Medicaid; provide for reimbursement for vagus nerve stimulation (VNS) surgical implant procedures.

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Mansell

HOUSE BILL NO. 1418

AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, 1
TO PROVIDE THAT THE DIVISION OF MEDICAID SHALL REIMBURSE FOR VAGUS 2
NERVE STIMULATION (VNS) SURGICAL IMPLANT PROCEDURES PERFORMED IN 3
HOSPITALS ON AN OUTPATIENT BASIS AND IN AMBULATORY SURGICAL 4
FACILITIES AND TO PRESCRIBE THE RATES OF REIMBURSEMENT; TO PROVIDE 5
THAT CONTRACTS ENTERED INTO OR RENEWED ON OR AFTER THE EFFECTIVE 6
DATE OF THIS ACT BETWEEN THE DIVISION AND A MANAGED CARE 7
ORGANIZATION MUST CONTAIN A REQUIREMENT THAT THE MANAGED CARE 8
ORGANIZATION COMPLY WITH PROVISION REGARDING REIMBURSEMENT RATES 9
FOR VNS SURGICAL IMPLANT PROCEDURES FOR FEE-FOR-SERVICE PROVIDERS; 10
AND FOR RELATED PURPOSES. 11
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 12
SECTION 1. Section 43-13-117, Mississippi Code of 1972, is 13
amended as follows: 14
43-13-117. (A) Medicaid as authorized by this article shall 15
include payment of part or all of the costs, at the discretion of 16
the division, with approval of the Governor and the Centers for 17
Medicare and Medicaid Services, of the following types of care and 18
services rendered to eligible applicants who have been determined 19
to be eligible for that care and services, within the limits of 20
state appropriations and federal matching funds: 21
(1) Inpatient hospital services. 22
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(a) The division is authorized to implement an All 23
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 24
methodology for inpatient hospital services. 25
(b) No service benefits or reimbursement 26
limitations in this subsection (A)(1) shall apply to payments 27
under an APR-DRG or Ambulatory Payment Classification (APC) model 28
or a managed care program or similar model described in subsection 29
(H) of this section unless specifically authorized by the 30
division. 31
(2) Outpatient hospital services. 32
(a) Emergency services. 33
(b) Other outpatient hospital services. The 34
division shall allow benefits for other medically necessary 35
outpatient hospital services (such as chemotherapy, radiation, 36
surgery and therapy), including outpatient services in a clinic or 37
other facility that is not located inside the hospital, but that 38
has been designated as an outpatient facility by the hospital, and 39
that was in operation or under construction on July 1, 2009, 40
provided that the costs and charges associated with the operation 41
of the hospital clinic are included in the hospital's cost report. 42
In addition, the Medicare thirty-five-mile rule will apply to 43
those hospital clinics not located inside the hospital that are 44
constructed after July 1, 2009. Where the same services are 45
reimbursed as clinic services, the division may revise the rate or 46
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methodology of outpatient reimbursement to maintain consistency, 47
efficiency, economy and quality of care. 48
(c) The division is authorized to implement an 49
Ambulatory Payment Classification (APC) methodology for outpatient 50
hospital services. The division shall give rural hospitals that 51
have fifty (50) or fewer licensed beds the option to not be 52
reimbursed for outpatient hospital services using the APC 53
methodology, but reimbursement for outpatient hospital services 54
provided by those hospitals shall be based on one hundred one 55
percent (101%) of the rate established under Medicare for 56
outpatient hospital services. Those hospitals choosing to not be 57
reimbursed under the APC methodology shall remain under cost-based 58
reimbursement for a two-year period. 59
(d) No service benefits or reimbursement 60
limitations in this subsection (A)(2) shall apply to payments 61
under an APR-DRG or APC model or a managed care program or similar 62
model described in subsection (H) of this section unless 63
specifically authorized by the division. 64
(3) Laboratory and x-ray services. 65
(4) Nursing facility services. 66
(a) The division shall make full payment to 67
nursing facilities for each day, not exceeding forty-two (42) days 68
per year, that a patient is absent from the facility on home 69
leave. Payment may be made for the following home leave days in 70
addition to the forty-two-day limitation: Christmas, the day 71
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before Christmas, the day after Christmas, Thanksgiving, the day 72
before Thanksgiving and the day after Thanksgiving. 73
(b) From and after July 1, 1997, the division 74
shall implement the integrated case-mix payment and quality 75
monitoring system, which includes the fair rental system for 76
property costs and in which recapture of depreciation is 77
eliminated. The division may reduce the payment for hospital 78
leave and therapeutic home leave days to the lower of the case-mix 79
category as computed for the resident on leave using the 80
assessment being utilized for payment at that point in time, or a 81
case-mix score of 1.000 for nursing facilities, and shall compute 82
case-mix scores of residents so that only services provided at the 83
nursing facility are considered in calculating a facility's per 84
diem. 85
(c) From and after July 1, 1997, all state-owned 86
nursing facilities shall be reimbursed on a full reasonable cost 87
basis. 88
(d) On or after January 1, 2015, the division 89
shall update the case-mix payment system resource utilization 90
grouper and classifications and fair rental reimbursement system. 91
The division shall develop and implement a payment add-on to 92
reimburse nursing facilities for ventilator-dependent resident 93
services. 94
(e) The division shall develop and implement, not 95
later than January 1, 2001, a case-mix payment add-on determined 96
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by time studies and other valid statistical data that will 97
reimburse a nursing facility for the additional cost of caring for 98
a resident who has a diagnosis of Alzheimer's or other related 99
dementia and exhibits symptoms that require special care. Any 100
such case-mix add-on payment shall be supported by a determination 101
of additional cost. The division shall also develop and implement 102
as part of the fair rental reimbursement system for nursing 103
facility beds, an Alzheimer's resident bed depreciation enhanced 104
reimbursement system that will provide an incentive to encourage 105
nursing facilities to convert or construct beds for residents with 106
Alzheimer's or other related dementia. 107
(f) The division shall develop and implement an 108
assessment process for long-term care services. The division may 109
provide the assessment and related functions directly or through 110
contract with the area agencies on aging. 111
The division shall apply for necessary federal waivers to 112
assure that additional services providing alternatives to nursing 113
facility care are made available to applicants for nursing 114
facility care. 115
(5) Periodic screening and diagnostic services for 116
individuals under age twenty-one (21) years as are needed to 117
identify physical and mental defects and to provide health care 118
treatment and other measures designed to correct or ameliorate 119
defects and physical and mental illness and conditions discovered 120
by the screening services, regardless of whether these services 121
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are included in the state plan. The division may include in its 122
periodic screening and diagnostic program those discretionary 123
services authorized under the federal regulations adopted to 124
implement Title XIX of the federal Social Security Act, as 125
amended. The division, in obtaining physical therapy services, 126
occupational therapy services, and services for individuals with 127
speech, hearing and language disorders, may enter into a 128
cooperative agreement with the State Department of Education for 129
the provision of those services to handicapped students by public 130
school districts using state funds that are provided from the 131
appropriation to the Department of Education to obtain federal 132
matching funds through the division. The division, in obtaining 133
medical and mental health assessments, treatment, care and 134
services for children who are in, or at risk of being put in, the 135
custody of the Mississippi Department of Human Services may enter 136
into a cooperative agreement with the Mississippi Department of 137
Human Services for the provision of those services using state 138
funds that are provided from the appropriation to the Department 139
of Human Services to obtain federal matching funds through the 140
division. 141
(6) Physician services. Fees for physician's services 142
that are covered only by Medicaid shall be reimbursed at ninety 143
percent (90%) of the rate established on January 1, 2018, and as 144
may be adjusted each July thereafter, under Medicare. The 145
division may provide for a reimbursement rate for physician's 146
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services of up to one hundred percent (100%) of the rate 147
established under Medicare for physician's services that are 148
provided after the normal working hours of the physician, as 149
determined in accordance with regulations of the division. The 150
division may reimburse eligible providers, as determined by the 151
division, for certain primary care services at one hundred percent 152
(100%) of the rate established under Medicare. The division shall 153
reimburse obstetricians and gynecologists for certain primary care 154
services as defined by the division at one hundred percent (100%) 155
of the rate established under Medicare. 156
(7) (a) Home health services for eligible persons, not 157
to exceed in cost the prevailing cost of nursing facility 158
services. All home health visits must be precertified as required 159
by the division. In addition to physicians, certified registered 160
nurse practitioners, physician assistants and clinical nurse 161
specialists are authorized to prescribe or order home health 162
services and plans of care, sign home health plans of care, 163
certify and recertify eligibility for home health services and 164
conduct the required initial face-to-face visit with the recipient 165
of the services. 166
(b) [Repealed] 167
(8) Emergency medical transportation services as 168
determined by the division. 169
(9) Prescription drugs and other covered drugs and 170
services as determined by the division. 171
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The division shall establish a mandatory preferred drug list. 172
Drugs not on the mandatory preferred drug list shall be made 173
available by utilizing prior authorization procedures established 174
by the division. 175
The division may seek to establish relationships with other 176
states in order to lower acquisition costs of prescription drugs 177
to include single-source and innovator multiple-source drugs or 178
generic drugs. In addition, if allowed by federal law or 179
regulation, the division may seek to establish relationships with 180
and negotiate with other countries to facilitate the acquisition 181
of prescription drugs to include single-source and innovator 182
multiple-source drugs or generic drugs, if that will lower the 183
acquisition costs of those prescription drugs. 184
The division may allow for a combination of prescriptions for 185
single-source and innovator multiple-source drugs and generic 186
drugs to meet the needs of the beneficiaries. 187
The executive director may approve specific maintenance drugs 188
for beneficiaries with certain medical conditions, which may be 189
prescribed and dispensed in three-month supply increments. 190
Drugs prescribed for a resident of a psychiatric residential 191
treatment facility must be provided in true unit doses when 192
available. The division may require that drugs not covered by 193
Medicare Part D for a resident of a long-term care facility be 194
provided in true unit doses when available. Those drugs that were 195
originally billed to the division but are not used by a resident 196
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in any of those facilities shall be returned to the billing 197
pharmacy for credit to the division, in accordance with the 198
guidelines of the State Board of Pharmacy and any requirements of 199
federal law and regulation. Drugs shall be dispensed to a 200
recipient and only one (1) dispensing fee per month may be 201
charged. The division shall develop a methodology for reimbursing 202
for restocked drugs, which shall include a restock fee as 203
determined by the division not exceeding Seven Dollars and 204
Eighty-two Cents ($7.82). 205
Except for those specific maintenance drugs approved by the 206
executive director, the division shall not reimburse for any 207
portion of a prescription that exceeds a thirty-one-day supply of 208
the drug based on the daily dosage. 209
The division is authorized to develop and implement a program 210
of payment for additional pharmacist services as determined by the 211
division. 212
All claims for drugs for dually eligible Medicare/Medicaid 213
beneficiaries that are paid for by Medicare must be submitted to 214
Medicare for payment before they may be processed by the 215
division's online payment system. 216
The division shall develop a pharmacy policy in which drugs 217
in tamper-resistant packaging that are prescribed for a resident 218
of a nursing facility but are not dispensed to the resident shall 219
be returned to the pharmacy and not billed to Medicaid, in 220
accordance with guidelines of the State Board of Pharmacy. 221
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The division shall develop and implement a method or methods 222
by which the division will provide on a regular basis to Medicaid 223
providers who are authorized to prescribe drugs, information about 224
the costs to the Medicaid program of single-source drugs and 225
innovator multiple-source drugs, and information about other drugs 226
that may be prescribed as alternatives to those single-source 227
drugs and innovator multiple-source drugs and the costs to the 228
Medicaid program of those alternative drugs. 229
Notwithstanding any law or regulation, information obtained 230
or maintained by the division regarding the prescription drug 231
program, including trade secrets and manufacturer or labeler 232
pricing, is confidential and not subject to disclosure except to 233
other state agencies. 234
The dispensing fee for each new or refill prescription, 235
including nonlegend or over-the-counter drugs covered by the 236
division, shall be not less than Three Dollars and Ninety-one 237
Cents ($3.91), as determined by the division. 238
The division shall not reimburse for single-source or 239
innovator multiple-source drugs if there are equally effective 240
generic equivalents available and if the generic equivalents are 241
the least expensive. 242
It is the intent of the Legislature that the pharmacists 243
providers be reimbursed for the reasonable costs of filling and 244
dispensing prescriptions for Medicaid beneficiaries. 245
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The division shall allow certain drugs, including 246
physician-administered drugs, and implantable drug system devices, 247
and medical supplies, with limited distribution or limited access 248
for beneficiaries and administered in an appropriate clinical 249
setting, to be reimbursed as either a medical claim or pharmacy 250
claim, as determined by the division. 251
It is the intent of the Legislature that the division and any 252
managed care entity described in subsection (H) of this section 253
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 254
prevent recurrent preterm birth. 255
(10) Dental and orthodontic services to be determined 256
by the division. 257
The division shall increase the amount of the reimbursement 258
rate for diagnostic and preventative dental services for each of 259
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 260
the amount of the reimbursement rate for the previous fiscal year. 261
The division shall increase the amount of the reimbursement rate 262
for restorative dental services for each of the fiscal years 2023, 263
2024 and 2025 by five percent (5%) above the amount of the 264
reimbursement rate for the previous fiscal year. It is the intent 265
of the Legislature that the reimbursement rate revision for 266
preventative dental services will be an incentive to increase the 267
number of dentists who actively provide Medicaid services. This 268
dental services reimbursement rate revision shall be known as the 269
"James Russell Dumas Medicaid Dental Services Incentive Program." 270
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The Medical Care Advisory Committee, assisted by the Division 271
of Medicaid, shall annually determine the effect of this incentive 272
by evaluating the number of dentists who are Medicaid providers, 273
the number who and the degree to which they are actively billing 274
Medicaid, the geographic trends of where dentists are offering 275
what types of Medicaid services and other statistics pertinent to 276
the goals of this legislative intent. This data shall annually be 277
presented to the Chair of the Senate Medicaid Committee and the 278
Chair of the House Medicaid Committee. 279
The division shall include dental services as a necessary 280
component of overall health services provided to children who are 281
eligible for services. 282
(11) Eyeglasses for all Medicaid beneficiaries who have 283
(a) had surgery on the eyeball or ocular muscle that results in a 284
vision change for which eyeglasses or a change in eyeglasses is 285
medically indicated within six (6) months of the surgery and is in 286
accordance with policies established by the division, or (b) one 287
(1) pair every five (5) years and in accordance with policies 288
established by the division. In either instance, the eyeglasses 289
must be prescribed by a physician skilled in diseases of the eye 290
or an optometrist, whichever the beneficiary may select. 291
(12) Intermediate care facility services. 292
(a) The division shall make full payment to all 293
intermediate care facilities for individuals with intellectual 294
disabilities for each day, not exceeding sixty-three (63) days per 295
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year, that a patient is absent from the facility on home leave. 296
Payment may be made for the following home leave days in addition 297
to the sixty-three-day limitation: Christmas, the day before 298
Christmas, the day after Christmas, Thanksgiving, the day before 299
Thanksgiving and the day after Thanksgiving. 300
(b) All state-owned intermediate care facilities 301
for individuals with intellectual disabilities shall be reimbursed 302
on a full reasonable cost basis. 303
(c) Effective January 1, 2015, the division shall 304
update the fair rental reimbursement system for intermediate care 305
facilities for individuals with intellectual disabilities. 306
(13) Family planning services, including drugs, 307
supplies and devices, when those services are under the 308
supervision of a physician or nurse practitioner. 309
(14) Clinic services. Preventive, diagnostic, 310
therapeutic, rehabilitative or palliative services that are 311
furnished by a facility that is not part of a hospital but is 312
organized and operated to provide medical care to outpatients. 313
Clinic services include, but are not limited to: 314
(a) Services provided by ambulatory surgical 315
centers (ASCs) as defined in Section 41-75-1(a); and 316
(b) Dialysis center services. 317
(15) Home- and community-based services for the elderly 318
and disabled, as provided under Title XIX of the federal Social 319
Security Act, as amended, under waivers, subject to the 320
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availability of funds specifically appropriated for that purpose 321
by the Legislature. 322
(16) Mental health services. Certain services provided 323
by a psychiatrist shall be reimbursed at up to one hundred percent 324
(100%) of the Medicare rate. Approved therapeutic and case 325
management services (a) provided by an approved regional mental 326
health/intellectual disability center established under Sections 327
41-19-31 through 41-19-39, or by another community mental health 328
service provider meeting the requirements of the Department of 329
Mental Health to be an approved mental health/intellectual 330
disability center if determined necessary by the Department of 331
Mental Health, using state funds that are provided in the 332
appropriation to the division to match federal funds, or (b) 333
provided by a facility that is certified by the State Department 334
of Mental Health to provide therapeutic and case management 335
services, to be reimbursed on a fee for service basis, or (c) 336
provided in the community by a facility or program operated by the 337
Department of Mental Health. Any such services provided by a 338
facility described in subparagraph (b) must have the prior 339
approval of the division to be reimbursable under this section. 340
(17) Durable medical equipment services and medical 341
supplies. Precertification of durable medical equipment and 342
medical supplies must be obtained as required by the division. 343
The Division of Medicaid may require durable medical equipment 344
providers to obtain a surety bond in the amount and to the 345
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specifications as established by the Balanced Budget Act of 1997. 346
A maximum dollar amount of reimbursement for noninvasive 347
ventilators or ventilation treatments properly ordered and being 348
used in an appropriate care setting shall not be set by any health 349
maintenance organization, coordinated care organization, 350
provider-sponsored health plan, or other organization paid for 351
services on a capitated basis by the division under any managed 352
care program or coordinated care program implemented by the 353
division under this section. Reimbursement by these organizations 354
to durable medical equipment suppliers for home use of noninvasive 355
and invasive ventilators shall be on a continuous monthly payment 356
basis for the duration of medical need throughout a patient's 357
valid prescription period. 358
(18) (a) Notwithstanding any other provision of this 359
section to the contrary, as provided in the Medicaid state plan 360
amendment or amendments as defined in Section 43-13-145(10), the 361
division shall make additional reimbursement to hospitals that 362
serve a disproportionate share of low-income patients and that 363
meet the federal requirements for those payments as provided in 364
Section 1923 of the federal Social Security Act and any applicable 365
regulations. It is the intent of the Legislature that the 366
division shall draw down all available federal funds allotted to 367
the state for disproportionate share hospitals. However, from and 368
after January 1, 1999, public hospitals participating in the 369
Medicaid disproportionate share program may be required to 370
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participate in an intergovernmental transfer program as provided 371
in Section 1903 of the federal Social Security Act and any 372
applicable regulations. 373
(b) (i) 1. The division may establish a Medicare 374
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 375
the federal Social Security Act and any applicable federal 376
regulations, or an allowable delivery system or provider payment 377
initiative authorized under 42 CFR 438.6(c), for hospitals, 378
nursing facilities and physicians employed or contracted by 379
hospitals. 380
2. The division shall establish a 381
Medicaid Supplemental Payment Program, as permitted by the federal 382
Social Security Act and a comparable allowable delivery system or 383
provider payment initiative authorized under 42 CFR 438.6(c), for 384
emergency ambulance transportation providers in accordance with 385
this subsection (A)(18)(b). 386
(ii) The division shall assess each hospital, 387
nursing facility, and emergency ambulance transportation provider 388
for the sole purpose of financing the state portion of the 389
Medicare Upper Payment Limits Program or other program(s) 390
authorized under this subsection (A)(18)(b). The hospital 391
assessment shall be as provided in Section 43-13-145(4)(a), and 392
the nursing facility and the emergency ambulance transportation 393
assessments, if established, shall be based on Medicaid 394
utilization or other appropriate method, as determined by the 395
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division, consistent with federal regulations. The assessments 396
will remain in effect as long as the state participates in the 397
Medicare Upper Payment Limits Program or other program(s) 398
authorized under this subsection (A)(18)(b). In addition to the 399
hospital assessment provided in Section 43-13-145(4)(a), hospitals 400
with physicians participating in the Medicare Upper Payment Limits 401
Program or other program(s) authorized under this subsection 402
(A)(18)(b) shall be required to participate in an 403
intergovernmental transfer or assessment, as determined by the 404
division, for the purpose of financing the state portion of the 405
physician UPL payments or other payment(s) authorized under this 406
subsection (A)(18)(b). 407
(iii) Subject to approval by the Centers for 408
Medicare and Medicaid Services (CMS) and the provisions of this 409
subsection (A)(18)(b), the division shall make additional 410
reimbursement to hospitals, nursing facilities, and emergency 411
ambulance transportation providers for the Medicare Upper Payment 412
Limits Program or other program(s) authorized under this 413
subsection (A)(18)(b), and, if the program is established for 414
physicians, shall make additional reimbursement for physicians, as 415
defined in Section 1902(a)(30) of the federal Social Security Act 416
and any applicable federal regulations, provided the assessment in 417
this subsection (A)(18)(b) is in effect. 418
(iv) Notwithstanding any other provision of 419
this article to the contrary, effective upon implementation of the 420
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Mississippi Hospital Access Program (MHAP) provided in 421
subparagraph (c)(i) below, the hospital portion of the inpatient 422
Upper Payment Limits Program shall transition into and be replaced 423
by the MHAP program. However, the division is authorized to 424
develop and implement an alternative fee-for-service Upper Payment 425
Limits model in accordance with federal laws and regulations if 426
necessary to preserve supplemental funding. Further, the 427
division, in consultation with the hospital industry shall develop 428
alternative models for distribution of medical claims and 429
supplemental payments for inpatient and outpatient hospital 430
services, and such models may include, but shall not be limited to 431
the following: increasing rates for inpatient and outpatient 432
services; creating a low-income utilization pool of funds to 433
reimburse hospitals for the costs of uncompensated care, charity 434
care and bad debts as permitted and approved pursuant to federal 435
regulations and the Centers for Medicare and Medicaid Services; 436
supplemental payments based upon Medicaid utilization, quality, 437
service lines and/or costs of providing such services to Medicaid 438
beneficiaries and to uninsured patients. The goals of such 439
payment models shall be to ensure access to inpatient and 440
outpatient care and to maximize any federal funds that are 441
available to reimburse hospitals for services provided. Any such 442
documents required to achieve the goals described in this 443
paragraph shall be submitted to the Centers for Medicare and 444
Medicaid Services, with a proposed effective date of July 1, 2019, 445
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to the extent possible, but in no event shall the effective date 446
of such payment models be later than July 1, 2020. The Chairmen 447
of the Senate and House Medicaid Committees shall be provided a 448
copy of the proposed payment model(s) prior to submission. 449
Effective July 1, 2018, and until such time as any payment 450
model(s) as described above become effective, the division, in 451
consultation with the hospital industry, is authorized to 452
implement a transitional program for inpatient and outpatient 453
payments and/or supplemental payments (including, but not limited 454
to, MHAP and directed payments), to redistribute available 455
supplemental funds among hospital providers, provided that when 456
compared to a hospital's prior year supplemental payments, 457
supplemental payments made pursuant to any such transitional 458
program shall not result in a decrease of more than five percent 459
(5%) and shall not increase by more than the amount needed to 460
maximize the distribution of the available funds. 461
(v) 1. To preserve and improve access to 462
ambulance transportation provider services, the division shall 463
seek CMS approval to make ambulance service access payments as set 464
forth in this subsection (A)(18)(b) for all covered emergency 465
ambulance services rendered on or after July 1, 2022, and shall 466
make such ambulance service access payments for all covered 467
services rendered on or after the effective date of CMS approval. 468
2. The division shall calculate the 469
ambulance service access payment amount as the balance of the 470
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portion of the Medical Care Fund related to ambulance 471
transportation service provider assessments plus any federal 472
matching funds earned on the balance, up to, but not to exceed, 473
the upper payment limit gap for all emergency ambulance service 474
providers. 475
3. a. Except for ambulance services 476
exempt from the assessment provided in this paragraph (18)(b), all 477
ambulance transportation service providers shall be eligible for 478
ambulance service access payments each state fiscal year as set 479
forth in this paragraph (18)(b). 480
b. In addition to any other funds 481
paid to ambulance transportation service providers for emergency 482
medical services provided to Medicaid beneficiaries, each eligible 483
ambulance transportation service provider shall receive ambulance 484
service access payments each state fiscal year equal to the 485
ambulance transportation service provider's upper payment limit 486
gap. Subject to approval by the Centers for Medicare and Medicaid 487
Services, ambulance service access payments shall be made no less 488
than on a quarterly basis. 489
c. As used in this paragraph 490
(18)(b)(v), the term "upper payment limit gap" means the 491
difference between the total amount that the ambulance 492
transportation service provider received from Medicaid and the 493
average amount that the ambulance transportation service provider 494
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would have received from commercial insurers for those services 495
reimbursed by Medicaid. 496
4. An ambulance service access payment 497
shall not be used to offset any other payment by the division for 498
emergency or nonemergency services to Medicaid beneficiaries. 499
(c) (i) Not later than December l, 2015, the 500
division shall, subject to approval by the Centers for Medicare 501
and Medicaid Services (CMS), establish, implement and operate a 502
Mississippi Hospital Access Program (MHAP) for the purpose of 503
protecting patient access to hospital care through hospital 504
inpatient reimbursement programs provided in this section designed 505
to maintain total hospital reimbursement for inpatient services 506
rendered by in-state hospitals and the out-of-state hospital that 507
is authorized by federal law to submit intergovernmental transfers 508
(IGTs) to the State of Mississippi and is classified as Level I 509
trauma center located in a county contiguous to the state line at 510
the maximum levels permissible under applicable federal statutes 511
and regulations, at which time the current inpatient Medicare 512
Upper Payment Limits (UPL) Program for hospital inpatient services 513
shall transition to the MHAP. 514
(ii) Subject to approval by the Centers for 515
Medicare and Medicaid Services (CMS), the MHAP shall provide 516
increased inpatient capitation (PMPM) payments to managed care 517
entities contracting with the division pursuant to subsection (H) 518
of this section to support availability of hospital services or 519
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such other payments permissible under federal law necessary to 520
accomplish the intent of this subsection. 521
(iii) The intent of this subparagraph (c) is 522
that effective for all inpatient hospital Medicaid services during 523
state fiscal year 2016, and so long as this provision shall remain 524
in effect hereafter, the division shall to the fullest extent 525
feasible replace the additional reimbursement for hospital 526
inpatient services under the inpatient Medicare Upper Payment 527
Limits (UPL) Program with additional reimbursement under the MHAP 528
and other payment programs for inpatient and/or outpatient 529
payments which may be developed under the authority of this 530
paragraph. 531
(iv) The division shall assess each hospital 532
as provided in Section 43-13-145(4)(a) for the purpose of 533
financing the state portion of the MHAP, supplemental payments and 534
such other purposes as specified in Section 43-13-145. The 535
assessment will remain in effect as long as the MHAP and 536
supplemental payments are in effect. 537
(19) (a) Perinatal risk management services. The 538
division shall promulgate regulations to be effective from and 539
after October 1, 1988, to establish a comprehensive perinatal 540
system for risk assessment of all pregnant and infant Medicaid 541
recipients and for management, education and follow-up for those 542
who are determined to be at risk. Services to be performed 543
include case management, nutrition assessment/counseling, 544
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psychosocial assessment/counseling and health education. The 545
division shall contract with the State Department of Health to 546
provide services within this paragraph (Perinatal High Risk 547
Management/Infant Services System (PHRM/ISS)). The State 548
Department of Health shall be reimbursed on a full reasonable cost 549
basis for services provided under this subparagraph (a). 550
(b) Early intervention system services. The 551
division shall cooperate with the State Department of Health, 552
acting as lead agency, in the development and implementation of a 553
statewide system of delivery of early intervention services, under 554
Part C of the Individuals with Disabilities Education Act (IDEA). 555
The State Department of Health shall certify annually in writing 556
to the executive director of the division the dollar amount of 557
state early intervention funds available that will be utilized as 558
a certified match for Medicaid matching funds. Those funds then 559
shall be used to provide expanded targeted case management 560
services for Medicaid eligible children with special needs who are 561
eligible for the state's early intervention system. 562
Qualifications for persons providing service coordination shall be 563
determined by the State Department of Health and the Division of 564
Medicaid. 565
(20) Home- and community-based services for physically 566
disabled approved services as allowed by a waiver from the United 567
States Department of Health and Human Services for home- and 568
community-based services for physically disabled people using 569
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state funds that are provided from the appropriation to the State 570
Department of Rehabilitation Services and used to match federal 571
funds under a cooperative agreement between the division and the 572
department, provided that funds for these services are 573
specifically appropriated to the Department of Rehabilitation 574
Services. 575
(21) Nurse practitioner services. Services furnished 576
by a registered nurse who is licensed and certified by the 577
Mississippi Board of Nursing as a nurse practitioner, including, 578
but not limited to, nurse anesthetists, nurse midwives, family 579
nurse practitioners, family planning nurse practitioners, 580
pediatric nurse practitioners, obstetrics-gynecology nurse 581
practitioners and neonatal nurse practitioners, under regulations 582
adopted by the division. Reimbursement for those services shall 583
not exceed ninety percent (90%) of the reimbursement rate for 584
comparable services rendered by a physician. The division may 585
provide for a reimbursement rate for nurse practitioner services 586
of up to one hundred percent (100%) of the reimbursement rate for 587
comparable services rendered by a physician for nurse practitioner 588
services that are provided after the normal working hours of the 589
nurse practitioner, as determined in accordance with regulations 590
of the division. 591
(22) Ambulatory services delivered in federally 592
qualified health centers, rural health centers and clinics of the 593
local health departments of the State Department of Health for 594
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individuals eligible for Medicaid under this article based on 595
reasonable costs as determined by the division. Federally 596
qualified health centers shall be reimbursed by the Medicaid 597
prospective payment system as approved by the Centers for Medicare 598
and Medicaid Services. The division shall recognize federally 599
qualified health centers (FQHCs), rural health clinics (RHCs) and 600
community mental health centers (CMHCs) as both an originating and 601
distant site provider for the purposes of telehealth 602
reimbursement. The division is further authorized and directed to 603
reimburse FQHCs, RHCs and CMHCs for both distant site and 604
originating site services when such services are appropriately 605
provided by the same organization. 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
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
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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
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
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(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
(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
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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
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
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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
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
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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
(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
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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
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
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(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
(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
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(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
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
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(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
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
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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
(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
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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
(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
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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
(62) Vagus nerve stimulation (VNS) surgical implant 905
procedures. The division shall reimburse for VNS surgical implant 906
procedures performed in hospitals on an outpatient basis and in 907
ambulatory surgical facilities in the following amounts, effective 908
July 1, 2026: CPT code 64568 procedures - Forty-five Thousand 909
Dollars ($45,000.00); and CPT code 61885 procedures - Thirty-five 910
Thousand Dollars ($35,000.00). 911
(B) Planning and development districts participating in the 912
home- and community-based services program for the elderly and 913
disabled as case management providers shall be reimbursed for case 914
management services at the maximum rate approved by the Centers 915
for Medicare and Medicaid Services (CMS). 916
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(C) The division may pay to those providers who participate 917
in and accept patient referrals from the division's emergency room 918
redirection program a percentage, as determined by the division, 919
of savings achieved according to the performance measures and 920
reduction of costs required of that program. Federally qualified 921
health centers may participate in the emergency room redirection 922
program, and the division may pay those centers a percentage of 923
any savings to the Medicaid program achieved by the centers' 924
accepting patient referrals through the program, as provided in 925
this subsection (C). 926
(D) (1) As used in this subsection (D), the following terms 927
shall be defined as provided in this paragraph, except as 928
otherwise provided in this subsection: 929
(a) "Committees" means the Medicaid Committees of 930
the House of Representatives and the Senate, and "committee" means 931
either one of those committees. 932
(b) "Rate change" means an increase, decrease or 933
other change in the payments or rates of reimbursement, or a 934
change in any payment methodology that results in an increase, 935
decrease or other change in the payments or rates of 936
reimbursement, to any Medicaid provider that renders any services 937
authorized to be provided to Medicaid recipients under this 938
article. 939
(2) Whenever the Division of Medicaid proposes a rate 940
change, the division shall give notice to the chairmen of the 941
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committees at least thirty (30) calendar days before the proposed 942
rate change is scheduled to take effect. The division shall 943
furnish the chairmen with a concise summary of each proposed rate 944
change along with the notice, and shall furnish the chairmen with 945
a copy of any proposed rate change upon request. The division 946
also shall provide a summary and copy of any proposed rate change 947
to any other member of the Legislature upon request. 948
(3) If the chairman of either committee or both 949
chairmen jointly object to the proposed rate change or any part 950
thereof, the chairman or chairmen shall notify the division and 951
provide the reasons for their objection in writing not later than 952
seven (7) calendar days after receipt of the notice from the 953
division. The chairman or chairmen may make written 954
recommendations to the division for changes to be made to a 955
proposed rate change. 956
(4) (a) The chairman of either committee or both 957
chairmen jointly may hold a committee meeting to review a proposed 958
rate change. If either chairman or both chairmen decide to hold a 959
meeting, they shall notify the division of their intention in 960
writing within seven (7) calendar days after receipt of the notice 961
from the division, and shall set the date and time for the meeting 962
in their notice to the division, which shall not be later than 963
fourteen (14) calendar days after receipt of the notice from the 964
division. 965
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(b) After the committee meeting, the committee or 966
committees may object to the proposed rate change or any part 967
thereof. The committee or committees shall notify the division 968
and the reasons for their objection in writing not later than 969
seven (7) calendar days after the meeting. The committee or 970
committees may make written recommendations to the division for 971
changes to be made to a proposed rate change. 972
(5) If both chairmen notify the division in writing 973
within seven (7) calendar days after receipt of the notice from 974
the division that they do not object to the proposed rate change 975
and will not be holding a meeting to review the proposed rate 976
change, the proposed rate change will take effect on the original 977
date as scheduled by the division or on such other date as 978
specified by the division. 979
(6) (a) If there are any objections to a proposed rate 980
change or any part thereof from either or both of the chairmen or 981
the committees, the division may withdraw the proposed rate 982
change, make any of the recommended changes to the proposed rate 983
change, or not make any changes to the proposed rate change. 984
(b) If the division does not make any changes to 985
the proposed rate change, it shall notify the chairmen of that 986
fact in writing, and the proposed rate change shall take effect on 987
the original date as scheduled by the division or on such other 988
date as specified by the division. 989
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(c) If the division makes any changes to the 990
proposed rate change, the division shall notify the chairmen of 991
its actions in writing, and the revised proposed rate change shall 992
take effect on the date as specified by the division. 993
(7) Nothing in this subsection (D) shall be construed 994
as giving the chairmen or the committees any authority to veto, 995
nullify or revise any rate change proposed by the division. The 996
authority of the chairmen or the committees under this subsection 997
shall be limited to reviewing, making objections to and making 998
recommendations for changes to rate changes proposed by the 999
division. 1000
(E) Notwithstanding any provision of this article, no new 1001
groups or categories of recipients and new types of care and 1002
services may be added without enabling legislation from the 1003
Mississippi Legislature, except that the division may authorize 1004
those changes without enabling legislation when the addition of 1005
recipients or services is ordered by a court of proper authority. 1006
(F) The executive director shall keep the Governor advised 1007
on a timely basis of the funds available for expenditure and the 1008
projected expenditures. Notwithstanding any other provisions of 1009
this article, if current or projected expenditures of the division 1010
are reasonably anticipated to exceed the amount of funds 1011
appropriated to the division for any fiscal year, the Governor, 1012
after consultation with the executive director, shall take all 1013
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appropriate measures to reduce costs, which may include, but are 1014
not limited to: 1015
(1) Reducing or discontinuing any or all services that 1016
are deemed to be optional under Title XIX of the Social Security 1017
Act; 1018
(2) Reducing reimbursement rates for any or all service 1019
types; 1020
(3) Imposing additional assessments on health care 1021
providers; or 1022
(4) Any additional cost-containment measures deemed 1023
appropriate by the Governor. 1024
To the extent allowed under federal law, any reduction to 1025
services or reimbursement rates under this subsection (F) shall be 1026
accompanied by a reduction, to the fullest allowable amount, to 1027
the profit margin and administrative fee portions of capitated 1028
payments to organizations described in paragraph (1) of subsection 1029
(H). 1030
Beginning in fiscal year 2010 and in fiscal years thereafter, 1031
when Medicaid expenditures are projected to exceed funds available 1032
for the fiscal year, the division shall submit the expected 1033
shortfall information to the PEER Committee not later than 1034
December 1 of the year in which the shortfall is projected to 1035
occur. PEER shall review the computations of the division and 1036
report its findings to the Legislative Budget Office not later 1037
than January 7 in any year. 1038
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(G) Notwithstanding any other provision of this article, it 1039
shall be the duty of each provider participating in the Medicaid 1040
program to keep and maintain books, documents and other records as 1041
prescribed by the Division of Medicaid in accordance with federal 1042
laws and regulations. 1043
(H) (1) Notwithstanding any other provision of this 1044
article, the division is authorized to implement (a) a managed 1045
care program, (b) a coordinated care program, (c) a coordinated 1046
care organization program, (d) a health maintenance organization 1047
program, (e) a patient-centered medical home program, (f) an 1048
accountable care organization program, (g) provider-sponsored 1049
health plan, or (h) any combination of the above programs. As a 1050
condition for the approval of any program under this subsection 1051
(H)(1), the division shall require that no managed care program, 1052
coordinated care program, coordinated care organization program, 1053
health maintenance organization program, or provider-sponsored 1054
health plan may: 1055
(a) Pay providers at a rate that is less than the 1056
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1057
reimbursement rate; 1058
(b) Override the medical decisions of hospital 1059
physicians or staff regarding patients admitted to a hospital for 1060
an emergency medical condition as defined by 42 US Code Section 1061
1395dd. This restriction (b) does not prohibit the retrospective 1062
review of the appropriateness of the determination that an 1063
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emergency medical condition exists by chart review or coding 1064
algorithm, nor does it prohibit prior authorization for 1065
nonemergency hospital admissions; 1066
(c) Pay providers at a rate that is less than the 1067
normal Medicaid reimbursement rate. It is the intent of the 1068
Legislature that all managed care entities described in this 1069
subsection (H), in collaboration with the division, develop and 1070
implement innovative payment models that incentivize improvements 1071
in health care quality, outcomes, or value, as determined by the 1072
division. Participation in the provider network of any managed 1073
care, coordinated care, provider-sponsored health plan, or similar 1074
contractor shall not be conditioned on the provider's agreement to 1075
accept such alternative payment models; 1076
(d) Implement a prior authorization and 1077
utilization review program for medical services, transportation 1078
services and prescription drugs that is more stringent than the 1079
prior authorization processes used by the division in its 1080
administration of the Medicaid program. Not later than December 1081
2, 2021, the contractors that are receiving capitated payments 1082
under a managed care delivery system established under this 1083
subsection (H) shall submit a report to the Chairmen of the House 1084
and Senate Medicaid Committees on the status of the prior 1085
authorization and utilization review program for medical services, 1086
transportation services and prescription drugs that is required to 1087
be implemented under this subparagraph (d); 1088
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(e) [Deleted] 1089
(f) Implement a preferred drug list that is more 1090
stringent than the mandatory preferred drug list established by 1091
the division under subsection (A)(9) of this section; 1092
(g) Implement a policy which denies beneficiaries 1093
with hemophilia access to the federally funded hemophilia 1094
treatment centers as part of the Medicaid Managed Care network of 1095
providers. 1096
Each health maintenance organization, coordinated care 1097
organization, provider-sponsored health plan, or other 1098
organization paid for services on a capitated basis by the 1099
division under any managed care program or coordinated care 1100
program implemented by the division under this section shall use a 1101
clear set of level of care guidelines in the determination of 1102
medical necessity and in all utilization management practices, 1103
including the prior authorization process, concurrent reviews, 1104
retrospective reviews and payments, that are consistent with 1105
widely accepted professional standards of care. Organizations 1106
participating in a managed care program or coordinated care 1107
program implemented by the division may not use any additional 1108
criteria that would result in denial of care that would be 1109
determined appropriate and, therefore, medically necessary under 1110
those levels of care guidelines. 1111
(2) Notwithstanding any provision of this section, the 1112
recipients eligible for enrollment into a Medicaid Managed Care 1113
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Program authorized under this subsection (H) may include only 1114
those categories of recipients eligible for participation in the 1115
Medicaid Managed Care Program as of January 1, 2021, the 1116
Children's Health Insurance Program (CHIP), and the CMS-approved 1117
Section 1115 demonstration waivers in operation as of January 1, 1118
2021. No expansion of Medicaid Managed Care Program contracts may 1119
be implemented by the division without enabling legislation from 1120
the Mississippi Legislature. 1121
(3) (a) Any contractors receiving capitated payments 1122
under a managed care delivery system established in this section 1123
shall provide to the Legislature and the division statistical data 1124
to be shared with provider groups in order to improve patient 1125
access, appropriate utilization, cost savings and health outcomes 1126
not later than October 1 of each year. Additionally, each 1127
contractor shall disclose to the Chairmen of the Senate and House 1128
Medicaid Committees the administrative expenses costs for the 1129
prior calendar year, and the number of full-equivalent employees 1130
located in the State of Mississippi dedicated to the Medicaid and 1131
CHIP lines of business as of June 30 of the current year. 1132
(b) The division and the contractors participating 1133
in the managed care program, a coordinated care program or a 1134
provider-sponsored health plan shall be subject to annual program 1135
reviews or audits performed by the Office of the State Auditor, 1136
the PEER Committee, the Department of Insurance and/or independent 1137
third parties. 1138
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(c) Those reviews shall include, but not be 1139
limited to, at least two (2) of the following items: 1140
(i) The financial benefit to the State of 1141
Mississippi of the managed care program, 1142
(ii) The difference between the premiums paid 1143
to the managed care contractors and the payments made by those 1144
contractors to health care providers, 1145
(iii) Compliance with performance measures 1146
required under the contracts, 1147
(iv) Administrative expense allocation 1148
methodologies, 1149
(v) Whether nonprovider payments assigned as 1150
medical expenses are appropriate, 1151
(vi) Capitated arrangements with related 1152
party subcontractors, 1153
(vii) Reasonableness of corporate 1154
allocations, 1155
(viii) Value-added benefits and the extent to 1156
which they are used, 1157
(ix) The effectiveness of subcontractor 1158
oversight, including subcontractor review, 1159
(x) Whether health care outcomes have been 1160
improved, and 1161
(xi) The most common claim denial codes to 1162
determine the reasons for the denials. 1163
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The audit reports shall be considered public documents and 1164
shall be posted in their entirety on the division's website. 1165
(4) All health maintenance organizations, coordinated 1166
care organizations, provider-sponsored health plans, or other 1167
organizations paid for services on a capitated basis by the 1168
division under any managed care program or coordinated care 1169
program implemented by the division under this section shall 1170
reimburse all providers in those organizations at rates no lower 1171
than those provided under this section for beneficiaries who are 1172
not participating in those programs. 1173
(5) No health maintenance organization, coordinated 1174
care organization, provider-sponsored health plan, or other 1175
organization paid for services on a capitated basis by the 1176
division under any managed care program or coordinated care 1177
program implemented by the division under this section shall 1178
require its providers or beneficiaries to use any pharmacy that 1179
ships, mails or delivers prescription drugs or legend drugs or 1180
devices. 1181
(6) (a) Not later than December 1, 2021, the 1182
contractors who are receiving capitated payments under a managed 1183
care delivery system established under this subsection (H) shall 1184
develop and implement a uniform credentialing process for 1185
providers. Under that uniform credentialing process, a provider 1186
who meets the criteria for credentialing will be credentialed with 1187
all of those contractors and no such provider will have to be 1188
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separately credentialed by any individual contractor in order to 1189
receive reimbursement from the contractor. Not later than 1190
December 2, 2021, those contractors shall submit a report to the 1191
Chairmen of the House and Senate Medicaid Committees on the status 1192
of the uniform credentialing process for providers that is 1193
required under this subparagraph (a). 1194
(b) If those contractors have not implemented a 1195
uniform credentialing process as described in subparagraph (a) by 1196
December 1, 2021, the division shall develop and implement, not 1197
later than July 1, 2022, a single, consolidated credentialing 1198
process by which all providers will be credentialed. Under the 1199
division's single, consolidated credentialing process, no such 1200
contractor shall require its providers to be separately 1201
credentialed by the contractor in order to receive reimbursement 1202
from the contractor, but those contractors shall recognize the 1203
credentialing of the providers by the division's credentialing 1204
process. 1205
(c) The division shall require a uniform provider 1206
credentialing application that shall be used in the credentialing 1207
process that is established under subparagraph (a) or (b). If the 1208
contractor or division, as applicable, has not approved or denied 1209
the provider credentialing application within sixty (60) days of 1210
receipt of the completed application that includes all required 1211
information necessary for credentialing, then the contractor or 1212
division, upon receipt of a written request from the applicant and 1213
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within five (5) business days of its receipt, shall issue a 1214
temporary provider credential/enrollment to the applicant if the 1215
applicant has a valid Mississippi professional or occupational 1216
license to provide the health care services to which the 1217
credential/enrollment would apply. The contractor or the division 1218
shall not issue a temporary credential/enrollment if the applicant 1219
has reported on the application a history of medical or other 1220
professional or occupational malpractice claims, a history of 1221
substance abuse or mental health issues, a criminal record, or a 1222
history of medical or other licensing board, state or federal 1223
disciplinary action, including any suspension from participation 1224
in a federal or state program. The temporary 1225
credential/enrollment shall be effective upon issuance and shall 1226
remain in effect until the provider's credentialing/enrollment 1227
application is approved or denied by the contractor or division. 1228
The contractor or division shall render a final decision regarding 1229
credentialing/enrollment of the provider within sixty (60) days 1230
from the date that the temporary provider credential/enrollment is 1231
issued to the applicant. 1232
(d) If the contractor or division does not render 1233
a final decision regarding credentialing/enrollment of the 1234
provider within the time required in subparagraph (c), the 1235
provider shall be deemed to be credentialed by and enrolled with 1236
all of the contractors and eligible to receive reimbursement from 1237
the contractors. 1238
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(7) (a) Each contractor that is receiving capitated 1239
payments under a managed care delivery system established under 1240
this subsection (H) shall provide to each provider for whom the 1241
contractor has denied the coverage of a procedure that was ordered 1242
or requested by the provider for or on behalf of a patient, a 1243
letter that provides a detailed explanation of the reasons for the 1244
denial of coverage of the procedure and the name and the 1245
credentials of the person who denied the coverage. The letter 1246
shall be sent to the provider in electronic format. 1247
(b) After a contractor that is receiving capitated 1248
payments under a managed care delivery system established under 1249
this subsection (H) has denied coverage for a claim submitted by a 1250
provider, the contractor shall issue to the provider within sixty 1251
(60) days a final ruling of denial of the claim that allows the 1252
provider to have a state fair hearing and/or agency appeal with 1253
the division. If a contractor does not issue a final ruling of 1254
denial within sixty (60) days as required by this subparagraph 1255
(b), the provider's claim shall be deemed to be automatically 1256
approved and the contractor shall pay the amount of the claim to 1257
the provider. 1258
(c) After a contractor has issued a final ruling 1259
of denial of a claim submitted by a provider, the division shall 1260
conduct a state fair hearing and/or agency appeal on the matter of 1261
the disputed claim between the contractor and the provider within 1262
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sixty (60) days, and shall render a decision on the matter within 1263
thirty (30) days after the date of the hearing and/or appeal. 1264
(8) It is the intention of the Legislature that the 1265
division evaluate the feasibility of using a single vendor to 1266
administer pharmacy benefits provided under a managed care 1267
delivery system established under this subsection (H). Providers 1268
of pharmacy benefits shall cooperate with the division in any 1269
transition to a carve-out of pharmacy benefits under managed care. 1270
(9) The division shall evaluate the feasibility of 1271
using a single vendor to administer dental benefits provided under 1272
a managed care delivery system established in this subsection (H). 1273
Providers of dental benefits shall cooperate with the division in 1274
any transition to a carve-out of dental benefits under managed 1275
care. 1276
(10) It is the intent of the Legislature that any 1277
contractor receiving capitated payments under a managed care 1278
delivery system established in this section shall implement 1279
innovative programs to improve the health and well-being of 1280
members diagnosed with prediabetes and diabetes. 1281
(11) It is the intent of the Legislature that any 1282
contractors receiving capitated payments under a managed care 1283
delivery system established under this subsection (H) shall work 1284
with providers of Medicaid services to improve the utilization of 1285
long-acting reversible contraceptives (LARCs). Not later than 1286
December 1, 2021, any contractors receiving capitated payments 1287
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under a managed care delivery system established under this 1288
subsection (H) shall provide to the Chairmen of the House and 1289
Senate Medicaid Committees and House and Senate Public Health 1290
Committees a report of LARC utilization for State Fiscal Years 1291
2018 through 2020 as well as any programs, initiatives, or efforts 1292
made by the contractors and providers to increase LARC 1293
utilization. This report shall be updated annually to include 1294
information for subsequent state fiscal years. 1295
(12) The division is authorized to make not more than 1296
one (1) emergency extension of the contracts that are in effect on 1297
July 1, 2021, with contractors who are receiving capitated 1298
payments under a managed care delivery system established under 1299
this subsection (H), as provided in this paragraph (12). The 1300
maximum period of any such extension shall be one (1) year, and 1301
under any such extensions, the contractors shall be subject to all 1302
of the provisions of this subsection (H). The extended contracts 1303
shall be revised to incorporate any provisions of this subsection 1304
(H). 1305
(13) Contracts entered into or renewed on or after the 1306
effective date of this act between the division and a managed care 1307
organization to provide managed care services under this 1308
subsection (H) must contain a requirement that the managed care 1309
organization comply with subsection (A)(62) regarding 1310
reimbursement rates for vagus nerve stimulation (VNS) surgical 1311
implant procedures. The division shall seek to amend contracts 1312
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with managed care organizations entered into before the effective 1313
date of this act to require those managed care organizations to 1314
comply with subsection (A)(62) regarding reimbursement rates for 1315
VNS surgical implant procedures. 1316
(I) [Deleted] 1317
(J) There shall be no cuts in inpatient and outpatient 1318
hospital payments, or allowable days or volumes, as long as the 1319
hospital assessment provided in Section 43-13-145 is in effect. 1320
This subsection (J) shall not apply to decreases in payments that 1321
are a result of: reduced hospital admissions, audits or payments 1322
under the APR-DRG or APC models, or a managed care program or 1323
similar model described in subsection (H) of this section. 1324
(K) In the negotiation and execution of such contracts 1325
involving services performed by actuarial firms, the Executive 1326
Director of the Division of Medicaid may negotiate a limitation on 1327
liability to the state of prospective contractors. 1328
(L) The Division of Medicaid shall reimburse for services 1329
provided to eligible Medicaid beneficiaries by a licensed birthing 1330
center in a method and manner to be determined by the division in 1331
accordance with federal laws and federal regulations. The 1332
division shall seek any necessary waivers, make any required 1333
amendments to its State Plan or revise any contracts authorized 1334
under subsection (H) of this section as necessary to provide the 1335
services authorized under this subsection. As used in this 1336
subsection, the term "birthing centers" shall have the meaning as 1337
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ST: Medicaid; provide for reimbursement for
vagus nerve stimulation (VNS) surgical implant
procedures.
defined in Section 41-77-1(a), which is a publicly or privately 1338
owned facility, place or institution constructed, renovated, 1339
leased or otherwise established where nonemergency births are 1340
planned to occur away from the mother's usual residence following 1341
a documented period of prenatal care for a normal uncomplicated 1342
pregnancy which has been determined to be low risk through a 1343
formal risk-scoring examination. 1344
(M) This section shall stand repealed on July 1, 2028. 1345
SECTION 2. This act shall take effect and be in force from 1346
and after July 1, 2026. 1347