| 1 | Representative Jones offered the following: |
| 2 |
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| 3 | Amendment (with title amendment) |
| 4 | Between lines 724 and 725, insert: |
| 5 | (4) MEDICAL LOSS RATIO FOR HEALTH PLANS.-An entity that |
| 6 | contracts with the agency on a prepaid or fixed-sum basis for |
| 7 | the provision of Medicaid services shall spend between 80 |
| 8 | percent and 85 percent of the Medicaid capitation revenue for |
| 9 | direct health services to enrollees. The plan is authorized to |
| 10 | spend up to 17 percent of the Medicaid capitation revenue on |
| 11 | costs other than direct health services, including, but not |
| 12 | limited to, profit, salaries, bonuses, administration, and |
| 13 | operating expenses. Administration and operating expenses |
| 14 | include costs incurred by the entity and its subcontractors for |
| 15 | prospective, concurrent, and retrospective utilization |
| 16 | management, pharmacy benefit management, network development, |
| 17 | and any other costs other than direct reimbursement to |
| 18 | providers. The agency shall adopt rules to administer this |
| 19 | subsection, including but not limited to, sanctions for |
| 20 | violations of this requirement. Any fines collected shall be |
| 21 | used to supplement the agency's Medicaid budget. |
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| 24 | ----------------------------------------------------- |
| 25 | T I T L E A M E N D M E N T |
| 26 | Remove line 50 and insert: |
| 27 | the agency to return prepaid plan overpayments; providing |
| 28 | for a medical loss ratio for health plans for entities |
| 29 | that contract with the agency on a prepaid or fixed-sum |
| 30 | basis; requiring the agency to adopt rules; providing for |
| 31 | collection of fines; creating |