Florida Senate - 2010                                    SB 1002
       
       
       
       By Senator Lawson
       
       
       
       
       6-00601-10                                            20101002__
    1                        A bill to be entitled                      
    2         An act relating to Medicaid; providing a purpose;
    3         providing definitions; requiring each managed care
    4         organization to certify to the Agency for Health Care
    5         Administration its medical loss ratio and the medical
    6         loss ratio for its subcontractors; providing
    7         requirements for the reporting of the medical loss
    8         ratios; requiring the managed care organization to pay
    9         a certain amount to the agency if the certified
   10         medical loss ratio is less than a specified ratio;
   11         requiring the agency to adopt rules; requiring that
   12         fines collected supplement the agency’s Medicaid
   13         budget; providing that the requirements and penalties
   14         imposed are assigned in full to any parent
   15         corporation, subsequent owner, or successor in
   16         interest of the managed care organization; providing
   17         an effective date.
   18  
   19  Be It Enacted by the Legislature of the State of Florida:
   20  
   21         Section 1. (1) The purpose of this section is to ensure
   22  that a managed care organization that contracts to provide
   23  services for Medicaid beneficiaries in this state expend at
   24  least 85 percent of the total revenue it receives from monthly
   25  premiums on direct health care benefits for its enrollees.
   26         (2) As used in this section, the term:
   27         (a) “Agency” means the Agency for Health Care
   28  Administration.
   29         (b) “Medical loss ratio” means the ratio of total revenue
   30  from monthly premium payments received from the agency by a
   31  managed care organization and expended for direct health care
   32  benefits to the total amount of such payments expended for any
   33  other purpose. Costs and expenditures that are not related to
   34  direct health care benefits include, but are not limited to,
   35  profit, salaries, bonuses, and administration and operating
   36  expenses, including expenses relating to prior authorization or
   37  other utilization review regarding the provision of direct
   38  health care benefits.
   39         (c) “Managed care organization” means a health maintenance
   40  organization or prepaid health plan providing goods and services
   41  under s. 409.912, Florida Statutes.
   42         (3) If a managed care organization enrolls Medicaid
   43  beneficiaries under the pilot program established at s.
   44  409.91211, Florida Statutes, the pilot program and nonpilot
   45  program portions of the organization’s health care financing and
   46  delivery system shall be considered separate and distinct
   47  managed care organizations for purposes of this section.
   48         (4) Beginning December 15, 2010, and each quarter
   49  thereafter, each managed care organization shall certify to the
   50  agency its medical loss ratio and the medical loss ratio of each
   51  of its subcontractors. The medical loss ratio for behavioral
   52  health shall be reported separately by each managed care
   53  organization.
   54         (5) If any medical loss ratio certified to the agency under
   55  subsection (4) is less than 85 to 15, the managed care
   56  organization and its subcontractors shall immediately pay to the
   57  agency an amount equal to the difference between 85 percent of
   58  total revenue from their monthly premium payments and their
   59  corresponding expenditures for direct health care benefits for
   60  the relevant quarter.
   61         (6) The agency shall adopt rules to administer this
   62  section, including, but not limited to, a schedule of sanctions
   63  for any violation of the 85-to-15 requirements set forth in this
   64  section. Any fines collected shall be used to supplement the
   65  agency’s Medicaid budget and do not revert to the General
   66  Revenue Fund.
   67         (7) All requirements of this section and penalties imposed
   68  pursuant to this section against a managed care organization
   69  shall be assigned in full to any parent corporation, subsequent
   70  owner, or subsequent successor in interest of the managed care
   71  organization.
   72         Section 2. This act shall take effect July 1, 2010.