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

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Scott

HOUSE BILL NO. 210

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