The Medicaid Agency may contract with an alternate care provider in a Medicaid region only under the terms of this section:
(1) If a regional care organization failed to provide adequate service pursuant to its contract, or had its certification terminated, or if the Medicaid Agency could not award a contract to a regional care organization under the terms of Section 22-6-153, or if no organization had been awarded a regional care organization certificate by October 1, 2016, or a later date established by the Medicaid Agency if an extension is determined, in the Medicaid Agency's sole discretion, to be in the best interest of the state, then the Medicaid Agency shall first offer a contract, to resume interrupted service or to assume service in the region, under the conditions of Section 22-6-153 to any other regional care organization that Medicaid judged would meet its quality criteria.
(2) If by October 1, 2014, no organization had a probationary regional care organization certification in a region. However, the Medicaid Agency could extend the deadline until January 1, 2015, if it judged an organization was making reasonable progress toward getting probationary certification. If the Medicaid Agency judged that no organization in the region likely would achieve probationary certification by January 1, 2015, then the Medicaid Agency shall let any organization with probationary or full regional care organization certification apply to develop a regional care organization in the region. If at least one organization made such an application, the agency no sooner than October 1, 2015, would decide whether any organization could reasonably be expected to become a fully certified regional care organization in the region and its initial region.
(3) If an organization lost its probationary certification before October 1, 2016, or a later date established by the Medicaid Agency if an extension is determined, in the Medicaid Agency's sole discretion, to be in the best interest of the state, Medicaid shall offer any other organization with probationary or full regional care organization certification, which it judged could successfully provide service in the region and its initial region, the opportunity to serve Medicaid beneficiaries in both regions.
(4) The Medicaid Agency may contract with an alternate care provider only if no regional care organization accepted a contract under the terms of subdivision (1), no organization was granted the opportunity to develop a regional care organization in the affected region under the terms of subdivision (2), or no organization was granted the opportunity to serve Medicaid beneficiaries under the terms of subdivision (3).
(5) The Medicaid Agency may contract with an alternate care provider under the terms of subdivision (4) only if, in the judgment of the Medicaid Agency, care of Medicaid enrollees would be better, more efficient, and less costly than under the then existing care delivery system. Medicaid may contract with more than one alternate care provider in a Medicaid region.
Last modified: May 3, 2021