CurrentAlabama MedicaidPolicy 560-X-64
Integrated Care Networks (ICNs) governance, solvency, service delivery, and enrollee information requirements
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Regulatory requirements for Alabama Medicaid Integrated Care Networks covering board composition, citizens' advisory committees, financial solvency, service delivery network adequacy, and information/marketing obligations affecting ICNs and Medicaid enrollees in Alabama.
Policy Summary
PayerAlabama Medicaid
PolicyIntegrated Care Networks (ICNs) governance, solvency, service delivery, and enrollee information requirements
Policy CodePolicy 560-X-64
Change TypeNo material change
Effective DateJan 26, 2017
Last ReviewAug 27, 2018
Next Review DateN/A
Key ActionICNs must establish coordination agreements with at least 50% of Medicaid nursing facilities' licensed beds and contracts with at least 75% of Care Management Organizations (CMOs).
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
60%Board risk-bearing share
$1,000,000Min capital/surplus
50%Nursing facility bed agreements
75%C M O contracts
120 daysAudited statements due
$100,000Max penalty (willful)
ICN Coverage, Operational, and Sanctions Criteria
ICN operational and compliance criteria
Requirements and criteria ICNs must meet to be certified and operate under Alabama Medicaid.
ALL of the following
ALL of the following
- Sixty percent (60%) of board members must represent risk-bearing participants; at least half of those risk-bearing participants must be long-term health care or medical providers (Provider Members).
Provider Members must collectively contribute cash, capital, or other assets approved by the Medicaid Agency to satisfy at least fifty percent (50%) of the minimum financial reserves and capital or surplus requirements.
ALL of the following
- At least twenty percent (20%) of the non-risk-bearing members shall be appointed by long-term care and/or disability advocacy groups (examples listed in rule).
- Two members shall be appointed by the Medical Association of the State of Alabama (or successor).
- One member shall be the chair of the Citizens' Advisory Committee (CAC).
- The ICN shall adopt policies and procedures, subject to Medicaid Agency review/approval, that ensure gender, race, and geographic diversity in board composition.
ALL of the following
- Each ICN must have a CAC inclusive of and reflecting racial, gender, geographic, urban/rural, and economic diversity of the population served.
- Selection method established by the ICN must be approved by the Medicaid Agency.
- At least 20% of CAC members must be Medicaid beneficiaries enrolled in the ICN or the beneficiary's sponsor; the ICN is responsible for obtaining necessary approvals, consents, or waivers and complying with privacy/confidentiality laws before sharing beneficiary information with the Agency.
- CAC must include representatives from specified advocacy organizations and non-at-risk providers serving Medicaid beneficiaries through the ICN, must elect a chair, and must meet at least every three months.
- Remote participation option: Members may participate and/or vote by telephone, videoconference, or similar equipment if (a) all participants can hear each other simultaneously, (b) necessary equipment is readily available to all committee members, and (c) the meeting has a physical location where members may attend in person.
ALL of the following
- Maintain minimum capital, surplus, or combination thereof of $1,000,000 unless adjusted by the Medicaid Agency.
- Medicaid Agency may adjust the minimum capital or surplus based on level of financial or other risk the ICN bears or other relevant factors.
- Capital and surplus is defined as admitted assets minus liabilities, determined per GAAP/GAAS as modified by the rule; admitted assets are limited to assets owned exclusively by the ICN (examples include cash, U.S. Treasury securities, Agency-approved investment grade bonds, and marketable equity securities).
ALL of the following
- Prior to program implementation and thereafter maintain adequate amount and geographic distribution of Nursing Facilities and Care Management Organizations (CMOs) to appropriately service enrollees and provide choice and timely care transitions.
- Coordination agreements with at least fifty percent (50%) of the Medicaid Nursing Facilities' total licensed beds in the State.
- Contracts with at least seventy-five percent (75%) of the CMOs in the State.
- Establish agreements with Alabama Department of Mental Health (ADMH) to collaborate on needs of enrollees with mental illness and substance abuse disorders.
- Establish agreements with Alabama Department of Human Resources (ADHR) to assist with prevention, reporting, and investigation activities of Adult Protection Services.
- Establish agreements with Alabama Department of Senior Services (ADSS) to maintain an adequate network for HCBS Waiver Case Management activities.
ALL of the following
- ICN is responsible for developing outreach and educational materials (prevention, disease management, healthy lifestyles, non-emergency transportation) which must be approved by the Medicaid Agency prior to use.
- All written materials critical to obtaining services (provider directories, enrollee handbooks, appeal/grievance notices, denial/termination notices) must be in English and all Prevalent non-English languages in the ICN's service area and be readily accessible; auxiliary aids/services must be provided at no cost upon request.
- Agency will mail an information packet to new enrollees within fifteen (15) calendar days of enrollment, including confirmation of enrollment and an enrollee handbook; enrollees may elect electronic delivery with procedures and timelines specified in the rule (ICN must contact enrollee within five business days to determine preference and mail written confirmation within fifteen calendar days).
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ICN Covered Services
Services the ICN must cover for enrolled Medicaid recipients:
ALL of the following
- Direct Home and Community-Based Service Case Management for the Alabama Community Transition (ACT) Waiver in accordance with Rule 560-X-44-.04.
- Direct Home and Community-Based Service Case Management for the Elderly and Disabled in accordance with Rule 560-X-36-.04.
ALL of the following
- ONE OR MORE of: Provision of intensive telephonic or face-to-face case management, including operation of a nurse triage advice line.
- Development of enrollee care plans.
- Execution of contracts with and/or oversight responsibilities for the activities of FFS providers in the FFS program.
- Provision of payments to FFS providers on behalf of the State.
- Provision of enrollee outreach and education activities.
- Operation of a customer service call center.
- Review of provider claims, utilization and practice patterns to conduct provider profiling and/or practice improvement.
- Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers.
- Coordination with behavioral health systems/providers.
- Coordination with long-term services and supports systems/providers.
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Sanctions and readiness assessment criteria
Conditions, actions, and procedural requirements related to sanctions and readiness:
SANCTION BASES
- Fails substantially to provide medically necessary services required by law or the risk contract.
- Imposes premiums or charges on enrollees in excess of amounts permitted under the Alabama Medicaid program.
- Discriminates among enrollees on the basis of health status or need for health care services (including impermissible termination or refusal to reenroll).
- Misrepresents or falsifies information furnished to the Medicaid Agency, CMS, enrollees, potential enrollees, or health care providers.
- Distributes marketing materials not approved in writing by the Medicaid Agency or that contain false or materially misleading information.
SANCTION TYPES / AGENCY ACTIONS
- Require development and implementation of a corrective action plan acceptable to the Medicaid Agency.
- Impose intermediate sanctions described in statute and regulation, including civil monetary penalties up to amounts set forth in 42 C.F.R. § 438.704.
- Grant enrollees the right to disenroll without cause (Agency may notify affected enrollees).
- Suspend all new enrollment, including auto-assignment, after notification of a determination of violation of Sections 1932 or 1905(t).
- Suspend payment for enrollees enrolled after the effective date of the sanction until CMS or the Agency is satisfied the reason no longer exists and is unlikely to recur.
- For acts or omissions not addressed by 42 C.F.R. Part 438 Subpart I or the risk contract, impose monetary penalties up to $100,000 per act or omission for willful, gross, or fraudulent misconduct; impose other sanctions available under federal or state law, including termination of the risk contract and other remedies specified in the rule (examples and per-determination caps described).
ALL of the following
- Before imposing a sanction the Agency will give timely written notice explaining the basis and nature of the sanction, the right to request a fair hearing if applicable, and any other due process protections the Agency elects to provide.
- The amount of a civil monetary penalty 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 (applies only to sanctions appealable under Rule No. 560-X-64-.15).
- Before terminating the contract as a sanction, the Agency will provide a pre-termination hearing in accordance with fair hearing procedures and will provide written notice of intent to terminate and the hearing details; after the hearing the Agency will provide written notice of its decision and, if affirmed, the effective date of termination.
ALL of the following
- ICNs are subject to a readiness assessment period and must demonstrate readiness to the Medicaid Agency's satisfaction before beginning to provide services under the contract.
- The Medicaid Agency will provide a readiness assessment tool and will conduct desk and onsite reviews of information submitted by the ICN; the Agency may require additional documentation or updates during the readiness period.
- The ICN must provide timely, convenient, and free access during reasonable business hours to all books, records, accounts, papers, documents, and electronic recordings related to the readiness assessment, and make private office space available to the Agency for onsite review at no cost.
- Only after demonstrating readiness in the Medicaid Agency's sole discretion may an ICN begin providing services pursuant to its contract.
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Codes, Financial Thresholds, and Penalty References
ICN covered servicesmixedCovered
| Direct Home and Community-Based Service Case Management for the Alabama Community Transition (ACT) Waiver (ref Rule 560-X-44-.04) | |
| Direct Home and Community-Based Service Case Management for the Elderly and Disabled (ref Rule 560-X-36-.04) | |
| Primary care case management services including location, coordination, and monitoring of primary health care services, and one or more specified functions such as: intensive telephonic or face-to-face case management (nurse triage advice line); development of enrollee care plans; contracts/oversight of FFS providers; payments to FFS providers on behalf of the State; enrollee outreach and education; customer service call center; review of provider claims/utilization for profiling and practice improvement; quality improvement activities including enrollee satisfaction surveys and performance measurement data collection; coordination with behavioral health systems/providers; and coordination with long-term services and supports systems/providers. |
Regulatory references for monetary penaltiesmixed
| 42 C.F.R. § 438.704 | Reference for maximum civil monetary penalties and intermediate sanctions |
| Monetary penalty up to $100,000 per act or omission for willful, gross, or fraudulent misconduct (per Rule No. 560-X-64-.18(f)) | |
| Specified intermediate sanctions examples with caps (e.g., up to $25,000 for certain determinations; up to $5,000 for first quarter claims performance deficiency; up to $25,000 per additional quarter; up to $100,000 for certain determinations) |
inv-06: Minimum capital/surplus
Minimum capital/surplus requiredMaintain minimum capital, surplus, or any combination thereof of $1,000,000 unless otherwise specified by the Medicaid Agency
Agency adjustment authorityMedicaid Agency may add to, reduce, or modify the minimum capital or surplus based on financial risk or other relevant factors
Definition of capital and surplusCapital and surplus equals admitted assets minus liabilities, determined per GAAP and GAAS as modified by the rule
Admitted assets — examplesIncludes cash, U.S. Treasury securities, investment-grade bonds (Agency-approved), and marketable equity securities (Agency-approved)
Admitted assets valuationClassification and value of assets and liabilities determined in accordance with GAAP and GAAS as modified by this rule
inv-07: Monetary penalty cap (willful/gross/fraudulent)
Maximum monetary penalty (willful/gross/fraudulent misconduct)Assessment of a monetary penalty up to $100,000 per act or omission
Other sanction authoritiesAgency may impose any other sanction available under federal or state law, including termination of the risk contract
Examples of specified sanctions and capsCertain violations may carry specified caps (e.g., up to $25,000 for specific determinations or per quarter as described in the rule)
Provider Obligations, Network Adequacy, Marketing, and Financial Reporting
Billing Rule
Service delivery network adequacy — contracts and coordination agreements
Establish and maintain coordination agreements and contracts to demonstrate network adequacy prior to program implementation and thereafter. Specifically, ICNs must have coordination agreements with at least fifty percent (50%) of the Medicaid nursing facilities' total licensed beds in the State and contracts with at least seventy-five percent (75%) of the Care Management Organizations (CMOs) in the State. ICNs must also establish agreements with ADMH, ADHR, and ADSS to collaborate on mental health/substance abuse, adult protection, and HCBS waiver case management activities.
- Coordination agreements with ≥50% of Medicaid Nursing Facilities' total licensed beds in the State
- Contracts with ≥75% of CMOs in the State
- Agreements with Alabama Department of Mental Health (ADMH) for mental health/substance abuse collaboration
- Agreements with Alabama Department of Human Resources (ADHR) for adult protection collaboration
- Agreements with Alabama Department of Senior Services (ADSS) for HCBS Waiver Case Management network adequacy
Documentation Required
Marketing restrictions — approval and prohibited practices
Do not directly market to individual Medicaid recipients or Potential Enrollees except as allowed by this rule; obtain Medicaid Agency approval for all marketing materials before use and distribute approved materials statewide. The ICN is prohibited from door-to-door, telephone, email, texting or other cold-call marketing and from marketing in prohibited clinical areas; marketing must comply with 42 C.F.R. §§ 438.10 and 438.104 and section 1557 of the ACA.
- Prohibited direct marketing methods include door-to-door, telephone, email, texting, cold-calls
- Marketing materials must receive Agency approval prior to use
- Distribution of approved materials must be statewide
- Marketing activities prohibited in waiting rooms, exam rooms, hospital patient rooms, dialysis treatment areas, and other areas where enrollees receive care
- May not assert enrollee must enroll to obtain or retain benefits or claim endorsement by CMS or government
Documentation Required
Financial reporting, notice of hazardous condition, and audits
Provide periodic financial reports as required by the Medicaid Agency, promptly notify the Agency of any change that could result in a hazardous financial condition or insolvency, and have the independent CPA deliver the annual audited financial statements directly to the Medicaid Agency no later than 120 calendar days after fiscal year end.
- Submit periodic financial reports on capital, surplus, and other information in the form/frequency prescribed by the Agency
- Report changes that could result in hazardous financial condition or insolvency promptly and describe corrective plan
- Independent CPA must deliver annual audited financial statements directly to the Medicaid Agency within 120 calendar days of fiscal year end
- Maintain books/records available for Agency inspection and audits; Agency (and federal auditors/OIG/Comptroller General) may audit and inspect records and premises
- Audit right extends for ten (10) years from final contract term or completion of any audit
Prior Authorization
Enrollment suspension risk following certain violations
Be aware that the Medicaid Agency may suspend all new enrollment, including auto-assignment, after notification of a determination of a violation of Sections 1932 or 1905(t) of the Social Security Act.
- Suspension of all new enrollment (including auto-assignment) may be imposed following notification of a determination of violation under Sections 1932 or 1905(t)
Billing Rule
Payment suspension during sanctions
Recognize that the Medicaid Agency may suspend payment for enrollees enrolled after the effective date of a sanction until CMS or the Agency is satisfied the reason for the sanction no longer exists and is unlikely to recur.
- Payment suspension applies to enrollees enrolled after the effective date of the sanction
- Payments may be withheld until Agency or CMS determines the issue is resolved and unlikely to recur
Definitions and Policy Terms
inv-13: Care Management Organization (CMO) definition
Definition of CMOCare Management Organization (CMO) is an organization providing case management for the 1915(c) waivers enrolled in the ICN program (e.g., AAAs and other agencies currently providing HCBS Case Management)
Role in network adequacyICN must contract with at least 75% of the CMOs in the State to satisfy service delivery network requirements
Relation to HCBS waiversCMOs provide case management services for ACT and Elderly & Disabled waivers enrolled in the ICN program
inv-14: Enrollee definition
Enrollee definitionAn Enrollee means a Medicaid beneficiary enrolled as a member of an Integrated Care Network (ICN)
Related term — Potential EnrolleePotential Enrollee means a Medicaid beneficiary subject to mandatory enrollment in an ICN or who may voluntarily be required to enroll
Materials and notices relevanceEnrollee status determines entitlement to ICN-issued materials such as handbooks, directories, and notices in English and Prevalent languages
inv-15: Prevalent languages list
Prevalent languages listSpanish (or Spanish Creole), Korean, Chinese, Vietnamese, Arabic, German, French, Gujarati, Tagalog, Hindi, Laotian, Russian, Portuguese, Turkish, and Japanese
LEP definitionLimited English Proficient (LEP) individuals do not speak English as primary language and have limited ability to read, write, speak, or understand English
Material availability requirementAll written materials critical to obtaining services must be available in English and all Prevalent Non-English Languages in the ICN's service area
inv-16: Readily Accessible (accessibility standards)
Readily Accessible definitionElectronic information and services that comply with modern accessibility standards such as Section 508, Section 504 of the Rehabilitation Act, and WCAG 2.0 AA (and successor versions)
Application to materialsICN materials and electronic services must meet these accessibility standards to be considered readily accessible
Auxiliary aidsAuxiliary aids and services must be made available at no cost to Enrollees or Potential Enrollees upon request
inv-17: ICN Covered Population
ICN covered population — nursing facility criteriaIndividuals meeting current admission criteria for nursing facility care and receiving nursing facility services as defined in applicable Alabama Medicaid rules
ICN covered population — ACT WaiverIndividuals meeting eligibility criteria for the Alabama Community Transition (ACT) Waiver
ICN covered population — Elderly & Disabled WaiverIndividuals meeting eligibility criteria for the Home and Community-Based Services for the Elderly and Disabled Waiver
Excluded groupsAll Medicaid beneficiaries not expressly included will continue to be served by Medicaid fee-for-service outside the ICN
inv-18: Conflict of Interest policy requirements
Disclosure requirementsDirectors and officers must disclose in writing all employments, associations, commitments and financial interests from the preceding two years and those reasonably expected to arise
Procedures to determine/address conflictsPolicy must provide a procedure satisfactory to the Medicaid Agency to determine actual or potential conflicts and a process to address them
Enforcement and recordsBoard is responsible for enforcement and must maintain minutes, disclosures, and related documents subject to Medicaid Agency review
Statutory disclosuresAn ICN and each director/officer must submit the Disclosure Statement required by Act 2001-955 prior to contracting with the Medicaid Agency
inv-19: Bases for Imposition of Sanctions
Primary bases for sanctionsFailure to provide medically necessary services, imposing unauthorized premiums/charges, discrimination among enrollees, misrepresentation or falsification to Agency/CMS/enrollees/providers, and distribution of unapproved or misleading marketing materials
Monetary penalties and intermediate sanctionsAgency may impose intermediate sanctions including civil monetary penalties per 42 C.F.R.; rule specifies caps for certain determinations and up to $100,000 per act for willful/gross/fraudulent misconduct
Procedural protectionsAgency will provide written notice explaining basis of sanction and right to request a fair hearing; 35% reduction in penalty if ICN waives hearing within 30 days
Other remediesAgency may require corrective action plans, suspend enrollment or payments, or terminate the risk contract consistent with contract terms
inv-20: Readiness assessment
Readiness assessment requirementICN must undergo a readiness assessment period and demonstrate readiness to the Medicaid Agency before beginning to provide services
Assessment methodsMedicaid Agency will use a readiness assessment tool and conduct desk and onsite reviews of submitted information
Documentation and accessICN must submit all requested documentation, provide timely access to books, records, and make private office space available for onsite reviews
Agency discretion to request moreMedicaid Agency may require additional documentation or updates throughout the readiness assessment period
Policy Summary
PayerAlabama Medicaid
PolicyIntegrated Care Networks (ICNs) governance, solvency, service delivery, and enrollee information requirements
Policy CodePolicy 560-X-64
Change TypeNo material change
Effective DateJan 26, 2017
Last ReviewAug 27, 2018
Next Review DateN/A
Key ActionICNs must establish coordination agreements with at least 50% of Medicaid nursing facilities' licensed beds and contracts with at least 75% of Care Management Organizations (CMOs).
SourceLink
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