GA HB947

Department of Community Health must engage an actuary to complete a study by December 1, 2020, on the fiscal impact of removing pharmacy benefits from Medicaid care management organizations (CMOs) and transferring them to the state's fee-for-service program

If the study projects combined state and federal savings of $20 million or more annually, the department must carve out pharmacy benefits from CMOs effective July 1, 2021, and administer them directly through the fee-for-service program

If projected savings fall between $10 million and $20 million, the department has discretionary authority—but no mandate—to proceed with the pharmacy benefit carve out, considering factors such as transparency and economic benefits

To fund the transition, the department would reduce each CMO's subsequent contract payment by 7.5 percent of the CMO's net underwriting gain for the July 1, 2020–June 30, 2021 contract year

Legislative findings cite over $50 million in spread pricing differentials, $499.8 million in CMO administrative expenses, self-dealing between CMOs and affiliated pharmacies, and bottom 25th percentile national rankings in multiple medication management measures as justification for the study