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HB605 ENROLLED
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HB605
AR46WQ7-3
By Representative Kiel
RFD: Judiciary
First Read: 10-Mar-26
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First Read: 10-Mar-26
Enrolled, An Act,
Relating to rural healthcare; to authorize regulated
collaboration among rural healthcare providers and related
entities; to establish a certification and active supervision
framework administered by the state; to articulate a state
policy to preserve rural healthcare access and quality; to
provide limited immunity from state and federal antitrust laws
consistent with the state action doctrine; to prescribe
application, review, monitoring, renewal, and enforcement
procedures; to limit immunity to approved and supervised
conduct; and to provide related protections and
safeguards.
BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
Section 1. This act may be known and cited as the Rural
Health Antitrust Immunity Act.
Section 2. The Legislature finds and declares the
following:
(1) Alabama’s rural communities face persistent
disparities in access to care, workforce capacity, health
outcomes, and healthcare infrastructure, requiring coordinated
and sustained action across state agencies, the Legislature,
providers, and community partners.
(2) Rural healthcare facilities are closing and losing
important specialty services due to increasing costs and the
inability to recruit and retain qualified physicians and other
healthcare professionals.
(3) The One Big Beautiful Bill Act, signed into law on
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(3) The One Big Beautiful Bill Act, signed into law on
July 4, 2025, by President Donald J. Trump, established the
Rural Health Transformation Program, which authorizes states
to submit plans to strengthen rural communities by improving
healthcare access, quality, and outcomes by transforming the
healthcare delivery system. On November 5, 2025, the state
submitted its plan, known as the Alabama Rural Health
Transformation Program, to the Centers for Medicare & Medicaid
Services, which includes policy reforms, innovative care
models, shared-service infrastructure, and workforce
initiatives.
(4) On December 18, 2025, Governor Kay Ivey issued
Executive Order No. 741 which established the Alabama Rural
Health Transformation Advisory Group to coordinate policy
development, stakeholder engagement, and intergovernmental
collaboration.
(5) Collaboration among entities and individuals to
expand access to healthcare in rural areas of the state is in
the best interest of Alabama citizens.
(6) It is the policy of this state to improve
healthcare access, healthcare quality, and health outcomes for
Alabama citizens who live in one of the state’s rural counties
through the Alabama Rural Health Transformation Program’s
initiatives, and, where necessary, to substitute regulated
collaboration and coordination for unfettered competition
under active state supervision. The Legislature further
articulates a state policy to displace competition in rural
healthcare markets, when reasonably necessary to advance the
purposes of this Act, including authorization of conduct that
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purposes of this Act, including authorization of conduct that
may otherwise restrain trade, affect prices, markets, or
output.
(7) It is the intent of the legislature to exempt from
state anti-trust laws, and provide immunity from federal
anti-trust laws through the state action doctrine, to entities
and individuals carrying out the state’s policy provided in
this Act.
(8) This Act is intended to satisfy the requirements of
the state-action doctrine under federal antitrust law.
Section 3. (a) Subject to approval as provided in this
Act, entities and individuals may engage in data sharing,
collaborating, and providing shared services to carry out the
state’s policy provided in this Act. Such activities may
include, but are not limited to:
(1) Joint purchasing and contracting;
(2) Shared clinical, administrative, and support
services;
(3) Coordinated staffing arrangements;
(4) Joint quality improvement initiatives;
(5) Shared technology platforms;
(6) Joint negotiations with payors, suppliers, and
vendors;
(7) Coordinated service line development; and
(8) Shared facilities, equipment, and infrastructure.
(b) Notwithstanding any language or provision to the
contrary, joint negotiations with a Health Benefit Plan or
Health Insurer, as those terms are defined in Alabama Code
Section 27-45A-3(4) and 27-45A-3(5),respectively; an employee
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Section 27-45A-3(4) and 27-45A-3(5),respectively; an employee
welfare benefit plan, as defined in 29 U.S.C. 1002(1); a plan
that pays or reimburses for health care services pursuant to
Chapter 25A of Title 16, Code of Alabama 1975, Chapter 29 of
Title 36, Code of Alabama 1975, or Chapter 91A of Title 11,
Code of Alabama; or the administrator of any such plan is not
included and is hereby expressly prohibited from approval by
the Agency as an allowed activity pursuant to this Act.
(c) Prior to engaging in activities provided in
subsection (a), an entity or individual shall obtain a valid
certificate authorizing such activities issued by the State
Health Planning and Development Agency, acting through its
Executive Director.
(d) An applicant shall describe with reasonable
particularity:
(1) The parties to the engagement;
(2) The nature and scope of the proposed activities;
(3) The anticipated effects of engagement, including
any expected impact on competition; and
(4) Any other information requested by the State Health
Planning and Development Agency.
(e) In addition, to the requirements of subsection (c),
the applicant shall certify that the engagement is in good
faith and is reasonably necessary to further the state’s
policy set forth in this Act.
(f) The State Health Planning and Development Agency
may issue a certificate if it determines that the activities
are reasonably necessary to further the state’s policy set
forth in this Act and the benefits of the proposed activities
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forth in this Act and the benefits of the proposed activities
outweigh foreseeable anticompetitive effects. In making this
determination, the State Health Planning and Development
Agency may consider the effects of the proposed engagement on:
(1) The quality of hospital and related care provided
to rural Alabama citizens;
(2) The continued availability of hospital facilities
in close geographical proximity to the rural communities they
serve;
(3) Potential cost efficiencies in the services
provided by the applicant and other individuals and entities
involved in the proposed engagement;
(4) The efficient use of rural healthcare resources and
equipment, including the avoidance of duplication of resources
and equipment;
(5) Improvements in health outcomes in the region
impacted by the proposed engagement;
(6) Access to care for medically underserved rural
populations and the extent to which these populations are
likely to benefit from the proposed activities;
(7) The ability of rural healthcare payors to negotiate
appropriate payment and service arrangements with rural
healthcare providers;
(8) Competition among rural healthcare providers and
others providing goods or services to, or competing with, such
providers;
(9) The quality, availability, and price of healthcare
services for rural Alabama citizens; and
(10) Whether other alternatives could reasonably
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(10) Whether other alternatives could reasonably
achieve the same or greater public health benefits with fewer
anticompetitive effects.
(g) A certificate issued under this section shall not
become effective unless and until it is reviewed and approved
in writing by the Governor or the Governor’s designee. The
Governor may approve, in whole or in part, disapprove, or
return the certificate for further consideration, and may
impose conditions consistent with the purposes of this Act.
Section 4. (a) A certificate issued pursuant to section
3. is valid for a period of three years. An applicant may
renew its certificate in three-year increments. An application
for renewal shall include:
(1) A certification that the engagement has continued
and will continue in good faith and continues to be reasonably
necessary to further the state’s policy set forth in this Act;
(2) An explanation of how the engagement has furthered
the state’s policy as set forth in this Act; and
(3) Any other information requested by the State Health
Planning and Development Agency.
(b) The State Health Planning and Development Agency
may approve the renewal, in whole or in part, or on an amended
basis, if it determines that the activities continue to be
reasonably necessary to further the state’s policy set forth
in this Act and the benefits of the proposed activities
outweigh foreseeable anticompetitive effects.
Section 5. (a) The State Health Planning and
Development Agency shall adopt rules that provide for the
ongoing and active supervision of activities conducted
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ongoing and active supervision of activities conducted
pursuant to a certificate issued under this Act.
(b) Notwithstanding Section 4., the State Health
Planning and Development Agency shall amend or revoke a
certificate at any time if it determines that the activities
conducted pursuant to a certificate under this act are not
reasonably necessary to further the state’s policy set forth
in this Act or the benefits of the proposed activities do not
outweigh foreseeable anticompetitive effects.
Section 6. The State Health Planning and Development
Agency shall adopt rules to implement this act.
Section 7. This act shall become effective immediately.
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Section 7. This act shall become effective immediately.
________________________________________________
Speaker of the House of Representatives
________________________________________________
President and Presiding Officer of the Senate
House of Representatives
I hereby certify that the within Act originated in and
was passed by the House 31-Mar-26.
John Treadwell
Clerk
Senate 09-Apr-26 Passed
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