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To: Insurance; Medicaid
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Hines

HOUSE BILL NO. 144

AN ACT TO PROHIBIT HEALTH BENEFIT PLANS, PHARMACY BENEFIT 1
MANAGERS AND PRIVATE REVIEW AGENTS FROM SUBJECTING DRUGS 2
PRESCRIBED FOR THE TREATMENT OR PREVENTION OF HIV OR AIDS TO A 3
PRIOR AUTHORIZATION REQUIREMENT, STEP THERAPY, OR ANY OTHER 4
PROTOCOL THAT COULD RESTRICT OR DELAY THE DISPENSING OF THE DRUG; 5
TO AMEND SECTIONS 83-9-36 AND 83-5-909, MISSISSIPPI CODE OF 1972, 6
TO CONFORM; TO BRING FORWARD SECTIONS 83-5-905 AND 43-13-117, 7
MISSISSIPPI CODE OF 1972, FOR THE PURPOSE OF POSSIBLE AMENDMENT; 8
AND FOR RELATED PURPOSES. 9
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 10
SECTION 1. (1) As used in this section, the following terms 11
shall be defined as provided in this subsection: 12
(a) "Health benefit plan" means services consisting of 13
medical care, provided directly, through insurance or 14
reimbursement, or otherwise, and including items and services paid 15
for as medical care under any hospital or medical service policy 16
or certificate, hospital or medical service plan contract, 17
preferred provider organization, or health maintenance 18
organization contract offered by a health insurance issuer. The 19
term "health benefit plan" includes the Medicaid fee-for-service 20
program and any managed care program, coordinated care program, 21
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coordinated care organization program, health maintenance 22
organization program or such other programs implemented by the 23
Division of Medicaid under Section 43-13-117(H). 24
(b) "Pharmacy benefit manager" has the meaning as 25
defined in Section 73-21-179. 26
(c) "Private review agent" has the meaning as defined 27
in Section 41-83-1. 28
(2) A health benefit plan, pharmacy benefit manager or 29
private review agent shall not refuse to authorize coverage for or 30
approve access to any antiretroviral (ARV) drugs with a United 31
States Food and Drug Administration label indicating the ARV is 32
for the treatment of HIV or AIDS on the basis that such a drug is 33
"not medically necessary". 34
(3) If the United States Food and Drug Administration 35
approves one or more therapeutically equivalent drugs, devices or 36
products for the treatment of HIV or AIDS, a health benefit plan, 37
pharmacy benefit manager or private review agent shall not be 38
required to cover all therapeutically equivalent versions without 39
prior authorizations or step therapy. However, the health benefit 40
plan, pharmacy benefit manager or private review agent shall cover 41
at least one (1) therapeutically equivalent version, per route of 42
administration, without requiring prior authorization or step 43
therapy. 44
SECTION 2. Section 83-9-36, Mississippi Code of 1972, is 45
amended as follows: 46
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83-9-36. (1) When medications for the treatment of any 47
medical condition are restricted for use by an insurer by a step 48
therapy or fail-first protocol, the prescribing practitioner shall 49
have access to a clear and convenient process to expeditiously 50
request an override of that restriction from the insurer. An 51
override of that restriction shall be expeditiously granted by the 52
insurer under the following circumstances: 53
(a) The prescribing practitioner can demonstrate, based 54
on sound clinical evidence, that the preferred treatment required 55
under step therapy or fail-first protocol has been ineffective in 56
the treatment of the insured's disease or medical condition; or 57
(b) Based on sound clinical evidence or medical and 58
scientific evidence: 59
(i) The prescribing practitioner can demonstrate 60
that the preferred treatment required under the step therapy or 61
fail-first protocol is expected or likely to be ineffective based 62
on the known relevant physical or mental characteristics of the 63
insured and known characteristics of the drug regimen; or 64
(ii) The prescribing practitioner can demonstrate 65
that the preferred treatment required under the step therapy or 66
fail-first protocol will cause or will likely cause an adverse 67
reaction or other physical harm to the insured. 68
(2) The duration of any step therapy or fail-first protocol 69
shall not be longer than a period of thirty (30) days when the 70
treatment is deemed clinically ineffective by the prescribing 71
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practitioner. When the prescribing practitioner can demonstrate, 72
through sound clinical evidence, that the originally prescribed 73
medication is likely to require more than thirty (30) days to 74
provide any relief or an amelioration to the insured, the step 75
therapy or fail-first protocol may be extended up to seven (7) 76
additional days. 77
(3) As used in this section: 78
(a) "Insurer" means any hospital, health, or medical 79
expense insurance policy, hospital or medical service contract, 80
employee welfare benefit plan, contract or agreement with a health 81
maintenance organization or a preferred provider organization, 82
health and accident insurance policy, or any other insurance 83
contract of this type, including a group insurance plan. However, 84
the term "insurer" does not include a preferred provider 85
organization that is only a network of providers and does not 86
define health care benefits for the purpose of coverage under a 87
health care benefits plan. 88
(b) "Practitioner" has the same meaning as defined in 89
Section 73-21-73. 90
(4) The provisions of Section 83-9-8.1 shall supersede the 91
provisions of this section to the extent of any conflict between 92
Section 83-9-8.1 and this section. 93
(5) The provisions of subsection (3) of Section 1 of this 94
act shall supersede the provisions of this section to the extent 95
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of any conflict between subsection (3) of Section 1 of this act 96
and this section. 97
SECTION 3. Section 83-5-909, Mississippi Code of 1972, is 98
amended as follows: 99
83-5-909. Disclosure and review of prior authorization 100
requirements. (1) A health insurance issuer shall maintain a 101
complete list of services for which prior authorization is 102
required, including for all services where prior authorization is 103
performed by an entity under contract with the health insurance 104
issuer. Prior authorization shall not be required for a 105
therapeutically equivalent drug, device or product that has been 106
approved by the United States Food and Drug Administration for the 107
treatment of HIV or AIDS as provided in subsection (3) of Section 108
1 of this act. 109
(2) A health insurance issuer shall make any current prior 110
authorization requirements and restrictions, including the written 111
clinical review criteria, readily accessible and conspicuously 112
posted on its website to enrollees, health care professionals and 113
health care providers. Content published by a third party and 114
licensed for use by a health insurance issuer may be made 115
available through the health insurance issuer's secure, 116
password-protected website so long as the access requirements of 117
the website do not unreasonably restrict access. Requirements 118
shall be described in detail, written in easily understandable 119
language, and readily available to the health care professional 120
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and health care provider at the point of care. The website shall 121
indicate for each service subject to prior authorization: 122
(a) When prior authorization became required for 123
policies issued or health benefit plan documents delivered in 124
Mississippi, including the effective date or dates and the 125
termination date or dates, if applicable, in Mississippi; 126
(b) The date the Mississippi-specific requirement was 127
listed on the health insurance issuer's, health benefit plan's, or 128
private review agent's website; 129
(c) Where applicable, the date that prior authorization 130
was removed for Mississippi; and 131
(d) Where applicable, access to a standardized 132
electronic prior authorization request transaction process. 133
(3) The clinical review criteria must: 134
(a) Be based on nationally recognized, generally 135
accepted standards except where state law provides its own 136
standard; 137
(b) Be developed in accordance with the current 138
standards of a national medical accreditation entity; 139
(c) Ensure quality of care and access to needed health 140
care services; 141
(d) Be evidence-based; 142
(e) Be sufficiently flexible to allow deviations from 143
norms when justified on a case-by-case basis; and 144
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(f) Be evaluated and updated, if necessary, at least 145
annually. 146
(4) A health insurance issuer shall not deny a claim for 147
failure to obtain prior authorization if the prior authorization 148
requirement was not in effect on the date of service on the claim. 149
(5) A health insurance issuer shall not deem as incidental 150
or deny supplies or health care services that are routinely used 151
as part of a health care service when: 152
(a) An associated health care service has received 153
prior authorization; or 154
(b) Prior authorization for the health care service is 155
not required. 156
(6) If a health insurance issuer intends either to implement 157
a new prior authorization requirement or restriction or amend an 158
existing requirement or restriction, the health insurance issuer 159
shall provide contracted health care professionals and contracted 160
health care providers of enrollees written notice of the new or 161
amended requirement or amendment no less than sixty (60) days 162
before the requirement or restriction is implemented. Written 163
notice may take the form of a conspicuous notice posted on the 164
health insurance issuer's public website or portal for contracted 165
health care professionals and contracted health care providers. A 166
health insurance issuer shall provide email notices to health care 167
professionals or health care providers if the health care 168
professional or health care provider has requested to receive the 169
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notice through email. The health insurance issuer shall ensure 170
that the new or amended requirement is not implemented unless the 171
health insurance issuer's website has been updated to reflect the 172
new or amended requirement or restriction. Written notice of a 173
new, amended, or restricted prior authorization requirement, as 174
required by this subsection (6), may be provided less than sixty 175
(60) days in advance if a health insurance issuer determines and 176
contemporaneously notifies the department in writing that: 177
(a) The health insurance issuer has identified 178
fraudulent or abusive practices related to the health care 179
service; 180
(b) The health care service is unavailable or scarce 181
which necessitates the use of an alternative health care service; 182
(c) The health care service is newly introduced to the 183
health care market and a delay in providing coverage for the 184
health care service and would not be in the best interests of 185
enrollees; 186
(d) The health care service is the subject of a 187
clinical trial authorized by the United States Food and Drug 188
Administration; or 189
(e) Changes to the health care service or its 190
availability are otherwise required by law to be made by the 191
health insurance issuer in less than sixty (60) days. 192
(7) Health insurance issuers using prior authorization shall 193
make statistics available regarding prior authorization approvals 194
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and denials on their website in a readily accessible format. 195
Following each calendar year, the statistics must be updated 196
annually, by March 31, and include all of the following 197
information: 198
(a) A list of all health care services, including 199
medications, that are subject to prior authorization; 200
(b) The percentage of standard prior authorization 201
requests that were approved, aggregated for all items and 202
services; 203
(c) The percentage of standard prior authorization 204
requests that were denied, aggregated for all items and services; 205
(d) The percentage of prior authorization requests that 206
were approved after appeal, aggregated for all items and services; 207
(e) The percentage of prior authorization requests for 208
which the timeframe for review was extended, and the request was 209
approved, aggregated for all items and services; 210
(f) The percentage of expedited prior authorization 211
requests that were approved, aggregated for all items and 212
services; 213
(g) The percentage of expedited prior authorization 214
requests that were denied, aggregated for all items and services; 215
(h) The average and median time that elapsed between 216
the submission of a request and a determination by the payer, plan 217
or health insurance issuer, for standard prior authorization, 218
aggregated for all items and services; 219
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(i) The average and median time that elapsed between 220
the submission of a request and a decision by the payer, plan or 221
health insurance issuer, for expedited prior authorizations, 222
aggregated for all items and services; and 223
(j) Any other information as the department determines 224
appropriate. 225
SECTION 4. Section 83-5-905, Mississippi Code of 1972, is 226
brought forward as follows: 227
83-5-905. Applicability and scope. This article applies to 228
every health insurance issuer and all health benefit plans, as 229
both terms are defined in Section 83-9-6.3, and all private review 230
agents and utilization review plans, as both terms are defined in 231
Section 41-83-1, with the exception of employee or employer 232
self-insured health benefit plans under the federal Employee 233
Retirement Income Security Act of 1974 or health care provided 234
pursuant to the Workers' Compensation Act. This article does not 235
diminish the duties and responsibilities under other federal or 236
state law or rules promulgated under those laws applicable to a 237
health insurer, health insurance issuer, health benefit plan, 238
private review agent or utilization review plan, including, but 239
not limited to, the requirement of a certificate in accordance 240
with Section 41-83-3. 241
SECTION 5. Section 43-13-117, Mississippi Code of 1972, is 242
brought forward as follows: 243
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43-13-117. (A) Medicaid as authorized by this article shall 244
include payment of part or all of the costs, at the discretion of 245
the division, with approval of the Governor and the Centers for 246
Medicare and Medicaid Services, of the following types of care and 247
services rendered to eligible applicants who have been determined 248
to be eligible for that care and services, within the limits of 249
state appropriations and federal matching funds: 250
(1) Inpatient hospital services. 251
(a) The division is authorized to implement an All 252
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 253
methodology for inpatient hospital services. 254
(b) No service benefits or reimbursement 255
limitations in this subsection (A)(1) shall apply to payments 256
under an APR-DRG or Ambulatory Payment Classification (APC) model 257
or a managed care program or similar model described in subsection 258
(H) of this section unless specifically authorized by the 259
division. 260
(2) Outpatient hospital services. 261
(a) Emergency services. 262
(b) Other outpatient hospital services. The 263
division shall allow benefits for other medically necessary 264
outpatient hospital services (such as chemotherapy, radiation, 265
surgery and therapy), including outpatient services in a clinic or 266
other facility that is not located inside the hospital, but that 267
has been designated as an outpatient facility by the hospital, and 268
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that was in operation or under construction on July 1, 2009, 269
provided that the costs and charges associated with the operation 270
of the hospital clinic are included in the hospital's cost report. 271
In addition, the Medicare thirty-five-mile rule will apply to 272
those hospital clinics not located inside the hospital that are 273
constructed after July 1, 2009. Where the same services are 274
reimbursed as clinic services, the division may revise the rate or 275
methodology of outpatient reimbursement to maintain consistency, 276
efficiency, economy and quality of care. 277
(c) The division is authorized to implement an 278
Ambulatory Payment Classification (APC) methodology for outpatient 279
hospital services. The division shall give rural hospitals that 280
have fifty (50) or fewer licensed beds the option to not be 281
reimbursed for outpatient hospital services using the APC 282
methodology, but reimbursement for outpatient hospital services 283
provided by those hospitals shall be based on one hundred one 284
percent (101%) of the rate established under Medicare for 285
outpatient hospital services. Those hospitals choosing to not be 286
reimbursed under the APC methodology shall remain under cost-based 287
reimbursement for a two-year period. 288
(d) No service benefits or reimbursement 289
limitations in this subsection (A)(2) shall apply to payments 290
under an APR-DRG or APC model or a managed care program or similar 291
model described in subsection (H) of this section unless 292
specifically authorized by the division. 293
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(3) Laboratory and x-ray services. 294
(4) Nursing facility services. 295
(a) The division shall make full payment to 296
nursing facilities for each day, not exceeding forty-two (42) days 297
per year, that a patient is absent from the facility on home 298
leave. Payment may be made for the following home leave days in 299
addition to the forty-two-day limitation: Christmas, the day 300
before Christmas, the day after Christmas, Thanksgiving, the day 301
before Thanksgiving and the day after Thanksgiving. 302
(b) From and after July 1, 1997, the division 303
shall implement the integrated case-mix payment and quality 304
monitoring system, which includes the fair rental system for 305
property costs and in which recapture of depreciation is 306
eliminated. The division may reduce the payment for hospital 307
leave and therapeutic home leave days to the lower of the case-mix 308
category as computed for the resident on leave using the 309
assessment being utilized for payment at that point in time, or a 310
case-mix score of 1.000 for nursing facilities, and shall compute 311
case-mix scores of residents so that only services provided at the 312
nursing facility are considered in calculating a facility's per 313
diem. 314
(c) From and after July 1, 1997, all state-owned 315
nursing facilities shall be reimbursed on a full reasonable cost 316
basis. 317
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(d) On or after January 1, 2015, the division 318
shall update the case-mix payment system resource utilization 319
grouper and classifications and fair rental reimbursement system. 320
The division shall develop and implement a payment add-on to 321
reimburse nursing facilities for ventilator-dependent resident 322
services. 323
(e) The division shall develop and implement, not 324
later than January 1, 2001, a case-mix payment add-on determined 325
by time studies and other valid statistical data that will 326
reimburse a nursing facility for the additional cost of caring for 327
a resident who has a diagnosis of Alzheimer's or other related 328
dementia and exhibits symptoms that require special care. Any 329
such case-mix add-on payment shall be supported by a determination 330
of additional cost. The division shall also develop and implement 331
as part of the fair rental reimbursement system for nursing 332
facility beds, an Alzheimer's resident bed depreciation enhanced 333
reimbursement system that will provide an incentive to encourage 334
nursing facilities to convert or construct beds for residents with 335
Alzheimer's or other related dementia. 336
(f) The division shall develop and implement an 337
assessment process for long-term care services. The division may 338
provide the assessment and related functions directly or through 339
contract with the area agencies on aging. 340
The division shall apply for necessary federal waivers to 341
assure that additional services providing alternatives to nursing 342
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facility care are made available to applicants for nursing 343
facility care. 344
(5) Periodic screening and diagnostic services for 345
individuals under age twenty-one (21) years as are needed to 346
identify physical and mental defects and to provide health care 347
treatment and other measures designed to correct or ameliorate 348
defects and physical and mental illness and conditions discovered 349
by the screening services, regardless of whether these services 350
are included in the state plan. The division may include in its 351
periodic screening and diagnostic program those discretionary 352
services authorized under the federal regulations adopted to 353
implement Title XIX of the federal Social Security Act, as 354
amended. The division, in obtaining physical therapy services, 355
occupational therapy services, and services for individuals with 356
speech, hearing and language disorders, may enter into a 357
cooperative agreement with the State Department of Education for 358
the provision of those services to handicapped students by public 359
school districts using state funds that are provided from the 360
appropriation to the Department of Education to obtain federal 361
matching funds through the division. The division, in obtaining 362
medical and mental health assessments, treatment, care and 363
services for children who are in, or at risk of being put in, the 364
custody of the Mississippi Department of Human Services may enter 365
into a cooperative agreement with the Mississippi Department of 366
Human Services for the provision of those services using state 367
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funds that are provided from the appropriation to the Department 368
of Human Services to obtain federal matching funds through the 369
division. 370
(6) Physician services. Fees for physician's services 371
that are covered only by Medicaid shall be reimbursed at ninety 372
percent (90%) of the rate established on January 1, 2018, and as 373
may be adjusted each July thereafter, under Medicare. The 374
division may provide for a reimbursement rate for physician's 375
services of up to one hundred percent (100%) of the rate 376
established under Medicare for physician's services that are 377
provided after the normal working hours of the physician, as 378
determined in accordance with regulations of the division. The 379
division may reimburse eligible providers, as determined by the 380
division, for certain primary care services at one hundred percent 381
(100%) of the rate established under Medicare. The division shall 382
reimburse obstetricians and gynecologists for certain primary care 383
services as defined by the division at one hundred percent (100%) 384
of the rate established under Medicare. 385
(7) (a) Home health services for eligible persons, not 386
to exceed in cost the prevailing cost of nursing facility 387
services. All home health visits must be precertified as required 388
by the division. In addition to physicians, certified registered 389
nurse practitioners, physician assistants and clinical nurse 390
specialists are authorized to prescribe or order home health 391
services and plans of care, sign home health plans of care, 392
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certify and recertify eligibility for home health services and 393
conduct the required initial face-to-face visit with the recipient 394
of the services. 395
(b) [Repealed] 396
(8) Emergency medical transportation services as 397
determined by the division. 398
(9) Prescription drugs and other covered drugs and 399
services as determined by the division. 400
The division shall establish a mandatory preferred drug list. 401
Drugs not on the mandatory preferred drug list shall be made 402
available by utilizing prior authorization procedures established 403
by the division. 404
The division may seek to establish relationships with other 405
states in order to lower acquisition costs of prescription drugs 406
to include single-source and innovator multiple-source drugs or 407
generic drugs. In addition, if allowed by federal law or 408
regulation, the division may seek to establish relationships with 409
and negotiate with other countries to facilitate the acquisition 410
of prescription drugs to include single-source and innovator 411
multiple-source drugs or generic drugs, if that will lower the 412
acquisition costs of those prescription drugs. 413
The division may allow for a combination of prescriptions for 414
single-source and innovator multiple-source drugs and generic 415
drugs to meet the needs of the beneficiaries. 416
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The executive director may approve specific maintenance drugs 417
for beneficiaries with certain medical conditions, which may be 418
prescribed and dispensed in three-month supply increments. 419
Drugs prescribed for a resident of a psychiatric residential 420
treatment facility must be provided in true unit doses when 421
available. The division may require that drugs not covered by 422
Medicare Part D for a resident of a long-term care facility be 423
provided in true unit doses when available. Those drugs that were 424
originally billed to the division but are not used by a resident 425
in any of those facilities shall be returned to the billing 426
pharmacy for credit to the division, in accordance with the 427
guidelines of the State Board of Pharmacy and any requirements of 428
federal law and regulation. Drugs shall be dispensed to a 429
recipient and only one (1) dispensing fee per month may be 430
charged. The division shall develop a methodology for reimbursing 431
for restocked drugs, which shall include a restock fee as 432
determined by the division not exceeding Seven Dollars and 433
Eighty-two Cents ($7.82). 434
Except for those specific maintenance drugs approved by the 435
executive director, the division shall not reimburse for any 436
portion of a prescription that exceeds a thirty-one-day supply of 437
the drug based on the daily dosage. 438
The division is authorized to develop and implement a program 439
of payment for additional pharmacist services as determined by the 440
division. 441
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All claims for drugs for dually eligible Medicare/Medicaid 442
beneficiaries that are paid for by Medicare must be submitted to 443
Medicare for payment before they may be processed by the 444
division's online payment system. 445
The division shall develop a pharmacy policy in which drugs 446
in tamper-resistant packaging that are prescribed for a resident 447
of a nursing facility but are not dispensed to the resident shall 448
be returned to the pharmacy and not billed to Medicaid, in 449
accordance with guidelines of the State Board of Pharmacy. 450
The division shall develop and implement a method or methods 451
by which the division will provide on a regular basis to Medicaid 452
providers who are authorized to prescribe drugs, information about 453
the costs to the Medicaid program of single-source drugs and 454
innovator multiple-source drugs, and information about other drugs 455
that may be prescribed as alternatives to those single-source 456
drugs and innovator multiple-source drugs and the costs to the 457
Medicaid program of those alternative drugs. 458
Notwithstanding any law or regulation, information obtained 459
or maintained by the division regarding the prescription drug 460
program, including trade secrets and manufacturer or labeler 461
pricing, is confidential and not subject to disclosure except to 462
other state agencies. 463
The dispensing fee for each new or refill prescription, 464
including nonlegend or over-the-counter drugs covered by the 465
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division, shall be not less than Three Dollars and Ninety-one 466
Cents ($3.91), as determined by the division. 467
The division shall not reimburse for single-source or 468
innovator multiple-source drugs if there are equally effective 469
generic equivalents available and if the generic equivalents are 470
the least expensive. 471
It is the intent of the Legislature that the pharmacists 472
providers be reimbursed for the reasonable costs of filling and 473
dispensing prescriptions for Medicaid beneficiaries. 474
The division shall allow certain drugs, including 475
physician-administered drugs, and implantable drug system devices, 476
and medical supplies, with limited distribution or limited access 477
for beneficiaries and administered in an appropriate clinical 478
setting, to be reimbursed as either a medical claim or pharmacy 479
claim, as determined by the division. 480
It is the intent of the Legislature that the division and any 481
managed care entity described in subsection (H) of this section 482
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 483
prevent recurrent preterm birth. 484
(10) Dental and orthodontic services to be determined 485
by the division. 486
The division shall increase the amount of the reimbursement 487
rate for diagnostic and preventative dental services for each of 488
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 489
the amount of the reimbursement rate for the previous fiscal year. 490
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The division shall increase the amount of the reimbursement rate 491
for restorative dental services for each of the fiscal years 2023, 492
2024 and 2025 by five percent (5%) above the amount of the 493
reimbursement rate for the previous fiscal year. It is the intent 494
of the Legislature that the reimbursement rate revision for 495
preventative dental services will be an incentive to increase the 496
number of dentists who actively provide Medicaid services. This 497
dental services reimbursement rate revision shall be known as the 498
"James Russell Dumas Medicaid Dental Services Incentive Program." 499
The Medical Care Advisory Committee, assisted by the Division 500
of Medicaid, shall annually determine the effect of this incentive 501
by evaluating the number of dentists who are Medicaid providers, 502
the number who and the degree to which they are actively billing 503
Medicaid, the geographic trends of where dentists are offering 504
what types of Medicaid services and other statistics pertinent to 505
the goals of this legislative intent. This data shall annually be 506
presented to the Chair of the Senate Medicaid Committee and the 507
Chair of the House Medicaid Committee. 508
The division shall include dental services as a necessary 509
component of overall health services provided to children who are 510
eligible for services. 511
(11) Eyeglasses for all Medicaid beneficiaries who have 512
(a) had surgery on the eyeball or ocular muscle that results in a 513
vision change for which eyeglasses or a change in eyeglasses is 514
medically indicated within six (6) months of the surgery and is in 515
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accordance with policies established by the division, or (b) one 516
(1) pair every five (5) years and in accordance with policies 517
established by the division. In either instance, the eyeglasses 518
must be prescribed by a physician skilled in diseases of the eye 519
or an optometrist, whichever the beneficiary may select. 520
(12) Intermediate care facility services. 521
(a) The division shall make full payment to all 522
intermediate care facilities for individuals with intellectual 523
disabilities for each day, not exceeding sixty-three (63) days per 524
year, that a patient is absent from the facility on home leave. 525
Payment may be made for the following home leave days in addition 526
to the sixty-three-day limitation: Christmas, the day before 527
Christmas, the day after Christmas, Thanksgiving, the day before 528
Thanksgiving and the day after Thanksgiving. 529
(b) All state-owned intermediate care facilities 530
for individuals with intellectual disabilities shall be reimbursed 531
on a full reasonable cost basis. 532
(c) Effective January 1, 2015, the division shall 533
update the fair rental reimbursement system for intermediate care 534
facilities for individuals with intellectual disabilities. 535
(13) Family planning services, including drugs, 536
supplies and devices, when those services are under the 537
supervision of a physician or nurse practitioner. 538
(14) Clinic services. Preventive, diagnostic, 539
therapeutic, rehabilitative or palliative services that are 540
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furnished by a facility that is not part of a hospital but is 541
organized and operated to provide medical care to outpatients. 542
Clinic services include, but are not limited to: 543
(a) Services provided by ambulatory surgical 544
centers (ASCs) as defined in Section 41-75-1(a); and 545
(b) Dialysis center services. 546
(15) Home- and community-based services for the elderly 547
and disabled, as provided under Title XIX of the federal Social 548
Security Act, as amended, under waivers, subject to the 549
availability of funds specifically appropriated for that purpose 550
by the Legislature. 551
(16) Mental health services. Certain services provided 552
by a psychiatrist shall be reimbursed at up to one hundred percent 553
(100%) of the Medicare rate. Approved therapeutic and case 554
management services (a) provided by an approved regional mental 555
health/intellectual disability center established under Sections 556
41-19-31 through 41-19-39, or by another community mental health 557
service provider meeting the requirements of the Department of 558
Mental Health to be an approved mental health/intellectual 559
disability center if determined necessary by the Department of 560
Mental Health, using state funds that are provided in the 561
appropriation to the division to match federal funds, or (b) 562
provided by a facility that is certified by the State Department 563
of Mental Health to provide therapeutic and case management 564
services, to be reimbursed on a fee for service basis, or (c) 565
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provided in the community by a facility or program operated by the 566
Department of Mental Health. Any such services provided by a 567
facility described in subparagraph (b) must have the prior 568
approval of the division to be reimbursable under this section. 569
(17) Durable medical equipment services and medical 570
supplies. Precertification of durable medical equipment and 571
medical supplies must be obtained as required by the division. 572
The Division of Medicaid may require durable medical equipment 573
providers to obtain a surety bond in the amount and to the 574
specifications as established by the Balanced Budget Act of 1997. 575
A maximum dollar amount of reimbursement for noninvasive 576
ventilators or ventilation treatments properly ordered and being 577
used in an appropriate care setting shall not be set by any health 578
maintenance organization, coordinated care organization, 579
provider-sponsored health plan, or other organization paid for 580
services on a capitated basis by the division under any managed 581
care program or coordinated care program implemented by the 582
division under this section. Reimbursement by these organizations 583
to durable medical equipment suppliers for home use of noninvasive 584
and invasive ventilators shall be on a continuous monthly payment 585
basis for the duration of medical need throughout a patient's 586
valid prescription period. 587
(18) (a) Notwithstanding any other provision of this 588
section to the contrary, as provided in the Medicaid state plan 589
amendment or amendments as defined in Section 43-13-145(10), the 590
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division shall make additional reimbursement to hospitals that 591
serve a disproportionate share of low-income patients and that 592
meet the federal requirements for those payments as provided in 593
Section 1923 of the federal Social Security Act and any applicable 594
regulations. It is the intent of the Legislature that the 595
division shall draw down all available federal funds allotted to 596
the state for disproportionate share hospitals. However, from and 597
after January 1, 1999, public hospitals participating in the 598
Medicaid disproportionate share program may be required to 599
participate in an intergovernmental transfer program as provided 600
in Section 1903 of the federal Social Security Act and any 601
applicable regulations. 602
(b) (i) 1. The division may establish a Medicare 603
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 604
the federal Social Security Act and any applicable federal 605
regulations, or an allowable delivery system or provider payment 606
initiative authorized under 42 CFR 438.6(c), for hospitals, 607
nursing facilities and physicians employed or contracted by 608
hospitals. 609
2. The division shall establish a 610
Medicaid Supplemental Payment Program, as permitted by the federal 611
Social Security Act and a comparable allowable delivery system or 612
provider payment initiative authorized under 42 CFR 438.6(c), for 613
emergency ambulance transportation providers in accordance with 614
this subsection (A)(18)(b). 615
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(ii) The division shall assess each hospital, 616
nursing facility, and emergency ambulance transportation provider 617
for the sole purpose of financing the state portion of the 618
Medicare Upper Payment Limits Program or other program(s) 619
authorized under this subsection (A)(18)(b). The hospital 620
assessment shall be as provided in Section 43-13-145(4)(a), and 621
the nursing facility and the emergency ambulance transportation 622
assessments, if established, shall be based on Medicaid 623
utilization or other appropriate method, as determined by the 624
division, consistent with federal regulations. The assessments 625
will remain in effect as long as the state participates in the 626
Medicare Upper Payment Limits Program or other program(s) 627
authorized under this subsection (A)(18)(b). In addition to the 628
hospital assessment provided in Section 43-13-145(4)(a), hospitals 629
with physicians participating in the Medicare Upper Payment Limits 630
Program or other program(s) authorized under this subsection 631
(A)(18)(b) shall be required to participate in an 632
intergovernmental transfer or assessment, as determined by the 633
division, for the purpose of financing the state portion of the 634
physician UPL payments or other payment(s) authorized under this 635
subsection (A)(18)(b). 636
(iii) Subject to approval by the Centers for 637
Medicare and Medicaid Services (CMS) and the provisions of this 638
subsection (A)(18)(b), the division shall make additional 639
reimbursement to hospitals, nursing facilities, and emergency 640
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ambulance transportation providers for the Medicare Upper Payment 641
Limits Program or other program(s) authorized under this 642
subsection (A)(18)(b), and, if the program is established for 643
physicians, shall make additional reimbursement for physicians, as 644
defined in Section 1902(a)(30) of the federal Social Security Act 645
and any applicable federal regulations, provided the assessment in 646
this subsection (A)(18)(b) is in effect. 647
(iv) Notwithstanding any other provision of 648
this article to the contrary, effective upon implementation of the 649
Mississippi Hospital Access Program (MHAP) provided in 650
subparagraph (c)(i) below, the hospital portion of the inpatient 651
Upper Payment Limits Program shall transition into and be replaced 652
by the MHAP program. However, the division is authorized to 653
develop and implement an alternative fee-for-service Upper Payment 654
Limits model in accordance with federal laws and regulations if 655
necessary to preserve supplemental funding. Further, the 656
division, in consultation with the hospital industry shall develop 657
alternative models for distribution of medical claims and 658
supplemental payments for inpatient and outpatient hospital 659
services, and such models may include, but shall not be limited to 660
the following: increasing rates for inpatient and outpatient 661
services; creating a low-income utilization pool of funds to 662
reimburse hospitals for the costs of uncompensated care, charity 663
care and bad debts as permitted and approved pursuant to federal 664
regulations and the Centers for Medicare and Medicaid Services; 665
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supplemental payments based upon Medicaid utilization, quality, 666
service lines and/or costs of providing such services to Medicaid 667
beneficiaries and to uninsured patients. The goals of such 668
payment models shall be to ensure access to inpatient and 669
outpatient care and to maximize any federal funds that are 670
available to reimburse hospitals for services provided. Any such 671
documents required to achieve the goals described in this 672
paragraph shall be submitted to the Centers for Medicare and 673
Medicaid Services, with a proposed effective date of July 1, 2019, 674
to the extent possible, but in no event shall the effective date 675
of such payment models be later than July 1, 2020. The Chairmen 676
of the Senate and House Medicaid Committees shall be provided a 677
copy of the proposed payment model(s) prior to submission. 678
Effective July 1, 2018, and until such time as any payment 679
model(s) as described above become effective, the division, in 680
consultation with the hospital industry, is authorized to 681
implement a transitional program for inpatient and outpatient 682
payments and/or supplemental payments (including, but not limited 683
to, MHAP and directed payments), to redistribute available 684
supplemental funds among hospital providers, provided that when 685
compared to a hospital's prior year supplemental payments, 686
supplemental payments made pursuant to any such transitional 687
program shall not result in a decrease of more than five percent 688
(5%) and shall not increase by more than the amount needed to 689
maximize the distribution of the available funds. 690
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(v) 1. To preserve and improve access to 691
ambulance transportation provider services, the division shall 692
seek CMS approval to make ambulance service access payments as set 693
forth in this subsection (A)(18)(b) for all covered emergency 694
ambulance services rendered on or after July 1, 2022, and shall 695
make such ambulance service access payments for all covered 696
services rendered on or after the effective date of CMS approval. 697
2. The division shall calculate the 698
ambulance service access payment amount as the balance of the 699
portion of the Medical Care Fund related to ambulance 700
transportation service provider assessments plus any federal 701
matching funds earned on the balance, up to, but not to exceed, 702
the upper payment limit gap for all emergency ambulance service 703
providers. 704
3. a. Except for ambulance services 705
exempt from the assessment provided in this paragraph (18)(b), all 706
ambulance transportation service providers shall be eligible for 707
ambulance service access payments each state fiscal year as set 708
forth in this paragraph (18)(b). 709
b. In addition to any other funds 710
paid to ambulance transportation service providers for emergency 711
medical services provided to Medicaid beneficiaries, each eligible 712
ambulance transportation service provider shall receive ambulance 713
service access payments each state fiscal year equal to the 714
ambulance transportation service provider's upper payment limit 715
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gap. Subject to approval by the Centers for Medicare and Medicaid 716
Services, ambulance service access payments shall be made no less 717
than on a quarterly basis. 718
c. As used in this paragraph 719
(18)(b)(v), the term "upper payment limit gap" means the 720
difference between the total amount that the ambulance 721
transportation service provider received from Medicaid and the 722
average amount that the ambulance transportation service provider 723
would have received from commercial insurers for those services 724
reimbursed by Medicaid. 725
4. An ambulance service access payment 726
shall not be used to offset any other payment by the division for 727
emergency or nonemergency services to Medicaid beneficiaries. 728
(c) (i) Not later than December l, 2015, the 729
division shall, subject to approval by the Centers for Medicare 730
and Medicaid Services (CMS), establish, implement and operate a 731
Mississippi Hospital Access Program (MHAP) for the purpose of 732
protecting patient access to hospital care through hospital 733
inpatient reimbursement programs provided in this section designed 734
to maintain total hospital reimbursement for inpatient services 735
rendered by in-state hospitals and the out-of-state hospital that 736
is authorized by federal law to submit intergovernmental transfers 737
(IGTs) to the State of Mississippi and is classified as Level I 738
trauma center located in a county contiguous to the state line at 739
the maximum levels permissible under applicable federal statutes 740
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and regulations, at which time the current inpatient Medicare 741
Upper Payment Limits (UPL) Program for hospital inpatient services 742
shall transition to the MHAP. 743
(ii) Subject to approval by the Centers for 744
Medicare and Medicaid Services (CMS), the MHAP shall provide 745
increased inpatient capitation (PMPM) payments to managed care 746
entities contracting with the division pursuant to subsection (H) 747
of this section to support availability of hospital services or 748
such other payments permissible under federal law necessary to 749
accomplish the intent of this subsection. 750
(iii) The intent of this subparagraph (c) is 751
that effective for all inpatient hospital Medicaid services during 752
state fiscal year 2016, and so long as this provision shall remain 753
in effect hereafter, the division shall to the fullest extent 754
feasible replace the additional reimbursement for hospital 755
inpatient services under the inpatient Medicare Upper Payment 756
Limits (UPL) Program with additional reimbursement under the MHAP 757
and other payment programs for inpatient and/or outpatient 758
payments which may be developed under the authority of this 759
paragraph. 760
(iv) The division shall assess each hospital 761
as provided in Section 43-13-145(4)(a) for the purpose of 762
financing the state portion of the MHAP, supplemental payments and 763
such other purposes as specified in Section 43-13-145. The 764
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assessment will remain in effect as long as the MHAP and 765
supplemental payments are in effect. 766
(19) (a) Perinatal risk management services. The 767
division shall promulgate regulations to be effective from and 768
after October 1, 1988, to establish a comprehensive perinatal 769
system for risk assessment of all pregnant and infant Medicaid 770
recipients and for management, education and follow-up for those 771
who are determined to be at risk. Services to be performed 772
include case management, nutrition assessment/counseling, 773
psychosocial assessment/counseling and health education. The 774
division shall contract with the State Department of Health to 775
provide services within this paragraph (Perinatal High Risk 776
Management/Infant Services System (PHRM/ISS)). The State 777
Department of Health shall be reimbursed on a full reasonable cost 778
basis for services provided under this subparagraph (a). 779
(b) Early intervention system services. The 780
division shall cooperate with the State Department of Health, 781
acting as lead agency, in the development and implementation of a 782
statewide system of delivery of early intervention services, under 783
Part C of the Individuals with Disabilities Education Act (IDEA). 784
The State Department of Health shall certify annually in writing 785
to the executive director of the division the dollar amount of 786
state early intervention funds available that will be utilized as 787
a certified match for Medicaid matching funds. Those funds then 788
shall be used to provide expanded targeted case management 789
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services for Medicaid eligible children with special needs who are 790
eligible for the state's early intervention system. 791
Qualifications for persons providing service coordination shall be 792
determined by the State Department of Health and the Division of 793
Medicaid. 794
(20) Home- and community-based services for physically 795
disabled approved services as allowed by a waiver from the United 796
States Department of Health and Human Services for home- and 797
community-based services for physically disabled people using 798
state funds that are provided from the appropriation to the State 799
Department of Rehabilitation Services and used to match federal 800
funds under a cooperative agreement between the division and the 801
department, provided that funds for these services are 802
specifically appropriated to the Department of Rehabilitation 803
Services. 804
(21) Nurse practitioner services. Services furnished 805
by a registered nurse who is licensed and certified by the 806
Mississippi Board of Nursing as a nurse practitioner, including, 807
but not limited to, nurse anesthetists, nurse midwives, family 808
nurse practitioners, family planning nurse practitioners, 809
pediatric nurse practitioners, obstetrics-gynecology nurse 810
practitioners and neonatal nurse practitioners, under regulations 811
adopted by the division. Reimbursement for those services shall 812
not exceed ninety percent (90%) of the reimbursement rate for 813
comparable services rendered by a physician. The division may 814
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provide for a reimbursement rate for nurse practitioner services 815
of up to one hundred percent (100%) of the reimbursement rate for 816
comparable services rendered by a physician for nurse practitioner 817
services that are provided after the normal working hours of the 818
nurse practitioner, as determined in accordance with regulations 819
of the division. 820
(22) Ambulatory services delivered in federally 821
qualified health centers, rural health centers and clinics of the 822
local health departments of the State Department of Health for 823
individuals eligible for Medicaid under this article based on 824
reasonable costs as determined by the division. Federally 825
qualified health centers shall be reimbursed by the Medicaid 826
prospective payment system as approved by the Centers for Medicare 827
and Medicaid Services. The division shall recognize federally 828
qualified health centers (FQHCs), rural health clinics (RHCs) and 829
community mental health centers (CMHCs) as both an originating and 830
distant site provider for the purposes of telehealth 831
reimbursement. The division is further authorized and directed to 832
reimburse FQHCs, RHCs and CMHCs for both distant site and 833
originating site services when such services are appropriately 834
provided by the same organization. 835
(23) Inpatient psychiatric services. 836
(a) Inpatient psychiatric services to be 837
determined by the division for recipients under age twenty-one 838
(21) that are provided under the direction of a physician in an 839
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inpatient program in a licensed acute care psychiatric facility or 840
in a licensed psychiatric residential treatment facility, before 841
the recipient reaches age twenty-one (21) or, if the recipient was 842
receiving the services immediately before he or she reached age 843
twenty-one (21), before the earlier of the date he or she no 844
longer requires the services or the date he or she reaches age 845
twenty-two (22), as provided by federal regulations. From and 846
after January 1, 2015, the division shall update the fair rental 847
reimbursement system for psychiatric residential treatment 848
facilities. Precertification of inpatient days and residential 849
treatment days must be obtained as required by the division. From 850
and after July 1, 2009, all state-owned and state-operated 851
facilities that provide inpatient psychiatric services to persons 852
under age twenty-one (21) who are eligible for Medicaid 853
reimbursement shall be reimbursed for those services on a full 854
reasonable cost basis. 855
(b) The division may reimburse for services 856
provided by a licensed freestanding psychiatric hospital to 857
Medicaid recipients over the age of twenty-one (21) in a method 858
and manner consistent with the provisions of Section 43-13-117.5. 859
(24) [Deleted] 860
(25) [Deleted] 861
(26) Hospice care. As used in this paragraph, the term 862
"hospice care" means a coordinated program of active professional 863
medical attention within the home and outpatient and inpatient 864
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care that treats the terminally ill patient and family as a unit, 865
employing a medically directed interdisciplinary team. The 866
program provides relief of severe pain or other physical symptoms 867
and supportive care to meet the special needs arising out of 868
physical, psychological, spiritual, social and economic stresses 869
that are experienced during the final stages of illness and during 870
dying and bereavement and meets the Medicare requirements for 871
participation as a hospice as provided in federal regulations. 872
(27) Group health plan premiums and cost-sharing if it 873
is cost-effective as defined by the United States Secretary of 874
Health and Human Services. 875
(28) Other health insurance premiums that are 876
cost-effective as defined by the United States Secretary of Health 877
and Human Services. Medicare eligible must have Medicare Part B 878
before other insurance premiums can be paid. 879
(29) The Division of Medicaid may apply for a waiver 880
from the United States Department of Health and Human Services for 881
home- and community-based services for developmentally disabled 882
people using state funds that are provided from the appropriation 883
to the State Department of Mental Health and/or funds transferred 884
to the department by a political subdivision or instrumentality of 885
the state and used to match federal funds under a cooperative 886
agreement between the division and the department, provided that 887
funds for these services are specifically appropriated to the 888
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Department of Mental Health and/or transferred to the department 889
by a political subdivision or instrumentality of the state. 890
(30) Pediatric skilled nursing services as determined 891
by the division and in a manner consistent with regulations 892
promulgated by the Mississippi State Department of Health. 893
(31) Targeted case management services for children 894
with special needs, under waivers from the United States 895
Department of Health and Human Services, using state funds that 896
are provided from the appropriation to the Mississippi Department 897
of Human Services and used to match federal funds under a 898
cooperative agreement between the division and the department. 899
(32) Care and services provided in Christian Science 900
Sanatoria listed and certified by the Commission for Accreditation 901
of Christian Science Nursing Organizations/Facilities, Inc., 902
rendered in connection with treatment by prayer or spiritual means 903
to the extent that those services are subject to reimbursement 904
under Section 1903 of the federal Social Security Act. 905
(33) Podiatrist services. 906
(34) Assisted living services as provided through 907
home- and community-based services under Title XIX of the federal 908
Social Security Act, as amended, subject to the availability of 909
funds specifically appropriated for that purpose by the 910
Legislature. 911
(35) Services and activities authorized in Sections 912
43-27-101 and 43-27-103, using state funds that are provided from 913
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the appropriation to the Mississippi Department of Human Services 914
and used to match federal funds under a cooperative agreement 915
between the division and the department. 916
(36) Nonemergency transportation services for 917
Medicaid-eligible persons as determined by the division. The PEER 918
Committee shall conduct a performance evaluation of the 919
nonemergency transportation program to evaluate the administration 920
of the program and the providers of transportation services to 921
determine the most cost-effective ways of providing nonemergency 922
transportation services to the patients served under the program. 923
The performance evaluation shall be completed and provided to the 924
members of the Senate Medicaid Committee and the House Medicaid 925
Committee not later than January 1, 2019, and every two (2) years 926
thereafter. 927
(37) [Deleted] 928
(38) Chiropractic services. A chiropractor's manual 929
manipulation of the spine to correct a subluxation, if x-ray 930
demonstrates that a subluxation exists and if the subluxation has 931
resulted in a neuromusculoskeletal condition for which 932
manipulation is appropriate treatment, and related spinal x-rays 933
performed to document these conditions. Reimbursement for 934
chiropractic services shall not exceed Seven Hundred Dollars 935
($700.00) per year per beneficiary. 936
(39) Dually eligible Medicare/Medicaid beneficiaries. 937
The division shall pay the Medicare deductible and coinsurance 938
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amounts for services available under Medicare, as determined by 939
the division. From and after July 1, 2009, the division shall 940
reimburse crossover claims for inpatient hospital services and 941
crossover claims covered under Medicare Part B in the same manner 942
that was in effect on January 1, 2008, unless specifically 943
authorized by the Legislature to change this method. 944
(40) [Deleted] 945
(41) Services provided by the State Department of 946
Rehabilitation Services for the care and rehabilitation of persons 947
with spinal cord injuries or traumatic brain injuries, as allowed 948
under waivers from the United States Department of Health and 949
Human Services, using up to seventy-five percent (75%) of the 950
funds that are appropriated to the Department of Rehabilitation 951
Services from the Spinal Cord and Head Injury Trust Fund 952
established under Section 37-33-261 and used to match federal 953
funds under a cooperative agreement between the division and the 954
department. 955
(42) [Deleted] 956
(43) The division shall provide reimbursement, 957
according to a payment schedule developed by the division, for 958
smoking cessation medications for pregnant women during their 959
pregnancy and other Medicaid-eligible women who are of 960
child-bearing age. 961
(44) Nursing facility services for the severely 962
disabled. 963
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(a) Severe disabilities include, but are not 964
limited to, spinal cord injuries, closed-head injuries and 965
ventilator-dependent patients. 966
(b) Those services must be provided in a long-term 967
care nursing facility dedicated to the care and treatment of 968
persons with severe disabilities. 969
(45) Physician assistant services. Services furnished 970
by a physician assistant who is licensed by the State Board of 971
Medical Licensure and is practicing with physician supervision 972
under regulations adopted by the board, under regulations adopted 973
by the division. Reimbursement for those services shall not 974
exceed ninety percent (90%) of the reimbursement rate for 975
comparable services rendered by a physician. The division may 976
provide for a reimbursement rate for physician assistant services 977
of up to one hundred percent (100%) or the reimbursement rate for 978
comparable services rendered by a physician for physician 979
assistant services that are provided after the normal working 980
hours of the physician assistant, as determined in accordance with 981
regulations of the division. 982
(46) The division shall make application to the federal 983
Centers for Medicare and Medicaid Services (CMS) for a waiver to 984
develop and provide services for children with serious emotional 985
disturbances as defined in Section 43-14-1(1), which may include 986
home- and community-based services, case management services or 987
managed care services through mental health providers certified by 988
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the Department of Mental Health. The division may implement and 989
provide services under this waivered program only if funds for 990
these services are specifically appropriated for this purpose by 991
the Legislature, or if funds are voluntarily provided by affected 992
agencies. 993
(47) (a) The division may develop and implement 994
disease management programs for individuals with high-cost chronic 995
diseases and conditions, including the use of grants, waivers, 996
demonstrations or other projects as necessary. 997
(b) Participation in any disease management 998
program implemented under this paragraph (47) is optional with the 999
individual. An individual must affirmatively elect to participate 1000
in the disease management program in order to participate, and may 1001
elect to discontinue participation in the program at any time. 1002
(48) Pediatric long-term acute care hospital services. 1003
(a) Pediatric long-term acute care hospital 1004
services means services provided to eligible persons under 1005
twenty-one (21) years of age by a freestanding Medicare-certified 1006
hospital that has an average length of inpatient stay greater than 1007
twenty-five (25) days and that is primarily engaged in providing 1008
chronic or long-term medical care to persons under twenty-one (21) 1009
years of age. 1010
(b) The services under this paragraph (48) shall 1011
be reimbursed as a separate category of hospital services. 1012
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(49) The division may establish copayments and/or 1013
coinsurance for any Medicaid services for which copayments and/or 1014
coinsurance are allowable under federal law or regulation. 1015
(50) Services provided by the State Department of 1016
Rehabilitation Services for the care and rehabilitation of persons 1017
who are deaf and blind, as allowed under waivers from the United 1018
States Department of Health and Human Services to provide home- 1019
and community-based services using state funds that are provided 1020
from the appropriation to the State Department of Rehabilitation 1021
Services or if funds are voluntarily provided by another agency. 1022
(51) Upon determination of Medicaid eligibility and in 1023
association with annual redetermination of Medicaid eligibility, 1024
beneficiaries shall be encouraged to undertake a physical 1025
examination that will establish a base-line level of health and 1026
identification of a usual and customary source of care (a medical 1027
home) to aid utilization of disease management tools. This 1028
physical examination and utilization of these disease management 1029
tools shall be consistent with current United States Preventive 1030
Services Task Force or other recognized authority recommendations. 1031
For persons who are determined ineligible for Medicaid, the 1032
division will provide information and direction for accessing 1033
medical care and services in the area of their residence. 1034
(52) Notwithstanding any provisions of this article, 1035
the division may pay enhanced reimbursement fees related to trauma 1036
care, as determined by the division in conjunction with the State 1037
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Department of Health, using funds appropriated to the State 1038
Department of Health for trauma care and services and used to 1039
match federal funds under a cooperative agreement between the 1040
division and the State Department of Health. The division, in 1041
conjunction with the State Department of Health, may use grants, 1042
waivers, demonstrations, enhanced reimbursements, Upper Payment 1043
Limits Programs, supplemental payments, or other projects as 1044
necessary in the development and implementation of this 1045
reimbursement program. 1046
(53) Targeted case management services for high-cost 1047
beneficiaries may be developed by the division for all services 1048
under this section. 1049
(54) [Deleted] 1050
(55) Therapy services. The plan of care for therapy 1051
services may be developed to cover a period of treatment for up to 1052
six (6) months, but in no event shall the plan of care exceed a 1053
six-month period of treatment. The projected period of treatment 1054
must be indicated on the initial plan of care and must be updated 1055
with each subsequent revised plan of care. Based on medical 1056
necessity, the division shall approve certification periods for 1057
less than or up to six (6) months, but in no event shall the 1058
certification period exceed the period of treatment indicated on 1059
the plan of care. The appeal process for any reduction in therapy 1060
services shall be consistent with the appeal process in federal 1061
regulations. 1062
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(56) Prescribed pediatric extended care centers 1063
services for medically dependent or technologically dependent 1064
children with complex medical conditions that require continual 1065
care as prescribed by the child's attending physician, as 1066
determined by the division. 1067
(57) No Medicaid benefit shall restrict coverage for 1068
medically appropriate treatment prescribed by a physician and 1069
agreed to by a fully informed individual, or if the individual 1070
lacks legal capacity to consent by a person who has legal 1071
authority to consent on his or her behalf, based on an 1072
individual's diagnosis with a terminal condition. As used in this 1073
paragraph (57), "terminal condition" means any aggressive 1074
malignancy, chronic end-stage cardiovascular or cerebral vascular 1075
disease, or any other disease, illness or condition which a 1076
physician diagnoses as terminal. 1077
(58) Treatment services for persons with opioid 1078
dependency or other highly addictive substance use disorders. The 1079
division is authorized to reimburse eligible providers for 1080
treatment of opioid dependency and other highly addictive 1081
substance use disorders, as determined by the division. Treatment 1082
related to these conditions shall not count against any physician 1083
visit limit imposed under this section. 1084
(59) The division shall allow beneficiaries between the 1085
ages of ten (10) and eighteen (18) years to receive vaccines 1086
through a pharmacy venue. The division and the State Department 1087
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of Health shall coordinate and notify OB-GYN providers that the 1088
Vaccines for Children program is available to providers free of 1089
charge. 1090
(60) Border city university-affiliated pediatric 1091
teaching hospital. 1092
(a) Payments may only be made to a border city 1093
university-affiliated pediatric teaching hospital if the Centers 1094
for Medicare and Medicaid Services (CMS) approve an increase in 1095
the annual request for the provider payment initiative authorized 1096
under 42 CFR Section 438.6(c) in an amount equal to or greater 1097
than the estimated annual payment to be made to the border city 1098
university-affiliated pediatric teaching hospital. The estimate 1099
shall be based on the hospital's prior year Mississippi managed 1100
care utilization. 1101
(b) As used in this paragraph (60), the term 1102
"border city university-affiliated pediatric teaching hospital" 1103
means an out-of-state hospital located within a city bordering the 1104
eastern bank of the Mississippi River and the State of Mississippi 1105
that submits to the division a copy of a current and effective 1106
affiliation agreement with an accredited university and other 1107
documentation establishing that the hospital is 1108
university-affiliated, is licensed and designated as a pediatric 1109
hospital or pediatric primary hospital within its home state, 1110
maintains at least five (5) different pediatric specialty training 1111
programs, and maintains at least one hundred (100) operated beds 1112
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dedicated exclusively for the treatment of patients under the age 1113
of twenty-one (21) years. 1114
(c) The cost of providing services to Mississippi 1115
Medicaid beneficiaries under the age of twenty-one (21) years who 1116
are treated by a border city university-affiliated pediatric 1117
teaching hospital shall not exceed the cost of providing the same 1118
services to individuals in hospitals in the state. 1119
(d) It is the intent of the Legislature that 1120
payments shall not result in any in-state hospital receiving 1121
payments lower than they would otherwise receive if not for the 1122
payments made to any border city university-affiliated pediatric 1123
teaching hospital. 1124
(e) This paragraph (60) shall stand repealed on 1125
July 1, 2024. 1126
(61) Services described in Section 41-140-3 that are 1127
provided by certified community health workers employed and 1128
supervised by a Medicaid provider. Reimbursement for these 1129
services shall be provided only if the division has received 1130
approval from the Centers for Medicare and Medicaid Services for a 1131
state plan amendment, waiver or alternative payment model for 1132
services delivered by certified community health workers. 1133
(B) Planning and development districts participating in the 1134
home- and community-based services program for the elderly and 1135
disabled as case management providers shall be reimbursed for case 1136
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management services at the maximum rate approved by the Centers 1137
for Medicare and Medicaid Services (CMS). 1138
(C) The division may pay to those providers who participate 1139
in and accept patient referrals from the division's emergency room 1140
redirection program a percentage, as determined by the division, 1141
of savings achieved according to the performance measures and 1142
reduction of costs required of that program. Federally qualified 1143
health centers may participate in the emergency room redirection 1144
program, and the division may pay those centers a percentage of 1145
any savings to the Medicaid program achieved by the centers' 1146
accepting patient referrals through the program, as provided in 1147
this subsection (C). 1148
(D) (1) As used in this subsection (D), the following terms 1149
shall be defined as provided in this paragraph, except as 1150
otherwise provided in this subsection: 1151
(a) "Committees" means the Medicaid Committees of 1152
the House of Representatives and the Senate, and "committee" means 1153
either one of those committees. 1154
(b) "Rate change" means an increase, decrease or 1155
other change in the payments or rates of reimbursement, or a 1156
change in any payment methodology that results in an increase, 1157
decrease or other change in the payments or rates of 1158
reimbursement, to any Medicaid provider that renders any services 1159
authorized to be provided to Medicaid recipients under this 1160
article. 1161
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(2) Whenever the Division of Medicaid proposes a rate 1162
change, the division shall give notice to the chairmen of the 1163
committees at least thirty (30) calendar days before the proposed 1164
rate change is scheduled to take effect. The division shall 1165
furnish the chairmen with a concise summary of each proposed rate 1166
change along with the notice, and shall furnish the chairmen with 1167
a copy of any proposed rate change upon request. The division 1168
also shall provide a summary and copy of any proposed rate change 1169
to any other member of the Legislature upon request. 1170
(3) If the chairman of either committee or both 1171
chairmen jointly object to the proposed rate change or any part 1172
thereof, the chairman or chairmen shall notify the division and 1173
provide the reasons for their objection in writing not later than 1174
seven (7) calendar days after receipt of the notice from the 1175
division. The chairman or chairmen may make written 1176
recommendations to the division for changes to be made to a 1177
proposed rate change. 1178
(4) (a) The chairman of either committee or both 1179
chairmen jointly may hold a committee meeting to review a proposed 1180
rate change. If either chairman or both chairmen decide to hold a 1181
meeting, they shall notify the division of their intention in 1182
writing within seven (7) calendar days after receipt of the notice 1183
from the division, and shall set the date and time for the meeting 1184
in their notice to the division, which shall not be later than 1185
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fourteen (14) calendar days after receipt of the notice from the 1186
division. 1187
(b) After the committee meeting, the committee or 1188
committees may object to the proposed rate change or any part 1189
thereof. The committee or committees shall notify the division 1190
and the reasons for their objection in writing not later than 1191
seven (7) calendar days after the meeting. The committee or 1192
committees may make written recommendations to the division for 1193
changes to be made to a proposed rate change. 1194
(5) If both chairmen notify the division in writing 1195
within seven (7) calendar days after receipt of the notice from 1196
the division that they do not object to the proposed rate change 1197
and will not be holding a meeting to review the proposed rate 1198
change, the proposed rate change will take effect on the original 1199
date as scheduled by the division or on such other date as 1200
specified by the division. 1201
(6) (a) If there are any objections to a proposed rate 1202
change or any part thereof from either or both of the chairmen or 1203
the committees, the division may withdraw the proposed rate 1204
change, make any of the recommended changes to the proposed rate 1205
change, or not make any changes to the proposed rate change. 1206
(b) If the division does not make any changes to 1207
the proposed rate change, it shall notify the chairmen of that 1208
fact in writing, and the proposed rate change shall take effect on 1209
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the original date as scheduled by the division or on such other 1210
date as specified by the division. 1211
(c) If the division makes any changes to the 1212
proposed rate change, the division shall notify the chairmen of 1213
its actions in writing, and the revised proposed rate change shall 1214
take effect on the date as specified by the division. 1215
(7) Nothing in this subsection (D) shall be construed 1216
as giving the chairmen or the committees any authority to veto, 1217
nullify or revise any rate change proposed by the division. The 1218
authority of the chairmen or the committees under this subsection 1219
shall be limited to reviewing, making objections to and making 1220
recommendations for changes to rate changes proposed by the 1221
division. 1222
(E) Notwithstanding any provision of this article, no new 1223
groups or categories of recipients and new types of care and 1224
services may be added without enabling legislation from the 1225
Mississippi Legislature, except that the division may authorize 1226
those changes without enabling legislation when the addition of 1227
recipients or services is ordered by a court of proper authority. 1228
(F) The executive director shall keep the Governor advised 1229
on a timely basis of the funds available for expenditure and the 1230
projected expenditures. Notwithstanding any other provisions of 1231
this article, if current or projected expenditures of the division 1232
are reasonably anticipated to exceed the amount of funds 1233
appropriated to the division for any fiscal year, the Governor, 1234
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after consultation with the executive director, shall take all 1235
appropriate measures to reduce costs, which may include, but are 1236
not limited to: 1237
(1) Reducing or discontinuing any or all services that 1238
are deemed to be optional under Title XIX of the Social Security 1239
Act; 1240
(2) Reducing reimbursement rates for any or all service 1241
types; 1242
(3) Imposing additional assessments on health care 1243
providers; or 1244
(4) Any additional cost-containment measures deemed 1245
appropriate by the Governor. 1246
To the extent allowed under federal law, any reduction to 1247
services or reimbursement rates under this subsection (F) shall be 1248
accompanied by a reduction, to the fullest allowable amount, to 1249
the profit margin and administrative fee portions of capitated 1250
payments to organizations described in paragraph (1) of subsection 1251
(H). 1252
Beginning in fiscal year 2010 and in fiscal years thereafter, 1253
when Medicaid expenditures are projected to exceed funds available 1254
for the fiscal year, the division shall submit the expected 1255
shortfall information to the PEER Committee not later than 1256
December 1 of the year in which the shortfall is projected to 1257
occur. PEER shall review the computations of the division and 1258
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report its findings to the Legislative Budget Office not later 1259
than January 7 in any year. 1260
(G) Notwithstanding any other provision of this article, it 1261
shall be the duty of each provider participating in the Medicaid 1262
program to keep and maintain books, documents and other records as 1263
prescribed by the Division of Medicaid in accordance with federal 1264
laws and regulations. 1265
(H) (1) Notwithstanding any other provision of this 1266
article, the division is authorized to implement (a) a managed 1267
care program, (b) a coordinated care program, (c) a coordinated 1268
care organization program, (d) a health maintenance organization 1269
program, (e) a patient-centered medical home program, (f) an 1270
accountable care organization program, (g) provider-sponsored 1271
health plan, or (h) any combination of the above programs. As a 1272
condition for the approval of any program under this subsection 1273
(H)(1), the division shall require that no managed care program, 1274
coordinated care program, coordinated care organization program, 1275
health maintenance organization program, or provider-sponsored 1276
health plan may: 1277
(a) Pay providers at a rate that is less than the 1278
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1279
reimbursement rate; 1280
(b) Override the medical decisions of hospital 1281
physicians or staff regarding patients admitted to a hospital for 1282
an emergency medical condition as defined by 42 US Code Section 1283
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1395dd. This restriction (b) does not prohibit the retrospective 1284
review of the appropriateness of the determination that an 1285
emergency medical condition exists by chart review or coding 1286
algorithm, nor does it prohibit prior authorization for 1287
nonemergency hospital admissions; 1288
(c) Pay providers at a rate that is less than the 1289
normal Medicaid reimbursement rate. It is the intent of the 1290
Legislature that all managed care entities described in this 1291
subsection (H), in collaboration with the division, develop and 1292
implement innovative payment models that incentivize improvements 1293
in health care quality, outcomes, or value, as determined by the 1294
division. Participation in the provider network of any managed 1295
care, coordinated care, provider-sponsored health plan, or similar 1296
contractor shall not be conditioned on the provider's agreement to 1297
accept such alternative payment models; 1298
(d) Implement a prior authorization and 1299
utilization review program for medical services, transportation 1300
services and prescription drugs that is more stringent than the 1301
prior authorization processes used by the division in its 1302
administration of the Medicaid program. Not later than December 1303
2, 2021, the contractors that are receiving capitated payments 1304
under a managed care delivery system established under this 1305
subsection (H) shall submit a report to the Chairmen of the House 1306
and Senate Medicaid Committees on the status of the prior 1307
authorization and utilization review program for medical services, 1308
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transportation services and prescription drugs that is required to 1309
be implemented under this subparagraph (d); 1310
(e) [Deleted] 1311
(f) Implement a preferred drug list that is more 1312
stringent than the mandatory preferred drug list established by 1313
the division under subsection (A)(9) of this section; 1314
(g) Implement a policy which denies beneficiaries 1315
with hemophilia access to the federally funded hemophilia 1316
treatment centers as part of the Medicaid Managed Care network of 1317
providers. 1318
Each health maintenance organization, coordinated care 1319
organization, provider-sponsored health plan, or other 1320
organization paid for services on a capitated basis by the 1321
division under any managed care program or coordinated care 1322
program implemented by the division under this section shall use a 1323
clear set of level of care guidelines in the determination of 1324
medical necessity and in all utilization management practices, 1325
including the prior authorization process, concurrent reviews, 1326
retrospective reviews and payments, that are consistent with 1327
widely accepted professional standards of care. Organizations 1328
participating in a managed care program or coordinated care 1329
program implemented by the division may not use any additional 1330
criteria that would result in denial of care that would be 1331
determined appropriate and, therefore, medically necessary under 1332
those levels of care guidelines. 1333
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(2) Notwithstanding any provision of this section, the 1334
recipients eligible for enrollment into a Medicaid Managed Care 1335
Program authorized under this subsection (H) may include only 1336
those categories of recipients eligible for participation in the 1337
Medicaid Managed Care Program as of January 1, 2021, the 1338
Children's Health Insurance Program (CHIP), and the CMS-approved 1339
Section 1115 demonstration waivers in operation as of January 1, 1340
2021. No expansion of Medicaid Managed Care Program contracts may 1341
be implemented by the division without enabling legislation from 1342
the Mississippi Legislature. 1343
(3) (a) Any contractors receiving capitated payments 1344
under a managed care delivery system established in this section 1345
shall provide to the Legislature and the division statistical data 1346
to be shared with provider groups in order to improve patient 1347
access, appropriate utilization, cost savings and health outcomes 1348
not later than October 1 of each year. Additionally, each 1349
contractor shall disclose to the Chairmen of the Senate and House 1350
Medicaid Committees the administrative expenses costs for the 1351
prior calendar year, and the number of full-equivalent employees 1352
located in the State of Mississippi dedicated to the Medicaid and 1353
CHIP lines of business as of June 30 of the current year. 1354
(b) The division and the contractors participating 1355
in the managed care program, a coordinated care program or a 1356
provider-sponsored health plan shall be subject to annual program 1357
reviews or audits performed by the Office of the State Auditor, 1358
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the PEER Committee, the Department of Insurance and/or independent 1359
third parties. 1360
(c) Those reviews shall include, but not be 1361
limited to, at least two (2) of the following items: 1362
(i) The financial benefit to the State of 1363
Mississippi of the managed care program, 1364
(ii) The difference between the premiums paid 1365
to the managed care contractors and the payments made by those 1366
contractors to health care providers, 1367
(iii) Compliance with performance measures 1368
required under the contracts, 1369
(iv) Administrative expense allocation 1370
methodologies, 1371
(v) Whether nonprovider payments assigned as 1372
medical expenses are appropriate, 1373
(vi) Capitated arrangements with related 1374
party subcontractors, 1375
(vii) Reasonableness of corporate 1376
allocations, 1377
(viii) Value-added benefits and the extent to 1378
which they are used, 1379
(ix) The effectiveness of subcontractor 1380
oversight, including subcontractor review, 1381
(x) Whether health care outcomes have been 1382
improved, and 1383
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(xi) The most common claim denial codes to 1384
determine the reasons for the denials. 1385
The audit reports shall be considered public documents and 1386
shall be posted in their entirety on the division's website. 1387
(4) All health maintenance organizations, coordinated 1388
care organizations, provider-sponsored health plans, or other 1389
organizations paid for services on a capitated basis by the 1390
division under any managed care program or coordinated care 1391
program implemented by the division under this section shall 1392
reimburse all providers in those organizations at rates no lower 1393
than those provided under this section for beneficiaries who are 1394
not participating in those programs. 1395
(5) No health maintenance organization, coordinated 1396
care organization, provider-sponsored health plan, or other 1397
organization paid for services on a capitated basis by the 1398
division under any managed care program or coordinated care 1399
program implemented by the division under this section shall 1400
require its providers or beneficiaries to use any pharmacy that 1401
ships, mails or delivers prescription drugs or legend drugs or 1402
devices. 1403
(6) (a) Not later than December 1, 2021, the 1404
contractors who are receiving capitated payments under a managed 1405
care delivery system established under this subsection (H) shall 1406
develop and implement a uniform credentialing process for 1407
providers. Under that uniform credentialing process, a provider 1408
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who meets the criteria for credentialing will be credentialed with 1409
all of those contractors and no such provider will have to be 1410
separately credentialed by any individual contractor in order to 1411
receive reimbursement from the contractor. Not later than 1412
December 2, 2021, those contractors shall submit a report to the 1413
Chairmen of the House and Senate Medicaid Committees on the status 1414
of the uniform credentialing process for providers that is 1415
required under this subparagraph (a). 1416
(b) If those contractors have not implemented a 1417
uniform credentialing process as described in subparagraph (a) by 1418
December 1, 2021, the division shall develop and implement, not 1419
later than July 1, 2022, a single, consolidated credentialing 1420
process by which all providers will be credentialed. Under the 1421
division's single, consolidated credentialing process, no such 1422
contractor shall require its providers to be separately 1423
credentialed by the contractor in order to receive reimbursement 1424
from the contractor, but those contractors shall recognize the 1425
credentialing of the providers by the division's credentialing 1426
process. 1427
(c) The division shall require a uniform provider 1428
credentialing application that shall be used in the credentialing 1429
process that is established under subparagraph (a) or (b). If the 1430
contractor or division, as applicable, has not approved or denied 1431
the provider credentialing application within sixty (60) days of 1432
receipt of the completed application that includes all required 1433
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information necessary for credentialing, then the contractor or 1434
division, upon receipt of a written request from the applicant and 1435
within five (5) business days of its receipt, shall issue a 1436
temporary provider credential/enrollment to the applicant if the 1437
applicant has a valid Mississippi professional or occupational 1438
license to provide the health care services to which the 1439
credential/enrollment would apply. The contractor or the division 1440
shall not issue a temporary credential/enrollment if the applicant 1441
has reported on the application a history of medical or other 1442
professional or occupational malpractice claims, a history of 1443
substance abuse or mental health issues, a criminal record, or a 1444
history of medical or other licensing board, state or federal 1445
disciplinary action, including any suspension from participation 1446
in a federal or state program. The temporary 1447
credential/enrollment shall be effective upon issuance and shall 1448
remain in effect until the provider's credentialing/enrollment 1449
application is approved or denied by the contractor or division. 1450
The contractor or division shall render a final decision regarding 1451
credentialing/enrollment of the provider within sixty (60) days 1452
from the date that the temporary provider credential/enrollment is 1453
issued to the applicant. 1454
(d) If the contractor or division does not render 1455
a final decision regarding credentialing/enrollment of the 1456
provider within the time required in subparagraph (c), the 1457
provider shall be deemed to be credentialed by and enrolled with 1458
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all of the contractors and eligible to receive reimbursement from 1459
the contractors. 1460
(7) (a) Each contractor that is receiving capitated 1461
payments under a managed care delivery system established under 1462
this subsection (H) shall provide to each provider for whom the 1463
contractor has denied the coverage of a procedure that was ordered 1464
or requested by the provider for or on behalf of a patient, a 1465
letter that provides a detailed explanation of the reasons for the 1466
denial of coverage of the procedure and the name and the 1467
credentials of the person who denied the coverage. The letter 1468
shall be sent to the provider in electronic format. 1469
(b) After a contractor that is receiving capitated 1470
payments under a managed care delivery system established under 1471
this subsection (H) has denied coverage for a claim submitted by a 1472
provider, the contractor shall issue to the provider within sixty 1473
(60) days a final ruling of denial of the claim that allows the 1474
provider to have a state fair hearing and/or agency appeal with 1475
the division. If a contractor does not issue a final ruling of 1476
denial within sixty (60) days as required by this subparagraph 1477
(b), the provider's claim shall be deemed to be automatically 1478
approved and the contractor shall pay the amount of the claim to 1479
the provider. 1480
(c) After a contractor has issued a final ruling 1481
of denial of a claim submitted by a provider, the division shall 1482
conduct a state fair hearing and/or agency appeal on the matter of 1483
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the disputed claim between the contractor and the provider within 1484
sixty (60) days, and shall render a decision on the matter within 1485
thirty (30) days after the date of the hearing and/or appeal. 1486
(8) It is the intention of the Legislature that the 1487
division evaluate the feasibility of using a single vendor to 1488
administer pharmacy benefits provided under a managed care 1489
delivery system established under this subsection (H). Providers 1490
of pharmacy benefits shall cooperate with the division in any 1491
transition to a carve-out of pharmacy benefits under managed care. 1492
(9) The division shall evaluate the feasibility of 1493
using a single vendor to administer dental benefits provided under 1494
a managed care delivery system established in this subsection (H). 1495
Providers of dental benefits shall cooperate with the division in 1496
any transition to a carve-out of dental benefits under managed 1497
care. 1498
(10) It is the intent of the Legislature that any 1499
contractor receiving capitated payments under a managed care 1500
delivery system established in this section shall implement 1501
innovative programs to improve the health and well-being of 1502
members diagnosed with prediabetes and diabetes. 1503
(11) It is the intent of the Legislature that any 1504
contractors receiving capitated payments under a managed care 1505
delivery system established under this subsection (H) shall work 1506
with providers of Medicaid services to improve the utilization of 1507
long-acting reversible contraceptives (LARCs). Not later than 1508
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December 1, 2021, any contractors receiving capitated payments 1509
under a managed care delivery system established under this 1510
subsection (H) shall provide to the Chairmen of the House and 1511
Senate Medicaid Committees and House and Senate Public Health 1512
Committees a report of LARC utilization for State Fiscal Years 1513
2018 through 2020 as well as any programs, initiatives, or efforts 1514
made by the contractors and providers to increase LARC 1515
utilization. This report shall be updated annually to include 1516
information for subsequent state fiscal years. 1517
(12) The division is authorized to make not more than 1518
one (1) emergency extension of the contracts that are in effect on 1519
July 1, 2021, with contractors who are receiving capitated 1520
payments under a managed care delivery system established under 1521
this subsection (H), as provided in this paragraph (12). The 1522
maximum period of any such extension shall be one (1) year, and 1523
under any such extensions, the contractors shall be subject to all 1524
of the provisions of this subsection (H). The extended contracts 1525
shall be revised to incorporate any provisions of this subsection 1526
(H). 1527
(I) [Deleted] 1528
(J) There shall be no cuts in inpatient and outpatient 1529
hospital payments, or allowable days or volumes, as long as the 1530
hospital assessment provided in Section 43-13-145 is in effect. 1531
This subsection (J) shall not apply to decreases in payments that 1532
are a result of: reduced hospital admissions, audits or payments 1533
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under the APR-DRG or APC models, or a managed care program or 1534
similar model described in subsection (H) of this section. 1535
(K) In the negotiation and execution of such contracts 1536
involving services performed by actuarial firms, the Executive 1537
Director of the Division of Medicaid may negotiate a limitation on 1538
liability to the state of prospective contractors. 1539
(L) The Division of Medicaid shall reimburse for services 1540
provided to eligible Medicaid beneficiaries by a licensed birthing 1541
center in a method and manner to be determined by the division in 1542
accordance with federal laws and federal regulations. The 1543
division shall seek any necessary waivers, make any required 1544
amendments to its State Plan or revise any contracts authorized 1545
under subsection (H) of this section as necessary to provide the 1546
services authorized under this subsection. As used in this 1547
subsection, the term "birthing centers" shall have the meaning as 1548
defined in Section 41-77-1(a), which is a publicly or privately 1549
owned facility, place or institution constructed, renovated, 1550
leased or otherwise established where nonemergency births are 1551
planned to occur away from the mother's usual residence following 1552
a documented period of prenatal care for a normal uncomplicated 1553
pregnancy which has been determined to be low risk through a 1554
formal risk-scoring examination. 1555
(M) This section shall stand repealed on July 1, 2028. 1556
SECTION 6. This act shall take effect and be in force from 1557
and after July 1, 2026. 1558