Medicaid; require managed care organizations to use certain level of care guidelines in determining medical necessity.

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To: Medicaid
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Hines

HOUSE BILL NO. 146

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