Ala. Admin. Code r. 560-X-37-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-37-.03 - Prepaid Inpatient Health Plans. (PIHP)

(1) A prepaid inpatient health plan (PIHP) is one that provides services to enrolled recipients on a capitated basis but does not qualify as a HMO.

(2) Capitated PIHPs do not need to meet the requirements of §1903(m)(2)(A) of the Social Security Act if services are less than fully comprehensive. Comprehensive services are defined as:

(a) Inpatient hospital services and one or more services or groups of services as follows:

1. Outpatient hospital services;

2. Laboratory and X-ray services;

3. Nursing Facility (NF) services;

4. Physician services;

5. Home health services;

6. Rural health clinic services;

7. FQHC services;

8. Early and periodic screening, diagnostic, and treatment (EPSDT) services; and

9. Family planning services.

(b) No inpatient services, but three or more services or groups of services listed in Section (2)(a).

(3) If inpatient services are capitated, but none of the additional services listed in Section (2)(a) above are capitated, the entity may be considered a PIHP.

(4) The Partnership Hospital Program is a non-comprehensive Prepaid Inpatient Health Plan (PIHP) operating under the Medicaid state plan. The following further describes the Partnership Hospital Program:

(a) It is an inpatient care program.

(b) It is mandatory for Medicaid recipients, with the exception of recipients with Part A Medicare coverage and SOBRA adults who are enrolled in and receive inpatient care through the Maternity Care program in counties covered by the PHP and children certified through the Children's Health Insurance Program (CHIP).

(c) It is composed of prepaid inpatient health plans organized by districts in the State of Alabama.

(d) PIHPs operate under the authority granted in the Partnership Hospital Program, a state plan service as approved by CMS.

(e) Medicaid reimburses the prepaid inpatient health plans participating in the Partnership Hospital Program on a per member per month capitation basis.

(f) Prepaid inpatient health plans provide medically necessary inpatient care for covered Medicaid recipients including:

1. Bed and board

2. Nursing services and other related services

3. Use of hospital facilities

4. Medical social services

5. Drugs, biologicals, supplies, appliances and equipment

6. Certain other diagnostic and therapeutic services, and

7. Medical or surgical services provided by certain interns or residents-in-training.

8. Excluded are inpatient family planning services and inpatient emergency services.

(g) Prepaid inpatient health plans will assist the participant in gaining access to the health care system and will monitor on an inpatient basis the participant's condition, health care needs, and service delivery.

(h) Prepaid inpatient health plans are responsible for locating, coordinating, and monitoring all inpatient care in acute care hospitals within the State.

(i) Systems required of prepaid health plans, at a minimum, include:

1. Quality assurance and utilization review systems

2. Grievance systems

3. Systems to furnish required services, including utilization review

4. Systems to prove financial capability

5. Systems to pay providers of care

(5) The PIHP and Medicaid shall operate a quality assurance (QA) program sufficient to meet those quality review requirements of 42 CFR Part 438, Subpart D, applicable to PIHPs and their providers. The QA Program and any revisions must be approved in writing by Medicaid.

(a) The PIHP shall appoint a QA Committee to implement and supervise the QA Program. This committee shall consist of not less than three healthcare professionals, who may be members of the PIHP board, employees of providers or such other persons in the healthcare field as the PIHP believes will be required to oversee the creation and control of a successful QA Program for the PIHP.

(b) The QA Program shall be a written program specifying:

1. Utilization control procedures for the on-going evaluation, on a sample basis, of the need for, and the quality and timeliness of care provided to Medicaid eligibles by the PIHP.

2. Review procedures by appropriate health professionals of the process, following the provision of health services.

3. Procedures for systematic data collection of performance and patient results.

Procedures for interpretation of these data to the provider.

4. Procedures for making needed changes.

(c) The QA Committee shall employ a professional staff to obtain and analyze data from Medicaid information systems, the provider hospitals, and such other sources as the staff deems necessary to carry out the QA Program. All costs of the QA Program shall be paid by the PIHP.

(d) PIHP member hospitals shall conduct continuing internal reviews of their own QA programs. The QA Committee staff shall be given all such assistance and direction by such provider QA programs and shall obtain such reasonable information from such providers as may be necessary to implement the PIHP QA Programs.

(e) The staff shall implement such focused medical reviews of the providers as may be required by Medicaid, required under the QA Program, or believed necessary the staff.

(f) Medicaid staff shall coordinate with the PIHP's QA Committee and staff on QA matters. Medicaid shall make such audits and surveys as it deems reasonably required, but shall do at least one annual medical audit on each PIHP and all of its providers. The PIHP shall provide all information, medical records, or assistance as may be reasonably required for Medicaid to conduct such audits.

(g) Medicaid QA personnel will make periodic on-site visits to review and monitor the QA Program and assess improvements in quality. The PIHP shall make certain all necessary information and records are available at such sites.

Author: Lynn Sharp, Associate Director, Institutional Services

Ala. Admin. Code r. 560-X-37-.03

Amended: March 11, 1986, ER April 1, 1987; June 10, 1987. Amended: Filed April 6, 1994; effective May 13, 1994. Amended: Filed August 12, 1994; effective September 17, 1994. Amended: Filed July 6, 1995; effective August 12, 1995. Repealed and Replaced: Filed June 6, 1996; effective July 12, 1996. Amended: Filed December 9, 1996; effective January 13, 1997. Amended: Filed December 8, 1997; effective January 12, 1998. Amended: Filed May 12, 2003; effective June 16, 2003. Amended: Filed June 11, 2004; effective July 16, 2004.

Statutory Authority: State Plan, attachment 2.1-A; Social Security Act, Title XIX, Section 1905(a)(2)(3)(4)(5)(7)(9); 42 C.F.R. Section 434.30, Section 434.6(a)(4).