Medicaid eligibility; provide coverage of the Program of All-Inclusive Care for the Elderly.

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Scott

HOUSE BILL NO. 179

AN ACT TO AMEND SECTION 43-13-115, MISSISSIPPI CODE OF 1972, 1
TO PROVIDE MEDICAID COVERAGE FOR INDIVIDUALS WHO ARE 55 YEARS OF 2
AGE OR OLDER, ARE DETERMINED TO NEED THE LEVEL OF CARE REQUIRED 3
FOR COVERAGE OF NURSING FACILITY SERVICES, RESIDE IN THE SERVICE 4
AREA OF THE PACE ORGANIZATION, AND MEET ANY ADDITIONAL 5
PROGRAM-SPECIFIC ELIGIBILITY CONDITIONS IMPOSED BY THE DIVISION OF 6
MEDICAID; TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, TO 7
CONFORM TO THE PREVIOUS SECTION; AND FOR RELATED PURPOSES. 8
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 9
SECTION 1. Section 43-13-115, Mississippi Code of 1972, is 10
amended as follows: 11
43-13-115. Recipients of Medicaid shall be the following 12
persons only: 13
(1) Those who are qualified for public assistance 14
grants under provisions of Title IV-A and E of the federal Social 15
Security Act, as amended, including those statutorily deemed to be 16
IV-A and low income families and children under Section 1931 of 17
the federal Social Security Act. For the purposes of this 18
paragraph (1) and paragraphs (8), (17) and (18) of this section, 19
any reference to Title IV-A or to Part A of Title IV of the 20
federal Social Security Act, as amended, or the state plan under 21
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Title IV-A or Part A of Title IV, shall be considered as a 22
reference to Title IV-A of the federal Social Security Act, as 23
amended, and the state plan under Title IV-A, including the income 24
and resource standards and methodologies under Title IV-A and the 25
state plan, as they existed on July 16, 1996. The Department of 26
Human Services shall determine Medicaid eligibility for children 27
receiving public assistance grants under Title IV-E. The division 28
shall determine eligibility for low income families under Section 29
1931 of the federal Social Security Act and shall redetermine 30
eligibility for those continuing under Title IV-A grants. 31
(2) Those qualified for Supplemental Security Income 32
(SSI) benefits under Title XVI of the federal Social Security Act, 33
as amended, and those who are deemed SSI eligible as contained in 34
federal statute. The eligibility of individuals covered in this 35
paragraph shall be determined by the Social Security 36
Administration and certified to the Division of Medicaid. 37
(3) Qualified pregnant women who would be eligible for 38
Medicaid as a low income family member under Section 1931 of the 39
federal Social Security Act if her child were born. The 40
eligibility of the individuals covered under this paragraph shall 41
be determined by the division. 42
(4) [Deleted] 43
(5) A child born on or after October 1, 1984, to a 44
woman eligible for and receiving Medicaid under the state plan on 45
the date of the child's birth shall be deemed to have applied for 46
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Medicaid and to have been found eligible for Medicaid under the 47
plan on the date of that birth, and will remain eligible for 48
Medicaid for a period of one (1) year so long as the child is a 49
member of the woman's household and the woman remains eligible for 50
Medicaid or would be eligible for Medicaid if pregnant. The 51
eligibility of individuals covered in this paragraph shall be 52
determined by the Division of Medicaid. 53
(6) Children certified by the State Department of Human 54
Services to the Division of Medicaid of whom the state and county 55
departments of human services have custody and financial 56
responsibility, and children who are in adoptions subsidized in 57
full or part by the Department of Human Services, including 58
special needs children in non-Title IV-E adoption assistance, who 59
are approvable under Title XIX of the Medicaid program. The 60
eligibility of the children covered under this paragraph shall be 61
determined by the State Department of Human Services. 62
(7) Persons certified by the Division of Medicaid who 63
are patients in a medical facility (nursing home, hospital, 64
tuberculosis sanatorium or institution for treatment of mental 65
diseases), and who, except for the fact that they are patients in 66
that medical facility, would qualify for grants under Title IV, 67
Supplementary Security Income (SSI) benefits under Title XVI or 68
state supplements, and those aged, blind and disabled persons who 69
would not be eligible for Supplemental Security Income (SSI) 70
benefits under Title XVI or state supplements if they were not 71
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institutionalized in a medical facility but whose income is below 72
the maximum standard set by the Division of Medicaid, which 73
standard shall not exceed that prescribed by federal regulation. 74
(8) Children under eighteen (18) years of age and 75
pregnant women (including those in intact families) who meet the 76
financial standards of the state plan approved under Title IV-A of 77
the federal Social Security Act, as amended. The eligibility of 78
children covered under this paragraph shall be determined by the 79
Division of Medicaid. 80
(9) Individuals who are: 81
(a) Children born after September 30, 1983, who 82
have not attained the age of nineteen (19), with family income 83
that does not exceed one hundred percent (100%) of the nonfarm 84
official poverty level; 85
(b) Pregnant women, infants and children who have 86
not attained the age of six (6), with family income that does not 87
exceed one hundred thirty-three percent (133%) of the federal 88
poverty level; and 89
(c) Pregnant women and infants who have not 90
attained the age of one (1), with family income that does not 91
exceed one hundred eighty-five percent (185%) of the federal 92
poverty level. 93
The eligibility of individuals covered in (a), (b) and (c) of 94
this paragraph shall be determined by the division. 95
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(10) Certain disabled children age eighteen (18) or 96
under who are living at home, who would be eligible, if in a 97
medical institution, for SSI or a state supplemental payment under 98
Title XVI of the federal Social Security Act, as amended, and 99
therefore for Medicaid under the plan, and for whom the state has 100
made a determination as required under Section 1902(e)(3)(b) of 101
the federal Social Security Act, as amended. The eligibility of 102
individuals under this paragraph shall be determined by the 103
Division of Medicaid. 104
(11) Until the end of the day on December 31, 2005, 105
individuals who are sixty-five (65) years of age or older or are 106
disabled as determined under Section 1614(a)(3) of the federal 107
Social Security Act, as amended, and whose income does not exceed 108
one hundred thirty-five percent (135%) of the nonfarm official 109
poverty level as defined by the Office of Management and Budget 110
and revised annually, and whose resources do not exceed those 111
established by the Division of Medicaid. The eligibility of 112
individuals covered under this paragraph shall be determined by 113
the Division of Medicaid. After December 31, 2005, only those 114
individuals covered under the 1115(c) Healthier Mississippi waiver 115
will be covered under this category. 116
Any individual who applied for Medicaid during the period 117
from July 1, 2004, through March 31, 2005, who otherwise would 118
have been eligible for coverage under this paragraph (11) if it 119
had been in effect at the time the individual submitted his or her 120
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application and is still eligible for coverage under this 121
paragraph (11) on March 31, 2005, shall be eligible for Medicaid 122
coverage under this paragraph (11) from March 31, 2005, through 123
December 31, 2005. The division shall give priority in processing 124
the applications for those individuals to determine their 125
eligibility under this paragraph (11). 126
(12) Individuals who are qualified Medicare 127
beneficiaries (QMB) entitled to Part A Medicare as defined under 128
Section 301, Public Law 100-360, known as the Medicare 129
Catastrophic Coverage Act of 1988, and whose income does not 130
exceed one hundred percent (100%) of the nonfarm official poverty 131
level as defined by the Office of Management and Budget and 132
revised annually. 133
The eligibility of individuals covered under this paragraph 134
shall be determined by the Division of Medicaid, and those 135
individuals determined eligible shall receive Medicare 136
cost-sharing expenses only as more fully defined by the Medicare 137
Catastrophic Coverage Act of 1988 and the Balanced Budget Act of 138
1997. 139
(13) (a) Individuals who are entitled to Medicare Part 140
A as defined in Section 4501 of the Omnibus Budget Reconciliation 141
Act of 1990, and whose income does not exceed one hundred twenty 142
percent (120%) of the nonfarm official poverty level as defined by 143
the Office of Management and Budget and revised annually. 144
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Eligibility for Medicaid benefits is limited to full payment of 145
Medicare Part B premiums. 146
(b) Individuals entitled to Part A of Medicare, 147
with income above one hundred twenty percent (120%), but less than 148
one hundred thirty-five percent (135%) of the federal poverty 149
level, and not otherwise eligible for Medicaid. Eligibility for 150
Medicaid benefits is limited to full payment of Medicare Part B 151
premiums. The number of eligible individuals is limited by the 152
availability of the federal capped allocation at one hundred 153
percent (100%) of federal matching funds, as more fully defined in 154
the Balanced Budget Act of 1997. 155
The eligibility of individuals covered under this paragraph 156
shall be determined by the Division of Medicaid. 157
(14) [Deleted] 158
(15) Disabled workers who are eligible to enroll in 159
Part A Medicare as required by Public Law 101-239, known as the 160
Omnibus Budget Reconciliation Act of 1989, and whose income does 161
not exceed two hundred percent (200%) of the federal poverty level 162
as determined in accordance with the Supplemental Security Income 163
(SSI) program. The eligibility of individuals covered under this 164
paragraph shall be determined by the Division of Medicaid and 165
those individuals shall be entitled to buy-in coverage of Medicare 166
Part A premiums only under the provisions of this paragraph (15). 167
(16) In accordance with the terms and conditions of 168
approved Title XIX waiver from the United States Department of 169
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Health and Human Services, persons provided home- and 170
community-based services who are physically disabled and certified 171
by the Division of Medicaid as eligible due to applying the income 172
and deeming requirements as if they were institutionalized. 173
(17) In accordance with the terms of the federal 174
Personal Responsibility and Work Opportunity Reconciliation Act of 175
1996 (Public Law 104-193), persons who become ineligible for 176
assistance under Title IV-A of the federal Social Security Act, as 177
amended, because of increased income from or hours of employment 178
of the caretaker relative or because of the expiration of the 179
applicable earned income disregards, who were eligible for 180
Medicaid for at least three (3) of the six (6) months preceding 181
the month in which the ineligibility begins, shall be eligible for 182
Medicaid for up to twelve (12) months. The eligibility of the 183
individuals covered under this paragraph shall be determined by 184
the division. 185
(18) Persons who become ineligible for assistance under 186
Title IV-A of the federal Social Security Act, as amended, as a 187
result, in whole or in part, of the collection or increased 188
collection of child or spousal support under Title IV-D of the 189
federal Social Security Act, as amended, who were eligible for 190
Medicaid for at least three (3) of the six (6) months immediately 191
preceding the month in which the ineligibility begins, shall be 192
eligible for Medicaid for an additional four (4) months beginning 193
with the month in which the ineligibility begins. The eligibility 194
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of the individuals covered under this paragraph shall be 195
determined by the division. 196
(19) Disabled workers, whose incomes are above the 197
Medicaid eligibility limits, but below two hundred fifty percent 198
(250%) of the federal poverty level, shall be allowed to purchase 199
Medicaid coverage on a sliding fee scale developed by the Division 200
of Medicaid. 201
(20) Medicaid eligible children under age eighteen (18) 202
shall remain eligible for Medicaid benefits until the end of a 203
period of twelve (12) months following an eligibility 204
determination, or until such time that the individual exceeds age 205
eighteen (18). 206
(21) Women of childbearing age whose family income does 207
not exceed one hundred eighty-five percent (185%) of the federal 208
poverty level. The eligibility of individuals covered under this 209
paragraph (21) shall be determined by the Division of Medicaid, 210
and those individuals determined eligible shall only receive 211
family planning services covered under Section 43-13-117(13) and 212
not any other services covered under Medicaid. However, any 213
individual eligible under this paragraph (21) who is also eligible 214
under any other provision of this section shall receive the 215
benefits to which he or she is entitled under that other 216
provision, in addition to family planning services covered under 217
Section 43-13-117(13). 218
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The Division of Medicaid shall apply to the United States 219
Secretary of Health and Human Services for a federal waiver of the 220
applicable provisions of Title XIX of the federal Social Security 221
Act, as amended, and any other applicable provisions of federal 222
law as necessary to allow for the implementation of this paragraph 223
(21). The provisions of this paragraph (21) shall be implemented 224
from and after the date that the Division of Medicaid receives the 225
federal waiver. 226
(22) Persons who are workers with a potentially severe 227
disability, as determined by the division, shall be allowed to 228
purchase Medicaid coverage. The term "worker with a potentially 229
severe disability" means a person who is at least sixteen (16) 230
years of age but under sixty-five (65) years of age, who has a 231
physical or mental impairment that is reasonably expected to cause 232
the person to become blind or disabled as defined under Section 233
1614(a) of the federal Social Security Act, as amended, if the 234
person does not receive items and services provided under 235
Medicaid. 236
The eligibility of persons under this paragraph (22) shall be 237
conducted as a demonstration project that is consistent with 238
Section 204 of the Ticket to Work and Work Incentives Improvement 239
Act of 1999, Public Law 106-170, for a certain number of persons 240
as specified by the division. The eligibility of individuals 241
covered under this paragraph (22) shall be determined by the 242
Division of Medicaid. 243
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(23) Children certified by the Mississippi Department 244
of Human Services for whom the state and county departments of 245
human services have custody and financial responsibility who are 246
in foster care on their eighteenth birthday as reported by the 247
Mississippi Department of Human Services shall be certified 248
Medicaid eligible by the Division of Medicaid until their 249
twenty-first birthday. 250
(24) Individuals who have not attained age sixty-five 251
(65), are not otherwise covered by creditable coverage as defined 252
in the Public Health Services Act, and have been screened for 253
breast and cervical cancer under the Centers for Disease Control 254
and Prevention Breast and Cervical Cancer Early Detection Program 255
established under Title XV of the Public Health Service Act in 256
accordance with the requirements of that act and who need 257
treatment for breast or cervical cancer. Eligibility of 258
individuals under this paragraph (24) shall be determined by the 259
Division of Medicaid. 260
(25) The division shall apply to the Centers for 261
Medicare and Medicaid Services (CMS) for any necessary waivers to 262
provide services to individuals who are sixty-five (65) years of 263
age or older or are disabled as determined under Section 264
1614(a)(3) of the federal Social Security Act, as amended, and 265
whose income does not exceed one hundred thirty-five percent 266
(135%) of the nonfarm official poverty level as defined by the 267
Office of Management and Budget and revised annually, and whose 268
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resources do not exceed those established by the Division of 269
Medicaid, and who are not otherwise covered by Medicare. Nothing 270
contained in this paragraph (25) shall entitle an individual to 271
benefits. The eligibility of individuals covered under this 272
paragraph shall be determined by the Division of Medicaid. 273
(26) The division shall apply to the Centers for 274
Medicare and Medicaid Services (CMS) for any necessary waivers to 275
provide services to individuals who are sixty-five (65) years of 276
age or older or are disabled as determined under Section 277
1614(a)(3) of the federal Social Security Act, as amended, who are 278
end stage renal disease patients on dialysis, cancer patients on 279
chemotherapy or organ transplant recipients on antirejection 280
drugs, whose income does not exceed one hundred thirty-five 281
percent (135%) of the nonfarm official poverty level as defined by 282
the Office of Management and Budget and revised annually, and 283
whose resources do not exceed those established by the division. 284
Nothing contained in this paragraph (26) shall entitle an 285
individual to benefits. The eligibility of individuals covered 286
under this paragraph shall be determined by the Division of 287
Medicaid. 288
(27) Individuals who are entitled to Medicare Part D 289
and whose income does not exceed one hundred fifty percent (150%) 290
of the nonfarm official poverty level as defined by the Office of 291
Management and Budget and revised annually. Eligibility for 292
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payment of the Medicare Part D subsidy under this paragraph shall 293
be determined by the division. 294
(28) The division is authorized and directed to provide 295
up to twelve (12) months of continuous coverage postpartum for any 296
individual who qualifies for Medicaid coverage under this section 297
as a pregnant woman, to the extent allowable under federal law and 298
as determined by the division. 299
(29) Individuals who are age fifty-five (55) years of 300
age or older, are determined to need the level of care required 301
for coverage of nursing facility services, reside in the service 302
area of the Program of All-Inclusive Care for the Elderly (PACE) 303
organization, and meet any additional program-specific eligibility 304
conditions imposed by the Division of Medicaid. 305
The division shall redetermine eligibility for all categories 306
of recipients described in each paragraph of this section not less 307
frequently than required by federal law. 308
SECTION 2. Section 43-13-117, Mississippi Code of 1972, is 309
amended as follows: 310
43-13-117. (A) Medicaid as authorized by this article shall 311
include payment of part or all of the costs, at the discretion of 312
the division, with approval of the Governor and the Centers for 313
Medicare and Medicaid Services, of the following types of care and 314
services rendered to eligible applicants who have been determined 315
to be eligible for that care and services, within the limits of 316
state appropriations and federal matching funds: 317
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(1) Inpatient hospital services. 318
(a) The division is authorized to implement an All 319
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 320
methodology for inpatient hospital services. 321
(b) No service benefits or reimbursement 322
limitations in this subsection (A)(1) shall apply to payments 323
under an APR-DRG or Ambulatory Payment Classification (APC) model 324
or a managed care program or similar model described in subsection 325
(H) of this section unless specifically authorized by the 326
division. 327
(2) Outpatient hospital services. 328
(a) Emergency services. 329
(b) Other outpatient hospital services. The 330
division shall allow benefits for other medically necessary 331
outpatient hospital services (such as chemotherapy, radiation, 332
surgery and therapy), including outpatient services in a clinic or 333
other facility that is not located inside the hospital, but that 334
has been designated as an outpatient facility by the hospital, and 335
that was in operation or under construction on July 1, 2009, 336
provided that the costs and charges associated with the operation 337
of the hospital clinic are included in the hospital's cost report. 338
In addition, the Medicare thirty-five-mile rule will apply to 339
those hospital clinics not located inside the hospital that are 340
constructed after July 1, 2009. Where the same services are 341
reimbursed as clinic services, the division may revise the rate or 342
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methodology of outpatient reimbursement to maintain consistency, 343
efficiency, economy and quality of care. 344
(c) The division is authorized to implement an 345
Ambulatory Payment Classification (APC) methodology for outpatient 346
hospital services. The division shall give rural hospitals that 347
have fifty (50) or fewer licensed beds the option to not be 348
reimbursed for outpatient hospital services using the APC 349
methodology, but reimbursement for outpatient hospital services 350
provided by those hospitals shall be based on one hundred one 351
percent (101%) of the rate established under Medicare for 352
outpatient hospital services. Those hospitals choosing to not be 353
reimbursed under the APC methodology shall remain under cost-based 354
reimbursement for a two-year period. 355
(d) No service benefits or reimbursement 356
limitations in this subsection (A)(2) shall apply to payments 357
under an APR-DRG or APC model or a managed care program or similar 358
model described in subsection (H) of this section unless 359
specifically authorized by the division. 360
(3) Laboratory and x-ray services. 361
(4) Nursing facility services. 362
(a) The division shall make full payment to 363
nursing facilities for each day, not exceeding forty-two (42) days 364
per year, that a patient is absent from the facility on home 365
leave. Payment may be made for the following home leave days in 366
addition to the forty-two-day limitation: Christmas, the day 367
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before Christmas, the day after Christmas, Thanksgiving, the day 368
before Thanksgiving and the day after Thanksgiving. 369
(b) From and after July 1, 1997, the division 370
shall implement the integrated case-mix payment and quality 371
monitoring system, which includes the fair rental system for 372
property costs and in which recapture of depreciation is 373
eliminated. The division may reduce the payment for hospital 374
leave and therapeutic home leave days to the lower of the case-mix 375
category as computed for the resident on leave using the 376
assessment being utilized for payment at that point in time, or a 377
case-mix score of 1.000 for nursing facilities, and shall compute 378
case-mix scores of residents so that only services provided at the 379
nursing facility are considered in calculating a facility's per 380
diem. 381
(c) From and after July 1, 1997, all state-owned 382
nursing facilities shall be reimbursed on a full reasonable cost 383
basis. 384
(d) On or after January 1, 2015, the division 385
shall update the case-mix payment system resource utilization 386
grouper and classifications and fair rental reimbursement system. 387
The division shall develop and implement a payment add-on to 388
reimburse nursing facilities for ventilator-dependent resident 389
services. 390
(e) The division shall develop and implement, not 391
later than January 1, 2001, a case-mix payment add-on determined 392
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by time studies and other valid statistical data that will 393
reimburse a nursing facility for the additional cost of caring for 394
a resident who has a diagnosis of Alzheimer's or other related 395
dementia and exhibits symptoms that require special care. Any 396
such case-mix add-on payment shall be supported by a determination 397
of additional cost. The division shall also develop and implement 398
as part of the fair rental reimbursement system for nursing 399
facility beds, an Alzheimer's resident bed depreciation enhanced 400
reimbursement system that will provide an incentive to encourage 401
nursing facilities to convert or construct beds for residents with 402
Alzheimer's or other related dementia. 403
(f) The division shall develop and implement an 404
assessment process for long-term care services. The division may 405
provide the assessment and related functions directly or through 406
contract with the area agencies on aging. 407
The division shall apply for necessary federal waivers to 408
assure that additional services providing alternatives to nursing 409
facility care are made available to applicants for nursing 410
facility care. 411
(5) Periodic screening and diagnostic services for 412
individuals under age twenty-one (21) years as are needed to 413
identify physical and mental defects and to provide health care 414
treatment and other measures designed to correct or ameliorate 415
defects and physical and mental illness and conditions discovered 416
by the screening services, regardless of whether these services 417
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are included in the state plan. The division may include in its 418
periodic screening and diagnostic program those discretionary 419
services authorized under the federal regulations adopted to 420
implement Title XIX of the federal Social Security Act, as 421
amended. The division, in obtaining physical therapy services, 422
occupational therapy services, and services for individuals with 423
speech, hearing and language disorders, may enter into a 424
cooperative agreement with the State Department of Education for 425
the provision of those services to handicapped students by public 426
school districts using state funds that are provided from the 427
appropriation to the Department of Education to obtain federal 428
matching funds through the division. The division, in obtaining 429
medical and mental health assessments, treatment, care and 430
services for children who are in, or at risk of being put in, the 431
custody of the Mississippi Department of Human Services may enter 432
into a cooperative agreement with the Mississippi Department of 433
Human Services for the provision of those services using state 434
funds that are provided from the appropriation to the Department 435
of Human Services to obtain federal matching funds through the 436
division. 437
(6) Physician services. Fees for physician's services 438
that are covered only by Medicaid shall be reimbursed at ninety 439
percent (90%) of the rate established on January 1, 2018, and as 440
may be adjusted each July thereafter, under Medicare. The 441
division may provide for a reimbursement rate for physician's 442
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services of up to one hundred percent (100%) of the rate 443
established under Medicare for physician's services that are 444
provided after the normal working hours of the physician, as 445
determined in accordance with regulations of the division. The 446
division may reimburse eligible providers, as determined by the 447
division, for certain primary care services at one hundred percent 448
(100%) of the rate established under Medicare. The division shall 449
reimburse obstetricians and gynecologists for certain primary care 450
services as defined by the division at one hundred percent (100%) 451
of the rate established under Medicare. 452
(7) (a) Home health services for eligible persons, not 453
to exceed in cost the prevailing cost of nursing facility 454
services. All home health visits must be precertified as required 455
by the division. In addition to physicians, certified registered 456
nurse practitioners, physician assistants and clinical nurse 457
specialists are authorized to prescribe or order home health 458
services and plans of care, sign home health plans of care, 459
certify and recertify eligibility for home health services and 460
conduct the required initial face-to-face visit with the recipient 461
of the services. 462
(b) [Repealed] 463
(8) Emergency medical transportation services as 464
determined by the division. 465
(9) Prescription drugs and other covered drugs and 466
services as determined by the division. 467
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The division shall establish a mandatory preferred drug list. 468
Drugs not on the mandatory preferred drug list shall be made 469
available by utilizing prior authorization procedures established 470
by the division. 471
The division may seek to establish relationships with other 472
states in order to lower acquisition costs of prescription drugs 473
to include single-source and innovator multiple-source drugs or 474
generic drugs. In addition, if allowed by federal law or 475
regulation, the division may seek to establish relationships with 476
and negotiate with other countries to facilitate the acquisition 477
of prescription drugs to include single-source and innovator 478
multiple-source drugs or generic drugs, if that will lower the 479
acquisition costs of those prescription drugs. 480
The division may allow for a combination of prescriptions for 481
single-source and innovator multiple-source drugs and generic 482
drugs to meet the needs of the beneficiaries. 483
The executive director may approve specific maintenance drugs 484
for beneficiaries with certain medical conditions, which may be 485
prescribed and dispensed in three-month supply increments. 486
Drugs prescribed for a resident of a psychiatric residential 487
treatment facility must be provided in true unit doses when 488
available. The division may require that drugs not covered by 489
Medicare Part D for a resident of a long-term care facility be 490
provided in true unit doses when available. Those drugs that were 491
originally billed to the division but are not used by a resident 492
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in any of those facilities shall be returned to the billing 493
pharmacy for credit to the division, in accordance with the 494
guidelines of the State Board of Pharmacy and any requirements of 495
federal law and regulation. Drugs shall be dispensed to a 496
recipient and only one (1) dispensing fee per month may be 497
charged. The division shall develop a methodology for reimbursing 498
for restocked drugs, which shall include a restock fee as 499
determined by the division not exceeding Seven Dollars and 500
Eighty-two Cents ($7.82). 501
Except for those specific maintenance drugs approved by the 502
executive director, the division shall not reimburse for any 503
portion of a prescription that exceeds a thirty-one-day supply of 504
the drug based on the daily dosage. 505
The division is authorized to develop and implement a program 506
of payment for additional pharmacist services as determined by the 507
division. 508
All claims for drugs for dually eligible Medicare/Medicaid 509
beneficiaries that are paid for by Medicare must be submitted to 510
Medicare for payment before they may be processed by the 511
division's online payment system. 512
The division shall develop a pharmacy policy in which drugs 513
in tamper-resistant packaging that are prescribed for a resident 514
of a nursing facility but are not dispensed to the resident shall 515
be returned to the pharmacy and not billed to Medicaid, in 516
accordance with guidelines of the State Board of Pharmacy. 517
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The division shall develop and implement a method or methods 518
by which the division will provide on a regular basis to Medicaid 519
providers who are authorized to prescribe drugs, information about 520
the costs to the Medicaid program of single-source drugs and 521
innovator multiple-source drugs, and information about other drugs 522
that may be prescribed as alternatives to those single-source 523
drugs and innovator multiple-source drugs and the costs to the 524
Medicaid program of those alternative drugs. 525
Notwithstanding any law or regulation, information obtained 526
or maintained by the division regarding the prescription drug 527
program, including trade secrets and manufacturer or labeler 528
pricing, is confidential and not subject to disclosure except to 529
other state agencies. 530
The dispensing fee for each new or refill prescription, 531
including nonlegend or over-the-counter drugs covered by the 532
division, shall be not less than Three Dollars and Ninety-one 533
Cents ($3.91), as determined by the division. 534
The division shall not reimburse for single-source or 535
innovator multiple-source drugs if there are equally effective 536
generic equivalents available and if the generic equivalents are 537
the least expensive. 538
It is the intent of the Legislature that the pharmacists 539
providers be reimbursed for the reasonable costs of filling and 540
dispensing prescriptions for Medicaid beneficiaries. 541
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The division shall allow certain drugs, including 542
physician-administered drugs, and implantable drug system devices, 543
and medical supplies, with limited distribution or limited access 544
for beneficiaries and administered in an appropriate clinical 545
setting, to be reimbursed as either a medical claim or pharmacy 546
claim, as determined by the division. 547
It is the intent of the Legislature that the division and any 548
managed care entity described in subsection (H) of this section 549
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 550
prevent recurrent preterm birth. 551
(10) Dental and orthodontic services to be determined 552
by the division. 553
The division shall increase the amount of the reimbursement 554
rate for diagnostic and preventative dental services for each of 555
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 556
the amount of the reimbursement rate for the previous fiscal year. 557
The division shall increase the amount of the reimbursement rate 558
for restorative dental services for each of the fiscal years 2023, 559
2024 and 2025 by five percent (5%) above the amount of the 560
reimbursement rate for the previous fiscal year. It is the intent 561
of the Legislature that the reimbursement rate revision for 562
preventative dental services will be an incentive to increase the 563
number of dentists who actively provide Medicaid services. This 564
dental services reimbursement rate revision shall be known as the 565
"James Russell Dumas Medicaid Dental Services Incentive Program." 566
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The Medical Care Advisory Committee, assisted by the Division 567
of Medicaid, shall annually determine the effect of this incentive 568
by evaluating the number of dentists who are Medicaid providers, 569
the number who and the degree to which they are actively billing 570
Medicaid, the geographic trends of where dentists are offering 571
what types of Medicaid services and other statistics pertinent to 572
the goals of this legislative intent. This data shall annually be 573
presented to the Chair of the Senate Medicaid Committee and the 574
Chair of the House Medicaid Committee. 575
The division shall include dental services as a necessary 576
component of overall health services provided to children who are 577
eligible for services. 578
(11) Eyeglasses for all Medicaid beneficiaries who have 579
(a) had surgery on the eyeball or ocular muscle that results in a 580
vision change for which eyeglasses or a change in eyeglasses is 581
medically indicated within six (6) months of the surgery and is in 582
accordance with policies established by the division, or (b) one 583
(1) pair every five (5) years and in accordance with policies 584
established by the division. In either instance, the eyeglasses 585
must be prescribed by a physician skilled in diseases of the eye 586
or an optometrist, whichever the beneficiary may select. 587
(12) Intermediate care facility services. 588
(a) The division shall make full payment to all 589
intermediate care facilities for individuals with intellectual 590
disabilities for each day, not exceeding sixty-three (63) days per 591
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year, that a patient is absent from the facility on home leave. 592
Payment may be made for the following home leave days in addition 593
to the sixty-three-day limitation: Christmas, the day before 594
Christmas, the day after Christmas, Thanksgiving, the day before 595
Thanksgiving and the day after Thanksgiving. 596
(b) All state-owned intermediate care facilities 597
for individuals with intellectual disabilities shall be reimbursed 598
on a full reasonable cost basis. 599
(c) Effective January 1, 2015, the division shall 600
update the fair rental reimbursement system for intermediate care 601
facilities for individuals with intellectual disabilities. 602
(13) Family planning services, including drugs, 603
supplies and devices, when those services are under the 604
supervision of a physician or nurse practitioner. 605
(14) Clinic services. Preventive, diagnostic, 606
therapeutic, rehabilitative or palliative services that are 607
furnished by a facility that is not part of a hospital but is 608
organized and operated to provide medical care to outpatients. 609
Clinic services include, but are not limited to: 610
(a) Services provided by ambulatory surgical 611
centers (ASCs) as defined in Section 41-75-1(a); and 612
(b) Dialysis center services. 613
(15) Home- and community-based services for the elderly 614
and disabled, as provided under Title XIX of the federal Social 615
Security Act, as amended, under waivers, subject to the 616
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availability of funds specifically appropriated for that purpose 617
by the Legislature. 618
(16) Mental health services. Certain services provided 619
by a psychiatrist shall be reimbursed at up to one hundred percent 620
(100%) of the Medicare rate. Approved therapeutic and case 621
management services (a) provided by an approved regional mental 622
health/intellectual disability center established under Sections 623
41-19-31 through 41-19-39, or by another community mental health 624
service provider meeting the requirements of the Department of 625
Mental Health to be an approved mental health/intellectual 626
disability center if determined necessary by the Department of 627
Mental Health, using state funds that are provided in the 628
appropriation to the division to match federal funds, or (b) 629
provided by a facility that is certified by the State Department 630
of Mental Health to provide therapeutic and case management 631
services, to be reimbursed on a fee for service basis, or (c) 632
provided in the community by a facility or program operated by the 633
Department of Mental Health. Any such services provided by a 634
facility described in subparagraph (b) must have the prior 635
approval of the division to be reimbursable under this section. 636
(17) Durable medical equipment services and medical 637
supplies. Precertification of durable medical equipment and 638
medical supplies must be obtained as required by the division. 639
The Division of Medicaid may require durable medical equipment 640
providers to obtain a surety bond in the amount and to the 641
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specifications as established by the Balanced Budget Act of 1997. 642
A maximum dollar amount of reimbursement for noninvasive 643
ventilators or ventilation treatments properly ordered and being 644
used in an appropriate care setting shall not be set by any health 645
maintenance organization, coordinated care organization, 646
provider-sponsored health plan, or other organization paid for 647
services on a capitated basis by the division under any managed 648
care program or coordinated care program implemented by the 649
division under this section. Reimbursement by these organizations 650
to durable medical equipment suppliers for home use of noninvasive 651
and invasive ventilators shall be on a continuous monthly payment 652
basis for the duration of medical need throughout a patient's 653
valid prescription period. 654
(18) (a) Notwithstanding any other provision of this 655
section to the contrary, as provided in the Medicaid state plan 656
amendment or amendments as defined in Section 43-13-145(10), the 657
division shall make additional reimbursement to hospitals that 658
serve a disproportionate share of low-income patients and that 659
meet the federal requirements for those payments as provided in 660
Section 1923 of the federal Social Security Act and any applicable 661
regulations. It is the intent of the Legislature that the 662
division shall draw down all available federal funds allotted to 663
the state for disproportionate share hospitals. However, from and 664
after January 1, 1999, public hospitals participating in the 665
Medicaid disproportionate share program may be required to 666
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participate in an intergovernmental transfer program as provided 667
in Section 1903 of the federal Social Security Act and any 668
applicable regulations. 669
(b) (i) 1. The division may establish a Medicare 670
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 671
the federal Social Security Act and any applicable federal 672
regulations, or an allowable delivery system or provider payment 673
initiative authorized under 42 CFR 438.6(c), for hospitals, 674
nursing facilities and physicians employed or contracted by 675
hospitals. 676
2. The division shall establish a 677
Medicaid Supplemental Payment Program, as permitted by the federal 678
Social Security Act and a comparable allowable delivery system or 679
provider payment initiative authorized under 42 CFR 438.6(c), for 680
emergency ambulance transportation providers in accordance with 681
this subsection (A)(18)(b). 682
(ii) The division shall assess each hospital, 683
nursing facility, and emergency ambulance transportation provider 684
for the sole purpose of financing the state portion of the 685
Medicare Upper Payment Limits Program or other program(s) 686
authorized under this subsection (A)(18)(b). The hospital 687
assessment shall be as provided in Section 43-13-145(4)(a), and 688
the nursing facility and the emergency ambulance transportation 689
assessments, if established, shall be based on Medicaid 690
utilization or other appropriate method, as determined by the 691
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division, consistent with federal regulations. The assessments 692
will remain in effect as long as the state participates in the 693
Medicare Upper Payment Limits Program or other program(s) 694
authorized under this subsection (A)(18)(b). In addition to the 695
hospital assessment provided in Section 43-13-145(4)(a), hospitals 696
with physicians participating in the Medicare Upper Payment Limits 697
Program or other program(s) authorized under this subsection 698
(A)(18)(b) shall be required to participate in an 699
intergovernmental transfer or assessment, as determined by the 700
division, for the purpose of financing the state portion of the 701
physician UPL payments or other payment(s) authorized under this 702
subsection (A)(18)(b). 703
(iii) Subject to approval by the Centers for 704
Medicare and Medicaid Services (CMS) and the provisions of this 705
subsection (A)(18)(b), the division shall make additional 706
reimbursement to hospitals, nursing facilities, and emergency 707
ambulance transportation providers for the Medicare Upper Payment 708
Limits Program or other program(s) authorized under this 709
subsection (A)(18)(b), and, if the program is established for 710
physicians, shall make additional reimbursement for physicians, as 711
defined in Section 1902(a)(30) of the federal Social Security Act 712
and any applicable federal regulations, provided the assessment in 713
this subsection (A)(18)(b) is in effect. 714
(iv) Notwithstanding any other provision of 715
this article to the contrary, effective upon implementation of the 716
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Mississippi Hospital Access Program (MHAP) provided in 717
subparagraph (c)(i) below, the hospital portion of the inpatient 718
Upper Payment Limits Program shall transition into and be replaced 719
by the MHAP program. However, the division is authorized to 720
develop and implement an alternative fee-for-service Upper Payment 721
Limits model in accordance with federal laws and regulations if 722
necessary to preserve supplemental funding. Further, the 723
division, in consultation with the hospital industry shall develop 724
alternative models for distribution of medical claims and 725
supplemental payments for inpatient and outpatient hospital 726
services, and such models may include, but shall not be limited to 727
the following: increasing rates for inpatient and outpatient 728
services; creating a low-income utilization pool of funds to 729
reimburse hospitals for the costs of uncompensated care, charity 730
care and bad debts as permitted and approved pursuant to federal 731
regulations and the Centers for Medicare and Medicaid Services; 732
supplemental payments based upon Medicaid utilization, quality, 733
service lines and/or costs of providing such services to Medicaid 734
beneficiaries and to uninsured patients. The goals of such 735
payment models shall be to ensure access to inpatient and 736
outpatient care and to maximize any federal funds that are 737
available to reimburse hospitals for services provided. Any such 738
documents required to achieve the goals described in this 739
paragraph shall be submitted to the Centers for Medicare and 740
Medicaid Services, with a proposed effective date of July 1, 2019, 741
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to the extent possible, but in no event shall the effective date 742
of such payment models be later than July 1, 2020. The Chairmen 743
of the Senate and House Medicaid Committees shall be provided a 744
copy of the proposed payment model(s) prior to submission. 745
Effective July 1, 2018, and until such time as any payment 746
model(s) as described above become effective, the division, in 747
consultation with the hospital industry, is authorized to 748
implement a transitional program for inpatient and outpatient 749
payments and/or supplemental payments (including, but not limited 750
to, MHAP and directed payments), to redistribute available 751
supplemental funds among hospital providers, provided that when 752
compared to a hospital's prior year supplemental payments, 753
supplemental payments made pursuant to any such transitional 754
program shall not result in a decrease of more than five percent 755
(5%) and shall not increase by more than the amount needed to 756
maximize the distribution of the available funds. 757
(v) 1. To preserve and improve access to 758
ambulance transportation provider services, the division shall 759
seek CMS approval to make ambulance service access payments as set 760
forth in this subsection (A)(18)(b) for all covered emergency 761
ambulance services rendered on or after July 1, 2022, and shall 762
make such ambulance service access payments for all covered 763
services rendered on or after the effective date of CMS approval. 764
2. The division shall calculate the 765
ambulance service access payment amount as the balance of the 766
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portion of the Medical Care Fund related to ambulance 767
transportation service provider assessments plus any federal 768
matching funds earned on the balance, up to, but not to exceed, 769
the upper payment limit gap for all emergency ambulance service 770
providers. 771
3. a. Except for ambulance services 772
exempt from the assessment provided in this paragraph (18)(b), all 773
ambulance transportation service providers shall be eligible for 774
ambulance service access payments each state fiscal year as set 775
forth in this paragraph (18)(b). 776
b. In addition to any other funds 777
paid to ambulance transportation service providers for emergency 778
medical services provided to Medicaid beneficiaries, each eligible 779
ambulance transportation service provider shall receive ambulance 780
service access payments each state fiscal year equal to the 781
ambulance transportation service provider's upper payment limit 782
gap. Subject to approval by the Centers for Medicare and Medicaid 783
Services, ambulance service access payments shall be made no less 784
than on a quarterly basis. 785
c. As used in this paragraph 786
(18)(b)(v), the term "upper payment limit gap" means the 787
difference between the total amount that the ambulance 788
transportation service provider received from Medicaid and the 789
average amount that the ambulance transportation service provider 790
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would have received from commercial insurers for those services 791
reimbursed by Medicaid. 792
4. An ambulance service access payment 793
shall not be used to offset any other payment by the division for 794
emergency or nonemergency services to Medicaid beneficiaries. 795
(c) (i) Not later than December l, 2015, the 796
division shall, subject to approval by the Centers for Medicare 797
and Medicaid Services (CMS), establish, implement and operate a 798
Mississippi Hospital Access Program (MHAP) for the purpose of 799
protecting patient access to hospital care through hospital 800
inpatient reimbursement programs provided in this section designed 801
to maintain total hospital reimbursement for inpatient services 802
rendered by in-state hospitals and the out-of-state hospital that 803
is authorized by federal law to submit intergovernmental transfers 804
(IGTs) to the State of Mississippi and is classified as Level I 805
trauma center located in a county contiguous to the state line at 806
the maximum levels permissible under applicable federal statutes 807
and regulations, at which time the current inpatient Medicare 808
Upper Payment Limits (UPL) Program for hospital inpatient services 809
shall transition to the MHAP. 810
(ii) Subject to approval by the Centers for 811
Medicare and Medicaid Services (CMS), the MHAP shall provide 812
increased inpatient capitation (PMPM) payments to managed care 813
entities contracting with the division pursuant to subsection (H) 814
of this section to support availability of hospital services or 815
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such other payments permissible under federal law necessary to 816
accomplish the intent of this subsection. 817
(iii) The intent of this subparagraph (c) is 818
that effective for all inpatient hospital Medicaid services during 819
state fiscal year 2016, and so long as this provision shall remain 820
in effect hereafter, the division shall to the fullest extent 821
feasible replace the additional reimbursement for hospital 822
inpatient services under the inpatient Medicare Upper Payment 823
Limits (UPL) Program with additional reimbursement under the MHAP 824
and other payment programs for inpatient and/or outpatient 825
payments which may be developed under the authority of this 826
paragraph. 827
(iv) The division shall assess each hospital 828
as provided in Section 43-13-145(4)(a) for the purpose of 829
financing the state portion of the MHAP, supplemental payments and 830
such other purposes as specified in Section 43-13-145. The 831
assessment will remain in effect as long as the MHAP and 832
supplemental payments are in effect. 833
(19) (a) Perinatal risk management services. The 834
division shall promulgate regulations to be effective from and 835
after October 1, 1988, to establish a comprehensive perinatal 836
system for risk assessment of all pregnant and infant Medicaid 837
recipients and for management, education and follow-up for those 838
who are determined to be at risk. Services to be performed 839
include case management, nutrition assessment/counseling, 840
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psychosocial assessment/counseling and health education. The 841
division shall contract with the State Department of Health to 842
provide services within this paragraph (Perinatal High Risk 843
Management/Infant Services System (PHRM/ISS)). The State 844
Department of Health shall be reimbursed on a full reasonable cost 845
basis for services provided under this subparagraph (a). 846
(b) Early intervention system services. The 847
division shall cooperate with the State Department of Health, 848
acting as lead agency, in the development and implementation of a 849
statewide system of delivery of early intervention services, under 850
Part C of the Individuals with Disabilities Education Act (IDEA). 851
The State Department of Health shall certify annually in writing 852
to the executive director of the division the dollar amount of 853
state early intervention funds available that will be utilized as 854
a certified match for Medicaid matching funds. Those funds then 855
shall be used to provide expanded targeted case management 856
services for Medicaid eligible children with special needs who are 857
eligible for the state's early intervention system. 858
Qualifications for persons providing service coordination shall be 859
determined by the State Department of Health and the Division of 860
Medicaid. 861
(20) Home- and community-based services for physically 862
disabled approved services as allowed by a waiver from the United 863
States Department of Health and Human Services for home- and 864
community-based services for physically disabled people using 865
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state funds that are provided from the appropriation to the State 866
Department of Rehabilitation Services and used to match federal 867
funds under a cooperative agreement between the division and the 868
department, provided that funds for these services are 869
specifically appropriated to the Department of Rehabilitation 870
Services. 871
(21) Nurse practitioner services. Services furnished 872
by a registered nurse who is licensed and certified by the 873
Mississippi Board of Nursing as a nurse practitioner, including, 874
but not limited to, nurse anesthetists, nurse midwives, family 875
nurse practitioners, family planning nurse practitioners, 876
pediatric nurse practitioners, obstetrics-gynecology nurse 877
practitioners and neonatal nurse practitioners, under regulations 878
adopted by the division. Reimbursement for those services shall 879
not exceed ninety percent (90%) of the reimbursement rate for 880
comparable services rendered by a physician. The division may 881
provide for a reimbursement rate for nurse practitioner services 882
of up to one hundred percent (100%) of the reimbursement rate for 883
comparable services rendered by a physician for nurse practitioner 884
services that are provided after the normal working hours of the 885
nurse practitioner, as determined in accordance with regulations 886
of the division. 887
(22) Ambulatory services delivered in federally 888
qualified health centers, rural health centers and clinics of the 889
local health departments of the State Department of Health for 890
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individuals eligible for Medicaid under this article based on 891
reasonable costs as determined by the division. Federally 892
qualified health centers shall be reimbursed by the Medicaid 893
prospective payment system as approved by the Centers for Medicare 894
and Medicaid Services. The division shall recognize federally 895
qualified health centers (FQHCs), rural health clinics (RHCs) and 896
community mental health centers (CMHCs) as both an originating and 897
distant site provider for the purposes of telehealth 898
reimbursement. The division is further authorized and directed to 899
reimburse FQHCs, RHCs and CMHCs for both distant site and 900
originating site services when such services are appropriately 901
provided by the same organization. 902
(23) Inpatient psychiatric services. 903
(a) Inpatient psychiatric services to be 904
determined by the division for recipients under age twenty-one 905
(21) that are provided under the direction of a physician in an 906
inpatient program in a licensed acute care psychiatric facility or 907
in a licensed psychiatric residential treatment facility, before 908
the recipient reaches age twenty-one (21) or, if the recipient was 909
receiving the services immediately before he or she reached age 910
twenty-one (21), before the earlier of the date he or she no 911
longer requires the services or the date he or she reaches age 912
twenty-two (22), as provided by federal regulations. From and 913
after January 1, 2015, the division shall update the fair rental 914
reimbursement system for psychiatric residential treatment 915
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facilities. Precertification of inpatient days and residential 916
treatment days must be obtained as required by the division. From 917
and after July 1, 2009, all state-owned and state-operated 918
facilities that provide inpatient psychiatric services to persons 919
under age twenty-one (21) who are eligible for Medicaid 920
reimbursement shall be reimbursed for those services on a full 921
reasonable cost basis. 922
(b) The division may reimburse for services 923
provided by a licensed freestanding psychiatric hospital to 924
Medicaid recipients over the age of twenty-one (21) in a method 925
and manner consistent with the provisions of Section 43-13-117.5. 926
(24) [Deleted] 927
(25) [Deleted] 928
(26) Hospice care. As used in this paragraph, the term 929
"hospice care" means a coordinated program of active professional 930
medical attention within the home and outpatient and inpatient 931
care that treats the terminally ill patient and family as a unit, 932
employing a medically directed interdisciplinary team. The 933
program provides relief of severe pain or other physical symptoms 934
and supportive care to meet the special needs arising out of 935
physical, psychological, spiritual, social and economic stresses 936
that are experienced during the final stages of illness and during 937
dying and bereavement and meets the Medicare requirements for 938
participation as a hospice as provided in federal regulations. 939
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(27) Group health plan premiums and cost-sharing if it 940
is cost-effective as defined by the United States Secretary of 941
Health and Human Services. 942
(28) Other health insurance premiums that are 943
cost-effective as defined by the United States Secretary of Health 944
and Human Services. Medicare eligible must have Medicare Part B 945
before other insurance premiums can be paid. 946
(29) The Division of Medicaid may apply for a waiver 947
from the United States Department of Health and Human Services for 948
home- and community-based services for developmentally disabled 949
people using state funds that are provided from the appropriation 950
to the State Department of Mental Health and/or funds transferred 951
to the department by a political subdivision or instrumentality of 952
the state and used to match federal funds under a cooperative 953
agreement between the division and the department, provided that 954
funds for these services are specifically appropriated to the 955
Department of Mental Health and/or transferred to the department 956
by a political subdivision or instrumentality of the state. 957
(30) Pediatric skilled nursing services as determined 958
by the division and in a manner consistent with regulations 959
promulgated by the Mississippi State Department of Health. 960
(31) Targeted case management services for children 961
with special needs, under waivers from the United States 962
Department of Health and Human Services, using state funds that 963
are provided from the appropriation to the Mississippi Department 964
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of Human Services and used to match federal funds under a 965
cooperative agreement between the division and the department. 966
(32) Care and services provided in Christian Science 967
Sanatoria listed and certified by the Commission for Accreditation 968
of Christian Science Nursing Organizations/Facilities, Inc., 969
rendered in connection with treatment by prayer or spiritual means 970
to the extent that those services are subject to reimbursement 971
under Section 1903 of the federal Social Security Act. 972
(33) Podiatrist services. 973
(34) Assisted living services as provided through 974
home- and community-based services under Title XIX of the federal 975
Social Security Act, as amended, subject to the availability of 976
funds specifically appropriated for that purpose by the 977
Legislature. 978
(35) Services and activities authorized in Sections 979
43-27-101 and 43-27-103, using state funds that are provided from 980
the appropriation to the Mississippi Department of Human Services 981
and used to match federal funds under a cooperative agreement 982
between the division and the department. 983
(36) Nonemergency transportation services for 984
Medicaid-eligible persons as determined by the division. The PEER 985
Committee shall conduct a performance evaluation of the 986
nonemergency transportation program to evaluate the administration 987
of the program and the providers of transportation services to 988
determine the most cost-effective ways of providing nonemergency 989
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transportation services to the patients served under the program. 990
The performance evaluation shall be completed and provided to the 991
members of the Senate Medicaid Committee and the House Medicaid 992
Committee not later than January 1, 2019, and every two (2) years 993
thereafter. 994
(37) [Deleted] 995
(38) Chiropractic services. A chiropractor's manual 996
manipulation of the spine to correct a subluxation, if x-ray 997
demonstrates that a subluxation exists and if the subluxation has 998
resulted in a neuromusculoskeletal condition for which 999
manipulation is appropriate treatment, and related spinal x-rays 1000
performed to document these conditions. Reimbursement for 1001
chiropractic services shall not exceed Seven Hundred Dollars 1002
($700.00) per year per beneficiary. 1003
(39) Dually eligible Medicare/Medicaid beneficiaries. 1004
The division shall pay the Medicare deductible and coinsurance 1005
amounts for services available under Medicare, as determined by 1006
the division. From and after July 1, 2009, the division shall 1007
reimburse crossover claims for inpatient hospital services and 1008
crossover claims covered under Medicare Part B in the same manner 1009
that was in effect on January 1, 2008, unless specifically 1010
authorized by the Legislature to change this method. 1011
(40) [Deleted] 1012
(41) Services provided by the State Department of 1013
Rehabilitation Services for the care and rehabilitation of persons 1014
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with spinal cord injuries or traumatic brain injuries, as allowed 1015
under waivers from the United States Department of Health and 1016
Human Services, using up to seventy-five percent (75%) of the 1017
funds that are appropriated to the Department of Rehabilitation 1018
Services from the Spinal Cord and Head Injury Trust Fund 1019
established under Section 37-33-261 and used to match federal 1020
funds under a cooperative agreement between the division and the 1021
department. 1022
(42) [Deleted] 1023
(43) The division shall provide reimbursement, 1024
according to a payment schedule developed by the division, for 1025
smoking cessation medications for pregnant women during their 1026
pregnancy and other Medicaid-eligible women who are of 1027
child-bearing age. 1028
(44) Nursing facility services for the severely 1029
disabled. 1030
(a) Severe disabilities include, but are not 1031
limited to, spinal cord injuries, closed-head injuries and 1032
ventilator-dependent patients. 1033
(b) Those services must be provided in a long-term 1034
care nursing facility dedicated to the care and treatment of 1035
persons with severe disabilities. 1036
(45) Physician assistant services. Services furnished 1037
by a physician assistant who is licensed by the State Board of 1038
Medical Licensure and is practicing with physician supervision 1039
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under regulations adopted by the board, under regulations adopted 1040
by the division. Reimbursement for those services shall not 1041
exceed ninety percent (90%) of the reimbursement rate for 1042
comparable services rendered by a physician. The division may 1043
provide for a reimbursement rate for physician assistant services 1044
of up to one hundred percent (100%) or the reimbursement rate for 1045
comparable services rendered by a physician for physician 1046
assistant services that are provided after the normal working 1047
hours of the physician assistant, as determined in accordance with 1048
regulations of the division. 1049
(46) The division shall make application to the federal 1050
Centers for Medicare and Medicaid Services (CMS) for a waiver to 1051
develop and provide services for children with serious emotional 1052
disturbances as defined in Section 43-14-1(1), which may include 1053
home- and community-based services, case management services or 1054
managed care services through mental health providers certified by 1055
the Department of Mental Health. The division may implement and 1056
provide services under this waivered program only if funds for 1057
these services are specifically appropriated for this purpose by 1058
the Legislature, or if funds are voluntarily provided by affected 1059
agencies. 1060
(47) (a) The division may develop and implement 1061
disease management programs for individuals with high-cost chronic 1062
diseases and conditions, including the use of grants, waivers, 1063
demonstrations or other projects as necessary. 1064
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(b) Participation in any disease management 1065
program implemented under this paragraph (47) is optional with the 1066
individual. An individual must affirmatively elect to participate 1067
in the disease management program in order to participate, and may 1068
elect to discontinue participation in the program at any time. 1069
(48) Pediatric long-term acute care hospital services. 1070
(a) Pediatric long-term acute care hospital 1071
services means services provided to eligible persons under 1072
twenty-one (21) years of age by a freestanding Medicare-certified 1073
hospital that has an average length of inpatient stay greater than 1074
twenty-five (25) days and that is primarily engaged in providing 1075
chronic or long-term medical care to persons under twenty-one (21) 1076
years of age. 1077
(b) The services under this paragraph (48) shall 1078
be reimbursed as a separate category of hospital services. 1079
(49) The division may establish copayments and/or 1080
coinsurance for any Medicaid services for which copayments and/or 1081
coinsurance are allowable under federal law or regulation. 1082
(50) Services provided by the State Department of 1083
Rehabilitation Services for the care and rehabilitation of persons 1084
who are deaf and blind, as allowed under waivers from the United 1085
States Department of Health and Human Services to provide home- 1086
and community-based services using state funds that are provided 1087
from the appropriation to the State Department of Rehabilitation 1088
Services or if funds are voluntarily provided by another agency. 1089
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(51) Upon determination of Medicaid eligibility and in 1090
association with annual redetermination of Medicaid eligibility, 1091
beneficiaries shall be encouraged to undertake a physical 1092
examination that will establish a base-line level of health and 1093
identification of a usual and customary source of care (a medical 1094
home) to aid utilization of disease management tools. This 1095
physical examination and utilization of these disease management 1096
tools shall be consistent with current United States Preventive 1097
Services Task Force or other recognized authority recommendations. 1098
For persons who are determined ineligible for Medicaid, the 1099
division will provide information and direction for accessing 1100
medical care and services in the area of their residence. 1101
(52) Notwithstanding any provisions of this article, 1102
the division may pay enhanced reimbursement fees related to trauma 1103
care, as determined by the division in conjunction with the State 1104
Department of Health, using funds appropriated to the State 1105
Department of Health for trauma care and services and used to 1106
match federal funds under a cooperative agreement between the 1107
division and the State Department of Health. The division, in 1108
conjunction with the State Department of Health, may use grants, 1109
waivers, demonstrations, enhanced reimbursements, Upper Payment 1110
Limits Programs, supplemental payments, or other projects as 1111
necessary in the development and implementation of this 1112
reimbursement program. 1113
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(53) Targeted case management services for high-cost 1114
beneficiaries may be developed by the division for all services 1115
under this section. 1116
(54) [Deleted] 1117
(55) Therapy services. The plan of care for therapy 1118
services may be developed to cover a period of treatment for up to 1119
six (6) months, but in no event shall the plan of care exceed a 1120
six-month period of treatment. The projected period of treatment 1121
must be indicated on the initial plan of care and must be updated 1122
with each subsequent revised plan of care. Based on medical 1123
necessity, the division shall approve certification periods for 1124
less than or up to six (6) months, but in no event shall the 1125
certification period exceed the period of treatment indicated on 1126
the plan of care. The appeal process for any reduction in therapy 1127
services shall be consistent with the appeal process in federal 1128
regulations. 1129
(56) Prescribed pediatric extended care centers 1130
services for medically dependent or technologically dependent 1131
children with complex medical conditions that require continual 1132
care as prescribed by the child's attending physician, as 1133
determined by the division. 1134
(57) No Medicaid benefit shall restrict coverage for 1135
medically appropriate treatment prescribed by a physician and 1136
agreed to by a fully informed individual, or if the individual 1137
lacks legal capacity to consent by a person who has legal 1138
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authority to consent on his or her behalf, based on an 1139
individual's diagnosis with a terminal condition. As used in this 1140
paragraph (57), "terminal condition" means any aggressive 1141
malignancy, chronic end-stage cardiovascular or cerebral vascular 1142
disease, or any other disease, illness or condition which a 1143
physician diagnoses as terminal. 1144
(58) Treatment services for persons with opioid 1145
dependency or other highly addictive substance use disorders. The 1146
division is authorized to reimburse eligible providers for 1147
treatment of opioid dependency and other highly addictive 1148
substance use disorders, as determined by the division. Treatment 1149
related to these conditions shall not count against any physician 1150
visit limit imposed under this section. 1151
(59) The division shall allow beneficiaries between the 1152
ages of ten (10) and eighteen (18) years to receive vaccines 1153
through a pharmacy venue. The division and the State Department 1154
of Health shall coordinate and notify OB-GYN providers that the 1155
Vaccines for Children program is available to providers free of 1156
charge. 1157
(60) Border city university-affiliated pediatric 1158
teaching hospital. 1159
(a) Payments may only be made to a border city 1160
university-affiliated pediatric teaching hospital if the Centers 1161
for Medicare and Medicaid Services (CMS) approve an increase in 1162
the annual request for the provider payment initiative authorized 1163
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under 42 CFR Section 438.6(c) in an amount equal to or greater 1164
than the estimated annual payment to be made to the border city 1165
university-affiliated pediatric teaching hospital. The estimate 1166
shall be based on the hospital's prior year Mississippi managed 1167
care utilization. 1168
(b) As used in this paragraph (60), the term 1169
"border city university-affiliated pediatric teaching hospital" 1170
means an out-of-state hospital located within a city bordering the 1171
eastern bank of the Mississippi River and the State of Mississippi 1172
that submits to the division a copy of a current and effective 1173
affiliation agreement with an accredited university and other 1174
documentation establishing that the hospital is 1175
university-affiliated, is licensed and designated as a pediatric 1176
hospital or pediatric primary hospital within its home state, 1177
maintains at least five (5) different pediatric specialty training 1178
programs, and maintains at least one hundred (100) operated beds 1179
dedicated exclusively for the treatment of patients under the age 1180
of twenty-one (21) years. 1181
(c) The cost of providing services to Mississippi 1182
Medicaid beneficiaries under the age of twenty-one (21) years who 1183
are treated by a border city university-affiliated pediatric 1184
teaching hospital shall not exceed the cost of providing the same 1185
services to individuals in hospitals in the state. 1186
(d) It is the intent of the Legislature that 1187
payments shall not result in any in-state hospital receiving 1188
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payments lower than they would otherwise receive if not for the 1189
payments made to any border city university-affiliated pediatric 1190
teaching hospital. 1191
(e) This paragraph (60) shall stand repealed on 1192
July 1, 2024. 1193
(61) Services described in Section 41-140-3 that are 1194
provided by certified community health workers employed and 1195
supervised by a Medicaid provider. Reimbursement for these 1196
services shall be provided only if the division has received 1197
approval from the Centers for Medicare and Medicaid Services for a 1198
state plan amendment, waiver or alternative payment model for 1199
services delivered by certified community health workers. 1200
(62) Program of All-Inclusive Care for the Elderly 1201
(PACE) services as determined by the Division of Medicaid. 1202
(B) Planning and development districts participating in the 1203
home- and community-based services program for the elderly and 1204
disabled as case management providers shall be reimbursed for case 1205
management services at the maximum rate approved by the Centers 1206
for Medicare and Medicaid Services (CMS). 1207
(C) The division may pay to those providers who participate 1208
in and accept patient referrals from the division's emergency room 1209
redirection program a percentage, as determined by the division, 1210
of savings achieved according to the performance measures and 1211
reduction of costs required of that program. Federally qualified 1212
health centers may participate in the emergency room redirection 1213
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program, and the division may pay those centers a percentage of 1214
any savings to the Medicaid program achieved by the centers' 1215
accepting patient referrals through the program, as provided in 1216
this subsection (C). 1217
(D) (1) As used in this subsection (D), the following terms 1218
shall be defined as provided in this paragraph, except as 1219
otherwise provided in this subsection: 1220
(a) "Committees" means the Medicaid Committees of 1221
the House of Representatives and the Senate, and "committee" means 1222
either one of those committees. 1223
(b) "Rate change" means an increase, decrease or 1224
other change in the payments or rates of reimbursement, or a 1225
change in any payment methodology that results in an increase, 1226
decrease or other change in the payments or rates of 1227
reimbursement, to any Medicaid provider that renders any services 1228
authorized to be provided to Medicaid recipients under this 1229
article. 1230
(2) Whenever the Division of Medicaid proposes a rate 1231
change, the division shall give notice to the chairmen of the 1232
committees at least thirty (30) calendar days before the proposed 1233
rate change is scheduled to take effect. The division shall 1234
furnish the chairmen with a concise summary of each proposed rate 1235
change along with the notice, and shall furnish the chairmen with 1236
a copy of any proposed rate change upon request. The division 1237
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also shall provide a summary and copy of any proposed rate change 1238
to any other member of the Legislature upon request. 1239
(3) If the chairman of either committee or both 1240
chairmen jointly object to the proposed rate change or any part 1241
thereof, the chairman or chairmen shall notify the division and 1242
provide the reasons for their objection in writing not later than 1243
seven (7) calendar days after receipt of the notice from the 1244
division. The chairman or chairmen may make written 1245
recommendations to the division for changes to be made to a 1246
proposed rate change. 1247
(4) (a) The chairman of either committee or both 1248
chairmen jointly may hold a committee meeting to review a proposed 1249
rate change. If either chairman or both chairmen decide to hold a 1250
meeting, they shall notify the division of their intention in 1251
writing within seven (7) calendar days after receipt of the notice 1252
from the division, and shall set the date and time for the meeting 1253
in their notice to the division, which shall not be later than 1254
fourteen (14) calendar days after receipt of the notice from the 1255
division. 1256
(b) After the committee meeting, the committee or 1257
committees may object to the proposed rate change or any part 1258
thereof. The committee or committees shall notify the division 1259
and the reasons for their objection in writing not later than 1260
seven (7) calendar days after the meeting. The committee or 1261
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committees may make written recommendations to the division for 1262
changes to be made to a proposed rate change. 1263
(5) If both chairmen notify the division in writing 1264
within seven (7) calendar days after receipt of the notice from 1265
the division that they do not object to the proposed rate change 1266
and will not be holding a meeting to review the proposed rate 1267
change, the proposed rate change will take effect on the original 1268
date as scheduled by the division or on such other date as 1269
specified by the division. 1270
(6) (a) If there are any objections to a proposed rate 1271
change or any part thereof from either or both of the chairmen or 1272
the committees, the division may withdraw the proposed rate 1273
change, make any of the recommended changes to the proposed rate 1274
change, or not make any changes to the proposed rate change. 1275
(b) If the division does not make any changes to 1276
the proposed rate change, it shall notify the chairmen of that 1277
fact in writing, and the proposed rate change shall take effect on 1278
the original date as scheduled by the division or on such other 1279
date as specified by the division. 1280
(c) If the division makes any changes to the 1281
proposed rate change, the division shall notify the chairmen of 1282
its actions in writing, and the revised proposed rate change shall 1283
take effect on the date as specified by the division. 1284
(7) Nothing in this subsection (D) shall be construed 1285
as giving the chairmen or the committees any authority to veto, 1286
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nullify or revise any rate change proposed by the division. The 1287
authority of the chairmen or the committees under this subsection 1288
shall be limited to reviewing, making objections to and making 1289
recommendations for changes to rate changes proposed by the 1290
division. 1291
(E) Notwithstanding any provision of this article, no new 1292
groups or categories of recipients and new types of care and 1293
services may be added without enabling legislation from the 1294
Mississippi Legislature, except that the division may authorize 1295
those changes without enabling legislation when the addition of 1296
recipients or services is ordered by a court of proper authority. 1297
(F) The executive director shall keep the Governor advised 1298
on a timely basis of the funds available for expenditure and the 1299
projected expenditures. Notwithstanding any other provisions of 1300
this article, if current or projected expenditures of the division 1301
are reasonably anticipated to exceed the amount of funds 1302
appropriated to the division for any fiscal year, the Governor, 1303
after consultation with the executive director, shall take all 1304
appropriate measures to reduce costs, which may include, but are 1305
not limited to: 1306
(1) Reducing or discontinuing any or all services that 1307
are deemed to be optional under Title XIX of the Social Security 1308
Act; 1309
(2) Reducing reimbursement rates for any or all service 1310
types; 1311
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(3) Imposing additional assessments on health care 1312
providers; or 1313
(4) Any additional cost-containment measures deemed 1314
appropriate by the Governor. 1315
To the extent allowed under federal law, any reduction to 1316
services or reimbursement rates under this subsection (F) shall be 1317
accompanied by a reduction, to the fullest allowable amount, to 1318
the profit margin and administrative fee portions of capitated 1319
payments to organizations described in paragraph (1) of subsection 1320
(H). 1321
Beginning in fiscal year 2010 and in fiscal years thereafter, 1322
when Medicaid expenditures are projected to exceed funds available 1323
for the fiscal year, the division shall submit the expected 1324
shortfall information to the PEER Committee not later than 1325
December 1 of the year in which the shortfall is projected to 1326
occur. PEER shall review the computations of the division and 1327
report its findings to the Legislative Budget Office not later 1328
than January 7 in any year. 1329
(G) Notwithstanding any other provision of this article, it 1330
shall be the duty of each provider participating in the Medicaid 1331
program to keep and maintain books, documents and other records as 1332
prescribed by the Division of Medicaid in accordance with federal 1333
laws and regulations. 1334
(H) (1) Notwithstanding any other provision of this 1335
article, the division is authorized to implement (a) a managed 1336
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care program, (b) a coordinated care program, (c) a coordinated 1337
care organization program, (d) a health maintenance organization 1338
program, (e) a patient-centered medical home program, (f) an 1339
accountable care organization program, (g) provider-sponsored 1340
health plan, or (h) any combination of the above programs. As a 1341
condition for the approval of any program under this subsection 1342
(H)(1), the division shall require that no managed care program, 1343
coordinated care program, coordinated care organization program, 1344
health maintenance organization program, or provider-sponsored 1345
health plan may: 1346
(a) Pay providers at a rate that is less than the 1347
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1348
reimbursement rate; 1349
(b) Override the medical decisions of hospital 1350
physicians or staff regarding patients admitted to a hospital for 1351
an emergency medical condition as defined by 42 US Code Section 1352
1395dd. This restriction (b) does not prohibit the retrospective 1353
review of the appropriateness of the determination that an 1354
emergency medical condition exists by chart review or coding 1355
algorithm, nor does it prohibit prior authorization for 1356
nonemergency hospital admissions; 1357
(c) Pay providers at a rate that is less than the 1358
normal Medicaid reimbursement rate. It is the intent of the 1359
Legislature that all managed care entities described in this 1360
subsection (H), in collaboration with the division, develop and 1361
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implement innovative payment models that incentivize improvements 1362
in health care quality, outcomes, or value, as determined by the 1363
division. Participation in the provider network of any managed 1364
care, coordinated care, provider-sponsored health plan, or similar 1365
contractor shall not be conditioned on the provider's agreement to 1366
accept such alternative payment models; 1367
(d) Implement a prior authorization and 1368
utilization review program for medical services, transportation 1369
services and prescription drugs that is more stringent than the 1370
prior authorization processes used by the division in its 1371
administration of the Medicaid program. Not later than December 1372
2, 2021, the contractors that are receiving capitated payments 1373
under a managed care delivery system established under this 1374
subsection (H) shall submit a report to the Chairmen of the House 1375
and Senate Medicaid Committees on the status of the prior 1376
authorization and utilization review program for medical services, 1377
transportation services and prescription drugs that is required to 1378
be implemented under this subparagraph (d); 1379
(e) [Deleted] 1380
(f) Implement a preferred drug list that is more 1381
stringent than the mandatory preferred drug list established by 1382
the division under subsection (A)(9) of this section; 1383
(g) Implement a policy which denies beneficiaries 1384
with hemophilia access to the federally funded hemophilia 1385
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treatment centers as part of the Medicaid Managed Care network of 1386
providers. 1387
Each health maintenance organization, coordinated care 1388
organization, provider-sponsored health plan, or other 1389
organization paid for services on a capitated basis by the 1390
division under any managed care program or coordinated care 1391
program implemented by the division under this section shall use a 1392
clear set of level of care guidelines in the determination of 1393
medical necessity and in all utilization management practices, 1394
including the prior authorization process, concurrent reviews, 1395
retrospective reviews and payments, that are consistent with 1396
widely accepted professional standards of care. Organizations 1397
participating in a managed care program or coordinated care 1398
program implemented by the division may not use any additional 1399
criteria that would result in denial of care that would be 1400
determined appropriate and, therefore, medically necessary under 1401
those levels of care guidelines. 1402
(2) Notwithstanding any provision of this section, the 1403
recipients eligible for enrollment into a Medicaid Managed Care 1404
Program authorized under this subsection (H) may include only 1405
those categories of recipients eligible for participation in the 1406
Medicaid Managed Care Program as of January 1, 2021, the 1407
Children's Health Insurance Program (CHIP), and the CMS-approved 1408
Section 1115 demonstration waivers in operation as of January 1, 1409
2021. No expansion of Medicaid Managed Care Program contracts may 1410
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be implemented by the division without enabling legislation from 1411
the Mississippi Legislature. 1412
(3) (a) Any contractors receiving capitated payments 1413
under a managed care delivery system established in this section 1414
shall provide to the Legislature and the division statistical data 1415
to be shared with provider groups in order to improve patient 1416
access, appropriate utilization, cost savings and health outcomes 1417
not later than October 1 of each year. Additionally, each 1418
contractor shall disclose to the Chairmen of the Senate and House 1419
Medicaid Committees the administrative expenses costs for the 1420
prior calendar year, and the number of full-equivalent employees 1421
located in the State of Mississippi dedicated to the Medicaid and 1422
CHIP lines of business as of June 30 of the current year. 1423
(b) The division and the contractors participating 1424
in the managed care program, a coordinated care program or a 1425
provider-sponsored health plan shall be subject to annual program 1426
reviews or audits performed by the Office of the State Auditor, 1427
the PEER Committee, the Department of Insurance and/or independent 1428
third parties. 1429
(c) Those reviews shall include, but not be 1430
limited to, at least two (2) of the following items: 1431
(i) The financial benefit to the State of 1432
Mississippi of the managed care program, 1433
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(ii) The difference between the premiums paid 1434
to the managed care contractors and the payments made by those 1435
contractors to health care providers, 1436
(iii) Compliance with performance measures 1437
required under the contracts, 1438
(iv) Administrative expense allocation 1439
methodologies, 1440
(v) Whether nonprovider payments assigned as 1441
medical expenses are appropriate, 1442
(vi) Capitated arrangements with related 1443
party subcontractors, 1444
(vii) Reasonableness of corporate 1445
allocations, 1446
(viii) Value-added benefits and the extent to 1447
which they are used, 1448
(ix) The effectiveness of subcontractor 1449
oversight, including subcontractor review, 1450
(x) Whether health care outcomes have been 1451
improved, and 1452
(xi) The most common claim denial codes to 1453
determine the reasons for the denials. 1454
The audit reports shall be considered public documents and 1455
shall be posted in their entirety on the division's website. 1456
(4) All health maintenance organizations, coordinated 1457
care organizations, provider-sponsored health plans, or other 1458
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organizations paid for services on a capitated basis by the 1459
division under any managed care program or coordinated care 1460
program implemented by the division under this section shall 1461
reimburse all providers in those organizations at rates no lower 1462
than those provided under this section for beneficiaries who are 1463
not participating in those programs. 1464
(5) No health maintenance organization, coordinated 1465
care organization, provider-sponsored health plan, or other 1466
organization paid for services on a capitated basis by the 1467
division under any managed care program or coordinated care 1468
program implemented by the division under this section shall 1469
require its providers or beneficiaries to use any pharmacy that 1470
ships, mails or delivers prescription drugs or legend drugs or 1471
devices. 1472
(6) (a) Not later than December 1, 2021, the 1473
contractors who are receiving capitated payments under a managed 1474
care delivery system established under this subsection (H) shall 1475
develop and implement a uniform credentialing process for 1476
providers. Under that uniform credentialing process, a provider 1477
who meets the criteria for credentialing will be credentialed with 1478
all of those contractors and no such provider will have to be 1479
separately credentialed by any individual contractor in order to 1480
receive reimbursement from the contractor. Not later than 1481
December 2, 2021, those contractors shall submit a report to the 1482
Chairmen of the House and Senate Medicaid Committees on the status 1483
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of the uniform credentialing process for providers that is 1484
required under this subparagraph (a). 1485
(b) If those contractors have not implemented a 1486
uniform credentialing process as described in subparagraph (a) by 1487
December 1, 2021, the division shall develop and implement, not 1488
later than July 1, 2022, a single, consolidated credentialing 1489
process by which all providers will be credentialed. Under the 1490
division's single, consolidated credentialing process, no such 1491
contractor shall require its providers to be separately 1492
credentialed by the contractor in order to receive reimbursement 1493
from the contractor, but those contractors shall recognize the 1494
credentialing of the providers by the division's credentialing 1495
process. 1496
(c) The division shall require a uniform provider 1497
credentialing application that shall be used in the credentialing 1498
process that is established under subparagraph (a) or (b). If the 1499
contractor or division, as applicable, has not approved or denied 1500
the provider credentialing application within sixty (60) days of 1501
receipt of the completed application that includes all required 1502
information necessary for credentialing, then the contractor or 1503
division, upon receipt of a written request from the applicant and 1504
within five (5) business days of its receipt, shall issue a 1505
temporary provider credential/enrollment to the applicant if the 1506
applicant has a valid Mississippi professional or occupational 1507
license to provide the health care services to which the 1508
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credential/enrollment would apply. The contractor or the division 1509
shall not issue a temporary credential/enrollment if the applicant 1510
has reported on the application a history of medical or other 1511
professional or occupational malpractice claims, a history of 1512
substance abuse or mental health issues, a criminal record, or a 1513
history of medical or other licensing board, state or federal 1514
disciplinary action, including any suspension from participation 1515
in a federal or state program. The temporary 1516
credential/enrollment shall be effective upon issuance and shall 1517
remain in effect until the provider's credentialing/enrollment 1518
application is approved or denied by the contractor or division. 1519
The contractor or division shall render a final decision regarding 1520
credentialing/enrollment of the provider within sixty (60) days 1521
from the date that the temporary provider credential/enrollment is 1522
issued to the applicant. 1523
(d) If the contractor or division does not render 1524
a final decision regarding credentialing/enrollment of the 1525
provider within the time required in subparagraph (c), the 1526
provider shall be deemed to be credentialed by and enrolled with 1527
all of the contractors and eligible to receive reimbursement from 1528
the contractors. 1529
(7) (a) Each contractor that is receiving capitated 1530
payments under a managed care delivery system established under 1531
this subsection (H) shall provide to each provider for whom the 1532
contractor has denied the coverage of a procedure that was ordered 1533
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or requested by the provider for or on behalf of a patient, a 1534
letter that provides a detailed explanation of the reasons for the 1535
denial of coverage of the procedure and the name and the 1536
credentials of the person who denied the coverage. The letter 1537
shall be sent to the provider in electronic format. 1538
(b) After a contractor that is receiving capitated 1539
payments under a managed care delivery system established under 1540
this subsection (H) has denied coverage for a claim submitted by a 1541
provider, the contractor shall issue to the provider within sixty 1542
(60) days a final ruling of denial of the claim that allows the 1543
provider to have a state fair hearing and/or agency appeal with 1544
the division. If a contractor does not issue a final ruling of 1545
denial within sixty (60) days as required by this subparagraph 1546
(b), the provider's claim shall be deemed to be automatically 1547
approved and the contractor shall pay the amount of the claim to 1548
the provider. 1549
(c) After a contractor has issued a final ruling 1550
of denial of a claim submitted by a provider, the division shall 1551
conduct a state fair hearing and/or agency appeal on the matter of 1552
the disputed claim between the contractor and the provider within 1553
sixty (60) days, and shall render a decision on the matter within 1554
thirty (30) days after the date of the hearing and/or appeal. 1555
(8) It is the intention of the Legislature that the 1556
division evaluate the feasibility of using a single vendor to 1557
administer pharmacy benefits provided under a managed care 1558
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delivery system established under this subsection (H). Providers 1559
of pharmacy benefits shall cooperate with the division in any 1560
transition to a carve-out of pharmacy benefits under managed care. 1561
(9) The division shall evaluate the feasibility of 1562
using a single vendor to administer dental benefits provided under 1563
a managed care delivery system established in this subsection (H). 1564
Providers of dental benefits shall cooperate with the division in 1565
any transition to a carve-out of dental benefits under managed 1566
care. 1567
(10) It is the intent of the Legislature that any 1568
contractor receiving capitated payments under a managed care 1569
delivery system established in this section shall implement 1570
innovative programs to improve the health and well-being of 1571
members diagnosed with prediabetes and diabetes. 1572
(11) It is the intent of the Legislature that any 1573
contractors receiving capitated payments under a managed care 1574
delivery system established under this subsection (H) shall work 1575
with providers of Medicaid services to improve the utilization of 1576
long-acting reversible contraceptives (LARCs). Not later than 1577
December 1, 2021, any contractors receiving capitated payments 1578
under a managed care delivery system established under this 1579
subsection (H) shall provide to the Chairmen of the House and 1580
Senate Medicaid Committees and House and Senate Public Health 1581
Committees a report of LARC utilization for State Fiscal Years 1582
2018 through 2020 as well as any programs, initiatives, or efforts 1583
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made by the contractors and providers to increase LARC 1584
utilization. This report shall be updated annually to include 1585
information for subsequent state fiscal years. 1586
(12) The division is authorized to make not more than 1587
one (1) emergency extension of the contracts that are in effect on 1588
July 1, 2021, with contractors who are receiving capitated 1589
payments under a managed care delivery system established under 1590
this subsection (H), as provided in this paragraph (12). The 1591
maximum period of any such extension shall be one (1) year, and 1592
under any such extensions, the contractors shall be subject to all 1593
of the provisions of this subsection (H). The extended contracts 1594
shall be revised to incorporate any provisions of this subsection 1595
(H). 1596
(I) [Deleted] 1597
(J) There shall be no cuts in inpatient and outpatient 1598
hospital payments, or allowable days or volumes, as long as the 1599
hospital assessment provided in Section 43-13-145 is in effect. 1600
This subsection (J) shall not apply to decreases in payments that 1601
are a result of: reduced hospital admissions, audits or payments 1602
under the APR-DRG or APC models, or a managed care program or 1603
similar model described in subsection (H) of this section. 1604
(K) In the negotiation and execution of such contracts 1605
involving services performed by actuarial firms, the Executive 1606
Director of the Division of Medicaid may negotiate a limitation on 1607
liability to the state of prospective contractors. 1608
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ST: Medicaid eligibility; provide coverage of
the Program of All-Inclusive Care for the
Elderly.
(L) The Division of Medicaid shall reimburse for services 1609
provided to eligible Medicaid beneficiaries by a licensed birthing 1610
center in a method and manner to be determined by the division in 1611
accordance with federal laws and federal regulations. The 1612
division shall seek any necessary waivers, make any required 1613
amendments to its State Plan or revise any contracts authorized 1614
under subsection (H) of this section as necessary to provide the 1615
services authorized under this subsection. As used in this 1616
subsection, the term "birthing centers" shall have the meaning as 1617
defined in Section 41-77-1(a), which is a publicly or privately 1618
owned facility, place or institution constructed, renovated, 1619
leased or otherwise established where nonemergency births are 1620
planned to occur away from the mother's usual residence following 1621
a documented period of prenatal care for a normal uncomplicated 1622
pregnancy which has been determined to be low risk through a 1623
formal risk-scoring examination. 1624
(M) This section shall stand repealed on July 1, 2028. 1625
SECTION 3. This act shall take effect and be in force from 1626
and after July 1, 2026. 1627