Medicaid; provide increased reimbursement rate for hospitals in counties with high unemployment and doctor shortage.

H. B. No. 152 *HR31/R616* ~ OFFICIAL ~ G1/2
26/HR31/R616
PAGE 1 (RF\JAB)

To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Hines

HOUSE BILL NO. 152

AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, 1
TO PROVIDE FOR AN INCREASED RATE OF MEDICAID REIMBURSEMENT FOR 2
INPATIENT AND OUTPATIENT HOSPITAL SERVICES FOR HOSPITALS THAT ARE 3
LOCATED IN A COUNTY THAT HAD AN AVERAGE MONTHLY UNEMPLOYMENT RATE 4
OF EIGHT PERCENT OR HIGHER FOR THE TWELVE MONTHS OF THE PREVIOUS 5
STATE FISCAL YEAR AND HAS A CRITICAL SHORTAGE OF PHYSICIANS AND 6
NURSES; AND FOR RELATED PURPOSES. 7
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 8
SECTION 1. Section 43-13-117, Mississippi Code of 1972, is 9
amended as follows: 10
43-13-117. (A) Medicaid as authorized by this article shall 11
include payment of part or all of the costs, at the discretion of 12
the division, with approval of the Governor and the Centers for 13
Medicare and Medicaid Services, of the following types of care and 14
services rendered to eligible applicants who have been determined 15
to be eligible for that care and services, within the limits of 16
state appropriations and federal matching funds: 17
(1) Inpatient hospital services. 18
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 2 (RF\JAB)

(a) The division is authorized to implement an All 19
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 20
methodology for inpatient hospital services. 21
(b) No service benefits or reimbursement 22
limitations in this subsection (A)(1) shall apply to payments 23
under an APR-DRG or Ambulatory Payment Classification (APC) model 24
or a managed care program or similar model described in subsection 25
(H) of this section unless specifically authorized by the 26
division. 27
(c) The division shall provide an increased rate 28
of reimbursement for inpatient hospital services that is not less 29
than eighty percent (80%) of the Medicare reimbursement rate for 30
the same services, for hospitals that are located in a county 31
that: 32
(i) Had an average monthly unemployment rate 33
of eight percent (8%) or higher, as determined by the United 34
States Bureau of Labor Statistics, for the twelve (12) months of 35
the previous state fiscal year; and 36
(ii) Has a critical shortage of physicians 37
and nurses, as determined by a committee composed of 38
representatives from the Mississippi Hospital Association, 39
Mississippi Nurses Association and Mississippi Primary Care 40
Association, and the Chairs of the House and Senate Medicaid 41
Committees. 42
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 3 (RF\JAB)

The increased rate of reimbursement provided for under this 43
subparagraph (c) shall be implemented by the division not later 44
than September 1, 2026, and shall be adjusted each year thereafter 45
not later than September 1 of the year. The increased rate of 46
reimbursement established each year shall remain in effect until 47
it is adjusted the next year. 48
(2) Outpatient hospital services. 49
(a) Emergency services. 50
(b) Other outpatient hospital services. The 51
division shall allow benefits for other medically necessary 52
outpatient hospital services (such as chemotherapy, radiation, 53
surgery and therapy), including outpatient services in a clinic or 54
other facility that is not located inside the hospital, but that 55
has been designated as an outpatient facility by the hospital, and 56
that was in operation or under construction on July 1, 2009, 57
provided that the costs and charges associated with the operation 58
of the hospital clinic are included in the hospital's cost report. 59
In addition, the Medicare thirty-five-mile rule will apply to 60
those hospital clinics not located inside the hospital that are 61
constructed after July 1, 2009. Where the same services are 62
reimbursed as clinic services, the division may revise the rate or 63
methodology of outpatient reimbursement to maintain consistency, 64
efficiency, economy and quality of care. 65
(c) The division is authorized to implement an 66
Ambulatory Payment Classification (APC) methodology for outpatient 67
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 4 (RF\JAB)

hospital services. The division shall give rural hospitals that 68
have fifty (50) or fewer licensed beds the option to not be 69
reimbursed for outpatient hospital services using the APC 70
methodology, but reimbursement for outpatient hospital services 71
provided by those hospitals shall be based on one hundred one 72
percent (101%) of the rate established under Medicare for 73
outpatient hospital services. Those hospitals choosing to not be 74
reimbursed under the APC methodology shall remain under cost-based 75
reimbursement for a two-year period. 76
(d) No service benefits or reimbursement 77
limitations in this subsection (A)(2) shall apply to payments 78
under an APR-DRG or APC model or a managed care program or similar 79
model described in subsection (H) of this section unless 80
specifically authorized by the division. 81
(3) Laboratory and x-ray services. 82
(4) Nursing facility services. 83
(a) The division shall make full payment to 84
nursing facilities for each day, not exceeding forty-two (42) days 85
per year, that a patient is absent from the facility on home 86
leave. Payment may be made for the following home leave days in 87
addition to the forty-two-day limitation: Christmas, the day 88
before Christmas, the day after Christmas, Thanksgiving, the day 89
before Thanksgiving and the day after Thanksgiving. 90
(b) From and after July 1, 1997, the division 91
shall implement the integrated case-mix payment and quality 92
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 5 (RF\JAB)

monitoring system, which includes the fair rental system for 93
property costs and in which recapture of depreciation is 94
eliminated. The division may reduce the payment for hospital 95
leave and therapeutic home leave days to the lower of the case-mix 96
category as computed for the resident on leave using the 97
assessment being utilized for payment at that point in time, or a 98
case-mix score of 1.000 for nursing facilities, and shall compute 99
case-mix scores of residents so that only services provided at the 100
nursing facility are considered in calculating a facility's per 101
diem. 102
(c) From and after July 1, 1997, all state-owned 103
nursing facilities shall be reimbursed on a full reasonable cost 104
basis. 105
(d) On or after January 1, 2015, the division 106
shall update the case-mix payment system resource utilization 107
grouper and classifications and fair rental reimbursement system. 108
The division shall develop and implement a payment add-on to 109
reimburse nursing facilities for ventilator-dependent resident 110
services. 111
(e) The division shall develop and implement, not 112
later than January 1, 2001, a case-mix payment add-on determined 113
by time studies and other valid statistical data that will 114
reimburse a nursing facility for the additional cost of caring for 115
a resident who has a diagnosis of Alzheimer's or other related 116
dementia and exhibits symptoms that require special care. Any 117
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 6 (RF\JAB)

such case-mix add-on payment shall be supported by a determination 118
of additional cost. The division shall also develop and implement 119
as part of the fair rental reimbursement system for nursing 120
facility beds, an Alzheimer's resident bed depreciation enhanced 121
reimbursement system that will provide an incentive to encourage 122
nursing facilities to convert or construct beds for residents with 123
Alzheimer's or other related dementia. 124
(f) The division shall develop and implement an 125
assessment process for long-term care services. The division may 126
provide the assessment and related functions directly or through 127
contract with the area agencies on aging. 128
The division shall apply for necessary federal waivers to 129
assure that additional services providing alternatives to nursing 130
facility care are made available to applicants for nursing 131
facility care. 132
(5) Periodic screening and diagnostic services for 133
individuals under age twenty-one (21) years as are needed to 134
identify physical and mental defects and to provide health care 135
treatment and other measures designed to correct or ameliorate 136
defects and physical and mental illness and conditions discovered 137
by the screening services, regardless of whether these services 138
are included in the state plan. The division may include in its 139
periodic screening and diagnostic program those discretionary 140
services authorized under the federal regulations adopted to 141
implement Title XIX of the federal Social Security Act, as 142
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 7 (RF\JAB)

amended. The division, in obtaining physical therapy services, 143
occupational therapy services, and services for individuals with 144
speech, hearing and language disorders, may enter into a 145
cooperative agreement with the State Department of Education for 146
the provision of those services to handicapped students by public 147
school districts using state funds that are provided from the 148
appropriation to the Department of Education to obtain federal 149
matching funds through the division. The division, in obtaining 150
medical and mental health assessments, treatment, care and 151
services for children who are in, or at risk of being put in, the 152
custody of the Mississippi Department of Human Services may enter 153
into a cooperative agreement with the Mississippi Department of 154
Human Services for the provision of those services using state 155
funds that are provided from the appropriation to the Department 156
of Human Services to obtain federal matching funds through the 157
division. 158
(6) Physician services. Fees for physician's services 159
that are covered only by Medicaid shall be reimbursed at ninety 160
percent (90%) of the rate established on January 1, 2018, and as 161
may be adjusted each July thereafter, under Medicare. The 162
division may provide for a reimbursement rate for physician's 163
services of up to one hundred percent (100%) of the rate 164
established under Medicare for physician's services that are 165
provided after the normal working hours of the physician, as 166
determined in accordance with regulations of the division. The 167
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 8 (RF\JAB)

division may reimburse eligible providers, as determined by the 168
division, for certain primary care services at one hundred percent 169
(100%) of the rate established under Medicare. The division shall 170
reimburse obstetricians and gynecologists for certain primary care 171
services as defined by the division at one hundred percent (100%) 172
of the rate established under Medicare. 173
(7) (a) Home health services for eligible persons, not 174
to exceed in cost the prevailing cost of nursing facility 175
services. All home health visits must be precertified as required 176
by the division. In addition to physicians, certified registered 177
nurse practitioners, physician assistants and clinical nurse 178
specialists are authorized to prescribe or order home health 179
services and plans of care, sign home health plans of care, 180
certify and recertify eligibility for home health services and 181
conduct the required initial face-to-face visit with the recipient 182
of the services. 183
(b) [Repealed] 184
(8) Emergency medical transportation services as 185
determined by the division. 186
(9) Prescription drugs and other covered drugs and 187
services as determined by the division. 188
The division shall establish a mandatory preferred drug list. 189
Drugs not on the mandatory preferred drug list shall be made 190
available by utilizing prior authorization procedures established 191
by the division. 192
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 9 (RF\JAB)

The division may seek to establish relationships with other 193
states in order to lower acquisition costs of prescription drugs 194
to include single-source and innovator multiple-source drugs or 195
generic drugs. In addition, if allowed by federal law or 196
regulation, the division may seek to establish relationships with 197
and negotiate with other countries to facilitate the acquisition 198
of prescription drugs to include single-source and innovator 199
multiple-source drugs or generic drugs, if that will lower the 200
acquisition costs of those prescription drugs. 201
The division may allow for a combination of prescriptions for 202
single-source and innovator multiple-source drugs and generic 203
drugs to meet the needs of the beneficiaries. 204
The executive director may approve specific maintenance drugs 205
for beneficiaries with certain medical conditions, which may be 206
prescribed and dispensed in three-month supply increments. 207
Drugs prescribed for a resident of a psychiatric residential 208
treatment facility must be provided in true unit doses when 209
available. The division may require that drugs not covered by 210
Medicare Part D for a resident of a long-term care facility be 211
provided in true unit doses when available. Those drugs that were 212
originally billed to the division but are not used by a resident 213
in any of those facilities shall be returned to the billing 214
pharmacy for credit to the division, in accordance with the 215
guidelines of the State Board of Pharmacy and any requirements of 216
federal law and regulation. Drugs shall be dispensed to a 217
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 10 (RF\JAB)

recipient and only one (1) dispensing fee per month may be 218
charged. The division shall develop a methodology for reimbursing 219
for restocked drugs, which shall include a restock fee as 220
determined by the division not exceeding Seven Dollars and 221
Eighty-two Cents ($7.82). 222
Except for those specific maintenance drugs approved by the 223
executive director, the division shall not reimburse for any 224
portion of a prescription that exceeds a thirty-one-day supply of 225
the drug based on the daily dosage. 226
The division is authorized to develop and implement a program 227
of payment for additional pharmacist services as determined by the 228
division. 229
All claims for drugs for dually eligible Medicare/Medicaid 230
beneficiaries that are paid for by Medicare must be submitted to 231
Medicare for payment before they may be processed by the 232
division's online payment system. 233
The division shall develop a pharmacy policy in which drugs 234
in tamper-resistant packaging that are prescribed for a resident 235
of a nursing facility but are not dispensed to the resident shall 236
be returned to the pharmacy and not billed to Medicaid, in 237
accordance with guidelines of the State Board of Pharmacy. 238
The division shall develop and implement a method or methods 239
by which the division will provide on a regular basis to Medicaid 240
providers who are authorized to prescribe drugs, information about 241
the costs to the Medicaid program of single-source drugs and 242
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 11 (RF\JAB)

innovator multiple-source drugs, and information about other drugs 243
that may be prescribed as alternatives to those single-source 244
drugs and innovator multiple-source drugs and the costs to the 245
Medicaid program of those alternative drugs. 246
Notwithstanding any law or regulation, information obtained 247
or maintained by the division regarding the prescription drug 248
program, including trade secrets and manufacturer or labeler 249
pricing, is confidential and not subject to disclosure except to 250
other state agencies. 251
The dispensing fee for each new or refill prescription, 252
including nonlegend or over-the-counter drugs covered by the 253
division, shall be not less than Three Dollars and Ninety-one 254
Cents ($3.91), as determined by the division. 255
The division shall not reimburse for single-source or 256
innovator multiple-source drugs if there are equally effective 257
generic equivalents available and if the generic equivalents are 258
the least expensive. 259
It is the intent of the Legislature that the pharmacists 260
providers be reimbursed for the reasonable costs of filling and 261
dispensing prescriptions for Medicaid beneficiaries. 262
The division shall allow certain drugs, including 263
physician-administered drugs, and implantable drug system devices, 264
and medical supplies, with limited distribution or limited access 265
for beneficiaries and administered in an appropriate clinical 266
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 12 (RF\JAB)

setting, to be reimbursed as either a medical claim or pharmacy 267
claim, as determined by the division. 268
It is the intent of the Legislature that the division and any 269
managed care entity described in subsection (H) of this section 270
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 271
prevent recurrent preterm birth. 272
(10) Dental and orthodontic services to be determined 273
by the division. 274
The division shall increase the amount of the reimbursement 275
rate for diagnostic and preventative dental services for each of 276
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 277
the amount of the reimbursement rate for the previous fiscal year. 278
The division shall increase the amount of the reimbursement rate 279
for restorative dental services for each of the fiscal years 2023, 280
2024 and 2025 by five percent (5%) above the amount of the 281
reimbursement rate for the previous fiscal year. It is the intent 282
of the Legislature that the reimbursement rate revision for 283
preventative dental services will be an incentive to increase the 284
number of dentists who actively provide Medicaid services. This 285
dental services reimbursement rate revision shall be known as the 286
"James Russell Dumas Medicaid Dental Services Incentive Program." 287
The Medical Care Advisory Committee, assisted by the Division 288
of Medicaid, shall annually determine the effect of this incentive 289
by evaluating the number of dentists who are Medicaid providers, 290
the number who and the degree to which they are actively billing 291
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 13 (RF\JAB)

Medicaid, the geographic trends of where dentists are offering 292
what types of Medicaid services and other statistics pertinent to 293
the goals of this legislative intent. This data shall annually be 294
presented to the Chair of the Senate Medicaid Committee and the 295
Chair of the House Medicaid Committee. 296
The division shall include dental services as a necessary 297
component of overall health services provided to children who are 298
eligible for services. 299
(11) Eyeglasses for all Medicaid beneficiaries who have 300
(a) had surgery on the eyeball or ocular muscle that results in a 301
vision change for which eyeglasses or a change in eyeglasses is 302
medically indicated within six (6) months of the surgery and is in 303
accordance with policies established by the division, or (b) one 304
(1) pair every five (5) years and in accordance with policies 305
established by the division. In either instance, the eyeglasses 306
must be prescribed by a physician skilled in diseases of the eye 307
or an optometrist, whichever the beneficiary may select. 308
(12) Intermediate care facility services. 309
(a) The division shall make full payment to all 310
intermediate care facilities for individuals with intellectual 311
disabilities for each day, not exceeding sixty-three (63) days per 312
year, that a patient is absent from the facility on home leave. 313
Payment may be made for the following home leave days in addition 314
to the sixty-three-day limitation: Christmas, the day before 315
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 14 (RF\JAB)

Christmas, the day after Christmas, Thanksgiving, the day before 316
Thanksgiving and the day after Thanksgiving. 317
(b) All state-owned intermediate care facilities 318
for individuals with intellectual disabilities shall be reimbursed 319
on a full reasonable cost basis. 320
(c) Effective January 1, 2015, the division shall 321
update the fair rental reimbursement system for intermediate care 322
facilities for individuals with intellectual disabilities. 323
(13) Family planning services, including drugs, 324
supplies and devices, when those services are under the 325
supervision of a physician or nurse practitioner. 326
(14) Clinic services. Preventive, diagnostic, 327
therapeutic, rehabilitative or palliative services that are 328
furnished by a facility that is not part of a hospital but is 329
organized and operated to provide medical care to outpatients. 330
Clinic services include, but are not limited to: 331
(a) Services provided by ambulatory surgical 332
centers (ASCs) as defined in Section 41-75-1(a); and 333
(b) Dialysis center services. 334
(15) Home- and community-based services for the elderly 335
and disabled, as provided under Title XIX of the federal Social 336
Security Act, as amended, under waivers, subject to the 337
availability of funds specifically appropriated for that purpose 338
by the Legislature. 339
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 15 (RF\JAB)

(16) Mental health services. Certain services provided 340
by a psychiatrist shall be reimbursed at up to one hundred percent 341
(100%) of the Medicare rate. Approved therapeutic and case 342
management services (a) provided by an approved regional mental 343
health/intellectual disability center established under Sections 344
41-19-31 through 41-19-39, or by another community mental health 345
service provider meeting the requirements of the Department of 346
Mental Health to be an approved mental health/intellectual 347
disability center if determined necessary by the Department of 348
Mental Health, using state funds that are provided in the 349
appropriation to the division to match federal funds, or (b) 350
provided by a facility that is certified by the State Department 351
of Mental Health to provide therapeutic and case management 352
services, to be reimbursed on a fee for service basis, or (c) 353
provided in the community by a facility or program operated by the 354
Department of Mental Health. Any such services provided by a 355
facility described in subparagraph (b) must have the prior 356
approval of the division to be reimbursable under this section. 357
(17) Durable medical equipment services and medical 358
supplies. Precertification of durable medical equipment and 359
medical supplies must be obtained as required by the division. 360
The Division of Medicaid may require durable medical equipment 361
providers to obtain a surety bond in the amount and to the 362
specifications as established by the Balanced Budget Act of 1997. 363
A maximum dollar amount of reimbursement for noninvasive 364
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 16 (RF\JAB)

ventilators or ventilation treatments properly ordered and being 365
used in an appropriate care setting shall not be set by any health 366
maintenance organization, coordinated care organization, 367
provider-sponsored health plan, or other organization paid for 368
services on a capitated basis by the division under any managed 369
care program or coordinated care program implemented by the 370
division under this section. Reimbursement by these organizations 371
to durable medical equipment suppliers for home use of noninvasive 372
and invasive ventilators shall be on a continuous monthly payment 373
basis for the duration of medical need throughout a patient's 374
valid prescription period. 375
(18) (a) Notwithstanding any other provision of this 376
section to the contrary, as provided in the Medicaid state plan 377
amendment or amendments as defined in Section 43-13-145(10), the 378
division shall make additional reimbursement to hospitals that 379
serve a disproportionate share of low-income patients and that 380
meet the federal requirements for those payments as provided in 381
Section 1923 of the federal Social Security Act and any applicable 382
regulations. It is the intent of the Legislature that the 383
division shall draw down all available federal funds allotted to 384
the state for disproportionate share hospitals. However, from and 385
after January 1, 1999, public hospitals participating in the 386
Medicaid disproportionate share program may be required to 387
participate in an intergovernmental transfer program as provided 388
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 17 (RF\JAB)

in Section 1903 of the federal Social Security Act and any 389
applicable regulations. 390
(b) (i) 1. The division may establish a Medicare 391
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 392
the federal Social Security Act and any applicable federal 393
regulations, or an allowable delivery system or provider payment 394
initiative authorized under 42 CFR 438.6(c), for hospitals, 395
nursing facilities and physicians employed or contracted by 396
hospitals. 397
2. The division shall establish a 398
Medicaid Supplemental Payment Program, as permitted by the federal 399
Social Security Act and a comparable allowable delivery system or 400
provider payment initiative authorized under 42 CFR 438.6(c), for 401
emergency ambulance transportation providers in accordance with 402
this subsection (A)(18)(b). 403
(ii) The division shall assess each hospital, 404
nursing facility, and emergency ambulance transportation provider 405
for the sole purpose of financing the state portion of the 406
Medicare Upper Payment Limits Program or other program(s) 407
authorized under this subsection (A)(18)(b). The hospital 408
assessment shall be as provided in Section 43-13-145(4)(a), and 409
the nursing facility and the emergency ambulance transportation 410
assessments, if established, shall be based on Medicaid 411
utilization or other appropriate method, as determined by the 412
division, consistent with federal regulations. The assessments 413
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 18 (RF\JAB)

will remain in effect as long as the state participates in the 414
Medicare Upper Payment Limits Program or other program(s) 415
authorized under this subsection (A)(18)(b). In addition to the 416
hospital assessment provided in Section 43-13-145(4)(a), hospitals 417
with physicians participating in the Medicare Upper Payment Limits 418
Program or other program(s) authorized under this subsection 419
(A)(18)(b) shall be required to participate in an 420
intergovernmental transfer or assessment, as determined by the 421
division, for the purpose of financing the state portion of the 422
physician UPL payments or other payment(s) authorized under this 423
subsection (A)(18)(b). 424
(iii) Subject to approval by the Centers for 425
Medicare and Medicaid Services (CMS) and the provisions of this 426
subsection (A)(18)(b), the division shall make additional 427
reimbursement to hospitals, nursing facilities, and emergency 428
ambulance transportation providers for the Medicare Upper Payment 429
Limits Program or other program(s) authorized under this 430
subsection (A)(18)(b), and, if the program is established for 431
physicians, shall make additional reimbursement for physicians, as 432
defined in Section 1902(a)(30) of the federal Social Security Act 433
and any applicable federal regulations, provided the assessment in 434
this subsection (A)(18)(b) is in effect. 435
(iv) Notwithstanding any other provision of 436
this article to the contrary, effective upon implementation of the 437
Mississippi Hospital Access Program (MHAP) provided in 438
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 19 (RF\JAB)

subparagraph (c)(i) below, the hospital portion of the inpatient 439
Upper Payment Limits Program shall transition into and be replaced 440
by the MHAP program. However, the division is authorized to 441
develop and implement an alternative fee-for-service Upper Payment 442
Limits model in accordance with federal laws and regulations if 443
necessary to preserve supplemental funding. Further, the 444
division, in consultation with the hospital industry shall develop 445
alternative models for distribution of medical claims and 446
supplemental payments for inpatient and outpatient hospital 447
services, and such models may include, but shall not be limited to 448
the following: increasing rates for inpatient and outpatient 449
services; creating a low-income utilization pool of funds to 450
reimburse hospitals for the costs of uncompensated care, charity 451
care and bad debts as permitted and approved pursuant to federal 452
regulations and the Centers for Medicare and Medicaid Services; 453
supplemental payments based upon Medicaid utilization, quality, 454
service lines and/or costs of providing such services to Medicaid 455
beneficiaries and to uninsured patients. The goals of such 456
payment models shall be to ensure access to inpatient and 457
outpatient care and to maximize any federal funds that are 458
available to reimburse hospitals for services provided. Any such 459
documents required to achieve the goals described in this 460
paragraph shall be submitted to the Centers for Medicare and 461
Medicaid Services, with a proposed effective date of July 1, 2019, 462
to the extent possible, but in no event shall the effective date 463
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 20 (RF\JAB)

of such payment models be later than July 1, 2020. The Chairmen 464
of the Senate and House Medicaid Committees shall be provided a 465
copy of the proposed payment model(s) prior to submission. 466
Effective July 1, 2018, and until such time as any payment 467
model(s) as described above become effective, the division, in 468
consultation with the hospital industry, is authorized to 469
implement a transitional program for inpatient and outpatient 470
payments and/or supplemental payments (including, but not limited 471
to, MHAP and directed payments), to redistribute available 472
supplemental funds among hospital providers, provided that when 473
compared to a hospital's prior year supplemental payments, 474
supplemental payments made pursuant to any such transitional 475
program shall not result in a decrease of more than five percent 476
(5%) and shall not increase by more than the amount needed to 477
maximize the distribution of the available funds. 478
(v) 1. To preserve and improve access to 479
ambulance transportation provider services, the division shall 480
seek CMS approval to make ambulance service access payments as set 481
forth in this subsection (A)(18)(b) for all covered emergency 482
ambulance services rendered on or after July 1, 2022, and shall 483
make such ambulance service access payments for all covered 484
services rendered on or after the effective date of CMS approval. 485
2. The division shall calculate the 486
ambulance service access payment amount as the balance of the 487
portion of the Medical Care Fund related to ambulance 488
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 21 (RF\JAB)

transportation service provider assessments plus any federal 489
matching funds earned on the balance, up to, but not to exceed, 490
the upper payment limit gap for all emergency ambulance service 491
providers. 492
3. a. Except for ambulance services 493
exempt from the assessment provided in this paragraph (18)(b), all 494
ambulance transportation service providers shall be eligible for 495
ambulance service access payments each state fiscal year as set 496
forth in this paragraph (18)(b). 497
b. In addition to any other funds 498
paid to ambulance transportation service providers for emergency 499
medical services provided to Medicaid beneficiaries, each eligible 500
ambulance transportation service provider shall receive ambulance 501
service access payments each state fiscal year equal to the 502
ambulance transportation service provider's upper payment limit 503
gap. Subject to approval by the Centers for Medicare and Medicaid 504
Services, ambulance service access payments shall be made no less 505
than on a quarterly basis. 506
c. As used in this paragraph 507
(18)(b)(v), the term "upper payment limit gap" means the 508
difference between the total amount that the ambulance 509
transportation service provider received from Medicaid and the 510
average amount that the ambulance transportation service provider 511
would have received from commercial insurers for those services 512
reimbursed by Medicaid. 513
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 22 (RF\JAB)

4. An ambulance service access payment 514
shall not be used to offset any other payment by the division for 515
emergency or nonemergency services to Medicaid beneficiaries. 516
(c) (i) Not later than December l, 2015, the 517
division shall, subject to approval by the Centers for Medicare 518
and Medicaid Services (CMS), establish, implement and operate a 519
Mississippi Hospital Access Program (MHAP) for the purpose of 520
protecting patient access to hospital care through hospital 521
inpatient reimbursement programs provided in this section designed 522
to maintain total hospital reimbursement for inpatient services 523
rendered by in-state hospitals and the out-of-state hospital that 524
is authorized by federal law to submit intergovernmental transfers 525
(IGTs) to the State of Mississippi and is classified as Level I 526
trauma center located in a county contiguous to the state line at 527
the maximum levels permissible under applicable federal statutes 528
and regulations, at which time the current inpatient Medicare 529
Upper Payment Limits (UPL) Program for hospital inpatient services 530
shall transition to the MHAP. 531
(ii) Subject to approval by the Centers for 532
Medicare and Medicaid Services (CMS), the MHAP shall provide 533
increased inpatient capitation (PMPM) payments to managed care 534
entities contracting with the division pursuant to subsection (H) 535
of this section to support availability of hospital services or 536
such other payments permissible under federal law necessary to 537
accomplish the intent of this subsection. 538
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 23 (RF\JAB)

(iii) The intent of this subparagraph (c) is 539
that effective for all inpatient hospital Medicaid services during 540
state fiscal year 2016, and so long as this provision shall remain 541
in effect hereafter, the division shall to the fullest extent 542
feasible replace the additional reimbursement for hospital 543
inpatient services under the inpatient Medicare Upper Payment 544
Limits (UPL) Program with additional reimbursement under the MHAP 545
and other payment programs for inpatient and/or outpatient 546
payments which may be developed under the authority of this 547
paragraph. 548
(iv) The division shall assess each hospital 549
as provided in Section 43-13-145(4)(a) for the purpose of 550
financing the state portion of the MHAP, supplemental payments and 551
such other purposes as specified in Section 43-13-145. The 552
assessment will remain in effect as long as the MHAP and 553
supplemental payments are in effect. 554
(19) (a) Perinatal risk management services. The 555
division shall promulgate regulations to be effective from and 556
after October 1, 1988, to establish a comprehensive perinatal 557
system for risk assessment of all pregnant and infant Medicaid 558
recipients and for management, education and follow-up for those 559
who are determined to be at risk. Services to be performed 560
include case management, nutrition assessment/counseling, 561
psychosocial assessment/counseling and health education. The 562
division shall contract with the State Department of Health to 563
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 24 (RF\JAB)

provide services within this paragraph (Perinatal High Risk 564
Management/Infant Services System (PHRM/ISS)). The State 565
Department of Health shall be reimbursed on a full reasonable cost 566
basis for services provided under this subparagraph (a). 567
(b) Early intervention system services. The 568
division shall cooperate with the State Department of Health, 569
acting as lead agency, in the development and implementation of a 570
statewide system of delivery of early intervention services, under 571
Part C of the Individuals with Disabilities Education Act (IDEA). 572
The State Department of Health shall certify annually in writing 573
to the executive director of the division the dollar amount of 574
state early intervention funds available that will be utilized as 575
a certified match for Medicaid matching funds. Those funds then 576
shall be used to provide expanded targeted case management 577
services for Medicaid eligible children with special needs who are 578
eligible for the state's early intervention system. 579
Qualifications for persons providing service coordination shall be 580
determined by the State Department of Health and the Division of 581
Medicaid. 582
(20) Home- and community-based services for physically 583
disabled approved services as allowed by a waiver from the United 584
States Department of Health and Human Services for home- and 585
community-based services for physically disabled people using 586
state funds that are provided from the appropriation to the State 587
Department of Rehabilitation Services and used to match federal 588
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 25 (RF\JAB)

funds under a cooperative agreement between the division and the 589
department, provided that funds for these services are 590
specifically appropriated to the Department of Rehabilitation 591
Services. 592
(21) Nurse practitioner services. Services furnished 593
by a registered nurse who is licensed and certified by the 594
Mississippi Board of Nursing as a nurse practitioner, including, 595
but not limited to, nurse anesthetists, nurse midwives, family 596
nurse practitioners, family planning nurse practitioners, 597
pediatric nurse practitioners, obstetrics-gynecology nurse 598
practitioners and neonatal nurse practitioners, under regulations 599
adopted by the division. Reimbursement for those services shall 600
not exceed ninety percent (90%) of the reimbursement rate for 601
comparable services rendered by a physician. The division may 602
provide for a reimbursement rate for nurse practitioner services 603
of up to one hundred percent (100%) of the reimbursement rate for 604
comparable services rendered by a physician for nurse practitioner 605
services that are provided after the normal working hours of the 606
nurse practitioner, as determined in accordance with regulations 607
of the division. 608
(22) Ambulatory services delivered in federally 609
qualified health centers, rural health centers and clinics of the 610
local health departments of the State Department of Health for 611
individuals eligible for Medicaid under this article based on 612
reasonable costs as determined by the division. Federally 613
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 26 (RF\JAB)

qualified health centers shall be reimbursed by the Medicaid 614
prospective payment system as approved by the Centers for Medicare 615
and Medicaid Services. The division shall recognize federally 616
qualified health centers (FQHCs), rural health clinics (RHCs) and 617
community mental health centers (CMHCs) as both an originating and 618
distant site provider for the purposes of telehealth 619
reimbursement. The division is further authorized and directed to 620
reimburse FQHCs, RHCs and CMHCs for both distant site and 621
originating site services when such services are appropriately 622
provided by the same organization. 623
(23) Inpatient psychiatric services. 624
(a) Inpatient psychiatric services to be 625
determined by the division for recipients under age twenty-one 626
(21) that are provided under the direction of a physician in an 627
inpatient program in a licensed acute care psychiatric facility or 628
in a licensed psychiatric residential treatment facility, before 629
the recipient reaches age twenty-one (21) or, if the recipient was 630
receiving the services immediately before he or she reached age 631
twenty-one (21), before the earlier of the date he or she no 632
longer requires the services or the date he or she reaches age 633
twenty-two (22), as provided by federal regulations. From and 634
after January 1, 2015, the division shall update the fair rental 635
reimbursement system for psychiatric residential treatment 636
facilities. Precertification of inpatient days and residential 637
treatment days must be obtained as required by the division. From 638
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 27 (RF\JAB)

and after July 1, 2009, all state-owned and state-operated 639
facilities that provide inpatient psychiatric services to persons 640
under age twenty-one (21) who are eligible for Medicaid 641
reimbursement shall be reimbursed for those services on a full 642
reasonable cost basis. 643
(b) The division may reimburse for services 644
provided by a licensed freestanding psychiatric hospital to 645
Medicaid recipients over the age of twenty-one (21) in a method 646
and manner consistent with the provisions of Section 43-13-117.5. 647
(24) [Deleted] 648
(25) [Deleted] 649
(26) Hospice care. As used in this paragraph, the term 650
"hospice care" means a coordinated program of active professional 651
medical attention within the home and outpatient and inpatient 652
care that treats the terminally ill patient and family as a unit, 653
employing a medically directed interdisciplinary team. The 654
program provides relief of severe pain or other physical symptoms 655
and supportive care to meet the special needs arising out of 656
physical, psychological, spiritual, social and economic stresses 657
that are experienced during the final stages of illness and during 658
dying and bereavement and meets the Medicare requirements for 659
participation as a hospice as provided in federal regulations. 660
(27) Group health plan premiums and cost-sharing if it 661
is cost-effective as defined by the United States Secretary of 662
Health and Human Services. 663
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 28 (RF\JAB)

(28) Other health insurance premiums that are 664
cost-effective as defined by the United States Secretary of Health 665
and Human Services. Medicare eligible must have Medicare Part B 666
before other insurance premiums can be paid. 667
(29) The Division of Medicaid may apply for a waiver 668
from the United States Department of Health and Human Services for 669
home- and community-based services for developmentally disabled 670
people using state funds that are provided from the appropriation 671
to the State Department of Mental Health and/or funds transferred 672
to the department by a political subdivision or instrumentality of 673
the state and used to match federal funds under a cooperative 674
agreement between the division and the department, provided that 675
funds for these services are specifically appropriated to the 676
Department of Mental Health and/or transferred to the department 677
by a political subdivision or instrumentality of the state. 678
(30) Pediatric skilled nursing services as determined 679
by the division and in a manner consistent with regulations 680
promulgated by the Mississippi State Department of Health. 681
(31) Targeted case management services for children 682
with special needs, under waivers from the United States 683
Department of Health and Human Services, using state funds that 684
are provided from the appropriation to the Mississippi Department 685
of Human Services and used to match federal funds under a 686
cooperative agreement between the division and the department. 687
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 29 (RF\JAB)

(32) Care and services provided in Christian Science 688
Sanatoria listed and certified by the Commission for Accreditation 689
of Christian Science Nursing Organizations/Facilities, Inc., 690
rendered in connection with treatment by prayer or spiritual means 691
to the extent that those services are subject to reimbursement 692
under Section 1903 of the federal Social Security Act. 693
(33) Podiatrist services. 694
(34) Assisted living services as provided through 695
home- and community-based services under Title XIX of the federal 696
Social Security Act, as amended, subject to the availability of 697
funds specifically appropriated for that purpose by the 698
Legislature. 699
(35) Services and activities authorized in Sections 700
43-27-101 and 43-27-103, using state funds that are provided from 701
the appropriation to the Mississippi Department of Human Services 702
and used to match federal funds under a cooperative agreement 703
between the division and the department. 704
(36) Nonemergency transportation services for 705
Medicaid-eligible persons as determined by the division. The PEER 706
Committee shall conduct a performance evaluation of the 707
nonemergency transportation program to evaluate the administration 708
of the program and the providers of transportation services to 709
determine the most cost-effective ways of providing nonemergency 710
transportation services to the patients served under the program. 711
The performance evaluation shall be completed and provided to the 712
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 30 (RF\JAB)

members of the Senate Medicaid Committee and the House Medicaid 713
Committee not later than January 1, 2019, and every two (2) years 714
thereafter. 715
(37) [Deleted] 716
(38) Chiropractic services. A chiropractor's manual 717
manipulation of the spine to correct a subluxation, if x-ray 718
demonstrates that a subluxation exists and if the subluxation has 719
resulted in a neuromusculoskeletal condition for which 720
manipulation is appropriate treatment, and related spinal x-rays 721
performed to document these conditions. Reimbursement for 722
chiropractic services shall not exceed Seven Hundred Dollars 723
($700.00) per year per beneficiary. 724
(39) Dually eligible Medicare/Medicaid beneficiaries. 725
The division shall pay the Medicare deductible and coinsurance 726
amounts for services available under Medicare, as determined by 727
the division. From and after July 1, 2009, the division shall 728
reimburse crossover claims for inpatient hospital services and 729
crossover claims covered under Medicare Part B in the same manner 730
that was in effect on January 1, 2008, unless specifically 731
authorized by the Legislature to change this method. 732
(40) [Deleted] 733
(41) Services provided by the State Department of 734
Rehabilitation Services for the care and rehabilitation of persons 735
with spinal cord injuries or traumatic brain injuries, as allowed 736
under waivers from the United States Department of Health and 737
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 31 (RF\JAB)

Human Services, using up to seventy-five percent (75%) of the 738
funds that are appropriated to the Department of Rehabilitation 739
Services from the Spinal Cord and Head Injury Trust Fund 740
established under Section 37-33-261 and used to match federal 741
funds under a cooperative agreement between the division and the 742
department. 743
(42) [Deleted] 744
(43) The division shall provide reimbursement, 745
according to a payment schedule developed by the division, for 746
smoking cessation medications for pregnant women during their 747
pregnancy and other Medicaid-eligible women who are of 748
child-bearing age. 749
(44) Nursing facility services for the severely 750
disabled. 751
(a) Severe disabilities include, but are not 752
limited to, spinal cord injuries, closed-head injuries and 753
ventilator-dependent patients. 754
(b) Those services must be provided in a long-term 755
care nursing facility dedicated to the care and treatment of 756
persons with severe disabilities. 757
(45) Physician assistant services. Services furnished 758
by a physician assistant who is licensed by the State Board of 759
Medical Licensure and is practicing with physician supervision 760
under regulations adopted by the board, under regulations adopted 761
by the division. Reimbursement for those services shall not 762
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 32 (RF\JAB)

exceed ninety percent (90%) of the reimbursement rate for 763
comparable services rendered by a physician. The division may 764
provide for a reimbursement rate for physician assistant services 765
of up to one hundred percent (100%) or the reimbursement rate for 766
comparable services rendered by a physician for physician 767
assistant services that are provided after the normal working 768
hours of the physician assistant, as determined in accordance with 769
regulations of the division. 770
(46) The division shall make application to the federal 771
Centers for Medicare and Medicaid Services (CMS) for a waiver to 772
develop and provide services for children with serious emotional 773
disturbances as defined in Section 43-14-1(1), which may include 774
home- and community-based services, case management services or 775
managed care services through mental health providers certified by 776
the Department of Mental Health. The division may implement and 777
provide services under this waivered program only if funds for 778
these services are specifically appropriated for this purpose by 779
the Legislature, or if funds are voluntarily provided by affected 780
agencies. 781
(47) (a) The division may develop and implement 782
disease management programs for individuals with high-cost chronic 783
diseases and conditions, including the use of grants, waivers, 784
demonstrations or other projects as necessary. 785
(b) Participation in any disease management 786
program implemented under this paragraph (47) is optional with the 787
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 33 (RF\JAB)

individual. An individual must affirmatively elect to participate 788
in the disease management program in order to participate, and may 789
elect to discontinue participation in the program at any time. 790
(48) Pediatric long-term acute care hospital services. 791
(a) Pediatric long-term acute care hospital 792
services means services provided to eligible persons under 793
twenty-one (21) years of age by a freestanding Medicare-certified 794
hospital that has an average length of inpatient stay greater than 795
twenty-five (25) days and that is primarily engaged in providing 796
chronic or long-term medical care to persons under twenty-one (21) 797
years of age. 798
(b) The services under this paragraph (48) shall 799
be reimbursed as a separate category of hospital services. 800
(49) The division may establish copayments and/or 801
coinsurance for any Medicaid services for which copayments and/or 802
coinsurance are allowable under federal law or regulation. 803
(50) Services provided by the State Department of 804
Rehabilitation Services for the care and rehabilitation of persons 805
who are deaf and blind, as allowed under waivers from the United 806
States Department of Health and Human Services to provide home- 807
and community-based services using state funds that are provided 808
from the appropriation to the State Department of Rehabilitation 809
Services or if funds are voluntarily provided by another agency. 810
(51) Upon determination of Medicaid eligibility and in 811
association with annual redetermination of Medicaid eligibility, 812
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 34 (RF\JAB)

beneficiaries shall be encouraged to undertake a physical 813
examination that will establish a base-line level of health and 814
identification of a usual and customary source of care (a medical 815
home) to aid utilization of disease management tools. This 816
physical examination and utilization of these disease management 817
tools shall be consistent with current United States Preventive 818
Services Task Force or other recognized authority recommendations. 819
For persons who are determined ineligible for Medicaid, the 820
division will provide information and direction for accessing 821
medical care and services in the area of their residence. 822
(52) Notwithstanding any provisions of this article, 823
the division may pay enhanced reimbursement fees related to trauma 824
care, as determined by the division in conjunction with the State 825
Department of Health, using funds appropriated to the State 826
Department of Health for trauma care and services and used to 827
match federal funds under a cooperative agreement between the 828
division and the State Department of Health. The division, in 829
conjunction with the State Department of Health, may use grants, 830
waivers, demonstrations, enhanced reimbursements, Upper Payment 831
Limits Programs, supplemental payments, or other projects as 832
necessary in the development and implementation of this 833
reimbursement program. 834
(53) Targeted case management services for high-cost 835
beneficiaries may be developed by the division for all services 836
under this section. 837
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 35 (RF\JAB)

(54) [Deleted] 838
(55) Therapy services. The plan of care for therapy 839
services may be developed to cover a period of treatment for up to 840
six (6) months, but in no event shall the plan of care exceed a 841
six-month period of treatment. The projected period of treatment 842
must be indicated on the initial plan of care and must be updated 843
with each subsequent revised plan of care. Based on medical 844
necessity, the division shall approve certification periods for 845
less than or up to six (6) months, but in no event shall the 846
certification period exceed the period of treatment indicated on 847
the plan of care. The appeal process for any reduction in therapy 848
services shall be consistent with the appeal process in federal 849
regulations. 850
(56) Prescribed pediatric extended care centers 851
services for medically dependent or technologically dependent 852
children with complex medical conditions that require continual 853
care as prescribed by the child's attending physician, as 854
determined by the division. 855
(57) No Medicaid benefit shall restrict coverage for 856
medically appropriate treatment prescribed by a physician and 857
agreed to by a fully informed individual, or if the individual 858
lacks legal capacity to consent by a person who has legal 859
authority to consent on his or her behalf, based on an 860
individual's diagnosis with a terminal condition. As used in this 861
paragraph (57), "terminal condition" means any aggressive 862
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 36 (RF\JAB)

malignancy, chronic end-stage cardiovascular or cerebral vascular 863
disease, or any other disease, illness or condition which a 864
physician diagnoses as terminal. 865
(58) Treatment services for persons with opioid 866
dependency or other highly addictive substance use disorders. The 867
division is authorized to reimburse eligible providers for 868
treatment of opioid dependency and other highly addictive 869
substance use disorders, as determined by the division. Treatment 870
related to these conditions shall not count against any physician 871
visit limit imposed under this section. 872
(59) The division shall allow beneficiaries between the 873
ages of ten (10) and eighteen (18) years to receive vaccines 874
through a pharmacy venue. The division and the State Department 875
of Health shall coordinate and notify OB-GYN providers that the 876
Vaccines for Children program is available to providers free of 877
charge. 878
(60) Border city university-affiliated pediatric 879
teaching hospital. 880
(a) Payments may only be made to a border city 881
university-affiliated pediatric teaching hospital if the Centers 882
for Medicare and Medicaid Services (CMS) approve an increase in 883
the annual request for the provider payment initiative authorized 884
under 42 CFR Section 438.6(c) in an amount equal to or greater 885
than the estimated annual payment to be made to the border city 886
university-affiliated pediatric teaching hospital. The estimate 887
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 37 (RF\JAB)

shall be based on the hospital's prior year Mississippi managed 888
care utilization. 889
(b) As used in this paragraph (60), the term 890
"border city university-affiliated pediatric teaching hospital" 891
means an out-of-state hospital located within a city bordering the 892
eastern bank of the Mississippi River and the State of Mississippi 893
that submits to the division a copy of a current and effective 894
affiliation agreement with an accredited university and other 895
documentation establishing that the hospital is 896
university-affiliated, is licensed and designated as a pediatric 897
hospital or pediatric primary hospital within its home state, 898
maintains at least five (5) different pediatric specialty training 899
programs, and maintains at least one hundred (100) operated beds 900
dedicated exclusively for the treatment of patients under the age 901
of twenty-one (21) years. 902
(c) The cost of providing services to Mississippi 903
Medicaid beneficiaries under the age of twenty-one (21) years who 904
are treated by a border city university-affiliated pediatric 905
teaching hospital shall not exceed the cost of providing the same 906
services to individuals in hospitals in the state. 907
(d) It is the intent of the Legislature that 908
payments shall not result in any in-state hospital receiving 909
payments lower than they would otherwise receive if not for the 910
payments made to any border city university-affiliated pediatric 911
teaching hospital. 912
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 38 (RF\JAB)

(e) This paragraph (60) shall stand repealed on 913
July 1, 2024. 914
(61) Services described in Section 41-140-3 that are 915
provided by certified community health workers employed and 916
supervised by a Medicaid provider. Reimbursement for these 917
services shall be provided only if the division has received 918
approval from the Centers for Medicare and Medicaid Services for a 919
state plan amendment, waiver or alternative payment model for 920
services delivered by certified community health workers. 921
(B) Planning and development districts participating in the 922
home- and community-based services program for the elderly and 923
disabled as case management providers shall be reimbursed for case 924
management services at the maximum rate approved by the Centers 925
for Medicare and Medicaid Services (CMS). 926
(C) The division may pay to those providers who participate 927
in and accept patient referrals from the division's emergency room 928
redirection program a percentage, as determined by the division, 929
of savings achieved according to the performance measures and 930
reduction of costs required of that program. Federally qualified 931
health centers may participate in the emergency room redirection 932
program, and the division may pay those centers a percentage of 933
any savings to the Medicaid program achieved by the centers' 934
accepting patient referrals through the program, as provided in 935
this subsection (C). 936
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 39 (RF\JAB)

(D) (1) As used in this subsection (D), the following terms 937
shall be defined as provided in this paragraph, except as 938
otherwise provided in this subsection: 939
(a) "Committees" means the Medicaid Committees of 940
the House of Representatives and the Senate, and "committee" means 941
either one of those committees. 942
(b) "Rate change" means an increase, decrease or 943
other change in the payments or rates of reimbursement, or a 944
change in any payment methodology that results in an increase, 945
decrease or other change in the payments or rates of 946
reimbursement, to any Medicaid provider that renders any services 947
authorized to be provided to Medicaid recipients under this 948
article. 949
(2) Whenever the Division of Medicaid proposes a rate 950
change, the division shall give notice to the chairmen of the 951
committees at least thirty (30) calendar days before the proposed 952
rate change is scheduled to take effect. The division shall 953
furnish the chairmen with a concise summary of each proposed rate 954
change along with the notice, and shall furnish the chairmen with 955
a copy of any proposed rate change upon request. The division 956
also shall provide a summary and copy of any proposed rate change 957
to any other member of the Legislature upon request. 958
(3) If the chairman of either committee or both 959
chairmen jointly object to the proposed rate change or any part 960
thereof, the chairman or chairmen shall notify the division and 961
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 40 (RF\JAB)

provide the reasons for their objection in writing not later than 962
seven (7) calendar days after receipt of the notice from the 963
division. The chairman or chairmen may make written 964
recommendations to the division for changes to be made to a 965
proposed rate change. 966
(4) (a) The chairman of either committee or both 967
chairmen jointly may hold a committee meeting to review a proposed 968
rate change. If either chairman or both chairmen decide to hold a 969
meeting, they shall notify the division of their intention in 970
writing within seven (7) calendar days after receipt of the notice 971
from the division, and shall set the date and time for the meeting 972
in their notice to the division, which shall not be later than 973
fourteen (14) calendar days after receipt of the notice from the 974
division. 975
(b) After the committee meeting, the committee or 976
committees may object to the proposed rate change or any part 977
thereof. The committee or committees shall notify the division 978
and the reasons for their objection in writing not later than 979
seven (7) calendar days after the meeting. The committee or 980
committees may make written recommendations to the division for 981
changes to be made to a proposed rate change. 982
(5) If both chairmen notify the division in writing 983
within seven (7) calendar days after receipt of the notice from 984
the division that they do not object to the proposed rate change 985
and will not be holding a meeting to review the proposed rate 986
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 41 (RF\JAB)

change, the proposed rate change will take effect on the original 987
date as scheduled by the division or on such other date as 988
specified by the division. 989
(6) (a) If there are any objections to a proposed rate 990
change or any part thereof from either or both of the chairmen or 991
the committees, the division may withdraw the proposed rate 992
change, make any of the recommended changes to the proposed rate 993
change, or not make any changes to the proposed rate change. 994
(b) If the division does not make any changes to 995
the proposed rate change, it shall notify the chairmen of that 996
fact in writing, and the proposed rate change shall take effect on 997
the original date as scheduled by the division or on such other 998
date as specified by the division. 999
(c) If the division makes any changes to the 1000
proposed rate change, the division shall notify the chairmen of 1001
its actions in writing, and the revised proposed rate change shall 1002
take effect on the date as specified by the division. 1003
(7) Nothing in this subsection (D) shall be construed 1004
as giving the chairmen or the committees any authority to veto, 1005
nullify or revise any rate change proposed by the division. The 1006
authority of the chairmen or the committees under this subsection 1007
shall be limited to reviewing, making objections to and making 1008
recommendations for changes to rate changes proposed by the 1009
division. 1010
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 42 (RF\JAB)

(E) Notwithstanding any provision of this article, no new 1011
groups or categories of recipients and new types of care and 1012
services may be added without enabling legislation from the 1013
Mississippi Legislature, except that the division may authorize 1014
those changes without enabling legislation when the addition of 1015
recipients or services is ordered by a court of proper authority. 1016
(F) The executive director shall keep the Governor advised 1017
on a timely basis of the funds available for expenditure and the 1018
projected expenditures. Notwithstanding any other provisions of 1019
this article, if current or projected expenditures of the division 1020
are reasonably anticipated to exceed the amount of funds 1021
appropriated to the division for any fiscal year, the Governor, 1022
after consultation with the executive director, shall take all 1023
appropriate measures to reduce costs, which may include, but are 1024
not limited to: 1025
(1) Reducing or discontinuing any or all services that 1026
are deemed to be optional under Title XIX of the Social Security 1027
Act; 1028
(2) Reducing reimbursement rates for any or all service 1029
types; 1030
(3) Imposing additional assessments on health care 1031
providers; or 1032
(4) Any additional cost-containment measures deemed 1033
appropriate by the Governor. 1034
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 43 (RF\JAB)

To the extent allowed under federal law, any reduction to 1035
services or reimbursement rates under this subsection (F) shall be 1036
accompanied by a reduction, to the fullest allowable amount, to 1037
the profit margin and administrative fee portions of capitated 1038
payments to organizations described in paragraph (1) of subsection 1039
(H). 1040
Beginning in fiscal year 2010 and in fiscal years thereafter, 1041
when Medicaid expenditures are projected to exceed funds available 1042
for the fiscal year, the division shall submit the expected 1043
shortfall information to the PEER Committee not later than 1044
December 1 of the year in which the shortfall is projected to 1045
occur. PEER shall review the computations of the division and 1046
report its findings to the Legislative Budget Office not later 1047
than January 7 in any year. 1048
(G) Notwithstanding any other provision of this article, it 1049
shall be the duty of each provider participating in the Medicaid 1050
program to keep and maintain books, documents and other records as 1051
prescribed by the Division of Medicaid in accordance with federal 1052
laws and regulations. 1053
(H) (1) Notwithstanding any other provision of this 1054
article, the division is authorized to implement (a) a managed 1055
care program, (b) a coordinated care program, (c) a coordinated 1056
care organization program, (d) a health maintenance organization 1057
program, (e) a patient-centered medical home program, (f) an 1058
accountable care organization program, (g) provider-sponsored 1059
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 44 (RF\JAB)

health plan, or (h) any combination of the above programs. As a 1060
condition for the approval of any program under this subsection 1061
(H)(1), the division shall require that no managed care program, 1062
coordinated care program, coordinated care organization program, 1063
health maintenance organization program, or provider-sponsored 1064
health plan may: 1065
(a) Pay providers at a rate that is less than the 1066
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1067
reimbursement rate; 1068
(b) Override the medical decisions of hospital 1069
physicians or staff regarding patients admitted to a hospital for 1070
an emergency medical condition as defined by 42 US Code Section 1071
1395dd. This restriction (b) does not prohibit the retrospective 1072
review of the appropriateness of the determination that an 1073
emergency medical condition exists by chart review or coding 1074
algorithm, nor does it prohibit prior authorization for 1075
nonemergency hospital admissions; 1076
(c) Pay providers at a rate that is less than the 1077
normal Medicaid reimbursement rate. It is the intent of the 1078
Legislature that all managed care entities described in this 1079
subsection (H), in collaboration with the division, develop and 1080
implement innovative payment models that incentivize improvements 1081
in health care quality, outcomes, or value, as determined by the 1082
division. Participation in the provider network of any managed 1083
care, coordinated care, provider-sponsored health plan, or similar 1084
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 45 (RF\JAB)

contractor shall not be conditioned on the provider's agreement to 1085
accept such alternative payment models; 1086
(d) Implement a prior authorization and 1087
utilization review program for medical services, transportation 1088
services and prescription drugs that is more stringent than the 1089
prior authorization processes used by the division in its 1090
administration of the Medicaid program. Not later than December 1091
2, 2021, the contractors that are receiving capitated payments 1092
under a managed care delivery system established under this 1093
subsection (H) shall submit a report to the Chairmen of the House 1094
and Senate Medicaid Committees on the status of the prior 1095
authorization and utilization review program for medical services, 1096
transportation services and prescription drugs that is required to 1097
be implemented under this subparagraph (d); 1098
(e) [Deleted] 1099
(f) Implement a preferred drug list that is more 1100
stringent than the mandatory preferred drug list established by 1101
the division under subsection (A)(9) of this section; 1102
(g) Implement a policy which denies beneficiaries 1103
with hemophilia access to the federally funded hemophilia 1104
treatment centers as part of the Medicaid Managed Care network of 1105
providers. 1106
Each health maintenance organization, coordinated care 1107
organization, provider-sponsored health plan, or other 1108
organization paid for services on a capitated basis by the 1109
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 46 (RF\JAB)

division under any managed care program or coordinated care 1110
program implemented by the division under this section shall use a 1111
clear set of level of care guidelines in the determination of 1112
medical necessity and in all utilization management practices, 1113
including the prior authorization process, concurrent reviews, 1114
retrospective reviews and payments, that are consistent with 1115
widely accepted professional standards of care. Organizations 1116
participating in a managed care program or coordinated care 1117
program implemented by the division may not use any additional 1118
criteria that would result in denial of care that would be 1119
determined appropriate and, therefore, medically necessary under 1120
those levels of care guidelines. 1121
(2) Notwithstanding any provision of this section, the 1122
recipients eligible for enrollment into a Medicaid Managed Care 1123
Program authorized under this subsection (H) may include only 1124
those categories of recipients eligible for participation in the 1125
Medicaid Managed Care Program as of January 1, 2021, the 1126
Children's Health Insurance Program (CHIP), and the CMS-approved 1127
Section 1115 demonstration waivers in operation as of January 1, 1128
2021. No expansion of Medicaid Managed Care Program contracts may 1129
be implemented by the division without enabling legislation from 1130
the Mississippi Legislature. 1131
(3) (a) Any contractors receiving capitated payments 1132
under a managed care delivery system established in this section 1133
shall provide to the Legislature and the division statistical data 1134
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 47 (RF\JAB)

to be shared with provider groups in order to improve patient 1135
access, appropriate utilization, cost savings and health outcomes 1136
not later than October 1 of each year. Additionally, each 1137
contractor shall disclose to the Chairmen of the Senate and House 1138
Medicaid Committees the administrative expenses costs for the 1139
prior calendar year, and the number of full-equivalent employees 1140
located in the State of Mississippi dedicated to the Medicaid and 1141
CHIP lines of business as of June 30 of the current year. 1142
(b) The division and the contractors participating 1143
in the managed care program, a coordinated care program or a 1144
provider-sponsored health plan shall be subject to annual program 1145
reviews or audits performed by the Office of the State Auditor, 1146
the PEER Committee, the Department of Insurance and/or independent 1147
third parties. 1148
(c) Those reviews shall include, but not be 1149
limited to, at least two (2) of the following items: 1150
(i) The financial benefit to the State of 1151
Mississippi of the managed care program, 1152
(ii) The difference between the premiums paid 1153
to the managed care contractors and the payments made by those 1154
contractors to health care providers, 1155
(iii) Compliance with performance measures 1156
required under the contracts, 1157
(iv) Administrative expense allocation 1158
methodologies, 1159
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 48 (RF\JAB)

(v) Whether nonprovider payments assigned as 1160
medical expenses are appropriate, 1161
(vi) Capitated arrangements with related 1162
party subcontractors, 1163
(vii) Reasonableness of corporate 1164
allocations, 1165
(viii) Value-added benefits and the extent to 1166
which they are used, 1167
(ix) The effectiveness of subcontractor 1168
oversight, including subcontractor review, 1169
(x) Whether health care outcomes have been 1170
improved, and 1171
(xi) The most common claim denial codes to 1172
determine the reasons for the denials. 1173
The audit reports shall be considered public documents and 1174
shall be posted in their entirety on the division's website. 1175
(4) All health maintenance organizations, coordinated 1176
care organizations, provider-sponsored health plans, or other 1177
organizations paid for services on a capitated basis by the 1178
division under any managed care program or coordinated care 1179
program implemented by the division under this section shall 1180
reimburse all providers in those organizations at rates no lower 1181
than those provided under this section for beneficiaries who are 1182
not participating in those programs. 1183
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 49 (RF\JAB)

(5) No health maintenance organization, coordinated 1184
care organization, provider-sponsored health plan, or other 1185
organization paid for services on a capitated basis by the 1186
division under any managed care program or coordinated care 1187
program implemented by the division under this section shall 1188
require its providers or beneficiaries to use any pharmacy that 1189
ships, mails or delivers prescription drugs or legend drugs or 1190
devices. 1191
(6) (a) Not later than December 1, 2021, the 1192
contractors who are receiving capitated payments under a managed 1193
care delivery system established under this subsection (H) shall 1194
develop and implement a uniform credentialing process for 1195
providers. Under that uniform credentialing process, a provider 1196
who meets the criteria for credentialing will be credentialed with 1197
all of those contractors and no such provider will have to be 1198
separately credentialed by any individual contractor in order to 1199
receive reimbursement from the contractor. Not later than 1200
December 2, 2021, those contractors shall submit a report to the 1201
Chairmen of the House and Senate Medicaid Committees on the status 1202
of the uniform credentialing process for providers that is 1203
required under this subparagraph (a). 1204
(b) If those contractors have not implemented a 1205
uniform credentialing process as described in subparagraph (a) by 1206
December 1, 2021, the division shall develop and implement, not 1207
later than July 1, 2022, a single, consolidated credentialing 1208
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 50 (RF\JAB)

process by which all providers will be credentialed. Under the 1209
division's single, consolidated credentialing process, no such 1210
contractor shall require its providers to be separately 1211
credentialed by the contractor in order to receive reimbursement 1212
from the contractor, but those contractors shall recognize the 1213
credentialing of the providers by the division's credentialing 1214
process. 1215
(c) The division shall require a uniform provider 1216
credentialing application that shall be used in the credentialing 1217
process that is established under subparagraph (a) or (b). If the 1218
contractor or division, as applicable, has not approved or denied 1219
the provider credentialing application within sixty (60) days of 1220
receipt of the completed application that includes all required 1221
information necessary for credentialing, then the contractor or 1222
division, upon receipt of a written request from the applicant and 1223
within five (5) business days of its receipt, shall issue a 1224
temporary provider credential/enrollment to the applicant if the 1225
applicant has a valid Mississippi professional or occupational 1226
license to provide the health care services to which the 1227
credential/enrollment would apply. The contractor or the division 1228
shall not issue a temporary credential/enrollment if the applicant 1229
has reported on the application a history of medical or other 1230
professional or occupational malpractice claims, a history of 1231
substance abuse or mental health issues, a criminal record, or a 1232
history of medical or other licensing board, state or federal 1233
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 51 (RF\JAB)

disciplinary action, including any suspension from participation 1234
in a federal or state program. The temporary 1235
credential/enrollment shall be effective upon issuance and shall 1236
remain in effect until the provider's credentialing/enrollment 1237
application is approved or denied by the contractor or division. 1238
The contractor or division shall render a final decision regarding 1239
credentialing/enrollment of the provider within sixty (60) days 1240
from the date that the temporary provider credential/enrollment is 1241
issued to the applicant. 1242
(d) If the contractor or division does not render 1243
a final decision regarding credentialing/enrollment of the 1244
provider within the time required in subparagraph (c), the 1245
provider shall be deemed to be credentialed by and enrolled with 1246
all of the contractors and eligible to receive reimbursement from 1247
the contractors. 1248
(7) (a) Each contractor that is receiving capitated 1249
payments under a managed care delivery system established under 1250
this subsection (H) shall provide to each provider for whom the 1251
contractor has denied the coverage of a procedure that was ordered 1252
or requested by the provider for or on behalf of a patient, a 1253
letter that provides a detailed explanation of the reasons for the 1254
denial of coverage of the procedure and the name and the 1255
credentials of the person who denied the coverage. The letter 1256
shall be sent to the provider in electronic format. 1257
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 52 (RF\JAB)

(b) After a contractor that is receiving capitated 1258
payments under a managed care delivery system established under 1259
this subsection (H) has denied coverage for a claim submitted by a 1260
provider, the contractor shall issue to the provider within sixty 1261
(60) days a final ruling of denial of the claim that allows the 1262
provider to have a state fair hearing and/or agency appeal with 1263
the division. If a contractor does not issue a final ruling of 1264
denial within sixty (60) days as required by this subparagraph 1265
(b), the provider's claim shall be deemed to be automatically 1266
approved and the contractor shall pay the amount of the claim to 1267
the provider. 1268
(c) After a contractor has issued a final ruling 1269
of denial of a claim submitted by a provider, the division shall 1270
conduct a state fair hearing and/or agency appeal on the matter of 1271
the disputed claim between the contractor and the provider within 1272
sixty (60) days, and shall render a decision on the matter within 1273
thirty (30) days after the date of the hearing and/or appeal. 1274
(8) It is the intention of the Legislature that the 1275
division evaluate the feasibility of using a single vendor to 1276
administer pharmacy benefits provided under a managed care 1277
delivery system established under this subsection (H). Providers 1278
of pharmacy benefits shall cooperate with the division in any 1279
transition to a carve-out of pharmacy benefits under managed care. 1280
(9) The division shall evaluate the feasibility of 1281
using a single vendor to administer dental benefits provided under 1282
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 53 (RF\JAB)

a managed care delivery system established in this subsection (H). 1283
Providers of dental benefits shall cooperate with the division in 1284
any transition to a carve-out of dental benefits under managed 1285
care. 1286
(10) It is the intent of the Legislature that any 1287
contractor receiving capitated payments under a managed care 1288
delivery system established in this section shall implement 1289
innovative programs to improve the health and well-being of 1290
members diagnosed with prediabetes and diabetes. 1291
(11) It is the intent of the Legislature that any 1292
contractors receiving capitated payments under a managed care 1293
delivery system established under this subsection (H) shall work 1294
with providers of Medicaid services to improve the utilization of 1295
long-acting reversible contraceptives (LARCs). Not later than 1296
December 1, 2021, any contractors receiving capitated payments 1297
under a managed care delivery system established under this 1298
subsection (H) shall provide to the Chairmen of the House and 1299
Senate Medicaid Committees and House and Senate Public Health 1300
Committees a report of LARC utilization for State Fiscal Years 1301
2018 through 2020 as well as any programs, initiatives, or efforts 1302
made by the contractors and providers to increase LARC 1303
utilization. This report shall be updated annually to include 1304
information for subsequent state fiscal years. 1305
(12) The division is authorized to make not more than 1306
one (1) emergency extension of the contracts that are in effect on 1307
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 54 (RF\JAB)

July 1, 2021, with contractors who are receiving capitated 1308
payments under a managed care delivery system established under 1309
this subsection (H), as provided in this paragraph (12). The 1310
maximum period of any such extension shall be one (1) year, and 1311
under any such extensions, the contractors shall be subject to all 1312
of the provisions of this subsection (H). The extended contracts 1313
shall be revised to incorporate any provisions of this subsection 1314
(H). 1315
(I) [Deleted] 1316
(J) There shall be no cuts in inpatient and outpatient 1317
hospital payments, or allowable days or volumes, as long as the 1318
hospital assessment provided in Section 43-13-145 is in effect. 1319
This subsection (J) shall not apply to decreases in payments that 1320
are a result of: reduced hospital admissions, audits or payments 1321
under the APR-DRG or APC models, or a managed care program or 1322
similar model described in subsection (H) of this section. 1323
(K) In the negotiation and execution of such contracts 1324
involving services performed by actuarial firms, the Executive 1325
Director of the Division of Medicaid may negotiate a limitation on 1326
liability to the state of prospective contractors. 1327
(L) The Division of Medicaid shall reimburse for services 1328
provided to eligible Medicaid beneficiaries by a licensed birthing 1329
center in a method and manner to be determined by the division in 1330
accordance with federal laws and federal regulations. The 1331
division shall seek any necessary waivers, make any required 1332
H. B. No. 152 *HR31/R616* ~ OFFICIAL ~
26/HR31/R616
PAGE 55 (RF\JAB)
ST: Medicaid; provide increased reimbursement
rate for hospitals in counties with high
unemployment and doctor shortage.
amendments to its State Plan or revise any contracts authorized 1333
under subsection (H) of this section as necessary to provide the 1334
services authorized under this subsection. As used in this 1335
subsection, the term "birthing centers" shall have the meaning as 1336
defined in Section 41-77-1(a), which is a publicly or privately 1337
owned facility, place or institution constructed, renovated, 1338
leased or otherwise established where nonemergency births are 1339
planned to occur away from the mother's usual residence following 1340
a documented period of prenatal care for a normal uncomplicated 1341
pregnancy which has been determined to be low risk through a 1342
formal risk-scoring examination. 1343
(M) This section shall stand repealed on July 1, 2028. 1344
SECTION 2. This act shall take effect and be in force from 1345
and after July 1, 2026. 1346