Essential disability-related services for children; require Medicaid and private insurance coverage.

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To: Medicaid; Insurance
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Senator(s) Blackmon

SENATE BILL NO. 2568

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