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AHCA says a Medicaid HMO will have to return money to state

TALLAHASSEE — One of the Medicaid HMOs that provides health care services to patients in Florida will be required to pay the state money under a provision in a law meant to prevent managed care plans from making a windfall off the health care program that pays for the poor, elderly and disabled.

Medicaid Deputy Secretary Beth Kidder told members of the House Health & Human Services Committee on Tuesday afternoon that there is a Medicaid health plan that will be required to pay the state money for failing to spend enough on health care services for Medicaid patients, but she did not tell House members the name of the plan.

“This year will be the first year one plans needs to return some dollars,” Kidder said responding to a question from panel member state Rep. Gayle Harrell. She asked whether the health plans were meeting an 85 percent medical loss ratio requirement and, if not, whether they are returning any dollars.

Kidder said that all the plans are meeting and exceeding the 85 percent requirement, but one of the plans is not meeting the spending ratios included in the “achieved savings rebate” provision of the 2011 law.

Agency for Health Care Administration Communications Director Mallory McManus refused to answer which plan would be required to return money to the state and how much money will be returned.

“The Agency anticipates that one plan will own (sic) money back,” McManus said in an email to POLITICO Florida. McManus said that the necessary audits are not complete. “Once finalized the Agency will notify plans of amounts due for the 2015 Achieved Savings Rebate, at which point the health plans will have 30 days from the date of notification to make payment.”

The Legislature passed a law in 2011 requiring most Medicaid patients to enroll in HMOs. In order to ensure that the monthly premium sent to the plans was being properly spent, and that the HMOs weren't making a windfall, lawmakers included “achieved savings rebates.”

The achieved savings rebate is established by determining pretax income as a percentage of revenues. The law lays out three income sharing ratios: plans can maintain 100 percent of income, up to and including 5 percent of revenue; plans keep 50 percent of income between 6 percent and 10 percent of revenue and the state receives the other 50 percent; the state receives 100 percent of income above 10 percent of the revenue.

Currently the law does not specify how returned savings are used.

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