Alabama

State Medicaid Integration Tracker

Regional Care OrganizationsAlabama flag

In June 2013, Alabama’s governor signed Act 2013-261 into law, approving a strategy to develop risk-bearing Regional Care Organizations (RCOs) to manage a continuum of health care services for Medicaid beneficiaries under a single capitated rate. RCOs are organizations of health care providers that contract with the state Medicaid agency to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries within a defined region of the state. They will coordinate care for the majority of the Medicaid population and manage Medicaid benefits including physical, behavioral, and pharmacy services. The initiative aims to build on four existing regional pilots (Patient Care Networks of Alabama) that better enable primary medical providers to function as a medical or health home by providing care management and other health care services for chronically ill Medicaid enrollees. The state submitted an 1115 Waiver Concept Paper in early 2013 and has plans to work with CMS regarding the development of an application for a §1115 Demonstration Waiver. The State Medicaid Agency plans to establish geographic Medicaid regions and designate RCOs or alternate care providers to operate in each region. Subject to approval of the CMS, the Medicaid Agency shall enter into a contract in each Medicaid region for at least one fully certified RCO to provide medical care to the Medicaid beneficiaries. (Source: National Academy for State Health Policy, 11/2013). The State Medicaid Agency released an RCO Implementation Timeline establishing October 2016 as the date for RCOs to begin accepting capitation payments from Medicaid. However, in July 2017 the state annoucned they would no longer be pursuing the RCO initiative (Source: Alabama Medicaid Site 7/27/2017)
 

On December 17, 2013, Alabama Medicaid filed five new rules to regulate the operation of Regional Care Organizations, outlining proposed state requirements that will be used to support the Agency’s move to Regional Care Organizations and to comply with state law. The proposed rules include requirements for: RCO Governing Boards; RCO Citizens’ Advisory Committees; receiving probationary certification as a RCO; contracting for specific case management services with probationary RCOs, and active supervision of probationarily-certified RCOs. (Source: State Medicaid Website, 1/10/2014). The original comment period for the RCO-related rules has been extended to March 2014. (Source: Alabama Medicaid Agency News, 1/10/2014)

On June 13, 2014, the state submitted to CMS a §1115 Demonstration Waiver Proposal to implement RCOs. RCOs are provider-based, community-led organizations that will, through an at-risk capitated payment model, manage State Plan benefits for the demonstration populations. However, long-term supports and services, hospice, and institutional and home and community-based services will not be managed by RCOs, because these services are excluded by statute. Beneficiaries will continue to receive these services through the fee-for-service delivery system. On October 1, 2015, the state Medicaid agency will submit a special study report to the Legislature and Governor, who will then determine whether these services will be included in the RCO benefit package or continue to be provided through the fee-for-service delivery system. (Source:  §1115 Waiver Demonstration Proposal 6/13/2014)

As of July 3, 2014, seven groups representing all five regions of the state have filed official Notices of Intent with the state Medicaid agency to apply for probationary certification as a Regional Care Organization. (Source: State Medicaid website)

On October 14, 2014, Alabama Medicaid reported twelve organizations had submitted applications for Regional Care Organization probationary certification by the September 30 application deadline.  These organizations must finalize their applications and receive official approval from the state Medicaid agency by the end of the year.  Probationary RCOs will be eligible to respond to the Health Home RFP scheduled to be released in January 2015.  (Source:  Alabama Medicaid website)  

On December 18, 2014, Governor Robert Bentley announced that six Regional Care Organizations have received probationary certification from the state to provide managed care for specific regions of the state.  These groups may now proceed to work with health care providers to show they have the ability to develop an adequate provider network by April 1, 2015.  (Source:  Alabama Medicaid website)  

On December 30, 2014, the state certified five additional organizations as probationary Regional Care Organizations (RCOs).  These five organizations join six previously-certified organizations, as all eleven probationary RCOs work toward final approval.  Final approval will require the probationary RCOs to demonstrate by April 1, 2015, the ability to develop an adequate provider network and demonstrate by October 1, 2015, the financial solvency to operate a viable program no later than October 1, 2016.  (Source:  Alabama Medicaid website)    

On April 1, 2015, Alabama’s Health Home program expanded statewide, as six probationary Regional Care Organizations (RCOs) began operating Health Homes.  The Health Home program will operate alongside the fee-for-service Patient 1st program until October 1, 2016, when the state will implement full-risk RCOs and incorporate the Health Home program into the full risk RCOs’ operations.  (Source:  Health Homes Website)

On December 21, 2016, the Alabama Medicaid Agency submitted a letter to the Centers for Medicare and Medicaid Services (CMS) requesting alterations to the Special Terms and Conditions (STCs) of the state’s section 1115 waiver. The original waiver would have implemented the Regional Care Organization (RCO) program starting on October 1, 2016; however, the letter requests to change the implementation date to October 1, 2017, to allow the state additional time to prepare. (Source: Letter 12/21/2016)  

On February 14, 2017, AL.com reported on how a growing number of Alabama’s largest hospitals have begun pulling out of plans to establish regional care organizations, or RCOs, under the state’s ongoing Medicaid program reforms. Major hospitals that have withdrawn plans include UAB and the University of South Alabama. While some health systems have expressed skepticism with the ongoing reforms, others such as Alabama Community Care remained committed to working toward the October 1, 2017, deadline to implement the program. If the state is unable to rollout the program on October 1, the state will lose its waiver approval as well as over $700 million in potential additional waiver funds. (Source: AL.com 2/14/2017)

On Thursday, July 27, 2017, Alabama’s governor announced the state would no longer move forward with implementing the regional care organizations (RCOs) program that has been in the works for approximately five years, and was set to go-live on October 1 of this year. Alabama will now pursue opportunities for additional flexibilities in its Medicaid program that may be attainable under the current administration. (Source: ABC 7/27/2017) 

Health Homes

In April 2013, CMS approved the state’s Health Homes State Plan Amendment. The state is implementing comprehensive care management in four networks over a two-year period from July 2013 to July 2014. The target population includes individuals with two chronic conditions, individuals with one chronic condition who are at risk for an additional chronic condition, and individuals with serious mental illness. (Source: Alabama Medicaid Agency News, 1/7/2013; Approved Health Homes State Plan Amendment, 4/9/2013)

Managed LTSS Program

On May 28, 2015, the Alabama House passed a major Medicaid reform bill to establish Integrated Care Networks (ICN) to contract with Medicaid to administer long-term care under a capitated system.  The bill also allows the current ratio of nursing homes to home-based care to rise from 75/25 to 50/50.  The reform is estimated to save the state $1.5 billion through the next decade, assuming 3 percent annual growth in the state Medicaid program.  The bill will now head to the governor for signing. (Source: Miami Herald, 5/28/2015; yellowhammernews.com, 5/20/2015)

On April 5, 2017, Alabama’s Medicaid agency released a draft concept paper regarding Alabama’s Integrated Care Network (ICN) program. The ICN program is modeled, in part, on the Regional Care Organization (RCO) program—however, the ICN program is specifically designed to cover Alabama Medicaid members requiring LTSS, including dual eligibles. Beneficiaries will either be enrolled in either an RCO or an ICN but not both.

ICNs will be paid a monthly capitated amount per-member per-month (PMPM), similarly to other fully capitated risk-based MLTSS programs. Individuals in three of Alabama’s Medicaid HCBS waivers will be enrolled into the program: the Elderly and Disabled waiver; the Alabama Community Transition Waiver; and the HIV/AIDS waivers. Beneficiaries in the State of Alabama Independent Living (SAIL) waiver, the technology Assisted (TA) waiver, or both of the state’s waivers for individuals with I/DD will not be enrolled into the ICN program. Alabama aims for no more than two ICNs to begin delivering services by October 1, 2018. (Source: Draft Concept Paper 4/5/2017)

On August 24, 2017, the Alabama Medicaid agency announced they are extending the deadline for integrated care network (ICN) probationary certification applications. Applications will be due after the mandated competitive procurement is released. (Source: Announcement 8/24/2017)  

On January 11, 2018, in a presentation to stakeholders, the Alabama Medicaid agency announced updates to its plan for the Integrated Care Network (ICN) program, which has been in the works since 2015. The state now intends to proceed with a Primary Care Case Management entity (PCCM entity) delivery model instead of full-risk managed care. Alabama will use a competitive procurement to select one ICN, which will maintain relationships with key LTSS providers such as Area Agencies on Aging (AAAs), nursing facilities, and the Department of Senior Services. The ICN will serve individuals both in nursing facilities and populations receiving HCBS waiver services.  The state expects to release a request for proposals (RFP) for the ICN in March 2018, and hopes to implement the program on October 1, 2018, pending Centers for Medicare & Medicaid Services (CMS) approval. (Source: Stakeholder Update 1/11/2018)

Governor Kay Ivey announced on October 1, 2018 that the Centers for Medicare and Medicaid Services (CMS) approved the state’s Integrated Care Network (ICN) program. This program is intended to offer more community options for Medicaid long-term care recipients. This includes both recipients who live in a nursing facility, and those who receive services in their homes through either Medicaid’s Elderly and Disabled (E&D) waiver or the Alabama Community Transition (ACT) waiver. The program does not change any Medicaid benefits, but is intended to help recipients learn about and apply for services available to them. The state will now move forward with implementing a system of case management, outreach, and education, with the long-term goal of increasing the percentage of Medicaid recipients receiving in-home care. An RFP for the proposed Integrated Care Network was released on April 20, 2018, and Alabama Select Network was chosen to administer the program. (Source: Governor Ivey Press Release Announcing Approval of ICN 10-1-2018)

Integrated Care Update

In an RFP issued 4/28/2023, the Alabama Medicaid Agency requests proposals from vendors with expertise for a plan to ensure the provisions of the comprehensive Primary Care Case Management Program. This program promotes a person-centered approach to care delivery while enhancing the integration of medical and LTSS for Medicaid beneficiaries. The projected implementation date of the RFP is 10/1/2023. (Source: Alabama Medicaid Agency; 4-28-2023)