HB5433 Summary

• Department of Healthcare and Family Services must calculate managed care organization (MCO) payout ratios at least annually and post results on its website, with a minimum required payout ratio of 85%.

• MCOs failing to meet the 85% payout ratio threshold must refund the State an amount equal to the difference between their calculated ratio and 85% multiplied by coverage year revenue.

• "Payout ratio" is defined as total paid claims to medical providers by an MCO divided by total capitation payments made by the Department to that MCO for a given period.

• Beginning with calendar year 2019 capitation rates, the Department must exclusively use paid claims data submitted by MCOs when establishing managed care capitation rates.

• MCOs shall not be reimbursed by the State for any costs associated with health insurance fees.