HB 331

This bill would require the Alabama Medicaid Agency to use certain eligibility verification measures to eliminate the duplication of assistance, and deter waste, fraud, and abuse of benefits and would allow the agency to contract with a third-party vendor under certain conditions

This bill would also require the Alabama Medicaid Agency to implement certain practices relating to semi-annual eligibility verification and would establish procedures for the dispute of findings by the agency

This bill would require the agency to refer certain instances of fraud to the appropriate district attorney for civil or criminal prosecution and to report to the Legislature regarding the effectiveness of the verification practices

This bill would also require the agency to submit a state plan amendment or waiver necessary to implement work requirements for the able-bodied population to participate in Medicaid

Relating to Medicaid; to require the Alabama Medicaid Agency to use certain eligibility verification measures; to authorize the use of third-party vendors under certain conditions; to require the Alabama Medicaid Agency to implement semi-annual eligibility verification checks; to provide for procedures for disputes of determinations by the agency; to require the referral of certain instances of identified fraud to appropriate district attorney; and to require the agency to report to the Governor, the Legislature, and the Department of Finance; to require the agency to submit a state plan amendment or waiver necessary to implement work requirements for participation in Medicaid; and to provide rulemaking authority.

Section 1

(a) To the extent allowed by federal law and regulations, and subject to Centers for Medicare and Medicaid Services ("CMS") approval of the Alabama Medicaid Agency's eligibility verification plan, prior to awarding assistance and completing enrollment, the agency shall verify eligibility information of each applicant. (b) The information verified by the agency shall include, but is not limited to, all of the following, provided such information is related to the eligibility criteria for the Medicaid eligibility group for which the applicant is applying: (1) Earned and unearned income. (2) Employment status and changes in employment. (3) Immigration status. (4) Residency status, including a nationwide best-address source to verify individuals are residents of this state. (5) Enrollment status in other state-administered public assistance programs. (6) Financial resources. (7) Incarceration status. (8) Death records. (9) Enrollment status in public assistance programs outside of this state. (10) Potential identity fraud or identity theft. (c) The agency shall sign a memorandum of understanding with any state department, agency, or division for information detailed in subsection (b). (d) The agency may contract with one or more independent vendors to provide information detailed in subsection (b). Except for a contract which is required by federal law, including but not limited to a contract to implement the asset verification program required by 42 U.S.C. § 1396w as amended, any contract entered under this subsection shall establish annualized savings that exceed the contract's total annual cost to the state. (e) Nothing in this section shall preclude the agency from receiving or reviewing additional information related to eligibility not detailed in this section or from contracting with one or more independent vendors to provide additional information not detailed in this section.

Section 2

(a) To the extent allowed by federal law and regulations, and subject to CMS approval of the agency's eligibility verification plan, on at least a semi-annual basis after initial enrollment, the agency shall receive and review eligibility-related information concerning individuals enrolled to receive benefits. (b) The information provided to the agency shall include, but is not limited to, all of the following, provided such information is related to the eligibility criteria for the Medicaid eligibility group for which the individual is currently eligible: (1) Earned and unearned income. (2) Employment status and changes in employment. (3) Immigration status. (4) Residency status, including a nationwide best-address source to verify individuals are residents of this state. (5) Enrollment status in other state-administered public assistance programs. (6) Financial resources. (7) Incarceration status. (8) Death records. (9) Enrollment status in public assistance programs outside of this state. (10) Potential identity fraud or identity theft. (c) The agency shall sign a memorandum of understanding with any state department, agency, or division for information detailed in subsection (b). (d) The agency may contract with one or more independent vendors to provide information detailed in subsection (b). Except for a contract which is required by federal law, including but not limited to a contract to implement the asset verification program required by 42 U.S.C. § 1396w as amended, any contract entered under this subsection shall establish annualized savings that exceed the contract's total annual cost to the state. (e) The agency shall explore joining any multi-state cooperative to identify individuals who are also enrolled in public assistance programs outside of this state, including the National Accuracy Clearinghouse. (f) Nothing in this section shall preclude the agency from receiving or reviewing additional information related to eligibility not detailed in this section or from contracting with one or more independent vendors to provide additional information not detailed in this section. (g) If the agency receives information that may affect eligibility concerning an individual enrolled to receive benefits, the agency shall review the individual's case using the following procedures: (1) If the information does not result in the agency finding a discrepancy or change in an individual's circumstances that may affect eligibility, the agency shall take no further action. (2) If the information results in the agency finding a discrepancy or change in an individual's circumstances that may affect eligibility, the agency shall promptly evaluate the effect of the information on the individual's eligibility after receiving such information, consistent with the procedures in this subsection (g). (3) If the information results in the agency finding a discrepancy or change in an individual's circumstances that may affect eligibility, the individual shall be given an opportunity to explain the discrepancy; provided, however, that self-declarations of eligibility-related information by applicants or recipients shall only be accepted as verification when adequate documentation does not exist or is not reasonably available. (4) The agency shall provide written notice to the individual, which shall describe in sufficient detail the circumstances of the discrepancy or change, the manner in which the applicant or recipient may respond, and the consequences of failing to take action. The applicant or recipient shall have a reasonable period to respond in an attempt to resolve the discrepancy or change. The explanation provided by the recipient or applicant shall be given in writing. After receiving the explanation, the agency may request additional documentation if it determines that there is risk of fraud, misrepresentation, or inadequate documentation. In no case shall the agency discontinue assistance upon finding a discrepancy or change in circumstances until the individual has been given notice of the discrepancy and the opportunity to respond as required under this act. (5) If the individual does not respond to the notice, the agency shall discontinue assistance for failure to cooperate, in which case the agency shall provide notice of intent to discontinue assistance. Eligibility for assistance shall not be established or reestablished until the discrepancy or change has been resolved. (6) If an individual responds to the notice and disagrees with the agency's finding of a discrepancy, the agency shall reinvestigate the matter. If the agency finds that there has been an error regarding its finding of a discrepancy, the agency shall take immediate action to correct it and no further action shall be taken. If, after an investigation, the agency determines that there is no error, the agency shall determine the effect on the individual's eligibility and take appropriate action. Written notice of the agency's action shall be provided to the individual. (7) If the individual agrees with the agency's finding of a discrepancy, the agency shall determine the effect on the individual's eligibility and take appropriate action. Written notice of the agency's action shall be given to the individual.

Section 3

The Alabama Medicaid Agency shall provide information obtained under Sections 1 and 2, inclusive, of this act to the appropriate district attorney for cases of suspected fraud.

Section 4

One year after the effective date of this act, and annually thereafter, the Alabama Medicaid Agency shall provide a written report to the Governor, the President Pro Tempore of the Senate, the Speaker of the House of Representatives, and the Department of Finance detailing the effectiveness and general findings of any eligibility verification measures utilized as provided in Sections through 3, inclusive, including the number of cases reviewed, the number of case closures, the number of referrals for criminal prosecution, recovery of improper payment, the disposition of cases referred to the appropriate district attorney, and any resulting savings that can accurately be estimated by the agency.

Section 5

The Alabama Medicaid Agency shall submit a state plan amendment or waiver necessary with the Centers for Medicare and Medicaid Services (CMS) to establish work requirements for eligibility, including exceptions from work requirements, for the able-bodied population to maintain assistance under Medicaid. Pursuant to this section, the agency shall request approval of the firmest but nonetheless most reasonable work requirements allowed by CMS, which are designed to help recipients attain independence and self-sufficiency. The work requirements should be in furtherance of the Medicaid program's objectives and are subject to CMS approval.

Section 6

The Alabama Medicaid Agency may adopt rules for the implementation and administration of this act.

Section 7

This act shall become effective on the first day of the third month following its passage and approval by the Governor, or its otherwise becoming law.