Frequently Asked Questions

Regional Care Organizations - Providers

Regional Care Organizations are expected to be implemented on July 1, 2017.
Below are some questions providers often ask about Regional Care Organizations.  Click on the questions to see the answers:

At a minimum, RCOs will be required to provide the same level of covered benefits and services as provided under the FFS program. Enhanced benefits and covered services will be at the RCOs discretion subject to Medicaid approval, but will not be accounted for in the development of capitation rates.
As long as the provider is contracted with the RCO, he or she can see recipients that are not on the panel. If the recipient is not eligible, the recipient can see any provider for fee-for-service. If the recipient is not assigned to a PMP but assigned to an RCO, the payment will come from the RCO – not the Medicaid Agency.
If the provider is not contracted with the RCO and if the RCO network is unable to provide necessary services covered within the RCO program, the RCO will coordinate with the non-participating provider for payment. The cost to the recipient will not be greater than if the services were furnished in network.
DME will be covered by the RCOs. DME Providers will need to contract with RCOs to provide covered services to RCO enrollees. Claims for services provided to Medicaid recipients outside of the RCO system (e.g. foster child) will be filed as usual to Medicaid through HP on a fee-for-service basis.
Testing strips (and lancets) are now considered to be a DME item and will be reimbursed by RCOs as an RCO-contracted service/supply. There is a rule regarding minimum FFS rates, see Rule No. 560-X-62-.10 Minimum Fee-For-Service Reimbursement Rates at this link: http://medicaid.alabama.gov/content/9.0_Resources/9.2.1_Proposed_Rules/9.2.1_Proposed_Rules.aspx.
Infusion services billed through HCPCs are currently billed through the DME NPI, not the pharmacy NPI. The infusion services billed through the DME NPI will be an RCO-contracted service.
At this time, the pharmacy program will not be an RCO-contracted service and will be operated by the state. DME Providers will eventually need to contract with one or more RCOs to be reimbursed for RCO-contracted services.
Infusion services billed through HCPCs are currently billed through the DME NPI, not the pharmacy NPI. The infusion services billed through the DME NPI will be an RCO-contracted service.
Physical therapy, occupational therapy, and speech therapy services will be covered by the RCOs. Providers will need to contract with RCOs to provide covered services to RCO enrollees after October 1, 2016. Claims for services provided to Medicaid recipients outside of the RCO system (e.g. foster child) will be filed as usual to Medicaid through HP on a fee-for-service basis. Any changes to limitations on the number of visits made by the RCOs must be approved by the Agency first. Reimbursement of services will only be decreased if the provider and RCO agree to this type of fee schedule.
Yes, Occupational Therapy for non-EPSDT recipients is covered for acute conditions in a hospital outpatient setting.