Medicaid; revise certain provisions regarding managed care providers and payments during appeals.

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To: Medicaid
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Roberson

HOUSE BILL NO. 623

AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, 1
TO AUTHORIZE THE DIRECT ON-SITE SUPERVISOR OF A PROVIDER IN A 2
MANAGED CARE ORGANIZATION UNDER ANY MANAGED CARE PROGRAM 3
IMPLEMENTED BY THE DIVISION OF MEDICAID WHO HAS BEGUN THE PROCESS 4
FOR CREDENTIALING AND PREVIOUSLY HAS NOT BEEN DENIED CREDENTIALING 5
TO SIGN OFF ON THE WORK OF THE PROVIDER DURING THE TIME THAT THE 6
PROVIDER IS AWAITING A DECISION ON HIS OR HER CREDENTIALING, AND 7
TO ALLOW THE PROVIDER TO RECEIVE REIMBURSEMENT FROM THE 8
ORGANIZATION FOR THE WORK THAT HAS BEEN SIGNED OFF ON BY THE 9
SUPERVISOR; TO AMEND SECTION 43-13-121, MISSISSIPPI CODE OF 1972, 10
TO PROVIDE THAT WHENEVER THE DIVISION DETERMINES AFTER A HEARING 11
THAT A PROVIDER HAS VIOLATED ANY PROVISION OF THE MEDICAID LAW, 12
THE DIVISION MAY NOT SUSPEND REIMBURSEMENT PAYMENTS TO THE 13
PROVIDER DURING THE TIME THAT THE DECISION OF THE DIVISION IS ON 14
APPEAL BY THE PROVIDER, UNLESS THE PROVIDER PREVIOUSLY HAS BEEN 15
CONVICTED OF FRAUD IN CONNECTION WITH THE MEDICAID PROGRAM; AND 16
FOR RELATED PURPOSES. 17
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 18
SECTION 1. Section 43-13-117, Mississippi Code of 1972, is 19
amended as follows: 20
43-13-117. (A) Medicaid as authorized by this article shall 21
include payment of part or all of the costs, at the discretion of 22
the division, with approval of the Governor and the Centers for 23
Medicare and Medicaid Services, of the following types of care and 24
services rendered to eligible applicants who have been determined 25
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to be eligible for that care and services, within the limits of 26
state appropriations and federal matching funds: 27
(1) Inpatient hospital services. 28
(a) The division is authorized to implement an All 29
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 30
methodology for inpatient hospital services. 31
(b) No service benefits or reimbursement 32
limitations in this subsection (A)(1) shall apply to payments 33
under an APR-DRG or Ambulatory Payment Classification (APC) model 34
or a managed care program or similar model described in subsection 35
(H) of this section unless specifically authorized by the 36
division. 37
(2) Outpatient hospital services. 38
(a) Emergency services. 39
(b) Other outpatient hospital services. The 40
division shall allow benefits for other medically necessary 41
outpatient hospital services (such as chemotherapy, radiation, 42
surgery and therapy), including outpatient services in a clinic or 43
other facility that is not located inside the hospital, but that 44
has been designated as an outpatient facility by the hospital, and 45
that was in operation or under construction on July 1, 2009, 46
provided that the costs and charges associated with the operation 47
of the hospital clinic are included in the hospital's cost report. 48
In addition, the Medicare thirty-five-mile rule will apply to 49
those hospital clinics not located inside the hospital that are 50
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constructed after July 1, 2009. Where the same services are 51
reimbursed as clinic services, the division may revise the rate or 52
methodology of outpatient reimbursement to maintain consistency, 53
efficiency, economy and quality of care. 54
(c) The division is authorized to implement an 55
Ambulatory Payment Classification (APC) methodology for outpatient 56
hospital services. The division shall give rural hospitals that 57
have fifty (50) or fewer licensed beds the option to not be 58
reimbursed for outpatient hospital services using the APC 59
methodology, but reimbursement for outpatient hospital services 60
provided by those hospitals shall be based on one hundred one 61
percent (101%) of the rate established under Medicare for 62
outpatient hospital services. Those hospitals choosing to not be 63
reimbursed under the APC methodology shall remain under cost-based 64
reimbursement for a two-year period. 65
(d) No service benefits or reimbursement 66
limitations in this subsection (A)(2) shall apply to payments 67
under an APR-DRG or APC model or a managed care program or similar 68
model described in subsection (H) of this section unless 69
specifically authorized by the division. 70
(3) Laboratory and x-ray services. 71
(4) Nursing facility services. 72
(a) The division shall make full payment to 73
nursing facilities for each day, not exceeding forty-two (42) days 74
per year, that a patient is absent from the facility on home 75
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leave. Payment may be made for the following home leave days in 76
addition to the forty-two-day limitation: Christmas, the day 77
before Christmas, the day after Christmas, Thanksgiving, the day 78
before Thanksgiving and the day after Thanksgiving. 79
(b) From and after July 1, 1997, the division 80
shall implement the integrated case-mix payment and quality 81
monitoring system, which includes the fair rental system for 82
property costs and in which recapture of depreciation is 83
eliminated. The division may reduce the payment for hospital 84
leave and therapeutic home leave days to the lower of the case-mix 85
category as computed for the resident on leave using the 86
assessment being utilized for payment at that point in time, or a 87
case-mix score of 1.000 for nursing facilities, and shall compute 88
case-mix scores of residents so that only services provided at the 89
nursing facility are considered in calculating a facility's per 90
diem. 91
(c) From and after July 1, 1997, all state-owned 92
nursing facilities shall be reimbursed on a full reasonable cost 93
basis. 94
(d) On or after January 1, 2015, the division 95
shall update the case-mix payment system resource utilization 96
grouper and classifications and fair rental reimbursement system. 97
The division shall develop and implement a payment add-on to 98
reimburse nursing facilities for ventilator-dependent resident 99
services. 100
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(e) The division shall develop and implement, not 101
later than January 1, 2001, a case-mix payment add-on determined 102
by time studies and other valid statistical data that will 103
reimburse a nursing facility for the additional cost of caring for 104
a resident who has a diagnosis of Alzheimer's or other related 105
dementia and exhibits symptoms that require special care. Any 106
such case-mix add-on payment shall be supported by a determination 107
of additional cost. The division shall also develop and implement 108
as part of the fair rental reimbursement system for nursing 109
facility beds, an Alzheimer's resident bed depreciation enhanced 110
reimbursement system that will provide an incentive to encourage 111
nursing facilities to convert or construct beds for residents with 112
Alzheimer's or other related dementia. 113
(f) The division shall develop and implement an 114
assessment process for long-term care services. The division may 115
provide the assessment and related functions directly or through 116
contract with the area agencies on aging. 117
The division shall apply for necessary federal waivers to 118
assure that additional services providing alternatives to nursing 119
facility care are made available to applicants for nursing 120
facility care. 121
(5) Periodic screening and diagnostic services for 122
individuals under age twenty-one (21) years as are needed to 123
identify physical and mental defects and to provide health care 124
treatment and other measures designed to correct or ameliorate 125
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defects and physical and mental illness and conditions discovered 126
by the screening services, regardless of whether these services 127
are included in the state plan. The division may include in its 128
periodic screening and diagnostic program those discretionary 129
services authorized under the federal regulations adopted to 130
implement Title XIX of the federal Social Security Act, as 131
amended. The division, in obtaining physical therapy services, 132
occupational therapy services, and services for individuals with 133
speech, hearing and language disorders, may enter into a 134
cooperative agreement with the State Department of Education for 135
the provision of those services to handicapped students by public 136
school districts using state funds that are provided from the 137
appropriation to the Department of Education to obtain federal 138
matching funds through the division. The division, in obtaining 139
medical and mental health assessments, treatment, care and 140
services for children who are in, or at risk of being put in, the 141
custody of the Mississippi Department of Human Services may enter 142
into a cooperative agreement with the Mississippi Department of 143
Human Services for the provision of those services using state 144
funds that are provided from the appropriation to the Department 145
of Human Services to obtain federal matching funds through the 146
division. 147
(6) Physician services. Fees for physician's services 148
that are covered only by Medicaid shall be reimbursed at ninety 149
percent (90%) of the rate established on January 1, 2018, and as 150
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may be adjusted each July thereafter, under Medicare. The 151
division may provide for a reimbursement rate for physician's 152
services of up to one hundred percent (100%) of the rate 153
established under Medicare for physician's services that are 154
provided after the normal working hours of the physician, as 155
determined in accordance with regulations of the division. The 156
division may reimburse eligible providers, as determined by the 157
division, for certain primary care services at one hundred percent 158
(100%) of the rate established under Medicare. The division shall 159
reimburse obstetricians and gynecologists for certain primary care 160
services as defined by the division at one hundred percent (100%) 161
of the rate established under Medicare. 162
(7) (a) Home health services for eligible persons, not 163
to exceed in cost the prevailing cost of nursing facility 164
services. All home health visits must be precertified as required 165
by the division. In addition to physicians, certified registered 166
nurse practitioners, physician assistants and clinical nurse 167
specialists are authorized to prescribe or order home health 168
services and plans of care, sign home health plans of care, 169
certify and recertify eligibility for home health services and 170
conduct the required initial face-to-face visit with the recipient 171
of the services. 172
(b) [Repealed] 173
(8) Emergency medical transportation services as 174
determined by the division. 175
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(9) Prescription drugs and other covered drugs and 176
services as determined by the division. 177
The division shall establish a mandatory preferred drug list. 178
Drugs not on the mandatory preferred drug list shall be made 179
available by utilizing prior authorization procedures established 180
by the division. 181
The division may seek to establish relationships with other 182
states in order to lower acquisition costs of prescription drugs 183
to include single-source and innovator multiple-source drugs or 184
generic drugs. In addition, if allowed by federal law or 185
regulation, the division may seek to establish relationships with 186
and negotiate with other countries to facilitate the acquisition 187
of prescription drugs to include single-source and innovator 188
multiple-source drugs or generic drugs, if that will lower the 189
acquisition costs of those prescription drugs. 190
The division may allow for a combination of prescriptions for 191
single-source and innovator multiple-source drugs and generic 192
drugs to meet the needs of the beneficiaries. 193
The executive director may approve specific maintenance drugs 194
for beneficiaries with certain medical conditions, which may be 195
prescribed and dispensed in three-month supply increments. 196
Drugs prescribed for a resident of a psychiatric residential 197
treatment facility must be provided in true unit doses when 198
available. The division may require that drugs not covered by 199
Medicare Part D for a resident of a long-term care facility be 200
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provided in true unit doses when available. Those drugs that were 201
originally billed to the division but are not used by a resident 202
in any of those facilities shall be returned to the billing 203
pharmacy for credit to the division, in accordance with the 204
guidelines of the State Board of Pharmacy and any requirements of 205
federal law and regulation. Drugs shall be dispensed to a 206
recipient and only one (1) dispensing fee per month may be 207
charged. The division shall develop a methodology for reimbursing 208
for restocked drugs, which shall include a restock fee as 209
determined by the division not exceeding Seven Dollars and 210
Eighty-two Cents ($7.82). 211
Except for those specific maintenance drugs approved by the 212
executive director, the division shall not reimburse for any 213
portion of a prescription that exceeds a thirty-one-day supply of 214
the drug based on the daily dosage. 215
The division is authorized to develop and implement a program 216
of payment for additional pharmacist services as determined by the 217
division. 218
All claims for drugs for dually eligible Medicare/Medicaid 219
beneficiaries that are paid for by Medicare must be submitted to 220
Medicare for payment before they may be processed by the 221
division's online payment system. 222
The division shall develop a pharmacy policy in which drugs 223
in tamper-resistant packaging that are prescribed for a resident 224
of a nursing facility but are not dispensed to the resident shall 225
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be returned to the pharmacy and not billed to Medicaid, in 226
accordance with guidelines of the State Board of Pharmacy. 227
The division shall develop and implement a method or methods 228
by which the division will provide on a regular basis to Medicaid 229
providers who are authorized to prescribe drugs, information about 230
the costs to the Medicaid program of single-source drugs and 231
innovator multiple-source drugs, and information about other drugs 232
that may be prescribed as alternatives to those single-source 233
drugs and innovator multiple-source drugs and the costs to the 234
Medicaid program of those alternative drugs. 235
Notwithstanding any law or regulation, information obtained 236
or maintained by the division regarding the prescription drug 237
program, including trade secrets and manufacturer or labeler 238
pricing, is confidential and not subject to disclosure except to 239
other state agencies. 240
The dispensing fee for each new or refill prescription, 241
including nonlegend or over-the-counter drugs covered by the 242
division, shall be not less than Three Dollars and Ninety-one 243
Cents ($3.91), as determined by the division. 244
The division shall not reimburse for single-source or 245
innovator multiple-source drugs if there are equally effective 246
generic equivalents available and if the generic equivalents are 247
the least expensive. 248
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It is the intent of the Legislature that the pharmacists 249
providers be reimbursed for the reasonable costs of filling and 250
dispensing prescriptions for Medicaid beneficiaries. 251
The division shall allow certain drugs, including 252
physician-administered drugs, and implantable drug system devices, 253
and medical supplies, with limited distribution or limited access 254
for beneficiaries and administered in an appropriate clinical 255
setting, to be reimbursed as either a medical claim or pharmacy 256
claim, as determined by the division. 257
It is the intent of the Legislature that the division and any 258
managed care entity described in subsection (H) of this section 259
encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to 260
prevent recurrent preterm birth. 261
(10) Dental and orthodontic services to be determined 262
by the division. 263
The division shall increase the amount of the reimbursement 264
rate for diagnostic and preventative dental services for each of 265
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 266
the amount of the reimbursement rate for the previous fiscal year. 267
The division shall increase the amount of the reimbursement rate 268
for restorative dental services for each of the fiscal years 2023, 269
2024 and 2025 by five percent (5%) above the amount of the 270
reimbursement rate for the previous fiscal year. It is the intent 271
of the Legislature that the reimbursement rate revision for 272
preventative dental services will be an incentive to increase the 273
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number of dentists who actively provide Medicaid services. This 274
dental services reimbursement rate revision shall be known as the 275
"James Russell Dumas Medicaid Dental Services Incentive Program." 276
The Medical Care Advisory Committee, assisted by the Division 277
of Medicaid, shall annually determine the effect of this incentive 278
by evaluating the number of dentists who are Medicaid providers, 279
the number who and the degree to which they are actively billing 280
Medicaid, the geographic trends of where dentists are offering 281
what types of Medicaid services and other statistics pertinent to 282
the goals of this legislative intent. This data shall annually be 283
presented to the Chair of the Senate Medicaid Committee and the 284
Chair of the House Medicaid Committee. 285
The division shall include dental services as a necessary 286
component of overall health services provided to children who are 287
eligible for services. 288
(11) Eyeglasses for all Medicaid beneficiaries who have 289
(a) had surgery on the eyeball or ocular muscle that results in a 290
vision change for which eyeglasses or a change in eyeglasses is 291
medically indicated within six (6) months of the surgery and is in 292
accordance with policies established by the division, or (b) one 293
(1) pair every five (5) years and in accordance with policies 294
established by the division. In either instance, the eyeglasses 295
must be prescribed by a physician skilled in diseases of the eye 296
or an optometrist, whichever the beneficiary may select. 297
(12) Intermediate care facility services. 298
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(a) The division shall make full payment to all 299
intermediate care facilities for individuals with intellectual 300
disabilities for each day, not exceeding sixty-three (63) days per 301
year, that a patient is absent from the facility on home leave. 302
Payment may be made for the following home leave days in addition 303
to the sixty-three-day limitation: Christmas, the day before 304
Christmas, the day after Christmas, Thanksgiving, the day before 305
Thanksgiving and the day after Thanksgiving. 306
(b) All state-owned intermediate care facilities 307
for individuals with intellectual disabilities shall be reimbursed 308
on a full reasonable cost basis. 309
(c) Effective January 1, 2015, the division shall 310
update the fair rental reimbursement system for intermediate care 311
facilities for individuals with intellectual disabilities. 312
(13) Family planning services, including drugs, 313
supplies and devices, when those services are under the 314
supervision of a physician or nurse practitioner. 315
(14) Clinic services. Preventive, diagnostic, 316
therapeutic, rehabilitative or palliative services that are 317
furnished by a facility that is not part of a hospital but is 318
organized and operated to provide medical care to outpatients. 319
Clinic services include, but are not limited to: 320
(a) Services provided by ambulatory surgical 321
centers (ASCs) as defined in Section 41-75-1(a); and 322
(b) Dialysis center services. 323
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(15) Home- and community-based services for the elderly 324
and disabled, as provided under Title XIX of the federal Social 325
Security Act, as amended, under waivers, subject to the 326
availability of funds specifically appropriated for that purpose 327
by the Legislature. 328
(16) Mental health services. Certain services provided 329
by a psychiatrist shall be reimbursed at up to one hundred percent 330
(100%) of the Medicare rate. Approved therapeutic and case 331
management services (a) provided by an approved regional mental 332
health/intellectual disability center established under Sections 333
41-19-31 through 41-19-39, or by another community mental health 334
service provider meeting the requirements of the Department of 335
Mental Health to be an approved mental health/intellectual 336
disability center if determined necessary by the Department of 337
Mental Health, using state funds that are provided in the 338
appropriation to the division to match federal funds, or (b) 339
provided by a facility that is certified by the State Department 340
of Mental Health to provide therapeutic and case management 341
services, to be reimbursed on a fee for service basis, or (c) 342
provided in the community by a facility or program operated by the 343
Department of Mental Health. Any such services provided by a 344
facility described in subparagraph (b) must have the prior 345
approval of the division to be reimbursable under this section. 346
(17) Durable medical equipment services and medical 347
supplies. Precertification of durable medical equipment and 348
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medical supplies must be obtained as required by the division. 349
The Division of Medicaid may require durable medical equipment 350
providers to obtain a surety bond in the amount and to the 351
specifications as established by the Balanced Budget Act of 1997. 352
A maximum dollar amount of reimbursement for noninvasive 353
ventilators or ventilation treatments properly ordered and being 354
used in an appropriate care setting shall not be set by any health 355
maintenance organization, coordinated care organization, 356
provider-sponsored health plan, or other organization paid for 357
services on a capitated basis by the division under any managed 358
care program or coordinated care program implemented by the 359
division under this section. Reimbursement by these organizations 360
to durable medical equipment suppliers for home use of noninvasive 361
and invasive ventilators shall be on a continuous monthly payment 362
basis for the duration of medical need throughout a patient's 363
valid prescription period. 364
(18) (a) Notwithstanding any other provision of this 365
section to the contrary, as provided in the Medicaid state plan 366
amendment or amendments as defined in Section 43-13-145(10), the 367
division shall make additional reimbursement to hospitals that 368
serve a disproportionate share of low-income patients and that 369
meet the federal requirements for those payments as provided in 370
Section 1923 of the federal Social Security Act and any applicable 371
regulations. It is the intent of the Legislature that the 372
division shall draw down all available federal funds allotted to 373
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the state for disproportionate share hospitals. However, from and 374
after January 1, 1999, public hospitals participating in the 375
Medicaid disproportionate share program may be required to 376
participate in an intergovernmental transfer program as provided 377
in Section 1903 of the federal Social Security Act and any 378
applicable regulations. 379
(b) (i) 1. The division may establish a Medicare 380
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 381
the federal Social Security Act and any applicable federal 382
regulations, or an allowable delivery system or provider payment 383
initiative authorized under 42 CFR 438.6(c), for hospitals, 384
nursing facilities and physicians employed or contracted by 385
hospitals. 386
2. The division shall establish a 387
Medicaid Supplemental Payment Program, as permitted by the federal 388
Social Security Act and a comparable allowable delivery system or 389
provider payment initiative authorized under 42 CFR 438.6(c), for 390
emergency ambulance transportation providers in accordance with 391
this subsection (A)(18)(b). 392
(ii) The division shall assess each hospital, 393
nursing facility, and emergency ambulance transportation provider 394
for the sole purpose of financing the state portion of the 395
Medicare Upper Payment Limits Program or other program(s) 396
authorized under this subsection (A)(18)(b). The hospital 397
assessment shall be as provided in Section 43-13-145(4)(a), and 398
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the nursing facility and the emergency ambulance transportation 399
assessments, if established, shall be based on Medicaid 400
utilization or other appropriate method, as determined by the 401
division, consistent with federal regulations. The assessments 402
will remain in effect as long as the state participates in the 403
Medicare Upper Payment Limits Program or other program(s) 404
authorized under this subsection (A)(18)(b). In addition to the 405
hospital assessment provided in Section 43-13-145(4)(a), hospitals 406
with physicians participating in the Medicare Upper Payment Limits 407
Program or other program(s) authorized under this subsection 408
(A)(18)(b) shall be required to participate in an 409
intergovernmental transfer or assessment, as determined by the 410
division, for the purpose of financing the state portion of the 411
physician UPL payments or other payment(s) authorized under this 412
subsection (A)(18)(b). 413
(iii) Subject to approval by the Centers for 414
Medicare and Medicaid Services (CMS) and the provisions of this 415
subsection (A)(18)(b), the division shall make additional 416
reimbursement to hospitals, nursing facilities, and emergency 417
ambulance transportation providers for the Medicare Upper Payment 418
Limits Program or other program(s) authorized under this 419
subsection (A)(18)(b), and, if the program is established for 420
physicians, shall make additional reimbursement for physicians, as 421
defined in Section 1902(a)(30) of the federal Social Security Act 422
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and any applicable federal regulations, provided the assessment in 423
this subsection (A)(18)(b) is in effect. 424
(iv) Notwithstanding any other provision of 425
this article to the contrary, effective upon implementation of the 426
Mississippi Hospital Access Program (MHAP) provided in 427
subparagraph (c)(i) below, the hospital portion of the inpatient 428
Upper Payment Limits Program shall transition into and be replaced 429
by the MHAP program. However, the division is authorized to 430
develop and implement an alternative fee-for-service Upper Payment 431
Limits model in accordance with federal laws and regulations if 432
necessary to preserve supplemental funding. Further, the 433
division, in consultation with the hospital industry shall develop 434
alternative models for distribution of medical claims and 435
supplemental payments for inpatient and outpatient hospital 436
services, and such models may include, but shall not be limited to 437
the following: increasing rates for inpatient and outpatient 438
services; creating a low-income utilization pool of funds to 439
reimburse hospitals for the costs of uncompensated care, charity 440
care and bad debts as permitted and approved pursuant to federal 441
regulations and the Centers for Medicare and Medicaid Services; 442
supplemental payments based upon Medicaid utilization, quality, 443
service lines and/or costs of providing such services to Medicaid 444
beneficiaries and to uninsured patients. The goals of such 445
payment models shall be to ensure access to inpatient and 446
outpatient care and to maximize any federal funds that are 447
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available to reimburse hospitals for services provided. Any such 448
documents required to achieve the goals described in this 449
paragraph shall be submitted to the Centers for Medicare and 450
Medicaid Services, with a proposed effective date of July 1, 2019, 451
to the extent possible, but in no event shall the effective date 452
of such payment models be later than July 1, 2020. The Chairmen 453
of the Senate and House Medicaid Committees shall be provided a 454
copy of the proposed payment model(s) prior to submission. 455
Effective July 1, 2018, and until such time as any payment 456
model(s) as described above become effective, the division, in 457
consultation with the hospital industry, is authorized to 458
implement a transitional program for inpatient and outpatient 459
payments and/or supplemental payments (including, but not limited 460
to, MHAP and directed payments), to redistribute available 461
supplemental funds among hospital providers, provided that when 462
compared to a hospital's prior year supplemental payments, 463
supplemental payments made pursuant to any such transitional 464
program shall not result in a decrease of more than five percent 465
(5%) and shall not increase by more than the amount needed to 466
maximize the distribution of the available funds. 467
(v) 1. To preserve and improve access to 468
ambulance transportation provider services, the division shall 469
seek CMS approval to make ambulance service access payments as set 470
forth in this subsection (A)(18)(b) for all covered emergency 471
ambulance services rendered on or after July 1, 2022, and shall 472
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make such ambulance service access payments for all covered 473
services rendered on or after the effective date of CMS approval. 474
2. The division shall calculate the 475
ambulance service access payment amount as the balance of the 476
portion of the Medical Care Fund related to ambulance 477
transportation service provider assessments plus any federal 478
matching funds earned on the balance, up to, but not to exceed, 479
the upper payment limit gap for all emergency ambulance service 480
providers. 481
3. a. Except for ambulance services 482
exempt from the assessment provided in this paragraph (18)(b), all 483
ambulance transportation service providers shall be eligible for 484
ambulance service access payments each state fiscal year as set 485
forth in this paragraph (18)(b). 486
b. In addition to any other funds 487
paid to ambulance transportation service providers for emergency 488
medical services provided to Medicaid beneficiaries, each eligible 489
ambulance transportation service provider shall receive ambulance 490
service access payments each state fiscal year equal to the 491
ambulance transportation service provider's upper payment limit 492
gap. Subject to approval by the Centers for Medicare and Medicaid 493
Services, ambulance service access payments shall be made no less 494
than on a quarterly basis. 495
c. As used in this paragraph 496
(18)(b)(v), the term "upper payment limit gap" means the 497
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difference between the total amount that the ambulance 498
transportation service provider received from Medicaid and the 499
average amount that the ambulance transportation service provider 500
would have received from commercial insurers for those services 501
reimbursed by Medicaid. 502
4. An ambulance service access payment 503
shall not be used to offset any other payment by the division for 504
emergency or nonemergency services to Medicaid beneficiaries. 505
(c) (i) Not later than December l, 2015, the 506
division shall, subject to approval by the Centers for Medicare 507
and Medicaid Services (CMS), establish, implement and operate a 508
Mississippi Hospital Access Program (MHAP) for the purpose of 509
protecting patient access to hospital care through hospital 510
inpatient reimbursement programs provided in this section designed 511
to maintain total hospital reimbursement for inpatient services 512
rendered by in-state hospitals and the out-of-state hospital that 513
is authorized by federal law to submit intergovernmental transfers 514
(IGTs) to the State of Mississippi and is classified as Level I 515
trauma center located in a county contiguous to the state line at 516
the maximum levels permissible under applicable federal statutes 517
and regulations, at which time the current inpatient Medicare 518
Upper Payment Limits (UPL) Program for hospital inpatient services 519
shall transition to the MHAP. 520
(ii) Subject to approval by the Centers for 521
Medicare and Medicaid Services (CMS), the MHAP shall provide 522
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increased inpatient capitation (PMPM) payments to managed care 523
entities contracting with the division pursuant to subsection (H) 524
of this section to support availability of hospital services or 525
such other payments permissible under federal law necessary to 526
accomplish the intent of this subsection. 527
(iii) The intent of this subparagraph (c) is 528
that effective for all inpatient hospital Medicaid services during 529
state fiscal year 2016, and so long as this provision shall remain 530
in effect hereafter, the division shall to the fullest extent 531
feasible replace the additional reimbursement for hospital 532
inpatient services under the inpatient Medicare Upper Payment 533
Limits (UPL) Program with additional reimbursement under the MHAP 534
and other payment programs for inpatient and/or outpatient 535
payments which may be developed under the authority of this 536
paragraph. 537
(iv) The division shall assess each hospital 538
as provided in Section 43-13-145(4)(a) for the purpose of 539
financing the state portion of the MHAP, supplemental payments and 540
such other purposes as specified in Section 43-13-145. The 541
assessment will remain in effect as long as the MHAP and 542
supplemental payments are in effect. 543
(19) (a) Perinatal risk management services. The 544
division shall promulgate regulations to be effective from and 545
after October 1, 1988, to establish a comprehensive perinatal 546
system for risk assessment of all pregnant and infant Medicaid 547
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recipients and for management, education and follow-up for those 548
who are determined to be at risk. Services to be performed 549
include case management, nutrition assessment/counseling, 550
psychosocial assessment/counseling and health education. The 551
division shall contract with the State Department of Health to 552
provide services within this paragraph (Perinatal High Risk 553
Management/Infant Services System (PHRM/ISS)). The State 554
Department of Health shall be reimbursed on a full reasonable cost 555
basis for services provided under this subparagraph (a). 556
(b) Early intervention system services. The 557
division shall cooperate with the State Department of Health, 558
acting as lead agency, in the development and implementation of a 559
statewide system of delivery of early intervention services, under 560
Part C of the Individuals with Disabilities Education Act (IDEA). 561
The State Department of Health shall certify annually in writing 562
to the executive director of the division the dollar amount of 563
state early intervention funds available that will be utilized as 564
a certified match for Medicaid matching funds. Those funds then 565
shall be used to provide expanded targeted case management 566
services for Medicaid eligible children with special needs who are 567
eligible for the state's early intervention system. 568
Qualifications for persons providing service coordination shall be 569
determined by the State Department of Health and the Division of 570
Medicaid. 571
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(20) Home- and community-based services for physically 572
disabled approved services as allowed by a waiver from the United 573
States Department of Health and Human Services for home- and 574
community-based services for physically disabled people using 575
state funds that are provided from the appropriation to the State 576
Department of Rehabilitation Services and used to match federal 577
funds under a cooperative agreement between the division and the 578
department, provided that funds for these services are 579
specifically appropriated to the Department of Rehabilitation 580
Services. 581
(21) Nurse practitioner services. Services furnished 582
by a registered nurse who is licensed and certified by the 583
Mississippi Board of Nursing as a nurse practitioner, including, 584
but not limited to, nurse anesthetists, nurse midwives, family 585
nurse practitioners, family planning nurse practitioners, 586
pediatric nurse practitioners, obstetrics-gynecology nurse 587
practitioners and neonatal nurse practitioners, under regulations 588
adopted by the division. Reimbursement for those services shall 589
not exceed ninety percent (90%) of the reimbursement rate for 590
comparable services rendered by a physician. The division may 591
provide for a reimbursement rate for nurse practitioner services 592
of up to one hundred percent (100%) of the reimbursement rate for 593
comparable services rendered by a physician for nurse practitioner 594
services that are provided after the normal working hours of the 595
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nurse practitioner, as determined in accordance with regulations 596
of the division. 597
(22) Ambulatory services delivered in federally 598
qualified health centers, rural health centers and clinics of the 599
local health departments of the State Department of Health for 600
individuals eligible for Medicaid under this article based on 601
reasonable costs as determined by the division. Federally 602
qualified health centers shall be reimbursed by the Medicaid 603
prospective payment system as approved by the Centers for Medicare 604
and Medicaid Services. The division shall recognize federally 605
qualified health centers (FQHCs), rural health clinics (RHCs) and 606
community mental health centers (CMHCs) as both an originating and 607
distant site provider for the purposes of telehealth 608
reimbursement. The division is further authorized and directed to 609
reimburse FQHCs, RHCs and CMHCs for both distant site and 610
originating site services when such services are appropriately 611
provided by the same organization. 612
(23) Inpatient psychiatric services. 613
(a) Inpatient psychiatric services to be 614
determined by the division for recipients under age twenty-one 615
(21) that are provided under the direction of a physician in an 616
inpatient program in a licensed acute care psychiatric facility or 617
in a licensed psychiatric residential treatment facility, before 618
the recipient reaches age twenty-one (21) or, if the recipient was 619
receiving the services immediately before he or she reached age 620
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twenty-one (21), before the earlier of the date he or she no 621
longer requires the services or the date he or she reaches age 622
twenty-two (22), as provided by federal regulations. From and 623
after January 1, 2015, the division shall update the fair rental 624
reimbursement system for psychiatric residential treatment 625
facilities. Precertification of inpatient days and residential 626
treatment days must be obtained as required by the division. From 627
and after July 1, 2009, all state-owned and state-operated 628
facilities that provide inpatient psychiatric services to persons 629
under age twenty-one (21) who are eligible for Medicaid 630
reimbursement shall be reimbursed for those services on a full 631
reasonable cost basis. 632
(b) The division may reimburse for services 633
provided by a licensed freestanding psychiatric hospital to 634
Medicaid recipients over the age of twenty-one (21) in a method 635
and manner consistent with the provisions of Section 43-13-117.5. 636
(24) [Deleted] 637
(25) [Deleted] 638
(26) Hospice care. As used in this paragraph, the term 639
"hospice care" means a coordinated program of active professional 640
medical attention within the home and outpatient and inpatient 641
care that treats the terminally ill patient and family as a unit, 642
employing a medically directed interdisciplinary team. The 643
program provides relief of severe pain or other physical symptoms 644
and supportive care to meet the special needs arising out of 645
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physical, psychological, spiritual, social and economic stresses 646
that are experienced during the final stages of illness and during 647
dying and bereavement and meets the Medicare requirements for 648
participation as a hospice as provided in federal regulations. 649
(27) Group health plan premiums and cost-sharing if it 650
is cost-effective as defined by the United States Secretary of 651
Health and Human Services. 652
(28) Other health insurance premiums that are 653
cost-effective as defined by the United States Secretary of Health 654
and Human Services. Medicare eligible must have Medicare Part B 655
before other insurance premiums can be paid. 656
(29) The Division of Medicaid may apply for a waiver 657
from the United States Department of Health and Human Services for 658
home- and community-based services for developmentally disabled 659
people using state funds that are provided from the appropriation 660
to the State Department of Mental Health and/or funds transferred 661
to the department by a political subdivision or instrumentality of 662
the state and used to match federal funds under a cooperative 663
agreement between the division and the department, provided that 664
funds for these services are specifically appropriated to the 665
Department of Mental Health and/or transferred to the department 666
by a political subdivision or instrumentality of the state. 667
(30) Pediatric skilled nursing services as determined 668
by the division and in a manner consistent with regulations 669
promulgated by the Mississippi State Department of Health. 670
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(31) Targeted case management services for children 671
with special needs, under waivers from the United States 672
Department of Health and Human Services, using state funds that 673
are provided from the appropriation to the Mississippi Department 674
of Human Services and used to match federal funds under a 675
cooperative agreement between the division and the department. 676
(32) Care and services provided in Christian Science 677
Sanatoria listed and certified by the Commission for Accreditation 678
of Christian Science Nursing Organizations/Facilities, Inc., 679
rendered in connection with treatment by prayer or spiritual means 680
to the extent that those services are subject to reimbursement 681
under Section 1903 of the federal Social Security Act. 682
(33) Podiatrist services. 683
(34) Assisted living services as provided through 684
home- and community-based services under Title XIX of the federal 685
Social Security Act, as amended, subject to the availability of 686
funds specifically appropriated for that purpose by the 687
Legislature. 688
(35) Services and activities authorized in Sections 689
43-27-101 and 43-27-103, using state funds that are provided from 690
the appropriation to the Mississippi Department of Human Services 691
and used to match federal funds under a cooperative agreement 692
between the division and the department. 693
(36) Nonemergency transportation services for 694
Medicaid-eligible persons as determined by the division. The PEER 695
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Committee shall conduct a performance evaluation of the 696
nonemergency transportation program to evaluate the administration 697
of the program and the providers of transportation services to 698
determine the most cost-effective ways of providing nonemergency 699
transportation services to the patients served under the program. 700
The performance evaluation shall be completed and provided to the 701
members of the Senate Medicaid Committee and the House Medicaid 702
Committee not later than January 1, 2019, and every two (2) years 703
thereafter. 704
(37) [Deleted] 705
(38) Chiropractic services. A chiropractor's manual 706
manipulation of the spine to correct a subluxation, if x-ray 707
demonstrates that a subluxation exists and if the subluxation has 708
resulted in a neuromusculoskeletal condition for which 709
manipulation is appropriate treatment, and related spinal x-rays 710
performed to document these conditions. Reimbursement for 711
chiropractic services shall not exceed Seven Hundred Dollars 712
($700.00) per year per beneficiary. 713
(39) Dually eligible Medicare/Medicaid beneficiaries. 714
The division shall pay the Medicare deductible and coinsurance 715
amounts for services available under Medicare, as determined by 716
the division. From and after July 1, 2009, the division shall 717
reimburse crossover claims for inpatient hospital services and 718
crossover claims covered under Medicare Part B in the same manner 719
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that was in effect on January 1, 2008, unless specifically 720
authorized by the Legislature to change this method. 721
(40) [Deleted] 722
(41) Services provided by the State Department of 723
Rehabilitation Services for the care and rehabilitation of persons 724
with spinal cord injuries or traumatic brain injuries, as allowed 725
under waivers from the United States Department of Health and 726
Human Services, using up to seventy-five percent (75%) of the 727
funds that are appropriated to the Department of Rehabilitation 728
Services from the Spinal Cord and Head Injury Trust Fund 729
established under Section 37-33-261 and used to match federal 730
funds under a cooperative agreement between the division and the 731
department. 732
(42) [Deleted] 733
(43) The division shall provide reimbursement, 734
according to a payment schedule developed by the division, for 735
smoking cessation medications for pregnant women during their 736
pregnancy and other Medicaid-eligible women who are of 737
child-bearing age. 738
(44) Nursing facility services for the severely 739
disabled. 740
(a) Severe disabilities include, but are not 741
limited to, spinal cord injuries, closed-head injuries and 742
ventilator-dependent patients. 743
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(b) Those services must be provided in a long-term 744
care nursing facility dedicated to the care and treatment of 745
persons with severe disabilities. 746
(45) Physician assistant services. Services furnished 747
by a physician assistant who is licensed by the State Board of 748
Medical Licensure and is practicing with physician supervision 749
under regulations adopted by the board, under regulations adopted 750
by the division. Reimbursement for those services shall not 751
exceed ninety percent (90%) of the reimbursement rate for 752
comparable services rendered by a physician. The division may 753
provide for a reimbursement rate for physician assistant services 754
of up to one hundred percent (100%) or the reimbursement rate for 755
comparable services rendered by a physician for physician 756
assistant services that are provided after the normal working 757
hours of the physician assistant, as determined in accordance with 758
regulations of the division. 759
(46) The division shall make application to the federal 760
Centers for Medicare and Medicaid Services (CMS) for a waiver to 761
develop and provide services for children with serious emotional 762
disturbances as defined in Section 43-14-1(1), which may include 763
home- and community-based services, case management services or 764
managed care services through mental health providers certified by 765
the Department of Mental Health. The division may implement and 766
provide services under this waivered program only if funds for 767
these services are specifically appropriated for this purpose by 768
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the Legislature, or if funds are voluntarily provided by affected 769
agencies. 770
(47) (a) The division may develop and implement 771
disease management programs for individuals with high-cost chronic 772
diseases and conditions, including the use of grants, waivers, 773
demonstrations or other projects as necessary. 774
(b) Participation in any disease management 775
program implemented under this paragraph (47) is optional with the 776
individual. An individual must affirmatively elect to participate 777
in the disease management program in order to participate, and may 778
elect to discontinue participation in the program at any time. 779
(48) Pediatric long-term acute care hospital services. 780
(a) Pediatric long-term acute care hospital 781
services means services provided to eligible persons under 782
twenty-one (21) years of age by a freestanding Medicare-certified 783
hospital that has an average length of inpatient stay greater than 784
twenty-five (25) days and that is primarily engaged in providing 785
chronic or long-term medical care to persons under twenty-one (21) 786
years of age. 787
(b) The services under this paragraph (48) shall 788
be reimbursed as a separate category of hospital services. 789
(49) The division may establish copayments and/or 790
coinsurance for any Medicaid services for which copayments and/or 791
coinsurance are allowable under federal law or regulation. 792
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(50) Services provided by the State Department of 793
Rehabilitation Services for the care and rehabilitation of persons 794
who are deaf and blind, as allowed under waivers from the United 795
States Department of Health and Human Services to provide home- 796
and community-based services using state funds that are provided 797
from the appropriation to the State Department of Rehabilitation 798
Services or if funds are voluntarily provided by another agency. 799
(51) Upon determination of Medicaid eligibility and in 800
association with annual redetermination of Medicaid eligibility, 801
beneficiaries shall be encouraged to undertake a physical 802
examination that will establish a base-line level of health and 803
identification of a usual and customary source of care (a medical 804
home) to aid utilization of disease management tools. This 805
physical examination and utilization of these disease management 806
tools shall be consistent with current United States Preventive 807
Services Task Force or other recognized authority recommendations. 808
For persons who are determined ineligible for Medicaid, the 809
division will provide information and direction for accessing 810
medical care and services in the area of their residence. 811
(52) Notwithstanding any provisions of this article, 812
the division may pay enhanced reimbursement fees related to trauma 813
care, as determined by the division in conjunction with the State 814
Department of Health, using funds appropriated to the State 815
Department of Health for trauma care and services and used to 816
match federal funds under a cooperative agreement between the 817
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division and the State Department of Health. The division, in 818
conjunction with the State Department of Health, may use grants, 819
waivers, demonstrations, enhanced reimbursements, Upper Payment 820
Limits Programs, supplemental payments, or other projects as 821
necessary in the development and implementation of this 822
reimbursement program. 823
(53) Targeted case management services for high-cost 824
beneficiaries may be developed by the division for all services 825
under this section. 826
(54) [Deleted] 827
(55) Therapy services. The plan of care for therapy 828
services may be developed to cover a period of treatment for up to 829
six (6) months, but in no event shall the plan of care exceed a 830
six-month period of treatment. The projected period of treatment 831
must be indicated on the initial plan of care and must be updated 832
with each subsequent revised plan of care. Based on medical 833
necessity, the division shall approve certification periods for 834
less than or up to six (6) months, but in no event shall the 835
certification period exceed the period of treatment indicated on 836
the plan of care. The appeal process for any reduction in therapy 837
services shall be consistent with the appeal process in federal 838
regulations. 839
(56) Prescribed pediatric extended care centers 840
services for medically dependent or technologically dependent 841
children with complex medical conditions that require continual 842
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care as prescribed by the child's attending physician, as 843
determined by the division. 844
(57) No Medicaid benefit shall restrict coverage for 845
medically appropriate treatment prescribed by a physician and 846
agreed to by a fully informed individual, or if the individual 847
lacks legal capacity to consent by a person who has legal 848
authority to consent on his or her behalf, based on an 849
individual's diagnosis with a terminal condition. As used in this 850
paragraph (57), "terminal condition" means any aggressive 851
malignancy, chronic end-stage cardiovascular or cerebral vascular 852
disease, or any other disease, illness or condition which a 853
physician diagnoses as terminal. 854
(58) Treatment services for persons with opioid 855
dependency or other highly addictive substance use disorders. The 856
division is authorized to reimburse eligible providers for 857
treatment of opioid dependency and other highly addictive 858
substance use disorders, as determined by the division. Treatment 859
related to these conditions shall not count against any physician 860
visit limit imposed under this section. 861
(59) The division shall allow beneficiaries between the 862
ages of ten (10) and eighteen (18) years to receive vaccines 863
through a pharmacy venue. The division and the State Department 864
of Health shall coordinate and notify OB-GYN providers that the 865
Vaccines for Children program is available to providers free of 866
charge. 867
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(60) Border city university-affiliated pediatric 868
teaching hospital. 869
(a) Payments may only be made to a border city 870
university-affiliated pediatric teaching hospital if the Centers 871
for Medicare and Medicaid Services (CMS) approve an increase in 872
the annual request for the provider payment initiative authorized 873
under 42 CFR Section 438.6(c) in an amount equal to or greater 874
than the estimated annual payment to be made to the border city 875
university-affiliated pediatric teaching hospital. The estimate 876
shall be based on the hospital's prior year Mississippi managed 877
care utilization. 878
(b) As used in this paragraph (60), the term 879
"border city university-affiliated pediatric teaching hospital" 880
means an out-of-state hospital located within a city bordering the 881
eastern bank of the Mississippi River and the State of Mississippi 882
that submits to the division a copy of a current and effective 883
affiliation agreement with an accredited university and other 884
documentation establishing that the hospital is 885
university-affiliated, is licensed and designated as a pediatric 886
hospital or pediatric primary hospital within its home state, 887
maintains at least five (5) different pediatric specialty training 888
programs, and maintains at least one hundred (100) operated beds 889
dedicated exclusively for the treatment of patients under the age 890
of twenty-one (21) years. 891
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(c) The cost of providing services to Mississippi 892
Medicaid beneficiaries under the age of twenty-one (21) years who 893
are treated by a border city university-affiliated pediatric 894
teaching hospital shall not exceed the cost of providing the same 895
services to individuals in hospitals in the state. 896
(d) It is the intent of the Legislature that 897
payments shall not result in any in-state hospital receiving 898
payments lower than they would otherwise receive if not for the 899
payments made to any border city university-affiliated pediatric 900
teaching hospital. 901
(e) This paragraph (60) shall stand repealed on 902
July 1, 2024. 903
(61) Services described in Section 41-140-3 that are 904
provided by certified community health workers employed and 905
supervised by a Medicaid provider. Reimbursement for these 906
services shall be provided only if the division has received 907
approval from the Centers for Medicare and Medicaid Services for a 908
state plan amendment, waiver or alternative payment model for 909
services delivered by certified community health workers. 910
(B) Planning and development districts participating in the 911
home- and community-based services program for the elderly and 912
disabled as case management providers shall be reimbursed for case 913
management services at the maximum rate approved by the Centers 914
for Medicare and Medicaid Services (CMS). 915
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(C) The division may pay to those providers who participate 916
in and accept patient referrals from the division's emergency room 917
redirection program a percentage, as determined by the division, 918
of savings achieved according to the performance measures and 919
reduction of costs required of that program. Federally qualified 920
health centers may participate in the emergency room redirection 921
program, and the division may pay those centers a percentage of 922
any savings to the Medicaid program achieved by the centers' 923
accepting patient referrals through the program, as provided in 924
this subsection (C). 925
(D) (1) As used in this subsection (D), the following terms 926
shall be defined as provided in this paragraph, except as 927
otherwise provided in this subsection: 928
(a) "Committees" means the Medicaid Committees of 929
the House of Representatives and the Senate, and "committee" means 930
either one of those committees. 931
(b) "Rate change" means an increase, decrease or 932
other change in the payments or rates of reimbursement, or a 933
change in any payment methodology that results in an increase, 934
decrease or other change in the payments or rates of 935
reimbursement, to any Medicaid provider that renders any services 936
authorized to be provided to Medicaid recipients under this 937
article. 938
(2) Whenever the Division of Medicaid proposes a rate 939
change, the division shall give notice to the chairmen of the 940
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committees at least thirty (30) calendar days before the proposed 941
rate change is scheduled to take effect. The division shall 942
furnish the chairmen with a concise summary of each proposed rate 943
change along with the notice, and shall furnish the chairmen with 944
a copy of any proposed rate change upon request. The division 945
also shall provide a summary and copy of any proposed rate change 946
to any other member of the Legislature upon request. 947
(3) If the chairman of either committee or both 948
chairmen jointly object to the proposed rate change or any part 949
thereof, the chairman or chairmen shall notify the division and 950
provide the reasons for their objection in writing not later than 951
seven (7) calendar days after receipt of the notice from the 952
division. The chairman or chairmen may make written 953
recommendations to the division for changes to be made to a 954
proposed rate change. 955
(4) (a) The chairman of either committee or both 956
chairmen jointly may hold a committee meeting to review a proposed 957
rate change. If either chairman or both chairmen decide to hold a 958
meeting, they shall notify the division of their intention in 959
writing within seven (7) calendar days after receipt of the notice 960
from the division, and shall set the date and time for the meeting 961
in their notice to the division, which shall not be later than 962
fourteen (14) calendar days after receipt of the notice from the 963
division. 964
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(b) After the committee meeting, the committee or 965
committees may object to the proposed rate change or any part 966
thereof. The committee or committees shall notify the division 967
and the reasons for their objection in writing not later than 968
seven (7) calendar days after the meeting. The committee or 969
committees may make written recommendations to the division for 970
changes to be made to a proposed rate change. 971
(5) If both chairmen notify the division in writing 972
within seven (7) calendar days after receipt of the notice from 973
the division that they do not object to the proposed rate change 974
and will not be holding a meeting to review the proposed rate 975
change, the proposed rate change will take effect on the original 976
date as scheduled by the division or on such other date as 977
specified by the division. 978
(6) (a) If there are any objections to a proposed rate 979
change or any part thereof from either or both of the chairmen or 980
the committees, the division may withdraw the proposed rate 981
change, make any of the recommended changes to the proposed rate 982
change, or not make any changes to the proposed rate change. 983
(b) If the division does not make any changes to 984
the proposed rate change, it shall notify the chairmen of that 985
fact in writing, and the proposed rate change shall take effect on 986
the original date as scheduled by the division or on such other 987
date as specified by the division. 988
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(c) If the division makes any changes to the 989
proposed rate change, the division shall notify the chairmen of 990
its actions in writing, and the revised proposed rate change shall 991
take effect on the date as specified by the division. 992
(7) Nothing in this subsection (D) shall be construed 993
as giving the chairmen or the committees any authority to veto, 994
nullify or revise any rate change proposed by the division. The 995
authority of the chairmen or the committees under this subsection 996
shall be limited to reviewing, making objections to and making 997
recommendations for changes to rate changes proposed by the 998
division. 999
(E) Notwithstanding any provision of this article, no new 1000
groups or categories of recipients and new types of care and 1001
services may be added without enabling legislation from the 1002
Mississippi Legislature, except that the division may authorize 1003
those changes without enabling legislation when the addition of 1004
recipients or services is ordered by a court of proper authority. 1005
(F) The executive director shall keep the Governor advised 1006
on a timely basis of the funds available for expenditure and the 1007
projected expenditures. Notwithstanding any other provisions of 1008
this article, if current or projected expenditures of the division 1009
are reasonably anticipated to exceed the amount of funds 1010
appropriated to the division for any fiscal year, the Governor, 1011
after consultation with the executive director, shall take all 1012
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appropriate measures to reduce costs, which may include, but are 1013
not limited to: 1014
(1) Reducing or discontinuing any or all services that 1015
are deemed to be optional under Title XIX of the Social Security 1016
Act; 1017
(2) Reducing reimbursement rates for any or all service 1018
types; 1019
(3) Imposing additional assessments on health care 1020
providers; or 1021
(4) Any additional cost-containment measures deemed 1022
appropriate by the Governor. 1023
To the extent allowed under federal law, any reduction to 1024
services or reimbursement rates under this subsection (F) shall be 1025
accompanied by a reduction, to the fullest allowable amount, to 1026
the profit margin and administrative fee portions of capitated 1027
payments to organizations described in paragraph (1) of subsection 1028
(H). 1029
Beginning in fiscal year 2010 and in fiscal years thereafter, 1030
when Medicaid expenditures are projected to exceed funds available 1031
for the fiscal year, the division shall submit the expected 1032
shortfall information to the PEER Committee not later than 1033
December 1 of the year in which the shortfall is projected to 1034
occur. PEER shall review the computations of the division and 1035
report its findings to the Legislative Budget Office not later 1036
than January 7 in any year. 1037
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(G) Notwithstanding any other provision of this article, it 1038
shall be the duty of each provider participating in the Medicaid 1039
program to keep and maintain books, documents and other records as 1040
prescribed by the Division of Medicaid in accordance with federal 1041
laws and regulations. 1042
(H) (1) Notwithstanding any other provision of this 1043
article, the division is authorized to implement (a) a managed 1044
care program, (b) a coordinated care program, (c) a coordinated 1045
care organization program, (d) a health maintenance organization 1046
program, (e) a patient-centered medical home program, (f) an 1047
accountable care organization program, (g) provider-sponsored 1048
health plan, or (h) any combination of the above programs. As a 1049
condition for the approval of any program under this subsection 1050
(H)(1), the division shall require that no managed care program, 1051
coordinated care program, coordinated care organization program, 1052
health maintenance organization program, or provider-sponsored 1053
health plan may: 1054
(a) Pay providers at a rate that is less than the 1055
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1056
reimbursement rate; 1057
(b) Override the medical decisions of hospital 1058
physicians or staff regarding patients admitted to a hospital for 1059
an emergency medical condition as defined by 42 US Code Section 1060
1395dd. This restriction (b) does not prohibit the retrospective 1061
review of the appropriateness of the determination that an 1062
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emergency medical condition exists by chart review or coding 1063
algorithm, nor does it prohibit prior authorization for 1064
nonemergency hospital admissions; 1065
(c) Pay providers at a rate that is less than the 1066
normal Medicaid reimbursement rate. It is the intent of the 1067
Legislature that all managed care entities described in this 1068
subsection (H), in collaboration with the division, develop and 1069
implement innovative payment models that incentivize improvements 1070
in health care quality, outcomes, or value, as determined by the 1071
division. Participation in the provider network of any managed 1072
care, coordinated care, provider-sponsored health plan, or similar 1073
contractor shall not be conditioned on the provider's agreement to 1074
accept such alternative payment models; 1075
(d) Implement a prior authorization and 1076
utilization review program for medical services, transportation 1077
services and prescription drugs that is more stringent than the 1078
prior authorization processes used by the division in its 1079
administration of the Medicaid program. Not later than December 1080
2, 2021, the contractors that are receiving capitated payments 1081
under a managed care delivery system established under this 1082
subsection (H) shall submit a report to the Chairmen of the House 1083
and Senate Medicaid Committees on the status of the prior 1084
authorization and utilization review program for medical services, 1085
transportation services and prescription drugs that is required to 1086
be implemented under this subparagraph (d); 1087
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(e) [Deleted] 1088
(f) Implement a preferred drug list that is more 1089
stringent than the mandatory preferred drug list established by 1090
the division under subsection (A)(9) of this section; 1091
(g) Implement a policy which denies beneficiaries 1092
with hemophilia access to the federally funded hemophilia 1093
treatment centers as part of the Medicaid Managed Care network of 1094
providers. 1095
Each health maintenance organization, coordinated care 1096
organization, provider-sponsored health plan, or other 1097
organization paid for services on a capitated basis by the 1098
division under any managed care program or coordinated care 1099
program implemented by the division under this section shall use a 1100
clear set of level of care guidelines in the determination of 1101
medical necessity and in all utilization management practices, 1102
including the prior authorization process, concurrent reviews, 1103
retrospective reviews and payments, that are consistent with 1104
widely accepted professional standards of care. Organizations 1105
participating in a managed care program or coordinated care 1106
program implemented by the division may not use any additional 1107
criteria that would result in denial of care that would be 1108
determined appropriate and, therefore, medically necessary under 1109
those levels of care guidelines. 1110
(2) Notwithstanding any provision of this section, the 1111
recipients eligible for enrollment into a Medicaid Managed Care 1112
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Program authorized under this subsection (H) may include only 1113
those categories of recipients eligible for participation in the 1114
Medicaid Managed Care Program as of January 1, 2021, the 1115
Children's Health Insurance Program (CHIP), and the CMS-approved 1116
Section 1115 demonstration waivers in operation as of January 1, 1117
2021. No expansion of Medicaid Managed Care Program contracts may 1118
be implemented by the division without enabling legislation from 1119
the Mississippi Legislature. 1120
(3) (a) Any contractors receiving capitated payments 1121
under a managed care delivery system established in this section 1122
shall provide to the Legislature and the division statistical data 1123
to be shared with provider groups in order to improve patient 1124
access, appropriate utilization, cost savings and health outcomes 1125
not later than October 1 of each year. Additionally, each 1126
contractor shall disclose to the Chairmen of the Senate and House 1127
Medicaid Committees the administrative expenses costs for the 1128
prior calendar year, and the number of full-equivalent employees 1129
located in the State of Mississippi dedicated to the Medicaid and 1130
CHIP lines of business as of June 30 of the current year. 1131
(b) The division and the contractors participating 1132
in the managed care program, a coordinated care program or a 1133
provider-sponsored health plan shall be subject to annual program 1134
reviews or audits performed by the Office of the State Auditor, 1135
the PEER Committee, the Department of Insurance and/or independent 1136
third parties. 1137
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(c) Those reviews shall include, but not be 1138
limited to, at least two (2) of the following items: 1139
(i) The financial benefit to the State of 1140
Mississippi of the managed care program, 1141
(ii) The difference between the premiums paid 1142
to the managed care contractors and the payments made by those 1143
contractors to health care providers, 1144
(iii) Compliance with performance measures 1145
required under the contracts, 1146
(iv) Administrative expense allocation 1147
methodologies, 1148
(v) Whether nonprovider payments assigned as 1149
medical expenses are appropriate, 1150
(vi) Capitated arrangements with related 1151
party subcontractors, 1152
(vii) Reasonableness of corporate 1153
allocations, 1154
(viii) Value-added benefits and the extent to 1155
which they are used, 1156
(ix) The effectiveness of subcontractor 1157
oversight, including subcontractor review, 1158
(x) Whether health care outcomes have been 1159
improved, and 1160
(xi) The most common claim denial codes to 1161
determine the reasons for the denials. 1162
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The audit reports shall be considered public documents and 1163
shall be posted in their entirety on the division's website. 1164
(4) All health maintenance organizations, coordinated 1165
care organizations, provider-sponsored health plans, or other 1166
organizations paid for services on a capitated basis by the 1167
division under any managed care program or coordinated care 1168
program implemented by the division under this section shall 1169
reimburse all providers in those organizations at rates no lower 1170
than those provided under this section for beneficiaries who are 1171
not participating in those programs. 1172
(5) No health maintenance organization, coordinated 1173
care organization, provider-sponsored health plan, or other 1174
organization paid for services on a capitated basis by the 1175
division under any managed care program or coordinated care 1176
program implemented by the division under this section shall 1177
require its providers or beneficiaries to use any pharmacy that 1178
ships, mails or delivers prescription drugs or legend drugs or 1179
devices. 1180
(6) (a) Not later than December 1, 2021, the 1181
contractors who are receiving capitated payments under a managed 1182
care delivery system established under this subsection (H) shall 1183
develop and implement a uniform credentialing process for 1184
providers. Under that uniform credentialing process, a provider 1185
who meets the criteria for credentialing will be credentialed with 1186
all of those contractors and no such provider will have to be 1187
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separately credentialed by any individual contractor in order to 1188
receive reimbursement from the contractor. Not later than 1189
December 2, 2021, those contractors shall submit a report to the 1190
Chairmen of the House and Senate Medicaid Committees on the status 1191
of the uniform credentialing process for providers that is 1192
required under this subparagraph (a). 1193
(b) If those contractors have not implemented a 1194
uniform credentialing process as described in subparagraph (a) by 1195
December 1, 2021, the division shall develop and implement, not 1196
later than July 1, 2022, a single, consolidated credentialing 1197
process by which all providers will be credentialed. Under the 1198
division's single, consolidated credentialing process, no such 1199
contractor shall require its providers to be separately 1200
credentialed by the contractor in order to receive reimbursement 1201
from the contractor, but those contractors shall recognize the 1202
credentialing of the providers by the division's credentialing 1203
process. 1204
(c) The division shall require a uniform provider 1205
credentialing application that shall be used in the credentialing 1206
process that is established under subparagraph (a) or (b). If the 1207
contractor or division, as applicable, has not approved or denied 1208
the provider credentialing application within sixty (60) days of 1209
receipt of the completed application that includes all required 1210
information necessary for credentialing, then the contractor or 1211
division, upon receipt of a written request from the applicant and 1212
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within five (5) business days of its receipt, shall issue a 1213
temporary provider credential/enrollment to the applicant if the 1214
applicant has a valid Mississippi professional or occupational 1215
license to provide the health care services to which the 1216
credential/enrollment would apply. The contractor or the division 1217
shall not issue a temporary credential/enrollment if the applicant 1218
has reported on the application a history of medical or other 1219
professional or occupational malpractice claims, a history of 1220
substance abuse or mental health issues, a criminal record, or a 1221
history of medical or other licensing board, state or federal 1222
disciplinary action, including any suspension from participation 1223
in a federal or state program. The temporary 1224
credential/enrollment shall be effective upon issuance and shall 1225
remain in effect until the provider's credentialing/enrollment 1226
application is approved or denied by the contractor or division. 1227
The contractor or division shall render a final decision regarding 1228
credentialing/enrollment of the provider within sixty (60) days 1229
from the date that the temporary provider credential/enrollment is 1230
issued to the applicant. 1231
(d) If the contractor or division does not render 1232
a final decision regarding credentialing/enrollment of the 1233
provider within the time required in subparagraph (c), the 1234
provider shall be deemed to be credentialed by and enrolled with 1235
all of the contractors and eligible to receive reimbursement from 1236
the contractors. 1237
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(e) The direct on-site supervisor of a provider in 1238
a health maintenance organization, coordinated care organization, 1239
provider-sponsored health plan, or other organization paid for 1240
services on a capitated basis by the division under any managed 1241
care program or coordinated care program implemented by the 1242
division under this subsection (H), who has begun the process for 1243
credentialing and who previously has not been denied 1244
credentialing, may sign off on the work of the provider during the 1245
time that the provider is awaiting a decision on his or her 1246
credentialing, and the provider may receive reimbursement from the 1247
organization for the work that has been signed off on by the 1248
supervisor. 1249
(7) (a) Each contractor that is receiving capitated 1250
payments under a managed care delivery system established under 1251
this subsection (H) shall provide to each provider for whom the 1252
contractor has denied the coverage of a procedure that was ordered 1253
or requested by the provider for or on behalf of a patient, a 1254
letter that provides a detailed explanation of the reasons for the 1255
denial of coverage of the procedure and the name and the 1256
credentials of the person who denied the coverage. The letter 1257
shall be sent to the provider in electronic format. 1258
(b) After a contractor that is receiving capitated 1259
payments under a managed care delivery system established under 1260
this subsection (H) has denied coverage for a claim submitted by a 1261
provider, the contractor shall issue to the provider within sixty 1262
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(60) days a final ruling of denial of the claim that allows the 1263
provider to have a state fair hearing and/or agency appeal with 1264
the division. If a contractor does not issue a final ruling of 1265
denial within sixty (60) days as required by this subparagraph 1266
(b), the provider's claim shall be deemed to be automatically 1267
approved and the contractor shall pay the amount of the claim to 1268
the provider. 1269
(c) After a contractor has issued a final ruling 1270
of denial of a claim submitted by a provider, the division shall 1271
conduct a state fair hearing and/or agency appeal on the matter of 1272
the disputed claim between the contractor and the provider within 1273
sixty (60) days, and shall render a decision on the matter within 1274
thirty (30) days after the date of the hearing and/or appeal. 1275
(8) It is the intention of the Legislature that the 1276
division evaluate the feasibility of using a single vendor to 1277
administer pharmacy benefits provided under a managed care 1278
delivery system established under this subsection (H). Providers 1279
of pharmacy benefits shall cooperate with the division in any 1280
transition to a carve-out of pharmacy benefits under managed care. 1281
(9) The division shall evaluate the feasibility of 1282
using a single vendor to administer dental benefits provided under 1283
a managed care delivery system established in this subsection (H). 1284
Providers of dental benefits shall cooperate with the division in 1285
any transition to a carve-out of dental benefits under managed 1286
care. 1287
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(10) It is the intent of the Legislature that any 1288
contractor receiving capitated payments under a managed care 1289
delivery system established in this section shall implement 1290
innovative programs to improve the health and well-being of 1291
members diagnosed with prediabetes and diabetes. 1292
(11) It is the intent of the Legislature that any 1293
contractors receiving capitated payments under a managed care 1294
delivery system established under this subsection (H) shall work 1295
with providers of Medicaid services to improve the utilization of 1296
long-acting reversible contraceptives (LARCs). Not later than 1297
December 1, 2021, any contractors receiving capitated payments 1298
under a managed care delivery system established under this 1299
subsection (H) shall provide to the Chairmen of the House and 1300
Senate Medicaid Committees and House and Senate Public Health 1301
Committees a report of LARC utilization for State Fiscal Years 1302
2018 through 2020 as well as any programs, initiatives, or efforts 1303
made by the contractors and providers to increase LARC 1304
utilization. This report shall be updated annually to include 1305
information for subsequent state fiscal years. 1306
(12) The division is authorized to make not more than 1307
one (1) emergency extension of the contracts that are in effect on 1308
July 1, 2021, with contractors who are receiving capitated 1309
payments under a managed care delivery system established under 1310
this subsection (H), as provided in this paragraph (12). The 1311
maximum period of any such extension shall be one (1) year, and 1312
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under any such extensions, the contractors shall be subject to all 1313
of the provisions of this subsection (H). The extended contracts 1314
shall be revised to incorporate any provisions of this subsection 1315
(H). 1316
(I) [Deleted] 1317
(J) There shall be no cuts in inpatient and outpatient 1318
hospital payments, or allowable days or volumes, as long as the 1319
hospital assessment provided in Section 43-13-145 is in effect. 1320
This subsection (J) shall not apply to decreases in payments that 1321
are a result of: reduced hospital admissions, audits or payments 1322
under the APR-DRG or APC models, or a managed care program or 1323
similar model described in subsection (H) of this section. 1324
(K) In the negotiation and execution of such contracts 1325
involving services performed by actuarial firms, the Executive 1326
Director of the Division of Medicaid may negotiate a limitation on 1327
liability to the state of prospective contractors. 1328
(L) The Division of Medicaid shall reimburse for services 1329
provided to eligible Medicaid beneficiaries by a licensed birthing 1330
center in a method and manner to be determined by the division in 1331
accordance with federal laws and federal regulations. The 1332
division shall seek any necessary waivers, make any required 1333
amendments to its State Plan or revise any contracts authorized 1334
under subsection (H) of this section as necessary to provide the 1335
services authorized under this subsection. As used in this 1336
subsection, the term "birthing centers" shall have the meaning as 1337
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defined in Section 41-77-1(a), which is a publicly or privately 1338
owned facility, place or institution constructed, renovated, 1339
leased or otherwise established where nonemergency births are 1340
planned to occur away from the mother's usual residence following 1341
a documented period of prenatal care for a normal uncomplicated 1342
pregnancy which has been determined to be low risk through a 1343
formal risk-scoring examination. 1344
(M) This section shall stand repealed on July 1, 2028. 1345
SECTION 2. Section 43-13-121, Mississippi Code of 1972, is 1346
amended as follows: 1347
43-13-121. (1) The division shall administer the Medicaid 1348
program under the provisions of this article, and may do the 1349
following: 1350
(a) Adopt and promulgate reasonable rules, regulations 1351
and standards, with approval of the Governor, and in accordance 1352
with the Administrative Procedures Law, Section 25-43-1.101 et 1353
seq.: 1354
(i) Establishing methods and procedures as may be 1355
necessary for the proper and efficient administration of this 1356
article; 1357
(ii) Providing Medicaid to all qualified 1358
recipients under the provisions of this article as the division 1359
may determine and within the limits of appropriated funds; 1360
(iii) Establishing reasonable fees, charges and 1361
rates for medical services and drugs; in doing so, the division 1362
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shall fix all of those fees, charges and rates at the minimum 1363
levels absolutely necessary to provide the medical assistance 1364
authorized by this article, and shall not change any of those 1365
fees, charges or rates except as may be authorized in Section 1366
43-13-117; 1367
(iv) Providing for fair and impartial hearings; 1368
(v) Providing safeguards for preserving the 1369
confidentiality of records; and 1370
(vi) For detecting and processing fraudulent 1371
practices and abuses of the program; 1372
(b) Receive and expend state, federal and other funds 1373
in accordance with court judgments or settlements and agreements 1374
between the State of Mississippi and the federal government, the 1375
rules and regulations promulgated by the division, with the 1376
approval of the Governor, and within the limitations and 1377
restrictions of this article and within the limits of funds 1378
available for that purpose; 1379
(c) Subject to the limits imposed by this article and 1380
subject to the provisions of subsection (8) of this section, to 1381
submit a Medicaid plan to the United States Department of Health 1382
and Human Services for approval under the provisions of the 1383
federal Social Security Act, to act for the state in making 1384
negotiations relative to the submission and approval of that plan, 1385
to make such arrangements, not inconsistent with the law, as may 1386
be required by or under federal law to obtain and retain that 1387
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approval and to secure for the state the benefits of the 1388
provisions of that law. 1389
No agreements, specifically including the general plan for 1390
the operation of the Medicaid program in this state, shall be made 1391
by and between the division and the United States Department of 1392
Health and Human Services unless the Attorney General of the State 1393
of Mississippi has reviewed the agreements, specifically including 1394
the operational plan, and has certified in writing to the Governor 1395
and to the executive director of the division that the agreements, 1396
including the plan of operation, have been drawn strictly in 1397
accordance with the terms and requirements of this article; 1398
(d) In accordance with the purposes and intent of this 1399
article and in compliance with its provisions, provide for aged 1400
persons otherwise eligible for the benefits provided under Title 1401
XVIII of the federal Social Security Act by expenditure of funds 1402
available for those purposes; 1403
(e) To make reports to the United States Department of 1404
Health and Human Services as from time to time may be required by 1405
that federal department and to the Mississippi Legislature as 1406
provided in this section; 1407
(f) Define and determine the scope, duration and amount 1408
of Medicaid that may be provided in accordance with this article 1409
and establish priorities therefor in conformity with this article; 1410
(g) Cooperate and contract with other state agencies 1411
for the purpose of coordinating Medicaid provided under this 1412
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article and eliminating duplication and inefficiency in the 1413
Medicaid program; 1414
(h) Adopt and use an official seal of the division; 1415
(i) Sue in its own name on behalf of the State of 1416
Mississippi and employ legal counsel on a contingency basis with 1417
the approval of the Attorney General; 1418
(j) To recover any and all payments incorrectly made by 1419
the division to a recipient or provider from the recipient or 1420
provider receiving the payments. The division shall be authorized 1421
to collect any overpayments to providers sixty (60) days after the 1422
conclusion of any administrative appeal unless the matter is 1423
appealed to a court of proper jurisdiction and bond is posted. 1424
Any appeal filed after July 1, 2015, shall be to the Chancery 1425
Court of the First Judicial District of Hinds County, Mississippi, 1426
within sixty (60) days after the date that the division has 1427
notified the provider by certified mail sent to the proper address 1428
of the provider on file with the division and the provider has 1429
signed for the certified mail notice, or sixty (60) days after the 1430
date of the final decision if the provider does not sign for the 1431
certified mail notice. To recover those payments, the division 1432
may use the following methods, in addition to any other methods 1433
available to the division: 1434
(i) The division shall report to the Department of 1435
Revenue the name of any current or former Medicaid recipient who 1436
has received medical services rendered during a period of 1437
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established Medicaid ineligibility and who has not reimbursed the 1438
division for the related medical service payment(s). The 1439
Department of Revenue shall withhold from the state tax refund of 1440
the individual, and pay to the division, the amount of the 1441
payment(s) for medical services rendered to the ineligible 1442
individual that have not been reimbursed to the division for the 1443
related medical service payment(s). 1444
(ii) The division shall report to the Department 1445
of Revenue the name of any Medicaid provider to whom payments were 1446
incorrectly made that the division has not been able to recover by 1447
other methods available to the division. The Department of 1448
Revenue shall withhold from the state tax refund of the provider, 1449
and pay to the division, the amount of the payments that were 1450
incorrectly made to the provider that have not been recovered by 1451
other available methods; 1452
(k) To recover any and all payments by the division 1453
fraudulently obtained by a recipient or provider. Additionally, 1454
if recovery of any payments fraudulently obtained by a recipient 1455
or provider is made in any court, then, upon motion of the 1456
Governor, the judge of the court may award twice the payments 1457
recovered as damages; 1458
(l) Have full, complete and plenary power and authority 1459
to conduct such investigations as it may deem necessary and 1460
requisite of alleged or suspected violations or abuses of the 1461
provisions of this article or of the regulations adopted under 1462
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this article, including, but not limited to, fraudulent or 1463
unlawful act or deed by applicants for Medicaid or other benefits, 1464
or payments made to any person, firm or corporation under the 1465
terms, conditions and authority of this article, to suspend or 1466
disqualify any provider of services, applicant or recipient for 1467
gross abuse, fraudulent or unlawful acts for such periods, 1468
including permanently, and under such conditions as the division 1469
deems proper and just, including the imposition of a legal rate of 1470
interest on the amount improperly or incorrectly paid. Recipients 1471
who are found to have misused or abused Medicaid benefits may be 1472
locked into one (1) physician and/or one (1) pharmacy of the 1473
recipient's choice for a reasonable amount of time in order to 1474
educate and promote appropriate use of medical services, in 1475
accordance with federal regulations. If an administrative hearing 1476
becomes necessary, the division may, if the provider does not 1477
succeed in his or her defense, tax the costs of the administrative 1478
hearing, including the costs of the court reporter or stenographer 1479
and transcript, to the provider. The convictions of a recipient 1480
or a provider in a state or federal court for abuse, fraudulent or 1481
unlawful acts under this chapter shall constitute an automatic 1482
disqualification of the recipient or automatic disqualification of 1483
the provider from participation under the Medicaid program. 1484
A conviction, for the purposes of this chapter, shall include 1485
a judgment entered on a plea of nolo contendere or a 1486
nonadjudicated guilty plea and shall have the same force as a 1487
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judgment entered pursuant to a guilty plea or a conviction 1488
following trial. A certified copy of the judgment of the court of 1489
competent jurisdiction of the conviction shall constitute prima 1490
facie evidence of the conviction for disqualification purposes; 1491
(m) Establish and provide such methods of 1492
administration as may be necessary for the proper and efficient 1493
operation of the Medicaid program, fully utilizing computer 1494
equipment as may be necessary to oversee and control all current 1495
expenditures for purposes of this article, and to closely monitor 1496
and supervise all recipient payments and vendors rendering 1497
services under this article. Notwithstanding any other provision 1498
of state law, the division is authorized to enter into a ten-year 1499
contract(s) with a vendor(s) to provide services described in this 1500
paragraph (m). Notwithstanding any provision of law to the 1501
contrary, the division is authorized to extend its Medicaid 1502
Management Information System, including all related components 1503
and services, and Decision Support System, including all related 1504
components and services, contracts in effect on June 30, 2020, for 1505
a period not to exceed two (2) years without complying with state 1506
procurement regulations; 1507
(n) To cooperate and contract with the federal 1508
government for the purpose of providing Medicaid to Vietnamese and 1509
Cambodian refugees, under the provisions of Public Law 94-23 and 1510
Public Law 94-24, including any amendments to those laws, only to 1511
the extent that the Medicaid assistance and the administrative 1512
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cost related thereto are one hundred percent (100%) reimbursable 1513
by the federal government. For the purposes of Section 43-13-117, 1514
persons receiving Medicaid under Public Law 94-23 and Public Law 1515
94-24, including any amendments to those laws, shall not be 1516
considered a new group or category of recipient; and 1517
(o) The division shall impose penalties upon Medicaid 1518
only, Title XIX participating long-term care facilities found to 1519
be in noncompliance with division and certification standards in 1520
accordance with federal and state regulations, including interest 1521
at the same rate calculated by the United States Department of 1522
Health and Human Services and/or the Centers for Medicare and 1523
Medicaid Services (CMS) under federal regulations. 1524
(2) The division also shall exercise such additional powers 1525
and perform such other duties as may be conferred upon the 1526
division by act of the Legislature. 1527
(3) The division, and the State Department of Health as the 1528
agency for licensure of health care facilities and certification 1529
and inspection for the Medicaid and/or Medicare programs, shall 1530
contract for or otherwise provide for the consolidation of on-site 1531
inspections of health care facilities that are necessitated by the 1532
respective programs and functions of the division and the 1533
department. 1534
(4) The division and its hearing officers shall have power 1535
to preserve and enforce order during hearings; to issue subpoenas 1536
for, to administer oaths to and to compel the attendance and 1537
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testimony of witnesses, or the production of books, papers, 1538
documents and other evidence, or the taking of depositions before 1539
any designated individual competent to administer oaths; to 1540
examine witnesses; and to do all things conformable to law that 1541
may be necessary to enable them effectively to discharge the 1542
duties of their office. In compelling the attendance and 1543
testimony of witnesses, or the production of books, papers, 1544
documents and other evidence, or the taking of depositions, as 1545
authorized by this section, the division or its hearing officers 1546
may designate an individual employed by the division or some other 1547
suitable person to execute and return that process, whose action 1548
in executing and returning that process shall be as lawful as if 1549
done by the sheriff or some other proper officer authorized to 1550
execute and return process in the county where the witness may 1551
reside. In carrying out the investigatory powers under the 1552
provisions of this article, the executive director or other 1553
designated person or persons may examine, obtain, copy or 1554
reproduce the books, papers, documents, medical charts, 1555
prescriptions and other records relating to medical care and 1556
services furnished by the provider to a recipient or designated 1557
recipients of Medicaid services under investigation. In the 1558
absence of the voluntary submission of the books, papers, 1559
documents, medical charts, prescriptions and other records, the 1560
Governor, the executive director, or other designated person may 1561
issue and serve subpoenas instantly upon the provider, his or her 1562
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agent, servant or employee for the production of the books, 1563
papers, documents, medical charts, prescriptions or other records 1564
during an audit or investigation of the provider. If any provider 1565
or his or her agent, servant or employee refuses to produce the 1566
records after being duly subpoenaed, the executive director may 1567
certify those facts and institute contempt proceedings in the 1568
manner, time and place as authorized by law for administrative 1569
proceedings. As an additional remedy, the division may recover 1570
all amounts paid to the provider covering the period of the audit 1571
or investigation, inclusive of a legal rate of interest and a 1572
reasonable attorney's fee and costs of court if suit becomes 1573
necessary. Division staff shall have immediate access to the 1574
provider's physical location, facilities, records, documents, 1575
books, and any other records relating to medical care and services 1576
rendered to recipients during regular business hours. 1577
(5) If any person in proceedings before the division 1578
disobeys or resists any lawful order or process, or misbehaves 1579
during a hearing or so near the place thereof as to obstruct the 1580
hearing, or neglects to produce, after having been ordered to do 1581
so, any pertinent book, paper or document, or refuses to appear 1582
after having been subpoenaed, or upon appearing refuses to take 1583
the oath as a witness, or after having taken the oath refuses to 1584
be examined according to law, the executive director shall certify 1585
the facts to any court having jurisdiction in the place in which 1586
it is sitting, and the court shall thereupon, in a summary manner, 1587
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hear the evidence as to the acts complained of, and if the 1588
evidence so warrants, punish that person in the same manner and to 1589
the same extent as for a contempt committed before the court, or 1590
commit that person upon the same condition as if the doing of the 1591
forbidden act had occurred with reference to the process of, or in 1592
the presence of, the court. 1593
(6) In suspending or terminating any provider from 1594
participation in the Medicaid program, the division shall preclude 1595
the provider from submitting claims for payment, either personally 1596
or through any clinic, group, corporation or other association to 1597
the division or its fiscal agents for any services or supplies 1598
provided under the Medicaid program except for those services or 1599
supplies provided before the suspension or termination. No 1600
clinic, group, corporation or other association that is a provider 1601
of services shall submit claims for payment to the division or its 1602
fiscal agents for any services or supplies provided by a person 1603
within that organization who has been suspended or terminated from 1604
participation in the Medicaid program except for those services or 1605
supplies provided before the suspension or termination. When this 1606
provision is violated by a provider of services that is a clinic, 1607
group, corporation or other association, the division may suspend 1608
or terminate that organization from participation. Suspension may 1609
be applied by the division to all known affiliates of a provider, 1610
provided that each decision to include an affiliate is made on a 1611
case-by-case basis after giving due regard to all relevant facts 1612
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and circumstances. The violation, failure or inadequacy of 1613
performance may be imputed to a person with whom the provider is 1614
affiliated where that conduct was accomplished within the course 1615
of his or her official duty or was effectuated by him or her with 1616
the knowledge or approval of that person. 1617
(7) The division may deny or revoke enrollment in the 1618
Medicaid program to a provider if any of the following are found 1619
to be applicable to the provider, his or her agent, a managing 1620
employee or any person having an ownership interest equal to five 1621
percent (5%) or greater in the provider: 1622
(a) Failure to truthfully or fully disclose any and all 1623
information required, or the concealment of any and all 1624
information required, on a claim, a provider application or a 1625
provider agreement, or the making of a false or misleading 1626
statement to the division relative to the Medicaid program. 1627
(b) Previous or current exclusion, suspension, 1628
termination from or the involuntary withdrawing from participation 1629
in the Medicaid program, any other state's Medicaid program, 1630
Medicare or any other public or private health or health insurance 1631
program. If the division ascertains that a provider has been 1632
convicted of a felony under federal or state law for an offense 1633
that the division determines is detrimental to the best interest 1634
of the program or of Medicaid beneficiaries, the division may 1635
refuse to enter into an agreement with that provider, or may 1636
terminate or refuse to renew an existing agreement. 1637
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(c) Conviction under federal or state law of a criminal 1638
offense relating to the delivery of any goods, services or 1639
supplies, including the performance of management or 1640
administrative services relating to the delivery of the goods, 1641
services or supplies, under the Medicaid program, any other 1642
state's Medicaid program, Medicare or any other public or private 1643
health or health insurance program. 1644
(d) Conviction under federal or state law of a criminal 1645
offense relating to the neglect or abuse of a patient in 1646
connection with the delivery of any goods, services or supplies. 1647
(e) Conviction under federal or state law of a criminal 1648
offense relating to the unlawful manufacture, distribution, 1649
prescription or dispensing of a controlled substance. 1650
(f) Conviction under federal or state law of a criminal 1651
offense relating to fraud, theft, embezzlement, breach of 1652
fiduciary responsibility or other financial misconduct. 1653
(g) Conviction under federal or state law of a criminal 1654
offense punishable by imprisonment of a year or more that involves 1655
moral turpitude, or acts against the elderly, children or infirm. 1656
(h) Conviction under federal or state law of a criminal 1657
offense in connection with the interference or obstruction of any 1658
investigation into any criminal offense listed in paragraphs (c) 1659
through (i) of this subsection. 1660
(i) Sanction for a violation of federal or state laws 1661
or rules relative to the Medicaid program, any other state's 1662
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Medicaid program, Medicare or any other public health care or 1663
health insurance program. 1664
(j) Revocation of license or certification. 1665
(k) Failure to pay recovery properly assessed or 1666
pursuant to an approved repayment schedule under the Medicaid 1667
program. 1668
(l) Failure to meet any condition of enrollment. 1669
(8) (a) As used in this subsection (8), the following terms 1670
shall be defined as provided in this paragraph, except as 1671
otherwise provided in this subsection: 1672
(i) "Committees" means the Medicaid Committees of 1673
the House of Representatives and the Senate, and "committee" means 1674
either one of those committees. 1675
(ii) "State Plan" means the agreement between the 1676
State of Mississippi and the federal government regarding the 1677
nature and scope of Mississippi's Medicaid Program. 1678
(iii) "State Plan Amendment" means a change to the 1679
State Plan, which must be approved by the Centers for Medicare and 1680
Medicaid Services (CMS) before its implementation. 1681
(b) Whenever the Division of Medicaid proposes a State 1682
Plan Amendment, the division shall give notice to the chairmen of 1683
the committees at least thirty (30) calendar days before the 1684
proposed State Plan Amendment is filed with CMS. The division 1685
shall furnish the chairmen with a concise summary of each proposed 1686
State Plan Amendment along with the notice, and shall furnish the 1687
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chairmen with a copy of any proposed State Plan Amendment upon 1688
request. The division also shall provide a summary and copy of 1689
any proposed State Plan Amendment to any other member of the 1690
Legislature upon request. 1691
(c) If the chairman of either committee or both 1692
chairmen jointly object to the proposed State Plan Amendment or 1693
any part thereof, the chairman or chairmen shall notify the 1694
division and provide the reasons for their objection in writing 1695
not later than seven (7) calendar days after receipt of the notice 1696
from the division. The chairman or chairmen may make written 1697
recommendations to the division for changes to be made to a 1698
proposed State Plan Amendment. 1699
(d) (i) The chairman of either committee or both 1700
chairmen jointly may hold a committee meeting to review a proposed 1701
State Plan Amendment. If either chairman or both chairmen decide 1702
to hold a meeting, they shall notify the division of their 1703
intention in writing within seven (7) calendar days after receipt 1704
of the notice from the division, and shall set the date and time 1705
for the meeting in their notice to the division, which shall not 1706
be later than fourteen (14) calendar days after receipt of the 1707
notice from the division. 1708
(ii) After the committee meeting, the committee or 1709
committees may object to the proposed State Plan Amendment or any 1710
part thereof. The committee or committees shall notify the 1711
division and the reasons for their objection in writing not later 1712
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than seven (7) calendar days after the meeting. The committee or 1713
committees may make written recommendations to the division for 1714
changes to be made to a proposed State Plan Amendment. 1715
(e) If both chairmen notify the division in writing 1716
within seven (7) calendar days after receipt of the notice from 1717
the division that they do not object to the proposed State Plan 1718
Amendment and will not be holding a meeting to review the proposed 1719
State Plan Amendment, the division may proceed to file the 1720
proposed State Plan Amendment with CMS. 1721
(f) (i) If there are any objections to a proposed rate 1722
change or any part thereof from either or both of the chairmen or 1723
the committees, the division may withdraw the proposed State Plan 1724
Amendment, make any of the recommended changes to the proposed 1725
State Plan Amendment, or not make any changes to the proposed 1726
State Plan Amendment. 1727
(ii) If the division does not make any changes to 1728
the proposed State Plan Amendment, it shall notify the chairmen of 1729
that fact in writing, and may proceed to file the State Plan 1730
Amendment with CMS. 1731
(iii) If the division makes any changes to the 1732
proposed State Plan Amendment, the division shall notify the 1733
chairmen of its actions in writing, and may proceed to file the 1734
State Plan Amendment with CMS. 1735
(g) Nothing in this subsection (8) shall be construed 1736
as giving the chairmen or the committees any authority to veto, 1737
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nullify or revise any State Plan Amendment proposed by the 1738
division. The authority of the chairmen or the committees under 1739
this subsection shall be limited to reviewing, making objections 1740
to and making recommendations for changes to State Plan Amendments 1741
proposed by the division. 1742
(i) If the division does not make any changes to 1743
the proposed State Plan Amendment, it shall notify the chairmen of 1744
that fact in writing, and may proceed to file the proposed State 1745
Plan Amendment with CMS. 1746
(ii) If the division makes any changes to the 1747
proposed State Plan Amendment, the division shall notify the 1748
chairmen of the changes in writing, and may proceed to file the 1749
proposed State Plan Amendment with CMS. 1750
(h) Nothing in this subsection (8) shall be construed 1751
as giving the chairmen of the committees any authority to veto, 1752
nullify or revise any State Plan Amendment proposed by the 1753
division. The authority of the chairmen of the committees under 1754
this subsection shall be limited to reviewing, making objections 1755
to and making recommendations for suggested changes to State Plan 1756
Amendments proposed by the division. 1757
(9) Whenever the division determines after a hearing that a 1758
provider has violated any provision of this article or Article 5 1759
of this chapter, the division may not suspend reimbursement 1760
payments to the provider during the time that the decision of the 1761
division is on appeal by the provider. This subsection does not 1762
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ST: Medicaid; revise certain provisions
regarding managed care providers and payments
during appeals.
apply: (a) if the provider previously has been convicted of fraud 1763
in connection with the Medicaid program; or (b) if the provider is 1764
a company or other entity, and an agent of the provider, a 1765
managing employee of the provider or a person having an ownership 1766
interest equal to five percent (5%) or greater in the provider 1767
previously has been convicted of fraud in connection with the 1768
Medicaid program. 1769
SECTION 3. This act shall take effect and be in force from 1770
and after July 1, 2026. 1771