MO SB243

Managed care organizations participating in MO HealthNet must maintain medical loss ratios of at least 85% as defined by the National Association of Insurance Commissioners

If a managed care organization's medical loss ratio falls below 85% over a cumulative three-year period, the organization must refund a portion of capitation payments to the state

Refund amounts are tiered: 25% of the difference returned when the ratio is between 80-85%, and 75% returned when the ratio falls below 80%

For non-emergency services, Medicaid managed care organizations must reimburse out-of-network providers at the published MO HealthNet Medicaid fee-for-service rate

Managed care organizations must document three good faith attempts to include out-of-network providers in their network before using the fee-for-service reimbursement rate