Ala. Admin. Code r. 560-X-62-.01

Current through Register Vol. 42, No. 12, September 30, 2024

Section 560-X-62-.01 - Certificate in Order to Collaborate with other Entities, Individuals, or Regional Care Organizations

(1) Every person or entity who is operating or may operate as a Collaborator shall possess a certificate (Certificate to Collaborate) issued by the Medicaid Agency qualifying such person or entity to collaborate as set forth in Section 22-6-163 of the Code of Ala. 1975. A Collaborator is defined in Section 22-6-150(4) of the Code of Ala. 1975, as: "A private health carrier, third party purchaser, provider, health care center, health care facility, state and local governmental entity, or other public payers, corporations, individuals, and consumers who are expecting to collectively cooperate, negotiate, or contract with another collaborator or regional care organizations in the health care system."

(2) Every person or entity seeking a Certificate to Collaborate shall submit an on-line application with the Medicaid Agency and must include the following information in the application:

(a) The applicant's name, business, occupation or medical specialty, principal address and the name, mailing address, e-mail address, and telephone number of each person authorized to receive notices and communications relating to the application;

(b) The applicant's National Provider Identifier (NPI) number(s), Medicaid ID number(s), Taxpayer Identification Number(s) (TIN), Social Security Number (SSN) and any state professional or facility license number(s);

(c) The name and address of each individual who the applicant authorizes to collaborate on its behalf with other entities, persons, or Regional Care Organizations (RCOs);

(d) Background information relating to the applicant and each individual authorized to collaborate on its behalf, including:

(i) whether the applicant or any individual authorized to collaborate on its behalf is currently excluded or suspended from the Medicare, Medicaid, or the Title XX services program;

(ii) whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty to or been convicted of a criminal offense related to the applicant's or the individual's involvement in any program under Medicare, Medicaid, or the Title XX services program;

(iii) whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty, been convicted, or found liable in a criminal or civil proceeding of engaging in any form of health care fraud or abuse;

(iv) whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty, been convicted, or found liable in a criminal or civil proceeding of engaging in any form of anti-competitive conduct or other anti-trust violation;

(v) whether the professional license or certification of the applicant or any individual authorized to collaborate on its behalf is currently suspended or revoked; and

(vi) whether the applicant or any individual authorized to collaborate on its behalf has ever pled guilty or been convicted of a violation of the state or federal securities or insurance laws.

(e) Information whether the applicant intends to help establish or develop a RCO, to enroll as a provider with a RCO, or to engage in other activity.

(f) Identification of the Medicaid region(s) in which the applicant intends to help establish or develop a RCO, to enroll as a provider with a RCO, or to engage in other activity.

(g) Description of what entities and persons with whom the applicant intends on collaborating or negotiating;

(h) Description of the expected effects of the negotiated contract, including whether the negotiated contract is expected to:

(i) result in improved quality of health care services to Medicaid beneficiaries;

(ii) result in cost containment in providing health care services;

(iii) result in enhancements in technology; and

(iv) maintain competition in the health care services market.

(i) Certification by the applicant that all information entered on the application is true, to the best of the applicant's knowledge, and (1) that the applicant will bargain in good faith, (2) that such bargaining is necessary to identify appropriate service delivery systems and reimbursement methods in order to align incentives in support of integrated and coordinated health care delivery, and (3) that such bargaining is necessary to provide quality health care to Alabama citizens who are Medicaid eligible at the lowest possible cost.

(3) The Medicaid Agency may inspect or request additional documentation and information from an applicant as the Medicaid Agency deems appropriate before issuance of a Certificate to Collaborate or at any other time to verify that the Medicaid laws are implemented in accordance with the legislative intent.

(4)

(a) The Medicaid Agency shall review the application and any additional documentation and information and, if the Medicaid Agency determines that the applicant has made a sufficient showing that the collaboration is in order to facilitate the development and establishment of the RCO or health care payment reforms, the Medicaid Agency shall issue a Certificate to Collaborate.

(b) Certificates to Collaborate issued by the Medicaid Agency pursuant to this rule and Section 22-6-163 of the Code of Ala. 1975, shall be issued to allow collective negotiations, bargaining, and cooperation among Collaborators and RCOs in accordance with Sections 22-6-150, et seq. of the Code of Ala. 1975.

(c) A Certificate to Collaborate shall be effective immediately upon issuance by the Medicaid Agency and shall expire on October 1, 2017. The Medicaid Agency may implement rules for renewals of Certificates to Collaborate.

(d) The holder of a Certificate to Collaborate (Certificate Holder) shall promptly notify the Medicaid Agency online of any substantial or material corrections or updates to the information provided in the Certificate Holder's application.

(5) All applications submitted pursuant to this rule, all Certificates to Collaborate, and the names and addresses of all persons and entities to whom the Medicaid Agency issues Certificates to Collaborate shall be public records and shall be subject to disclosure. The names and addresses of all Certificate Holders and all individuals authorized to collaborate on behalf of Certificate Holders shall be posted on the Medicaid Agency's website for review.

(6) The Medicaid Agency shall actively monitor and supervise collective negotiations, bargaining, and cooperation among Collaborators and RCOs in accordance with Sections 22-6-150, et seq. of the Code of Ala. 1975. As part of its monitoring and supervision, the Medicaid Agency shall, as it deems appropriate, request periodic reports and additional information regarding the status, progress being made and problems encountered in the collaborative process, and the status of efforts to create integrated networks intended to provide for the delivery of a coordinated system of healthcare. Failure to file a periodic report or to provide information or documents requested by the Medicaid Agency is grounds for revocation of a Certificate to Collaborate.

(7) Any person or entity may notify the Medicaid Agency of conduct of a Certificate Holder that is alleged to violate any of the certifications by the Certificate Holder pursuant to Section 22-6-163(c) of the Code of Ala. 1975, and subsection 2(i) of this rule. The notice must be signed, in writing and include a statement of facts supporting the allegation of a violation. Upon receipt of such notice or upon receipt of such information obtained by Medicaid on its own, the Medicaid Agency shall review the notice and conduct any inquiry it finds appropriate and may refer the allegation of a violation to the State of Alabama Attorney General. The Medicaid Agency may revoke a Certificate to Collaborate upon finding that the Certificate Holder has violated any of the certifications by the Certificate Holder pursuant to Section 22-6-163(c) of the Code of Ala. 1975, and subsection 2(i) of this rule or it may in its discretion impose additional terms and conditions determined necessary to effectuate the objectives of the Certificate to Collaborate.

(8) Should Collaborators or a RCO be unable to reach an agreement, they may request that the Medicaid Agency intervene and facilitate negotiations.

(9) The Medicaid Commissioner or the Medicaid Commissioner's designee(s) may enter into discussions with, meet with, or convene Collaborators and RCOs to facilitate the development and establishments of the RCOs and health care payment reforms and discuss questions, concerns, or complaints related thereto.

(10) Given the important governmental and public interest to ensure that state action immunity is not conferred upon persons or entities who fail to sufficiently show that their collaboration is in furtherance of the goals of Section 22-6-150et seq. of the Code of Ala. 1975, all decisions to grant, deny, or revoke, a Certificate to Collaborate shall serve as the final decision of the Medicaid Agency and shall be appealable immediately to circuit court. Notwithstanding this rule, a holder of a Certificate to Collaborate that is revoked for failure to provide a timely periodic report or other requested information or documents, may apply for reinstatement of the Certificate to Collaborate no more than two times (which number may be expanded by the Medicaid Agency for special circumstances as determined in the Medicaid Agency's sole discretion) upon submission of the delinquent periodic report or information, an explanation for failure to provide a timely periodic report or other requested information, and any other information deemed necessary by the Medicaid Agency.

Ala. Admin. Code r. 560-X-62-.01

New Rule: Filed December 17, 2013; effective January 21, 2014.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 11, August 31, 2016, eff. 9/25/2016.

Author: Sharon Weaver, Administrator, Administrative Procedures Office

Statutory Authority:Code of Ala. 1975, §§ 22-6-150 et seq.