SB 1111 - Under this act, any contract between the state and a vendor of prepaid capitated health services issued, reauthorized, or renewed after August 28, 2016, shall incorporate the standards specified in this act, including: (1)utilization review protocols, standards for determining medical necessity for services, and payment authorizations; (2) timely appeals of utilization reviews and payment authorizations; (3) network adequacy standards; (4) standardized administrative requirements; (5) alternative or supplemental payments made to hospitals if Medicaid upper payment limit payments are prevented by federal statutory or regulatory requirements; (6) actuarially-sound capitation rates; (7) penalties for failure to reduce non-emergency use of hospital emergency departments; (8) medical loss ratios; (9) the provision of monitoring data; (10) shared savings and risk-and-gain-sharing arrangements between vendors and health care providers; (11) prohibitions on compelling or coercing health care providers to participate in a health care system; and (12) timely payment of providers.
The Department of Social Services shall accept regional plan proposals from provider-sponsored care management organizations as an option for coverage of beneficiaries. Such regional proposals may be submitted by coordinated care organizations (CCOs), which are organizations that are accountable for the quality, cost, coordination, and overall care of a defined group of MO HealthNet participants. The regional or statewide CCOs shall use a shared savings-shared risk model, and the Department shall reimburse the CCOs through a global payment methodology, which may utilize a population-based mechanism based on a per-member, per-month calculation with risk-adjustment, risk sharing, and aligned payment incentives. The Department may develop performance incentive payments designed to reward increased quality and decreased cost of care.
The State Auditor shall conduct an annual evaluation of the savings and costs attributable to state government, political subdivisions, health care providers, and MO HealthNet participants following the expansion of MO HealthNet managed care on or after May 1, 2017. The annual evaluations shall include an assessment of the financial implications attributable to the use of subcontractors by prepaid capitated health services to administer the delivery of health services, including behavioral health services, to MO HealthNet participants.