Medicaid; restrict frequency of managed care organizations transferring enrollees to other organizations.

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To: Medicaid
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Representative Roberson

HOUSE BILL NO. 624

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