HB454 Alabama 2013 Session

Summary

Primary Sponsor

Jim McClendon

Republican

Session

Regular Session 2013

Title

Medicaid Agency, delivery of medical services to Medicaid eligible persons through regional care organizations

Summary

HB454 would move Alabama's Medicaid delivery to regional managed care through regional care organizations or alternate providers within defined geographic regions.

What This Bill Does

It creates up to eight Medicaid regions and allows regional care organizations or alternate care providers to deliver a comprehensive package of Medicaid benefits under risk contracts with capitated payments. It sets up governing boards with diverse representation, requires financial solvency and quality standards, and creates a framework for enrollment, grievances, and appeals. It also allows collaborative arrangements with protections from anti-trust laws and requires regular reporting and evaluations.

Who It Affects

• Medicaid beneficiaries in Alabama who may be enrolled in or assigned to a regional care organization or alternate care provider, affecting how they receive Medicaid services and how they can appeal decisions.
• Providers and organizations that participate in Medicaid delivery, including regional care organizations, hospitals, physicians, dentists, pharmacists, and other care providers who may contract under risk-based capitation and sit on governing boards or advisory committees.

Key Provisions

• Establish up to eight geographic Medicaid regions and authorize regional care organizations (RCOs) or alternate care providers to deliver Medicaid benefits under risk contracts with capitated payments.
• Define key terms (Alternate Care Provider, Capitation Payment, Risk Contract, Regional Care Organization, Collaborator, Quality Assurance Provisions) and specify that RCOs serve only Medicaid beneficiaries and are not insurance companies.
• Create governing boards for RCOs with a mix of risk-bearing participants, medical professionals, and community representatives, and require Medicaid Agency approval of board structures.
• Require financial solvency and reserves for RCOs (restricted reserves, capital/surplus), with option to secure a performance bond in lieu of reserves; mandate periodic financial audits.
• Implement enrollment for beneficiaries into RCOs (choice if multiple exist; assignment otherwise) and require adequate medical service delivery networks.
• Establish a comprehensive grievance and appeal process (medical director decision, peer review, Medicaid Agency appeal) with specified timelines and binding decisions.
• Provide for state action antitrust immunity for collaborators and RCOs through certificates, with confidentiality protections and state supervision as needed.
• Outline timeline for implementation (regions by 2013, probationary certification by 2016, milestones to demonstrate solvency and network adequacy) and allow termination or replacement if performance fails.
• Require evaluation of long-term care and dental care programs with possible shifts to regional care delivery and maintain current programs until evaluation is completed.

AI-generated summary using openai/gpt-5-nano on Feb 24, 2026. May contain errors — refer to the official bill text for accuracy.

Subjects

Medicaid Agency