CurrentAlabama MedicaidPolicy N/A

Chapter Thirty-Seven — Managed Care

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Sets rules and requirements for managed care systems (including HMOs, PIHPs, PCCM) operated under Alabama Medicaid, governing plan design, provider responsibilities, quality assurance, enrollment/disenrollment, grievances, and compliance with federal and state laws.

Policy Summary

PayerAlabama Medicaid

PolicyChapter Thirty-Seven — Managed Care (Rules governing HMOs, PIHPs, PCCM, ACHN, sanctions, attribution, and payments)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Last ReviewMar 31, 2025

Next Review DateN/A

Key ActionPIHPs must operate a quality assurance program, appoint a QA committee, employ staff to obtain and analyze data, and provide records for Medicaid audits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12+rule subsections

7ACHN regions

1PIHP audits/yr

$100/dayfinancial penalty

35%sanction reduction

Coverage, Enrollment, Attribution, and Payment Rules

General Compliance and Model Use

Managed care systems must meet State Plan, CFR, and applicable federal/state legal requirements; Medicaid may use multiple plan models and must obtain CMS approvals where required.

Comply with the Alabama Medicaid State Plan and any CMS-approved waivers, award letters, or directives before operation.

Include any provisions required by state or federal laws or regulations and be approved by CMS in accordance with 42 C.F.R. § 438.3(a).

Comply with the information requirements of 42 C.F.R. § 438.10 and meet obligations under 42 C.F.R. Subpart B; Medicaid Agency must maintain policies/procedures to ensure compliance and employees must follow state ethics laws.

Permitted managed care models (one or more of):

Health Maintenance Organizations (HMO)
Managed Care Organizations (MCO)
Prepaid Ambulatory Health Plans (PAHP)
Prepaid Inpatient Health Plans (PIHP)
Primary Care Case Management systems (PCCM) or PCCM entities

Medicaid Agency retains flexibility to design area-specific plans (voluntary or mandatory) consistent with local needs; required federal approvals must be obtained by Medicaid prior to implementation.

HMO Enrollment/Disenrollment

Rules governing HMO enrollment and disenrollment, including mandatory assignment under waivers and procedural requirements for voluntary/involuntary disenrollment.

HMOs must obtain Certificate of Authority from Alabama Department of Insurance and, when applicable, Certificate of Need or letter of non-reviewability before providing services.

HMOs must submit written documentation for approval including description of services, marketing plan and materials, QA plan, enrollment plan, education plan, COA, CON or non-reviewability letter, examples of subcontracts, and proposed enrollment sites.

In areas served by a freedom-of-choice waiver, enrollment in an approved HMO is mandatory for recipients included in the waiver; recipients in waiver areas may voluntarily enroll during open enrollment if applicable.

If a recipient in a waiver area does not select an HMO, Medicaid will mandatorily assign the recipient to an HMO and notify both the HMO and recipient; effective date is generally first day of month following a full calendar month after assignment.

HMOs must send monthly to Medicaid, on computer compatible media, current enrollees, new enrollees and disenrollments, and must ensure contracted services are available and coordinated through Medicaid-enrolled PCPs.

Disenrollment is effective the first day of the month following a full calendar month after receipt of the written disenrollment request; enrollees must submit written disenrollment request to the HMO with reason documented in the patient file and on monthly enrollment information.

Involuntary disenrollment may occur when: (one or more apply)

Enrollee becomes ineligible for Medicaid, is deceased, moves out of service area, or is changed to a non-covered aid category (effective first day of month following documentation).
Enrollee's disruptive, abusive, or unruly behavior (not caused by medical condition) that seriously impairs the HMO's ability to furnish services — HMO must provide at least one verbal and one written warning and obtain prior written approval from Medicaid before involuntary disenrollment.
Enrollee knowingly commits fraud or permits abuse of Medicaid card — must be promptly reported to Medicaid and prior authorized by Medicaid.

Unacceptable reasons for HMO to disenroll an enrollee include pre-existing medical conditions, changes in health status, and periodic missed appointments.

PIHP QA Requirements

PIHPs must operate an Agency-approved quality assurance program and support Medicaid audits and reviews.

PIHPs and Medicaid shall operate a quality assurance (QA) program sufficient to meet quality review requirements of 42 C.F.R. Part 438, Subpart D; the QA Program and any revisions must be approved in writing by Medicaid.

The PIHP shall appoint a QA Committee of at least three health care professionals to implement and supervise the QA Program; the QA Program must be written and specify utilization control, review procedures, data collection, interpretation, and procedures for making changes.

The QA Committee shall employ professional staff to obtain and analyze data from Medicaid information systems, provider hospitals, and other sources; all QA program costs are the PIHP's responsibility.

PIHP member hospitals must conduct continuing internal QA reviews and provide assistance and information to the PIHP QA Committee and staff as necessary.

The PIHP staff shall implement focused medical reviews as required; Medicaid staff shall coordinate with PIHP QA Committee on QA matters, perform audits and surveys as needed, including at least one annual medical audit on each PIHP and all its providers, and PIHP shall provide all information and records reasonably required for audits.

Coverage stance for HMOs and Medicare HMOs/CMPs

Coverage and payment stance for services provided through HMOs and for Medicare HMOs/CMPs.

HMOs shall accept capitation fees as payment in full for Medicaid benefits and must require their providers to accept those payments as payment in full.

Capitation payments to HMOs for all eligible enrollees shall be made monthly.

In-plan covered services must be provided by the enrollee's chosen HMO and may be provided directly, through subcontract providers, or by non-contract out-of-plan providers when appropriately referred.

If an enrollee uses a non-contract provider for an in-plan service (except emergency services, family planning, and services by an FQHC), the HMO may not be liable for the cost unless it referred or authorized the service; payments by HMOs to non-contract providers for properly documented claims shall not exceed applicable maximum fee-for-service rates unless otherwise agreed.

No reimbursement shall be available directly from Medicaid for in-plan services provided by non-contract providers unless agreed otherwise.

For Medicare HMOs and CMPs: all services covered by Medicare shall be covered by the Medicare HMO or CMP at no cost to the beneficiary; Medicare HMOs/CMPs may offer additional services but must notify Alabama Medicaid prior to adding additional services identified by procedure code.

Medicare HMOs/CMPs may enroll with Medicaid to receive a fixed PMPM capitated payment to cover premiums and cost sharing and must submit required materials (HCFA approval, member handbook, COA) and a monthly electronic enrollment listing in a format specified by Medicaid.

Attribution and Reconsideration

Attribution rules for ACHN PCP Groups and the reconsideration process for disputed attributions.

Medicaid will perform quarterly attribution for each recipient under ACHN based on historical visitation practices and prescription history; a recipient must have been ACHN-eligible for 3 of the previous 24 months to be attributed.

Medicaid will review the prior two-year doctor visit history (preventive and regular visits) and prior 12-month filled prescriptions for chronic conditions; preventive and recent visits score higher; visits with PCPs score higher than specialist visits; prescriptions count when >1 and correspond to an office visit within previous two years.

Point values are assigned to individual provider visits and prescriptions; individual PCP scores are combined to form the PCP Group total; the PCP Group with the highest points is attributed the recipient; if a specialist group has the highest points it may be attributed but is not eligible for PCP bonus payments.

A PCP Group may request the attribution calculation or request reconsideration in writing within seven (7) business days of the quarterly attribution notification; the request must include the attribution period, the recipient(s) believed misattributed, and supporting documentation demonstrating material impact.

The currently attributed PCP Group will be notified and may submit information within three (3) business days; Medicaid will review relevant information and complete adjustments within seven (7) business days of receipt of the reconsideration request.

Participation and Payment Criteria

Participation requirements and payment eligibility for PCP Groups and Maternity Care Providers (MCPs) working with ACHNs, and rules for performance-related bonus payments.

PCP Groups must sign a PCP Group Agreement with Alabama Medicaid and an agreement with an ACHN; over a 12-month period they must attend at least three (3) Medical Management Meetings (in person or virtual) with the ACHN's Medical Director; attendance may be satisfied by one PCP or NP/PA from the group.

PCP Groups must engage in ACHN quality initiatives, review ACHN-provided data to achieve Medicaid and ACHN quality goals, and participate in ACHN multidisciplinary care teams and individualized care plan development as appropriate.

ACHNs and Alabama Medicaid will monitor participation monthly; failure to meet participation requirements may result in termination of the PCP Group Agreement and loss of ACHN participation.

PCP Groups participating with an ACHN are eligible for ACHN Participation Rates for 13 E&M codes (see State Plan Attachment 4.19-B) and for performance bonus payments; certain provider types (FQHCs, RHCs, OB/GYNs and nurse midwives, nursing facilities) are not eligible for ACHN Participation Rates.

Performance payment pool allocation: 50% quality, 45% cost effectiveness, and 5% PCMH Recognition. Quality bonus payments are distributed quarterly based on attributed recipients; cost effectiveness bonuses are based on an efficiency score comparing actual 12-month PMPM to risk-adjusted expected PMPM (groups with score <1.0000 eligible); PCMH bonuses require recognized PCMH certification/attestation.

Quality payment timing: for Oct 1, 2024–Mar 31, 2026 payments are distributed based on prior quarterly attributed recipients; beginning April 2026, quarterly payments are based on actual performance over the prior 12 months with a 9-month time lag.

MCPs must sign a Maternity Care Provider Group Agreement with an ACHN, provide data, engage in development of care plans, and participate in MCP selection/referral processes; participation monitored monthly and failure may end contract and referral eligibility.

MCPs participating with the ACHN are eligible for bonus payments for initial prenatal visits in the first trimester and/or post-partum visits.

Regulatory References and Code Lists

Regulatory referencesmixed

No codes listed

Medicare vs Medicaid coverage notesmixed

No codes listed

ACHN Participation E&M Codesmixed

State Plan Attachment 4.19-B, page 2c.1

List of 13 E&M codes eligible for ACHN Participation Rate

Financial report submission deadlines

Quarterly financial reportsDue within 45 days of the period end (quarterly).

Annual financial reportAnnual report due by March 1 of the following year.

Audited financial statementAudited financial statement due within 90 days of the fiscal year end.

Cost Effectiveness Score Threshold

Cost effectiveness eligibility thresholdParticipating PCP groups with a cost effectiveness score of less than 1.0000 are eligible for cost effectiveness bonus payments.

Comparison basisScore compares a 12‑month PMPM actual to a risk‑adjusted expected PMPM based on similar PCP groups.

Calculation timingCalculation occurs as soon as the previous calendar year's performance has been calculated; payments distributed based on attributed recipients for the prior quarterly period.

Provider Responsibilities, Reporting, Sanctions, and Hearings

Documentation Required

Operate and Staff a Medicaid‑Approved PIHP QA Program

PIHPs must operate a written Quality Assurance (QA) Program meeting 42 C.F.R. Part 438, Subpart D, and obtain Medicaid approval for the program and any revisions; appoint a QA Committee of at least three health care professionals; employ professional QA staff to obtain and analyze data from Medicaid information systems, provider hospitals, and other sources; conduct focused medical reviews as required; cooperate with Medicaid audits and on-site reviews; and provide all requested information and medical records to Medicaid for at least one annual medical audit of the PIHP and its providers.

QA Program must be approved in writing by Medicaid.
QA Committee: minimum three health care professionals.
QA staff must obtain/analyze data from Medicaid systems and providers and implement focused medical reviews.
PIHP must provide all information, medical records, and assistance for Medicaid audits; Medicaid will perform at least one annual medical audit and periodic on-site visits.

Prior Authorization

Maintain Medicaid‑Approved Grievance Procedures and Submit Marketing Plans

HMOs must maintain a written internal grievance procedure approved by Medicaid, keep grievance logs, and submit marketing plans, procedures, and materials to Medicaid for approval prior to implementation.

Grievance procedure must be approved by Medicaid.
HMOs must ensure disenrollees wishing to file grievances are afforded notice and opportunity to do so and maintain grievance documentation in enrollee records.
Submit written marketing plan, procedures, and materials to Medicaid for approval before beginning enrollment or marketing; marketing practices (mailings, gifts, telemarketing, door‑to‑door) are subject to prior approval.
No more than 50% of a marketing representative's annual compensation may be from commissions.

Billing Rule

Accept Monthly Capitation as Payment in Full

Capitation payments to the HMO for all eligible enrollees are made monthly; the HMO shall accept capitation fees as payment in full for Medicaid benefits and require its providers to accept those payments as full payment.

Capitation payments are payable monthly to the HMO.
HMO must accept capitation as payment in full and require providers to accept payments in full for Medicaid benefits.
Neither enrollees nor Medicaid are liable for HMO debts in the event of insolvency.

Documentation Required

Submit Monthly Electronic Enrollment Listings and Notify Before Adding Services

Medicare HMOs and CMPs must submit a monthly electronic enrollment listing to Medicaid in the format specified by Medicaid, and must notify Alabama Medicaid before adding additional services (identified by procedure code) to the Plan.

Submit monthly electronic enrollment listing to Medicaid in the format specified by Medicaid.
Notify Alabama Medicaid prior to adding additional services identified by procedure code.

Denial Risk

Waive or Timely File for Fair Hearing to Preserve Sanction Reduction or Appeal

An Entity may waive its right to a fair hearing in writing within 30 calendar days of a sanction notice to receive a 35% reduction of a monetary sanction; alternatively, the Entity must file a written request for a fair hearing within 30 calendar days of the sanction notice to preserve appeal rights.

Waiver of fair hearing must be in writing and filed within 30 calendar days to obtain 35% reduction of the monetary sanction.
If appealing, written fair hearing request must be filed with Medicaid within 30 calendar days of the sanction notice and include factual/legal basis and requested relief.

Documentation Required

Request Informal Conference and Proceed to Fair Hearing if Unresolved

If an informal conference does not resolve a sanction dispute, the Entity may request a fair hearing before an impartial hearing officer at the Medicaid Agency's central office in Montgomery; the Entity may be represented by counsel, call and examine witnesses, and will receive written notice of the hearing at least 10 calendar days prior.

Entity may request an informal conference when filing a written fair hearing request.
If unresolved, fair hearing conducted before an impartial hearing officer under the Alabama Administrative Procedure Act; hearing authority is the Commissioner who appoints hearing officers.
Written notice of date/time/place sent by certified mail (and possibly email/fax) at least 10 calendar days before the hearing.
Entity may be represented by counsel and may call and examine witnesses; findings/recommendations submitted to Commissioner and final decision issued within 30 days of recommendation.

Denial Risk

Provide Written Notice and Hold Pre‑termination Hearing Before Contract Termination

Before terminating a contract as a sanction, Medicaid will provide a pre‑termination hearing: the Agency must give the Entity written notice of intent to terminate, the reasons, and the time and place of the hearing, and conduct the pre‑termination hearing in accordance with the fair hearing procedures described in the rule.

Agency must give written notice of intent to terminate the contract, the reason(s) for termination, and the time and place of the pre‑termination hearing.
Pre‑termination hearing conducted in accordance with the fair hearing procedures set forth in the rule and 42 C.F.R. § 438.708/438.710.

Key Term Definitions

Primary Care Case Management (PCCM)

Model definitionPCCM assigns each Medicaid recipient to a primary care provider (PCP) responsible for managing the recipient's health care needs; this management neither reduces nor expands covered services.

Services includedPCCM services include case management functions: location, coordination, and monitoring of primary health care services under contract between Medicaid and the PCP or PCP group.

Participation scopePCCM may be offered as a mandatory state option under the Medicaid state plan, except for dually eligible beneficiaries, American Indians/Alaska Natives, and children with special health care needs.

Prepaid Inpatient Health Plan (PIHP)

DefinitionA Prepaid Inpatient Health Plan (PIHP) provides services to enrolled recipients on a capitated basis but does not qualify as an HMO.

Scope of servicesPIHPs may be comprehensive or non‑comprehensive; responsibilities include assisting participants in accessing care, monitoring inpatient conditions, and locating, coordinating, and monitoring all inpatient care in acute care hospitals within the state.

Required systemsPIHPs must maintain systems including, at minimum, quality assurance and utilization review systems and other operational systems to manage inpatient services.

Health Maintenance Organization (HMO)

DefinitionAn HMO is an entity that provides or arranges basic health care services through an organized system combining delivery and financing, providing physician services directly or via contract, and reimbursed on a monthly capitation basis.

Operational requirementsHMOs must obtain a Certificate of Authority from the Department of Insurance and may be required to obtain a Certificate of Need or letter of non‑reviewability prior to providing services.

Payment postureCovered services are reimbursed on a monthly capitation basis; HMOs must accept capitation fees as payment in full and require providers to accept those payments as full payment.

Competitive Medical Plan (CMP)

DefinitionA Competitive Medical Plan (CMP) is a legal entity that provides physician, laboratory, x‑ray, emergency, preventive, out‑of‑area coverage, and inpatient hospital services and receives Medicaid compensation on a prepaid capitation basis.

Financial riskThe CMP assumes full financial risk prospectively for provision of health care services and must meet fiscal solvency requirements per applicable CFR provisions.

HCFA/Medicare roleCMPs may contract with HCFA to enroll Medicare beneficiaries and must meet qualifying criteria specified in federal regulations to do so.

Medicare Health Maintenance Organization (MHMO)

DefinitionA Medicare Health Maintenance Organization (MHMO) is an organization that may contract with HCFA to enroll Medicare beneficiaries and deliver a comprehensive range of services and must meet HCFA qualifying criteria.

Organization and servicesAn MHMO must be organized under state law, provide a comprehensive range of high‑quality services to Medicare enrollees efficiently and economically, and meet federal qualifying criteria (42 C.F.R. sections referenced).

Solvency requirementsMHMO must provide adequate protections against insolvency by meeting specified fiscal and administrative federal requirements.

Attribution (ACHN)

Process overviewAttribution is the process used under the ACHN Program to associate a Medicaid recipient to the PCP Group that provides primary care, based on historical visitation practices.

Look‑back and data sourcesThe Agency reviews the previous 2‑year history of doctor visit utilization (preventive and regular visits) and prior 12‑month prescription history for chronic conditions; points are assigned to visits and prescriptions to score providers/groups.

Reconsideration timingPCP Groups may request an attribution calculation or reconsideration in writing within 7 business days of quarterly attribution notification; attributed PCP Groups may submit documentation within 3 business days; Agency completes adjustments within 7 business days of receipt.

Primary Care Physician (PCP) definition

PCP specialties includedPCP is defined by specialty to include Family Practice, Pediatricians, Internists, General Practitioners, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Nurse Practitioners/Physician Assistants within a PCP Group.

Nontraditional PCPsWhen in the patient's best interest (e.g., children with special health care needs), a nontraditional PCP specialty may be considered for PCP assignment if willing to meet contractual requirements.

Assignment optionsPatients may be assigned to an individual physician or to a group of physicians if approved by the Medical Director.

Policy Summary

PayerAlabama Medicaid

PolicyChapter Thirty-Seven — Managed Care (Rules governing HMOs, PIHPs, PCCM, ACHN, sanctions, attribution, and payments)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Last ReviewMar 31, 2025

Next Review DateN/A

Key ActionPIHPs must operate a quality assurance program, appoint a QA committee, employ staff to obtain and analyze data, and provide records for Medicaid audits.

SourceLink

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Chapter Thirty-Seven — Managed Care

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Sign up for all Alabama Medicaid policy alerts

Know when Alabama Medicaid releases new policies or updates existing guidance.

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Coverage, Enrollment, Attribution, and Payment Rules

General Compliance and Model Use

Managed care systems must meet State Plan, CFR, and applicable federal/state legal requirements; Medicaid may use multiple plan models and must obtain CMS approvals where required.

Comply with the Alabama Medicaid State Plan and any CMS-approved waivers, award letters, or directives before operation.

Include any provisions required by state or federal laws or regulations and be approved by CMS in accordance with 42 C.F.R. § 438.3(a).

Permitted managed care models (one or more of):

Health Maintenance Organizations (HMO)
Managed Care Organizations (MCO)
Prepaid Ambulatory Health Plans (PAHP)
Prepaid Inpatient Health Plans (PIHP)
Primary Care Case Management systems (PCCM) or PCCM entities

HMO Enrollment/Disenrollment

Rules governing HMO enrollment and disenrollment, including mandatory assignment under waivers and procedural requirements for voluntary/involuntary disenrollment.

HMOs must obtain Certificate of Authority from Alabama Department of Insurance and, when applicable, Certificate of Need or letter of non-reviewability before providing services.

Involuntary disenrollment may occur when: (one or more apply)

Enrollee becomes ineligible for Medicaid, is deceased, moves out of service area, or is changed to a non-covered aid category (effective first day of month following documentation).
Enrollee's disruptive, abusive, or unruly behavior (not caused by medical condition) that seriously impairs the HMO's ability to furnish services — HMO must provide at least one verbal and one written warning and obtain prior written approval from Medicaid before involuntary disenrollment.
Enrollee knowingly commits fraud or permits abuse of Medicaid card — must be promptly reported to Medicaid and prior authorized by Medicaid.

Unacceptable reasons for HMO to disenroll an enrollee include pre-existing medical conditions, changes in health status, and periodic missed appointments.

PIHP QA Requirements

PIHPs must operate an Agency-approved quality assurance program and support Medicaid audits and reviews.

PIHP member hospitals must conduct continuing internal QA reviews and provide assistance and information to the PIHP QA Committee and staff as necessary.

Coverage stance for HMOs and Medicare HMOs/CMPs

Coverage and payment stance for services provided through HMOs and for Medicare HMOs/CMPs.

HMOs shall accept capitation fees as payment in full for Medicaid benefits and must require their providers to accept those payments as payment in full.

Capitation payments to HMOs for all eligible enrollees shall be made monthly.

No reimbursement shall be available directly from Medicaid for in-plan services provided by non-contract providers unless agreed otherwise.

Attribution and Reconsideration

Attribution rules for ACHN PCP Groups and the reconsideration process for disputed attributions.

Participation and Payment Criteria

Participation requirements and payment eligibility for PCP Groups and Maternity Care Providers (MCPs) working with ACHNs, and rules for performance-related bonus payments.

ACHNs and Alabama Medicaid will monitor participation monthly; failure to meet participation requirements may result in termination of the PCP Group Agreement and loss of ACHN participation.

MCPs participating with the ACHN are eligible for bonus payments for initial prenatal visits in the first trimester and/or post-partum visits.

Regulatory References and Code Lists

Regulatory referencesmixed

No codes listed

Medicare vs Medicaid coverage notesmixed

No codes listed

ACHN Participation E&M Codesmixed

State Plan Attachment 4.19-B, page 2c.1

List of 13 E&M codes eligible for ACHN Participation Rate

Financial report submission deadlines

Quarterly financial reportsDue within 45 days of the period end (quarterly).

Annual financial reportAnnual report due by March 1 of the following year.

Audited financial statementAudited financial statement due within 90 days of the fiscal year end.

Cost Effectiveness Score Threshold

Cost effectiveness eligibility thresholdParticipating PCP groups with a cost effectiveness score of less than 1.0000 are eligible for cost effectiveness bonus payments.

Comparison basisScore compares a 12‑month PMPM actual to a risk‑adjusted expected PMPM based on similar PCP groups.

Calculation timingCalculation occurs as soon as the previous calendar year's performance has been calculated; payments distributed based on attributed recipients for the prior quarterly period.

Provider Responsibilities, Reporting, Sanctions, and Hearings

Documentation Required

Operate and Staff a Medicaid‑Approved PIHP QA Program

QA Program must be approved in writing by Medicaid.
QA Committee: minimum three health care professionals.
QA staff must obtain/analyze data from Medicaid systems and providers and implement focused medical reviews.
PIHP must provide all information, medical records, and assistance for Medicaid audits; Medicaid will perform at least one annual medical audit and periodic on-site visits.

Prior Authorization

Maintain Medicaid‑Approved Grievance Procedures and Submit Marketing Plans

Grievance procedure must be approved by Medicaid.
HMOs must ensure disenrollees wishing to file grievances are afforded notice and opportunity to do so and maintain grievance documentation in enrollee records.
Submit written marketing plan, procedures, and materials to Medicaid for approval before beginning enrollment or marketing; marketing practices (mailings, gifts, telemarketing, door‑to‑door) are subject to prior approval.
No more than 50% of a marketing representative's annual compensation may be from commissions.

Billing Rule

Accept Monthly Capitation as Payment in Full

Capitation payments are payable monthly to the HMO.
HMO must accept capitation as payment in full and require providers to accept payments in full for Medicaid benefits.
Neither enrollees nor Medicaid are liable for HMO debts in the event of insolvency.

Documentation Required

Submit Monthly Electronic Enrollment Listings and Notify Before Adding Services

Submit monthly electronic enrollment listing to Medicaid in the format specified by Medicaid.
Notify Alabama Medicaid prior to adding additional services identified by procedure code.

Denial Risk

Waive or Timely File for Fair Hearing to Preserve Sanction Reduction or Appeal

Waiver of fair hearing must be in writing and filed within 30 calendar days to obtain 35% reduction of the monetary sanction.
If appealing, written fair hearing request must be filed with Medicaid within 30 calendar days of the sanction notice and include factual/legal basis and requested relief.

Documentation Required

Request Informal Conference and Proceed to Fair Hearing if Unresolved

Entity may request an informal conference when filing a written fair hearing request.
If unresolved, fair hearing conducted before an impartial hearing officer under the Alabama Administrative Procedure Act; hearing authority is the Commissioner who appoints hearing officers.
Written notice of date/time/place sent by certified mail (and possibly email/fax) at least 10 calendar days before the hearing.
Entity may be represented by counsel and may call and examine witnesses; findings/recommendations submitted to Commissioner and final decision issued within 30 days of recommendation.

Denial Risk

Provide Written Notice and Hold Pre‑termination Hearing Before Contract Termination

Agency must give written notice of intent to terminate the contract, the reason(s) for termination, and the time and place of the pre‑termination hearing.
Pre‑termination hearing conducted in accordance with the fair hearing procedures set forth in the rule and 42 C.F.R. § 438.708/438.710.

Key Term Definitions

Primary Care Case Management (PCCM)

Services includedPCCM services include case management functions: location, coordination, and monitoring of primary health care services under contract between Medicaid and the PCP or PCP group.

Prepaid Inpatient Health Plan (PIHP)

DefinitionA Prepaid Inpatient Health Plan (PIHP) provides services to enrolled recipients on a capitated basis but does not qualify as an HMO.

Required systemsPIHPs must maintain systems including, at minimum, quality assurance and utilization review systems and other operational systems to manage inpatient services.

Health Maintenance Organization (HMO)

Payment postureCovered services are reimbursed on a monthly capitation basis; HMOs must accept capitation fees as payment in full and require providers to accept those payments as full payment.

Competitive Medical Plan (CMP)

Financial riskThe CMP assumes full financial risk prospectively for provision of health care services and must meet fiscal solvency requirements per applicable CFR provisions.

HCFA/Medicare roleCMPs may contract with HCFA to enroll Medicare beneficiaries and must meet qualifying criteria specified in federal regulations to do so.

Medicare Health Maintenance Organization (MHMO)

Solvency requirementsMHMO must provide adequate protections against insolvency by meeting specified fiscal and administrative federal requirements.

Attribution (ACHN)

Process overviewAttribution is the process used under the ACHN Program to associate a Medicaid recipient to the PCP Group that provides primary care, based on historical visitation practices.

Primary Care Physician (PCP) definition

Assignment optionsPatients may be assigned to an individual physician or to a group of physicians if approved by the Medical Director.