,,ii #aacth ,,congress #ast ,session ,s4 #aghg ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,december #aj1 #bjac,mr4 ,rockefeller introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to require a medical loss ratio of #he percent for ,medicaid managed care plans1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,medicaid ,managed ,care ,responsibility and ,equity ,act4 #b4 ,minimum medical loss ratio requirements for ,medicaid and ,,chip managed care plans 7a7 ,minimum medical loss ratio requirements for ,medicaid and ,,chip managed care plans ,section #aijc7m7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7m77 is amended-- 7#a7 in paragraph 7#b77;,a7-- 7,a7 by striking and at the end of clause 7xii72 7,b7 by realigning the left margin of clause 7xiii7 so as to align with the left margin of clause 7xii7 and by striking the period at the end of clause 7xiii7 and inserting 2 and2 and 7,c7 by adding at the end the following new clause3 7xiv7 such contract provides that if the ,secretary determines for a contract year 7beginning on or after ,october #a1 #bjag7 that the entity has failed to have a medical loss ratio1 as determined in accordance with paragraph 7#c71 of at least 4#he 74#hj in the case of an entity in which at least #aj percent of the individuals enrolled in the plan are optional targeted low-income children described in section #aije7u77#b77;,b77-- 7,i7 the entity shall remit 7not later than ,january #a of the first calendar year that begins on or after the first day of the contract year7 to the ,state an amount equal to the product of the total revenue of the entity under the ,state plan under this title 7or under a waiver of such plan7 for the contract year and the difference between 4#he 7or 4#hj1 if applicable7 and the medical loss ratio 7as so determined7 and that any such remittances paid by an entity shall be treated as an overpayment under section #aijc7;d77#c77;,a72 7,,ii7 for #c consecutive contract years1 the ,state shall not permit the enrollment of new enrollees with the entity for coverage during the second succeeding contract year2 and 7,,iii7 the ,state shall terminate the contract if the entity fails to have such a medical loss ratio for #e consecutive contract years4 2 and 7#b7 by inserting after paragraph 7#b71 the following3 7#c7 7,a7 ,for purposes of paragraph 7#b77;,a77xiv71 the medical loss ratio for an entity with a contract under this subsection shall be equal to the ratio of-- 7i7 the sum of the amount of contract revenue 7as determined in accordance with subparagraph 7,b77 expended by the entity-- 7,i7 for providing medical assistance to individuals who are eligible under the ,state plan under this title or under a waiver of such plan and who are enrolled with the entity2 and 7,,ii7 for quality improvement activities 7as determined in accordance with subparagraph 7,c772 to 7ii7 the total amount of contract revenue 7as determined in accordance with subparagraph 7,b774 7,b7 ,for purposes of subparagraph 7,a71 the ,secretary shall by regulation specify how contract revenue shall be determined with respect to an entity with a contract with the ,state under this subsection and a contract year4 ,the regulations shall provide that the following shall be disregarded from the determination of contract revenue for a contract year3 7i7 7,i7 ,only in the case of an entity that is exempt from ,federal income tax1 community benefit expenditures made by the entity 7not to exceed the limit described in subclause 7,,ii77 and reserve funds 7not to exceed the limit described in subclause 7,,iv774 7,,ii7 ,the limit described in this subclause is the amount equal to #c percent of the contract revenue for the contract year or the amount equal to the product of the highest premium tax rate in the ,state and the contract revenue1 whichever is greater4 7,,iii7 ,in this clause1 the term community benefit expenditures means expenditures for activities or programs that seek to achieve the objectives of improving access to health services1 enhancing public health1 and relieving government burden4 7,,iv7 ,the limit described in this subclause is the amount equal to #c percent of the contract revenue for the contract year except that an entity that is exempt from ,federal income tax may increase the amount of reserve funds to be disregarded for a contract year up to a limit that does not exceed the amount equal to the sum of #c percent of the contract revenue for the contract year and the total amount of the reserve funds disregarded for the #b preceding contract years or #i percent of the contract revenues during such #c-year period1 whichever is greater4 7ii7 ,expenditures for providing medical assistance to a new beneficiary population enrolled with the entity for the first #b contract years of such population's enrollment4 7,c7 7i7 ,for purposes of subparagraph 7,a71 quality improvement activities are activities designed to do any of the following3 7,i7 ,to improve health outcomes by implementing activities such as effective case management1 care coordination1 quality reporting1 chronic disease management or medication and care compliance activities4 7,,ii7 ,to prevent hospital readmissions1 including a comprehensive program for hospital discharge that includes patient education and counseling1 discharge planning1 and post-discharge follow-up by an appropriate health care professional4 7,,iii7 ,to improve patient safety and reduce medical errors through the use of best clinical practices1 evidence-based medicine1 and health information technology4 7,,iv7 ,to implement a significant investment 7as defined by the ,secretary and based on a #b-year average of expenditures7 in technology improvements such as through electronic medical records1 telemedicine1 and smart phone or tablet technology4 7,v7 ,to implement wellness and health promotion activities1 including programs designed to address the social determinants of health 7as defined in clause 7iii77,i77 or to promote patient engagement 7as defined in clause 7iii77,,ii774 7ii7 ,for purposes of subparagraph 7,a71 an expenditure only shall be considered to be an expenditure for a quality improvement activity if the expenditure satisfies #a or more of the following requirements3 7,i7 ,the expenditure is designed to improve healthcare quality4 7,,ii7 ,the expenditure is designed to increase the likelihood of desired health outcomes in ways that can be objectively measured1 and that can produce verifiable results and achievements4 7,,iii7 ,the expenditure is directed toward individual enrollees1 incurred for specific segments of enrollees1 or provides health improvements to a population beyond the population enrolled in coverage with the entity so long as no additional costs are incurred due to the non-enrollees4 7,,iv7 ,the expenditure is grounded in evidence based medicine 7including promising practices which1 with documented justification1 go beyond the existing evidence base71 or widely accepted best clinical practice1 or criteria issued by recognized professional medical associations1 accreditation bodies1 government agencies1 or other nationally recognized health care quality or health improvement organizations4 7iii7 7,i7 ,for purposes of clause 7i77,,iv71 the term social determinants of health means conditions in the environments in which people are born1 live1 learn1 work1 play1 worship1 and age2 that affect a wide range of health1 functioning1 and quality-of-life outcomes1 risks1 patterns of social engagement and sense of security and well-being1 and have a significant influence on population health outcomes4 ,these conditions include1 but are not limited to1 safe and affordable housing1 access to education1 public safety1 availability of healthy foods1 local emergency and local health services1 and environments free of life-threatening toxins4 7,,ii7 ,for purposes of clause 7i77,,iv71 the term patient engagement means actions individuals must take to obtain the greatest benefit for the health care services available to them1 and through which process an individual harmonizes robust information and professional advice with the individual's own needs1 preferences and abilities in order to prevent1 manage and cure disease4 7,d7 ,the ,secretary may waive the application of a requirement of this paragraph or of paragraph 7#b77;,a77xiv7 to a ,medicaid managed care organization for not more than #b years1 based on the following3 7i7 ,the extent to which the organization is likely to cease offering coverage without the waiver4 7ii7 ,the number of individuals in the plan likely to be affected by loss of coverage4 7iii7 ,the impact of the loss of coverage on the ability of the beneficiaries to receive coverage under another plan and to have continuity of care4 7iv7 ,the impact on the rates calculated for other ,medicaid managed care organizations that would provide coverage for the beneficiaries that would be affected by the termination of coverage4 7v7 ,upon the request of a ,medicaid managed care organization1 to permit implementation of major plan changes 7but only for #a contract year74 7vi7 ,any other relevant information submitted by the ,medicaid managed care organization or the ,state4 4 7b7 ,application to managed care plans under ,,chip ,section #bajc7;f77#c7 of such ,act 7#db ,u4,s4,c4 #acig;cc7f77#c77 is amended-- 7#a7 by inserting subsection 7m77#b77;,a77xiv7 of section #aijc 7relating to minimum medical loss ratio requirements1 except that the minimum medical loss ratio applicable to managed care organizations under this title shall be 4#hj7 and after application of2 and 7#b7 by inserting other before requirements for4 7c7 ,regulations ,not later than ,october #a1 #bjae1 the ,secretary of ,health and ,human ,services shall promulgate regulations implementing the amendments made by this section4 ,the regulations shall require that initial test reporting of medical loss ratios by ,medicaid managed care organizations be made not later than ,october #a1 #bjaf4