Medicaid; telehealth services provided by FQHCs, rural health clinics and community mental health centers reimbursed at same rate as face-to-face encounters.

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Johnson

HOUSE BILL NO. 107

AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, 1
TO PROVIDE THAT TELEHEALTH SERVICES PROVIDED BY FEDERALLY 2
QUALIFIED HEALTH CENTERS, RURAL HEALTH CLINICS AND COMMUNITY 3
MENTAL HEALTH CENTERS ARE CONSIDERED TO BE BILLABLE AT THE SAME 4
FACE-TO-FACE ENCOUNTER RATE USED FOR ALL OTHER MEDICAID 5
REIMBURSEMENTS TO THOSE CENTERS UNDER THE PROSPECTIVE PAYMENT 6
SYSTEM; AND FOR RELATED PURPOSES. 7
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 8
SECTION 1. Section 43-13-117, Mississippi Code of 1972, is 9
amended as follows: 10
43-13-117. (A) Medicaid as authorized by this article shall 11
include payment of part or all of the costs, at the discretion of 12
the division, with approval of the Governor and the Centers for 13
Medicare and Medicaid Services, of the following types of care and 14
services rendered to eligible applicants who have been determined 15
to be eligible for that care and services, within the limits of 16
state appropriations and federal matching funds: 17
(1) Inpatient hospital services. 18
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(a) The division is authorized to implement an All 19
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 20
methodology for inpatient hospital services. 21
(b) No service benefits or reimbursement 22
limitations in this subsection (A)(1) shall apply to payments 23
under an APR-DRG or Ambulatory Payment Classification (APC) model 24
or a managed care program or similar model described in subsection 25
(H) of this section unless specifically authorized by the 26
division. 27
(2) Outpatient hospital services. 28
(a) Emergency services. 29
(b) Other outpatient hospital services. The 30
division shall allow benefits for other medically necessary 31
outpatient hospital services (such as chemotherapy, radiation, 32
surgery and therapy), including outpatient services in a clinic or 33
other facility that is not located inside the hospital, but that 34
has been designated as an outpatient facility by the hospital, and 35
that was in operation or under construction on July 1, 2009, 36
provided that the costs and charges associated with the operation 37
of the hospital clinic are included in the hospital's cost report. 38
In addition, the Medicare thirty-five-mile rule will apply to 39
those hospital clinics not located inside the hospital that are 40
constructed after July 1, 2009. Where the same services are 41
reimbursed as clinic services, the division may revise the rate or 42
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methodology of outpatient reimbursement to maintain consistency, 43
efficiency, economy and quality of care. 44
(c) The division is authorized to implement an 45
Ambulatory Payment Classification (APC) methodology for outpatient 46
hospital services. The division shall give rural hospitals that 47
have fifty (50) or fewer licensed beds the option to not be 48
reimbursed for outpatient hospital services using the APC 49
methodology, but reimbursement for outpatient hospital services 50
provided by those hospitals shall be based on one hundred one 51
percent (101%) of the rate established under Medicare for 52
outpatient hospital services. Those hospitals choosing to not be 53
reimbursed under the APC methodology shall remain under cost-based 54
reimbursement for a two-year period. 55
(d) No service benefits or reimbursement 56
limitations in this subsection (A)(2) shall apply to payments 57
under an APR-DRG or APC model or a managed care program or similar 58
model described in subsection (H) of this section unless 59
specifically authorized by the division. 60
(3) Laboratory and x-ray services. 61
(4) Nursing facility services. 62
(a) The division shall make full payment to 63
nursing facilities for each day, not exceeding forty-two (42) days 64
per year, that a patient is absent from the facility on home 65
leave. Payment may be made for the following home leave days in 66
addition to the forty-two-day limitation: Christmas, the day 67
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before Christmas, the day after Christmas, Thanksgiving, the day 68
before Thanksgiving and the day after Thanksgiving. 69
(b) From and after July 1, 1997, the division 70
shall implement the integrated case-mix payment and quality 71
monitoring system, which includes the fair rental system for 72
property costs and in which recapture of depreciation is 73
eliminated. The division may reduce the payment for hospital 74
leave and therapeutic home leave days to the lower of the case-mix 75
category as computed for the resident on leave using the 76
assessment being utilized for payment at that point in time, or a 77
case-mix score of 1.000 for nursing facilities, and shall compute 78
case-mix scores of residents so that only services provided at the 79
nursing facility are considered in calculating a facility's per 80
diem. 81
(c) From and after July 1, 1997, all state-owned 82
nursing facilities shall be reimbursed on a full reasonable cost 83
basis. 84
(d) On or after January 1, 2015, the division 85
shall update the case-mix payment system resource utilization 86
grouper and classifications and fair rental reimbursement system. 87
The division shall develop and implement a payment add-on to 88
reimburse nursing facilities for ventilator-dependent resident 89
services. 90
(e) The division shall develop and implement, not 91
later than January 1, 2001, a case-mix payment add-on determined 92
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by time studies and other valid statistical data that will 93
reimburse a nursing facility for the additional cost of caring for 94
a resident who has a diagnosis of Alzheimer's or other related 95
dementia and exhibits symptoms that require special care. Any 96
such case-mix add-on payment shall be supported by a determination 97
of additional cost. The division shall also develop and implement 98
as part of the fair rental reimbursement system for nursing 99
facility beds, an Alzheimer's resident bed depreciation enhanced 100
reimbursement system that will provide an incentive to encourage 101
nursing facilities to convert or construct beds for residents with 102
Alzheimer's or other related dementia. 103
(f) The division shall develop and implement an 104
assessment process for long-term care services. The division may 105
provide the assessment and related functions directly or through 106
contract with the area agencies on aging. 107
The division shall apply for necessary federal waivers to 108
assure that additional services providing alternatives to nursing 109
facility care are made available to applicants for nursing 110
facility care. 111
(5) Periodic screening and diagnostic services for 112
individuals under age twenty-one (21) years as are needed to 113
identify physical and mental defects and to provide health care 114
treatment and other measures designed to correct or ameliorate 115
defects and physical and mental illness and conditions discovered 116
by the screening services, regardless of whether these services 117
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are included in the state plan. The division may include in its 118
periodic screening and diagnostic program those discretionary 119
services authorized under the federal regulations adopted to 120
implement Title XIX of the federal Social Security Act, as 121
amended. The division, in obtaining physical therapy services, 122
occupational therapy services, and services for individuals with 123
speech, hearing and language disorders, may enter into a 124
cooperative agreement with the State Department of Education for 125
the provision of those services to handicapped students by public 126
school districts using state funds that are provided from the 127
appropriation to the Department of Education to obtain federal 128
matching funds through the division. The division, in obtaining 129
medical and mental health assessments, treatment, care and 130
services for children who are in, or at risk of being put in, the 131
custody of the Mississippi Department of Human Services may enter 132
into a cooperative agreement with the Mississippi Department of 133
Human Services for the provision of those services using state 134
funds that are provided from the appropriation to the Department 135
of Human Services to obtain federal matching funds through the 136
division. 137
(6) Physician services. Fees for physician's services 138
that are covered only by Medicaid shall be reimbursed at ninety 139
percent (90%) of the rate established on January 1, 2018, and as 140
may be adjusted each July thereafter, under Medicare. The 141
division may provide for a reimbursement rate for physician's 142
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services of up to one hundred percent (100%) of the rate 143
established under Medicare for physician's services that are 144
provided after the normal working hours of the physician, as 145
determined in accordance with regulations of the division. The 146
division may reimburse eligible providers, as determined by the 147
division, for certain primary care services at one hundred percent 148
(100%) of the rate established under Medicare. The division shall 149
reimburse obstetricians and gynecologists for certain primary care 150
services as defined by the division at one hundred percent (100%) 151
of the rate established under Medicare. 152
(7) (a) Home health services for eligible persons, not 153
to exceed in cost the prevailing cost of nursing facility 154
services. All home health visits must be precertified as required 155
by the division. In addition to physicians, certified registered 156
nurse practitioners, physician assistants and clinical nurse 157
specialists are authorized to prescribe or order home health 158
services and plans of care, sign home health plans of care, 159
certify and recertify eligibility for home health services and 160
conduct the required initial face-to-face visit with the recipient 161
of the services. 162
(b) [Repealed] 163
(8) Emergency medical transportation services as 164
determined by the division. 165
(9) Prescription drugs and other covered drugs and 166
services as determined by the division. 167
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The division shall establish a mandatory preferred drug list. 168
Drugs not on the mandatory preferred drug list shall be made 169
available by utilizing prior authorization procedures established 170
by the division. 171
The division may seek to establish relationships with other 172
states in order to lower acquisition costs of prescription drugs 173
to include single-source and innovator multiple-source drugs or 174
generic drugs. In addition, if allowed by federal law or 175
regulation, the division may seek to establish relationships with 176
and negotiate with other countries to facilitate the acquisition 177
of prescription drugs to include single-source and innovator 178
multiple-source drugs or generic drugs, if that will lower the 179
acquisition costs of those prescription drugs. 180
The division may allow for a combination of prescriptions for 181
single-source and innovator multiple-source drugs and generic 182
drugs to meet the needs of the beneficiaries. 183
The executive director may approve specific maintenance drugs 184
for beneficiaries with certain medical conditions, which may be 185
prescribed and dispensed in three-month supply increments. 186
Drugs prescribed for a resident of a psychiatric residential 187
treatment facility must be provided in true unit doses when 188
available. The division may require that drugs not covered by 189
Medicare Part D for a resident of a long-term care facility be 190
provided in true unit doses when available. Those drugs that were 191
originally billed to the division but are not used by a resident 192
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in any of those facilities shall be returned to the billing 193
pharmacy for credit to the division, in accordance with the 194
guidelines of the State Board of Pharmacy and any requirements of 195
federal law and regulation. Drugs shall be dispensed to a 196
recipient and only one (1) dispensing fee per month may be 197
charged. The division shall develop a methodology for reimbursing 198
for restocked drugs, which shall include a restock fee as 199
determined by the division not exceeding Seven Dollars and 200
Eighty-two Cents ($7.82). 201
Except for those specific maintenance drugs approved by the 202
executive director, the division shall not reimburse for any 203
portion of a prescription that exceeds a thirty-one-day supply of 204
the drug based on the daily dosage. 205
The division is authorized to develop and implement a program 206
of payment for additional pharmacist services as determined by the 207
division. 208
All claims for drugs for dually eligible Medicare/Medicaid 209
beneficiaries that are paid for by Medicare must be submitted to 210
Medicare for payment before they may be processed by the 211
division's online payment system. 212
The division shall develop a pharmacy policy in which drugs 213
in tamper-resistant packaging that are prescribed for a resident 214
of a nursing facility but are not dispensed to the resident shall 215
be returned to the pharmacy and not billed to Medicaid, in 216
accordance with guidelines of the State Board of Pharmacy. 217
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The division shall develop and implement a method or methods 218
by which the division will provide on a regular basis to Medicaid 219
providers who are authorized to prescribe drugs, information about 220
the costs to the Medicaid program of single-source drugs and 221
innovator multiple-source drugs, and information about other drugs 222
that may be prescribed as alternatives to those single-source 223
drugs and innovator multiple-source drugs and the costs to the 224
Medicaid program of those alternative drugs. 225
Notwithstanding any law or regulation, information obtained 226
or maintained by the division regarding the prescription drug 227
program, including trade secrets and manufacturer or labeler 228
pricing, is confidential and not subject to disclosure except to 229
other state agencies. 230
The dispensing fee for each new or refill prescription, 231
including nonlegend or over-the-counter drugs covered by the 232
division, shall be not less than Three Dollars and Ninety-one 233
Cents ($3.91), as determined by the division. 234
The division shall not reimburse for single-source or 235
innovator multiple-source drugs if there are equally effective 236
generic equivalents available and if the generic equivalents are 237
the least expensive. 238
It is the intent of the Legislature that the pharmacists 239
providers be reimbursed for the reasonable costs of filling and 240
dispensing prescriptions for Medicaid beneficiaries. 241
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The division shall allow certain drugs, including 242
physician-administered drugs, and implantable drug system devices, 243
and medical supplies, with limited distribution or limited access 244
for beneficiaries and administered in an appropriate clinical 245
setting, to be reimbursed as either a medical claim or pharmacy 246
claim, as determined by the division. 247
It is the intent of the Legislature that the division and any 248
managed care entity described in subsection (H) of this section 249
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 250
prevent recurrent preterm birth. 251
(10) Dental and orthodontic services to be determined 252
by the division. 253
The division shall increase the amount of the reimbursement 254
rate for diagnostic and preventative dental services for each of 255
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 256
the amount of the reimbursement rate for the previous fiscal year. 257
The division shall increase the amount of the reimbursement rate 258
for restorative dental services for each of the fiscal years 2023, 259
2024 and 2025 by five percent (5%) above the amount of the 260
reimbursement rate for the previous fiscal year. It is the intent 261
of the Legislature that the reimbursement rate revision for 262
preventative dental services will be an incentive to increase the 263
number of dentists who actively provide Medicaid services. This 264
dental services reimbursement rate revision shall be known as the 265
"James Russell Dumas Medicaid Dental Services Incentive Program." 266
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The Medical Care Advisory Committee, assisted by the Division 267
of Medicaid, shall annually determine the effect of this incentive 268
by evaluating the number of dentists who are Medicaid providers, 269
the number who and the degree to which they are actively billing 270
Medicaid, the geographic trends of where dentists are offering 271
what types of Medicaid services and other statistics pertinent to 272
the goals of this legislative intent. This data shall annually be 273
presented to the Chair of the Senate Medicaid Committee and the 274
Chair of the House Medicaid Committee. 275
The division shall include dental services as a necessary 276
component of overall health services provided to children who are 277
eligible for services. 278
(11) Eyeglasses for all Medicaid beneficiaries who have 279
(a) had surgery on the eyeball or ocular muscle that results in a 280
vision change for which eyeglasses or a change in eyeglasses is 281
medically indicated within six (6) months of the surgery and is in 282
accordance with policies established by the division, or (b) one 283
(1) pair every five (5) years and in accordance with policies 284
established by the division. In either instance, the eyeglasses 285
must be prescribed by a physician skilled in diseases of the eye 286
or an optometrist, whichever the beneficiary may select. 287
(12) Intermediate care facility services. 288
(a) The division shall make full payment to all 289
intermediate care facilities for individuals with intellectual 290
disabilities for each day, not exceeding sixty-three (63) days per 291
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year, that a patient is absent from the facility on home leave. 292
Payment may be made for the following home leave days in addition 293
to the sixty-three-day limitation: Christmas, the day before 294
Christmas, the day after Christmas, Thanksgiving, the day before 295
Thanksgiving and the day after Thanksgiving. 296
(b) All state-owned intermediate care facilities 297
for individuals with intellectual disabilities shall be reimbursed 298
on a full reasonable cost basis. 299
(c) Effective January 1, 2015, the division shall 300
update the fair rental reimbursement system for intermediate care 301
facilities for individuals with intellectual disabilities. 302
(13) Family planning services, including drugs, 303
supplies and devices, when those services are under the 304
supervision of a physician or nurse practitioner. 305
(14) Clinic services. Preventive, diagnostic, 306
therapeutic, rehabilitative or palliative services that are 307
furnished by a facility that is not part of a hospital but is 308
organized and operated to provide medical care to outpatients. 309
Clinic services include, but are not limited to: 310
(a) Services provided by ambulatory surgical 311
centers (ASCs) as defined in Section 41-75-1(a); and 312
(b) Dialysis center services. 313
(15) Home- and community-based services for the elderly 314
and disabled, as provided under Title XIX of the federal Social 315
Security Act, as amended, under waivers, subject to the 316
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availability of funds specifically appropriated for that purpose 317
by the Legislature. 318
(16) Mental health services. Certain services provided 319
by a psychiatrist shall be reimbursed at up to one hundred percent 320
(100%) of the Medicare rate. Approved therapeutic and case 321
management services (a) provided by an approved regional mental 322
health/intellectual disability center established under Sections 323
41-19-31 through 41-19-39, or by another community mental health 324
service provider meeting the requirements of the Department of 325
Mental Health to be an approved mental health/intellectual 326
disability center if determined necessary by the Department of 327
Mental Health, using state funds that are provided in the 328
appropriation to the division to match federal funds, or (b) 329
provided by a facility that is certified by the State Department 330
of Mental Health to provide therapeutic and case management 331
services, to be reimbursed on a fee for service basis, or (c) 332
provided in the community by a facility or program operated by the 333
Department of Mental Health. Any such services provided by a 334
facility described in subparagraph (b) must have the prior 335
approval of the division to be reimbursable under this section. 336
(17) Durable medical equipment services and medical 337
supplies. Precertification of durable medical equipment and 338
medical supplies must be obtained as required by the division. 339
The Division of Medicaid may require durable medical equipment 340
providers to obtain a surety bond in the amount and to the 341
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specifications as established by the Balanced Budget Act of 1997. 342
A maximum dollar amount of reimbursement for noninvasive 343
ventilators or ventilation treatments properly ordered and being 344
used in an appropriate care setting shall not be set by any health 345
maintenance organization, coordinated care organization, 346
provider-sponsored health plan, or other organization paid for 347
services on a capitated basis by the division under any managed 348
care program or coordinated care program implemented by the 349
division under this section. Reimbursement by these organizations 350
to durable medical equipment suppliers for home use of noninvasive 351
and invasive ventilators shall be on a continuous monthly payment 352
basis for the duration of medical need throughout a patient's 353
valid prescription period. 354
(18) (a) Notwithstanding any other provision of this 355
section to the contrary, as provided in the Medicaid state plan 356
amendment or amendments as defined in Section 43-13-145(10), the 357
division shall make additional reimbursement to hospitals that 358
serve a disproportionate share of low-income patients and that 359
meet the federal requirements for those payments as provided in 360
Section 1923 of the federal Social Security Act and any applicable 361
regulations. It is the intent of the Legislature that the 362
division shall draw down all available federal funds allotted to 363
the state for disproportionate share hospitals. However, from and 364
after January 1, 1999, public hospitals participating in the 365
Medicaid disproportionate share program may be required to 366
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participate in an intergovernmental transfer program as provided 367
in Section 1903 of the federal Social Security Act and any 368
applicable regulations. 369
(b) (i) 1. The division may establish a Medicare 370
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 371
the federal Social Security Act and any applicable federal 372
regulations, or an allowable delivery system or provider payment 373
initiative authorized under 42 CFR 438.6(c), for hospitals, 374
nursing facilities and physicians employed or contracted by 375
hospitals. 376
2. The division shall establish a 377
Medicaid Supplemental Payment Program, as permitted by the federal 378
Social Security Act and a comparable allowable delivery system or 379
provider payment initiative authorized under 42 CFR 438.6(c), for 380
emergency ambulance transportation providers in accordance with 381
this subsection (A)(18)(b). 382
(ii) The division shall assess each hospital, 383
nursing facility, and emergency ambulance transportation provider 384
for the sole purpose of financing the state portion of the 385
Medicare Upper Payment Limits Program or other program(s) 386
authorized under this subsection (A)(18)(b). The hospital 387
assessment shall be as provided in Section 43-13-145(4)(a), and 388
the nursing facility and the emergency ambulance transportation 389
assessments, if established, shall be based on Medicaid 390
utilization or other appropriate method, as determined by the 391
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division, consistent with federal regulations. The assessments 392
will remain in effect as long as the state participates in the 393
Medicare Upper Payment Limits Program or other program(s) 394
authorized under this subsection (A)(18)(b). In addition to the 395
hospital assessment provided in Section 43-13-145(4)(a), hospitals 396
with physicians participating in the Medicare Upper Payment Limits 397
Program or other program(s) authorized under this subsection 398
(A)(18)(b) shall be required to participate in an 399
intergovernmental transfer or assessment, as determined by the 400
division, for the purpose of financing the state portion of the 401
physician UPL payments or other payment(s) authorized under this 402
subsection (A)(18)(b). 403
(iii) Subject to approval by the Centers for 404
Medicare and Medicaid Services (CMS) and the provisions of this 405
subsection (A)(18)(b), the division shall make additional 406
reimbursement to hospitals, nursing facilities, and emergency 407
ambulance transportation providers for the Medicare Upper Payment 408
Limits Program or other program(s) authorized under this 409
subsection (A)(18)(b), and, if the program is established for 410
physicians, shall make additional reimbursement for physicians, as 411
defined in Section 1902(a)(30) of the federal Social Security Act 412
and any applicable federal regulations, provided the assessment in 413
this subsection (A)(18)(b) is in effect. 414
(iv) Notwithstanding any other provision of 415
this article to the contrary, effective upon implementation of the 416
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Mississippi Hospital Access Program (MHAP) provided in 417
subparagraph (c)(i) below, the hospital portion of the inpatient 418
Upper Payment Limits Program shall transition into and be replaced 419
by the MHAP program. However, the division is authorized to 420
develop and implement an alternative fee-for-service Upper Payment 421
Limits model in accordance with federal laws and regulations if 422
necessary to preserve supplemental funding. Further, the 423
division, in consultation with the hospital industry shall develop 424
alternative models for distribution of medical claims and 425
supplemental payments for inpatient and outpatient hospital 426
services, and such models may include, but shall not be limited to 427
the following: increasing rates for inpatient and outpatient 428
services; creating a low-income utilization pool of funds to 429
reimburse hospitals for the costs of uncompensated care, charity 430
care and bad debts as permitted and approved pursuant to federal 431
regulations and the Centers for Medicare and Medicaid Services; 432
supplemental payments based upon Medicaid utilization, quality, 433
service lines and/or costs of providing such services to Medicaid 434
beneficiaries and to uninsured patients. The goals of such 435
payment models shall be to ensure access to inpatient and 436
outpatient care and to maximize any federal funds that are 437
available to reimburse hospitals for services provided. Any such 438
documents required to achieve the goals described in this 439
paragraph shall be submitted to the Centers for Medicare and 440
Medicaid Services, with a proposed effective date of July 1, 2019, 441
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to the extent possible, but in no event shall the effective date 442
of such payment models be later than July 1, 2020. The Chairmen 443
of the Senate and House Medicaid Committees shall be provided a 444
copy of the proposed payment model(s) prior to submission. 445
Effective July 1, 2018, and until such time as any payment 446
model(s) as described above become effective, the division, in 447
consultation with the hospital industry, is authorized to 448
implement a transitional program for inpatient and outpatient 449
payments and/or supplemental payments (including, but not limited 450
to, MHAP and directed payments), to redistribute available 451
supplemental funds among hospital providers, provided that when 452
compared to a hospital's prior year supplemental payments, 453
supplemental payments made pursuant to any such transitional 454
program shall not result in a decrease of more than five percent 455
(5%) and shall not increase by more than the amount needed to 456
maximize the distribution of the available funds. 457
(v) 1. To preserve and improve access to 458
ambulance transportation provider services, the division shall 459
seek CMS approval to make ambulance service access payments as set 460
forth in this subsection (A)(18)(b) for all covered emergency 461
ambulance services rendered on or after July 1, 2022, and shall 462
make such ambulance service access payments for all covered 463
services rendered on or after the effective date of CMS approval. 464
2. The division shall calculate the 465
ambulance service access payment amount as the balance of the 466
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portion of the Medical Care Fund related to ambulance 467
transportation service provider assessments plus any federal 468
matching funds earned on the balance, up to, but not to exceed, 469
the upper payment limit gap for all emergency ambulance service 470
providers. 471
3. a. Except for ambulance services 472
exempt from the assessment provided in this paragraph (18)(b), all 473
ambulance transportation service providers shall be eligible for 474
ambulance service access payments each state fiscal year as set 475
forth in this paragraph (18)(b). 476
b. In addition to any other funds 477
paid to ambulance transportation service providers for emergency 478
medical services provided to Medicaid beneficiaries, each eligible 479
ambulance transportation service provider shall receive ambulance 480
service access payments each state fiscal year equal to the 481
ambulance transportation service provider's upper payment limit 482
gap. Subject to approval by the Centers for Medicare and Medicaid 483
Services, ambulance service access payments shall be made no less 484
than on a quarterly basis. 485
c. As used in this paragraph 486
(18)(b)(v), the term "upper payment limit gap" means the 487
difference between the total amount that the ambulance 488
transportation service provider received from Medicaid and the 489
average amount that the ambulance transportation service provider 490
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would have received from commercial insurers for those services 491
reimbursed by Medicaid. 492
4. An ambulance service access payment 493
shall not be used to offset any other payment by the division for 494
emergency or nonemergency services to Medicaid beneficiaries. 495
(c) (i) Not later than December l, 2015, the 496
division shall, subject to approval by the Centers for Medicare 497
and Medicaid Services (CMS), establish, implement and operate a 498
Mississippi Hospital Access Program (MHAP) for the purpose of 499
protecting patient access to hospital care through hospital 500
inpatient reimbursement programs provided in this section designed 501
to maintain total hospital reimbursement for inpatient services 502
rendered by in-state hospitals and the out-of-state hospital that 503
is authorized by federal law to submit intergovernmental transfers 504
(IGTs) to the State of Mississippi and is classified as Level I 505
trauma center located in a county contiguous to the state line at 506
the maximum levels permissible under applicable federal statutes 507
and regulations, at which time the current inpatient Medicare 508
Upper Payment Limits (UPL) Program for hospital inpatient services 509
shall transition to the MHAP. 510
(ii) Subject to approval by the Centers for 511
Medicare and Medicaid Services (CMS), the MHAP shall provide 512
increased inpatient capitation (PMPM) payments to managed care 513
entities contracting with the division pursuant to subsection (H) 514
of this section to support availability of hospital services or 515
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such other payments permissible under federal law necessary to 516
accomplish the intent of this subsection. 517
(iii) The intent of this subparagraph (c) is 518
that effective for all inpatient hospital Medicaid services during 519
state fiscal year 2016, and so long as this provision shall remain 520
in effect hereafter, the division shall to the fullest extent 521
feasible replace the additional reimbursement for hospital 522
inpatient services under the inpatient Medicare Upper Payment 523
Limits (UPL) Program with additional reimbursement under the MHAP 524
and other payment programs for inpatient and/or outpatient 525
payments which may be developed under the authority of this 526
paragraph. 527
(iv) The division shall assess each hospital 528
as provided in Section 43-13-145(4)(a) for the purpose of 529
financing the state portion of the MHAP, supplemental payments and 530
such other purposes as specified in Section 43-13-145. The 531
assessment will remain in effect as long as the MHAP and 532
supplemental payments are in effect. 533
(19) (a) Perinatal risk management services. The 534
division shall promulgate regulations to be effective from and 535
after October 1, 1988, to establish a comprehensive perinatal 536
system for risk assessment of all pregnant and infant Medicaid 537
recipients and for management, education and follow-up for those 538
who are determined to be at risk. Services to be performed 539
include case management, nutrition assessment/counseling, 540
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psychosocial assessment/counseling and health education. The 541
division shall contract with the State Department of Health to 542
provide services within this paragraph (Perinatal High Risk 543
Management/Infant Services System (PHRM/ISS)). The State 544
Department of Health shall be reimbursed on a full reasonable cost 545
basis for services provided under this subparagraph (a). 546
(b) Early intervention system services. The 547
division shall cooperate with the State Department of Health, 548
acting as lead agency, in the development and implementation of a 549
statewide system of delivery of early intervention services, under 550
Part C of the Individuals with Disabilities Education Act (IDEA). 551
The State Department of Health shall certify annually in writing 552
to the executive director of the division the dollar amount of 553
state early intervention funds available that will be utilized as 554
a certified match for Medicaid matching funds. Those funds then 555
shall be used to provide expanded targeted case management 556
services for Medicaid eligible children with special needs who are 557
eligible for the state's early intervention system. 558
Qualifications for persons providing service coordination shall be 559
determined by the State Department of Health and the Division of 560
Medicaid. 561
(20) Home- and community-based services for physically 562
disabled approved services as allowed by a waiver from the United 563
States Department of Health and Human Services for home- and 564
community-based services for physically disabled people using 565
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state funds that are provided from the appropriation to the State 566
Department of Rehabilitation Services and used to match federal 567
funds under a cooperative agreement between the division and the 568
department, provided that funds for these services are 569
specifically appropriated to the Department of Rehabilitation 570
Services. 571
(21) Nurse practitioner services. Services furnished 572
by a registered nurse who is licensed and certified by the 573
Mississippi Board of Nursing as a nurse practitioner, including, 574
but not limited to, nurse anesthetists, nurse midwives, family 575
nurse practitioners, family planning nurse practitioners, 576
pediatric nurse practitioners, obstetrics-gynecology nurse 577
practitioners and neonatal nurse practitioners, under regulations 578
adopted by the division. Reimbursement for those services shall 579
not exceed ninety percent (90%) of the reimbursement rate for 580
comparable services rendered by a physician. The division may 581
provide for a reimbursement rate for nurse practitioner services 582
of up to one hundred percent (100%) of the reimbursement rate for 583
comparable services rendered by a physician for nurse practitioner 584
services that are provided after the normal working hours of the 585
nurse practitioner, as determined in accordance with regulations 586
of the division. 587
(22) Ambulatory services delivered in federally 588
qualified health centers, rural health centers and clinics of the 589
local health departments of the State Department of Health for 590
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individuals eligible for Medicaid under this article based on 591
reasonable costs as determined by the division. Federally 592
qualified health centers shall be reimbursed by the Medicaid 593
prospective payment system as approved by the Centers for Medicare 594
and Medicaid Services. The division shall recognize federally 595
qualified health centers (FQHCs), rural health clinics (RHCs) and 596
community mental health centers (CMHCs) as both an originating and 597
distant site provider for the purposes of telehealth 598
reimbursement. The division * * * shall reimburse FQHCs, RHCs and 599
CMHCs the applicable Medicaid fee for both distant site and 600
originating site telehealth services when such services are 601
appropriately provided by the same organization. Telehealth 602
services provided by FQHCs, RHCs and CMHCs are considered billable 603
at the same face-to-face encounter rate used for all other 604
Medicaid reimbursements to FQHCs, RHCs and CMHCs under the 605
prospective payment system. 606
(23) Inpatient psychiatric services. 607
(a) Inpatient psychiatric services to be 608
determined by the division for recipients under age twenty-one 609
(21) that are provided under the direction of a physician in an 610
inpatient program in a licensed acute care psychiatric facility or 611
in a licensed psychiatric residential treatment facility, before 612
the recipient reaches age twenty-one (21) or, if the recipient was 613
receiving the services immediately before he or she reached age 614
twenty-one (21), before the earlier of the date he or she no 615
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longer requires the services or the date he or she reaches age 616
twenty-two (22), as provided by federal regulations. From and 617
after January 1, 2015, the division shall update the fair rental 618
reimbursement system for psychiatric residential treatment 619
facilities. Precertification of inpatient days and residential 620
treatment days must be obtained as required by the division. From 621
and after July 1, 2009, all state-owned and state-operated 622
facilities that provide inpatient psychiatric services to persons 623
under age twenty-one (21) who are eligible for Medicaid 624
reimbursement shall be reimbursed for those services on a full 625
reasonable cost basis. 626
(b) The division may reimburse for services 627
provided by a licensed freestanding psychiatric hospital to 628
Medicaid recipients over the age of twenty-one (21) in a method 629
and manner consistent with the provisions of Section 43-13-117.5. 630
(24) [Deleted] 631
(25) [Deleted] 632
(26) Hospice care. As used in this paragraph, the term 633
"hospice care" means a coordinated program of active professional 634
medical attention within the home and outpatient and inpatient 635
care that treats the terminally ill patient and family as a unit, 636
employing a medically directed interdisciplinary team. The 637
program provides relief of severe pain or other physical symptoms 638
and supportive care to meet the special needs arising out of 639
physical, psychological, spiritual, social and economic stresses 640
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that are experienced during the final stages of illness and during 641
dying and bereavement and meets the Medicare requirements for 642
participation as a hospice as provided in federal regulations. 643
(27) Group health plan premiums and cost-sharing if it 644
is cost-effective as defined by the United States Secretary of 645
Health and Human Services. 646
(28) Other health insurance premiums that are 647
cost-effective as defined by the United States Secretary of Health 648
and Human Services. Medicare eligible must have Medicare Part B 649
before other insurance premiums can be paid. 650
(29) The Division of Medicaid may apply for a waiver 651
from the United States Department of Health and Human Services for 652
home- and community-based services for developmentally disabled 653
people using state funds that are provided from the appropriation 654
to the State Department of Mental Health and/or funds transferred 655
to the department by a political subdivision or instrumentality of 656
the state and used to match federal funds under a cooperative 657
agreement between the division and the department, provided that 658
funds for these services are specifically appropriated to the 659
Department of Mental Health and/or transferred to the department 660
by a political subdivision or instrumentality of the state. 661
(30) Pediatric skilled nursing services as determined 662
by the division and in a manner consistent with regulations 663
promulgated by the Mississippi State Department of Health. 664
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(31) Targeted case management services for children 665
with special needs, under waivers from the United States 666
Department of Health and Human Services, using state funds that 667
are provided from the appropriation to the Mississippi Department 668
of Human Services and used to match federal funds under a 669
cooperative agreement between the division and the department. 670
(32) Care and services provided in Christian Science 671
Sanatoria listed and certified by the Commission for Accreditation 672
of Christian Science Nursing Organizations/Facilities, Inc., 673
rendered in connection with treatment by prayer or spiritual means 674
to the extent that those services are subject to reimbursement 675
under Section 1903 of the federal Social Security Act. 676
(33) Podiatrist services. 677
(34) Assisted living services as provided through 678
home- and community-based services under Title XIX of the federal 679
Social Security Act, as amended, subject to the availability of 680
funds specifically appropriated for that purpose by the 681
Legislature. 682
(35) Services and activities authorized in Sections 683
43-27-101 and 43-27-103, using state funds that are provided from 684
the appropriation to the Mississippi Department of Human Services 685
and used to match federal funds under a cooperative agreement 686
between the division and the department. 687
(36) Nonemergency transportation services for 688
Medicaid-eligible persons as determined by the division. The PEER 689
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Committee shall conduct a performance evaluation of the 690
nonemergency transportation program to evaluate the administration 691
of the program and the providers of transportation services to 692
determine the most cost-effective ways of providing nonemergency 693
transportation services to the patients served under the program. 694
The performance evaluation shall be completed and provided to the 695
members of the Senate Medicaid Committee and the House Medicaid 696
Committee not later than January 1, 2019, and every two (2) years 697
thereafter. 698
(37) [Deleted] 699
(38) Chiropractic services. A chiropractor's manual 700
manipulation of the spine to correct a subluxation, if x-ray 701
demonstrates that a subluxation exists and if the subluxation has 702
resulted in a neuromusculoskeletal condition for which 703
manipulation is appropriate treatment, and related spinal x-rays 704
performed to document these conditions. Reimbursement for 705
chiropractic services shall not exceed Seven Hundred Dollars 706
($700.00) per year per beneficiary. 707
(39) Dually eligible Medicare/Medicaid beneficiaries. 708
The division shall pay the Medicare deductible and coinsurance 709
amounts for services available under Medicare, as determined by 710
the division. From and after July 1, 2009, the division shall 711
reimburse crossover claims for inpatient hospital services and 712
crossover claims covered under Medicare Part B in the same manner 713
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that was in effect on January 1, 2008, unless specifically 714
authorized by the Legislature to change this method. 715
(40) [Deleted] 716
(41) Services provided by the State Department of 717
Rehabilitation Services for the care and rehabilitation of persons 718
with spinal cord injuries or traumatic brain injuries, as allowed 719
under waivers from the United States Department of Health and 720
Human Services, using up to seventy-five percent (75%) of the 721
funds that are appropriated to the Department of Rehabilitation 722
Services from the Spinal Cord and Head Injury Trust Fund 723
established under Section 37-33-261 and used to match federal 724
funds under a cooperative agreement between the division and the 725
department. 726
(42) [Deleted] 727
(43) The division shall provide reimbursement, 728
according to a payment schedule developed by the division, for 729
smoking cessation medications for pregnant women during their 730
pregnancy and other Medicaid-eligible women who are of 731
child-bearing age. 732
(44) Nursing facility services for the severely 733
disabled. 734
(a) Severe disabilities include, but are not 735
limited to, spinal cord injuries, closed-head injuries and 736
ventilator-dependent patients. 737
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(b) Those services must be provided in a long-term 738
care nursing facility dedicated to the care and treatment of 739
persons with severe disabilities. 740
(45) Physician assistant services. Services furnished 741
by a physician assistant who is licensed by the State Board of 742
Medical Licensure and is practicing with physician supervision 743
under regulations adopted by the board, under regulations adopted 744
by the division. Reimbursement for those services shall not 745
exceed ninety percent (90%) of the reimbursement rate for 746
comparable services rendered by a physician. The division may 747
provide for a reimbursement rate for physician assistant services 748
of up to one hundred percent (100%) or the reimbursement rate for 749
comparable services rendered by a physician for physician 750
assistant services that are provided after the normal working 751
hours of the physician assistant, as determined in accordance with 752
regulations of the division. 753
(46) The division shall make application to the federal 754
Centers for Medicare and Medicaid Services (CMS) for a waiver to 755
develop and provide services for children with serious emotional 756
disturbances as defined in Section 43-14-1(1), which may include 757
home- and community-based services, case management services or 758
managed care services through mental health providers certified by 759
the Department of Mental Health. The division may implement and 760
provide services under this waivered program only if funds for 761
these services are specifically appropriated for this purpose by 762
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the Legislature, or if funds are voluntarily provided by affected 763
agencies. 764
(47) (a) The division may develop and implement 765
disease management programs for individuals with high-cost chronic 766
diseases and conditions, including the use of grants, waivers, 767
demonstrations or other projects as necessary. 768
(b) Participation in any disease management 769
program implemented under this paragraph (47) is optional with the 770
individual. An individual must affirmatively elect to participate 771
in the disease management program in order to participate, and may 772
elect to discontinue participation in the program at any time. 773
(48) Pediatric long-term acute care hospital services. 774
(a) Pediatric long-term acute care hospital 775
services means services provided to eligible persons under 776
twenty-one (21) years of age by a freestanding Medicare-certified 777
hospital that has an average length of inpatient stay greater than 778
twenty-five (25) days and that is primarily engaged in providing 779
chronic or long-term medical care to persons under twenty-one (21) 780
years of age. 781
(b) The services under this paragraph (48) shall 782
be reimbursed as a separate category of hospital services. 783
(49) The division may establish copayments and/or 784
coinsurance for any Medicaid services for which copayments and/or 785
coinsurance are allowable under federal law or regulation. 786
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(50) Services provided by the State Department of 787
Rehabilitation Services for the care and rehabilitation of persons 788
who are deaf and blind, as allowed under waivers from the United 789
States Department of Health and Human Services to provide home- 790
and community-based services using state funds that are provided 791
from the appropriation to the State Department of Rehabilitation 792
Services or if funds are voluntarily provided by another agency. 793
(51) Upon determination of Medicaid eligibility and in 794
association with annual redetermination of Medicaid eligibility, 795
beneficiaries shall be encouraged to undertake a physical 796
examination that will establish a base-line level of health and 797
identification of a usual and customary source of care (a medical 798
home) to aid utilization of disease management tools. This 799
physical examination and utilization of these disease management 800
tools shall be consistent with current United States Preventive 801
Services Task Force or other recognized authority recommendations. 802
For persons who are determined ineligible for Medicaid, the 803
division will provide information and direction for accessing 804
medical care and services in the area of their residence. 805
(52) Notwithstanding any provisions of this article, 806
the division may pay enhanced reimbursement fees related to trauma 807
care, as determined by the division in conjunction with the State 808
Department of Health, using funds appropriated to the State 809
Department of Health for trauma care and services and used to 810
match federal funds under a cooperative agreement between the 811
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division and the State Department of Health. The division, in 812
conjunction with the State Department of Health, may use grants, 813
waivers, demonstrations, enhanced reimbursements, Upper Payment 814
Limits Programs, supplemental payments, or other projects as 815
necessary in the development and implementation of this 816
reimbursement program. 817
(53) Targeted case management services for high-cost 818
beneficiaries may be developed by the division for all services 819
under this section. 820
(54) [Deleted] 821
(55) Therapy services. The plan of care for therapy 822
services may be developed to cover a period of treatment for up to 823
six (6) months, but in no event shall the plan of care exceed a 824
six-month period of treatment. The projected period of treatment 825
must be indicated on the initial plan of care and must be updated 826
with each subsequent revised plan of care. Based on medical 827
necessity, the division shall approve certification periods for 828
less than or up to six (6) months, but in no event shall the 829
certification period exceed the period of treatment indicated on 830
the plan of care. The appeal process for any reduction in therapy 831
services shall be consistent with the appeal process in federal 832
regulations. 833
(56) Prescribed pediatric extended care centers 834
services for medically dependent or technologically dependent 835
children with complex medical conditions that require continual 836
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care as prescribed by the child's attending physician, as 837
determined by the division. 838
(57) No Medicaid benefit shall restrict coverage for 839
medically appropriate treatment prescribed by a physician and 840
agreed to by a fully informed individual, or if the individual 841
lacks legal capacity to consent by a person who has legal 842
authority to consent on his or her behalf, based on an 843
individual's diagnosis with a terminal condition. As used in this 844
paragraph (57), "terminal condition" means any aggressive 845
malignancy, chronic end-stage cardiovascular or cerebral vascular 846
disease, or any other disease, illness or condition which a 847
physician diagnoses as terminal. 848
(58) Treatment services for persons with opioid 849
dependency or other highly addictive substance use disorders. The 850
division is authorized to reimburse eligible providers for 851
treatment of opioid dependency and other highly addictive 852
substance use disorders, as determined by the division. Treatment 853
related to these conditions shall not count against any physician 854
visit limit imposed under this section. 855
(59) The division shall allow beneficiaries between the 856
ages of ten (10) and eighteen (18) years to receive vaccines 857
through a pharmacy venue. The division and the State Department 858
of Health shall coordinate and notify OB-GYN providers that the 859
Vaccines for Children program is available to providers free of 860
charge. 861
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(60) Border city university-affiliated pediatric 862
teaching hospital. 863
(a) Payments may only be made to a border city 864
university-affiliated pediatric teaching hospital if the Centers 865
for Medicare and Medicaid Services (CMS) approve an increase in 866
the annual request for the provider payment initiative authorized 867
under 42 CFR Section 438.6(c) in an amount equal to or greater 868
than the estimated annual payment to be made to the border city 869
university-affiliated pediatric teaching hospital. The estimate 870
shall be based on the hospital's prior year Mississippi managed 871
care utilization. 872
(b) As used in this paragraph (60), the term 873
"border city university-affiliated pediatric teaching hospital" 874
means an out-of-state hospital located within a city bordering the 875
eastern bank of the Mississippi River and the State of Mississippi 876
that submits to the division a copy of a current and effective 877
affiliation agreement with an accredited university and other 878
documentation establishing that the hospital is 879
university-affiliated, is licensed and designated as a pediatric 880
hospital or pediatric primary hospital within its home state, 881
maintains at least five (5) different pediatric specialty training 882
programs, and maintains at least one hundred (100) operated beds 883
dedicated exclusively for the treatment of patients under the age 884
of twenty-one (21) years. 885
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(c) The cost of providing services to Mississippi 886
Medicaid beneficiaries under the age of twenty-one (21) years who 887
are treated by a border city university-affiliated pediatric 888
teaching hospital shall not exceed the cost of providing the same 889
services to individuals in hospitals in the state. 890
(d) It is the intent of the Legislature that 891
payments shall not result in any in-state hospital receiving 892
payments lower than they would otherwise receive if not for the 893
payments made to any border city university-affiliated pediatric 894
teaching hospital. 895
(e) This paragraph (60) shall stand repealed on 896
July 1, 2024. 897
(61) Services described in Section 41-140-3 that are 898
provided by certified community health workers employed and 899
supervised by a Medicaid provider. Reimbursement for these 900
services shall be provided only if the division has received 901
approval from the Centers for Medicare and Medicaid Services for a 902
state plan amendment, waiver or alternative payment model for 903
services delivered by certified community health workers. 904
(B) Planning and development districts participating in the 905
home- and community-based services program for the elderly and 906
disabled as case management providers shall be reimbursed for case 907
management services at the maximum rate approved by the Centers 908
for Medicare and Medicaid Services (CMS). 909
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(C) The division may pay to those providers who participate 910
in and accept patient referrals from the division's emergency room 911
redirection program a percentage, as determined by the division, 912
of savings achieved according to the performance measures and 913
reduction of costs required of that program. Federally qualified 914
health centers may participate in the emergency room redirection 915
program, and the division may pay those centers a percentage of 916
any savings to the Medicaid program achieved by the centers' 917
accepting patient referrals through the program, as provided in 918
this subsection (C). 919
(D) (1) As used in this subsection (D), the following terms 920
shall be defined as provided in this paragraph, except as 921
otherwise provided in this subsection: 922
(a) "Committees" means the Medicaid Committees of 923
the House of Representatives and the Senate, and "committee" means 924
either one of those committees. 925
(b) "Rate change" means an increase, decrease or 926
other change in the payments or rates of reimbursement, or a 927
change in any payment methodology that results in an increase, 928
decrease or other change in the payments or rates of 929
reimbursement, to any Medicaid provider that renders any services 930
authorized to be provided to Medicaid recipients under this 931
article. 932
(2) Whenever the Division of Medicaid proposes a rate 933
change, the division shall give notice to the chairmen of the 934
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committees at least thirty (30) calendar days before the proposed 935
rate change is scheduled to take effect. The division shall 936
furnish the chairmen with a concise summary of each proposed rate 937
change along with the notice, and shall furnish the chairmen with 938
a copy of any proposed rate change upon request. The division 939
also shall provide a summary and copy of any proposed rate change 940
to any other member of the Legislature upon request. 941
(3) If the chairman of either committee or both 942
chairmen jointly object to the proposed rate change or any part 943
thereof, the chairman or chairmen shall notify the division and 944
provide the reasons for their objection in writing not later than 945
seven (7) calendar days after receipt of the notice from the 946
division. The chairman or chairmen may make written 947
recommendations to the division for changes to be made to a 948
proposed rate change. 949
(4) (a) The chairman of either committee or both 950
chairmen jointly may hold a committee meeting to review a proposed 951
rate change. If either chairman or both chairmen decide to hold a 952
meeting, they shall notify the division of their intention in 953
writing within seven (7) calendar days after receipt of the notice 954
from the division, and shall set the date and time for the meeting 955
in their notice to the division, which shall not be later than 956
fourteen (14) calendar days after receipt of the notice from the 957
division. 958
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(b) After the committee meeting, the committee or 959
committees may object to the proposed rate change or any part 960
thereof. The committee or committees shall notify the division 961
and the reasons for their objection in writing not later than 962
seven (7) calendar days after the meeting. The committee or 963
committees may make written recommendations to the division for 964
changes to be made to a proposed rate change. 965
(5) If both chairmen notify the division in writing 966
within seven (7) calendar days after receipt of the notice from 967
the division that they do not object to the proposed rate change 968
and will not be holding a meeting to review the proposed rate 969
change, the proposed rate change will take effect on the original 970
date as scheduled by the division or on such other date as 971
specified by the division. 972
(6) (a) If there are any objections to a proposed rate 973
change or any part thereof from either or both of the chairmen or 974
the committees, the division may withdraw the proposed rate 975
change, make any of the recommended changes to the proposed rate 976
change, or not make any changes to the proposed rate change. 977
(b) If the division does not make any changes to 978
the proposed rate change, it shall notify the chairmen of that 979
fact in writing, and the proposed rate change shall take effect on 980
the original date as scheduled by the division or on such other 981
date as specified by the division. 982
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(c) If the division makes any changes to the 983
proposed rate change, the division shall notify the chairmen of 984
its actions in writing, and the revised proposed rate change shall 985
take effect on the date as specified by the division. 986
(7) Nothing in this subsection (D) shall be construed 987
as giving the chairmen or the committees any authority to veto, 988
nullify or revise any rate change proposed by the division. The 989
authority of the chairmen or the committees under this subsection 990
shall be limited to reviewing, making objections to and making 991
recommendations for changes to rate changes proposed by the 992
division. 993
(E) Notwithstanding any provision of this article, no new 994
groups or categories of recipients and new types of care and 995
services may be added without enabling legislation from the 996
Mississippi Legislature, except that the division may authorize 997
those changes without enabling legislation when the addition of 998
recipients or services is ordered by a court of proper authority. 999
(F) The executive director shall keep the Governor advised 1000
on a timely basis of the funds available for expenditure and the 1001
projected expenditures. Notwithstanding any other provisions of 1002
this article, if current or projected expenditures of the division 1003
are reasonably anticipated to exceed the amount of funds 1004
appropriated to the division for any fiscal year, the Governor, 1005
after consultation with the executive director, shall take all 1006
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appropriate measures to reduce costs, which may include, but are 1007
not limited to: 1008
(1) Reducing or discontinuing any or all services that 1009
are deemed to be optional under Title XIX of the Social Security 1010
Act; 1011
(2) Reducing reimbursement rates for any or all service 1012
types; 1013
(3) Imposing additional assessments on health care 1014
providers; or 1015
(4) Any additional cost-containment measures deemed 1016
appropriate by the Governor. 1017
To the extent allowed under federal law, any reduction to 1018
services or reimbursement rates under this subsection (F) shall be 1019
accompanied by a reduction, to the fullest allowable amount, to 1020
the profit margin and administrative fee portions of capitated 1021
payments to organizations described in paragraph (1) of subsection 1022
(H). 1023
Beginning in fiscal year 2010 and in fiscal years thereafter, 1024
when Medicaid expenditures are projected to exceed funds available 1025
for the fiscal year, the division shall submit the expected 1026
shortfall information to the PEER Committee not later than 1027
December 1 of the year in which the shortfall is projected to 1028
occur. PEER shall review the computations of the division and 1029
report its findings to the Legislative Budget Office not later 1030
than January 7 in any year. 1031
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(G) Notwithstanding any other provision of this article, it 1032
shall be the duty of each provider participating in the Medicaid 1033
program to keep and maintain books, documents and other records as 1034
prescribed by the Division of Medicaid in accordance with federal 1035
laws and regulations. 1036
(H) (1) Notwithstanding any other provision of this 1037
article, the division is authorized to implement (a) a managed 1038
care program, (b) a coordinated care program, (c) a coordinated 1039
care organization program, (d) a health maintenance organization 1040
program, (e) a patient-centered medical home program, (f) an 1041
accountable care organization program, (g) provider-sponsored 1042
health plan, or (h) any combination of the above programs. As a 1043
condition for the approval of any program under this subsection 1044
(H)(1), the division shall require that no managed care program, 1045
coordinated care program, coordinated care organization program, 1046
health maintenance organization program, or provider-sponsored 1047
health plan may: 1048
(a) Pay providers at a rate that is less than the 1049
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1050
reimbursement rate; 1051
(b) Override the medical decisions of hospital 1052
physicians or staff regarding patients admitted to a hospital for 1053
an emergency medical condition as defined by 42 US Code Section 1054
1395dd. This restriction (b) does not prohibit the retrospective 1055
review of the appropriateness of the determination that an 1056
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emergency medical condition exists by chart review or coding 1057
algorithm, nor does it prohibit prior authorization for 1058
nonemergency hospital admissions; 1059
(c) Pay providers at a rate that is less than the 1060
normal Medicaid reimbursement rate. It is the intent of the 1061
Legislature that all managed care entities described in this 1062
subsection (H), in collaboration with the division, develop and 1063
implement innovative payment models that incentivize improvements 1064
in health care quality, outcomes, or value, as determined by the 1065
division. Participation in the provider network of any managed 1066
care, coordinated care, provider-sponsored health plan, or similar 1067
contractor shall not be conditioned on the provider's agreement to 1068
accept such alternative payment models; 1069
(d) Implement a prior authorization and 1070
utilization review program for medical services, transportation 1071
services and prescription drugs that is more stringent than the 1072
prior authorization processes used by the division in its 1073
administration of the Medicaid program. Not later than December 1074
2, 2021, the contractors that are receiving capitated payments 1075
under a managed care delivery system established under this 1076
subsection (H) shall submit a report to the Chairmen of the House 1077
and Senate Medicaid Committees on the status of the prior 1078
authorization and utilization review program for medical services, 1079
transportation services and prescription drugs that is required to 1080
be implemented under this subparagraph (d); 1081
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(e) [Deleted] 1082
(f) Implement a preferred drug list that is more 1083
stringent than the mandatory preferred drug list established by 1084
the division under subsection (A)(9) of this section; 1085
(g) Implement a policy which denies beneficiaries 1086
with hemophilia access to the federally funded hemophilia 1087
treatment centers as part of the Medicaid Managed Care network of 1088
providers. 1089
Each health maintenance organization, coordinated care 1090
organization, provider-sponsored health plan, or other 1091
organization paid for services on a capitated basis by the 1092
division under any managed care program or coordinated care 1093
program implemented by the division under this section shall use a 1094
clear set of level of care guidelines in the determination of 1095
medical necessity and in all utilization management practices, 1096
including the prior authorization process, concurrent reviews, 1097
retrospective reviews and payments, that are consistent with 1098
widely accepted professional standards of care. Organizations 1099
participating in a managed care program or coordinated care 1100
program implemented by the division may not use any additional 1101
criteria that would result in denial of care that would be 1102
determined appropriate and, therefore, medically necessary under 1103
those levels of care guidelines. 1104
(2) Notwithstanding any provision of this section, the 1105
recipients eligible for enrollment into a Medicaid Managed Care 1106
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Program authorized under this subsection (H) may include only 1107
those categories of recipients eligible for participation in the 1108
Medicaid Managed Care Program as of January 1, 2021, the 1109
Children's Health Insurance Program (CHIP), and the CMS-approved 1110
Section 1115 demonstration waivers in operation as of January 1, 1111
2021. No expansion of Medicaid Managed Care Program contracts may 1112
be implemented by the division without enabling legislation from 1113
the Mississippi Legislature. 1114
(3) (a) Any contractors receiving capitated payments 1115
under a managed care delivery system established in this section 1116
shall provide to the Legislature and the division statistical data 1117
to be shared with provider groups in order to improve patient 1118
access, appropriate utilization, cost savings and health outcomes 1119
not later than October 1 of each year. Additionally, each 1120
contractor shall disclose to the Chairmen of the Senate and House 1121
Medicaid Committees the administrative expenses costs for the 1122
prior calendar year, and the number of full-equivalent employees 1123
located in the State of Mississippi dedicated to the Medicaid and 1124
CHIP lines of business as of June 30 of the current year. 1125
(b) The division and the contractors participating 1126
in the managed care program, a coordinated care program or a 1127
provider-sponsored health plan shall be subject to annual program 1128
reviews or audits performed by the Office of the State Auditor, 1129
the PEER Committee, the Department of Insurance and/or independent 1130
third parties. 1131
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(c) Those reviews shall include, but not be 1132
limited to, at least two (2) of the following items: 1133
(i) The financial benefit to the State of 1134
Mississippi of the managed care program, 1135
(ii) The difference between the premiums paid 1136
to the managed care contractors and the payments made by those 1137
contractors to health care providers, 1138
(iii) Compliance with performance measures 1139
required under the contracts, 1140
(iv) Administrative expense allocation 1141
methodologies, 1142
(v) Whether nonprovider payments assigned as 1143
medical expenses are appropriate, 1144
(vi) Capitated arrangements with related 1145
party subcontractors, 1146
(vii) Reasonableness of corporate 1147
allocations, 1148
(viii) Value-added benefits and the extent to 1149
which they are used, 1150
(ix) The effectiveness of subcontractor 1151
oversight, including subcontractor review, 1152
(x) Whether health care outcomes have been 1153
improved, and 1154
(xi) The most common claim denial codes to 1155
determine the reasons for the denials. 1156
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The audit reports shall be considered public documents and 1157
shall be posted in their entirety on the division's website. 1158
(4) All health maintenance organizations, coordinated 1159
care organizations, provider-sponsored health plans, or other 1160
organizations paid for services on a capitated basis by the 1161
division under any managed care program or coordinated care 1162
program implemented by the division under this section shall 1163
reimburse all providers in those organizations at rates no lower 1164
than those provided under this section for beneficiaries who are 1165
not participating in those programs. 1166
(5) No health maintenance organization, coordinated 1167
care organization, provider-sponsored health plan, or other 1168
organization paid for services on a capitated basis by the 1169
division under any managed care program or coordinated care 1170
program implemented by the division under this section shall 1171
require its providers or beneficiaries to use any pharmacy that 1172
ships, mails or delivers prescription drugs or legend drugs or 1173
devices. 1174
(6) (a) Not later than December 1, 2021, the 1175
contractors who are receiving capitated payments under a managed 1176
care delivery system established under this subsection (H) shall 1177
develop and implement a uniform credentialing process for 1178
providers. Under that uniform credentialing process, a provider 1179
who meets the criteria for credentialing will be credentialed with 1180
all of those contractors and no such provider will have to be 1181
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separately credentialed by any individual contractor in order to 1182
receive reimbursement from the contractor. Not later than 1183
December 2, 2021, those contractors shall submit a report to the 1184
Chairmen of the House and Senate Medicaid Committees on the status 1185
of the uniform credentialing process for providers that is 1186
required under this subparagraph (a). 1187
(b) If those contractors have not implemented a 1188
uniform credentialing process as described in subparagraph (a) by 1189
December 1, 2021, the division shall develop and implement, not 1190
later than July 1, 2022, a single, consolidated credentialing 1191
process by which all providers will be credentialed. Under the 1192
division's single, consolidated credentialing process, no such 1193
contractor shall require its providers to be separately 1194
credentialed by the contractor in order to receive reimbursement 1195
from the contractor, but those contractors shall recognize the 1196
credentialing of the providers by the division's credentialing 1197
process. 1198
(c) The division shall require a uniform provider 1199
credentialing application that shall be used in the credentialing 1200
process that is established under subparagraph (a) or (b). If the 1201
contractor or division, as applicable, has not approved or denied 1202
the provider credentialing application within sixty (60) days of 1203
receipt of the completed application that includes all required 1204
information necessary for credentialing, then the contractor or 1205
division, upon receipt of a written request from the applicant and 1206
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within five (5) business days of its receipt, shall issue a 1207
temporary provider credential/enrollment to the applicant if the 1208
applicant has a valid Mississippi professional or occupational 1209
license to provide the health care services to which the 1210
credential/enrollment would apply. The contractor or the division 1211
shall not issue a temporary credential/enrollment if the applicant 1212
has reported on the application a history of medical or other 1213
professional or occupational malpractice claims, a history of 1214
substance abuse or mental health issues, a criminal record, or a 1215
history of medical or other licensing board, state or federal 1216
disciplinary action, including any suspension from participation 1217
in a federal or state program. The temporary 1218
credential/enrollment shall be effective upon issuance and shall 1219
remain in effect until the provider's credentialing/enrollment 1220
application is approved or denied by the contractor or division. 1221
The contractor or division shall render a final decision regarding 1222
credentialing/enrollment of the provider within sixty (60) days 1223
from the date that the temporary provider credential/enrollment is 1224
issued to the applicant. 1225
(d) If the contractor or division does not render 1226
a final decision regarding credentialing/enrollment of the 1227
provider within the time required in subparagraph (c), the 1228
provider shall be deemed to be credentialed by and enrolled with 1229
all of the contractors and eligible to receive reimbursement from 1230
the contractors. 1231
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(7) (a) Each contractor that is receiving capitated 1232
payments under a managed care delivery system established under 1233
this subsection (H) shall provide to each provider for whom the 1234
contractor has denied the coverage of a procedure that was ordered 1235
or requested by the provider for or on behalf of a patient, a 1236
letter that provides a detailed explanation of the reasons for the 1237
denial of coverage of the procedure and the name and the 1238
credentials of the person who denied the coverage. The letter 1239
shall be sent to the provider in electronic format. 1240
(b) After a contractor that is receiving capitated 1241
payments under a managed care delivery system established under 1242
this subsection (H) has denied coverage for a claim submitted by a 1243
provider, the contractor shall issue to the provider within sixty 1244
(60) days a final ruling of denial of the claim that allows the 1245
provider to have a state fair hearing and/or agency appeal with 1246
the division. If a contractor does not issue a final ruling of 1247
denial within sixty (60) days as required by this subparagraph 1248
(b), the provider's claim shall be deemed to be automatically 1249
approved and the contractor shall pay the amount of the claim to 1250
the provider. 1251
(c) After a contractor has issued a final ruling 1252
of denial of a claim submitted by a provider, the division shall 1253
conduct a state fair hearing and/or agency appeal on the matter of 1254
the disputed claim between the contractor and the provider within 1255
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sixty (60) days, and shall render a decision on the matter within 1256
thirty (30) days after the date of the hearing and/or appeal. 1257
(8) It is the intention of the Legislature that the 1258
division evaluate the feasibility of using a single vendor to 1259
administer pharmacy benefits provided under a managed care 1260
delivery system established under this subsection (H). Providers 1261
of pharmacy benefits shall cooperate with the division in any 1262
transition to a carve-out of pharmacy benefits under managed care. 1263
(9) The division shall evaluate the feasibility of 1264
using a single vendor to administer dental benefits provided under 1265
a managed care delivery system established in this subsection (H). 1266
Providers of dental benefits shall cooperate with the division in 1267
any transition to a carve-out of dental benefits under managed 1268
care. 1269
(10) It is the intent of the Legislature that any 1270
contractor receiving capitated payments under a managed care 1271
delivery system established in this section shall implement 1272
innovative programs to improve the health and well-being of 1273
members diagnosed with prediabetes and diabetes. 1274
(11) It is the intent of the Legislature that any 1275
contractors receiving capitated payments under a managed care 1276
delivery system established under this subsection (H) shall work 1277
with providers of Medicaid services to improve the utilization of 1278
long-acting reversible contraceptives (LARCs). Not later than 1279
December 1, 2021, any contractors receiving capitated payments 1280
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under a managed care delivery system established under this 1281
subsection (H) shall provide to the Chairmen of the House and 1282
Senate Medicaid Committees and House and Senate Public Health 1283
Committees a report of LARC utilization for State Fiscal Years 1284
2018 through 2020 as well as any programs, initiatives, or efforts 1285
made by the contractors and providers to increase LARC 1286
utilization. This report shall be updated annually to include 1287
information for subsequent state fiscal years. 1288
(12) The division is authorized to make not more than 1289
one (1) emergency extension of the contracts that are in effect on 1290
July 1, 2021, with contractors who are receiving capitated 1291
payments under a managed care delivery system established under 1292
this subsection (H), as provided in this paragraph (12). The 1293
maximum period of any such extension shall be one (1) year, and 1294
under any such extensions, the contractors shall be subject to all 1295
of the provisions of this subsection (H). The extended contracts 1296
shall be revised to incorporate any provisions of this subsection 1297
(H). 1298
(I) [Deleted] 1299
(J) There shall be no cuts in inpatient and outpatient 1300
hospital payments, or allowable days or volumes, as long as the 1301
hospital assessment provided in Section 43-13-145 is in effect. 1302
This subsection (J) shall not apply to decreases in payments that 1303
are a result of: reduced hospital admissions, audits or payments 1304
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ST: Medicaid; telehealth services provided by
FQHCs, rural health clinics and community mental
health centers reimbursed at same rate as face-
to-face encounters.
under the APR-DRG or APC models, or a managed care program or 1305
similar model described in subsection (H) of this section. 1306
(K) In the negotiation and execution of such contracts 1307
involving services performed by actuarial firms, the Executive 1308
Director of the Division of Medicaid may negotiate a limitation on 1309
liability to the state of prospective contractors. 1310
(L) The Division of Medicaid shall reimburse for services 1311
provided to eligible Medicaid beneficiaries by a licensed birthing 1312
center in a method and manner to be determined by the division in 1313
accordance with federal laws and federal regulations. The 1314
division shall seek any necessary waivers, make any required 1315
amendments to its State Plan or revise any contracts authorized 1316
under subsection (H) of this section as necessary to provide the 1317
services authorized under this subsection. As used in this 1318
subsection, the term "birthing centers" shall have the meaning as 1319
defined in Section 41-77-1(a), which is a publicly or privately 1320
owned facility, place or institution constructed, renovated, 1321
leased or otherwise established where nonemergency births are 1322
planned to occur away from the mother's usual residence following 1323
a documented period of prenatal care for a normal uncomplicated 1324
pregnancy which has been determined to be low risk through a 1325
formal risk-scoring examination. 1326
(M) This section shall stand repealed on July 1, 2028. 1327
SECTION 2. This act shall take effect and be in force from 1328
and after July 1, 2026. 1329