outside the network, at no cost to the enrollee. (v) Meets and requires its providers to meet the following state standards for timely access to care and services, taking into account the urgency of the need for services: Supp. 12/31/

26 Chapter 560-X-64 Medicaid Appointment Availability Office Appointments Life-Threatening Emergency Care Urgent Care Routine Sick Care PMP Routine Sick Care Core Specialist Routine Well Care Behavioral Health Services Non-Life-Threatening Emergency Urgent Care Routine Visits Phone Access Appointment with behavioral health provider following a discharge from hospital Wait Times Office-based Appointments Walk-Ins Scheduled Appointment Life-Threatening Emergency Home and Community Based Services Site-Based Services In-Home Services Transportation Services Non-Emergency Transportation Services Immediate 24 hours 3 calendar days of presentation or notification excluding legal holidays 30 calendar days of presentation or notification excluding legal holidays 90 calendar days (15 calendar days if pregnant) 6 hours 48 hours 30 calendar days 24 hours 72 hours 2 hours or schedule an appointment within the standards of appointment availability 1 hour Immediate No greater than 1-hour difference between enrollee arrival and departure as scheduled and documented in the enrollee s person centered service plan. No greater than 1-hour difference between delivery of the service as scheduled and documented in the enrollee s person centered service plan. Transportation scheduled so that the enrollee arrives on time for the appointment, but no sooner than 1 hour before the appointment; and no greater than 1 hour wait after the conclusion of the appointment for transportation home; and not be picked up prior to the completion of the appointment. (vi) Establishes appropriate policies and procedures to regularly monitor providers and ensure compliance with the above listed accessibility standards. The policies and procedures shall require a correction action if there is a failure to comply. (vii) Maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet Supp. 12/31/

27 Medicaid Chapter 560-X-64 the needs of the anticipated number of enrollees. The network criteria ( Provider-Specific Network Criteria ) are as follows: Provider Type Minimum Number Distance PMPs 1.5 per 1,000 non-dual eligible enrollees, with a minimum of two Core Specialists (for each of the types identified in section (1)(b) of this rule) Facilities (for each of the types identified in section (1)(c) of this rule) excluding Nursing Facilities as defined in Rule 560-X Nursing Facilities as defined in Rule 560-X Hospice Provider as defined in Rule 560-X and which meets the requirements in Rule 560-X Home and Community Based Service Site-Based Services Provider (for the type identified in section (1)(e) of this rule) Home and Community Based Service In-Home Services Provider (for type identified in section (1)(f) of this rule) 0.2 per 1,000 non-dual eligible enrollees No requirement No requirement 50 miles from each non-dual eligible enrollee s residence 50 miles from each non-dual eligible enrollee s residence 50 miles from each enrollee s residence 25 miles from each enrollee s residence before entering the Nursing Facility who resides in an urban county, 50 miles from each enrollee s residence before entering the Nursing Facility who resides in a rural county 2 provider options per county No requirement 2 provider options per county 25 miles from each enrollee s primary community residence who resides in an urban county, 50 miles from each enrollee s primary community residence who resides in a rural county 2 provider options per county No requirement The distance requirement for each provider type listed above is limited to 30 miles from the state line border for out-of-state providers. (viii) Must have an adequate amount of Non-Core Specialists, as needed to appropriately service its enrollees and provide care delivery for all of the services and benefits covered by the ICN program. Supp. 12/31/