Health Network Medical Loss Ratio Review Services

The vendor required to provide consulting organization with experience auditing Medi-Cal and medicare accounting practices to provide the following:
•    Professional and technical services to verify and calculate the medical loss ratio (MLR) and administrative costs of agency health’s ten contracted health networks. 
•    Evaluation of each health network’s compliance with contractual obligations related to minimum MLR. 
•    Assessment of the financial solvency and business continuity of each contracted health network and the appropriateness of risk arrangements of each contracted health network.
- Consultant tasks
•    For each MLR reporting year from 2025 through 2031, calculate each health network’s MLR for each of agency three product lines, which are Medi-Cal, one-care, and covered state (effective 2027), and issue a report documenting the results along with an evaluation of each health network’s compliance with contractual obligations.
•    Evaluate each health network’s compliance with the following minimum MLRs:
o    Minimum 85% MLR in aggregate for all defined lines of business. 
o    Minimum 85% MLR for Medi-Cal as required by department.
o    Minimum 85% MLR for Medi-Cal by each network’s level 1 subcontractors. 
o    Minimum 85% MLR for covered state.
•    Summarize the Medi-Cal results for each health network and each health network’s eligible level 1 subcontractors in a written “close” report and present the findings to agency to assist health networks with completion of the department special terms and conditions (STC) subcontractor MLR report template.
•    Provide exhibits detailing the source documentation review and calculated MLRs, and exhibits detailing the compliance with contractual obligations noted above, for each health network.