Medicaid; expand eligibility to include individuals entitled to benefits under federal Patient Protection and Affordable Care Act.

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Scott

HOUSE BILL NO. 226

AN ACT TO AMEND SECTION 43-13-115, MISSISSIPPI CODE OF 1972, 1
TO REVISE MEDICAID ELIGIBILITY TO INCLUDE THOSE INDIVIDUALS WHO 2
ARE ENTITLED TO BENEFITS UNDER THE FEDERAL PATIENT PROTECTION AND 3
AFFORDABLE CARE ACT OF 2010 (ACA), AS AMENDED; TO AMEND SECTION 4
43-13-117, MISSISSIPPI CODE OF 1972, TO INCLUDE ESSENTIAL HEALTH 5
BENEFITS FOR INDIVIDUALS ELIGIBLE FOR MEDICAID UNDER THE FEDERAL 6
PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 (ACA), AS 7
AMENDED; 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) Under the federal Patient Protection and 300
Affordable Care Act of 2010 and as amended, beginning July 1, 301
2026, individuals who are under sixty-five (65) years of age, not 302
pregnant, not entitled to nor enrolled for benefits in Part A of 303
Title XVIII of the federal Social Security Act or enrolled for 304
benefits in Part B of Title XVIII of the federal Social Security 305
Act, not described in any other part of this section, and whose 306
income does not exceed one hundred thirty-three percent (133%) of 307
the Federal Poverty Level applicable to a family of the size 308
involved. The eligibility of individuals covered under this 309
paragraph (29) shall be determined by the Division of Medicaid, 310
and those individuals determined eligible shall only receive 311
essential health benefits as described in the federal Patient 312
Protection and Affordable Care Act of 2010, as amended. This 313
paragraph (29) shall stand repealed on December 31, 2028. 314
The division shall redetermine eligibility for all categories 315
of recipients described in each paragraph of this section not less 316
frequently than required by federal law. 317
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SECTION 2. Section 43-13-117, Mississippi Code of 1972, is 318
amended as follows: 319
43-13-117. (A) Medicaid as authorized by this article shall 320
include payment of part or all of the costs, at the discretion of 321
the division, with approval of the Governor and the Centers for 322
Medicare and Medicaid Services, of the following types of care and 323
services rendered to eligible applicants who have been determined 324
to be eligible for that care and services, within the limits of 325
state appropriations and federal matching funds: 326
(1) Inpatient hospital services. 327
(a) The division is authorized to implement an All 328
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 329
methodology for inpatient hospital services. 330
(b) No service benefits or reimbursement 331
limitations in this subsection (A)(1) shall apply to payments 332
under an APR-DRG or Ambulatory Payment Classification (APC) model 333
or a managed care program or similar model described in subsection 334
(H) of this section unless specifically authorized by the 335
division. 336
(2) Outpatient hospital services. 337
(a) Emergency services. 338
(b) Other outpatient hospital services. The 339
division shall allow benefits for other medically necessary 340
outpatient hospital services (such as chemotherapy, radiation, 341
surgery and therapy), including outpatient services in a clinic or 342
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other facility that is not located inside the hospital, but that 343
has been designated as an outpatient facility by the hospital, and 344
that was in operation or under construction on July 1, 2009, 345
provided that the costs and charges associated with the operation 346
of the hospital clinic are included in the hospital's cost report. 347
In addition, the Medicare thirty-five-mile rule will apply to 348
those hospital clinics not located inside the hospital that are 349
constructed after July 1, 2009. Where the same services are 350
reimbursed as clinic services, the division may revise the rate or 351
methodology of outpatient reimbursement to maintain consistency, 352
efficiency, economy and quality of care. 353
(c) The division is authorized to implement an 354
Ambulatory Payment Classification (APC) methodology for outpatient 355
hospital services. The division shall give rural hospitals that 356
have fifty (50) or fewer licensed beds the option to not be 357
reimbursed for outpatient hospital services using the APC 358
methodology, but reimbursement for outpatient hospital services 359
provided by those hospitals shall be based on one hundred one 360
percent (101%) of the rate established under Medicare for 361
outpatient hospital services. Those hospitals choosing to not be 362
reimbursed under the APC methodology shall remain under cost-based 363
reimbursement for a two-year period. 364
(d) No service benefits or reimbursement 365
limitations in this subsection (A)(2) shall apply to payments 366
under an APR-DRG or APC model or a managed care program or similar 367
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model described in subsection (H) of this section unless 368
specifically authorized by the division. 369
(3) Laboratory and x-ray services. 370
(4) Nursing facility services. 371
(a) The division shall make full payment to 372
nursing facilities for each day, not exceeding forty-two (42) days 373
per year, that a patient is absent from the facility on home 374
leave. Payment may be made for the following home leave days in 375
addition to the forty-two-day limitation: Christmas, the day 376
before Christmas, the day after Christmas, Thanksgiving, the day 377
before Thanksgiving and the day after Thanksgiving. 378
(b) From and after July 1, 1997, the division 379
shall implement the integrated case-mix payment and quality 380
monitoring system, which includes the fair rental system for 381
property costs and in which recapture of depreciation is 382
eliminated. The division may reduce the payment for hospital 383
leave and therapeutic home leave days to the lower of the case-mix 384
category as computed for the resident on leave using the 385
assessment being utilized for payment at that point in time, or a 386
case-mix score of 1.000 for nursing facilities, and shall compute 387
case-mix scores of residents so that only services provided at the 388
nursing facility are considered in calculating a facility's per 389
diem. 390
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(c) From and after July 1, 1997, all state-owned 391
nursing facilities shall be reimbursed on a full reasonable cost 392
basis. 393
(d) On or after January 1, 2015, the division 394
shall update the case-mix payment system resource utilization 395
grouper and classifications and fair rental reimbursement system. 396
The division shall develop and implement a payment add-on to 397
reimburse nursing facilities for ventilator-dependent resident 398
services. 399
(e) The division shall develop and implement, not 400
later than January 1, 2001, a case-mix payment add-on determined 401
by time studies and other valid statistical data that will 402
reimburse a nursing facility for the additional cost of caring for 403
a resident who has a diagnosis of Alzheimer's or other related 404
dementia and exhibits symptoms that require special care. Any 405
such case-mix add-on payment shall be supported by a determination 406
of additional cost. The division shall also develop and implement 407
as part of the fair rental reimbursement system for nursing 408
facility beds, an Alzheimer's resident bed depreciation enhanced 409
reimbursement system that will provide an incentive to encourage 410
nursing facilities to convert or construct beds for residents with 411
Alzheimer's or other related dementia. 412
(f) The division shall develop and implement an 413
assessment process for long-term care services. The division may 414
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provide the assessment and related functions directly or through 415
contract with the area agencies on aging. 416
The division shall apply for necessary federal waivers to 417
assure that additional services providing alternatives to nursing 418
facility care are made available to applicants for nursing 419
facility care. 420
(5) Periodic screening and diagnostic services for 421
individuals under age twenty-one (21) years as are needed to 422
identify physical and mental defects and to provide health care 423
treatment and other measures designed to correct or ameliorate 424
defects and physical and mental illness and conditions discovered 425
by the screening services, regardless of whether these services 426
are included in the state plan. The division may include in its 427
periodic screening and diagnostic program those discretionary 428
services authorized under the federal regulations adopted to 429
implement Title XIX of the federal Social Security Act, as 430
amended. The division, in obtaining physical therapy services, 431
occupational therapy services, and services for individuals with 432
speech, hearing and language disorders, may enter into a 433
cooperative agreement with the State Department of Education for 434
the provision of those services to handicapped students by public 435
school districts using state funds that are provided from the 436
appropriation to the Department of Education to obtain federal 437
matching funds through the division. The division, in obtaining 438
medical and mental health assessments, treatment, care and 439
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services for children who are in, or at risk of being put in, the 440
custody of the Mississippi Department of Human Services may enter 441
into a cooperative agreement with the Mississippi Department of 442
Human Services for the provision of those services using state 443
funds that are provided from the appropriation to the Department 444
of Human Services to obtain federal matching funds through the 445
division. 446
(6) Physician services. Fees for physician's services 447
that are covered only by Medicaid shall be reimbursed at ninety 448
percent (90%) of the rate established on January 1, 2018, and as 449
may be adjusted each July thereafter, under Medicare. The 450
division may provide for a reimbursement rate for physician's 451
services of up to one hundred percent (100%) of the rate 452
established under Medicare for physician's services that are 453
provided after the normal working hours of the physician, as 454
determined in accordance with regulations of the division. The 455
division may reimburse eligible providers, as determined by the 456
division, for certain primary care services at one hundred percent 457
(100%) of the rate established under Medicare. The division shall 458
reimburse obstetricians and gynecologists for certain primary care 459
services as defined by the division at one hundred percent (100%) 460
of the rate established under Medicare. 461
(7) (a) Home health services for eligible persons, not 462
to exceed in cost the prevailing cost of nursing facility 463
services. All home health visits must be precertified as required 464
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by the division. In addition to physicians, certified registered 465
nurse practitioners, physician assistants and clinical nurse 466
specialists are authorized to prescribe or order home health 467
services and plans of care, sign home health plans of care, 468
certify and recertify eligibility for home health services and 469
conduct the required initial face-to-face visit with the recipient 470
of the services. 471
(b) [Repealed] 472
(8) Emergency medical transportation services as 473
determined by the division. 474
(9) Prescription drugs and other covered drugs and 475
services as determined by the division. 476
The division shall establish a mandatory preferred drug list. 477
Drugs not on the mandatory preferred drug list shall be made 478
available by utilizing prior authorization procedures established 479
by the division. 480
The division may seek to establish relationships with other 481
states in order to lower acquisition costs of prescription drugs 482
to include single-source and innovator multiple-source drugs or 483
generic drugs. In addition, if allowed by federal law or 484
regulation, the division may seek to establish relationships with 485
and negotiate with other countries to facilitate the acquisition 486
of prescription drugs to include single-source and innovator 487
multiple-source drugs or generic drugs, if that will lower the 488
acquisition costs of those prescription drugs. 489
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The division may allow for a combination of prescriptions for 490
single-source and innovator multiple-source drugs and generic 491
drugs to meet the needs of the beneficiaries. 492
The executive director may approve specific maintenance drugs 493
for beneficiaries with certain medical conditions, which may be 494
prescribed and dispensed in three-month supply increments. 495
Drugs prescribed for a resident of a psychiatric residential 496
treatment facility must be provided in true unit doses when 497
available. The division may require that drugs not covered by 498
Medicare Part D for a resident of a long-term care facility be 499
provided in true unit doses when available. Those drugs that were 500
originally billed to the division but are not used by a resident 501
in any of those facilities shall be returned to the billing 502
pharmacy for credit to the division, in accordance with the 503
guidelines of the State Board of Pharmacy and any requirements of 504
federal law and regulation. Drugs shall be dispensed to a 505
recipient and only one (1) dispensing fee per month may be 506
charged. The division shall develop a methodology for reimbursing 507
for restocked drugs, which shall include a restock fee as 508
determined by the division not exceeding Seven Dollars and 509
Eighty-two Cents ($7.82). 510
Except for those specific maintenance drugs approved by the 511
executive director, the division shall not reimburse for any 512
portion of a prescription that exceeds a thirty-one-day supply of 513
the drug based on the daily dosage. 514
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The division is authorized to develop and implement a program 515
of payment for additional pharmacist services as determined by the 516
division. 517
All claims for drugs for dually eligible Medicare/Medicaid 518
beneficiaries that are paid for by Medicare must be submitted to 519
Medicare for payment before they may be processed by the 520
division's online payment system. 521
The division shall develop a pharmacy policy in which drugs 522
in tamper-resistant packaging that are prescribed for a resident 523
of a nursing facility but are not dispensed to the resident shall 524
be returned to the pharmacy and not billed to Medicaid, in 525
accordance with guidelines of the State Board of Pharmacy. 526
The division shall develop and implement a method or methods 527
by which the division will provide on a regular basis to Medicaid 528
providers who are authorized to prescribe drugs, information about 529
the costs to the Medicaid program of single-source drugs and 530
innovator multiple-source drugs, and information about other drugs 531
that may be prescribed as alternatives to those single-source 532
drugs and innovator multiple-source drugs and the costs to the 533
Medicaid program of those alternative drugs. 534
Notwithstanding any law or regulation, information obtained 535
or maintained by the division regarding the prescription drug 536
program, including trade secrets and manufacturer or labeler 537
pricing, is confidential and not subject to disclosure except to 538
other state agencies. 539
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The dispensing fee for each new or refill prescription, 540
including nonlegend or over-the-counter drugs covered by the 541
division, shall be not less than Three Dollars and Ninety-one 542
Cents ($3.91), as determined by the division. 543
The division shall not reimburse for single-source or 544
innovator multiple-source drugs if there are equally effective 545
generic equivalents available and if the generic equivalents are 546
the least expensive. 547
It is the intent of the Legislature that the pharmacists 548
providers be reimbursed for the reasonable costs of filling and 549
dispensing prescriptions for Medicaid beneficiaries. 550
The division shall allow certain drugs, including 551
physician-administered drugs, and implantable drug system devices, 552
and medical supplies, with limited distribution or limited access 553
for beneficiaries and administered in an appropriate clinical 554
setting, to be reimbursed as either a medical claim or pharmacy 555
claim, as determined by the division. 556
It is the intent of the Legislature that the division and any 557
managed care entity described in subsection (H) of this section 558
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 559
prevent recurrent preterm birth. 560
(10) Dental and orthodontic services to be determined 561
by the division. 562
The division shall increase the amount of the reimbursement 563
rate for diagnostic and preventative dental services for each of 564
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the fiscal years 2022, 2023 and 2024 by five percent (5%) above 565
the amount of the reimbursement rate for the previous fiscal year. 566
The division shall increase the amount of the reimbursement rate 567
for restorative dental services for each of the fiscal years 2023, 568
2024 and 2025 by five percent (5%) above the amount of the 569
reimbursement rate for the previous fiscal year. It is the intent 570
of the Legislature that the reimbursement rate revision for 571
preventative dental services will be an incentive to increase the 572
number of dentists who actively provide Medicaid services. This 573
dental services reimbursement rate revision shall be known as the 574
"James Russell Dumas Medicaid Dental Services Incentive Program." 575
The Medical Care Advisory Committee, assisted by the Division 576
of Medicaid, shall annually determine the effect of this incentive 577
by evaluating the number of dentists who are Medicaid providers, 578
the number who and the degree to which they are actively billing 579
Medicaid, the geographic trends of where dentists are offering 580
what types of Medicaid services and other statistics pertinent to 581
the goals of this legislative intent. This data shall annually be 582
presented to the Chair of the Senate Medicaid Committee and the 583
Chair of the House Medicaid Committee. 584
The division shall include dental services as a necessary 585
component of overall health services provided to children who are 586
eligible for services. 587
(11) Eyeglasses for all Medicaid beneficiaries who have 588
(a) had surgery on the eyeball or ocular muscle that results in a 589
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vision change for which eyeglasses or a change in eyeglasses is 590
medically indicated within six (6) months of the surgery and is in 591
accordance with policies established by the division, or (b) one 592
(1) pair every five (5) years and in accordance with policies 593
established by the division. In either instance, the eyeglasses 594
must be prescribed by a physician skilled in diseases of the eye 595
or an optometrist, whichever the beneficiary may select. 596
(12) Intermediate care facility services. 597
(a) The division shall make full payment to all 598
intermediate care facilities for individuals with intellectual 599
disabilities for each day, not exceeding sixty-three (63) days per 600
year, that a patient is absent from the facility on home leave. 601
Payment may be made for the following home leave days in addition 602
to the sixty-three-day limitation: Christmas, the day before 603
Christmas, the day after Christmas, Thanksgiving, the day before 604
Thanksgiving and the day after Thanksgiving. 605
(b) All state-owned intermediate care facilities 606
for individuals with intellectual disabilities shall be reimbursed 607
on a full reasonable cost basis. 608
(c) Effective January 1, 2015, the division shall 609
update the fair rental reimbursement system for intermediate care 610
facilities for individuals with intellectual disabilities. 611
(13) Family planning services, including drugs, 612
supplies and devices, when those services are under the 613
supervision of a physician or nurse practitioner. 614
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(14) Clinic services. Preventive, diagnostic, 615
therapeutic, rehabilitative or palliative services that are 616
furnished by a facility that is not part of a hospital but is 617
organized and operated to provide medical care to outpatients. 618
Clinic services include, but are not limited to: 619
(a) Services provided by ambulatory surgical 620
centers (ASCs) as defined in Section 41-75-1(a); and 621
(b) Dialysis center services. 622
(15) Home- and community-based services for the elderly 623
and disabled, as provided under Title XIX of the federal Social 624
Security Act, as amended, under waivers, subject to the 625
availability of funds specifically appropriated for that purpose 626
by the Legislature. 627
(16) Mental health services. Certain services provided 628
by a psychiatrist shall be reimbursed at up to one hundred percent 629
(100%) of the Medicare rate. Approved therapeutic and case 630
management services (a) provided by an approved regional mental 631
health/intellectual disability center established under Sections 632
41-19-31 through 41-19-39, or by another community mental health 633
service provider meeting the requirements of the Department of 634
Mental Health to be an approved mental health/intellectual 635
disability center if determined necessary by the Department of 636
Mental Health, using state funds that are provided in the 637
appropriation to the division to match federal funds, or (b) 638
provided by a facility that is certified by the State Department 639
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of Mental Health to provide therapeutic and case management 640
services, to be reimbursed on a fee for service basis, or (c) 641
provided in the community by a facility or program operated by the 642
Department of Mental Health. Any such services provided by a 643
facility described in subparagraph (b) must have the prior 644
approval of the division to be reimbursable under this section. 645
(17) Durable medical equipment services and medical 646
supplies. Precertification of durable medical equipment and 647
medical supplies must be obtained as required by the division. 648
The Division of Medicaid may require durable medical equipment 649
providers to obtain a surety bond in the amount and to the 650
specifications as established by the Balanced Budget Act of 1997. 651
A maximum dollar amount of reimbursement for noninvasive 652
ventilators or ventilation treatments properly ordered and being 653
used in an appropriate care setting shall not be set by any health 654
maintenance organization, coordinated care organization, 655
provider-sponsored health plan, or other organization paid for 656
services on a capitated basis by the division under any managed 657
care program or coordinated care program implemented by the 658
division under this section. Reimbursement by these organizations 659
to durable medical equipment suppliers for home use of noninvasive 660
and invasive ventilators shall be on a continuous monthly payment 661
basis for the duration of medical need throughout a patient's 662
valid prescription period. 663
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(18) (a) Notwithstanding any other provision of this 664
section to the contrary, as provided in the Medicaid state plan 665
amendment or amendments as defined in Section 43-13-145(10), the 666
division shall make additional reimbursement to hospitals that 667
serve a disproportionate share of low-income patients and that 668
meet the federal requirements for those payments as provided in 669
Section 1923 of the federal Social Security Act and any applicable 670
regulations. It is the intent of the Legislature that the 671
division shall draw down all available federal funds allotted to 672
the state for disproportionate share hospitals. However, from and 673
after January 1, 1999, public hospitals participating in the 674
Medicaid disproportionate share program may be required to 675
participate in an intergovernmental transfer program as provided 676
in Section 1903 of the federal Social Security Act and any 677
applicable regulations. 678
(b) (i) 1. The division may establish a Medicare 679
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 680
the federal Social Security Act and any applicable federal 681
regulations, or an allowable delivery system or provider payment 682
initiative authorized under 42 CFR 438.6(c), for hospitals, 683
nursing facilities and physicians employed or contracted by 684
hospitals. 685
2. The division shall establish a 686
Medicaid Supplemental Payment Program, as permitted by the federal 687
Social Security Act and a comparable allowable delivery system or 688
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provider payment initiative authorized under 42 CFR 438.6(c), for 689
emergency ambulance transportation providers in accordance with 690
this subsection (A)(18)(b). 691
(ii) The division shall assess each hospital, 692
nursing facility, and emergency ambulance transportation provider 693
for the sole purpose of financing the state portion of the 694
Medicare Upper Payment Limits Program or other program(s) 695
authorized under this subsection (A)(18)(b). The hospital 696
assessment shall be as provided in Section 43-13-145(4)(a), and 697
the nursing facility and the emergency ambulance transportation 698
assessments, if established, shall be based on Medicaid 699
utilization or other appropriate method, as determined by the 700
division, consistent with federal regulations. The assessments 701
will remain in effect as long as the state participates in the 702
Medicare Upper Payment Limits Program or other program(s) 703
authorized under this subsection (A)(18)(b). In addition to the 704
hospital assessment provided in Section 43-13-145(4)(a), hospitals 705
with physicians participating in the Medicare Upper Payment Limits 706
Program or other program(s) authorized under this subsection 707
(A)(18)(b) shall be required to participate in an 708
intergovernmental transfer or assessment, as determined by the 709
division, for the purpose of financing the state portion of the 710
physician UPL payments or other payment(s) authorized under this 711
subsection (A)(18)(b). 712
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(iii) Subject to approval by the Centers for 713
Medicare and Medicaid Services (CMS) and the provisions of this 714
subsection (A)(18)(b), the division shall make additional 715
reimbursement to hospitals, nursing facilities, and emergency 716
ambulance transportation providers for the Medicare Upper Payment 717
Limits Program or other program(s) authorized under this 718
subsection (A)(18)(b), and, if the program is established for 719
physicians, shall make additional reimbursement for physicians, as 720
defined in Section 1902(a)(30) of the federal Social Security Act 721
and any applicable federal regulations, provided the assessment in 722
this subsection (A)(18)(b) is in effect. 723
(iv) Notwithstanding any other provision of 724
this article to the contrary, effective upon implementation of the 725
Mississippi Hospital Access Program (MHAP) provided in 726
subparagraph (c)(i) below, the hospital portion of the inpatient 727
Upper Payment Limits Program shall transition into and be replaced 728
by the MHAP program. However, the division is authorized to 729
develop and implement an alternative fee-for-service Upper Payment 730
Limits model in accordance with federal laws and regulations if 731
necessary to preserve supplemental funding. Further, the 732
division, in consultation with the hospital industry shall develop 733
alternative models for distribution of medical claims and 734
supplemental payments for inpatient and outpatient hospital 735
services, and such models may include, but shall not be limited to 736
the following: increasing rates for inpatient and outpatient 737
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services; creating a low-income utilization pool of funds to 738
reimburse hospitals for the costs of uncompensated care, charity 739
care and bad debts as permitted and approved pursuant to federal 740
regulations and the Centers for Medicare and Medicaid Services; 741
supplemental payments based upon Medicaid utilization, quality, 742
service lines and/or costs of providing such services to Medicaid 743
beneficiaries and to uninsured patients. The goals of such 744
payment models shall be to ensure access to inpatient and 745
outpatient care and to maximize any federal funds that are 746
available to reimburse hospitals for services provided. Any such 747
documents required to achieve the goals described in this 748
paragraph shall be submitted to the Centers for Medicare and 749
Medicaid Services, with a proposed effective date of July 1, 2019, 750
to the extent possible, but in no event shall the effective date 751
of such payment models be later than July 1, 2020. The Chairmen 752
of the Senate and House Medicaid Committees shall be provided a 753
copy of the proposed payment model(s) prior to submission. 754
Effective July 1, 2018, and until such time as any payment 755
model(s) as described above become effective, the division, in 756
consultation with the hospital industry, is authorized to 757
implement a transitional program for inpatient and outpatient 758
payments and/or supplemental payments (including, but not limited 759
to, MHAP and directed payments), to redistribute available 760
supplemental funds among hospital providers, provided that when 761
compared to a hospital's prior year supplemental payments, 762
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supplemental payments made pursuant to any such transitional 763
program shall not result in a decrease of more than five percent 764
(5%) and shall not increase by more than the amount needed to 765
maximize the distribution of the available funds. 766
(v) 1. To preserve and improve access to 767
ambulance transportation provider services, the division shall 768
seek CMS approval to make ambulance service access payments as set 769
forth in this subsection (A)(18)(b) for all covered emergency 770
ambulance services rendered on or after July 1, 2022, and shall 771
make such ambulance service access payments for all covered 772
services rendered on or after the effective date of CMS approval. 773
2. The division shall calculate the 774
ambulance service access payment amount as the balance of the 775
portion of the Medical Care Fund related to ambulance 776
transportation service provider assessments plus any federal 777
matching funds earned on the balance, up to, but not to exceed, 778
the upper payment limit gap for all emergency ambulance service 779
providers. 780
3. a. Except for ambulance services 781
exempt from the assessment provided in this paragraph (18)(b), all 782
ambulance transportation service providers shall be eligible for 783
ambulance service access payments each state fiscal year as set 784
forth in this paragraph (18)(b). 785
b. In addition to any other funds 786
paid to ambulance transportation service providers for emergency 787
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medical services provided to Medicaid beneficiaries, each eligible 788
ambulance transportation service provider shall receive ambulance 789
service access payments each state fiscal year equal to the 790
ambulance transportation service provider's upper payment limit 791
gap. Subject to approval by the Centers for Medicare and Medicaid 792
Services, ambulance service access payments shall be made no less 793
than on a quarterly basis. 794
c. As used in this paragraph 795
(18)(b)(v), the term "upper payment limit gap" means the 796
difference between the total amount that the ambulance 797
transportation service provider received from Medicaid and the 798
average amount that the ambulance transportation service provider 799
would have received from commercial insurers for those services 800
reimbursed by Medicaid. 801
4. An ambulance service access payment 802
shall not be used to offset any other payment by the division for 803
emergency or nonemergency services to Medicaid beneficiaries. 804
(c) (i) Not later than December l, 2015, the 805
division shall, subject to approval by the Centers for Medicare 806
and Medicaid Services (CMS), establish, implement and operate a 807
Mississippi Hospital Access Program (MHAP) for the purpose of 808
protecting patient access to hospital care through hospital 809
inpatient reimbursement programs provided in this section designed 810
to maintain total hospital reimbursement for inpatient services 811
rendered by in-state hospitals and the out-of-state hospital that 812
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is authorized by federal law to submit intergovernmental transfers 813
(IGTs) to the State of Mississippi and is classified as Level I 814
trauma center located in a county contiguous to the state line at 815
the maximum levels permissible under applicable federal statutes 816
and regulations, at which time the current inpatient Medicare 817
Upper Payment Limits (UPL) Program for hospital inpatient services 818
shall transition to the MHAP. 819
(ii) Subject to approval by the Centers for 820
Medicare and Medicaid Services (CMS), the MHAP shall provide 821
increased inpatient capitation (PMPM) payments to managed care 822
entities contracting with the division pursuant to subsection (H) 823
of this section to support availability of hospital services or 824
such other payments permissible under federal law necessary to 825
accomplish the intent of this subsection. 826
(iii) The intent of this subparagraph (c) is 827
that effective for all inpatient hospital Medicaid services during 828
state fiscal year 2016, and so long as this provision shall remain 829
in effect hereafter, the division shall to the fullest extent 830
feasible replace the additional reimbursement for hospital 831
inpatient services under the inpatient Medicare Upper Payment 832
Limits (UPL) Program with additional reimbursement under the MHAP 833
and other payment programs for inpatient and/or outpatient 834
payments which may be developed under the authority of this 835
paragraph. 836
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(iv) The division shall assess each hospital 837
as provided in Section 43-13-145(4)(a) for the purpose of 838
financing the state portion of the MHAP, supplemental payments and 839
such other purposes as specified in Section 43-13-145. The 840
assessment will remain in effect as long as the MHAP and 841
supplemental payments are in effect. 842
(19) (a) Perinatal risk management services. The 843
division shall promulgate regulations to be effective from and 844
after October 1, 1988, to establish a comprehensive perinatal 845
system for risk assessment of all pregnant and infant Medicaid 846
recipients and for management, education and follow-up for those 847
who are determined to be at risk. Services to be performed 848
include case management, nutrition assessment/counseling, 849
psychosocial assessment/counseling and health education. The 850
division shall contract with the State Department of Health to 851
provide services within this paragraph (Perinatal High Risk 852
Management/Infant Services System (PHRM/ISS)). The State 853
Department of Health shall be reimbursed on a full reasonable cost 854
basis for services provided under this subparagraph (a). 855
(b) Early intervention system services. The 856
division shall cooperate with the State Department of Health, 857
acting as lead agency, in the development and implementation of a 858
statewide system of delivery of early intervention services, under 859
Part C of the Individuals with Disabilities Education Act (IDEA). 860
The State Department of Health shall certify annually in writing 861
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to the executive director of the division the dollar amount of 862
state early intervention funds available that will be utilized as 863
a certified match for Medicaid matching funds. Those funds then 864
shall be used to provide expanded targeted case management 865
services for Medicaid eligible children with special needs who are 866
eligible for the state's early intervention system. 867
Qualifications for persons providing service coordination shall be 868
determined by the State Department of Health and the Division of 869
Medicaid. 870
(20) Home- and community-based services for physically 871
disabled approved services as allowed by a waiver from the United 872
States Department of Health and Human Services for home- and 873
community-based services for physically disabled people using 874
state funds that are provided from the appropriation to the State 875
Department of Rehabilitation Services and used to match federal 876
funds under a cooperative agreement between the division and the 877
department, provided that funds for these services are 878
specifically appropriated to the Department of Rehabilitation 879
Services. 880
(21) Nurse practitioner services. Services furnished 881
by a registered nurse who is licensed and certified by the 882
Mississippi Board of Nursing as a nurse practitioner, including, 883
but not limited to, nurse anesthetists, nurse midwives, family 884
nurse practitioners, family planning nurse practitioners, 885
pediatric nurse practitioners, obstetrics-gynecology nurse 886
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practitioners and neonatal nurse practitioners, under regulations 887
adopted by the division. Reimbursement for those services shall 888
not exceed ninety percent (90%) of the reimbursement rate for 889
comparable services rendered by a physician. The division may 890
provide for a reimbursement rate for nurse practitioner services 891
of up to one hundred percent (100%) of the reimbursement rate for 892
comparable services rendered by a physician for nurse practitioner 893
services that are provided after the normal working hours of the 894
nurse practitioner, as determined in accordance with regulations 895
of the division. 896
(22) Ambulatory services delivered in federally 897
qualified health centers, rural health centers and clinics of the 898
local health departments of the State Department of Health for 899
individuals eligible for Medicaid under this article based on 900
reasonable costs as determined by the division. Federally 901
qualified health centers shall be reimbursed by the Medicaid 902
prospective payment system as approved by the Centers for Medicare 903
and Medicaid Services. The division shall recognize federally 904
qualified health centers (FQHCs), rural health clinics (RHCs) and 905
community mental health centers (CMHCs) as both an originating and 906
distant site provider for the purposes of telehealth 907
reimbursement. The division is further authorized and directed to 908
reimburse FQHCs, RHCs and CMHCs for both distant site and 909
originating site services when such services are appropriately 910
provided by the same organization. 911
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(23) Inpatient psychiatric services. 912
(a) Inpatient psychiatric services to be 913
determined by the division for recipients under age twenty-one 914
(21) that are provided under the direction of a physician in an 915
inpatient program in a licensed acute care psychiatric facility or 916
in a licensed psychiatric residential treatment facility, before 917
the recipient reaches age twenty-one (21) or, if the recipient was 918
receiving the services immediately before he or she reached age 919
twenty-one (21), before the earlier of the date he or she no 920
longer requires the services or the date he or she reaches age 921
twenty-two (22), as provided by federal regulations. From and 922
after January 1, 2015, the division shall update the fair rental 923
reimbursement system for psychiatric residential treatment 924
facilities. Precertification of inpatient days and residential 925
treatment days must be obtained as required by the division. From 926
and after July 1, 2009, all state-owned and state-operated 927
facilities that provide inpatient psychiatric services to persons 928
under age twenty-one (21) who are eligible for Medicaid 929
reimbursement shall be reimbursed for those services on a full 930
reasonable cost basis. 931
(b) The division may reimburse for services 932
provided by a licensed freestanding psychiatric hospital to 933
Medicaid recipients over the age of twenty-one (21) in a method 934
and manner consistent with the provisions of Section 43-13-117.5. 935
(24) [Deleted] 936
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(25) [Deleted] 937
(26) Hospice care. As used in this paragraph, the term 938
"hospice care" means a coordinated program of active professional 939
medical attention within the home and outpatient and inpatient 940
care that treats the terminally ill patient and family as a unit, 941
employing a medically directed interdisciplinary team. The 942
program provides relief of severe pain or other physical symptoms 943
and supportive care to meet the special needs arising out of 944
physical, psychological, spiritual, social and economic stresses 945
that are experienced during the final stages of illness and during 946
dying and bereavement and meets the Medicare requirements for 947
participation as a hospice as provided in federal regulations. 948
(27) Group health plan premiums and cost-sharing if it 949
is cost-effective as defined by the United States Secretary of 950
Health and Human Services. 951
(28) Other health insurance premiums that are 952
cost-effective as defined by the United States Secretary of Health 953
and Human Services. Medicare eligible must have Medicare Part B 954
before other insurance premiums can be paid. 955
(29) The Division of Medicaid may apply for a waiver 956
from the United States Department of Health and Human Services for 957
home- and community-based services for developmentally disabled 958
people using state funds that are provided from the appropriation 959
to the State Department of Mental Health and/or funds transferred 960
to the department by a political subdivision or instrumentality of 961
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the state and used to match federal funds under a cooperative 962
agreement between the division and the department, provided that 963
funds for these services are specifically appropriated to the 964
Department of Mental Health and/or transferred to the department 965
by a political subdivision or instrumentality of the state. 966
(30) Pediatric skilled nursing services as determined 967
by the division and in a manner consistent with regulations 968
promulgated by the Mississippi State Department of Health. 969
(31) Targeted case management services for children 970
with special needs, under waivers from the United States 971
Department of Health and Human Services, using state funds that 972
are provided from the appropriation to the Mississippi Department 973
of Human Services and used to match federal funds under a 974
cooperative agreement between the division and the department. 975
(32) Care and services provided in Christian Science 976
Sanatoria listed and certified by the Commission for Accreditation 977
of Christian Science Nursing Organizations/Facilities, Inc., 978
rendered in connection with treatment by prayer or spiritual means 979
to the extent that those services are subject to reimbursement 980
under Section 1903 of the federal Social Security Act. 981
(33) Podiatrist services. 982
(34) Assisted living services as provided through 983
home- and community-based services under Title XIX of the federal 984
Social Security Act, as amended, subject to the availability of 985
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funds specifically appropriated for that purpose by the 986
Legislature. 987
(35) Services and activities authorized in Sections 988
43-27-101 and 43-27-103, using state funds that are provided from 989
the appropriation to the Mississippi Department of Human Services 990
and used to match federal funds under a cooperative agreement 991
between the division and the department. 992
(36) Nonemergency transportation services for 993
Medicaid-eligible persons as determined by the division. The PEER 994
Committee shall conduct a performance evaluation of the 995
nonemergency transportation program to evaluate the administration 996
of the program and the providers of transportation services to 997
determine the most cost-effective ways of providing nonemergency 998
transportation services to the patients served under the program. 999
The performance evaluation shall be completed and provided to the 1000
members of the Senate Medicaid Committee and the House Medicaid 1001
Committee not later than January 1, 2019, and every two (2) years 1002
thereafter. 1003
(37) [Deleted] 1004
(38) Chiropractic services. A chiropractor's manual 1005
manipulation of the spine to correct a subluxation, if x-ray 1006
demonstrates that a subluxation exists and if the subluxation has 1007
resulted in a neuromusculoskeletal condition for which 1008
manipulation is appropriate treatment, and related spinal x-rays 1009
performed to document these conditions. Reimbursement for 1010
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chiropractic services shall not exceed Seven Hundred Dollars 1011
($700.00) per year per beneficiary. 1012
(39) Dually eligible Medicare/Medicaid beneficiaries. 1013
The division shall pay the Medicare deductible and coinsurance 1014
amounts for services available under Medicare, as determined by 1015
the division. From and after July 1, 2009, the division shall 1016
reimburse crossover claims for inpatient hospital services and 1017
crossover claims covered under Medicare Part B in the same manner 1018
that was in effect on January 1, 2008, unless specifically 1019
authorized by the Legislature to change this method. 1020
(40) [Deleted] 1021
(41) Services provided by the State Department of 1022
Rehabilitation Services for the care and rehabilitation of persons 1023
with spinal cord injuries or traumatic brain injuries, as allowed 1024
under waivers from the United States Department of Health and 1025
Human Services, using up to seventy-five percent (75%) of the 1026
funds that are appropriated to the Department of Rehabilitation 1027
Services from the Spinal Cord and Head Injury Trust Fund 1028
established under Section 37-33-261 and used to match federal 1029
funds under a cooperative agreement between the division and the 1030
department. 1031
(42) [Deleted] 1032
(43) The division shall provide reimbursement, 1033
according to a payment schedule developed by the division, for 1034
smoking cessation medications for pregnant women during their 1035
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pregnancy and other Medicaid-eligible women who are of 1036
child-bearing age. 1037
(44) Nursing facility services for the severely 1038
disabled. 1039
(a) Severe disabilities include, but are not 1040
limited to, spinal cord injuries, closed-head injuries and 1041
ventilator-dependent patients. 1042
(b) Those services must be provided in a long-term 1043
care nursing facility dedicated to the care and treatment of 1044
persons with severe disabilities. 1045
(45) Physician assistant services. Services furnished 1046
by a physician assistant who is licensed by the State Board of 1047
Medical Licensure and is practicing with physician supervision 1048
under regulations adopted by the board, under regulations adopted 1049
by the division. Reimbursement for those services shall not 1050
exceed ninety percent (90%) of the reimbursement rate for 1051
comparable services rendered by a physician. The division may 1052
provide for a reimbursement rate for physician assistant services 1053
of up to one hundred percent (100%) or the reimbursement rate for 1054
comparable services rendered by a physician for physician 1055
assistant services that are provided after the normal working 1056
hours of the physician assistant, as determined in accordance with 1057
regulations of the division. 1058
(46) The division shall make application to the federal 1059
Centers for Medicare and Medicaid Services (CMS) for a waiver to 1060
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develop and provide services for children with serious emotional 1061
disturbances as defined in Section 43-14-1(1), which may include 1062
home- and community-based services, case management services or 1063
managed care services through mental health providers certified by 1064
the Department of Mental Health. The division may implement and 1065
provide services under this waivered program only if funds for 1066
these services are specifically appropriated for this purpose by 1067
the Legislature, or if funds are voluntarily provided by affected 1068
agencies. 1069
(47) (a) The division may develop and implement 1070
disease management programs for individuals with high-cost chronic 1071
diseases and conditions, including the use of grants, waivers, 1072
demonstrations or other projects as necessary. 1073
(b) Participation in any disease management 1074
program implemented under this paragraph (47) is optional with the 1075
individual. An individual must affirmatively elect to participate 1076
in the disease management program in order to participate, and may 1077
elect to discontinue participation in the program at any time. 1078
(48) Pediatric long-term acute care hospital services. 1079
(a) Pediatric long-term acute care hospital 1080
services means services provided to eligible persons under 1081
twenty-one (21) years of age by a freestanding Medicare-certified 1082
hospital that has an average length of inpatient stay greater than 1083
twenty-five (25) days and that is primarily engaged in providing 1084
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chronic or long-term medical care to persons under twenty-one (21) 1085
years of age. 1086
(b) The services under this paragraph (48) shall 1087
be reimbursed as a separate category of hospital services. 1088
(49) The division may establish copayments and/or 1089
coinsurance for any Medicaid services for which copayments and/or 1090
coinsurance are allowable under federal law or regulation. 1091
(50) Services provided by the State Department of 1092
Rehabilitation Services for the care and rehabilitation of persons 1093
who are deaf and blind, as allowed under waivers from the United 1094
States Department of Health and Human Services to provide home- 1095
and community-based services using state funds that are provided 1096
from the appropriation to the State Department of Rehabilitation 1097
Services or if funds are voluntarily provided by another agency. 1098
(51) Upon determination of Medicaid eligibility and in 1099
association with annual redetermination of Medicaid eligibility, 1100
beneficiaries shall be encouraged to undertake a physical 1101
examination that will establish a base-line level of health and 1102
identification of a usual and customary source of care (a medical 1103
home) to aid utilization of disease management tools. This 1104
physical examination and utilization of these disease management 1105
tools shall be consistent with current United States Preventive 1106
Services Task Force or other recognized authority recommendations. 1107
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For persons who are determined ineligible for Medicaid, the 1108
division will provide information and direction for accessing 1109
medical care and services in the area of their residence. 1110
(52) Notwithstanding any provisions of this article, 1111
the division may pay enhanced reimbursement fees related to trauma 1112
care, as determined by the division in conjunction with the State 1113
Department of Health, using funds appropriated to the State 1114
Department of Health for trauma care and services and used to 1115
match federal funds under a cooperative agreement between the 1116
division and the State Department of Health. The division, in 1117
conjunction with the State Department of Health, may use grants, 1118
waivers, demonstrations, enhanced reimbursements, Upper Payment 1119
Limits Programs, supplemental payments, or other projects as 1120
necessary in the development and implementation of this 1121
reimbursement program. 1122
(53) Targeted case management services for high-cost 1123
beneficiaries may be developed by the division for all services 1124
under this section. 1125
(54) [Deleted] 1126
(55) Therapy services. The plan of care for therapy 1127
services may be developed to cover a period of treatment for up to 1128
six (6) months, but in no event shall the plan of care exceed a 1129
six-month period of treatment. The projected period of treatment 1130
must be indicated on the initial plan of care and must be updated 1131
with each subsequent revised plan of care. Based on medical 1132
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necessity, the division shall approve certification periods for 1133
less than or up to six (6) months, but in no event shall the 1134
certification period exceed the period of treatment indicated on 1135
the plan of care. The appeal process for any reduction in therapy 1136
services shall be consistent with the appeal process in federal 1137
regulations. 1138
(56) Prescribed pediatric extended care centers 1139
services for medically dependent or technologically dependent 1140
children with complex medical conditions that require continual 1141
care as prescribed by the child's attending physician, as 1142
determined by the division. 1143
(57) No Medicaid benefit shall restrict coverage for 1144
medically appropriate treatment prescribed by a physician and 1145
agreed to by a fully informed individual, or if the individual 1146
lacks legal capacity to consent by a person who has legal 1147
authority to consent on his or her behalf, based on an 1148
individual's diagnosis with a terminal condition. As used in this 1149
paragraph (57), "terminal condition" means any aggressive 1150
malignancy, chronic end-stage cardiovascular or cerebral vascular 1151
disease, or any other disease, illness or condition which a 1152
physician diagnoses as terminal. 1153
(58) Treatment services for persons with opioid 1154
dependency or other highly addictive substance use disorders. The 1155
division is authorized to reimburse eligible providers for 1156
treatment of opioid dependency and other highly addictive 1157
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substance use disorders, as determined by the division. Treatment 1158
related to these conditions shall not count against any physician 1159
visit limit imposed under this section. 1160
(59) The division shall allow beneficiaries between the 1161
ages of ten (10) and eighteen (18) years to receive vaccines 1162
through a pharmacy venue. The division and the State Department 1163
of Health shall coordinate and notify OB-GYN providers that the 1164
Vaccines for Children program is available to providers free of 1165
charge. 1166
(60) Border city university-affiliated pediatric 1167
teaching hospital. 1168
(a) Payments may only be made to a border city 1169
university-affiliated pediatric teaching hospital if the Centers 1170
for Medicare and Medicaid Services (CMS) approve an increase in 1171
the annual request for the provider payment initiative authorized 1172
under 42 CFR Section 438.6(c) in an amount equal to or greater 1173
than the estimated annual payment to be made to the border city 1174
university-affiliated pediatric teaching hospital. The estimate 1175
shall be based on the hospital's prior year Mississippi managed 1176
care utilization. 1177
(b) As used in this paragraph (60), the term 1178
"border city university-affiliated pediatric teaching hospital" 1179
means an out-of-state hospital located within a city bordering the 1180
eastern bank of the Mississippi River and the State of Mississippi 1181
that submits to the division a copy of a current and effective 1182
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affiliation agreement with an accredited university and other 1183
documentation establishing that the hospital is 1184
university-affiliated, is licensed and designated as a pediatric 1185
hospital or pediatric primary hospital within its home state, 1186
maintains at least five (5) different pediatric specialty training 1187
programs, and maintains at least one hundred (100) operated beds 1188
dedicated exclusively for the treatment of patients under the age 1189
of twenty-one (21) years. 1190
(c) The cost of providing services to Mississippi 1191
Medicaid beneficiaries under the age of twenty-one (21) years who 1192
are treated by a border city university-affiliated pediatric 1193
teaching hospital shall not exceed the cost of providing the same 1194
services to individuals in hospitals in the state. 1195
(d) It is the intent of the Legislature that 1196
payments shall not result in any in-state hospital receiving 1197
payments lower than they would otherwise receive if not for the 1198
payments made to any border city university-affiliated pediatric 1199
teaching hospital. 1200
(e) This paragraph (60) shall stand repealed on 1201
July 1, 2024. 1202
(61) Services described in Section 41-140-3 that are 1203
provided by certified community health workers employed and 1204
supervised by a Medicaid provider. Reimbursement for these 1205
services shall be provided only if the division has received 1206
approval from the Centers for Medicare and Medicaid Services for a 1207
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state plan amendment, waiver or alternative payment model for 1208
services delivered by certified community health workers. 1209
(62) Beginning July 1, 2026, essential health benefits 1210
as described in the federal Patient Protection and Affordable Care 1211
Act of 2010 and as amended, for individuals eligible for Medicaid 1212
under the federal Patient Protection and Affordable Care Act of 1213
2010, as amended, as described in Section 43-13-115(29). These 1214
services shall be provided only as long as the Medicaid federal 1215
matching percentage is not less than ninety percent (90%) for 1216
Medicaid services to this population. This paragraph (62) shall 1217
stand repealed on December 31, 2028. 1218
(B) Planning and development districts participating in the 1219
home- and community-based services program for the elderly and 1220
disabled as case management providers shall be reimbursed for case 1221
management services at the maximum rate approved by the Centers 1222
for Medicare and Medicaid Services (CMS). 1223
(C) The division may pay to those providers who participate 1224
in and accept patient referrals from the division's emergency room 1225
redirection program a percentage, as determined by the division, 1226
of savings achieved according to the performance measures and 1227
reduction of costs required of that program. Federally qualified 1228
health centers may participate in the emergency room redirection 1229
program, and the division may pay those centers a percentage of 1230
any savings to the Medicaid program achieved by the centers' 1231
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accepting patient referrals through the program, as provided in 1232
this subsection (C). 1233
(D) (1) As used in this subsection (D), the following terms 1234
shall be defined as provided in this paragraph, except as 1235
otherwise provided in this subsection: 1236
(a) "Committees" means the Medicaid Committees of 1237
the House of Representatives and the Senate, and "committee" means 1238
either one of those committees. 1239
(b) "Rate change" means an increase, decrease or 1240
other change in the payments or rates of reimbursement, or a 1241
change in any payment methodology that results in an increase, 1242
decrease or other change in the payments or rates of 1243
reimbursement, to any Medicaid provider that renders any services 1244
authorized to be provided to Medicaid recipients under this 1245
article. 1246
(2) Whenever the Division of Medicaid proposes a rate 1247
change, the division shall give notice to the chairmen of the 1248
committees at least thirty (30) calendar days before the proposed 1249
rate change is scheduled to take effect. The division shall 1250
furnish the chairmen with a concise summary of each proposed rate 1251
change along with the notice, and shall furnish the chairmen with 1252
a copy of any proposed rate change upon request. The division 1253
also shall provide a summary and copy of any proposed rate change 1254
to any other member of the Legislature upon request. 1255
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(3) If the chairman of either committee or both 1256
chairmen jointly object to the proposed rate change or any part 1257
thereof, the chairman or chairmen shall notify the division and 1258
provide the reasons for their objection in writing not later than 1259
seven (7) calendar days after receipt of the notice from the 1260
division. The chairman or chairmen may make written 1261
recommendations to the division for changes to be made to a 1262
proposed rate change. 1263
(4) (a) The chairman of either committee or both 1264
chairmen jointly may hold a committee meeting to review a proposed 1265
rate change. If either chairman or both chairmen decide to hold a 1266
meeting, they shall notify the division of their intention in 1267
writing within seven (7) calendar days after receipt of the notice 1268
from the division, and shall set the date and time for the meeting 1269
in their notice to the division, which shall not be later than 1270
fourteen (14) calendar days after receipt of the notice from the 1271
division. 1272
(b) After the committee meeting, the committee or 1273
committees may object to the proposed rate change or any part 1274
thereof. The committee or committees shall notify the division 1275
and the reasons for their objection in writing not later than 1276
seven (7) calendar days after the meeting. The committee or 1277
committees may make written recommendations to the division for 1278
changes to be made to a proposed rate change. 1279
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(5) If both chairmen notify the division in writing 1280
within seven (7) calendar days after receipt of the notice from 1281
the division that they do not object to the proposed rate change 1282
and will not be holding a meeting to review the proposed rate 1283
change, the proposed rate change will take effect on the original 1284
date as scheduled by the division or on such other date as 1285
specified by the division. 1286
(6) (a) If there are any objections to a proposed rate 1287
change or any part thereof from either or both of the chairmen or 1288
the committees, the division may withdraw the proposed rate 1289
change, make any of the recommended changes to the proposed rate 1290
change, or not make any changes to the proposed rate change. 1291
(b) If the division does not make any changes to 1292
the proposed rate change, it shall notify the chairmen of that 1293
fact in writing, and the proposed rate change shall take effect on 1294
the original date as scheduled by the division or on such other 1295
date as specified by the division. 1296
(c) If the division makes any changes to the 1297
proposed rate change, the division shall notify the chairmen of 1298
its actions in writing, and the revised proposed rate change shall 1299
take effect on the date as specified by the division. 1300
(7) Nothing in this subsection (D) shall be construed 1301
as giving the chairmen or the committees any authority to veto, 1302
nullify or revise any rate change proposed by the division. The 1303
authority of the chairmen or the committees under this subsection 1304
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shall be limited to reviewing, making objections to and making 1305
recommendations for changes to rate changes proposed by the 1306
division. 1307
(E) Notwithstanding any provision of this article, no new 1308
groups or categories of recipients and new types of care and 1309
services may be added without enabling legislation from the 1310
Mississippi Legislature, except that the division may authorize 1311
those changes without enabling legislation when the addition of 1312
recipients or services is ordered by a court of proper authority. 1313
(F) The executive director shall keep the Governor advised 1314
on a timely basis of the funds available for expenditure and the 1315
projected expenditures. Notwithstanding any other provisions of 1316
this article, if current or projected expenditures of the division 1317
are reasonably anticipated to exceed the amount of funds 1318
appropriated to the division for any fiscal year, the Governor, 1319
after consultation with the executive director, shall take all 1320
appropriate measures to reduce costs, which may include, but are 1321
not limited to: 1322
(1) Reducing or discontinuing any or all services that 1323
are deemed to be optional under Title XIX of the Social Security 1324
Act; 1325
(2) Reducing reimbursement rates for any or all service 1326
types; 1327
(3) Imposing additional assessments on health care 1328
providers; or 1329
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(4) Any additional cost-containment measures deemed 1330
appropriate by the Governor. 1331
To the extent allowed under federal law, any reduction to 1332
services or reimbursement rates under this subsection (F) shall be 1333
accompanied by a reduction, to the fullest allowable amount, to 1334
the profit margin and administrative fee portions of capitated 1335
payments to organizations described in paragraph (1) of subsection 1336
(H). 1337
Beginning in fiscal year 2010 and in fiscal years thereafter, 1338
when Medicaid expenditures are projected to exceed funds available 1339
for the fiscal year, the division shall submit the expected 1340
shortfall information to the PEER Committee not later than 1341
December 1 of the year in which the shortfall is projected to 1342
occur. PEER shall review the computations of the division and 1343
report its findings to the Legislative Budget Office not later 1344
than January 7 in any year. 1345
(G) Notwithstanding any other provision of this article, it 1346
shall be the duty of each provider participating in the Medicaid 1347
program to keep and maintain books, documents and other records as 1348
prescribed by the Division of Medicaid in accordance with federal 1349
laws and regulations. 1350
(H) (1) Notwithstanding any other provision of this 1351
article, the division is authorized to implement (a) a managed 1352
care program, (b) a coordinated care program, (c) a coordinated 1353
care organization program, (d) a health maintenance organization 1354
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program, (e) a patient-centered medical home program, (f) an 1355
accountable care organization program, (g) provider-sponsored 1356
health plan, or (h) any combination of the above programs. As a 1357
condition for the approval of any program under this subsection 1358
(H)(1), the division shall require that no managed care program, 1359
coordinated care program, coordinated care organization program, 1360
health maintenance organization program, or provider-sponsored 1361
health plan may: 1362
(a) Pay providers at a rate that is less than the 1363
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1364
reimbursement rate; 1365
(b) Override the medical decisions of hospital 1366
physicians or staff regarding patients admitted to a hospital for 1367
an emergency medical condition as defined by 42 US Code Section 1368
1395dd. This restriction (b) does not prohibit the retrospective 1369
review of the appropriateness of the determination that an 1370
emergency medical condition exists by chart review or coding 1371
algorithm, nor does it prohibit prior authorization for 1372
nonemergency hospital admissions; 1373
(c) Pay providers at a rate that is less than the 1374
normal Medicaid reimbursement rate. It is the intent of the 1375
Legislature that all managed care entities described in this 1376
subsection (H), in collaboration with the division, develop and 1377
implement innovative payment models that incentivize improvements 1378
in health care quality, outcomes, or value, as determined by the 1379
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division. Participation in the provider network of any managed 1380
care, coordinated care, provider-sponsored health plan, or similar 1381
contractor shall not be conditioned on the provider's agreement to 1382
accept such alternative payment models; 1383
(d) Implement a prior authorization and 1384
utilization review program for medical services, transportation 1385
services and prescription drugs that is more stringent than the 1386
prior authorization processes used by the division in its 1387
administration of the Medicaid program. Not later than December 1388
2, 2021, the contractors that are receiving capitated payments 1389
under a managed care delivery system established under this 1390
subsection (H) shall submit a report to the Chairmen of the House 1391
and Senate Medicaid Committees on the status of the prior 1392
authorization and utilization review program for medical services, 1393
transportation services and prescription drugs that is required to 1394
be implemented under this subparagraph (d); 1395
(e) [Deleted] 1396
(f) Implement a preferred drug list that is more 1397
stringent than the mandatory preferred drug list established by 1398
the division under subsection (A)(9) of this section; 1399
(g) Implement a policy which denies beneficiaries 1400
with hemophilia access to the federally funded hemophilia 1401
treatment centers as part of the Medicaid Managed Care network of 1402
providers. 1403
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Each health maintenance organization, coordinated care 1404
organization, provider-sponsored health plan, or other 1405
organization paid for services on a capitated basis by the 1406
division under any managed care program or coordinated care 1407
program implemented by the division under this section shall use a 1408
clear set of level of care guidelines in the determination of 1409
medical necessity and in all utilization management practices, 1410
including the prior authorization process, concurrent reviews, 1411
retrospective reviews and payments, that are consistent with 1412
widely accepted professional standards of care. Organizations 1413
participating in a managed care program or coordinated care 1414
program implemented by the division may not use any additional 1415
criteria that would result in denial of care that would be 1416
determined appropriate and, therefore, medically necessary under 1417
those levels of care guidelines. 1418
(2) Notwithstanding any provision of this section, the 1419
recipients eligible for enrollment into a Medicaid Managed Care 1420
Program authorized under this subsection (H) may include only 1421
those categories of recipients eligible for participation in the 1422
Medicaid Managed Care Program as of January 1, 2021, the 1423
Children's Health Insurance Program (CHIP), and the CMS-approved 1424
Section 1115 demonstration waivers in operation as of January 1, 1425
2021. No expansion of Medicaid Managed Care Program contracts may 1426
be implemented by the division without enabling legislation from 1427
the Mississippi Legislature. 1428
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(3) (a) Any contractors receiving capitated payments 1429
under a managed care delivery system established in this section 1430
shall provide to the Legislature and the division statistical data 1431
to be shared with provider groups in order to improve patient 1432
access, appropriate utilization, cost savings and health outcomes 1433
not later than October 1 of each year. Additionally, each 1434
contractor shall disclose to the Chairmen of the Senate and House 1435
Medicaid Committees the administrative expenses costs for the 1436
prior calendar year, and the number of full-equivalent employees 1437
located in the State of Mississippi dedicated to the Medicaid and 1438
CHIP lines of business as of June 30 of the current year. 1439
(b) The division and the contractors participating 1440
in the managed care program, a coordinated care program or a 1441
provider-sponsored health plan shall be subject to annual program 1442
reviews or audits performed by the Office of the State Auditor, 1443
the PEER Committee, the Department of Insurance and/or independent 1444
third parties. 1445
(c) Those reviews shall include, but not be 1446
limited to, at least two (2) of the following items: 1447
(i) The financial benefit to the State of 1448
Mississippi of the managed care program, 1449
(ii) The difference between the premiums paid 1450
to the managed care contractors and the payments made by those 1451
contractors to health care providers, 1452
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(iii) Compliance with performance measures 1453
required under the contracts, 1454
(iv) Administrative expense allocation 1455
methodologies, 1456
(v) Whether nonprovider payments assigned as 1457
medical expenses are appropriate, 1458
(vi) Capitated arrangements with related 1459
party subcontractors, 1460
(vii) Reasonableness of corporate 1461
allocations, 1462
(viii) Value-added benefits and the extent to 1463
which they are used, 1464
(ix) The effectiveness of subcontractor 1465
oversight, including subcontractor review, 1466
(x) Whether health care outcomes have been 1467
improved, and 1468
(xi) The most common claim denial codes to 1469
determine the reasons for the denials. 1470
The audit reports shall be considered public documents and 1471
shall be posted in their entirety on the division's website. 1472
(4) All health maintenance organizations, coordinated 1473
care organizations, provider-sponsored health plans, or other 1474
organizations paid for services on a capitated basis by the 1475
division under any managed care program or coordinated care 1476
program implemented by the division under this section shall 1477
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reimburse all providers in those organizations at rates no lower 1478
than those provided under this section for beneficiaries who are 1479
not participating in those programs. 1480
(5) No health maintenance organization, coordinated 1481
care organization, provider-sponsored health plan, or other 1482
organization paid for services on a capitated basis by the 1483
division under any managed care program or coordinated care 1484
program implemented by the division under this section shall 1485
require its providers or beneficiaries to use any pharmacy that 1486
ships, mails or delivers prescription drugs or legend drugs or 1487
devices. 1488
(6) (a) Not later than December 1, 2021, the 1489
contractors who are receiving capitated payments under a managed 1490
care delivery system established under this subsection (H) shall 1491
develop and implement a uniform credentialing process for 1492
providers. Under that uniform credentialing process, a provider 1493
who meets the criteria for credentialing will be credentialed with 1494
all of those contractors and no such provider will have to be 1495
separately credentialed by any individual contractor in order to 1496
receive reimbursement from the contractor. Not later than 1497
December 2, 2021, those contractors shall submit a report to the 1498
Chairmen of the House and Senate Medicaid Committees on the status 1499
of the uniform credentialing process for providers that is 1500
required under this subparagraph (a). 1501
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(b) If those contractors have not implemented a 1502
uniform credentialing process as described in subparagraph (a) by 1503
December 1, 2021, the division shall develop and implement, not 1504
later than July 1, 2022, a single, consolidated credentialing 1505
process by which all providers will be credentialed. Under the 1506
division's single, consolidated credentialing process, no such 1507
contractor shall require its providers to be separately 1508
credentialed by the contractor in order to receive reimbursement 1509
from the contractor, but those contractors shall recognize the 1510
credentialing of the providers by the division's credentialing 1511
process. 1512
(c) The division shall require a uniform provider 1513
credentialing application that shall be used in the credentialing 1514
process that is established under subparagraph (a) or (b). If the 1515
contractor or division, as applicable, has not approved or denied 1516
the provider credentialing application within sixty (60) days of 1517
receipt of the completed application that includes all required 1518
information necessary for credentialing, then the contractor or 1519
division, upon receipt of a written request from the applicant and 1520
within five (5) business days of its receipt, shall issue a 1521
temporary provider credential/enrollment to the applicant if the 1522
applicant has a valid Mississippi professional or occupational 1523
license to provide the health care services to which the 1524
credential/enrollment would apply. The contractor or the division 1525
shall not issue a temporary credential/enrollment if the applicant 1526
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has reported on the application a history of medical or other 1527
professional or occupational malpractice claims, a history of 1528
substance abuse or mental health issues, a criminal record, or a 1529
history of medical or other licensing board, state or federal 1530
disciplinary action, including any suspension from participation 1531
in a federal or state program. The temporary 1532
credential/enrollment shall be effective upon issuance and shall 1533
remain in effect until the provider's credentialing/enrollment 1534
application is approved or denied by the contractor or division. 1535
The contractor or division shall render a final decision regarding 1536
credentialing/enrollment of the provider within sixty (60) days 1537
from the date that the temporary provider credential/enrollment is 1538
issued to the applicant. 1539
(d) If the contractor or division does not render 1540
a final decision regarding credentialing/enrollment of the 1541
provider within the time required in subparagraph (c), the 1542
provider shall be deemed to be credentialed by and enrolled with 1543
all of the contractors and eligible to receive reimbursement from 1544
the contractors. 1545
(7) (a) Each contractor that is receiving capitated 1546
payments under a managed care delivery system established under 1547
this subsection (H) shall provide to each provider for whom the 1548
contractor has denied the coverage of a procedure that was ordered 1549
or requested by the provider for or on behalf of a patient, a 1550
letter that provides a detailed explanation of the reasons for the 1551
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denial of coverage of the procedure and the name and the 1552
credentials of the person who denied the coverage. The letter 1553
shall be sent to the provider in electronic format. 1554
(b) After a contractor that is receiving capitated 1555
payments under a managed care delivery system established under 1556
this subsection (H) has denied coverage for a claim submitted by a 1557
provider, the contractor shall issue to the provider within sixty 1558
(60) days a final ruling of denial of the claim that allows the 1559
provider to have a state fair hearing and/or agency appeal with 1560
the division. If a contractor does not issue a final ruling of 1561
denial within sixty (60) days as required by this subparagraph 1562
(b), the provider's claim shall be deemed to be automatically 1563
approved and the contractor shall pay the amount of the claim to 1564
the provider. 1565
(c) After a contractor has issued a final ruling 1566
of denial of a claim submitted by a provider, the division shall 1567
conduct a state fair hearing and/or agency appeal on the matter of 1568
the disputed claim between the contractor and the provider within 1569
sixty (60) days, and shall render a decision on the matter within 1570
thirty (30) days after the date of the hearing and/or appeal. 1571
(8) It is the intention of the Legislature that the 1572
division evaluate the feasibility of using a single vendor to 1573
administer pharmacy benefits provided under a managed care 1574
delivery system established under this subsection (H). Providers 1575
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of pharmacy benefits shall cooperate with the division in any 1576
transition to a carve-out of pharmacy benefits under managed care. 1577
(9) The division shall evaluate the feasibility of 1578
using a single vendor to administer dental benefits provided under 1579
a managed care delivery system established in this subsection (H). 1580
Providers of dental benefits shall cooperate with the division in 1581
any transition to a carve-out of dental benefits under managed 1582
care. 1583
(10) It is the intent of the Legislature that any 1584
contractor receiving capitated payments under a managed care 1585
delivery system established in this section shall implement 1586
innovative programs to improve the health and well-being of 1587
members diagnosed with prediabetes and diabetes. 1588
(11) It is the intent of the Legislature that any 1589
contractors receiving capitated payments under a managed care 1590
delivery system established under this subsection (H) shall work 1591
with providers of Medicaid services to improve the utilization of 1592
long-acting reversible contraceptives (LARCs). Not later than 1593
December 1, 2021, any contractors receiving capitated payments 1594
under a managed care delivery system established under this 1595
subsection (H) shall provide to the Chairmen of the House and 1596
Senate Medicaid Committees and House and Senate Public Health 1597
Committees a report of LARC utilization for State Fiscal Years 1598
2018 through 2020 as well as any programs, initiatives, or efforts 1599
made by the contractors and providers to increase LARC 1600
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utilization. This report shall be updated annually to include 1601
information for subsequent state fiscal years. 1602
(12) The division is authorized to make not more than 1603
one (1) emergency extension of the contracts that are in effect on 1604
July 1, 2021, with contractors who are receiving capitated 1605
payments under a managed care delivery system established under 1606
this subsection (H), as provided in this paragraph (12). The 1607
maximum period of any such extension shall be one (1) year, and 1608
under any such extensions, the contractors shall be subject to all 1609
of the provisions of this subsection (H). The extended contracts 1610
shall be revised to incorporate any provisions of this subsection 1611
(H). 1612
(I) [Deleted] 1613
(J) There shall be no cuts in inpatient and outpatient 1614
hospital payments, or allowable days or volumes, as long as the 1615
hospital assessment provided in Section 43-13-145 is in effect. 1616
This subsection (J) shall not apply to decreases in payments that 1617
are a result of: reduced hospital admissions, audits or payments 1618
under the APR-DRG or APC models, or a managed care program or 1619
similar model described in subsection (H) of this section. 1620
(K) In the negotiation and execution of such contracts 1621
involving services performed by actuarial firms, the Executive 1622
Director of the Division of Medicaid may negotiate a limitation on 1623
liability to the state of prospective contractors. 1624
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ST: Medicaid; expand eligibility to include
individuals entitled to benefits under federal
Patient Protection and Affordable Care Act.
(L) The Division of Medicaid shall reimburse for services 1625
provided to eligible Medicaid beneficiaries by a licensed birthing 1626
center in a method and manner to be determined by the division in 1627
accordance with federal laws and federal regulations. The 1628
division shall seek any necessary waivers, make any required 1629
amendments to its State Plan or revise any contracts authorized 1630
under subsection (H) of this section as necessary to provide the 1631
services authorized under this subsection. As used in this 1632
subsection, the term "birthing centers" shall have the meaning as 1633
defined in Section 41-77-1(a), which is a publicly or privately 1634
owned facility, place or institution constructed, renovated, 1635
leased or otherwise established where nonemergency births are 1636
planned to occur away from the mother's usual residence following 1637
a documented period of prenatal care for a normal uncomplicated 1638
pregnancy which has been determined to be low risk through a 1639
formal risk-scoring examination. 1640
(M) This section shall stand repealed on July 1, 2028. 1641
SECTION 3. This act shall take effect and be in force from 1642
and after July 1, 2026. 1643