SB 243 - This act modifies provisions relating to MO HealthNet managed care organizations rate setting.
Managed care organizations are required to maintain medical loss ratios of at least 85%, as defined by the National Association of Insurance Commissioners, for MO HealthNet operations. If a managed care organization's medical loss ratio falls below 85% over a cumulative period of 3 years, the organization shall be required to refund a portion of the capitation rates paid to the managed care plan in a tiered amount equal to the difference between the plan's medical loss ratio and 85% of the capitated payment to the managed care organization. When the medical loss ratio is between 85% and 80%, then 25% percent of the tier shall be returned to the state. When the medical loss ratio is less than 80%, then 75% of the tier shall be returned to the state.
This provision is similar to a provision in HCS/HB 1662 (2014).
This act also provides that for services that do not meet the definition of emergency services, a Medicaid managed care organization shall be required to reimburse out of network providers at the published MO HealthNet Medicaid fee-for-service schedule at the time of the service. A Medicaid managed care organization shall document three good faith attempts to include the provider in their network, using their standard participating provider agreement and fee schedule.