Ala. Admin. Code r. 560-X-62-.22

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

Section 560-X-62-.22 - Readiness Assessment Requirements

(1) Each organization that intends to enter into a risk contract with the Medicaid Agency shall be subject to a readiness assessment period. The readiness assessment period shall commence on January 1, 2015 and shall conclude with the Medicaid Agency's award or denial of full regional care organization certification to the organization.

(2) The Medicaid Agency will provide draft(s) of a risk contract to any organization seeking full regional care organization certification. Upon the Medicaid Agency's request, the organization will have forty-five (45) days to submit a written plan and other necessary documentation describing the organization's readiness to satisfy requirements of the Medicaid Agency in the areas set forth below and as may otherwise be required by Section 22-6-150, et seq. and rules promulgated thereunder:

(a) April 1, 2015 - Demonstrate the ability to establish an adequate medical service delivery network.

(b) October 1, 2015 - Demonstrate compliance with the solvency and financial requirements for a regional care organization

(c) May 1, 2016 - Demonstrate ability to provide services pursuant to a risk contract to be effective October 1, 2016 including development and readiness to operate:

1. Key Staffing

2. Governance

3. Provider Services and Materials

4. Network Adequacy

5. Claims Processing and Payment

6. Solvency and Audit

7. Financial

8. Care Coordination

9. Quality Management

10. Grievance and Appeals

11. Requirements Related to Enrollees

(i) Enrollment

(I) Disenrollment

(II) Enrollee Services

(III) Information Requirements

(ii) Marketing, Outreach and Member Materials

12. Administrative Support

13. Technical Infrastructure

(i) Management Information Systems (MIS)

14. Utilization Management

15. Compliance and Oversight

16. Other Requirements as requested by the Medicaid Agency pursuant to final RCO Contract

(3) Upon the Medicaid Agency's approval of the organization's written plan, the Medicaid Agency will provide a readiness assessment tool detailing the requirements necessary to demonstrate the organization's readiness to fulfill the obligations of a risk contract. The Medicaid Agency will conduct a readiness review which will include desk and onsite reviews of information submitted by the organization.

(4) All requested documentation, information and/or demonstrations must be submitted or conducted as specified by the Medicaid Agency. The Medicaid Agency may require additional documentation or updates to submissions throughout the readiness assessment period.

(5) The organization shall produce or provide timely, convenient, and free access at reasonable business hours at the offices of the organization to all books, records, accounts, papers, documents, and electronic and other recordings in its possession or control relating to the matter related to the readiness assessment, including as applicable the property, assets, business and affairs of the organization.

(6) The organization shall make private office space available to the Medicaid Agency and its contractors for the duration of any onsite review without cost to the Medicaid Agency or its contractors.

(7) The organization's final submission of the readiness assessment tool and all required documents will serve as the organization's submission of the report required by Rule No. 560-X-62-.06(5)(c).

Ala. Admin. Code r. 560-X-62-.22

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 06, March 31, 2015, eff. 4/24/2015.

Author: Sharon Weaver, Administrator, Administrative Procedures Office

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