68-995. Contracts and agreements; department; duties; contractor; mental health and substance use disorder services; requirements.
449 words·~2 min read·
/ne/chapter-68/68-995A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(1)All contracts and agreements relating to the medical assistance program governing at-risk managed care service delivery for health services entered into by the department and existing on or after August 11, 2020, shall:
(a)Provide a definition and cap on administrative spending such that
(i)administrative expenditures do not include profit greater than the contracted amount,
(ii)any administrative spending is necessary to improve the health status of the population to be served, and
(iii)administrative expenditures do not include contractor incentives. Administrative spending shall not under any circumstances exceed twelve percent;
(b)Provide a definition of annual contractor profits and losses and restrict such profits and losses under the contract so that profit shall not exceed a percentage specified by the department but not more than three percent per year as a percentage of the aggregate of all income and revenue earned by the contractor and related parties, including parent and subsidiary companies and risk-bearing partners, under the contract;
(c)Provide for return of
(i)any remittance if the contractor does not meet the minimum medical loss ratio,
(ii)any unearned incentive funds, and
(iii)any other funds in excess of the contractor limitations identified in state or federal statute or contract to the State Treasurer for credit to the Medicaid Managed Care Excess Profit Fund;
(d)Provide for a minimum medical loss ratio of eighty-five percent of the aggregate of all income and revenue earned by the contractor and related parties under the contract;
(e)Provide that contractor incentives, in addition to potential profit, be up to two percent of the aggregate of all income and revenue earned by the contractor and related parties under the contract; and
(f)Be reviewed and awarded competitively and in full compliance with the procurement requirements of the State of Nebraska.
(2)A contractor shall:
(a)Not impose quantitative treatment limitations, or financial restrictions, limitations, or requirements, on the provision of mental health or substance use disorder services that are more restrictive than the predominant restrictions, limitations, or requirements imposed on substantially all benefit coverage for other conditions;
(b)Maintain an adequate provider network to provide mental health and substance use disorder services;
(c)Apply criteria in accordance with generally recognized standards of care and make utilization review policies available to the public, providers, and recipients through electronic or paper means when performing a utilization review of mental health or substance use disorder services; and
(d)Not rescind or modify an authorization for a mental health or substance use disorder service after the provider renders the service pursuant to a determination of medical necessity, except in cases of fraud or a violation of a provider's contract with a health insurer.