Health insurance; require coverage for biomarker testing for certain purposes when supported by medical and scientific evidence.

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To: Insurance;
Appropriations
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Senator(s) Michel, McLendon, Blackwell,
Blackmon, Frazier, Thomas, Younger, Simmons
(13th), Williams

SENATE BILL NO. 2694

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