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AL Medicaid RCO Update

Below area few updates from AL Medicaid regarding RCOs:

Alabama Medicaid’s Regional Care Organizations (RCO’s)

Regional Care Organizations are locally led managed care organizations that will ultimately provide healthcare services to most Alabama Medicaid recipients at an established cost under the supervision and approval of the Alabama Medicaid Agency.  Once certified, RCO’s will assume the risk of managing the full cost of covered Medicaid services and care coordination for most Medicaid recipients.

Covered Populations (Recipients)  Full list on Medicaid website

Aged, blind and disabled recipients      Breast and Cervical Cancer Treatment Programs

Adults covered under Parent/Caretaker Program (MLIF)   SOBRA children and adults (Pregnant Women)

Excluded Populations (Recipients)   Full list on Medicaid website

Medicare/dual eligible        Foster Children        Hospice Patients        ICF-MR recipients

Nursing home/institutional recipients                 Plan 1st and unborn recipients

Home and Community Based Services (Waiver recipients)

Covered Services (Providers)  Full list on Medicaid website

Hospital and Inpatient Care    Emergency room    Primary and Specialty Care    FQHC’s/RHC’s

Lab/Radiology    Mental/Behavioral Health/Substance Abuse

Eyecare                    Maternity                        DME

Excluded Services (Providers)  Full list on Medicaid website

Pharmacy    Nursing Home    Dental  (Nursing home and dental for at least first two years)

Contracting, Prior Authorization and Referral Information

Providers must contract with at least one RCO to be paid for services; may contract with multiple RCO’s.  RCO’s will determine how patients will be assigned to providers.  Patient 1st program will change from today’s model.  Any willing provider rule applies, providers are eligible to contract with any or all RCO’s.  Medicaid requires payment to be no less than prevailing fee schedule in place on 10/1/2016.  Program, Prior Authorization and referrals are to be no more restrictive than currently in place on 10/1/2016.  Prior Authorizations will be handled by the RCO’s.  The EPSDT program will remain in place.  Referral process and forms may vary from RCO to RCO.  RCO’s must cover the same services and benefit limits in place when RCO’s are implemented; however, an RCO may add services or benefits but will not receive extra capitation payments.

Recipient Eligibility Verification

Current eligibility verification tools will remain in place.  The eligibility verification process will display which RCO a recipient is assigned to for coverage, if they are eligible for date of service, and type of Medicaid coverage.  HPE eligibility verification will not display benefit limits.  Questions related to benefit limits will need to be answered/verified by the RCO’s.  Recipients will have two Medicaid cards, the traditional card, and a card from the assigned RCO.

Recipient Enrollment Process

An enrollment broker will be used for enrollment.  Recipient enrollment process will begin in July 2016 and go through August 28, 2016.  Significant outreach is planned to encourage recipients to choose an RCO.  Recipients who do not choose an RCO will be auto assigned.

The enrollment broker will have a list of each RCO’s contracted providers.  Providers will be identified by name and practice group.  Information will be shared in a uniform, unbiased manner.

Recipients may change their choice of RCO within first 90 days after that time, may only change during open enrollment period.

Claims Filing Information

Claims for recipients in an RCO will no longer be filed to Hewlett Packard Enterprise.  Claims will be filed to the assigned RCO for payment.  Follow up on claims, research and training will be handled by the assigned RCO.  Prior Authorizations will also be handled by the RCO.

Where Can I Find More Information?


RCO Medicaid AL