TO: Primary Medical Providers (PMPs), Core Specialists and Designated Facilities
On December 18, 2014, Governor Robert Bentley announced that six Medicaid Regional Care Organizations have received probationary certification from the State. These groups may now proceed to work with health care providers to show that they have the ability to develop an adequate provider network by April 1, 2015.
The six organizations approved thus far are:
Region A: Alabama Community Care – Region A
My Care Alabama
Region B: Alabama Care Plan
Region C: Alabama Community Care – Region C
Region D: Care Network of Alabama
Region E: Gulf Coast Regional Care Organization
Additional approvals may be announced in coming weeks.
RCOs are locally-led managed care systems that will provide health care to Medicaid beneficiaries under the supervision and approval of the Alabama Medicaid Agency. State legislation passed in 2013 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 services for patients at an established cost.
As an interim step, the State will offer probationary RCOs an opportunity to participate in Medicaid’s federally-approved Health Home program. Probationary RCOs that participate in this program will provide care management for recipients with certain chronic health conditions while accelerating development of an adequate provider network.
Questions regarding this process may be directed to Carolyn Miller at carolyn.miller@medicaid.alabama.gov or by calling (334) 353-5539.
What Alabama Medicaid providers need to know:
1) RCOs which have received probationary certification are required to demonstrate by April 1, 2015 to the State that they will have an adequate provider network. To do this, probationary RCOs will ask primary medical providers, core specialists and certain facilities (see list below) to submit a Letter of Intent (LOI). The LOI is a standard form developed by the Alabama Medicaid Agency.
2) Probationary RCOs that wish to participate in the Health Home program will need completed LOIs from primary medical providers no later than February 11, 2015.
3) Providers interested in contracting with one or more RCOs to provide covered services to Medicaid recipients, should indicate so by signing the LOI to express their interest. By signing the LOI, the provider is not obligated to sign a contract and may rescind his or her intent to subcontract with the RCO upon review of a final contract.
4) Providers may sign LOIs or contract with more than one RCO.
5) An RCO must contract with “any willing provider” as long as he or she agrees to the terms offered to comparable providers. The minimum fee-for-service reimbursement rates that a Regional Care Organization is to pay providers for covered services provided to a Medicaid recipient is to be the prevailing Medicaid fee-for-service schedule, unless otherwise jointly agreed to by a provider and an RCO through a contract or mandated by federal law.
Primary Medical Providers (PMP)
Family practitioner
Federally Qualified Health Center
General practitioner
Internist
Pediatrician
Obstetrician or gynecologist
Rural Health Clinic
Facilities
Hospitals (as defined in Rule 560-X-7-.02)
Inpatient Psychiatric Hospitals
Laboratory Services
End State Renal Disease Treatment and
Transplant Center
Outpatient Mental Health Center
Independent Radiology Center
Core Specialists
Allergist
Anesthesiologist
Cardiologist
Cardiovascular Surgeon
Dermatologist
Gastroenterologist
General Surgeon
Neurologist
Oncologist
Ophthalmologist
Optometrist
Orthopedic surgeon
Psychiatrist
Pulmonologist
Radiologist
Urologist