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To: Public Health and Human
Services; Insurance
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representatives Creekmore IV, Bell
(65th), Felsher, Owen, Eure, McKnight,
Currie, Scott

HOUSE BILL NO. 565
(As Passed the House)

AN ACT TO BE KNOWN AS THE "JILL GARY EURE ACT" OR "JILL'S 1
LAW"; TO REQUIRE EACH HEALTH BENEFIT PLAN, CONTRACT OR AGREEMENT 2
THAT IS ENTERED INTO OR RENEWED ON OR AFTER JULY 1, 2026, 3
INCLUDING THE MEDICAID PROGRAM AND THE STATE AND SCHOOL EMPLOYEES 4
HEALTH INSURANCE PLAN, TO OFFER COVERAGE FOR BIOMARKER TESTING FOR 5
THE PURPOSES OF DIAGNOSIS, TREATMENT, APPROPRIATE MANAGEMENT, OR 6
ONGOING MONITORING OF AN ENROLLEE'S DISEASE OR CONDITION WHEN USE 7
OF THE TEST IS SUPPORTED BY MEDICAL AND SCIENTIFIC EVIDENCE; TO 8
AMEND SECTIONS 43-13-117 AND 83-5-907, MISSISSIPPI CODE OF 1972, 9
TO CONFORM TO THE PROVISIONS OF THIS ACT; AND FOR RELATED 10
PURPOSES. 11
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 12
SECTION 1. This act shall be known and may be cited as the 13
"Jill Gary Eure Act" or "Jill's Law". 14
SECTION 2. As used in Sections 2 and 3 of this act, the 15
following terms shall be defined as provided in this section: 16
(a) "Biomarker" means a characteristic that is 17
objectively measured and evaluated as an indicator of normal 18
biological processes, pathogenic processes or pharmacologic 19
responses to a specific therapeutic intervention, including known 20
gene-drug interactions for medications being considered for use or 21
already being administered. Biomarkers include, but are not 22
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limited to, gene mutations, characteristics of genes, or protein 23
expression. 24
(b) "Biomarker testing" means the analysis of a 25
patient's tissue, blood or other biospecimen for the presence of a 26
biomarker. Biomarker testing includes, but is not limited to, 27
single-analyte tests, multi-plex panel tests, protein expression, 28
whole exome, whole genome, and whole transcriptome sequencing and 29
other genomic or molecular sequencing. 30
(c) "Consensus statement" means a statement developed 31
by an independent, multidisciplinary panel of experts using a 32
transparent methodology and reporting structure and with a 33
conflict of interest policy. A consensus statement is aimed at 34
specific clinical circumstances and the statement is based on the 35
best available evidence for the purpose of optimizing the outcomes 36
of clinical care. 37
(d) "Health benefit plan" has the meaning given to that 38
term in Section 83-9-6.3, and also includes nonprofit health 39
service plans and the State and School Employees Health Insurance 40
Plan. 41
(e) "Health insurance issuer" has the meaning given to 42
that term in Section 83-9-6.3. 43
(f) "Nationally recognized clinical practice 44
guidelines" means evidence-based clinical practice guidelines 45
developed by independent organizations or medical professional 46
societies using a transparent methodology and reporting structure 47
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and with a conflict of interest policy. Clinical practice 48
guidelines establish standards of care informed by a systematic 49
review of evidence and an assessment of the benefits and risks of 50
alternative care options and include recommendations intended to 51
optimize patient care. 52
SECTION 3. (1) All health benefit plans and any third-party 53
contractor or agent of such entities shall provide coverage for 54
biomarker testing for the purposes of diagnosis, treatment, 55
appropriate management, or ongoing monitoring of an enrollee's 56
disease or condition when use of the test is supported by medical 57
and scientific evidence, including, but not limited to, any one of 58
the following: 59
(a) Labeled indications for an FDA-approved or -cleared 60
test; 61
(b) Indicated tests for an FDA-approved drug; 62
(c) Warnings and precautions on FDA-approved drug 63
labels; 64
(d) Centers for Medicare and Medicaid Services (CMS) 65
National Coverage Determinations or any Medicare Administrative 66
Contractor (MAC) Local Coverage Determinations and associated 67
Local Coverage Articles, regardless of jurisdiction; or 68
(e) Testing recommendations or considerations from a: 69
(i) Nationally recognized clinical practice 70
guideline; or 71
(ii) Consensus statement. 72
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(2) All health benefit plans shall ensure that coverage as 73
required in subsection (1) of this section is provided in a manner 74
that limits disruptions in care including the need for multiple 75
biopsies or biospecimen samples. 76
(3) Health benefit plans and health insurance issuers 77
subject to this section shall update and make publicly available 78
medical policies and coverage guidelines within sixty (60) days 79
after enactment. Any updates or changes to medical policies 80
impacting coverage of biomarker testing must be made publicly 81
available thirty (30) days in advance of the effective date of the 82
updated policy. 83
(4) If a health benefit plan or health insurance issuer 84
denies a claim for coverage of testing that is supported by any 85
evidence in subsection (1) of this section, the health benefit 86
plan or health insurance issuer shall provide to the requesting 87
entity, whether it is the provider, individual or laboratory, 88
specific written justification explaining in detail why the claim 89
for coverage was denied as it pertains to the individual for whom 90
the test was ordered. 91
(5) If utilization review, including, but not limited to, 92
prior authorization, is required, the health benefit plan, 93
utilization review entity or any third party acting on behalf of 94
an organization or entity subject to Sections 2 and 3 of this act 95
shall approve or deny a prior authorization request and notify the 96
enrollee, the enrollee's health care provider, and any entity 97
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requesting authorization of the service within the timeframe 98
established in Section 83-5-913 for nonurgent requests and Section 99
83-5-915 for urgent requests. 100
(6) If prior authorization is required, requests for 101
biomarker tests may be submitted by: 102
(a) The ordering or treating provider; 103
(b) The rendering laboratory provider; or 104
(c) The enrollee or enrollee's representative. 105
(7) In addition to the provisions of Section 83-5-901 et 106
seq., a patient and prescribing practitioner shall have access to 107
a clear, readily accessible, and convenient process to request an 108
exception to a coverage policy or an adverse utilization review 109
determination of a health benefit plan or health insurance issuer. 110
The process shall be made readily accessible on the health benefit 111
plan's or health insurance issuer's website. 112
(8) The Department of Insurance may conduct periodic audits 113
and reviews to ensure entity compliance with Sections 2 and 3 of 114
this act. 115
(9) Sections 2 and 3 of this act shall apply to all health 116
benefit plans, contracts or agreements that are entered into or 117
renewed on or after July 1, 2026. 118
SECTION 4. Section 43-13-117, Mississippi Code of 1972, is 119
amended as follows: 120
43-13-117. (A) Medicaid as authorized by this article shall 121
include payment of part or all of the costs, at the discretion of 122
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the division, with approval of the Governor and the Centers for 123
Medicare and Medicaid Services, of the following types of care and 124
services rendered to eligible applicants who have been determined 125
to be eligible for that care and services, within the limits of 126
state appropriations and federal matching funds: 127
(1) Inpatient hospital services. 128
(a) The division is authorized to implement an All 129
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 130
methodology for inpatient hospital services. 131
(b) No service benefits or reimbursement 132
limitations in this subsection (A)(1) shall apply to payments 133
under an APR-DRG or Ambulatory Payment Classification (APC) model 134
or a managed care program or similar model described in subsection 135
(H) of this section unless specifically authorized by the 136
division. 137
(2) Outpatient hospital services. 138
(a) Emergency services. 139
(b) Other outpatient hospital services. The 140
division shall allow benefits for other medically necessary 141
outpatient hospital services (such as chemotherapy, radiation, 142
surgery and therapy), including outpatient services in a clinic or 143
other facility that is not located inside the hospital, but that 144
has been designated as an outpatient facility by the hospital, and 145
that was in operation or under construction on July 1, 2009, 146
provided that the costs and charges associated with the operation 147
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of the hospital clinic are included in the hospital's cost report. 148
In addition, the Medicare thirty-five-mile rule will apply to 149
those hospital clinics not located inside the hospital that are 150
constructed after July 1, 2009. Where the same services are 151
reimbursed as clinic services, the division may revise the rate or 152
methodology of outpatient reimbursement to maintain consistency, 153
efficiency, economy and quality of care. 154
(c) The division is authorized to implement an 155
Ambulatory Payment Classification (APC) methodology for outpatient 156
hospital services. The division shall give rural hospitals that 157
have fifty (50) or fewer licensed beds the option to not be 158
reimbursed for outpatient hospital services using the APC 159
methodology, but reimbursement for outpatient hospital services 160
provided by those hospitals shall be based on one hundred one 161
percent (101%) of the rate established under Medicare for 162
outpatient hospital services. Those hospitals choosing to not be 163
reimbursed under the APC methodology shall remain under cost-based 164
reimbursement for a two-year period. 165
(d) No service benefits or reimbursement 166
limitations in this subsection (A)(2) shall apply to payments 167
under an APR-DRG or APC model or a managed care program or similar 168
model described in subsection (H) of this section unless 169
specifically authorized by the division. 170
(3) Laboratory and x-ray services. 171
(4) Nursing facility services. 172
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(a) The division shall make full payment to 173
nursing facilities for each day, not exceeding forty-two (42) days 174
per year, that a patient is absent from the facility on home 175
leave. Payment may be made for the following home leave days in 176
addition to the forty-two-day limitation: Christmas, the day 177
before Christmas, the day after Christmas, Thanksgiving, the day 178
before Thanksgiving and the day after Thanksgiving. 179
(b) From and after July 1, 1997, the division 180
shall implement the integrated case-mix payment and quality 181
monitoring system, which includes the fair rental system for 182
property costs and in which recapture of depreciation is 183
eliminated. The division may reduce the payment for hospital 184
leave and therapeutic home leave days to the lower of the case-mix 185
category as computed for the resident on leave using the 186
assessment being utilized for payment at that point in time, or a 187
case-mix score of 1.000 for nursing facilities, and shall compute 188
case-mix scores of residents so that only services provided at the 189
nursing facility are considered in calculating a facility's per 190
diem. 191
(c) From and after July 1, 1997, all state-owned 192
nursing facilities shall be reimbursed on a full reasonable cost 193
basis. 194
(d) On or after January 1, 2015, the division 195
shall update the case-mix payment system resource utilization 196
grouper and classifications and fair rental reimbursement system. 197
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The division shall develop and implement a payment add-on to 198
reimburse nursing facilities for ventilator-dependent resident 199
services. 200
(e) The division shall develop and implement, not 201
later than January 1, 2001, a case-mix payment add-on determined 202
by time studies and other valid statistical data that will 203
reimburse a nursing facility for the additional cost of caring for 204
a resident who has a diagnosis of Alzheimer's or other related 205
dementia and exhibits symptoms that require special care. Any 206
such case-mix add-on payment shall be supported by a determination 207
of additional cost. The division shall also develop and implement 208
as part of the fair rental reimbursement system for nursing 209
facility beds, an Alzheimer's resident bed depreciation enhanced 210
reimbursement system that will provide an incentive to encourage 211
nursing facilities to convert or construct beds for residents with 212
Alzheimer's or other related dementia. 213
(f) The division shall develop and implement an 214
assessment process for long-term care services. The division may 215
provide the assessment and related functions directly or through 216
contract with the area agencies on aging. 217
The division shall apply for necessary federal waivers to 218
assure that additional services providing alternatives to nursing 219
facility care are made available to applicants for nursing 220
facility care. 221
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(5) Periodic screening and diagnostic services for 222
individuals under age twenty-one (21) years as are needed to 223
identify physical and mental defects and to provide health care 224
treatment and other measures designed to correct or ameliorate 225
defects and physical and mental illness and conditions discovered 226
by the screening services, regardless of whether these services 227
are included in the state plan. The division may include in its 228
periodic screening and diagnostic program those discretionary 229
services authorized under the federal regulations adopted to 230
implement Title XIX of the federal Social Security Act, as 231
amended. The division, in obtaining physical therapy services, 232
occupational therapy services, and services for individuals with 233
speech, hearing and language disorders, may enter into a 234
cooperative agreement with the State Department of Education for 235
the provision of those services to handicapped students by public 236
school districts using state funds that are provided from the 237
appropriation to the Department of Education to obtain federal 238
matching funds through the division. The division, in obtaining 239
medical and mental health assessments, treatment, care and 240
services for children who are in, or at risk of being put in, the 241
custody of the Mississippi Department of Human Services may enter 242
into a cooperative agreement with the Mississippi Department of 243
Human Services for the provision of those services using state 244
funds that are provided from the appropriation to the Department 245
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of Human Services to obtain federal matching funds through the 246
division. 247
(6) Physician services. Fees for physician's services 248
that are covered only by Medicaid shall be reimbursed at ninety 249
percent (90%) of the rate established on January 1, 2018, and as 250
may be adjusted each July thereafter, under Medicare. The 251
division may provide for a reimbursement rate for physician's 252
services of up to one hundred percent (100%) of the rate 253
established under Medicare for physician's services that are 254
provided after the normal working hours of the physician, as 255
determined in accordance with regulations of the division. The 256
division may reimburse eligible providers, as determined by the 257
division, for certain primary care services at one hundred percent 258
(100%) of the rate established under Medicare. The division shall 259
reimburse obstetricians and gynecologists for certain primary care 260
services as defined by the division at one hundred percent (100%) 261
of the rate established under Medicare. 262
(7) (a) Home health services for eligible persons, not 263
to exceed in cost the prevailing cost of nursing facility 264
services. All home health visits must be precertified as required 265
by the division. In addition to physicians, certified registered 266
nurse practitioners, physician assistants and clinical nurse 267
specialists are authorized to prescribe or order home health 268
services and plans of care, sign home health plans of care, 269
certify and recertify eligibility for home health services and 270
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conduct the required initial face-to-face visit with the recipient 271
of the services. 272
(b) [Repealed] 273
(8) Emergency medical transportation services as 274
determined by the division. 275
(9) Prescription drugs and other covered drugs and 276
services as determined by the division. 277
The division shall establish a mandatory preferred drug list. 278
Drugs not on the mandatory preferred drug list shall be made 279
available by utilizing prior authorization procedures established 280
by the division. 281
The division may seek to establish relationships with other 282
states in order to lower acquisition costs of prescription drugs 283
to include single-source and innovator multiple-source drugs or 284
generic drugs. In addition, if allowed by federal law or 285
regulation, the division may seek to establish relationships with 286
and negotiate with other countries to facilitate the acquisition 287
of prescription drugs to include single-source and innovator 288
multiple-source drugs or generic drugs, if that will lower the 289
acquisition costs of those prescription drugs. 290
The division may allow for a combination of prescriptions for 291
single-source and innovator multiple-source drugs and generic 292
drugs to meet the needs of the beneficiaries. 293
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The executive director may approve specific maintenance drugs 294
for beneficiaries with certain medical conditions, which may be 295
prescribed and dispensed in three-month supply increments. 296
Drugs prescribed for a resident of a psychiatric residential 297
treatment facility must be provided in true unit doses when 298
available. The division may require that drugs not covered by 299
Medicare Part D for a resident of a long-term care facility be 300
provided in true unit doses when available. Those drugs that were 301
originally billed to the division but are not used by a resident 302
in any of those facilities shall be returned to the billing 303
pharmacy for credit to the division, in accordance with the 304
guidelines of the State Board of Pharmacy and any requirements of 305
federal law and regulation. Drugs shall be dispensed to a 306
recipient and only one (1) dispensing fee per month may be 307
charged. The division shall develop a methodology for reimbursing 308
for restocked drugs, which shall include a restock fee as 309
determined by the division not exceeding Seven Dollars and 310
Eighty-two Cents ($7.82). 311
Except for those specific maintenance drugs approved by the 312
executive director, the division shall not reimburse for any 313
portion of a prescription that exceeds a thirty-one-day supply of 314
the drug based on the daily dosage. 315
The division is authorized to develop and implement a program 316
of payment for additional pharmacist services as determined by the 317
division. 318
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All claims for drugs for dually eligible Medicare/Medicaid 319
beneficiaries that are paid for by Medicare must be submitted to 320
Medicare for payment before they may be processed by the 321
division's online payment system. 322
The division shall develop a pharmacy policy in which drugs 323
in tamper-resistant packaging that are prescribed for a resident 324
of a nursing facility but are not dispensed to the resident shall 325
be returned to the pharmacy and not billed to Medicaid, in 326
accordance with guidelines of the State Board of Pharmacy. 327
The division shall develop and implement a method or methods 328
by which the division will provide on a regular basis to Medicaid 329
providers who are authorized to prescribe drugs, information about 330
the costs to the Medicaid program of single-source drugs and 331
innovator multiple-source drugs, and information about other drugs 332
that may be prescribed as alternatives to those single-source 333
drugs and innovator multiple-source drugs and the costs to the 334
Medicaid program of those alternative drugs. 335
Notwithstanding any law or regulation, information obtained 336
or maintained by the division regarding the prescription drug 337
program, including trade secrets and manufacturer or labeler 338
pricing, is confidential and not subject to disclosure except to 339
other state agencies. 340
The dispensing fee for each new or refill prescription, 341
including nonlegend or over-the-counter drugs covered by the 342
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division, shall be not less than Three Dollars and Ninety-one 343
Cents ($3.91), as determined by the division. 344
The division shall not reimburse for single-source or 345
innovator multiple-source drugs if there are equally effective 346
generic equivalents available and if the generic equivalents are 347
the least expensive. 348
It is the intent of the Legislature that the pharmacists 349
providers be reimbursed for the reasonable costs of filling and 350
dispensing prescriptions for Medicaid beneficiaries. 351
The division shall allow certain drugs, including 352
physician-administered drugs, and implantable drug system devices, 353
and medical supplies, with limited distribution or limited access 354
for beneficiaries and administered in an appropriate clinical 355
setting, to be reimbursed as either a medical claim or pharmacy 356
claim, as determined by the division. 357
It is the intent of the Legislature that the division and any 358
managed care entity described in subsection (H) of this section 359
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 360
prevent recurrent preterm birth. 361
(10) Dental and orthodontic services to be determined 362
by the division. 363
The division shall increase the amount of the reimbursement 364
rate for diagnostic and preventative dental services for each of 365
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 366
the amount of the reimbursement rate for the previous fiscal year. 367
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The division shall increase the amount of the reimbursement rate 368
for restorative dental services for each of the fiscal years 2023, 369
2024 and 2025 by five percent (5%) above the amount of the 370
reimbursement rate for the previous fiscal year. It is the intent 371
of the Legislature that the reimbursement rate revision for 372
preventative dental services will be an incentive to increase the 373
number of dentists who actively provide Medicaid services. This 374
dental services reimbursement rate revision shall be known as the 375
"James Russell Dumas Medicaid Dental Services Incentive Program." 376
The Medical Care Advisory Committee, assisted by the Division 377
of Medicaid, shall annually determine the effect of this incentive 378
by evaluating the number of dentists who are Medicaid providers, 379
the number who and the degree to which they are actively billing 380
Medicaid, the geographic trends of where dentists are offering 381
what types of Medicaid services and other statistics pertinent to 382
the goals of this legislative intent. This data shall annually be 383
presented to the Chair of the Senate Medicaid Committee and the 384
Chair of the House Medicaid Committee. 385
The division shall include dental services as a necessary 386
component of overall health services provided to children who are 387
eligible for services. 388
(11) Eyeglasses for all Medicaid beneficiaries who have 389
(a) had surgery on the eyeball or ocular muscle that results in a 390
vision change for which eyeglasses or a change in eyeglasses is 391
medically indicated within six (6) months of the surgery and is in 392
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accordance with policies established by the division, or (b) one 393
(1) pair every five (5) years and in accordance with policies 394
established by the division. In either instance, the eyeglasses 395
must be prescribed by a physician skilled in diseases of the eye 396
or an optometrist, whichever the beneficiary may select. 397
(12) Intermediate care facility services. 398
(a) The division shall make full payment to all 399
intermediate care facilities for individuals with intellectual 400
disabilities for each day, not exceeding sixty-three (63) days per 401
year, that a patient is absent from the facility on home leave. 402
Payment may be made for the following home leave days in addition 403
to the sixty-three-day limitation: Christmas, the day before 404
Christmas, the day after Christmas, Thanksgiving, the day before 405
Thanksgiving and the day after Thanksgiving. 406
(b) All state-owned intermediate care facilities 407
for individuals with intellectual disabilities shall be reimbursed 408
on a full reasonable cost basis. 409
(c) Effective January 1, 2015, the division shall 410
update the fair rental reimbursement system for intermediate care 411
facilities for individuals with intellectual disabilities. 412
(13) Family planning services, including drugs, 413
supplies and devices, when those services are under the 414
supervision of a physician or nurse practitioner. 415
(14) Clinic services. Preventive, diagnostic, 416
therapeutic, rehabilitative or palliative services that are 417
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furnished by a facility that is not part of a hospital but is 418
organized and operated to provide medical care to outpatients. 419
Clinic services include, but are not limited to: 420
(a) Services provided by ambulatory surgical 421
centers (ASCs) as defined in Section 41-75-1(a); and 422
(b) Dialysis center services. 423
(15) Home- and community-based services for the elderly 424
and disabled, as provided under Title XIX of the federal Social 425
Security Act, as amended, under waivers, subject to the 426
availability of funds specifically appropriated for that purpose 427
by the Legislature. 428
(16) Mental health services. Certain services provided 429
by a psychiatrist shall be reimbursed at up to one hundred percent 430
(100%) of the Medicare rate. Approved therapeutic and case 431
management services (a) provided by an approved regional mental 432
health/intellectual disability center established under Sections 433
41-19-31 through 41-19-39, or by another community mental health 434
service provider meeting the requirements of the Department of 435
Mental Health to be an approved mental health/intellectual 436
disability center if determined necessary by the Department of 437
Mental Health, using state funds that are provided in the 438
appropriation to the division to match federal funds, or (b) 439
provided by a facility that is certified by the State Department 440
of Mental Health to provide therapeutic and case management 441
services, to be reimbursed on a fee for service basis, or (c) 442
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provided in the community by a facility or program operated by the 443
Department of Mental Health. Any such services provided by a 444
facility described in subparagraph (b) must have the prior 445
approval of the division to be reimbursable under this section. 446
(17) Durable medical equipment services and medical 447
supplies. Precertification of durable medical equipment and 448
medical supplies must be obtained as required by the division. 449
The Division of Medicaid may require durable medical equipment 450
providers to obtain a surety bond in the amount and to the 451
specifications as established by the Balanced Budget Act of 1997. 452
A maximum dollar amount of reimbursement for noninvasive 453
ventilators or ventilation treatments properly ordered and being 454
used in an appropriate care setting shall not be set by any health 455
maintenance organization, coordinated care organization, 456
provider-sponsored health plan, or other organization paid for 457
services on a capitated basis by the division under any managed 458
care program or coordinated care program implemented by the 459
division under this section. Reimbursement by these organizations 460
to durable medical equipment suppliers for home use of noninvasive 461
and invasive ventilators shall be on a continuous monthly payment 462
basis for the duration of medical need throughout a patient's 463
valid prescription period. 464
(18) (a) Notwithstanding any other provision of this 465
section to the contrary, as provided in the Medicaid state plan 466
amendment or amendments as defined in Section 43-13-145(10), the 467
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division shall make additional reimbursement to hospitals that 468
serve a disproportionate share of low-income patients and that 469
meet the federal requirements for those payments as provided in 470
Section 1923 of the federal Social Security Act and any applicable 471
regulations. It is the intent of the Legislature that the 472
division shall draw down all available federal funds allotted to 473
the state for disproportionate share hospitals. However, from and 474
after January 1, 1999, public hospitals participating in the 475
Medicaid disproportionate share program may be required to 476
participate in an intergovernmental transfer program as provided 477
in Section 1903 of the federal Social Security Act and any 478
applicable regulations. 479
(b) (i) 1. The division may establish a Medicare 480
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 481
the federal Social Security Act and any applicable federal 482
regulations, or an allowable delivery system or provider payment 483
initiative authorized under 42 CFR 438.6(c), for hospitals, 484
nursing facilities and physicians employed or contracted by 485
hospitals. 486
2. The division shall establish a 487
Medicaid Supplemental Payment Program, as permitted by the federal 488
Social Security Act and a comparable allowable delivery system or 489
provider payment initiative authorized under 42 CFR 438.6(c), for 490
emergency ambulance transportation providers in accordance with 491
this subsection (A)(18)(b). 492
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(ii) The division shall assess each hospital, 493
nursing facility, and emergency ambulance transportation provider 494
for the sole purpose of financing the state portion of the 495
Medicare Upper Payment Limits Program or other program(s) 496
authorized under this subsection (A)(18)(b). The hospital 497
assessment shall be as provided in Section 43-13-145(4)(a), and 498
the nursing facility and the emergency ambulance transportation 499
assessments, if established, shall be based on Medicaid 500
utilization or other appropriate method, as determined by the 501
division, consistent with federal regulations. The assessments 502
will remain in effect as long as the state participates in the 503
Medicare Upper Payment Limits Program or other program(s) 504
authorized under this subsection (A)(18)(b). In addition to the 505
hospital assessment provided in Section 43-13-145(4)(a), hospitals 506
with physicians participating in the Medicare Upper Payment Limits 507
Program or other program(s) authorized under this subsection 508
(A)(18)(b) shall be required to participate in an 509
intergovernmental transfer or assessment, as determined by the 510
division, for the purpose of financing the state portion of the 511
physician UPL payments or other payment(s) authorized under this 512
subsection (A)(18)(b). 513
(iii) Subject to approval by the Centers for 514
Medicare and Medicaid Services (CMS) and the provisions of this 515
subsection (A)(18)(b), the division shall make additional 516
reimbursement to hospitals, nursing facilities, and emergency 517
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ambulance transportation providers for the Medicare Upper Payment 518
Limits Program or other program(s) authorized under this 519
subsection (A)(18)(b), and, if the program is established for 520
physicians, shall make additional reimbursement for physicians, as 521
defined in Section 1902(a)(30) of the federal Social Security Act 522
and any applicable federal regulations, provided the assessment in 523
this subsection (A)(18)(b) is in effect. 524
(iv) Notwithstanding any other provision of 525
this article to the contrary, effective upon implementation of the 526
Mississippi Hospital Access Program (MHAP) provided in 527
subparagraph (c)(i) below, the hospital portion of the inpatient 528
Upper Payment Limits Program shall transition into and be replaced 529
by the MHAP program. However, the division is authorized to 530
develop and implement an alternative fee-for-service Upper Payment 531
Limits model in accordance with federal laws and regulations if 532
necessary to preserve supplemental funding. Further, the 533
division, in consultation with the hospital industry shall develop 534
alternative models for distribution of medical claims and 535
supplemental payments for inpatient and outpatient hospital 536
services, and such models may include, but shall not be limited to 537
the following: increasing rates for inpatient and outpatient 538
services; creating a low-income utilization pool of funds to 539
reimburse hospitals for the costs of uncompensated care, charity 540
care and bad debts as permitted and approved pursuant to federal 541
regulations and the Centers for Medicare and Medicaid Services; 542
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supplemental payments based upon Medicaid utilization, quality, 543
service lines and/or costs of providing such services to Medicaid 544
beneficiaries and to uninsured patients. The goals of such 545
payment models shall be to ensure access to inpatient and 546
outpatient care and to maximize any federal funds that are 547
available to reimburse hospitals for services provided. Any such 548
documents required to achieve the goals described in this 549
paragraph shall be submitted to the Centers for Medicare and 550
Medicaid Services, with a proposed effective date of July 1, 2019, 551
to the extent possible, but in no event shall the effective date 552
of such payment models be later than July 1, 2020. The Chairmen 553
of the Senate and House Medicaid Committees shall be provided a 554
copy of the proposed payment model(s) prior to submission. 555
Effective July 1, 2018, and until such time as any payment 556
model(s) as described above become effective, the division, in 557
consultation with the hospital industry, is authorized to 558
implement a transitional program for inpatient and outpatient 559
payments and/or supplemental payments (including, but not limited 560
to, MHAP and directed payments), to redistribute available 561
supplemental funds among hospital providers, provided that when 562
compared to a hospital's prior year supplemental payments, 563
supplemental payments made pursuant to any such transitional 564
program shall not result in a decrease of more than five percent 565
(5%) and shall not increase by more than the amount needed to 566
maximize the distribution of the available funds. 567
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(v) 1. To preserve and improve access to 568
ambulance transportation provider services, the division shall 569
seek CMS approval to make ambulance service access payments as set 570
forth in this subsection (A)(18)(b) for all covered emergency 571
ambulance services rendered on or after July 1, 2022, and shall 572
make such ambulance service access payments for all covered 573
services rendered on or after the effective date of CMS approval. 574
2. The division shall calculate the 575
ambulance service access payment amount as the balance of the 576
portion of the Medical Care Fund related to ambulance 577
transportation service provider assessments plus any federal 578
matching funds earned on the balance, up to, but not to exceed, 579
the upper payment limit gap for all emergency ambulance service 580
providers. 581
3. a. Except for ambulance services 582
exempt from the assessment provided in this paragraph (18)(b), all 583
ambulance transportation service providers shall be eligible for 584
ambulance service access payments each state fiscal year as set 585
forth in this paragraph (18)(b). 586
b. In addition to any other funds 587
paid to ambulance transportation service providers for emergency 588
medical services provided to Medicaid beneficiaries, each eligible 589
ambulance transportation service provider shall receive ambulance 590
service access payments each state fiscal year equal to the 591
ambulance transportation service provider's upper payment limit 592
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gap. Subject to approval by the Centers for Medicare and Medicaid 593
Services, ambulance service access payments shall be made no less 594
than on a quarterly basis. 595
c. As used in this paragraph 596
(18)(b)(v), the term "upper payment limit gap" means the 597
difference between the total amount that the ambulance 598
transportation service provider received from Medicaid and the 599
average amount that the ambulance transportation service provider 600
would have received from commercial insurers for those services 601
reimbursed by Medicaid. 602
4. An ambulance service access payment 603
shall not be used to offset any other payment by the division for 604
emergency or nonemergency services to Medicaid beneficiaries. 605
(c) (i) Not later than December l, 2015, the 606
division shall, subject to approval by the Centers for Medicare 607
and Medicaid Services (CMS), establish, implement and operate a 608
Mississippi Hospital Access Program (MHAP) for the purpose of 609
protecting patient access to hospital care through hospital 610
inpatient reimbursement programs provided in this section designed 611
to maintain total hospital reimbursement for inpatient services 612
rendered by in-state hospitals and the out-of-state hospital that 613
is authorized by federal law to submit intergovernmental transfers 614
(IGTs) to the State of Mississippi and is classified as Level I 615
trauma center located in a county contiguous to the state line at 616
the maximum levels permissible under applicable federal statutes 617
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and regulations, at which time the current inpatient Medicare 618
Upper Payment Limits (UPL) Program for hospital inpatient services 619
shall transition to the MHAP. 620
(ii) Subject to approval by the Centers for 621
Medicare and Medicaid Services (CMS), the MHAP shall provide 622
increased inpatient capitation (PMPM) payments to managed care 623
entities contracting with the division pursuant to subsection (H) 624
of this section to support availability of hospital services or 625
such other payments permissible under federal law necessary to 626
accomplish the intent of this subsection. 627
(iii) The intent of this subparagraph (c) is 628
that effective for all inpatient hospital Medicaid services during 629
state fiscal year 2016, and so long as this provision shall remain 630
in effect hereafter, the division shall to the fullest extent 631
feasible replace the additional reimbursement for hospital 632
inpatient services under the inpatient Medicare Upper Payment 633
Limits (UPL) Program with additional reimbursement under the MHAP 634
and other payment programs for inpatient and/or outpatient 635
payments which may be developed under the authority of this 636
paragraph. 637
(iv) The division shall assess each hospital 638
as provided in Section 43-13-145(4)(a) for the purpose of 639
financing the state portion of the MHAP, supplemental payments and 640
such other purposes as specified in Section 43-13-145. The 641
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assessment will remain in effect as long as the MHAP and 642
supplemental payments are in effect. 643
(19) (a) Perinatal risk management services. The 644
division shall promulgate regulations to be effective from and 645
after October 1, 1988, to establish a comprehensive perinatal 646
system for risk assessment of all pregnant and infant Medicaid 647
recipients and for management, education and follow-up for those 648
who are determined to be at risk. Services to be performed 649
include case management, nutrition assessment/counseling, 650
psychosocial assessment/counseling and health education. The 651
division shall contract with the State Department of Health to 652
provide services within this paragraph (Perinatal High Risk 653
Management/Infant Services System (PHRM/ISS)). The State 654
Department of Health shall be reimbursed on a full reasonable cost 655
basis for services provided under this subparagraph (a). 656
(b) Early intervention system services. The 657
division shall cooperate with the State Department of Health, 658
acting as lead agency, in the development and implementation of a 659
statewide system of delivery of early intervention services, under 660
Part C of the Individuals with Disabilities Education Act (IDEA). 661
The State Department of Health shall certify annually in writing 662
to the executive director of the division the dollar amount of 663
state early intervention funds available that will be utilized as 664
a certified match for Medicaid matching funds. Those funds then 665
shall be used to provide expanded targeted case management 666
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services for Medicaid eligible children with special needs who are 667
eligible for the state's early intervention system. 668
Qualifications for persons providing service coordination shall be 669
determined by the State Department of Health and the Division of 670
Medicaid. 671
(20) Home- and community-based services for physically 672
disabled approved services as allowed by a waiver from the United 673
States Department of Health and Human Services for home- and 674
community-based services for physically disabled people using 675
state funds that are provided from the appropriation to the State 676
Department of Rehabilitation Services and used to match federal 677
funds under a cooperative agreement between the division and the 678
department, provided that funds for these services are 679
specifically appropriated to the Department of Rehabilitation 680
Services. 681
(21) Nurse practitioner services. Services furnished 682
by a registered nurse who is licensed and certified by the 683
Mississippi Board of Nursing as a nurse practitioner, including, 684
but not limited to, nurse anesthetists, nurse midwives, family 685
nurse practitioners, family planning nurse practitioners, 686
pediatric nurse practitioners, obstetrics-gynecology nurse 687
practitioners and neonatal nurse practitioners, under regulations 688
adopted by the division. Reimbursement for those services shall 689
not exceed ninety percent (90%) of the reimbursement rate for 690
comparable services rendered by a physician. The division may 691
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provide for a reimbursement rate for nurse practitioner services 692
of up to one hundred percent (100%) of the reimbursement rate for 693
comparable services rendered by a physician for nurse practitioner 694
services that are provided after the normal working hours of the 695
nurse practitioner, as determined in accordance with regulations 696
of the division. 697
(22) Ambulatory services delivered in federally 698
qualified health centers, rural health centers and clinics of the 699
local health departments of the State Department of Health for 700
individuals eligible for Medicaid under this article based on 701
reasonable costs as determined by the division. Federally 702
qualified health centers shall be reimbursed by the Medicaid 703
prospective payment system as approved by the Centers for Medicare 704
and Medicaid Services. The division shall recognize federally 705
qualified health centers (FQHCs), rural health clinics (RHCs) and 706
community mental health centers (CMHCs) as both an originating and 707
distant site provider for the purposes of telehealth 708
reimbursement. The division is further authorized and directed to 709
reimburse FQHCs, RHCs and CMHCs for both distant site and 710
originating site services when such services are appropriately 711
provided by the same organization. 712
(23) Inpatient psychiatric services. 713
(a) Inpatient psychiatric services to be 714
determined by the division for recipients under age twenty-one 715
(21) that are provided under the direction of a physician in an 716
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inpatient program in a licensed acute care psychiatric facility or 717
in a licensed psychiatric residential treatment facility, before 718
the recipient reaches age twenty-one (21) or, if the recipient was 719
receiving the services immediately before he or she reached age 720
twenty-one (21), before the earlier of the date he or she no 721
longer requires the services or the date he or she reaches age 722
twenty-two (22), as provided by federal regulations. From and 723
after January 1, 2015, the division shall update the fair rental 724
reimbursement system for psychiatric residential treatment 725
facilities. Precertification of inpatient days and residential 726
treatment days must be obtained as required by the division. From 727
and after July 1, 2009, all state-owned and state-operated 728
facilities that provide inpatient psychiatric services to persons 729
under age twenty-one (21) who are eligible for Medicaid 730
reimbursement shall be reimbursed for those services on a full 731
reasonable cost basis. 732
(b) The division may reimburse for services 733
provided by a licensed freestanding psychiatric hospital to 734
Medicaid recipients over the age of twenty-one (21) in a method 735
and manner consistent with the provisions of Section 43-13-117.5. 736
(24) [Deleted] 737
(25) [Deleted] 738
(26) Hospice care. As used in this paragraph, the term 739
"hospice care" means a coordinated program of active professional 740
medical attention within the home and outpatient and inpatient 741
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care that treats the terminally ill patient and family as a unit, 742
employing a medically directed interdisciplinary team. The 743
program provides relief of severe pain or other physical symptoms 744
and supportive care to meet the special needs arising out of 745
physical, psychological, spiritual, social and economic stresses 746
that are experienced during the final stages of illness and during 747
dying and bereavement and meets the Medicare requirements for 748
participation as a hospice as provided in federal regulations. 749
(27) Group health plan premiums and cost-sharing if it 750
is cost-effective as defined by the United States Secretary of 751
Health and Human Services. 752
(28) Other health insurance premiums that are 753
cost-effective as defined by the United States Secretary of Health 754
and Human Services. Medicare eligible must have Medicare Part B 755
before other insurance premiums can be paid. 756
(29) The Division of Medicaid may apply for a waiver 757
from the United States Department of Health and Human Services for 758
home- and community-based services for developmentally disabled 759
people using state funds that are provided from the appropriation 760
to the State Department of Mental Health and/or funds transferred 761
to the department by a political subdivision or instrumentality of 762
the state and used to match federal funds under a cooperative 763
agreement between the division and the department, provided that 764
funds for these services are specifically appropriated to the 765
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Department of Mental Health and/or transferred to the department 766
by a political subdivision or instrumentality of the state. 767
(30) Pediatric skilled nursing services as determined 768
by the division and in a manner consistent with regulations 769
promulgated by the Mississippi State Department of Health. 770
(31) Targeted case management services for children 771
with special needs, under waivers from the United States 772
Department of Health and Human Services, using state funds that 773
are provided from the appropriation to the Mississippi Department 774
of Human Services and used to match federal funds under a 775
cooperative agreement between the division and the department. 776
(32) Care and services provided in Christian Science 777
Sanatoria listed and certified by the Commission for Accreditation 778
of Christian Science Nursing Organizations/Facilities, Inc., 779
rendered in connection with treatment by prayer or spiritual means 780
to the extent that those services are subject to reimbursement 781
under Section 1903 of the federal Social Security Act. 782
(33) Podiatrist services. 783
(34) Assisted living services as provided through 784
home- and community-based services under Title XIX of the federal 785
Social Security Act, as amended, subject to the availability of 786
funds specifically appropriated for that purpose by the 787
Legislature. 788
(35) Services and activities authorized in Sections 789
43-27-101 and 43-27-103, using state funds that are provided from 790
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the appropriation to the Mississippi Department of Human Services 791
and used to match federal funds under a cooperative agreement 792
between the division and the department. 793
(36) Nonemergency transportation services for 794
Medicaid-eligible persons as determined by the division. The PEER 795
Committee shall conduct a performance evaluation of the 796
nonemergency transportation program to evaluate the administration 797
of the program and the providers of transportation services to 798
determine the most cost-effective ways of providing nonemergency 799
transportation services to the patients served under the program. 800
The performance evaluation shall be completed and provided to the 801
members of the Senate Medicaid Committee and the House Medicaid 802
Committee not later than January 1, 2019, and every two (2) years 803
thereafter. 804
(37) [Deleted] 805
(38) Chiropractic services. A chiropractor's manual 806
manipulation of the spine to correct a subluxation, if x-ray 807
demonstrates that a subluxation exists and if the subluxation has 808
resulted in a neuromusculoskeletal condition for which 809
manipulation is appropriate treatment, and related spinal x-rays 810
performed to document these conditions. Reimbursement for 811
chiropractic services shall not exceed Seven Hundred Dollars 812
($700.00) per year per beneficiary. 813
(39) Dually eligible Medicare/Medicaid beneficiaries. 814
The division shall pay the Medicare deductible and coinsurance 815
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amounts for services available under Medicare, as determined by 816
the division. From and after July 1, 2009, the division shall 817
reimburse crossover claims for inpatient hospital services and 818
crossover claims covered under Medicare Part B in the same manner 819
that was in effect on January 1, 2008, unless specifically 820
authorized by the Legislature to change this method. 821
(40) [Deleted] 822
(41) Services provided by the State Department of 823
Rehabilitation Services for the care and rehabilitation of persons 824
with spinal cord injuries or traumatic brain injuries, as allowed 825
under waivers from the United States Department of Health and 826
Human Services, using up to seventy-five percent (75%) of the 827
funds that are appropriated to the Department of Rehabilitation 828
Services from the Spinal Cord and Head Injury Trust Fund 829
established under Section 37-33-261 and used to match federal 830
funds under a cooperative agreement between the division and the 831
department. 832
(42) [Deleted] 833
(43) The division shall provide reimbursement, 834
according to a payment schedule developed by the division, for 835
smoking cessation medications for pregnant women during their 836
pregnancy and other Medicaid-eligible women who are of 837
child-bearing age. 838
(44) Nursing facility services for the severely 839
disabled. 840
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(a) Severe disabilities include, but are not 841
limited to, spinal cord injuries, closed-head injuries and 842
ventilator-dependent patients. 843
(b) Those services must be provided in a long-term 844
care nursing facility dedicated to the care and treatment of 845
persons with severe disabilities. 846
(45) Physician assistant services. Services furnished 847
by a physician assistant who is licensed by the State Board of 848
Medical Licensure and is practicing with physician supervision 849
under regulations adopted by the board, under regulations adopted 850
by the division. Reimbursement for those services shall not 851
exceed ninety percent (90%) of the reimbursement rate for 852
comparable services rendered by a physician. The division may 853
provide for a reimbursement rate for physician assistant services 854
of up to one hundred percent (100%) or the reimbursement rate for 855
comparable services rendered by a physician for physician 856
assistant services that are provided after the normal working 857
hours of the physician assistant, as determined in accordance with 858
regulations of the division. 859
(46) The division shall make application to the federal 860
Centers for Medicare and Medicaid Services (CMS) for a waiver to 861
develop and provide services for children with serious emotional 862
disturbances as defined in Section 43-14-1(1), which may include 863
home- and community-based services, case management services or 864
managed care services through mental health providers certified by 865
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the Department of Mental Health. The division may implement and 866
provide services under this waivered program only if funds for 867
these services are specifically appropriated for this purpose by 868
the Legislature, or if funds are voluntarily provided by affected 869
agencies. 870
(47) (a) The division may develop and implement 871
disease management programs for individuals with high-cost chronic 872
diseases and conditions, including the use of grants, waivers, 873
demonstrations or other projects as necessary. 874
(b) Participation in any disease management 875
program implemented under this paragraph (47) is optional with the 876
individual. An individual must affirmatively elect to participate 877
in the disease management program in order to participate, and may 878
elect to discontinue participation in the program at any time. 879
(48) Pediatric long-term acute care hospital services. 880
(a) Pediatric long-term acute care hospital 881
services means services provided to eligible persons under 882
twenty-one (21) years of age by a freestanding Medicare-certified 883
hospital that has an average length of inpatient stay greater than 884
twenty-five (25) days and that is primarily engaged in providing 885
chronic or long-term medical care to persons under twenty-one (21) 886
years of age. 887
(b) The services under this paragraph (48) shall 888
be reimbursed as a separate category of hospital services. 889
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(49) The division may establish copayments and/or 890
coinsurance for any Medicaid services for which copayments and/or 891
coinsurance are allowable under federal law or regulation. 892
(50) Services provided by the State Department of 893
Rehabilitation Services for the care and rehabilitation of persons 894
who are deaf and blind, as allowed under waivers from the United 895
States Department of Health and Human Services to provide home- 896
and community-based services using state funds that are provided 897
from the appropriation to the State Department of Rehabilitation 898
Services or if funds are voluntarily provided by another agency. 899
(51) Upon determination of Medicaid eligibility and in 900
association with annual redetermination of Medicaid eligibility, 901
beneficiaries shall be encouraged to undertake a physical 902
examination that will establish a base-line level of health and 903
identification of a usual and customary source of care (a medical 904
home) to aid utilization of disease management tools. This 905
physical examination and utilization of these disease management 906
tools shall be consistent with current United States Preventive 907
Services Task Force or other recognized authority recommendations. 908
For persons who are determined ineligible for Medicaid, the 909
division will provide information and direction for accessing 910
medical care and services in the area of their residence. 911
(52) Notwithstanding any provisions of this article, 912
the division may pay enhanced reimbursement fees related to trauma 913
care, as determined by the division in conjunction with the State 914
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Department of Health, using funds appropriated to the State 915
Department of Health for trauma care and services and used to 916
match federal funds under a cooperative agreement between the 917
division and the State Department of Health. The division, in 918
conjunction with the State Department of Health, may use grants, 919
waivers, demonstrations, enhanced reimbursements, Upper Payment 920
Limits Programs, supplemental payments, or other projects as 921
necessary in the development and implementation of this 922
reimbursement program. 923
(53) Targeted case management services for high-cost 924
beneficiaries may be developed by the division for all services 925
under this section. 926
(54) [Deleted] 927
(55) Therapy services. The plan of care for therapy 928
services may be developed to cover a period of treatment for up to 929
six (6) months, but in no event shall the plan of care exceed a 930
six-month period of treatment. The projected period of treatment 931
must be indicated on the initial plan of care and must be updated 932
with each subsequent revised plan of care. Based on medical 933
necessity, the division shall approve certification periods for 934
less than or up to six (6) months, but in no event shall the 935
certification period exceed the period of treatment indicated on 936
the plan of care. The appeal process for any reduction in therapy 937
services shall be consistent with the appeal process in federal 938
regulations. 939
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(56) Prescribed pediatric extended care centers 940
services for medically dependent or technologically dependent 941
children with complex medical conditions that require continual 942
care as prescribed by the child's attending physician, as 943
determined by the division. 944
(57) No Medicaid benefit shall restrict coverage for 945
medically appropriate treatment prescribed by a physician and 946
agreed to by a fully informed individual, or if the individual 947
lacks legal capacity to consent by a person who has legal 948
authority to consent on his or her behalf, based on an 949
individual's diagnosis with a terminal condition. As used in this 950
paragraph (57), "terminal condition" means any aggressive 951
malignancy, chronic end-stage cardiovascular or cerebral vascular 952
disease, or any other disease, illness or condition which a 953
physician diagnoses as terminal. 954
(58) Treatment services for persons with opioid 955
dependency or other highly addictive substance use disorders. The 956
division is authorized to reimburse eligible providers for 957
treatment of opioid dependency and other highly addictive 958
substance use disorders, as determined by the division. Treatment 959
related to these conditions shall not count against any physician 960
visit limit imposed under this section. 961
(59) The division shall allow beneficiaries between the 962
ages of ten (10) and eighteen (18) years to receive vaccines 963
through a pharmacy venue. The division and the State Department 964
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of Health shall coordinate and notify OB-GYN providers that the 965
Vaccines for Children program is available to providers free of 966
charge. 967
(60) Border city university-affiliated pediatric 968
teaching hospital. 969
(a) Payments may only be made to a border city 970
university-affiliated pediatric teaching hospital if the Centers 971
for Medicare and Medicaid Services (CMS) approve an increase in 972
the annual request for the provider payment initiative authorized 973
under 42 CFR Section 438.6(c) in an amount equal to or greater 974
than the estimated annual payment to be made to the border city 975
university-affiliated pediatric teaching hospital. The estimate 976
shall be based on the hospital's prior year Mississippi managed 977
care utilization. 978
(b) As used in this paragraph (60), the term 979
"border city university-affiliated pediatric teaching hospital" 980
means an out-of-state hospital located within a city bordering the 981
eastern bank of the Mississippi River and the State of Mississippi 982
that submits to the division a copy of a current and effective 983
affiliation agreement with an accredited university and other 984
documentation establishing that the hospital is 985
university-affiliated, is licensed and designated as a pediatric 986
hospital or pediatric primary hospital within its home state, 987
maintains at least five (5) different pediatric specialty training 988
programs, and maintains at least one hundred (100) operated beds 989
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dedicated exclusively for the treatment of patients under the age 990
of twenty-one (21) years. 991
(c) The cost of providing services to Mississippi 992
Medicaid beneficiaries under the age of twenty-one (21) years who 993
are treated by a border city university-affiliated pediatric 994
teaching hospital shall not exceed the cost of providing the same 995
services to individuals in hospitals in the state. 996
(d) It is the intent of the Legislature that 997
payments shall not result in any in-state hospital receiving 998
payments lower than they would otherwise receive if not for the 999
payments made to any border city university-affiliated pediatric 1000
teaching hospital. 1001
(e) This paragraph (60) shall stand repealed on 1002
July 1, 2024. 1003
(61) Services described in Section 41-140-3 that are 1004
provided by certified community health workers employed and 1005
supervised by a Medicaid provider. Reimbursement for these 1006
services shall be provided only if the division has received 1007
approval from the Centers for Medicare and Medicaid Services for a 1008
state plan amendment, waiver or alternative payment model for 1009
services delivered by certified community health workers. 1010
(62) Biomarker testing in accordance with the 1011
provisions of Sections 2 and 3 of this act. With respect to 1012
biomarker testing, the division shall, within sixty (60) days 1013
after the effective date of this act, update the fee schedule for 1014
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Medicaid services to include the appropriate current procedural 1015
terminology (CPT) and proprietary laboratory analysis (PLA) codes 1016
for all biomarker tests coverage that is mandated under Sections 2 1017
and 3 of this act. 1018
(B) Planning and development districts participating in the 1019
home- and community-based services program for the elderly and 1020
disabled as case management providers shall be reimbursed for case 1021
management services at the maximum rate approved by the Centers 1022
for Medicare and Medicaid Services (CMS). 1023
(C) The division may pay to those providers who participate 1024
in and accept patient referrals from the division's emergency room 1025
redirection program a percentage, as determined by the division, 1026
of savings achieved according to the performance measures and 1027
reduction of costs required of that program. Federally qualified 1028
health centers may participate in the emergency room redirection 1029
program, and the division may pay those centers a percentage of 1030
any savings to the Medicaid program achieved by the centers' 1031
accepting patient referrals through the program, as provided in 1032
this subsection (C). 1033
(D) (1) As used in this subsection (D), the following terms 1034
shall be defined as provided in this paragraph, except as 1035
otherwise provided in this subsection: 1036
(a) "Committees" means the Medicaid Committees of 1037
the House of Representatives and the Senate, and "committee" means 1038
either one of those committees. 1039
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(b) "Rate change" means an increase, decrease or 1040
other change in the payments or rates of reimbursement, or a 1041
change in any payment methodology that results in an increase, 1042
decrease or other change in the payments or rates of 1043
reimbursement, to any Medicaid provider that renders any services 1044
authorized to be provided to Medicaid recipients under this 1045
article. 1046
(2) Whenever the Division of Medicaid proposes a rate 1047
change, the division shall give notice to the chairmen of the 1048
committees at least thirty (30) calendar days before the proposed 1049
rate change is scheduled to take effect. The division shall 1050
furnish the chairmen with a concise summary of each proposed rate 1051
change along with the notice, and shall furnish the chairmen with 1052
a copy of any proposed rate change upon request. The division 1053
also shall provide a summary and copy of any proposed rate change 1054
to any other member of the Legislature upon request. 1055
(3) If the chairman of either committee or both 1056
chairmen jointly object to the proposed rate change or any part 1057
thereof, the chairman or chairmen shall notify the division and 1058
provide the reasons for their objection in writing not later than 1059
seven (7) calendar days after receipt of the notice from the 1060
division. The chairman or chairmen may make written 1061
recommendations to the division for changes to be made to a 1062
proposed rate change. 1063
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(4) (a) The chairman of either committee or both 1064
chairmen jointly may hold a committee meeting to review a proposed 1065
rate change. If either chairman or both chairmen decide to hold a 1066
meeting, they shall notify the division of their intention in 1067
writing within seven (7) calendar days after receipt of the notice 1068
from the division, and shall set the date and time for the meeting 1069
in their notice to the division, which shall not be later than 1070
fourteen (14) calendar days after receipt of the notice from the 1071
division. 1072
(b) After the committee meeting, the committee or 1073
committees may object to the proposed rate change or any part 1074
thereof. The committee or committees shall notify the division 1075
and the reasons for their objection in writing not later than 1076
seven (7) calendar days after the meeting. The committee or 1077
committees may make written recommendations to the division for 1078
changes to be made to a proposed rate change. 1079
(5) If both chairmen notify the division in writing 1080
within seven (7) calendar days after receipt of the notice from 1081
the division that they do not object to the proposed rate change 1082
and will not be holding a meeting to review the proposed rate 1083
change, the proposed rate change will take effect on the original 1084
date as scheduled by the division or on such other date as 1085
specified by the division. 1086
(6) (a) If there are any objections to a proposed rate 1087
change or any part thereof from either or both of the chairmen or 1088
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the committees, the division may withdraw the proposed rate 1089
change, make any of the recommended changes to the proposed rate 1090
change, or not make any changes to the proposed rate change. 1091
(b) If the division does not make any changes to 1092
the proposed rate change, it shall notify the chairmen of that 1093
fact in writing, and the proposed rate change shall take effect on 1094
the original date as scheduled by the division or on such other 1095
date as specified by the division. 1096
(c) If the division makes any changes to the 1097
proposed rate change, the division shall notify the chairmen of 1098
its actions in writing, and the revised proposed rate change shall 1099
take effect on the date as specified by the division. 1100
(7) Nothing in this subsection (D) shall be construed 1101
as giving the chairmen or the committees any authority to veto, 1102
nullify or revise any rate change proposed by the division. The 1103
authority of the chairmen or the committees under this subsection 1104
shall be limited to reviewing, making objections to and making 1105
recommendations for changes to rate changes proposed by the 1106
division. 1107
(E) Notwithstanding any provision of this article, no new 1108
groups or categories of recipients and new types of care and 1109
services may be added without enabling legislation from the 1110
Mississippi Legislature, except that the division may authorize 1111
those changes without enabling legislation when the addition of 1112
recipients or services is ordered by a court of proper authority. 1113
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(F) The executive director shall keep the Governor advised 1114
on a timely basis of the funds available for expenditure and the 1115
projected expenditures. Notwithstanding any other provisions of 1116
this article, if current or projected expenditures of the division 1117
are reasonably anticipated to exceed the amount of funds 1118
appropriated to the division for any fiscal year, the Governor, 1119
after consultation with the executive director, shall take all 1120
appropriate measures to reduce costs, which may include, but are 1121
not limited to: 1122
(1) Reducing or discontinuing any or all services that 1123
are deemed to be optional under Title XIX of the Social Security 1124
Act; 1125
(2) Reducing reimbursement rates for any or all service 1126
types; 1127
(3) Imposing additional assessments on health care 1128
providers; or 1129
(4) Any additional cost-containment measures deemed 1130
appropriate by the Governor. 1131
To the extent allowed under federal law, any reduction to 1132
services or reimbursement rates under this subsection (F) shall be 1133
accompanied by a reduction, to the fullest allowable amount, to 1134
the profit margin and administrative fee portions of capitated 1135
payments to organizations described in paragraph (1) of subsection 1136
(H). 1137
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Beginning in fiscal year 2010 and in fiscal years thereafter, 1138
when Medicaid expenditures are projected to exceed funds available 1139
for the fiscal year, the division shall submit the expected 1140
shortfall information to the PEER Committee not later than 1141
December 1 of the year in which the shortfall is projected to 1142
occur. PEER shall review the computations of the division and 1143
report its findings to the Legislative Budget Office not later 1144
than January 7 in any year. 1145
(G) Notwithstanding any other provision of this article, it 1146
shall be the duty of each provider participating in the Medicaid 1147
program to keep and maintain books, documents and other records as 1148
prescribed by the Division of Medicaid in accordance with federal 1149
laws and regulations. 1150
(H) (1) Notwithstanding any other provision of this 1151
article, the division is authorized to implement (a) a managed 1152
care program, (b) a coordinated care program, (c) a coordinated 1153
care organization program, (d) a health maintenance organization 1154
program, (e) a patient-centered medical home program, (f) an 1155
accountable care organization program, (g) provider-sponsored 1156
health plan, or (h) any combination of the above programs. As a 1157
condition for the approval of any program under this subsection 1158
(H)(1), the division shall require that no managed care program, 1159
coordinated care program, coordinated care organization program, 1160
health maintenance organization program, or provider-sponsored 1161
health plan may: 1162
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(a) Pay providers at a rate that is less than the 1163
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1164
reimbursement rate; 1165
(b) Override the medical decisions of hospital 1166
physicians or staff regarding patients admitted to a hospital for 1167
an emergency medical condition as defined by 42 US Code Section 1168
1395dd. This restriction (b) does not prohibit the retrospective 1169
review of the appropriateness of the determination that an 1170
emergency medical condition exists by chart review or coding 1171
algorithm, nor does it prohibit prior authorization for 1172
nonemergency hospital admissions; 1173
(c) Pay providers at a rate that is less than the 1174
normal Medicaid reimbursement rate. It is the intent of the 1175
Legislature that all managed care entities described in this 1176
subsection (H), in collaboration with the division, develop and 1177
implement innovative payment models that incentivize improvements 1178
in health care quality, outcomes, or value, as determined by the 1179
division. Participation in the provider network of any managed 1180
care, coordinated care, provider-sponsored health plan, or similar 1181
contractor shall not be conditioned on the provider's agreement to 1182
accept such alternative payment models; 1183
(d) Implement a prior authorization and 1184
utilization review program for medical services, transportation 1185
services and prescription drugs that is more stringent than the 1186
prior authorization processes used by the division in its 1187
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administration of the Medicaid program. Not later than December 1188
2, 2021, the contractors that are receiving capitated payments 1189
under a managed care delivery system established under this 1190
subsection (H) shall submit a report to the Chairmen of the House 1191
and Senate Medicaid Committees on the status of the prior 1192
authorization and utilization review program for medical services, 1193
transportation services and prescription drugs that is required to 1194
be implemented under this subparagraph (d); 1195
(e) [Deleted] 1196
(f) Implement a preferred drug list that is more 1197
stringent than the mandatory preferred drug list established by 1198
the division under subsection (A)(9) of this section; 1199
(g) Implement a policy which denies beneficiaries 1200
with hemophilia access to the federally funded hemophilia 1201
treatment centers as part of the Medicaid Managed Care network of 1202
providers. 1203
Each health maintenance organization, coordinated care 1204
organization, provider-sponsored health plan, or other 1205
organization paid for services on a capitated basis by the 1206
division under any managed care program or coordinated care 1207
program implemented by the division under this section shall use a 1208
clear set of level of care guidelines in the determination of 1209
medical necessity and in all utilization management practices, 1210
including the prior authorization process, concurrent reviews, 1211
retrospective reviews and payments, that are consistent with 1212
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widely accepted professional standards of care. Organizations 1213
participating in a managed care program or coordinated care 1214
program implemented by the division may not use any additional 1215
criteria that would result in denial of care that would be 1216
determined appropriate and, therefore, medically necessary under 1217
those levels of care guidelines. 1218
(2) Notwithstanding any provision of this section, the 1219
recipients eligible for enrollment into a Medicaid Managed Care 1220
Program authorized under this subsection (H) may include only 1221
those categories of recipients eligible for participation in the 1222
Medicaid Managed Care Program as of January 1, 2021, the 1223
Children's Health Insurance Program (CHIP), and the CMS-approved 1224
Section 1115 demonstration waivers in operation as of January 1, 1225
2021. No expansion of Medicaid Managed Care Program contracts may 1226
be implemented by the division without enabling legislation from 1227
the Mississippi Legislature. 1228
(3) (a) Any contractors receiving capitated payments 1229
under a managed care delivery system established in this section 1230
shall provide to the Legislature and the division statistical data 1231
to be shared with provider groups in order to improve patient 1232
access, appropriate utilization, cost savings and health outcomes 1233
not later than October 1 of each year. Additionally, each 1234
contractor shall disclose to the Chairmen of the Senate and House 1235
Medicaid Committees the administrative expenses costs for the 1236
prior calendar year, and the number of full-equivalent employees 1237
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located in the State of Mississippi dedicated to the Medicaid and 1238
CHIP lines of business as of June 30 of the current year. 1239
(b) The division and the contractors participating 1240
in the managed care program, a coordinated care program or a 1241
provider-sponsored health plan shall be subject to annual program 1242
reviews or audits performed by the Office of the State Auditor, 1243
the PEER Committee, the Department of Insurance and/or independent 1244
third parties. 1245
(c) Those reviews shall include, but not be 1246
limited to, at least two (2) of the following items: 1247
(i) The financial benefit to the State of 1248
Mississippi of the managed care program, 1249
(ii) The difference between the premiums paid 1250
to the managed care contractors and the payments made by those 1251
contractors to health care providers, 1252
(iii) Compliance with performance measures 1253
required under the contracts, 1254
(iv) Administrative expense allocation 1255
methodologies, 1256
(v) Whether nonprovider payments assigned as 1257
medical expenses are appropriate, 1258
(vi) Capitated arrangements with related 1259
party subcontractors, 1260
(vii) Reasonableness of corporate 1261
allocations, 1262
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(viii) Value-added benefits and the extent to 1263
which they are used, 1264
(ix) The effectiveness of subcontractor 1265
oversight, including subcontractor review, 1266
(x) Whether health care outcomes have been 1267
improved, and 1268
(xi) The most common claim denial codes to 1269
determine the reasons for the denials. 1270
The audit reports shall be considered public documents and 1271
shall be posted in their entirety on the division's website. 1272
(4) All health maintenance organizations, coordinated 1273
care organizations, provider-sponsored health plans, or other 1274
organizations paid for services on a capitated basis by the 1275
division under any managed care program or coordinated care 1276
program implemented by the division under this section shall 1277
reimburse all providers in those organizations at rates no lower 1278
than those provided under this section for beneficiaries who are 1279
not participating in those programs. 1280
(5) No health maintenance organization, coordinated 1281
care organization, provider-sponsored health plan, or other 1282
organization paid for services on a capitated basis by the 1283
division under any managed care program or coordinated care 1284
program implemented by the division under this section shall 1285
require its providers or beneficiaries to use any pharmacy that 1286
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ships, mails or delivers prescription drugs or legend drugs or 1287
devices. 1288
(6) (a) Not later than December 1, 2021, the 1289
contractors who are receiving capitated payments under a managed 1290
care delivery system established under this subsection (H) shall 1291
develop and implement a uniform credentialing process for 1292
providers. Under that uniform credentialing process, a provider 1293
who meets the criteria for credentialing will be credentialed with 1294
all of those contractors and no such provider will have to be 1295
separately credentialed by any individual contractor in order to 1296
receive reimbursement from the contractor. Not later than 1297
December 2, 2021, those contractors shall submit a report to the 1298
Chairmen of the House and Senate Medicaid Committees on the status 1299
of the uniform credentialing process for providers that is 1300
required under this subparagraph (a). 1301
(b) If those contractors have not implemented a 1302
uniform credentialing process as described in subparagraph (a) by 1303
December 1, 2021, the division shall develop and implement, not 1304
later than July 1, 2022, a single, consolidated credentialing 1305
process by which all providers will be credentialed. Under the 1306
division's single, consolidated credentialing process, no such 1307
contractor shall require its providers to be separately 1308
credentialed by the contractor in order to receive reimbursement 1309
from the contractor, but those contractors shall recognize the 1310
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credentialing of the providers by the division's credentialing 1311
process. 1312
(c) The division shall require a uniform provider 1313
credentialing application that shall be used in the credentialing 1314
process that is established under subparagraph (a) or (b). If the 1315
contractor or division, as applicable, has not approved or denied 1316
the provider credentialing application within sixty (60) days of 1317
receipt of the completed application that includes all required 1318
information necessary for credentialing, then the contractor or 1319
division, upon receipt of a written request from the applicant and 1320
within five (5) business days of its receipt, shall issue a 1321
temporary provider credential/enrollment to the applicant if the 1322
applicant has a valid Mississippi professional or occupational 1323
license to provide the health care services to which the 1324
credential/enrollment would apply. The contractor or the division 1325
shall not issue a temporary credential/enrollment if the applicant 1326
has reported on the application a history of medical or other 1327
professional or occupational malpractice claims, a history of 1328
substance abuse or mental health issues, a criminal record, or a 1329
history of medical or other licensing board, state or federal 1330
disciplinary action, including any suspension from participation 1331
in a federal or state program. The temporary 1332
credential/enrollment shall be effective upon issuance and shall 1333
remain in effect until the provider's credentialing/enrollment 1334
application is approved or denied by the contractor or division. 1335
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The contractor or division shall render a final decision regarding 1336
credentialing/enrollment of the provider within sixty (60) days 1337
from the date that the temporary provider credential/enrollment is 1338
issued to the applicant. 1339
(d) If the contractor or division does not render 1340
a final decision regarding credentialing/enrollment of the 1341
provider within the time required in subparagraph (c), the 1342
provider shall be deemed to be credentialed by and enrolled with 1343
all of the contractors and eligible to receive reimbursement from 1344
the contractors. 1345
(7) (a) Each contractor that is receiving capitated 1346
payments under a managed care delivery system established under 1347
this subsection (H) shall provide to each provider for whom the 1348
contractor has denied the coverage of a procedure that was ordered 1349
or requested by the provider for or on behalf of a patient, a 1350
letter that provides a detailed explanation of the reasons for the 1351
denial of coverage of the procedure and the name and the 1352
credentials of the person who denied the coverage. The letter 1353
shall be sent to the provider in electronic format. 1354
(b) After a contractor that is receiving capitated 1355
payments under a managed care delivery system established under 1356
this subsection (H) has denied coverage for a claim submitted by a 1357
provider, the contractor shall issue to the provider within sixty 1358
(60) days a final ruling of denial of the claim that allows the 1359
provider to have a state fair hearing and/or agency appeal with 1360
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the division. If a contractor does not issue a final ruling of 1361
denial within sixty (60) days as required by this subparagraph 1362
(b), the provider's claim shall be deemed to be automatically 1363
approved and the contractor shall pay the amount of the claim to 1364
the provider. 1365
(c) After a contractor has issued a final ruling 1366
of denial of a claim submitted by a provider, the division shall 1367
conduct a state fair hearing and/or agency appeal on the matter of 1368
the disputed claim between the contractor and the provider within 1369
sixty (60) days, and shall render a decision on the matter within 1370
thirty (30) days after the date of the hearing and/or appeal. 1371
(8) It is the intention of the Legislature that the 1372
division evaluate the feasibility of using a single vendor to 1373
administer pharmacy benefits provided under a managed care 1374
delivery system established under this subsection (H). Providers 1375
of pharmacy benefits shall cooperate with the division in any 1376
transition to a carve-out of pharmacy benefits under managed care. 1377
(9) The division shall evaluate the feasibility of 1378
using a single vendor to administer dental benefits provided under 1379
a managed care delivery system established in this subsection (H). 1380
Providers of dental benefits shall cooperate with the division in 1381
any transition to a carve-out of dental benefits under managed 1382
care. 1383
(10) It is the intent of the Legislature that any 1384
contractor receiving capitated payments under a managed care 1385
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delivery system established in this section shall implement 1386
innovative programs to improve the health and well-being of 1387
members diagnosed with prediabetes and diabetes. 1388
(11) It is the intent of the Legislature that any 1389
contractors receiving capitated payments under a managed care 1390
delivery system established under this subsection (H) shall work 1391
with providers of Medicaid services to improve the utilization of 1392
long-acting reversible contraceptives (LARCs). Not later than 1393
December 1, 2021, any contractors receiving capitated payments 1394
under a managed care delivery system established under this 1395
subsection (H) shall provide to the Chairmen of the House and 1396
Senate Medicaid Committees and House and Senate Public Health 1397
Committees a report of LARC utilization for State Fiscal Years 1398
2018 through 2020 as well as any programs, initiatives, or efforts 1399
made by the contractors and providers to increase LARC 1400
utilization. This report shall be updated annually to include 1401
information for subsequent state fiscal years. 1402
(12) The division is authorized to make not more than 1403
one (1) emergency extension of the contracts that are in effect on 1404
July 1, 2021, with contractors who are receiving capitated 1405
payments under a managed care delivery system established under 1406
this subsection (H), as provided in this paragraph (12). The 1407
maximum period of any such extension shall be one (1) year, and 1408
under any such extensions, the contractors shall be subject to all 1409
of the provisions of this subsection (H). The extended contracts 1410
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shall be revised to incorporate any provisions of this subsection 1411
(H). 1412
(I) [Deleted] 1413
(J) There shall be no cuts in inpatient and outpatient 1414
hospital payments, or allowable days or volumes, as long as the 1415
hospital assessment provided in Section 43-13-145 is in effect. 1416
This subsection (J) shall not apply to decreases in payments that 1417
are a result of: reduced hospital admissions, audits or payments 1418
under the APR-DRG or APC models, or a managed care program or 1419
similar model described in subsection (H) of this section. 1420
(K) In the negotiation and execution of such contracts 1421
involving services performed by actuarial firms, the Executive 1422
Director of the Division of Medicaid may negotiate a limitation on 1423
liability to the state of prospective contractors. 1424
(L) The Division of Medicaid shall reimburse for services 1425
provided to eligible Medicaid beneficiaries by a licensed birthing 1426
center in a method and manner to be determined by the division in 1427
accordance with federal laws and federal regulations. The 1428
division shall seek any necessary waivers, make any required 1429
amendments to its State Plan or revise any contracts authorized 1430
under subsection (H) of this section as necessary to provide the 1431
services authorized under this subsection. As used in this 1432
subsection, the term "birthing centers" shall have the meaning as 1433
defined in Section 41-77-1(a), which is a publicly or privately 1434
owned facility, place or institution constructed, renovated, 1435
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leased or otherwise established where nonemergency births are 1436
planned to occur away from the mother's usual residence following 1437
a documented period of prenatal care for a normal uncomplicated 1438
pregnancy which has been determined to be low risk through a 1439
formal risk-scoring examination. 1440
(M) This section shall stand repealed on July 1, 2028. 1441
SECTION 5. Section 83-5-907, Mississippi Code of 1972, is 1442
amended as follows: 1443
83-5-907. Definitions. For purposes of this article, unless 1444
the context requires otherwise, the following terms shall have the 1445
meanings as defined in this section: 1446
(a) "Adverse determination" means a determination by a 1447
health insurance issuer that, based on the information provided, a 1448
request for a benefit under the health insurance issuer's health 1449
benefit plan upon application of any utilization review technique 1450
does not meet the health insurance issuer's requirements for 1451
medical necessity, appropriateness, health care setting, level of 1452
care, or effectiveness or is determined to be experimental or 1453
investigational and the requested benefit is therefore denied, 1454
reduced, or terminated or payment is not provided or made, in 1455
whole or in part, for the benefit; the denial, reduction, or 1456
termination of or failure to provide or make payment, in whole or 1457
in part, for a benefit based on a determination by a health 1458
insurance issuer that a preexisting condition was present before 1459
the effective date of coverage; or a rescission of coverage 1460
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determination, which does not include a cancellation or 1461
discontinuance of coverage that is attributable to a failure to 1462
timely pay required premiums or contributions toward the cost of 1463
coverage. 1464
(b) "Appeal" means a formal request, either orally or 1465
in writing, to reconsider an adverse determination. 1466
(c) "Approval" means a determination by a health 1467
insurance issuer that a health care service has been reviewed and, 1468
based on the information provided, satisfies the health insurance 1469
issuer's requirements for medical necessity and appropriateness. 1470
(d) "Clinical review criteria" means the written 1471
screening procedures, decision abstracts, clinical protocols and 1472
practice guidelines used by a health insurance issuer to determine 1473
the necessity and appropriateness of health care services. 1474
(e) "Department" means the Mississippi State Department 1475
of Insurance. 1476
(f) "Emergency medical condition" means a medical 1477
condition manifesting itself by acute symptoms of sufficient 1478
severity, including, but not limited to, severe pain, such that a 1479
prudent layperson who possesses an average knowledge of health and 1480
medicine could reasonably expect the absence of immediate medical 1481
attention to result in: 1482
(i) Placing the health of the individual or, with 1483
respect to a pregnant woman, the health of the woman or her unborn 1484
child, in serious jeopardy; 1485
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(ii) Serious impairment to bodily functions; or 1486
(iii) Serious dysfunction of any bodily organ or 1487
part. 1488
(g) "Emergency services" means health care items and 1489
services furnished or required to evaluate and treat an emergency 1490
medical condition. 1491
(h) "Enrollee" means any person and his or her 1492
dependents enrolled in or covered by a health care plan. 1493
(i) "Health care professional" means a physician, a 1494
registered professional nurse or other individual appropriately 1495
licensed or registered to provide health care services. 1496
(j) "Health care provider" means any physician, 1497
hospital, ambulatory surgery center, or other person or facility 1498
that is licensed or otherwise authorized to deliver health care 1499
services. 1500
(k) "Health care service" means any services or level 1501
of services included in the furnishing to an individual of medical 1502
care or the hospitalization incident to the furnishing of such 1503
care, as well as the furnishing to any person of any other 1504
services for the purpose of preventing, alleviating, curing, 1505
diagnosing, screening for, or healing human illness or injury, 1506
including behavioral health, mental health, home health and 1507
pharmaceutical services and products. 1508
(l) "Health insurance issuer" has the meaning given to 1509
that term in Section 83-9-6.3. Any provision of this article that 1510
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applies to a "health insurance issuer" also applies to any person 1511
or entity covered under the scope of this article in Section 1512
83-5-905. 1513
(m) "Medically necessary" means a health care 1514
professional exercising prudent clinical judgment would provide 1515
care to a patient for the purpose of preventing, diagnosing, or 1516
treating an illness, injury, disease or its symptoms and that are: 1517
(i) In accordance with generally accepted 1518
standards of medical practice; and 1519
(ii) Clinically appropriate in terms of type, 1520
frequency, extent, site and duration and are considered effective 1521
for the patient's illness, injury or disease; and not primarily 1522
for the convenience of the patient, treating physician, other 1523
health care professional, caregiver, family member or other 1524
interested party, but focused on what is best for the patient's 1525
health outcome. 1526
(n) "Physician" means any person with a valid doctor of 1527
medicine, doctor of osteopathy or doctor of podiatry degree. 1528
(o) "Prior authorization" means the process by which a 1529
health insurance issuer determines the medical necessity and 1530
medical appropriateness of an otherwise covered health care 1531
service before the rendering of such health care service. "Prior 1532
authorization" includes any health insurance issuer's requirement 1533
that an enrollee, health care professional or health care provider 1534
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notify the health insurance issuer before, at the time of, or 1535
concurrent to providing a health care service. 1536
(p) "Urgent health care service" means a health care 1537
service with respect to which the application of the time periods 1538
for making a nonexpedited prior authorization that in the opinion 1539
of a treating health care professional or health care provider 1540
with knowledge of the enrollee's medical condition: 1541
(i) Could seriously jeopardize the life or health 1542
of the enrollee or the ability of the enrollee to regain maximum 1543
function; 1544
(ii) Could subject the enrollee to severe pain 1545
that cannot be adequately managed without the care or treatment 1546
that is the subject of the utilization review; or 1547
(iii) Could lead to likely onset of an emergency 1548
medical condition if the service is not rendered during the time 1549
period to render a prior authorization determination for an urgent 1550
medical service. 1551
(q) "Urgent health care service" does not include 1552
emergency services. 1553
(r) "Private review agent" has the meaning given to 1554
that term in Section 41-83-1. 1555
SECTION 6. This act shall take effect and be in force from 1556
and after July 1, 2026. 1557