Frequently Asked Questions

Regional Care Organizations - Recipients

Medicaid is planning to start Regional Care Organizations on October 1, 2017.
Below are some questions people often ask about Regional Care Organizations.  Click on the questions to see the answers:

Regional Care Organizations (RCOs) are locally-led managed care organizations that will ultimately provide healthcare services to most Alabama Medicaid recipients at an established cost under the supervision and approval of the Alabama Medicaid Agency. State legislation passed in 2013 and updated in 2014 created the new managed care structure to enable Medicaid to move away from a volume-based, fee-for-service environment to a payment system that incentivizes the delivery of quality health care and improved health outcomes. Under the new structure, Alabama Medicaid will enter into contracts with RCOs to provide certain covered services for Medicaid patients at a set cost.
Medicaid is making these changes to improve the Medicaid program. Instead of focusing on "visits and volume," the new program will focus on quality and outcomes such as improving prenatal care, preventing and managing chronic diseases, coordinating care of health services and making the program more efficient.
Medicaid recipients who are required to participate in the RCOs will be asked to choose an RCO for their health care during summer of 2017. Medicaid recipients who do not select an RCO, will be assigned to one in their region based on past claims history and other factors. In all cases, recipients will have a 90-day period in which they can switch RCOs. After that, recipients will be able to change RCOs during an annual open enrollment period.
Most physical and behavioral health services now covered by Medicaid will be RCO-covered services as well. Some of the services to be covered by RCOs include hospital inpatient and outpatient care, emergency room services, primary and specialty medical care, services provided by a federally-qualified health center or rural health clinic, lab and radiology services, mental/behavioral health, eye care, maternity care and transportation.
Excluded services include home and community-based waiver services (HCBS), targeted case management, nursing home care, pharmacy services, dental care and school-based services. A list of RCO-covered services is on the Agency’s website.
Approximately two-thirds of the Agency’s recipients, or about 650,000 Alabama citizens, will receive their care via RCOs. Covered populations include aged, blind and disabled recipients, pregnant women and children under age 19 (formerly known as SOBRA recipients), and parent/caretaker relatives (formerly known as Medicaid for Low Income Families). Foster children, people who have both Medicare and Medicaid, and those recipients who reside in a nursing facility or receive long-term care services and supports such as HCBS waiver services, will continue to receive care via the current fee-for-service system. A list of Medicaid recipients who will be required to participate in RCOs is on the Agency's website.
Helping Medicaid recipients choose a doctor is the responsibility of the RCO. Recipients will first go through an enrollment broker set up by Medicaid to help them choose their RCO. When they contact the enrollment broker (or are contacted by the enrollment broker), they will be given information about the RCOs with which their doctor has signed a contract. Recipients are not required to stay with the same doctor, however. If the recipient chooses an RCO that their previous doctor has not contracted with, they will need to select a new primary care physician.
As required by state law, the state established regions that would ensure that there were a sufficient number of Medicaid recipients (as determined by an actuary) in each region. In developing the regions, state officials also sought to honor existing referral patterns, to keep health systems together when possible and to allow for more than one RCO in a region.
Yes. Medicaid recipients who will be in the RCO program will choose from certified RCOs in their particular region. The choice of RCOs will be based on the region the recipient lives in. All RCOs will be required to offer the same level of services Medicaid now has, but some may offer additional services or benefits such as unlimited visits for adults, or no requirement for referrals. Recipients who do not choose an RCO will be assigned one based on their past history. Family groups will be kept together unless a family member specifically asks that family members be in different RCOs.
Most Medicaid recipients who were previously under the Patient 1st program will be sent a letter with instructions on how to choose an RCO during the summer of 2017. Recipients will be able to choose an RCO by mail, by phone, by fax or online. In the same letter, information will be sent about the RCO programs recipients may choose from. All RCOs will be required to offer the same level of services Medicaid now has, but some may offer additional services or benefits such as unlimited visits for adults, or no requirement for referrals. Recipients who do not choose an RCO will be assigned one based on their past history. Family groups will be kept together unless a family member specifically asks that family members be in different RCOs.