33-21A-14. Minimum medical loss ratio standard; remittance directions; required website information.

The intent of this Code section is to implement the state option in subdivision (j) of 42 C.F.R. Section 438.8.#

As used in this Code section, the term “medical loss ratio reporting year” or “MLR reporting year” shall have the same meaning as that term is defined in 42 C.F.R. Section 438.8.#

Beginning July 1, 2023, care management organizations shall comply with a minimum 85 percent medical loss ratio or such higher minimum percentage as may be set out in a contract between the department and a care management organization consistent with 42 C.F.R. Section 438.8. The ratio shall be calculated and reported for each MLR reporting year by each care management organization consistent with 42 C.F.R. Section 438.8.#

1. (1)

   Effective for contract rating periods beginning on and after July 1, 2023, each care management organization shall provide a remittance for an MLR reporting year if the ratio for that MLR reporting year does not meet the minimum MLR standard of 85 percent. The department shall determine the remittance amount on a plan-specific basis for each rating region of the plan and shall calculate the federal and nonfederal share amounts associated with each remittance.#

2. (2)

   After the department returns the requisite federal share amounts associated with any remittance funds collected in any applicable fiscal year to the federal Centers for Medicare and Medicaid Services, the remaining amounts remitted by care management organizations pursuant to this section shall be transferred to the general fund.#

Except as otherwise required under this Code section, the requirements under this Code section shall not apply to a health care service plan under a subcontract with a care management organization to provide covered health care services to Medicaid and PeachCare for Kids members.#

The department shall post on its website the following information:#

1. (1)

   The aggregate MLR of all care management organizations;#

2. (2)

   The MLR of each care management organization; and#

3. (3)

   Any required remittances owed by each care management organization.#

The department shall seek any federal approvals it deems necessary to implement this Code section.#