Letter to CMS - Medicaid Managed Care Policies - Agency for ...

RICK SCOTT
GOVERNOR
Better Health Care for all Floridians
DRAFT QUARTERLY AND ANNUAL
MEDICAL LOSS RATIO (85%)
REFORM COUNITES ONLY
ELIZABETH DUDEK
SECRETARY
As a managed care plan providing health care covered services to Medicaid beneficiaries in
Reform counties (Baker, Broward, Clay, Duval, Nassau), your organization is subject to the
requirements of Section II, Medicaid Health Plan Medicaid Contract, CFR 45 Part 158, and
Chapter 409, Florida Statutes. This reads, in part, as follows:
“To ensure unimpaired access to health care covered services by Medicaid
beneficiaries in Reform counties, all contracts issued pursuant to this paragraph
shall require 85 percent of the capitation paid to the managed care plan to be
expended for the provision of health care covered services. In the event the
managed care plan expends less than 85 percent of the capitation paid pursuant to
this paragraph for the provision of health care covered services, the Federal Centers
for Medicare and Medicaid Services (CMS) will determine corrective action for
non-compliance under this contract.”
The Agency has determined that for this purpose, “health care covered services” are defined as
services provided by the health plan to Medicaid beneficiaries in Reform counties in accordance
with the Health Plan Medicaid Contract and as outlined in Section V, Covered Services, and
Section VI, Behavioral Health Care, and Attachment I.
Report the total capitation paid to your health plan for these specific services in Reform counties
(Baker, Broward, Clay, Duval, Nassau) only. Use this financial worksheet for calculating the
medical loss ratio (MLR). The calculation shall utilize uniform financial data collected from all
plans and shall be computed for each plan on a statewide basis. The method for calculating the
medical loss ratio shall meet the following criteria:
(a) Except as provided in paragraphs (b) and (c), expenditures shall be classified in a manner
consistent with 45 C.F.R. part 158.
(b) Funds provided by plans to graduate medical education institutions to underwrite the costs
of residency positions shall be classified as medical expenditures, provided the funding is
sufficient to sustain the position for the number of years necessary to complete the
residency requirements and the residency positions funded by the plans are active providers
of care to Medicaid and uninsured patients.
(c) Prior to final determination of the medical loss ratio for any period, a plan may contribute
to a designated state trust fund for the purpose of supporting Medicaid and indigent care
and have the contribution counted as a medical expenditure for the period.
272 7 M ah an D r i v e , MS # 2 6
T al l a has s ee, F l or i da 3 23 08
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