2013 Code of Alabama
Title 22 - HEALTH, MENTAL HEALTH, AND ENVIRONMENTAL CONTROL.
Title 1 - HEALTH AND ENVIRONMENTAL CONTROL GENERALLY.
Section 22-6-151 - Regional care organizations; governing board of directors; citizen's advisory committee; solvency and financial requirements; reporting.
(a) A regional care organization shall serve only Medicaid beneficiaries in providing medical care and services.
(b) Notwithstanding any other provision of law, a regional care organization shall not be deemed an insurance company under state law.
(c)(1) A regional care organization and an organization with probationary regional care organization certification shall have a governing board of directors composed of the following members:
a. Twelve members shall be persons representing risk-bearing participants in the regional care organization or organization with probationary certification. A participant bears risk by contributing cash, capital, or other assets to the regional care organization. A participant also bears risk by contracting with the regional care organization to treat Medicaid beneficiaries at a capitated rate per beneficiary or to treat Medicaid beneficiaries even if the regional care organization does not reimburse the participant.
b. Eight members shall be persons who do not represent a risk-bearing participant in the regional care organization. Of these eight members, five members shall be medical professionals who provide care to Medicaid beneficiaries in the region. Three of these members shall be primary care physicians, one an optometrist, and one a pharmacist. One primary care physician shall be from a Federally Qualified Health Center appointed jointly by the Alabama Primary Health Care Association and the Alabama Chapter of the National Medical Association and the other two primary care physicians shall be appointed by a caucus of county boards of health in the region. The optometrist shall be appointed by the Alabama Optometric Association, or its successor organization. The pharmacist shall be appointed by the Alabama Pharmacy Association, or its successor organization. All five medical professionals shall work in the region served by the regional care organization. None of these members shall be a risk-bearing participant in the regional care organization or be an employee of a risk-bearing participant, but these members may contract with the regional care organization on a fee-for-service basis.
c. Three members shall be community representatives as follows: 1. The chair of the citizens' advisory committee established pursuant to subsection (d). 2. Another citizens' advisory committee member, elected by the committee, who is a representative of an organization that is part of the Disabilities Leadership Coalition of Alabama or Alabama Arise, or their successor organizations. 3. A business executive, nominated by a chamber of commerce in the region, who works in the region. These members may not be risk-bearing participants in the regional care organization or employees of a risk-bearing participant.
(2) A majority of the members of the board may not represent a single type of provider, such as hospitals or doctors engaged in medical practice.
(3) The Medicaid Agency shall have the power to approve the members of the governing board and the board's structure, powers, bylaws, or other rules of procedure. No organization shall be granted probationary regional care organization certification or full regional care organization certification without approval.
(4) The regional care organization, the caucus of county boards of health in the region, the citizens' advisory committee, and the optometric, and pharmacy associations shall promptly fill any vacancy on the board of directors. Notwithstanding other provisions of this subsection, the Medicaid Commissioner shall fill a board seat left vacant for at least three months.
(5) The governing board may not take any action unless at least one physician appointed by a caucus of county boards of health in the region, who does not represent a risk-bearing participant and who does not hold one of the three seats held by community representatives, votes on the prevailing side.
(6) The membership of the governing board of directors shall be inclusive and reflect the racial, gender, geographic, urban/rural, and economic diversity of the region.
(d) A citizen's advisory committee shall advise the organization on ways the organization may be more efficient in providing quality care to Medicaid beneficiaries. In addition, an advisory committee shall carry out other functions and duties assigned to it by a regional care organization and approved by the Medicaid Agency. Each regional care organization shall have a citizens' advisory committee, as shall an organization seeking to become a regional care organization, which membership shall be inclusive and reflect the racial, gender, geographic, urban/rural, and economic diversity of the state. The committee shall meet all of the following criteria:
(1) Be selected in a method established by the organization seeking to become a regional care organization, or established by the regional care organization, and approved by the Medicaid Agency.
(2) At least 20 percent of its members shall be Medicaid beneficiaries or, if the organization has been certified as a regional care organization, at least 20 percent of its members shall be Medicaid beneficiaries enrolled in the regional care organization.
(3) Include members who are representatives of organizations that are part of the Disabilities Leadership Coalition of Alabama or Alabama Arise, or their successor organizations.
(4) Include only persons who live in the Medicaid region the organization plans to serve; or if the organization has become a regional care organization, include only persons who live in the Medicaid region served by the regional care organization. The membership of the committee shall be inclusive and reflect the racial, gender, geographic, urban/rural, and economic diversity of the region.
(5) Elect a chair.
(6) Meet at least every three months.
(e)(1) Each regional care organization shall meet minimum solvency and financial requirements as provided in this subsection. The Medicaid Agency shall require a regional care organization, as a condition of certification or continued certification, to maintain minimum financial reserves at the following levels:
a. Restricted reserves of two hundred fifty thousand dollars ($250,000) or an amount equal to 25 percent of the regional care organization's total actual or projected average monthly expenditures, whichever is greater.
b. Capital or surplus, or any combination thereof, of two million five hundred thousand dollars ($2,500,000).
(2) Instead of maintaining the financial reserves required in subdivision (1), a regional care organization that has entered into a risk contract with the Medicaid Agency may submit to the agency a written guaranty in the form of a bond issued by an insurer, in an amount equal to the financial reserves that would otherwise be required of the regional care organization under subdivision (1), to guarantee the performance of the provisions of the risk contract. The bond shall be issued by an insurer authorized in this state and approved by the Medicaid Commissioner. No assets of the regional care organization shall be pledged or encumbered for the payment of the performance bond.
(f) A regional care organization shall provide such financial reports and information as required by the Medicaid Agency.
(g) A regional care organization shall report all data as required by the Medicaid Agency, consistent with the federal Health Insurance Portability and Accountability Act (HIPAA).
(Act 2013-261, §2.)Disclaimer: These codes may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
