Medicaid; provide coverage for neonatal circumcision procedures.

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To: Medicaid; Appropriations
A
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Karriem

HOUSE BILL NO. 412

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