409.9124 Managed care reimbursement.
409.9124 Managed care reimbursement.
The agency shall develop and adopt by rule a methodology for reimbursing managed care plans.
(1) Final managed care rates shall be published annually prior to September 1 of each year, based on methodology that:
(a) Uses Medicaid’s fee-for-service expenditures.
(b) Is certified as an actuarially sound computation of Medicaid fee-for-service expenditures for comparable groups of Medicaid recipients and includes all fee-for-service expenditures, including those fee-for-service expenditures attributable to recipients who are enrolled for a portion of a year in a managed care plan or waiver program.
(c) Is compliant with applicable federal laws and regulations, including, but not limited to, the requirements to include an allowance for administrative expenses and to account for all fee-for-service expenditures, including fee-for-service expenditures for those groups enrolled for part of a year.
(2) Each year prior to establishing new managed care rates, the agency shall review all prior year adjustments for changes in trend, and shall reduce or eliminate those adjustments which are not reasonable and which reflect policies or programs which are not in effect. In addition, the agency shall apply only those policy reductions applicable to the fiscal year for which the rates are being set, which can be accurately estimated and verified by an independent actuary, and which have been implemented prior to or will be implemented during the fiscal year.
(3) The agency shall by rule prescribe those items of financial information which each managed care plan shall report to the agency, in the time periods prescribed by rule. In prescribing items for reporting and definitions of terms, the agency shall consult with the Office of Insurance Regulation of the Financial Services Commission wherever possible.
(4) The agency shall quarterly examine the financial condition of each managed care plan, and its performance in serving Medicaid patients, and shall utilize examinations performed by the Office of Insurance Regulation wherever possible.
(5) The agency shall develop two rates for children under 1 year of age. One set of rates shall cover the month of birth through the second complete month subsequent to the month of birth, and a separate set of rates shall cover the third complete month subsequent to the month of birth through the eleventh complete month subsequent to the month of birth. The agency shall amend the payment methodology for participating Medicaid-managed health care plans to comply with this subsection.
(6) For the 2005-2006 fiscal year only, the agency shall make an additional adjustment in calculating the capitation payments to prepaid health plans, excluding prepaid mental health plans. This adjustment must result in an increase of 2.8 percent in the average per-member, per-month rate paid to prepaid health plans, excluding prepaid mental health plans, which are funded from Specific Appropriations 225 and 226 in the 2005-2006 General Appropriations Act.
History. s. 9, ch. 96-199; s. 451, ch. 2003-261; s. 19, ch. 2004-270; s. 18, ch. 2005-60; s. 20, ch. 2005-133; s. 13, ch. 2008-143.