HB 7187 - Medicaid Summary

• Requires Medicaid providers to comply with the Medicaid Encounter Data System as a condition of provider agreements and mandates annual agency reports to the Governor and Legislature on system participation and compliance.

• Implements budget-neutral risk-adjusted capitation rates for prepaid Medicaid plans beginning October 1, 2010, phased in over 3 years, with a technical advisory panel to advise on transition and rate-setting methodology.

• Establishes medical homes as a care delivery model with three certification tiers (Tier One, Two, and Three) that provide enhanced primary care case management and care coordination, with monthly enhanced case management fees and a statewide advisory panel for oversight.

• Requires prepaid and fixed-sum Medicaid contracts to maintain an 85% medical loss ratio, with agency authority to recoup excess payments and redistribute them to plans spending above 85% on medical services.

• Sets mandatory enrollment targets of 65% in provider service networks certified as medical homes and 35% in other managed care plans for Medicaid recipients who fail to choose a plan.