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Alabama Medicaid Agency Updates

Alabama Medicaid Agency Updates

Short-Acting Opioid Naïve Limits — Effective Nov. 1

Effective Nov. 1, 2018, the Alabama Medicaid Agency will begin implementing limits on short-acting opiates for opioid naïve recipients. The Agency defines “opioid naïve” as a recipient with no opioid claim in the past 180 days.

Edit Details:

  • A 7-day supply limit for adults age 19 and older
  • A 5-day supply limit for children age 18 and younger
  • A maximum of 50 morphine milligram equivalents (MME) per day allowed on a claim for an opioid naïve recipient
  • Any claim for a short-acting opioid for an opioid naïve recipient exceeding the maximum days’ supply limit or MME limit will be denied.
  • Claims prescribed by oncologists will bypass the edit.
  • Long-term care and hospice recipients are excluded.
  • Refills of remaining quantities and/or new prescriptions filled within 180 days of the initial opioid naive claim will require an override.
  • Refills of remaining quantities of prescriptions that are partially-filled will be allowed per State and federal law* but will require an override through Medicaid. See below for more details from the State Board of Pharmacy.
  • For adults, the refill of the quantity remaining on the partial fill will not count towards the prescription limit if filled within 30 days of the original prescription. Monthly maximum unit quantities still apply.
  • Overrides for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria Booklet for information about override requirements. Please refer to the following link for more information regarding overrides for opioid naïve patients:
  • A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found at

IMPORTANT: A recipient may not pay cash for the remaining amount over 7 days for the same prescription of a Medicaid-paid opioid claim (ie a single fill/dispense/claim may not be ‘split billed’ to both Medicaid and cash). If the prescription to be paid by Medicaid exceeds the drug’s limit allowed, an override may be requested. Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit. A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process. FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS. Source: Provider Billing Manual 27.2.3 

Morphine Milligram Equivalents (MME) Information/Examples

Higher doses of opioids are associated with a higher risk of overdose and death. Even relatively low dosages (20-50 MME per day) increase risk.1

Examples of MME calculations/day include:

  • 10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
  • 6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
  • 5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
  • 2 tablets per day of oxycodone 15 mg = 45 MME/day
  • 3 tablets per day of oxycodone 10 mg = 45 MME/day
  • 10 tablets per day of tramadol 50 mg = 50 MME/day
  • 1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

A link with more information regarding MME calculations is

*Partial Filling of Schedule II Medication: Per the Alabama State Board of Pharmacy website, there has been a change in federal law regarding partial filling of Schedule II controlled substance (CS). The Comprehensive Addiction and Recovery Act (CARA) of 2016 passed the United States Senate and was signed into law on July 22, 2016. CARA allows pharmacists to partially fill Schedule II CS. According to CARA, a prescription may be partially filled if: it is written and filled according to state and federal law; the partial fill is requested by the patient or prescribing practitioner; and the total quantity dispensed does not exceed the quantity prescribed. Remaining portions of partially filled prescriptions must be filled within 30 days of the original written prescription date. There is no single specified way to fill or bill prescriptions under the CARA update.2

Override Requests
Pharmacy override requests for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria instructions for information about override requirements at:

The Override Request Form is to be used by the prescriber or the dispensing pharmacy when requesting an override. The form can be found at:

Providers requesting overrides by mail or fax should send requests to:

Health Information Designs (HID)
Medicaid Pharmacy Administrative Services
P. O. Box 3210 Auburn, AL 36832-3210
Fax: 1-800-748-0116
Phone: 1-800-748-0130

Incomplete requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the override form to HID. Additional information may be requested. Staff physicians will review this information.

Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding override procedures should be directed to the HID help desk at 1-800-748-0130.

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Alabama Medicaid Seeks Public Comments

Alabama Medicaid Seeks Public Comments

Alabama Medicaid is seeking public comment on an amendment to the Alabama Home and Community-Based Intellectual Disabilities Waiver.

Medicaid Intellectual Disabilities Waiver Amendment | Comments Submitted by October 8, 2017

The Alabama Medicaid Agency is seeking public comment on its proposal to amend the Alabama Home and Community-Based Intellectual Disabilities Waiver (ID Waiver).

The waiver supports Alabama citizens who have a diagnosis of Intellectual Disabilities and who would otherwise require the level of care offered in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) institution to remain in the community. The waiver provides services such as day services and in-home supports. The amendment proposes changes to the sections pertaining to Individual Directed Goods and Services and self-directed services.

A copy of the proposed application can be found on the Alabama Medicaid Agency website. Click here to view waiver documents.

The comment period is open until October 8, 2017. Written comment regarding the proposed waiver amendment are welcome and should be mailed to Samantha McLeod, Associate Director via mail to: Alabama Medicaid Agency, Long Term Care Division, P.O. Box 5624, Montgomery, AL 36103-5624 or via email to

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Alabama Medicaid to Pursue an Alternative to RCOs

Alabama Medicaid to Pursue an Alternative to RCOs

MONTGOMERY – Alabama Medicaid Commissioner Stephanie Azar announced Thursday that in light of known federal administration changes and potential congressional adjustments, the Alabama Medicaid Agency will pursue an alternative to the Regional Care Organization initiative to transform the Medicaid delivery system. The state will work with the Centers for Medicare and Medicaid Services to create a flexible program that builds off the Agency’s current case management structure as a more cost-efficient mechanism to improve recipients’ health care outcomes.

Commissioner Azar cited major changes in federal regulations, funding considerations, and the potential for new opportunities for state flexibility regarding Medicaid spending and services under the Trump Administration as key factors in the decision to employ a new strategy for the state Medicaid program. Since the passage of the RCO statute, new managed care regulations have made the RCO program less viable for the state. Additionally, funding uncertainties at the state and federal levels led to the withdrawal of several probationary RCOs.

“It is highly likely that federal health care changes are on the horizon,” Commissioner Azar said. “While the financial implications could be challenging for our state, the new flexibilities and waiver options that the Trump Administration is willing to consider gives our state Medicaid program new options to accomplish similar goals without incurring the same level of increased upfront costs associated with the RCO program. In the coming days, I will work with Gov. Ivey, our stakeholders and CMS to develop an innovative model to accomplish our goal of retooling Medicaid to better serve the needs of Alabamians.”

The Medical Association would like to thank Commissioner Azar for her diligence through the RCO process and willingness to work with Alabama’s physicians.

“Navigating through this process hasn’t been an easy one, and we certainly recognize the work that Commissioner Azar has done on the behalf of Alabama’s physicians to help improve the Medicaid program,” said Medical Association Executive Director Mark Jackson. “We look forward to our continued working relationship with the Commissioner and Gov. Ivey’s administration to solve the challenges on the road ahead.”

Gov. Ivey also supported the shift in strategy adding by statement: “The RCO model didn’t fail; instead the alternative is a recognition that the circumstances surrounding Medicaid have changed, thus our approach must change. Our end goal is clear – to increase the quality of services provided and protect the investment of Alabama taxpayers.”

RCOs were mandated by state law in 2013 to move the Medicaid agency away from its current payment system to one that would incentivize efficient delivery of high-quality healthcare services and improve health outcomes. When the RCOs were first proposed after the Affordable Care Act under the Obama Administration, the plan was appropriate; however, in today’s climate, it is no longer the best use of taxpayer resources, she said. The program was set to launch in 23 north and west Alabama counties on Oct. 1, 2017.

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AARP: States Lag In Keeping Medicaid Enrollees Out Of Nursing Homes

AARP: States Lag In Keeping Medicaid Enrollees Out Of Nursing Homes

By Phil Galewitz, Kaiser Health News | June 14, 2017

States are making tepid progress helping millions of elderly and disabled people on Medicaid avoid costly nursing home care by arranging home or community services for them instead, according to an AARP report released Wednesday.

“Although most states have experienced modest improvements over time, the pace of change is not keeping up with demographic demands,” said the report, which compared states’ efforts to improve long-term care services over the past several years. AARP’s first two reports on the subject were in 2011 and 2014.

The organization ranked states’ performance on long-term care benchmarks such as a supply of home health aides, nursing home costs, long nursing home stays, the employment rate of people with disabilities and support for working caregivers.

With 10,000 people a day turning 65 and the eldest baby boomers beginning to turn 80 in 2026, the demand for long-term care services is expected to soar in coming years.

AARP officials said the House’s bill to repeal the Affordable Care Act would worsen the situation by capping annual federal revenue for states’ Medicaid programs. That bill is now before the Senate.

“The proposed cuts to Medicaid — the largest public payer of long-term assistance — would result in millions of older adults and people with disabilities losing lifesaving supports,” said Susan Reinhard, senior vice president and director of the AARP Public Policy Institute.

The report found strikingly wide variances in the share of state Medicaid spending for long-term care directed to home- and community-based services for elderly and disabled adults in 2014, the latest year for data covering all states. Minnesota, the top-ranked state, spent about 69 percent, but Alabama, ranked last, spent less than 14 percent.

Nationwide, the average edged up from 39 percent in 2011 to 41 percent in 2014.

Only nine states and the District of Columbia spent more on home- and community-based services than on nursing home care, according to the report. Such services include home health care, caregiver training and adult day care.

People turning 65 this year face about a 50-50 chance of needing long-term care services in their lifetime, AARP officials said.

Trish Riley, executive director of the National Academy for State Health Policy, said states face several obstacles to expand home- and community-based options. They include a strong nursing home lobby that does not want to give up its Medicaid dollars and a shortage of transportation and housing options, particularly in rural areas.

An Alabama Medicaid spokeswoman said the state is working on the issue highlighted by AARP but refused to comment on its report.

John Matson, a spokesman for the Alabama Nursing Home Association, rejected the notion that nursing homes are to blame. “We think it’s a shift that needs to happen in Alabama. We can’t build enough nursing homes to meet [the needs of] everyone that is coming,” he said.

The state’s effort to shift Medicaid patients from long-term care into managed care organizations starting next year will help, because those entities will have a financial incentive to keep people at home for care when possible, Matson said.

Reinhard said many states have struggled to expand home- and community-based options for Medicaid enrollees needing long-term care because that is an optional benefit. Nursing homes are mandatory under federal law. While states focus on Medicaid coverage for children and families — as well as non-disabled adults covered by the Medicaid expansion under the Affordable Care Act — adults with disabilities have received less attention.

“Long-term care is a stepchild of the program and not a top focus for states,” she said.

To view the full report, go to The report was funded by the AARP Foundation, The Commonwealth Fund and The SCAN Foundation.

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation. | @philgalewitz

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RCO Implementation On Schedule; New Regions Offered to Other Probationary RCOs

RCO Implementation On Schedule; New Regions Offered to Other Probationary RCOs

MONTGOMERY – The Alabama Medicaid Agency has been notified that Envolve, a wholly-owned subsidiary of Centene, is ending its agreement as a capital contributor with all five Alabama Healthcare Advantage (AHA) organizations that had planned to operate as Regional Care Organizations this fall.

Alabama Medicaid Commissioner Stephanie Azar said the AHA organizations have notified the Agency that they intend to end their pursuit of full certification, pending a final decision by the five regional boards in the upcoming days.

While the immediate result would be the loss of five probationary RCOs, the Agency is still in position to implement Regional Care Organizations by Oct. 1, 2017, under a 2013 state law that allows current probationary RCOs to provide services in additional regions, Commissioner Azar said.

The law requires the State to first offer existing probationary RCOs the opportunity to provide services in other regions if no RCOs are certified in a region. The withdrawal of AHA would leave Regions B, D and E without a certified RCO.  The Agency has implemented a process to offer the vacant regions to other probationary RCOS.

Two probationary RCOs have availed themselves of the process. Alabama Community Care – Region A and My Care Alabama have taken initial steps to qualify to offer services in these three regions. Both organizations are already probationary RCOs in the north Alabama region (Region A) and Alabama Community Care – Region C is also a probationary RCO in the western region of the state. Both have put in writing interest to provide services in Regions B, D, and E and are working closely with the Agency to accomplish this goal. As a result, the Agency has confidence the state can have at least one certified RCO in each of the regions by Oct. 1, 2017.

If for some reason no probationary RCO becomes fully certified and contracts to offer services in these regions, then state law allows the state to offer “alternative care providers” the opportunity to operate in those regions.

Gov. Robert Bentley emphasized that Regional Care Organizations represent the best plan to transform the Medicaid health care delivery system in Alabama.

“We will continue to move forward with our Regional Care Organizations, because we must have a delivery system for Medicaid that provides high-quality care, while working to reduce the cost of healthcare. In Alabama, we have already started engaging in conversations with President Trump and incoming Health and Human Services Secretary Tom Price. We are closely monitoring Congress as they work to repeal and replace the Affordable Care Act,” he said. “As the federal government works with states to help develop a plan, in Alabama, we will continue to support RCOs because we feel it’s the best plan for the state.”

On the Web:

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Alabama Medicaid Pushes RCO Start Date to October 2017

Alabama Medicaid Pushes RCO Start Date to October 2017

The State of Alabama’s shift to managed care has been long in the works, and it looks as though the wait will be a little longer before the regional care organizations will be officially operational, according to the Alabama Medicaid Agency.

While Gov. Robert Bentley has said repeatedly that he remains committed to moving forward with the RCO system, earlier this week he admitted that there are too many questions and not enough answers to allow the system to become effective this summer as originally planned.

“The election changed things, but I think long-term funding is the real issue,” Gov. Bentley said. “I believe a managed care system based on outcomes rather than on fee-for-service is the best way to go for our Medicaid patients.”

Alabama has been working since 2013 toward a managed care system that would shift some of the state’s 1 million Medicaid patients to care through the RCO system, ensuring patients receive check-ups and preventive care while limiting expensive ER visits later on.

Also earlier this week, Alabama Medicaid issued clarification regarding reimbursement by RCOs for services provided to RCO Enrollees by out-of-network providers. This guidance only applies to the populations and the services included in the RCOs. For a listing of the populations and services included in the RCO please visit the Medicaid website.

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RCO Implementation Changes and Service Delivery Network Timelines

RCO Implementation Changes and Service Delivery Network Timelines

The Alabama Medicaid Agency is working with Centers for Medicare and Medicaid Services to amend the approved 1115 waiver to allow for an Oct. 1, 2017, start date for the Regional Care Organization program.

The deadline for probationary RCOs to demonstrate the existence of an adequate service delivery network by submitting to Medicaid signed contracts from their network providers is Jan. 10, 2017. As probationary RCOs work to meet this service delivery network adequacy deadline, providers may be contacted by probationary RCOs with whom they are not currently contracted.

Information about RCOs, implementation or other aspects of this managed care program may be found on the Agency’s RCO webpage

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Primary Care Cut Restored; Physicians Must Re-Attest to Qualify

Primary Care Cut Restored; Physicians Must Re-Attest to Qualify

In a press conference Thursday, Sept. 22, Gov. Robert Bentley and Alabama Medicaid Commissioner Stephanie Azar announced that the primary care cut, which became effective Aug. 1, will be restored on Oct. 1. However, Medicaid-enrolled primary care physicians who qualify for the Primary Care Enhanced Physicians Rates must self-attest in order to continue to receive the payments. No dates have been set by Medicaid for the attestation process. Medicaid will be sending a notice out to providers shortly on how to re-attest.

To qualify for the reinstated bump beginning Oct. 1, physicians will need to re-attest and meet one of the following requirements:

  1. A physician must have a specialty or subspecialty designation in family medicine, general internal medicine, or pediatrics that is recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA), and they actually practice in their specialty.
  2. A NON-board certified physician who practices in the field of family medicine, general internal medicine, or pediatrics or a subspecialty under one of these specialties, is eligible if he/she can attest that 60 percent of their paid Medicaid procedures billed are for certain specified procedure codes for evaluation and management (E&M) services and certain Vaccines for Children (VFC) vaccine administration codes.

Alabama Medicaid: Primary Care Enhanced Physician Rates “Bump” Certification and Attestation Form

*Note: Practitioners (physician assistants or certified registered nurse practitioners) providing services under the personal supervision of eligible physicians may qualify.

When the cuts originally took effect on Aug. 1, they amounted to 30 to 40 percent of medical practice revenue, according to Executive Director Mark Jackson.

“Regardless of what kind of business you’re in, if you’re seeing cuts of 30 and 40 percent, it’s going to make a major impact on your bottom line,” Jackson said.

The restoration of the bump will also allow the state to continue to implement RCOs. This renewed funding should put the rollout of the RCOs on track by next July, according to Azar.

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