Medicaid; make various amendments to the provisions of the program.

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To: Medicaid
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Senator(s) Blackwell

COMMITTEE SUBSTITUTE
FOR
SENATE BILL NO. 2735

AN ACT TO AMEND SECTION 43-13-115, MISSISSIPPI CODE OF 1972, 1
TO MAKE CERTAIN TECHNICAL AMENDMENTS TO THE PROVISIONS THAT 2
PROVIDE FOR MEDICAID ELIGIBILITY AND TO MODIFY AGE AND INCOME AND 3
ELIGIBILITY CRITERIA TO REFLECT THE CURRENT CRITERIA; TO PROVIDE 4
THAT MEN OF REPRODUCTIVE AGE ARE ELIGIBLE UNDER THE FAMILY 5
PLANNING PROGRAM; TO CONFORM WITH FEDERAL LAW TO ALLOW CHILDREN IN 6
FOSTER CARE TO BE ELIGIBLE UNTIL THEIR 26TH BIRTHDAY; TO ELIMINATE 7
THE REQUIREMENT THAT THE DIVISION MUST APPLY TO CMS FOR WAIVERS TO 8
PROVIDE SERVICES FOR CERTAIN INDIVIDUALS WHO ARE END STAGE RENAL 9
DISEASE PATIENTS ON DIALYSIS, CANCER PATIENTS ON CHEMOTHERAPY OR 10
ORGAN TRANSPLANT RECIPIENTS ON ANTIREJECTION DRUGS; TO AMEND 11
SECTION 43-13-117, MISSISSIPPI CODE OF 1972, TO MAKE CERTAIN 12
TECHNICAL AMENDMENTS TO THE PROVISIONS THAT PROVIDE FOR MEDICAID 13
SERVICES TO COMPLY WITH FEDERAL LAW; TO ENABLE RURAL HOSPITALS TO 14
ELECT AGAINST REIMBURSEMENT FOR OUTPATIENT HOSPITAL SERVICES USING 15
THE AMBULATORY PAYMENT CLASSIFICATION (APC) METHODOLOGY; TO 16
AUTHORIZE THE DIVISION TO MAKE PAYMENT TO NURSING FACILITIES AND 17
TO INTERMEDIATE CARE FACILITIES FOR EACH DAY, NOT EXCEEDING 21 18
DAYS PER YEAR FOR NURSING FACILITIES OR 31 DAYS PER YEAR FOR 19
INTERMEDIATE CARE FACILITIES, THAT A PATIENT IS ABSENT FROM THE 20
FACILITY ON HOME LEAVE; TO REQUIRE THE DIVISION TO UPDATE THE 21
CASE-MIX PAYMENT SYSTEM AND FAIR RENTAL REIMBURSEMENT SYSTEM AS 22
NECESSARY TO MAINTAIN COMPLIANCE WITH FEDERAL LAW; TO AUTHORIZE 23
THE DIVISION TO IMPLEMENT A QUALITY OR VALUE-BASED COMPONENT TO 24
THE NURSING FACILITY PAYMENT SYSTEM; TO REQUIRE THE DIVISION TO 25
REIMBURSE PEDIATRICIANS FOR CERTAIN PRIMARY CARE SERVICES AS 26
DEFINED BY THE DIVISION AT 100% OF THE RATE ESTABLISHED UNDER 27
MEDICARE; TO AUTHORIZE THE DIVISION TO REIMBURSE AMBULATORY 28
SURGICAL CARE (ASC) BASED ON 85% OF THE MEDICARE ASC PAYMENT 29
SYSTEM RATE IN EFFECT JULY 1 OF EACH YEAR AS SET BY CMS; TO 30
PROVIDE THAT THE DIVISION MAY DEVELOP ALTERNATIVE MODELS FOR 31
DISTRIBUTION OF MEDICAL CLAIMS AND SUPPLEMENTAL PAYMENTS FOR 32
INPATIENT AND OUTPATIENT HOSPITAL SERVICES; TO AUTHORIZE THE 33
DIVISION TO CONTRACT WITH THE STATE DEPARTMENT OF HEALTH TO 34
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PROVIDE FOR A PERINATAL HIGH RISK-MANAGEMENT/INFANT SERVICES 35
SYSTEM FOR ANY ELIGIBLE BENEFICIARY THAT CANNOT RECEIVE SUCH 36
SERVICES UNDER A DIFFERENT PROGRAM; TO AUTHORIZE THE DIVISION TO 37
REIMBURSE FOR SERVICES AT CERTIFIED COMMUNITY BEHAVIORAL HEALTH 38
CENTERS; TO DELETE THE PROVISION OF LAW THAT PROVIDES THAT THE 39
DIVISION SHALL REIMBURSE FOR OUTPATIENT HOSPITAL SERVICES PROVIDED 40
TO ELIGIBLE MEDICAID BENEFICIARIES UNDER THE AGE OF 21 YEARS BY 41
BORDER CITY UNIVERSITY-AFFILIATED PEDIATRIC TEACHING HOSPITALS, 42
WHICH WAS REPEALED BY OPERATION OF LAW IN 2024; TO REDUCE THE 43
LENGTH OF NOTICE THE DIVISION MUST PROVIDE THE MEDICAID COMMITTEE 44
CHAIRMEN FOR PROPOSED RATE CHANGES AND TO PROVIDE THAT SUCH 45
LEGISLATIVE NOTICE MAY BE EXPEDITED; TO AUTHORIZE THE DIVISION, 46
EFFECTIVE JULY 1, 2027, TO REIMBURSE AMBULANCE TRANSPORTATION 47
SERVICE PROVIDERS THAT PROVIDE AN ASSESSMENT, TRIAGE OR TREATMENT 48
FOR ELIGIBLE MEDICAID BENEFICIARIES; TO SET CERTAIN REIMBURSEMENT 49
LEVELS FOR SUCH PROVIDERS; TO DELETE THE DATE OF THE REPEALER ON 50
SUCH SECTION; TO AMEND SECTION 43-13-121, MISSISSIPPI CODE OF 51
1972, TO AUTHORIZE THE DIVISION TO EXTEND ITS MEDICAID ENTERPRISE 52
SYSTEM AND FISCAL AGENT SERVICES, INCLUDING ALL RELATED COMPONENTS 53
AND SERVICES, CONTRACTS IN EFFECT ON JUNE 30, 2026, FOR ADDITIONAL 54
CONTRACT PERIODS AT THE DISCRETION OF THE DIVISION; TO AUTHORIZE 55
THE DIVISION TO ENTER INTO A TWO-YEAR CONTRACT ENDING NO LATER 56
THAN JUNE 30, 2028, WITH A VENDOR TO PROVIDE SUPPORT OF THE 57
DIVISION'S ELIGIBILITY SYSTEM; TO REDUCE THE LENGTH OF NOTICE THE 58
DIVISION MUST PROVIDE THE MEDICAID COMMITTEE CHAIRMEN FOR A 59
PROPOSED STATE PLAN AMENDMENT AND TO PROVIDE THAT SUCH LEGISLATIVE 60
NOTICE MAY BE EXPEDITED; TO AMEND SECTION 43-13-305, MISSISSIPPI 61
CODE OF 1972, TO PROVIDE THAT WHEN A THIRD PARTY PAYOR REQUIRES 62
PRIOR AUTHORIZATION FOR AN ITEM OR SERVICE FURNISHED TO A MEDICAID 63
RECIPIENT, THE PAYOR SHALL ACCEPT AUTHORIZATION PROVIDED BY THE 64
DIVISION OF MEDICAID THAT THE ITEM OR SERVICE IS COVERED UNDER THE 65
STATE PLAN AS IF SUCH AUTHORIZATION WERE THE PRIOR AUTHORIZATION 66
MADE BY THE THIRD PARTY PAYOR FOR SUCH ITEM OR SERVICE; TO AMEND 67
SECTION 43-13-117.7, MISSISSIPPI CODE OF 1972, TO PROVIDE THAT THE 68
DIVISION SHALL NOT REIMBURSE OR PROVIDE COVERAGE FOR GENDER 69
TRANSITION PROCEDURES FOR ANY PERSON; TO AMEND SECTION 43-13-145, 70
MISSISSIPPI CODE OF 1972, TO PROVIDE THAT A QUARTERLY HOSPITAL 71
ASSESSMENT MAY EXCEED THE ASSESSMENT IN THE PRIOR QUARTER BY MORE 72
THAN $3,750,000.00 IF SUCH INCREASE IS TO MAXIMIZE FEDERAL FUNDS 73
THAT ARE AVAILABLE TO REIMBURSE HOSPITALS FOR SERVICES PROVIDED 74
UNDER NEW PROGRAMS FOR HOSPITALS, FOR INCREASED SUPPLEMENTAL 75
PAYMENT PROGRAMS FOR HOSPITALS OR TO ASSIST WITH STATE MATCHING 76
FUNDS AS AUTHORIZED BY THE LEGISLATURE; TO AMEND SECTION 77
43-13-107, MISSISSIPPI CODE OF 1972, TO ESTABLISH A MEDICAID 78
ADVISORY COMMITTEE AND BENEFICIARY ADVISORY COUNCIL IN ACCORDANCE 79
WITH FEDERAL LAW; TO PROVIDE THAT ALL MEMBERS OF THE PREVIOUSLY 80
ESTABLISHED MEDICAL CARE ADVISORY COMMITTEE SERVING ON JANUARY 1, 81
2026, SHALL BE SELECTED TO SERVE ON THE MEDICAID ADVISORY 82
COMMITTEE, AND SUCH MEMBERS SHALL SERVE UNTIL JULY 1, 2029; AND 83
FOR RELATED PURPOSES. 84
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 85
SECTION 1. Section 43-13-115, Mississippi Code of 1972, is 86
amended as follows: 87
43-13-115. Recipients of Medicaid shall be the following 88
persons only: 89
(1) Those who are qualified for public assistance 90
grants under provisions of Title IV-A and E of the federal Social 91
Security Act, as amended, including those statutorily deemed to be 92
IV-A and low income families and children under Section 1931 of 93
the federal Social Security Act. For the purposes of this 94
paragraph (1) and paragraphs (8), (17) and (18) of this section, 95
any reference to Title IV-A or to Part A of Title IV of the 96
federal Social Security Act, as amended, or the state plan under 97
Title IV-A or Part A of Title IV, shall be considered as a 98
reference to Title IV-A of the federal Social Security Act, as 99
amended, and the state plan under Title IV-A, including the income 100
and resource standards and methodologies under Title IV-A and the 101
state plan, as they existed on July 16, 1996. The Department of 102
Human Services shall determine Medicaid eligibility for children 103
receiving public assistance grants under Title IV-E. The division 104
shall determine eligibility for low income families under Section 105
1931 of the federal Social Security Act and shall redetermine 106
eligibility for those continuing under Title IV-A grants. 107
(2) Those qualified for Supplemental Security Income 108
(SSI) benefits under Title XVI of the federal Social Security Act, 109
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as amended, and those who are deemed SSI eligible as contained in 110
federal statute. The eligibility of individuals covered in this 111
paragraph shall be determined by the Social Security 112
Administration and certified to the Division of Medicaid. 113
(3) Qualified pregnant women who would be eligible for 114
Medicaid as a low income family member under Section 1931 of the 115
federal Social Security Act if her child were born. The 116
eligibility of the individuals covered under this paragraph shall 117
be determined by the division. 118
(4) [Deleted] 119
(5) A child born on or after October 1, 1984, to a 120
woman eligible for and receiving Medicaid under the state plan on 121
the date of the child's birth shall be deemed to have applied for 122
Medicaid and to have been found eligible for Medicaid under the 123
plan on the date of that birth, and will remain eligible for 124
Medicaid for a period of one (1) year so long as the child is a 125
member of the woman's household and the woman remains eligible for 126
Medicaid or would be eligible for Medicaid if pregnant. The 127
eligibility of individuals covered in this paragraph shall be 128
determined by the Division of Medicaid. 129
(6) Children certified by the State Department of Human 130
Services to the Division of Medicaid of whom the state and county 131
departments of human services have custody and financial 132
responsibility, and children who are in adoptions subsidized in 133
full or part by the Department of Human Services, including 134
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special needs children in non-Title IV-E adoption assistance, who 135
are approvable under Title XIX of the Medicaid program. The 136
eligibility of the children covered under this paragraph shall be 137
determined by the State Department of Human Services. 138
(7) Persons certified by the Division of Medicaid who 139
are patients in a medical facility (nursing home, hospital, 140
tuberculosis sanatorium or institution for treatment of mental 141
diseases), and who, except for the fact that they are patients in 142
that medical facility, would qualify for grants under Title IV, 143
Supplementary Security Income (SSI) benefits under Title XVI or 144
state supplements, and those aged, blind and disabled persons who 145
would not be eligible for Supplemental Security Income (SSI) 146
benefits under Title XVI or state supplements if they were not 147
institutionalized in a medical facility but whose income is below 148
the maximum standard set by the Division of Medicaid, which 149
standard shall not exceed that prescribed by federal regulation. 150
(8) Children under eighteen (18) years of age and 151
pregnant women (including those in intact families) who meet the 152
financial standards of the state plan approved under Title IV-A of 153
the federal Social Security Act, as amended. The eligibility of 154
children covered under this paragraph shall be determined by the 155
Division of Medicaid. 156
(9) Individuals who are: 157
(a) Children born after September 30, 1983, * * * 158
between the ages of six (6) and nineteen (19), with family income 159
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that does not exceed * * * one hundred thirty-three percent (133%) 160
of the * * * federal poverty level; 161
(b) Pregnant women, infants and children * * * 162
between the ages of one (1) and seven (7), with family income that 163
does not exceed * * * one hundred forty-three percent (143%) of 164
the federal poverty level; and 165
(c) Pregnant women and infants who have not 166
attained the age of one (1), with family income that does not 167
exceed * * * one hundred ninety-four percent (194%) of the federal 168
poverty level. 169
The eligibility of individuals covered in (a), (b) and (c) of 170
this paragraph shall be determined by the division. 171
(10) Certain disabled children age eighteen (18) or 172
under who are living at home, who would be eligible, if in a 173
medical institution, for SSI or a state supplemental payment under 174
Title XVI of the federal Social Security Act, as amended, and 175
therefore for Medicaid under the plan, and for whom the state has 176
made a determination as required under Section 1902(e)(3)(b) of 177
the federal Social Security Act, as amended. The eligibility of 178
individuals under this paragraph shall be determined by the 179
Division of Medicaid. 180
(11) * * * Individuals who are sixty-five (65) years of 181
age or older or are disabled as determined under Section 182
1614(a)(3) of the federal Social Security Act, as amended, and 183
whose income does not exceed one hundred thirty-five percent 184
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(135%) of the * * * federal poverty level, and whose resources do 185
not exceed those established by the Division of Medicaid. The 186
eligibility of individuals covered under this paragraph shall be 187
determined by the Division of Medicaid. * * * Only those 188
individuals covered under the 1115(c) Healthier Mississippi waiver 189
will be covered under this category. 190
Any individual who applied for Medicaid during the period 191
from July 1, 2004, through March 31, 2005, who otherwise would 192
have been eligible for coverage under this paragraph (11) if it 193
had been in effect at the time the individual submitted his or her 194
application and is still eligible for coverage under this 195
paragraph (11) on March 31, 2005, shall be eligible for Medicaid 196
coverage under this paragraph (11) from March 31, 2005, through 197
December 31, 2005. The division shall give priority in processing 198
the applications for those individuals to determine their 199
eligibility under this paragraph (11). 200
(12) Individuals who are qualified Medicare 201
beneficiaries (QMB) entitled to Part A Medicare as defined under 202
Section 301, Public Law 100-360, known as the Medicare 203
Catastrophic Coverage Act of 1988, and whose income does not 204
exceed one hundred percent (100%) of the * * * federal poverty 205
level. 206
The eligibility of individuals covered under this paragraph 207
shall be determined by the Division of Medicaid, and those 208
individuals determined eligible shall receive Medicare 209
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cost-sharing expenses only as more fully defined by the Medicare 210
Catastrophic Coverage Act of 1988 and the Balanced Budget Act of 211
1997. 212
(13) (a) Individuals who are entitled to Medicare Part 213
A as defined in Section 4501 of the Omnibus Budget Reconciliation 214
Act of 1990, and whose income does not exceed one hundred twenty 215
percent (120%) of the * * * federal poverty level. Eligibility 216
for Medicaid benefits is limited to full payment of Medicare Part 217
B premiums. 218
(b) Individuals entitled to Part A of Medicare, 219
with income above one hundred twenty percent (120%), but less than 220
one hundred thirty-five percent (135%) of the federal poverty 221
level, and not otherwise eligible for Medicaid. Eligibility for 222
Medicaid benefits is limited to full payment of Medicare Part B 223
premiums. The number of eligible individuals is limited by the 224
availability of the federal capped allocation at one hundred 225
percent (100%) of federal matching funds, as more fully defined in 226
the Balanced Budget Act of 1997. 227
The eligibility of individuals covered under this paragraph 228
shall be determined by the Division of Medicaid. 229
(14) [Deleted] 230
(15) Disabled workers who are eligible to enroll in 231
Part A Medicare as required by Public Law 101-239, known as the 232
Omnibus Budget Reconciliation Act of 1989, and whose income does 233
not exceed two hundred percent (200%) of the federal poverty level 234
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as determined in accordance with the Supplemental Security Income 235
(SSI) program. The eligibility of individuals covered under this 236
paragraph shall be determined by the Division of Medicaid and 237
those individuals shall be entitled to buy-in coverage of Medicare 238
Part A premiums only under the provisions of this paragraph (15). 239
(16) In accordance with the terms and conditions of 240
approved Title XIX waiver from the United States Department of 241
Health and Human Services, persons provided home- and 242
community-based services who are physically disabled and certified 243
by the Division of Medicaid as eligible due to applying the income 244
and deeming requirements as if they were institutionalized. 245
(17) In accordance with the terms of the federal 246
Personal Responsibility and Work Opportunity Reconciliation Act of 247
1996 (Public Law 104-193), persons who become ineligible for 248
assistance under Title IV-A of the federal Social Security Act, as 249
amended, because of increased income from or hours of employment 250
of the caretaker relative or because of the expiration of the 251
applicable earned income disregards, who were eligible for 252
Medicaid for at least three (3) of the six (6) months preceding 253
the month in which the ineligibility begins, shall be eligible for 254
Medicaid for up to twelve (12) months. The eligibility of the 255
individuals covered under this paragraph shall be determined by 256
the division. 257
(18) Persons who become ineligible for assistance under 258
Title IV-A of the federal Social Security Act, as amended, as a 259
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result, in whole or in part, of the collection or increased 260
collection of child or spousal support under Title IV-D of the 261
federal Social Security Act, as amended, who were eligible for 262
Medicaid for at least three (3) of the six (6) months immediately 263
preceding the month in which the ineligibility begins, shall be 264
eligible for Medicaid for an additional four (4) months beginning 265
with the month in which the ineligibility begins. The eligibility 266
of the individuals covered under this paragraph shall be 267
determined by the division. 268
(19) Disabled workers, whose incomes are above the 269
Medicaid eligibility limits, but below two hundred fifty percent 270
(250%) of the federal poverty level, shall be allowed to purchase 271
Medicaid coverage on a sliding fee scale developed by the Division 272
of Medicaid. 273
(20) Medicaid eligible children under age eighteen (18) 274
shall remain eligible for Medicaid benefits until the end of a 275
period of twelve (12) months following an eligibility 276
determination, or until such time that the individual exceeds age 277
eighteen (18). 278
(21) Women and men of * * * reproductive age whose 279
family income does not exceed * * * one hundred ninety-four 280
percent (194%) of the federal poverty level. The eligibility of 281
individuals covered under this paragraph (21) shall be determined 282
by the Division of Medicaid, and those individuals determined 283
eligible shall only receive family planning services covered under 284
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Section 43-13-117(13) and not any other services covered under 285
Medicaid. However, any individual eligible under this paragraph 286
(21) who is also eligible under any other provision of this 287
section shall receive the benefits to which he or she is entitled 288
under that other provision, in addition to family planning 289
services covered under Section 43-13-117(13). 290
The Division of Medicaid * * * may apply to the United States 291
Secretary of Health and Human Services for a federal waiver of the 292
applicable provisions of Title XIX of the federal Social Security 293
Act, as amended, and any other applicable provisions of federal 294
law as necessary to allow for the implementation of this paragraph 295
(21). * * * 296
(22) Persons who are workers with a potentially severe 297
disability, as determined by the division, shall be allowed to 298
purchase Medicaid coverage. The term "worker with a potentially 299
severe disability" means a person who is at least sixteen (16) 300
years of age but under sixty-five (65) years of age, who has a 301
physical or mental impairment that is reasonably expected to cause 302
the person to become blind or disabled as defined under Section 303
1614(a) of the federal Social Security Act, as amended, if the 304
person does not receive items and services provided under 305
Medicaid. 306
The eligibility of persons under this paragraph (22) shall be 307
conducted as a demonstration project that is consistent with 308
Section 204 of the Ticket to Work and Work Incentives Improvement 309
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Act of 1999, Public Law 106-170, for a certain number of persons 310
as specified by the division. The eligibility of individuals 311
covered under this paragraph (22) shall be determined by the 312
Division of Medicaid. 313
(23) Children certified by the Mississippi Department 314
of Human Services for whom the state and county departments of 315
human services have custody and financial responsibility who are 316
in foster care on their eighteenth birthday as reported by the 317
Mississippi Department of Human Services shall be certified 318
Medicaid eligible by the Division of Medicaid until their * * * 319
twenty-sixth birthday. Children who have aged out of foster care 320
while on Medicaid in other states shall qualify until their 321
twenty-sixth birthday. 322
(24) Individuals who have not attained age sixty-five 323
(65), are not otherwise covered by creditable coverage as defined 324
in the Public Health Services Act, and have been screened for 325
breast and cervical cancer under the Centers for Disease Control 326
and Prevention Breast and Cervical Cancer Early Detection Program 327
established under Title XV of the Public Health Service Act in 328
accordance with the requirements of that act and who need 329
treatment for breast or cervical cancer. Eligibility of 330
individuals under this paragraph (24) shall be determined by the 331
Division of Medicaid. 332
(25) The division shall apply to the Centers for 333
Medicare and Medicaid Services (CMS) for any necessary waivers to 334
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provide services to individuals who are sixty-five (65) years of 335
age or older or are disabled as determined under Section 336
1614(a)(3) of the federal Social Security Act, as amended, and 337
whose income does not exceed one hundred thirty-five percent 338
(135%) of the * * * federal poverty level, and whose resources do 339
not exceed those established by the Division of Medicaid, and who 340
are not otherwise covered by Medicare. Nothing contained in this 341
paragraph (25) shall entitle an individual to benefits. The 342
eligibility of individuals covered under this paragraph shall be 343
determined by the Division of Medicaid. 344
(26) * * * [Deleted] 345
(27) Individuals who are entitled to Medicare Part D 346
and whose income does not exceed one hundred fifty percent (150%) 347
of the * * * federal poverty level. Eligibility for payment of 348
the Medicare Part D subsidy under this paragraph shall be 349
determined by the division. 350
(28) The division is authorized and directed to provide 351
up to twelve (12) months of continuous coverage postpartum for any 352
individual who qualifies for Medicaid coverage under this section 353
as a pregnant woman, to the extent allowable under federal law and 354
as determined by the division. 355
The division shall redetermine eligibility for all categories 356
of recipients described in each paragraph of this section not less 357
frequently than required by federal law. 358
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SECTION 2. Section 43-13-117, Mississippi Code of 1972, is 359
amended as follows: 360
43-13-117. (A) Medicaid as authorized by this article shall 361
include payment of part or all of the costs, at the discretion of 362
the division, with approval of the Governor and the Centers for 363
Medicare and Medicaid Services, of the following types of care and 364
services rendered to eligible applicants who have been determined 365
to be eligible for that care and services, within the limits of 366
state appropriations and federal matching funds: 367
(1) Inpatient hospital services. 368
(a) The division is authorized to implement an All 369
Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement 370
methodology for inpatient hospital services. 371
(b) No service benefits or reimbursement 372
limitations in this subsection (A)(1) shall apply to payments 373
under an APR-DRG or Ambulatory Payment Classification (APC) model 374
or a managed care program or similar model described in subsection 375
(H) of this section unless specifically authorized by the 376
division. 377
(2) Outpatient hospital services. 378
(a) Emergency services. 379
(b) Other outpatient hospital services. The 380
division shall allow benefits for other medically necessary 381
outpatient hospital services (such as chemotherapy, radiation, 382
surgery and therapy), including outpatient services in a clinic or 383
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other facility that is not located inside the hospital, but that 384
has been designated as an outpatient facility by the hospital, and 385
that was in operation or under construction on July 1, 2009, 386
provided that the costs and charges associated with the operation 387
of the hospital clinic are included in the hospital's cost report. 388
In addition, the Medicare thirty-five-mile rule will apply to 389
those hospital clinics not located inside the hospital that are 390
constructed after July 1, 2009. Where the same services are 391
reimbursed as clinic services, the division may revise the rate or 392
methodology of outpatient reimbursement to maintain consistency, 393
efficiency, economy and quality of care. 394
(c) The division is authorized to implement an 395
Ambulatory Payment Classification (APC) methodology for outpatient 396
hospital services. The division * * * may give rural hospitals 397
that have fifty (50) or fewer licensed beds the option to not be 398
reimbursed for outpatient hospital services using the APC 399
methodology, but reimbursement for outpatient hospital services 400
provided by those hospitals shall be based on one hundred one 401
percent (101%) of the rate established under Medicare for 402
outpatient hospital services. Those hospitals choosing to not be 403
reimbursed under the APC methodology shall remain under cost-based 404
reimbursement for a two-year period. 405
(d) No service benefits or reimbursement 406
limitations in this subsection (A)(2) shall apply to payments 407
under an APR-DRG or APC model or a managed care program or similar 408
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model described in subsection (H) of this section unless 409
specifically authorized by the division. 410
(3) Laboratory and x-ray services. 411
(4) Nursing facility services. 412
(a) The division * * * may make * * * payment to 413
nursing facilities for each day, not exceeding * * * twenty-one 414
(21) days per year, that a patient is absent from the facility on 415
home leave. Payment may be made for the following home leave days 416
in addition to the * * * twenty-one-day limitation: Christmas, 417
the day before Christmas, the day after Christmas, Thanksgiving, 418
the day before Thanksgiving and the day after Thanksgiving. 419
(b) From and after July 1, 1997, the division 420
shall implement the integrated case-mix payment and quality 421
monitoring system, which includes the fair rental system for 422
property costs and in which recapture of depreciation is 423
eliminated. The division may reduce the payment for hospital 424
leave and therapeutic home leave days to the lower of the case-mix 425
category as computed for the resident on leave using the 426
assessment being utilized for payment at that point in time, or a 427
case-mix score of 1.000 for nursing facilities, and shall compute 428
case-mix scores of residents so that only services provided at the 429
nursing facility are considered in calculating a facility's per 430
diem. 431
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(c) From and after July 1, 1997, all state-owned 432
nursing facilities shall be reimbursed on a full reasonable cost 433
basis. 434
(d) * * * The division shall update the case-mix 435
payment system * * * and fair rental reimbursement system as 436
necessary to maintain compliance with federal law. The division 437
shall develop and implement a payment add-on to reimburse nursing 438
facilities for ventilator-dependent resident services. 439
(e) The division shall develop and implement, not 440
later than January 1, 2001, a case-mix payment add-on determined 441
by time studies and other valid statistical data that will 442
reimburse a nursing facility for the additional cost of caring for 443
a resident who has a diagnosis of Alzheimer's or other related 444
dementia and exhibits symptoms that require special care. Any 445
such case-mix add-on payment shall be supported by a determination 446
of additional cost. The division shall also develop and implement 447
as part of the fair rental reimbursement system for nursing 448
facility beds, an Alzheimer's resident bed depreciation enhanced 449
reimbursement system that will provide an incentive to encourage 450
nursing facilities to convert or construct beds for residents with 451
Alzheimer's or other related dementia. 452
(f) The division shall develop and implement an 453
assessment process for long-term care services. The division may 454
provide the assessment and related functions directly or through 455
contract with the area agencies on aging. 456
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(g) The division may implement a quality or 457
value-based component to the nursing facility payment system. 458
The division shall apply for necessary federal waivers to 459
assure that additional services providing alternatives to nursing 460
facility care are made available to applicants for nursing 461
facility care. 462
(5) Periodic screening and diagnostic services for 463
individuals under age twenty-one (21) years as are needed to 464
identify physical and mental defects and to provide health care 465
treatment and other measures designed to correct or ameliorate 466
defects and physical and mental illness and conditions discovered 467
by the screening services, regardless of whether these services 468
are included in the state plan. The division may include in its 469
periodic screening and diagnostic program those discretionary 470
services authorized under the federal regulations adopted to 471
implement Title XIX of the federal Social Security Act, as 472
amended. The division, in obtaining physical therapy services, 473
occupational therapy services, and services for individuals with 474
speech, hearing and language disorders, may enter into a 475
cooperative agreement with the State Department of Education for 476
the provision of those services to handicapped students by public 477
school districts using state funds that are provided from the 478
appropriation to the Department of Education to obtain federal 479
matching funds through the division. The division, in obtaining 480
medical and mental health assessments, treatment, care and 481
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services for children who are in, or at risk of being put in, the 482
custody of the Mississippi Department of Human Services may enter 483
into a cooperative agreement with the Mississippi Department of 484
Human Services for the provision of those services using state 485
funds that are provided from the appropriation to the Department 486
of Human Services to obtain federal matching funds through the 487
division. 488
(6) Physician services. Fees for physician's services 489
that are covered only by Medicaid shall be reimbursed at ninety 490
percent (90%) of the rate established on January 1, 2018, and as 491
may be adjusted each July thereafter, under Medicare. The 492
division may provide for a reimbursement rate for physician's 493
services of up to one hundred percent (100%) of the rate 494
established under Medicare for physician's services that are 495
provided after the normal working hours of the physician, as 496
determined in accordance with regulations of the division. The 497
division may reimburse eligible providers, as determined by the 498
division, for certain primary care services at one hundred percent 499
(100%) of the rate established under Medicare. The division shall 500
reimburse obstetricians * * *, gynecologists and pediatricians for 501
certain primary care services as defined by the division at one 502
hundred percent (100%) of the rate established under Medicare. 503
(7) (a) Home health services for eligible persons, not 504
to exceed in cost the prevailing cost of nursing facility 505
services. All home health visits must be precertified as required 506
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by the division. In addition to physicians, certified registered 507
nurse practitioners, physician assistants and clinical nurse 508
specialists are authorized to prescribe or order home health 509
services and plans of care, sign home health plans of care, 510
certify and recertify eligibility for home health services and 511
conduct the required initial face-to-face visit with the recipient 512
of the services. 513
(b) [Repealed] 514
(8) Emergency medical transportation services as 515
determined by the division. 516
(9) Prescription drugs and other covered drugs and 517
services as determined by the division. 518
The division shall establish a mandatory preferred drug list. 519
Drugs not on the mandatory preferred drug list shall be made 520
available by utilizing prior authorization procedures established 521
by the division. 522
The division may seek to establish relationships with other 523
states in order to lower acquisition costs of prescription drugs 524
to include single-source and innovator multiple-source drugs or 525
generic drugs. In addition, if allowed by federal law or 526
regulation, the division may seek to establish relationships with 527
and negotiate with other countries to facilitate the acquisition 528
of prescription drugs to include single-source and innovator 529
multiple-source drugs or generic drugs, if that will lower the 530
acquisition costs of those prescription drugs. 531
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The division may allow for a combination of prescriptions for 532
single-source and innovator multiple-source drugs and generic 533
drugs to meet the needs of the beneficiaries. 534
The executive director may approve specific maintenance drugs 535
for beneficiaries with certain medical conditions, which may be 536
prescribed and dispensed in three-month supply increments. 537
Drugs prescribed for a resident of a psychiatric residential 538
treatment facility must be provided in true unit doses when 539
available. The division may require that drugs not covered by 540
Medicare Part D for a resident of a long-term care facility be 541
provided in true unit doses when available. Those drugs that were 542
originally billed to the division but are not used by a resident 543
in any of those facilities shall be returned to the billing 544
pharmacy for credit to the division, in accordance with the 545
guidelines of the State Board of Pharmacy and any requirements of 546
federal law and regulation. Drugs shall be dispensed to a 547
recipient and only one (1) dispensing fee per month may be 548
charged. The division shall develop a methodology for reimbursing 549
for restocked drugs, which shall include a restock fee as 550
determined by the division not exceeding Seven Dollars and 551
Eighty-two Cents ($7.82). 552
Except for those specific maintenance drugs approved by the 553
executive director, the division shall not reimburse for any 554
portion of a prescription that exceeds a thirty-one-day supply of 555
the drug based on the daily dosage. 556
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The division is authorized to develop and implement a program 557
of payment for additional pharmacist services as determined by the 558
division. 559
All claims for drugs for dually eligible Medicare/Medicaid 560
beneficiaries that are paid for by Medicare must be submitted to 561
Medicare for payment before they may be processed by the 562
division's online payment system. 563
The division shall develop a pharmacy policy in which drugs 564
in tamper-resistant packaging that are prescribed for a resident 565
of a nursing facility but are not dispensed to the resident shall 566
be returned to the pharmacy and not billed to Medicaid, in 567
accordance with guidelines of the State Board of Pharmacy. 568
The division shall develop and implement a method or methods 569
by which the division will provide on a regular basis to Medicaid 570
providers who are authorized to prescribe drugs, information about 571
the costs to the Medicaid program of single-source drugs and 572
innovator multiple-source drugs, and information about other drugs 573
that may be prescribed as alternatives to those single-source 574
drugs and innovator multiple-source drugs and the costs to the 575
Medicaid program of those alternative drugs. 576
Notwithstanding any law or regulation, information obtained 577
or maintained by the division regarding the prescription drug 578
program, including trade secrets and manufacturer or labeler 579
pricing, is confidential and not subject to disclosure except to 580
other state agencies. 581
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The dispensing fee for each new or refill prescription, 582
including nonlegend or over-the-counter drugs covered by the 583
division, shall be not less than Three Dollars and Ninety-one 584
Cents ($3.91), as determined by the division. 585
The division shall not reimburse for single-source or 586
innovator multiple-source drugs if there are equally effective 587
generic equivalents available and if the generic equivalents are 588
the least expensive. 589
It is the intent of the Legislature that the pharmacists 590
providers be reimbursed for the reasonable costs of filling and 591
dispensing prescriptions for Medicaid beneficiaries. 592
The division shall allow certain drugs, including 593
physician-administered drugs, and implantable drug system devices, 594
and medical supplies, with limited distribution or limited access 595
for beneficiaries and administered in an appropriate clinical 596
setting, to be reimbursed as either a medical claim or pharmacy 597
claim, as determined by the division. 598
* * * 599
(10) Dental and orthodontic services to be determined 600
by the division. 601
The division shall increase the amount of the reimbursement 602
rate for diagnostic and preventative dental services for each of 603
the fiscal years 2022, 2023 and 2024 by five percent (5%) above 604
the amount of the reimbursement rate for the previous fiscal year. 605
The division shall increase the amount of the reimbursement rate 606
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for restorative dental services for each of the fiscal years 2023, 607
2024 and 2025 by five percent (5%) above the amount of the 608
reimbursement rate for the previous fiscal year. It is the intent 609
of the Legislature that the reimbursement rate revision for 610
preventative dental services will be an incentive to increase the 611
number of dentists who actively provide Medicaid services. This 612
dental services reimbursement rate revision shall be known as the 613
"James Russell Dumas Medicaid Dental Services Incentive Program." 614
The Medical Care Advisory Committee, assisted by the Division 615
of Medicaid, shall annually determine the effect of this incentive 616
by evaluating the number of dentists who are Medicaid providers, 617
the number who and the degree to which they are actively billing 618
Medicaid, the geographic trends of where dentists are offering 619
what types of Medicaid services and other statistics pertinent to 620
the goals of this legislative intent. This data shall annually be 621
presented to the Chair of the Senate Medicaid Committee and the 622
Chair of the House Medicaid Committee. 623
The division shall include dental services as a necessary 624
component of overall health services provided to children who are 625
eligible for services. 626
(11) Eyeglasses for all Medicaid beneficiaries who have 627
(a) had surgery on the eyeball or ocular muscle that results in a 628
vision change for which eyeglasses or a change in eyeglasses is 629
medically indicated within six (6) months of the surgery and is in 630
accordance with policies established by the division, or (b) one 631
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(1) pair every five (5) years and in accordance with policies 632
established by the division. In either instance, the eyeglasses 633
must be prescribed by a physician skilled in diseases of the eye 634
or an optometrist, whichever the beneficiary may select. 635
(12) Intermediate care facility services. 636
(a) The division * * * may make * * * payment to 637
all intermediate care facilities for individuals with intellectual 638
disabilities for each day, not exceeding * * * thirty-one (31) 639
days per year, that a patient is absent from the facility on home 640
leave. Payment may be made for the following home leave days in 641
addition to the * * * thirty-one-day limitation: Christmas, the 642
day before Christmas, the day after Christmas, Thanksgiving, the 643
day before Thanksgiving and the day after Thanksgiving. 644
(b) All state-owned intermediate care facilities 645
for individuals with intellectual disabilities shall be reimbursed 646
on a full reasonable cost basis. 647
(c) Effective January 1, 2015, the division shall 648
update the fair rental reimbursement system for intermediate care 649
facilities for individuals with intellectual disabilities. 650
(13) Family planning services, including drugs, 651
supplies and devices, when those services are under the 652
supervision of a physician or nurse practitioner. 653
(14) Clinic services. Preventive, diagnostic, 654
therapeutic, rehabilitative or palliative services that are 655
furnished by a facility that is not part of a hospital but is 656
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organized and operated to provide medical care to outpatients. 657
Clinic services include, but are not limited to: 658
(a) Services provided by ambulatory surgical 659
centers (ASCs) as defined in Section 41-75-1(a); and 660
(b) Dialysis center services. 661
Ambulatory Surgical Care (ASCs) may be reimbursed by the 662
division based on eighty-five percent (85%) of the Medicare ASC 663
Payment System rate in effect July 1 of each year as set by the 664
Center for Medicare and Medicaid Services. 665
(15) Home- and community-based services for the elderly 666
and disabled, as provided under Title XIX of the federal Social 667
Security Act, as amended, under waivers, subject to the 668
availability of funds specifically appropriated for that purpose 669
by the Legislature. 670
(16) Mental health services. Certain services provided 671
by a psychiatrist shall be reimbursed at up to one hundred percent 672
(100%) of the Medicare rate. Approved therapeutic and case 673
management services (a) provided by an approved regional mental 674
health/intellectual disability center established under Sections 675
41-19-31 through 41-19-39, or by another community mental health 676
service provider meeting the requirements of the Department of 677
Mental Health to be an approved mental health/intellectual 678
disability center if determined necessary by the Department of 679
Mental Health, using state funds that are provided in the 680
appropriation to the division to match federal funds, or (b) 681
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provided by a facility that is certified by the State Department 682
of Mental Health to provide therapeutic and case management 683
services, to be reimbursed on a fee for service basis, or (c) 684
provided in the community by a facility or program operated by the 685
Department of Mental Health. Any such services provided by a 686
facility described in subparagraph (b) must have the prior 687
approval of the division to be reimbursable under this section. 688
(17) Durable medical equipment services and medical 689
supplies. Precertification of durable medical equipment and 690
medical supplies must be obtained as required by the division. 691
The Division of Medicaid may require durable medical equipment 692
providers to obtain a surety bond in the amount and to the 693
specifications as established by the Balanced Budget Act of 1997. 694
A maximum dollar amount of reimbursement for noninvasive 695
ventilators or ventilation treatments properly ordered and being 696
used in an appropriate care setting shall not be set by any health 697
maintenance organization, coordinated care organization, 698
provider-sponsored health plan, or other organization paid for 699
services on a capitated basis by the division under any managed 700
care program or coordinated care program implemented by the 701
division under this section. Reimbursement by these organizations 702
to durable medical equipment suppliers for home use of noninvasive 703
and invasive ventilators shall be on a continuous monthly payment 704
basis for the duration of medical need throughout a patient's 705
valid prescription period. 706
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(18) (a) Notwithstanding any other provision of this 707
section to the contrary, as provided in the Medicaid state plan 708
amendment or amendments as defined in Section 43-13-145(10), the 709
division shall make additional reimbursement to hospitals that 710
serve a disproportionate share of low-income patients and that 711
meet the federal requirements for those payments as provided in 712
Section 1923 of the federal Social Security Act and any applicable 713
regulations. It is the intent of the Legislature that the 714
division shall draw down all available federal funds allotted to 715
the state for disproportionate share hospitals. However, from and 716
after January 1, 1999, public hospitals participating in the 717
Medicaid disproportionate share program may be required to 718
participate in an intergovernmental transfer program as provided 719
in Section 1903 of the federal Social Security Act and any 720
applicable regulations. 721
(b) (i) 1. The division may establish a Medicare 722
Upper Payment Limits Program, as defined in Section 1902(a)(30) of 723
the federal Social Security Act and any applicable federal 724
regulations, or an allowable delivery system or provider payment 725
initiative authorized under 42 CFR 438.6(c), for hospitals, 726
nursing facilities and physicians employed or contracted by 727
hospitals. 728
2. The division shall establish a 729
Medicaid Supplemental Payment Program, as permitted by the federal 730
Social Security Act and a comparable allowable delivery system or 731
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provider payment initiative authorized under 42 CFR 438.6(c), for 732
emergency ambulance transportation providers in accordance with 733
this subsection (A)(18)(b). 734
(ii) The division shall assess each hospital, 735
nursing facility, and emergency ambulance transportation provider 736
for the sole purpose of financing the state portion of the 737
Medicare Upper Payment Limits Program or other program(s) 738
authorized under this subsection (A)(18)(b). The hospital 739
assessment shall be as provided in Section 43-13-145(4)(a), and 740
the nursing facility and the emergency ambulance transportation 741
assessments, if established, shall be based on Medicaid 742
utilization or other appropriate method, as determined by the 743
division, consistent with federal regulations. The assessments 744
will remain in effect as long as the state participates in the 745
Medicare Upper Payment Limits Program or other program(s) 746
authorized under this subsection (A)(18)(b). * * * Hospitals with 747
physicians participating in the Medicare Upper Payment Limits 748
Program or other program(s) authorized under this subsection 749
(A)(18)(b) shall be required to participate in an 750
intergovernmental transfer or assessment, as determined by the 751
division, for the purpose of financing the state portion of the 752
physician UPL payments or other payment(s) authorized under this 753
subsection (A)(18)(b). 754
(iii) Subject to approval by the Centers for 755
Medicare and Medicaid Services (CMS) and the provisions of this 756
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subsection (A)(18)(b), the division shall make additional 757
reimbursement to hospitals, nursing facilities, and emergency 758
ambulance transportation providers for the Medicare Upper Payment 759
Limits Program or other program(s) authorized under this 760
subsection (A)(18)(b), and, if the program is established for 761
physicians, shall make additional reimbursement for physicians, as 762
defined in Section 1902(a)(30) of the federal Social Security Act 763
and any applicable federal regulations, provided the assessment in 764
this subsection (A)(18)(b) is in effect. 765
(iv) * * * The division is authorized to 766
develop and implement an alternative fee-for-service Upper Payment 767
Limits model in accordance with federal laws and regulations if 768
necessary to preserve supplemental funding. * * * The division 769
may develop alternative models for distribution of medical claims 770
and supplemental payments for inpatient and outpatient hospital 771
services, with input from the stakeholders of such claims and 772
payments. The goals of such payment models shall be to ensure 773
access to inpatient and outpatient care and to maximize any 774
federal funds that are available to reimburse hospitals for 775
services provided. The Chairmen of the Senate and House Medicaid 776
Committees shall be provided copies of the proposed payment 777
model(s) before submission. 778
(v) 1. To preserve and improve access to 779
ambulance transportation provider services, the division shall 780
seek CMS approval to make ambulance service access payments as set 781
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forth in this subsection (A)(18)(b) for all covered emergency 782
ambulance services rendered on or after July 1, 2022, and shall 783
make such ambulance service access payments for all covered 784
services rendered on or after the effective date of CMS approval. 785
2. The division shall calculate the 786
ambulance service access payment amount as the balance of the 787
portion of the Medical Care Fund related to ambulance 788
transportation service provider assessments plus any federal 789
matching funds earned on the balance, up to, but not to exceed, 790
the upper payment limit gap for all emergency ambulance service 791
providers. 792
3. a. Except for ambulance services 793
exempt from the assessment provided in this paragraph (18)(b), all 794
ambulance transportation service providers shall be eligible for 795
ambulance service access payments each state fiscal year as set 796
forth in this paragraph (18)(b). 797
b. In addition to any other funds 798
paid to ambulance transportation service providers for emergency 799
medical services provided to Medicaid beneficiaries, each eligible 800
ambulance transportation service provider shall receive ambulance 801
service access payments each state fiscal year equal to the 802
ambulance transportation service provider's upper payment limit 803
gap. Subject to approval by the Centers for Medicare and Medicaid 804
Services, ambulance service access payments shall be made no less 805
than on a quarterly basis. 806
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c. As used in this paragraph 807
(18)(b)(v), the term "upper payment limit gap" means the 808
difference between the total amount that the ambulance 809
transportation service provider received from Medicaid and the 810
average amount that the ambulance transportation service provider 811
would have received from commercial insurers for those services 812
reimbursed by Medicaid. 813
4. An ambulance service access payment 814
shall not be used to offset any other payment by the division for 815
emergency or nonemergency services to Medicaid beneficiaries. 816
(c) (i) * * * The division shall, subject to 817
approval by the Centers for Medicare and Medicaid Services (CMS), 818
establish, implement and operate a Mississippi Hospital Access 819
Program (MHAP) for the purpose of protecting patient access to 820
hospital care through hospital inpatient reimbursement programs 821
provided in this section designed to maintain total hospital 822
reimbursement for inpatient services rendered by in-state 823
hospitals and the out-of-state hospital that is authorized by 824
federal law to submit intergovernmental transfers (IGTs) to the 825
State of Mississippi and is classified as Level I trauma center 826
located in a county contiguous to the state line at the maximum 827
levels permissible under applicable federal statutes and 828
regulations * * *. 829
(ii) Subject to approval by the Centers for 830
Medicare and Medicaid Services (CMS), the MHAP shall provide 831
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increased inpatient capitation (PMPM) payments to managed care 832
entities contracting with the division pursuant to subsection (H) 833
of this section to support availability of hospital services or 834
such other payments permissible under federal law necessary to 835
accomplish the intent of this subsection. 836
* * * 837
( * * *iii) The division shall assess each 838
hospital as provided in Section 43-13-145(4)(a) for the purpose of 839
financing the state portion of the MHAP, supplemental payments and 840
such other purposes as specified in Section 43-13-145. The 841
assessment will remain in effect as long as the MHAP and 842
supplemental payments are in effect. 843
(19) (a) Perinatal risk-management services. The 844
division shall promulgate regulations to be effective from and 845
after October 1, 1988, to establish a comprehensive perinatal 846
system for risk assessment of all pregnant and infant Medicaid 847
recipients and for management, education and follow-up for those 848
who are determined to be at risk. Services to be performed 849
include case management, nutrition assessment/counseling, 850
psychosocial assessment/counseling and health education. The 851
division * * * may contract with the State Department of Health to 852
provide services within this paragraph (Perinatal High Risk 853
Management/Infant Services System (PHRM/ISS)) for any eligible 854
beneficiary who cannot receive these services under a different 855
program. The State Department of Health shall be reimbursed on a 856
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full reasonable cost basis for services provided under this 857
subparagraph (a). Any program authorized under subsection (H) of 858
this section shall develop a perinatal risk-management services 859
program in consultation with the division and the State Department 860
of Health or may contract with the State Department of Health for 861
these services, and the programs shall begin providing these 862
services no later than January 1, 2027. 863
(b) Early intervention system services. The 864
division shall cooperate with the State Department of Health, 865
acting as lead agency, in the development and implementation of a 866
statewide system of delivery of early intervention services, under 867
Part C of the Individuals with Disabilities Education Act (IDEA). 868
The State Department of Health shall certify annually in writing 869
to the executive director of the division the dollar amount of 870
state early intervention funds available that will be utilized as 871
a certified match for Medicaid matching funds. Those funds then 872
shall be used to provide expanded targeted case management 873
services for Medicaid eligible children with special needs who are 874
eligible for the state's early intervention system. 875
Qualifications for persons providing service coordination shall be 876
determined by the State Department of Health and the Division of 877
Medicaid. 878
(20) Home- and community-based services for physically 879
disabled approved services as allowed by a waiver from the United 880
States Department of Health and Human Services for home- and 881
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community-based services for physically disabled people using 882
state funds that are provided from the appropriation to the State 883
Department of Rehabilitation Services and used to match federal 884
funds under a cooperative agreement between the division and the 885
department, provided that funds for these services are 886
specifically appropriated to the Department of Rehabilitation 887
Services. 888
(21) Nurse practitioner services. Services furnished 889
by a registered nurse who is licensed and certified by the 890
Mississippi Board of Nursing as a nurse practitioner, including, 891
but not limited to, nurse anesthetists, nurse midwives, family 892
nurse practitioners, family planning nurse practitioners, 893
pediatric nurse practitioners, obstetrics-gynecology nurse 894
practitioners and neonatal nurse practitioners, under regulations 895
adopted by the division. Reimbursement for those services shall 896
not exceed ninety percent (90%) of the reimbursement rate for 897
comparable services rendered by a physician. The division may 898
provide for a reimbursement rate for nurse practitioner services 899
of up to one hundred percent (100%) of the reimbursement rate for 900
comparable services rendered by a physician for nurse practitioner 901
services that are provided after the normal working hours of the 902
nurse practitioner, as determined in accordance with regulations 903
of the division. 904
(22) Ambulatory services delivered in federally 905
qualified health centers, rural health centers and clinics of the 906
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local health departments of the State Department of Health for 907
individuals eligible for Medicaid under this article based on 908
reasonable costs as determined by the division. Federally 909
qualified health centers shall be reimbursed by the Medicaid 910
prospective payment system as approved by the Centers for Medicare 911
and Medicaid Services. The division shall recognize federally 912
qualified health centers (FQHCs), rural health clinics (RHCs) and 913
community mental health centers (CMHCs) as both an originating and 914
distant site provider for the purposes of telehealth 915
reimbursement. The division is further authorized and directed to 916
reimburse FQHCs, RHCs and CMHCs for both distant site and 917
originating site services when such services are appropriately 918
provided by the same organization. 919
(23) Inpatient psychiatric services. 920
(a) Inpatient psychiatric services to be 921
determined by the division for recipients under age twenty-one 922
(21) that are provided under the direction of a physician in an 923
inpatient program in a licensed acute care psychiatric facility or 924
in a licensed psychiatric residential treatment facility, before 925
the recipient reaches age twenty-one (21) or, if the recipient was 926
receiving the services immediately before he or she reached age 927
twenty-one (21), before the earlier of the date he or she no 928
longer requires the services or the date he or she reaches age 929
twenty-two (22), as provided by federal regulations. From and 930
after January 1, 2015, the division shall update the fair rental 931
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reimbursement system for psychiatric residential treatment 932
facilities. Precertification of inpatient days and residential 933
treatment days must be obtained as required by the division. From 934
and after July 1, 2009, all state-owned and state-operated 935
facilities that provide inpatient psychiatric services to persons 936
under age twenty-one (21) who are eligible for Medicaid 937
reimbursement shall be reimbursed for those services on a full 938
reasonable cost basis. 939
(b) The division may reimburse for services 940
provided by a licensed freestanding psychiatric hospital to 941
Medicaid recipients over the age of twenty-one (21) in a method 942
and manner consistent with the provisions of Section 43-13-117.5. 943
(24) * * * Certified Community Behavioral Health 944
Centers (CCBHCs). The division may reimburse CCBHCs in a manner 945
as determined by the division. 946
(25) [Deleted] 947
(26) Hospice care. As used in this paragraph, the term 948
"hospice care" means a coordinated program of active professional 949
medical attention within the home and outpatient and inpatient 950
care that treats the terminally ill patient and family as a unit, 951
employing a medically directed interdisciplinary team. The 952
program provides relief of severe pain or other physical symptoms 953
and supportive care to meet the special needs arising out of 954
physical, psychological, spiritual, social and economic stresses 955
that are experienced during the final stages of illness and during 956
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dying and bereavement and meets the Medicare requirements for 957
participation as a hospice as provided in federal regulations. 958
(27) Group health plan premiums and cost-sharing if it 959
is cost-effective as defined by the United States Secretary of 960
Health and Human Services. 961
(28) Other health insurance premiums that are 962
cost-effective as defined by the United States Secretary of Health 963
and Human Services. Medicare eligible must have Medicare Part B 964
before other insurance premiums can be paid. 965
(29) The Division of Medicaid may apply for a waiver 966
from the United States Department of Health and Human Services for 967
home- and community-based services for developmentally disabled 968
people using state funds that are provided from the appropriation 969
to the State Department of Mental Health and/or funds transferred 970
to the department by a political subdivision or instrumentality of 971
the state and used to match federal funds under a cooperative 972
agreement between the division and the department, provided that 973
funds for these services are specifically appropriated to the 974
Department of Mental Health and/or transferred to the department 975
by a political subdivision or instrumentality of the state. 976
(30) Pediatric skilled nursing services as determined 977
by the division and in a manner consistent with regulations 978
promulgated by the Mississippi State Department of Health. 979
(31) Targeted case management services for children 980
with special needs, under waivers from the United States 981
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Department of Health and Human Services, using state funds that 982
are provided from the appropriation to the Mississippi Department 983
of Human Services and used to match federal funds under a 984
cooperative agreement between the division and the department. 985
(32) Care and services provided in Christian Science 986
Sanatoria listed and certified by the Commission for Accreditation 987
of Christian Science Nursing Organizations/Facilities, Inc., 988
rendered in connection with treatment by prayer or spiritual means 989
to the extent that those services are subject to reimbursement 990
under Section 1903 of the federal Social Security Act. 991
(33) Podiatrist services. 992
(34) Assisted living services as provided through 993
home- and community-based services under Title XIX of the federal 994
Social Security Act, as amended, subject to the availability of 995
funds specifically appropriated for that purpose by the 996
Legislature. 997
(35) Services and activities authorized in Sections 998
43-27-101 and 43-27-103, using state funds that are provided from 999
the appropriation to the Mississippi Department of Human Services 1000
and used to match federal funds under a cooperative agreement 1001
between the division and the department. 1002
(36) Nonemergency transportation services for 1003
Medicaid-eligible persons as determined by the division. The PEER 1004
Committee shall conduct a performance evaluation of the 1005
nonemergency transportation program to evaluate the administration 1006
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of the program and the providers of transportation services to 1007
determine the most cost-effective ways of providing nonemergency 1008
transportation services to the patients served under the program. 1009
The performance evaluation shall be completed and provided to the 1010
members of the Senate Medicaid Committee and the House Medicaid 1011
Committee not later than January 1, 2019, and every two (2) years 1012
thereafter. 1013
(37) [Deleted] 1014
(38) Chiropractic services. A chiropractor's manual 1015
manipulation of the spine to correct a subluxation, if x-ray 1016
demonstrates that a subluxation exists and if the subluxation has 1017
resulted in a neuromusculoskeletal condition for which 1018
manipulation is appropriate treatment, and related spinal x-rays 1019
performed to document these conditions. Reimbursement for 1020
chiropractic services shall not exceed Seven Hundred Dollars 1021
($700.00) per year per beneficiary. 1022
(39) Dually eligible Medicare/Medicaid beneficiaries. 1023
The division shall pay the Medicare deductible and coinsurance 1024
amounts for services available under Medicare, as determined by 1025
the division. From and after July 1, 2009, the division shall 1026
reimburse crossover claims for inpatient hospital services and 1027
crossover claims covered under Medicare Part B in the same manner 1028
that was in effect on January 1, 2008, unless specifically 1029
authorized by the Legislature to change this method. 1030
(40) [Deleted] 1031
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(41) Services provided by the State Department of 1032
Rehabilitation Services for the care and rehabilitation of persons 1033
with spinal cord injuries or traumatic brain injuries, as allowed 1034
under waivers from the United States Department of Health and 1035
Human Services, using up to seventy-five percent (75%) of the 1036
funds that are appropriated to the Department of Rehabilitation 1037
Services from the Spinal Cord and Head Injury Trust Fund 1038
established under Section 37-33-261 and used to match federal 1039
funds under a cooperative agreement between the division and the 1040
department. 1041
(42) [Deleted] 1042
(43) The division shall provide reimbursement, 1043
according to a payment schedule developed by the division, for 1044
smoking cessation medications for pregnant women during their 1045
pregnancy and other Medicaid-eligible women who are of 1046
child-bearing age. 1047
(44) Nursing facility services for the severely 1048
disabled. 1049
(a) Severe disabilities include, but are not 1050
limited to, spinal cord injuries, closed-head injuries and 1051
ventilator-dependent patients. 1052
(b) Those services must be provided in a long-term 1053
care nursing facility dedicated to the care and treatment of 1054
persons with severe disabilities. 1055
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(45) Physician assistant services. Services furnished 1056
by a physician assistant who is licensed by the State Board of 1057
Medical Licensure and is practicing with physician supervision 1058
under regulations adopted by the board, under regulations adopted 1059
by the division. Reimbursement for those services shall not 1060
exceed ninety percent (90%) of the reimbursement rate for 1061
comparable services rendered by a physician. The division may 1062
provide for a reimbursement rate for physician assistant services 1063
of up to one hundred percent (100%) or the reimbursement rate for 1064
comparable services rendered by a physician for physician 1065
assistant services that are provided after the normal working 1066
hours of the physician assistant, as determined in accordance with 1067
regulations of the division. 1068
(46) The division shall make application to the federal 1069
Centers for Medicare and Medicaid Services (CMS) for a waiver to 1070
develop and provide services for children with serious emotional 1071
disturbances as defined in Section 43-14-1(1), which may include 1072
home- and community-based services, case management services or 1073
managed care services through mental health providers certified by 1074
the Department of Mental Health. The division may implement and 1075
provide services under this waivered program only if funds for 1076
these services are specifically appropriated for this purpose by 1077
the Legislature, or if funds are voluntarily provided by affected 1078
agencies. 1079
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(47) (a) The division may develop and implement 1080
disease management programs for individuals with high-cost chronic 1081
diseases and conditions, including the use of grants, waivers, 1082
demonstrations or other projects as necessary. 1083
(b) Participation in any disease management 1084
program implemented under this paragraph (47) is optional with the 1085
individual. An individual must affirmatively elect to participate 1086
in the disease management program in order to participate, and may 1087
elect to discontinue participation in the program at any time. 1088
(48) Pediatric long-term acute care hospital services. 1089
(a) Pediatric long-term acute care hospital 1090
services means services provided to eligible persons under 1091
twenty-one (21) years of age by a freestanding Medicare-certified 1092
hospital that has an average length of inpatient stay greater than 1093
twenty-five (25) days and that is primarily engaged in providing 1094
chronic or long-term medical care to persons under twenty-one (21) 1095
years of age. 1096
(b) The services under this paragraph (48) shall 1097
be reimbursed as a separate category of hospital services. 1098
(49) The division may establish copayments and/or 1099
coinsurance for any Medicaid services for which copayments and/or 1100
coinsurance are allowable under federal law or regulation. 1101
(50) Services provided by the State Department of 1102
Rehabilitation Services for the care and rehabilitation of persons 1103
who are deaf and blind, as allowed under waivers from the United 1104
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States Department of Health and Human Services to provide home- 1105
and community-based services using state funds that are provided 1106
from the appropriation to the State Department of Rehabilitation 1107
Services or if funds are voluntarily provided by another agency. 1108
(51) Upon determination of Medicaid eligibility and in 1109
association with annual redetermination of Medicaid eligibility, 1110
beneficiaries shall be encouraged to undertake a physical 1111
examination that will establish a base-line level of health and 1112
identification of a usual and customary source of care (a medical 1113
home) to aid utilization of disease management tools. This 1114
physical examination and utilization of these disease management 1115
tools shall be consistent with current United States Preventive 1116
Services Task Force or other recognized authority recommendations. 1117
For persons who are determined ineligible for Medicaid, the 1118
division will provide information and direction for accessing 1119
medical care and services in the area of their residence. 1120
(52) Notwithstanding any provisions of this article, 1121
the division may pay enhanced reimbursement fees related to trauma 1122
care, as determined by the division in conjunction with the State 1123
Department of Health, using funds appropriated to the State 1124
Department of Health for trauma care and services and used to 1125
match federal funds under a cooperative agreement between the 1126
division and the State Department of Health. The division, in 1127
conjunction with the State Department of Health, may use grants, 1128
waivers, demonstrations, enhanced reimbursements, Upper Payment 1129
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Limits Programs, supplemental payments, or other projects as 1130
necessary in the development and implementation of this 1131
reimbursement program. 1132
(53) Targeted case management services for high-cost 1133
beneficiaries may be developed by the division for all services 1134
under this section. 1135
(54) [Deleted] 1136
(55) Therapy services. The plan of care for therapy 1137
services may be developed to cover a period of treatment for up to 1138
six (6) months, but in no event shall the plan of care exceed a 1139
six-month period of treatment. The projected period of treatment 1140
must be indicated on the initial plan of care and must be updated 1141
with each subsequent revised plan of care. Based on medical 1142
necessity, the division shall approve certification periods for 1143
less than or up to six (6) months, but in no event shall the 1144
certification period exceed the period of treatment indicated on 1145
the plan of care. The appeal process for any reduction in therapy 1146
services shall be consistent with the appeal process in federal 1147
regulations. 1148
(56) Prescribed pediatric extended care centers 1149
services for medically dependent or technologically dependent 1150
children with complex medical conditions that require continual 1151
care as prescribed by the child's attending physician, as 1152
determined by the division. 1153
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(57) No Medicaid benefit shall restrict coverage for 1154
medically appropriate treatment prescribed by a physician and 1155
agreed to by a fully informed individual, or if the individual 1156
lacks legal capacity to consent by a person who has legal 1157
authority to consent on his or her behalf, based on an 1158
individual's diagnosis with a terminal condition. As used in this 1159
paragraph (57), "terminal condition" means any aggressive 1160
malignancy, chronic end-stage cardiovascular or cerebral vascular 1161
disease, or any other disease, illness or condition which a 1162
physician diagnoses as terminal. 1163
(58) Treatment services for persons with opioid 1164
dependency or other highly addictive substance use disorders. The 1165
division is authorized to reimburse eligible providers for 1166
treatment of opioid dependency and other highly addictive 1167
substance use disorders, as determined by the division. Treatment 1168
related to these conditions shall not count against any physician 1169
visit limit imposed under this section. 1170
(59) The division shall allow beneficiaries between the 1171
ages of ten (10) and eighteen (18) years to receive vaccines 1172
through a pharmacy venue. The division and the State Department 1173
of Health shall coordinate and notify OB-GYN providers that the 1174
Vaccines for Children program is available to providers free of 1175
charge. 1176
* * * 1177
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( * * *60) Services described in Section 41-140-3 that 1178
are provided by certified community health workers employed and 1179
supervised by a Medicaid provider. Reimbursement for these 1180
services shall be provided only if the division has received 1181
approval from the Centers for Medicare and Medicaid Services for a 1182
state plan amendment, waiver or alternative payment model for 1183
services delivered by certified community health workers. 1184
(B) Planning and development districts participating in the 1185
home- and community-based services program for the elderly and 1186
disabled as case management providers shall be reimbursed for case 1187
management services at the maximum rate approved by the Centers 1188
for Medicare and Medicaid Services (CMS). 1189
(C) The division may pay to those providers who participate 1190
in and accept patient referrals from the division's emergency room 1191
redirection program a percentage, as determined by the division, 1192
of savings achieved according to the performance measures and 1193
reduction of costs required of that program. Federally qualified 1194
health centers may participate in the emergency room redirection 1195
program, and the division may pay those centers a percentage of 1196
any savings to the Medicaid program achieved by the centers' 1197
accepting patient referrals through the program, as provided in 1198
this subsection (C). 1199
(D) (1) As used in this subsection (D), the following terms 1200
shall be defined as provided in this paragraph, except as 1201
otherwise provided in this subsection: 1202
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(a) "Committees" means the Medicaid Committees of 1203
the House of Representatives and the Senate, and "committee" means 1204
either one of those committees. 1205
(b) "Rate change" means an increase, decrease or 1206
other change in the payments or rates of reimbursement, or a 1207
change in any payment methodology that results in an increase, 1208
decrease or other change in the payments or rates of 1209
reimbursement, to any Medicaid provider that renders any services 1210
authorized to be provided to Medicaid recipients under this 1211
article. 1212
(2) Whenever the Division of Medicaid proposes a rate 1213
change, the division shall give notice to the chairmen of the 1214
committees at least * * * fifteen (15) calendar days, when 1215
possible, before the proposed rate change is scheduled to take 1216
effect. If the division needs to expedite the fifteen-day notice, 1217
the division shall notify both chairmen of the fact as soon as 1218
possible. The division shall furnish the chairmen with a concise 1219
summary of each proposed rate change along with the notice, and 1220
shall furnish the chairmen with a copy of any proposed rate change 1221
upon request. The division also shall provide a summary and copy 1222
of any proposed rate change to any other member of the Legislature 1223
upon request. 1224
(3) If the chairman of either committee or both 1225
chairmen jointly object to the proposed rate change or any part 1226
thereof, the chairman or chairmen shall notify the division and 1227
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provide the reasons for their objection in writing not later than 1228
seven (7) calendar days after receipt of the notice from the 1229
division. The chairman or chairmen may make written 1230
recommendations to the division for changes to be made to a 1231
proposed rate change. 1232
(4) (a) The chairman of either committee or both 1233
chairmen jointly may hold a committee meeting to review a proposed 1234
rate change. If either chairman or both chairmen decide to hold a 1235
meeting, they shall notify the division of their intention in 1236
writing within seven (7) calendar days after receipt of the notice 1237
from the division, and shall set the date and time for the meeting 1238
in their notice to the division, which shall not be later than 1239
fourteen (14) calendar days after receipt of the notice from the 1240
division. 1241
(b) After the committee meeting, the committee or 1242
committees may object to the proposed rate change or any part 1243
thereof. The committee or committees shall notify the division 1244
and the reasons for their objection in writing not later than 1245
seven (7) calendar days after the meeting. The committee or 1246
committees may make written recommendations to the division for 1247
changes to be made to a proposed rate change. 1248
(5) If both chairmen notify the division in writing 1249
within seven (7) calendar days after receipt of the notice from 1250
the division that they do not object to the proposed rate change 1251
and will not be holding a meeting to review the proposed rate 1252
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change, the proposed rate change will take effect on the original 1253
date as scheduled by the division or on such other date as 1254
specified by the division. 1255
(6) (a) If there are any objections to a proposed rate 1256
change or any part thereof from either or both of the chairmen or 1257
the committees, the division may withdraw the proposed rate 1258
change, make any of the recommended changes to the proposed rate 1259
change, or not make any changes to the proposed rate change. 1260
(b) If the division does not make any changes to 1261
the proposed rate change, it shall notify the chairmen of that 1262
fact in writing, and the proposed rate change shall take effect on 1263
the original date as scheduled by the division or on such other 1264
date as specified by the division. 1265
(c) If the division makes any changes to the 1266
proposed rate change, the division shall notify the chairmen of 1267
its actions in writing, and the revised proposed rate change shall 1268
take effect on the date as specified by the division. 1269
(7) Nothing in this subsection (D) shall be construed 1270
as giving the chairmen or the committees any authority to veto, 1271
nullify or revise any rate change proposed by the division. The 1272
authority of the chairmen or the committees under this subsection 1273
shall be limited to reviewing, making objections to and making 1274
recommendations for changes to rate changes proposed by the 1275
division. 1276
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(E) Notwithstanding any provision of this article, no new 1277
groups or categories of recipients and new types of care and 1278
services may be added without enabling legislation from the 1279
Mississippi Legislature, except that the division may authorize 1280
those changes without enabling legislation when the addition of 1281
recipients or services is ordered by a court of proper authority. 1282
(F) The executive director shall keep the Governor advised 1283
on a timely basis of the funds available for expenditure and the 1284
projected expenditures. Notwithstanding any other provisions of 1285
this article, if current or projected expenditures of the division 1286
are reasonably anticipated to exceed the amount of funds 1287
appropriated to the division for any fiscal year, the Governor, 1288
after consultation with the executive director, shall take all 1289
appropriate measures to reduce costs, which may include, but are 1290
not limited to: 1291
(1) Reducing or discontinuing any or all services that 1292
are deemed to be optional under Title XIX of the Social Security 1293
Act; 1294
(2) Reducing reimbursement rates for any or all service 1295
types; 1296
(3) Imposing additional assessments on health care 1297
providers; or 1298
(4) Any additional cost-containment measures deemed 1299
appropriate by the Governor. 1300
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To the extent allowed under federal law, any reduction to 1301
services or reimbursement rates under this subsection (F) shall be 1302
accompanied by a reduction, to the fullest allowable amount, to 1303
the profit margin and administrative fee portions of capitated 1304
payments to organizations described in paragraph (1) of subsection 1305
(H). 1306
Beginning in fiscal year 2010 and in fiscal years thereafter, 1307
when Medicaid expenditures are projected to exceed funds available 1308
for the fiscal year, the division shall submit the expected 1309
shortfall information to the PEER Committee not later than 1310
December 1 of the year in which the shortfall is projected to 1311
occur. PEER shall review the computations of the division and 1312
report its findings to the Legislative Budget Office not later 1313
than January 7 in any year. 1314
(G) Notwithstanding any other provision of this article, it 1315
shall be the duty of each provider participating in the Medicaid 1316
program to keep and maintain books, documents and other records as 1317
prescribed by the Division of Medicaid in accordance with federal 1318
laws and regulations. 1319
(H) (1) Notwithstanding any other provision of this 1320
article, the division is authorized to implement (a) a managed 1321
care program, (b) a coordinated care program, (c) a coordinated 1322
care organization program, (d) a health maintenance organization 1323
program, (e) a patient-centered medical home program, (f) an 1324
accountable care organization program, (g) provider-sponsored 1325
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health plan, or (h) any combination of the above programs. As a 1326
condition for the approval of any program under this subsection 1327
(H)(1), the division shall require that no managed care program, 1328
coordinated care program, coordinated care organization program, 1329
health maintenance organization program, or provider-sponsored 1330
health plan may: 1331
(a) Pay providers at a rate that is less than the 1332
Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) 1333
reimbursement rate; 1334
(b) Override the medical decisions of hospital 1335
physicians or staff regarding patients admitted to a hospital for 1336
an emergency medical condition as defined by 42 US Code Section 1337
1395dd. This restriction (b) does not prohibit the retrospective 1338
review of the appropriateness of the determination that an 1339
emergency medical condition exists by chart review or coding 1340
algorithm, nor does it prohibit prior authorization for 1341
nonemergency hospital admissions; 1342
(c) Pay providers at a rate that is less than the 1343
normal Medicaid reimbursement rate. It is the intent of the 1344
Legislature that all managed care entities described in this 1345
subsection (H), in collaboration with the division, develop and 1346
implement innovative payment models that incentivize improvements 1347
in health care quality, outcomes, or value, as determined by the 1348
division. Participation in the provider network of any managed 1349
care, coordinated care, provider-sponsored health plan, or similar 1350
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contractor shall not be conditioned on the provider's agreement to 1351
accept such alternative payment models; 1352
(d) Implement a prior authorization and 1353
utilization review program for medical services, transportation 1354
services and prescription drugs that is more stringent than the 1355
prior authorization processes used by the division in its 1356
administration of the Medicaid program. Not later than December 1357
2, 2021, the contractors that are receiving capitated payments 1358
under a managed care delivery system established under this 1359
subsection (H) shall submit a report to the Chairmen of the House 1360
and Senate Medicaid Committees on the status of the prior 1361
authorization and utilization review program for medical services, 1362
transportation services and prescription drugs that is required to 1363
be implemented under this subparagraph (d); 1364
(e) [Deleted] 1365
(f) Implement a preferred drug list that is more 1366
stringent than the mandatory preferred drug list established by 1367
the division under subsection (A)(9) of this section; 1368
(g) Implement a policy which denies beneficiaries 1369
with hemophilia access to the federally funded hemophilia 1370
treatment centers as part of the Medicaid Managed Care network of 1371
providers. 1372
Each health maintenance organization, coordinated care 1373
organization, provider-sponsored health plan, or other 1374
organization paid for services on a capitated basis by the 1375
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division under any managed care program or coordinated care 1376
program implemented by the division under this section shall use a 1377
clear set of level of care guidelines in the determination of 1378
medical necessity and in all utilization management practices, 1379
including the prior authorization process, concurrent reviews, 1380
retrospective reviews and payments, that are consistent with 1381
widely accepted professional standards of care. Organizations 1382
participating in a managed care program or coordinated care 1383
program implemented by the division may not use any additional 1384
criteria that would result in denial of care that would be 1385
determined appropriate and, therefore, medically necessary under 1386
those levels of care guidelines. 1387
(2) Notwithstanding any provision of this section, the 1388
recipients eligible for enrollment into a Medicaid Managed Care 1389
Program authorized under this subsection (H) may include only 1390
those categories of recipients eligible for participation in the 1391
Medicaid Managed Care Program as of January 1, 2021, the 1392
Children's Health Insurance Program (CHIP), and the CMS-approved 1393
Section 1115 demonstration waivers in operation as of January 1, 1394
2021. No expansion of Medicaid Managed Care Program contracts may 1395
be implemented by the division without enabling legislation from 1396
the Mississippi Legislature. 1397
(3) (a) Any contractors receiving capitated payments 1398
under a managed care delivery system established in this section 1399
shall provide to the Legislature and the division statistical data 1400
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to be shared with provider groups in order to improve patient 1401
access, appropriate utilization, cost savings and health outcomes 1402
not later than October 1 of each year. Additionally, each 1403
contractor shall disclose to the Chairmen of the Senate and House 1404
Medicaid Committees the administrative expenses costs for the 1405
prior calendar year, and the number of full-equivalent employees 1406
located in the State of Mississippi dedicated to the Medicaid and 1407
CHIP lines of business as of June 30 of the current year. 1408
(b) The division and the contractors participating 1409
in the managed care program, a coordinated care program or a 1410
provider-sponsored health plan shall be subject to annual program 1411
reviews or audits performed by the Office of the State Auditor, 1412
the PEER Committee, the Department of Insurance and/or independent 1413
third parties. 1414
(c) Those reviews shall include, but not be 1415
limited to, at least two (2) of the following items: 1416
(i) The financial benefit to the State of 1417
Mississippi of the managed care program, 1418
(ii) The difference between the premiums paid 1419
to the managed care contractors and the payments made by those 1420
contractors to health care providers, 1421
(iii) Compliance with performance measures 1422
required under the contracts, 1423
(iv) Administrative expense allocation 1424
methodologies, 1425
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(v) Whether nonprovider payments assigned as 1426
medical expenses are appropriate, 1427
(vi) Capitated arrangements with related 1428
party subcontractors, 1429
(vii) Reasonableness of corporate 1430
allocations, 1431
(viii) Value-added benefits and the extent to 1432
which they are used, 1433
(ix) The effectiveness of subcontractor 1434
oversight, including subcontractor review, 1435
(x) Whether health care outcomes have been 1436
improved, and 1437
(xi) The most common claim denial codes to 1438
determine the reasons for the denials. 1439
The audit reports shall be considered public documents and 1440
shall be posted in their entirety on the division's website. 1441
(4) All health maintenance organizations, coordinated 1442
care organizations, provider-sponsored health plans, or other 1443
organizations paid for services on a capitated basis by the 1444
division under any managed care program or coordinated care 1445
program implemented by the division under this section shall 1446
reimburse all providers in those organizations at rates no lower 1447
than those provided under this section for beneficiaries who are 1448
not participating in those programs. 1449
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(5) No health maintenance organization, coordinated 1450
care organization, provider-sponsored health plan, or other 1451
organization paid for services on a capitated basis by the 1452
division under any managed care program or coordinated care 1453
program implemented by the division under this section shall 1454
require its providers or beneficiaries to use any pharmacy that 1455
ships, mails or delivers prescription drugs or legend drugs or 1456
devices. 1457
(6) (a) Not later than December 1, 2021, the 1458
contractors who are receiving capitated payments under a managed 1459
care delivery system established under this subsection (H) shall 1460
develop and implement a uniform credentialing process for 1461
providers. Under that uniform credentialing process, a provider 1462
who meets the criteria for credentialing will be credentialed with 1463
all of those contractors and no such provider will have to be 1464
separately credentialed by any individual contractor in order to 1465
receive reimbursement from the contractor. Not later than 1466
December 2, 2021, those contractors shall submit a report to the 1467
Chairmen of the House and Senate Medicaid Committees on the status 1468
of the uniform credentialing process for providers that is 1469
required under this subparagraph (a). 1470
(b) If those contractors have not implemented a 1471
uniform credentialing process as described in subparagraph (a) by 1472
December 1, 2021, the division shall develop and implement, not 1473
later than July 1, 2022, a single, consolidated credentialing 1474
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process by which all providers will be credentialed. Under the 1475
division's single, consolidated credentialing process, no such 1476
contractor shall require its providers to be separately 1477
credentialed by the contractor in order to receive reimbursement 1478
from the contractor, but those contractors shall recognize the 1479
credentialing of the providers by the division's credentialing 1480
process. 1481
(c) The division shall require a uniform provider 1482
credentialing application that shall be used in the credentialing 1483
process that is established under subparagraph (a) or (b). If the 1484
contractor or division, as applicable, has not approved or denied 1485
the provider credentialing application within sixty (60) days of 1486
receipt of the completed application that includes all required 1487
information necessary for credentialing, then the contractor or 1488
division, upon receipt of a written request from the applicant and 1489
within five (5) business days of its receipt, shall issue a 1490
temporary provider credential/enrollment to the applicant if the 1491
applicant has a valid Mississippi professional or occupational 1492
license to provide the health care services to which the 1493
credential/enrollment would apply. The contractor or the division 1494
shall not issue a temporary credential/enrollment if the applicant 1495
has reported on the application a history of medical or other 1496
professional or occupational malpractice claims, a history of 1497
substance abuse or mental health issues, a criminal record, or a 1498
history of medical or other licensing board, state or federal 1499
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disciplinary action, including any suspension from participation 1500
in a federal or state program. The temporary 1501
credential/enrollment shall be effective upon issuance and shall 1502
remain in effect until the provider's credentialing/enrollment 1503
application is approved or denied by the contractor or division. 1504
The contractor or division shall render a final decision regarding 1505
credentialing/enrollment of the provider within sixty (60) days 1506
from the date that the temporary provider credential/enrollment is 1507
issued to the applicant. 1508
(d) If the contractor or division does not render 1509
a final decision regarding credentialing/enrollment of the 1510
provider within the time required in subparagraph (c), the 1511
provider shall be deemed to be credentialed by and enrolled with 1512
all of the contractors and eligible to receive reimbursement from 1513
the contractors. 1514
(7) (a) Each contractor that is receiving capitated 1515
payments under a managed care delivery system established under 1516
this subsection (H) shall provide to each provider for whom the 1517
contractor has denied the coverage of a procedure that was ordered 1518
or requested by the provider for or on behalf of a patient, a 1519
letter that provides a detailed explanation of the reasons for the 1520
denial of coverage of the procedure and the name and the 1521
credentials of the person who denied the coverage. The letter 1522
shall be sent to the provider in electronic format. 1523
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(b) After a contractor that is receiving capitated 1524
payments under a managed care delivery system established under 1525
this subsection (H) has denied coverage for a claim submitted by a 1526
provider, the contractor shall issue to the provider within sixty 1527
(60) days a final ruling of denial of the claim that allows the 1528
provider to have a state fair hearing and/or agency appeal with 1529
the division. If a contractor does not issue a final ruling of 1530
denial within sixty (60) days as required by this subparagraph 1531
(b), the provider's claim shall be deemed to be automatically 1532
approved and the contractor shall pay the amount of the claim to 1533
the provider. 1534
(c) After a contractor has issued a final ruling 1535
of denial of a claim submitted by a provider, the division shall 1536
conduct a state fair hearing and/or agency appeal on the matter of 1537
the disputed claim between the contractor and the provider within 1538
sixty (60) days, and shall render a decision on the matter within 1539
thirty (30) days after the date of the hearing and/or appeal. 1540
(8) It is the intention of the Legislature that the 1541
division evaluate the feasibility of using a single vendor to 1542
administer pharmacy benefits provided under a managed care 1543
delivery system established under this subsection (H). Providers 1544
of pharmacy benefits shall cooperate with the division in any 1545
transition to a carve-out of pharmacy benefits under managed care. 1546
(9) The division shall evaluate the feasibility of 1547
using a single vendor to administer dental benefits provided under 1548
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a managed care delivery system established in this subsection (H). 1549
Providers of dental benefits shall cooperate with the division in 1550
any transition to a carve-out of dental benefits under managed 1551
care. 1552
(10) It is the intent of the Legislature that any 1553
contractor receiving capitated payments under a managed care 1554
delivery system established in this section shall implement 1555
innovative programs to improve the health and well-being of 1556
members diagnosed with prediabetes and diabetes. 1557
(11) It is the intent of the Legislature that any 1558
contractors receiving capitated payments under a managed care 1559
delivery system established under this subsection (H) shall work 1560
with providers of Medicaid services to improve the utilization of 1561
long-acting reversible contraceptives (LARCs). Not later than 1562
December 1, 2021, any contractors receiving capitated payments 1563
under a managed care delivery system established under this 1564
subsection (H) shall provide to the Chairmen of the House and 1565
Senate Medicaid Committees and House and Senate Public Health 1566
Committees a report of LARC utilization for State Fiscal Years 1567
2018 through 2020 as well as any programs, initiatives, or efforts 1568
made by the contractors and providers to increase LARC 1569
utilization. This report shall be updated annually to include 1570
information for subsequent state fiscal years. 1571
(12) The division is authorized to make not more than 1572
one (1) emergency extension of the contracts that are in effect on 1573
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July 1, 2021, with contractors who are receiving capitated 1574
payments under a managed care delivery system established under 1575
this subsection (H), as provided in this paragraph (12). The 1576
maximum period of any such extension shall be one (1) year, and 1577
under any such extensions, the contractors shall be subject to all 1578
of the provisions of this subsection (H). The extended contracts 1579
shall be revised to incorporate any provisions of this subsection 1580
(H). 1581
(I) [Deleted] 1582
(J) There shall be no cuts in inpatient and outpatient 1583
hospital payments, or allowable days or volumes, as long as the 1584
hospital assessment provided in Section 43-13-145 is in effect. 1585
This subsection (J) shall not apply to decreases in payments that 1586
are a result of: reduced hospital admissions, audits or payments 1587
under the APR-DRG or APC models, or a managed care program or 1588
similar model described in subsection (H) of this section. 1589
(K) In the negotiation and execution of such contracts 1590
involving services performed by actuarial firms, the Executive 1591
Director of the Division of Medicaid may negotiate a limitation on 1592
liability to the state of prospective contractors. 1593
(L) The Division of Medicaid shall reimburse for services 1594
provided to eligible Medicaid beneficiaries by a licensed birthing 1595
center in a method and manner to be determined by the division in 1596
accordance with federal laws and federal regulations. The 1597
division shall seek any necessary waivers, make any required 1598
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amendments to its State Plan or revise any contracts authorized 1599
under subsection (H) of this section as necessary to provide the 1600
services authorized under this subsection. As used in this 1601
subsection, the term "birthing centers" shall have the meaning as 1602
defined in Section 41-77-1(a), which is a publicly or privately 1603
owned facility, place or institution constructed, renovated, 1604
leased or otherwise established where nonemergency births are 1605
planned to occur away from the mother's usual residence following 1606
a documented period of prenatal care for a normal uncomplicated 1607
pregnancy which has been determined to be low risk through a 1608
formal risk-scoring examination. 1609
(M) * * * Effective July 1, 2027, the Division of Medicaid 1610
may reimburse ambulance service providers that provide an 1611
assessment, triage or treatment for eligible Medicaid 1612
beneficiaries. The reimbursement rate for an ambulance service 1613
provider whose operators provide an assessment, triage or 1614
treatment shall be reimbursed at a rate or methodology as 1615
determined by the division. The division shall consult with the 1616
Mississippi Ambulance Alliance in determining the initial rate or 1617
methodology, and the division shall give due consideration of the 1618
inclusion in the Transforming Reimbursement for Emergency 1619
Ambulance Transportation program. 1620
SECTION 3. Section 43-13-121, Mississippi Code of 1972, is 1621
amended as follows: 1622
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43-13-121. (1) The division shall administer the Medicaid 1623
program under the provisions of this article, and may do the 1624
following: 1625
(a) Adopt and promulgate reasonable rules, regulations 1626
and standards, with approval of the Governor, and in accordance 1627
with the Administrative Procedures Law, Section 25-43-1.101 et 1628
seq.: 1629
(i) Establishing methods and procedures as may be 1630
necessary for the proper and efficient administration of this 1631
article; 1632
(ii) Providing Medicaid to all qualified 1633
recipients under the provisions of this article as the division 1634
may determine and within the limits of appropriated funds; 1635
(iii) Establishing reasonable fees, charges and 1636
rates for medical services and drugs; in doing so, the division 1637
shall fix all of those fees, charges and rates at the minimum 1638
levels absolutely necessary to provide the medical assistance 1639
authorized by this article, and shall not change any of those 1640
fees, charges or rates except as may be authorized in Section 1641
43-13-117; 1642
(iv) Providing for fair and impartial hearings; 1643
(v) Providing safeguards for preserving the 1644
confidentiality of records; and 1645
(vi) For detecting and processing fraudulent 1646
practices and abuses of the program; 1647
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(b) Receive and expend state, federal and other funds 1648
in accordance with court judgments or settlements and agreements 1649
between the State of Mississippi and the federal government, the 1650
rules and regulations promulgated by the division, with the 1651
approval of the Governor, and within the limitations and 1652
restrictions of this article and within the limits of funds 1653
available for that purpose; 1654
(c) Subject to the limits imposed by this article and 1655
subject to the provisions of subsection (8) of this section, to 1656
submit a Medicaid plan to the United States Department of Health 1657
and Human Services for approval under the provisions of the 1658
federal Social Security Act, to act for the state in making 1659
negotiations relative to the submission and approval of that plan, 1660
to make such arrangements, not inconsistent with the law, as may 1661
be required by or under federal law to obtain and retain that 1662
approval and to secure for the state the benefits of the 1663
provisions of that law. 1664
No agreements, specifically including the general plan for 1665
the operation of the Medicaid program in this state, shall be made 1666
by and between the division and the United States Department of 1667
Health and Human Services unless the Attorney General of the State 1668
of Mississippi has reviewed the agreements, specifically including 1669
the operational plan, and has certified in writing to the Governor 1670
and to the executive director of the division that the agreements, 1671
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including the plan of operation, have been drawn strictly in 1672
accordance with the terms and requirements of this article; 1673
(d) In accordance with the purposes and intent of this 1674
article and in compliance with its provisions, provide for aged 1675
persons otherwise eligible for the benefits provided under Title 1676
XVIII of the federal Social Security Act by expenditure of funds 1677
available for those purposes; 1678
(e) To make reports to the United States Department of 1679
Health and Human Services as from time to time may be required by 1680
that federal department and to the Mississippi Legislature as 1681
provided in this section; 1682
(f) Define and determine the scope, duration and amount 1683
of Medicaid that may be provided in accordance with this article 1684
and establish priorities therefor in conformity with this article; 1685
(g) Cooperate and contract with other state agencies 1686
for the purpose of coordinating Medicaid provided under this 1687
article and eliminating duplication and inefficiency in the 1688
Medicaid program; 1689
(h) Adopt and use an official seal of the division; 1690
(i) Sue in its own name on behalf of the State of 1691
Mississippi and employ legal counsel on a contingency basis with 1692
the approval of the Attorney General; 1693
(j) To recover any and all payments incorrectly made by 1694
the division to a recipient or provider from the recipient or 1695
provider receiving the payments. The division shall be authorized 1696
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to collect any overpayments to providers sixty (60) days after the 1697
conclusion of any administrative appeal unless the matter is 1698
appealed to a court of proper jurisdiction and bond is posted. 1699
Any appeal filed after July 1, 2015, shall be to the Chancery 1700
Court of the First Judicial District of Hinds County, Mississippi, 1701
within sixty (60) days after the date that the division has 1702
notified the provider by certified mail sent to the proper address 1703
of the provider on file with the division and the provider has 1704
signed for the certified mail notice, or sixty (60) days after the 1705
date of the final decision if the provider does not sign for the 1706
certified mail notice. To recover those payments, the division 1707
may use the following methods, in addition to any other methods 1708
available to the division: 1709
(i) The division shall report to the Department of 1710
Revenue the name of any current or former Medicaid recipient who 1711
has received medical services rendered during a period of 1712
established Medicaid ineligibility and who has not reimbursed the 1713
division for the related medical service payment(s). The 1714
Department of Revenue shall withhold from the state tax refund of 1715
the individual, and pay to the division, the amount of the 1716
payment(s) for medical services rendered to the ineligible 1717
individual that have not been reimbursed to the division for the 1718
related medical service payment(s). 1719
(ii) The division shall report to the Department 1720
of Revenue the name of any Medicaid provider to whom payments were 1721
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incorrectly made that the division has not been able to recover by 1722
other methods available to the division. The Department of 1723
Revenue shall withhold from the state tax refund of the provider, 1724
and pay to the division, the amount of the payments that were 1725
incorrectly made to the provider that have not been recovered by 1726
other available methods; 1727
(k) To recover any and all payments by the division 1728
fraudulently obtained by a recipient or provider. Additionally, 1729
if recovery of any payments fraudulently obtained by a recipient 1730
or provider is made in any court, then, upon motion of the 1731
Governor, the judge of the court may award twice the payments 1732
recovered as damages; 1733
(l) Have full, complete and plenary power and authority 1734
to conduct such investigations as it may deem necessary and 1735
requisite of alleged or suspected violations or abuses of the 1736
provisions of this article or of the regulations adopted under 1737
this article, including, but not limited to, fraudulent or 1738
unlawful act or deed by applicants for Medicaid or other benefits, 1739
or payments made to any person, firm or corporation under the 1740
terms, conditions and authority of this article, to suspend or 1741
disqualify any provider of services, applicant or recipient for 1742
gross abuse, fraudulent or unlawful acts for such periods, 1743
including permanently, and under such conditions as the division 1744
deems proper and just, including the imposition of a legal rate of 1745
interest on the amount improperly or incorrectly paid. Recipients 1746
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who are found to have misused or abused Medicaid benefits may be 1747
locked into one (1) physician and/or one (1) pharmacy of the 1748
recipient's choice for a reasonable amount of time in order to 1749
educate and promote appropriate use of medical services, in 1750
accordance with federal regulations. If an administrative hearing 1751
becomes necessary, the division may, if the provider does not 1752
succeed in his or her defense, tax the costs of the administrative 1753
hearing, including the costs of the court reporter or stenographer 1754
and transcript, to the provider. The convictions of a recipient 1755
or a provider in a state or federal court for abuse, fraudulent or 1756
unlawful acts under this chapter shall constitute an automatic 1757
disqualification of the recipient or automatic disqualification of 1758
the provider from participation under the Medicaid program. 1759
A conviction, for the purposes of this chapter, shall include 1760
a judgment entered on a plea of nolo contendere or a 1761
nonadjudicated guilty plea and shall have the same force as a 1762
judgment entered pursuant to a guilty plea or a conviction 1763
following trial. A certified copy of the judgment of the court of 1764
competent jurisdiction of the conviction shall constitute prima 1765
facie evidence of the conviction for disqualification purposes; 1766
(m) Establish and provide such methods of 1767
administration as may be necessary for the proper and efficient 1768
operation of the Medicaid program, fully utilizing computer 1769
equipment as may be necessary to oversee and control all current 1770
expenditures for purposes of this article, and to closely monitor 1771
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and supervise all recipient payments and vendors rendering 1772
services under this article. Notwithstanding any other provision 1773
of state law, the division is authorized to enter into a ten-year 1774
contract(s) with a vendor(s) to provide services described in this 1775
paragraph (m). Notwithstanding any other provision of state law, 1776
the division is authorized to enter into a ten year contract(s) 1777
with a vendor(s) to provide services described in this paragraph 1778
(m). Notwithstanding any provision of law to the contrary, the 1779
division is authorized to extend its Medicaid * * * Enterprise 1780
System * * * and fiscal agent services, including all related 1781
components and services, contracts in effect on June 30, * * * 1782
2026, for * * * additional contract periods, the length of which 1783
shall be at the discretion of the division, if the executive 1784
director has determined that the system continues to meet the 1785
needs of the state and the cost continues to represent fair market 1786
value. Price adjustments in new contract period(s), if any, shall 1787
not exceed the lesser of five percent (5%) of the contract value 1788
or the change in the Consumer Price Index over the prior 1789
twelve-month period. Notwithstanding any other provision of state 1790
law, the division is authorized to enter into a two-year contract 1791
ending no later than June 30, 2028, with a vendor to provide 1792
support of the division's eligibility system; 1793
(n) To cooperate and contract with the federal 1794
government for the purpose of providing Medicaid to Vietnamese and 1795
Cambodian refugees, under the provisions of Public Law 94-23 and 1796
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Public Law 94-24, including any amendments to those laws, only to 1797
the extent that the Medicaid assistance and the administrative 1798
cost related thereto are one hundred percent (100%) reimbursable 1799
by the federal government. For the purposes of Section 43-13-117, 1800
persons receiving Medicaid under Public Law 94-23 and Public Law 1801
94-24, including any amendments to those laws, shall not be 1802
considered a new group or category of recipient; and 1803
(o) The division shall impose penalties upon Medicaid 1804
only, Title XIX participating long-term care facilities found to 1805
be in noncompliance with division and certification standards in 1806
accordance with federal and state regulations, including interest 1807
at the same rate calculated by the United States Department of 1808
Health and Human Services and/or the Centers for Medicare and 1809
Medicaid Services (CMS) under federal regulations. 1810
(2) The division also shall exercise such additional powers 1811
and perform such other duties as may be conferred upon the 1812
division by act of the Legislature. 1813
(3) The division, and the State Department of Health as the 1814
agency for licensure of health care facilities and certification 1815
and inspection for the Medicaid and/or Medicare programs, shall 1816
contract for or otherwise provide for the consolidation of on-site 1817
inspections of health care facilities that are necessitated by the 1818
respective programs and functions of the division and the 1819
department. 1820
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(4) The division and its hearing officers shall have power 1821
to preserve and enforce order during hearings; to issue subpoenas 1822
for, to administer oaths to and to compel the attendance and 1823
testimony of witnesses, or the production of books, papers, 1824
documents and other evidence, or the taking of depositions before 1825
any designated individual competent to administer oaths; to 1826
examine witnesses; and to do all things conformable to law that 1827
may be necessary to enable them effectively to discharge the 1828
duties of their office. In compelling the attendance and 1829
testimony of witnesses, or the production of books, papers, 1830
documents and other evidence, or the taking of depositions, as 1831
authorized by this section, the division or its hearing officers 1832
may designate an individual employed by the division or some other 1833
suitable person to execute and return that process, whose action 1834
in executing and returning that process shall be as lawful as if 1835
done by the sheriff or some other proper officer authorized to 1836
execute and return process in the county where the witness may 1837
reside. In carrying out the investigatory powers under the 1838
provisions of this article, the executive director or other 1839
designated person or persons may examine, obtain, copy or 1840
reproduce the books, papers, documents, medical charts, 1841
prescriptions and other records relating to medical care and 1842
services furnished by the provider to a recipient or designated 1843
recipients of Medicaid services under investigation. In the 1844
absence of the voluntary submission of the books, papers, 1845
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documents, medical charts, prescriptions and other records, the 1846
Governor, the executive director, or other designated person may 1847
issue and serve subpoenas instantly upon the provider, his or her 1848
agent, servant or employee for the production of the books, 1849
papers, documents, medical charts, prescriptions or other records 1850
during an audit or investigation of the provider. If any provider 1851
or his or her agent, servant or employee refuses to produce the 1852
records after being duly subpoenaed, the executive director may 1853
certify those facts and institute contempt proceedings in the 1854
manner, time and place as authorized by law for administrative 1855
proceedings. As an additional remedy, the division may recover 1856
all amounts paid to the provider covering the period of the audit 1857
or investigation, inclusive of a legal rate of interest and a 1858
reasonable attorney's fee and costs of court if suit becomes 1859
necessary. Division staff shall have immediate access to the 1860
provider's physical location, facilities, records, documents, 1861
books, and any other records relating to medical care and services 1862
rendered to recipients during regular business hours. 1863
(5) If any person in proceedings before the division 1864
disobeys or resists any lawful order or process, or misbehaves 1865
during a hearing or so near the place thereof as to obstruct the 1866
hearing, or neglects to produce, after having been ordered to do 1867
so, any pertinent book, paper or document, or refuses to appear 1868
after having been subpoenaed, or upon appearing refuses to take 1869
the oath as a witness, or after having taken the oath refuses to 1870
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be examined according to law, the executive director shall certify 1871
the facts to any court having jurisdiction in the place in which 1872
it is sitting, and the court shall thereupon, in a summary manner, 1873
hear the evidence as to the acts complained of, and if the 1874
evidence so warrants, punish that person in the same manner and to 1875
the same extent as for a contempt committed before the court, or 1876
commit that person upon the same condition as if the doing of the 1877
forbidden act had occurred with reference to the process of, or in 1878
the presence of, the court. 1879
(6) In suspending or terminating any provider from 1880
participation in the Medicaid program, the division shall preclude 1881
the provider from submitting claims for payment, either personally 1882
or through any clinic, group, corporation or other association to 1883
the division or its fiscal agents for any services or supplies 1884
provided under the Medicaid program except for those services or 1885
supplies provided before the suspension or termination. No 1886
clinic, group, corporation or other association that is a provider 1887
of services shall submit claims for payment to the division or its 1888
fiscal agents for any services or supplies provided by a person 1889
within that organization who has been suspended or terminated from 1890
participation in the Medicaid program except for those services or 1891
supplies provided before the suspension or termination. When this 1892
provision is violated by a provider of services that is a clinic, 1893
group, corporation or other association, the division may suspend 1894
or terminate that organization from participation. Suspension may 1895
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be applied by the division to all known affiliates of a provider, 1896
provided that each decision to include an affiliate is made on a 1897
case-by-case basis after giving due regard to all relevant facts 1898
and circumstances. The violation, failure or inadequacy of 1899
performance may be imputed to a person with whom the provider is 1900
affiliated where that conduct was accomplished within the course 1901
of his or her official duty or was effectuated by him or her with 1902
the knowledge or approval of that person. 1903
(7) The division may deny or revoke enrollment in the 1904
Medicaid program to a provider if any of the following are found 1905
to be applicable to the provider, his or her agent, a managing 1906
employee or any person having an ownership interest equal to five 1907
percent (5%) or greater in the provider: 1908
(a) Failure to truthfully or fully disclose any and all 1909
information required, or the concealment of any and all 1910
information required, on a claim, a provider application or a 1911
provider agreement, or the making of a false or misleading 1912
statement to the division relative to the Medicaid program. 1913
(b) Previous or current exclusion, suspension, 1914
termination from or the involuntary withdrawing from participation 1915
in the Medicaid program, any other state's Medicaid program, 1916
Medicare or any other public or private health or health insurance 1917
program. If the division ascertains that a provider has been 1918
convicted of a felony under federal or state law for an offense 1919
that the division determines is detrimental to the best interest 1920
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of the program or of Medicaid beneficiaries, the division may 1921
refuse to enter into an agreement with that provider, or may 1922
terminate or refuse to renew an existing agreement. 1923
(c) Conviction under federal or state law of a criminal 1924
offense relating to the delivery of any goods, services or 1925
supplies, including the performance of management or 1926
administrative services relating to the delivery of the goods, 1927
services or supplies, under the Medicaid program, any other 1928
state's Medicaid program, Medicare or any other public or private 1929
health or health insurance program. 1930
(d) Conviction under federal or state law of a criminal 1931
offense relating to the neglect or abuse of a patient in 1932
connection with the delivery of any goods, services or supplies. 1933
(e) Conviction under federal or state law of a criminal 1934
offense relating to the unlawful manufacture, distribution, 1935
prescription or dispensing of a controlled substance. 1936
(f) Conviction under federal or state law of a criminal 1937
offense relating to fraud, theft, embezzlement, breach of 1938
fiduciary responsibility or other financial misconduct. 1939
(g) Conviction under federal or state law of a criminal 1940
offense punishable by imprisonment of a year or more that involves 1941
moral turpitude, or acts against the elderly, children or infirm. 1942
(h) Conviction under federal or state law of a criminal 1943
offense in connection with the interference or obstruction of any 1944
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investigation into any criminal offense listed in paragraphs (c) 1945
through (i) of this subsection. 1946
(i) Sanction for a violation of federal or state laws 1947
or rules relative to the Medicaid program, any other state's 1948
Medicaid program, Medicare or any other public health care or 1949
health insurance program. 1950
(j) Revocation of license or certification. 1951
(k) Failure to pay recovery properly assessed or 1952
pursuant to an approved repayment schedule under the Medicaid 1953
program. 1954
(l) Failure to meet any condition of enrollment. 1955
(8) (a) As used in this subsection (8), the following terms 1956
shall be defined as provided in this paragraph, except as 1957
otherwise provided in this subsection: 1958
(i) "Committees" means the Medicaid Committees of 1959
the House of Representatives and the Senate, and "committee" means 1960
either one of those committees. 1961
(ii) "State Plan" means the agreement between the 1962
State of Mississippi and the federal government regarding the 1963
nature and scope of Mississippi's Medicaid Program. 1964
(iii) "State Plan Amendment" means a change to the 1965
State Plan, which must be approved by the Centers for Medicare and 1966
Medicaid Services (CMS) before its implementation. 1967
(b) Whenever the Division of Medicaid proposes a State 1968
Plan Amendment, the division shall give notice to the chairmen of 1969
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the committees at least * * * fifteen (15) calendar days, when 1970
possible, before the proposed State Plan Amendment is filed with 1971
CMS. If the division needs to expedite the fifteen-day notice, 1972
the division will notify both chairmen of that fact as soon as 1973
possible. The division shall furnish the chairmen with a concise 1974
summary of each proposed State Plan Amendment along with the 1975
notice, and shall furnish the chairmen with a copy of any proposed 1976
State Plan Amendment upon request. The division also shall 1977
provide a summary and copy of any proposed State Plan Amendment to 1978
any other member of the Legislature upon request. 1979
(c) If the chairman of either committee or both 1980
chairmen jointly object to the proposed State Plan Amendment or 1981
any part thereof, the chairman or chairmen shall notify the 1982
division and provide the reasons for their objection in writing 1983
not later than seven (7) calendar days after receipt of the notice 1984
from the division. The chairman or chairmen may make written 1985
recommendations to the division for changes to be made to a 1986
proposed State Plan Amendment. 1987
(d) (i) The chairman of either committee or both 1988
chairmen jointly may hold a committee meeting to review a proposed 1989
State Plan Amendment. If either chairman or both chairmen decide 1990
to hold a meeting, they shall notify the division of their 1991
intention in writing within seven (7) calendar days after receipt 1992
of the notice from the division, and shall set the date and time 1993
for the meeting in their notice to the division, which shall not 1994
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be later than fourteen (14) calendar days after receipt of the 1995
notice from the division. 1996
(ii) After the committee meeting, the committee or 1997
committees may object to the proposed State Plan Amendment or any 1998
part thereof. The committee or committees shall notify the 1999
division and the reasons for their objection in writing not later 2000
than seven (7) calendar days after the meeting. The committee or 2001
committees may make written recommendations to the division for 2002
changes to be made to a proposed State Plan Amendment. 2003
(e) If both chairmen notify the division in writing 2004
within seven (7) calendar days after receipt of the notice from 2005
the division that they do not object to the proposed State Plan 2006
Amendment and will not be holding a meeting to review the proposed 2007
State Plan Amendment, the division may proceed to file the 2008
proposed State Plan Amendment with CMS. 2009
(f) (i) If there are any objections to a proposed rate 2010
change or any part thereof from either or both of the chairmen or 2011
the committees, the division may withdraw the proposed State Plan 2012
Amendment, make any of the recommended changes to the proposed 2013
State Plan Amendment, or not make any changes to the proposed 2014
State Plan Amendment. 2015
(ii) If the division does not make any changes to 2016
the proposed State Plan Amendment, it shall notify the chairmen of 2017
that fact in writing, and may proceed to file the State Plan 2018
Amendment with CMS. 2019
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(iii) If the division makes any changes to the 2020
proposed State Plan Amendment, the division shall notify the 2021
chairmen of its actions in writing, and may proceed to file the 2022
State Plan Amendment with CMS. 2023
(g) Nothing in this subsection (8) shall be construed 2024
as giving the chairmen or the committees any authority to veto, 2025
nullify or revise any State Plan Amendment proposed by the 2026
division. The authority of the chairmen or the committees under 2027
this subsection shall be limited to reviewing, making objections 2028
to and making recommendations for changes to State Plan Amendments 2029
proposed by the division. 2030
(i) If the division does not make any changes to 2031
the proposed State Plan Amendment, it shall notify the chairmen of 2032
that fact in writing, and may proceed to file the proposed State 2033
Plan Amendment with CMS. 2034
(ii) If the division makes any changes to the 2035
proposed State Plan Amendment, the division shall notify the 2036
chairmen of the changes in writing, and may proceed to file the 2037
proposed State Plan Amendment with CMS. 2038
(h) Nothing in this subsection (8) shall be construed 2039
as giving the chairmen of the committees any authority to veto, 2040
nullify or revise any State Plan Amendment proposed by the 2041
division. The authority of the chairmen of the committees under 2042
this subsection shall be limited to reviewing, making objections 2043
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to and making recommendations for suggested changes to State Plan 2044
Amendments proposed by the division. 2045
SECTION 4. Section 43-13-305, Mississippi Code of 1972, is 2046
amended as follows: 2047
43-13-305. (1) By accepting Medicaid from the Division of 2048
Medicaid in the Office of the Governor, the recipient shall, to 2049
the extent of the payment of medical expenses by the Division of 2050
Medicaid, be deemed to have made an assignment to the Division of 2051
Medicaid of any and all rights and interests in any third-party 2052
benefits, hospitalization or indemnity contract or any cause of 2053
action, past, present or future, against any person, firm or 2054
corporation for Medicaid benefits provided to the recipient by the 2055
Division of Medicaid for injuries, disease or sickness caused or 2056
suffered under circumstances creating a cause of action in favor 2057
of the recipient against any such person, firm or corporation as 2058
set out in Section 43-13-125. The recipient shall be deemed, 2059
without the necessity of signing any document, to have appointed 2060
the Division of Medicaid as his or her true and lawful 2061
attorney-in-fact in his or her name, place and stead in collecting 2062
any and all amounts due and owing for medical expenses paid by the 2063
Division of Medicaid against such person, firm or corporation. 2064
(2) Whenever a provider of medical services or the Division 2065
of Medicaid submits claims to an insurer on behalf of a Medicaid 2066
recipient for whom an assignment of rights has been received, or 2067
whose rights have been assigned by the operation of law, the 2068
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insurer must respond within sixty (60) days of receipt of a claim 2069
by forwarding payment or issuing a notice of denial directly to 2070
the submitter of the claim. The failure of the insuring entity to 2071
comply with the provisions of this section shall subject the 2072
insuring entity to recourse by the Division of Medicaid in 2073
accordance with the provision of Section 43-13-315. In the case 2074
of a responsible insurer, other than the insurers exempted under 2075
federal law, that requires prior authorization for an item or 2076
service furnished to a recipient, the insurer shall accept 2077
authorization provided by the Division of Medicaid that the item 2078
or service is covered under the state plan (or waiver of such 2079
plan) for such recipient, as if such authorization were the prior 2080
authorization made by the third party for such item or service. 2081
The Division of Medicaid shall be authorized to endorse any and 2082
all, including, but not limited to, multi-payee checks, drafts, 2083
money orders or other negotiable instruments representing Medicaid 2084
payment recoveries that are received by the Division of Medicaid. 2085
(3) Court orders or agreements for medical support shall 2086
direct such payments to the Division of Medicaid, which shall be 2087
authorized to endorse any and all checks, drafts, money orders or 2088
other negotiable instruments representing medical support payments 2089
which are received. Any designated medical support funds received 2090
by the State Department of Human Services or through its local 2091
county departments shall be paid over to the Division of Medicaid. 2092
When medical support for a Medicaid recipient is available through 2093
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an absent parent or custodial parent, the insuring entity shall 2094
direct the medical support payment(s) to the provider of medical 2095
services or to the Division of Medicaid. 2096
SECTION 5. Section 43-13-117.7, Mississippi Code of 1972, is 2097
amended as follows: 2098
43-13-117.7. Notwithstanding any other provisions of Section 2099
43-13-117, the division shall not reimburse or provide coverage 2100
for gender transition procedures for * * * any person * * *. 2101
SECTION 6. Section 43-13-145, Mississippi Code of 1972, is 2102
amended as follows: 2103
43-13-145. (1) (a) Upon each nursing facility licensed by 2104
the State of Mississippi, there is levied an assessment in an 2105
amount set by the division, equal to the maximum rate allowed by 2106
federal law or regulation, for each licensed and occupied bed of 2107
the facility. 2108
(b) A nursing facility is exempt from the assessment 2109
levied under this subsection if the facility is operated under the 2110
direction and control of: 2111
(i) The United States Veterans Administration or 2112
other agency or department of the United States government; or 2113
(ii) The State Veterans Affairs Board. 2114
(2) (a) Upon each intermediate care facility for 2115
individuals with intellectual disabilities licensed by the State 2116
of Mississippi, there is levied an assessment in an amount set by 2117
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the division, equal to the maximum rate allowed by federal law or 2118
regulation, for each licensed and occupied bed of the facility. 2119
(b) An intermediate care facility for individuals with 2120
intellectual disabilities is exempt from the assessment levied 2121
under this subsection if the facility is operated under the 2122
direction and control of: 2123
(i) The United States Veterans Administration or 2124
other agency or department of the United States government; 2125
(ii) The State Veterans Affairs Board; or 2126
(iii) The University of Mississippi Medical 2127
Center. 2128
(3) (a) Upon each psychiatric residential treatment 2129
facility licensed by the State of Mississippi, there is levied an 2130
assessment in an amount set by the division, equal to the maximum 2131
rate allowed by federal law or regulation, for each licensed and 2132
occupied bed of the facility. 2133
(b) A psychiatric residential treatment facility is 2134
exempt from the assessment levied under this subsection if the 2135
facility is operated under the direction and control of: 2136
(i) The United States Veterans Administration or 2137
other agency or department of the United States government; 2138
(ii) The University of Mississippi Medical Center; 2139
or 2140
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(iii) A state agency or a state facility that 2141
either provides its own state match through intergovernmental 2142
transfer or certification of funds to the division. 2143
(4) Hospital assessment. 2144
(a) (i) Subject to and upon fulfillment of the 2145
requirements and conditions of paragraph (f) below, and 2146
notwithstanding any other provisions of this section, an annual 2147
assessment on each hospital licensed in the state is imposed on 2148
each non-Medicare hospital inpatient day as defined below at a 2149
rate that is determined by dividing the sum prescribed in this 2150
subparagraph (i), plus the nonfederal share necessary to maximize 2151
the Disproportionate Share Hospital (DSH) and Medicare Upper 2152
Payment Limits (UPL) Program payments and hospital access payments 2153
and such other supplemental payments as may be developed pursuant 2154
to Section 43-13-117(A)(18), by the total number of non-Medicare 2155
hospital inpatient days as defined below for all licensed 2156
Mississippi hospitals, except as provided in paragraph (d) below. 2157
If the state-matching funds percentage for the Mississippi 2158
Medicaid program is sixteen percent (16%) or less, the sum used in 2159
the formula under this subparagraph (i) shall be Seventy-four 2160
Million Dollars ($74,000,000.00). If the state-matching funds 2161
percentage for the Mississippi Medicaid program is twenty-four 2162
percent (24%) or higher, the sum used in the formula under this 2163
subparagraph (i) shall be One Hundred Four Million Dollars 2164
($104,000,000.00). If the state-matching funds percentage for the 2165
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Mississippi Medicaid program is between sixteen percent (16%) and 2166
twenty-four percent (24%), the sum used in the formula under this 2167
subparagraph (i) shall be a pro rata amount determined as follows: 2168
the current state-matching funds percentage rate minus sixteen 2169
percent (16%) divided by eight percent (8%) multiplied by Thirty 2170
Million Dollars ($30,000,000.00) and add that amount to 2171
Seventy-four Million Dollars ($74,000,000.00). However, no 2172
assessment in a quarter under this subparagraph (i) may exceed the 2173
assessment in the previous quarter by more than Three Million 2174
Seven Hundred Fifty Thousand Dollars ($3,750,000.00) (which would 2175
be Fifteen Million Dollars ($15,000,000.00) on an annualized 2176
basis), unless such increase is to maximize federal funds that are 2177
available to reimburse hospitals for services provided under new 2178
programs for hospitals, for increased supplemental payment 2179
programs for hospitals or to assist with state matching funds as 2180
authorized by the Legislature. The division shall publish the 2181
state-matching funds percentage rate applicable to the Mississippi 2182
Medicaid program on the tenth day of the first month of each 2183
quarter and the assessment determined under the formula prescribed 2184
above shall be applicable in the quarter following any adjustment 2185
in that state-matching funds percentage rate. The division shall 2186
notify each hospital licensed in the state as to any projected 2187
increases or decreases in the assessment determined under this 2188
subparagraph (i). However, if the Centers for Medicare and 2189
Medicaid Services (CMS) does not approve the provision in Section 2190
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43-13-117(39) requiring the division to reimburse crossover claims 2191
for inpatient hospital services and crossover claims covered under 2192
Medicare Part B for dually eligible beneficiaries in the same 2193
manner that was in effect on January 1, 2008, the sum that 2194
otherwise would have been used in the formula under this 2195
subparagraph (i) shall be reduced by Seven Million Dollars 2196
($7,000,000.00). 2197
(ii) In addition to the assessment provided under 2198
subparagraph (i), an additional annual assessment on each hospital 2199
licensed in the state is imposed on each non-Medicare hospital 2200
inpatient day as defined below at a rate that is determined by 2201
dividing twenty-five percent (25%) of any provider reductions in 2202
the Medicaid program as authorized in Section 43-13-117(F) for 2203
that fiscal year up to the following maximum amount, plus the 2204
nonfederal share necessary to maximize the Disproportionate Share 2205
Hospital (DSH) and inpatient Medicare Upper Payment Limits (UPL) 2206
Program payments and inpatient hospital access payments, by the 2207
total number of non-Medicare hospital inpatient days as defined 2208
below for all licensed Mississippi hospitals: in fiscal year 2209
2010, the maximum amount shall be Twenty-four Million Dollars 2210
($24,000,000.00); in fiscal year 2011, the maximum amount shall be 2211
Thirty-two Million Dollars ($32,000,000.00); and in fiscal year 2212
2012 and thereafter, the maximum amount shall be Forty Million 2213
Dollars ($40,000,000.00). Any such deficit in the Medicaid 2214
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program shall be reviewed by the PEER Committee as provided in 2215
Section 43-13-117(F). 2216
(iii) In addition to the assessments provided in 2217
subparagraphs (i) and (ii), an additional annual assessment on 2218
each hospital licensed in the state is imposed pursuant to the 2219
provisions of Section 43-13-117(F) if the cost-containment 2220
measures described therein have been implemented and there are 2221
insufficient funds in the Health Care Trust Fund to reconcile any 2222
remaining deficit in any fiscal year. If the Governor institutes 2223
any other additional cost-containment measures on any program or 2224
programs authorized under the Medicaid program pursuant to Section 2225
43-13-117(F), hospitals shall be responsible for twenty-five 2226
percent (25%) of any such additional imposed provider cuts, which 2227
shall be in the form of an additional assessment not to exceed the 2228
twenty-five percent (25%) of provider expenditure reductions. 2229
Such additional assessment shall be imposed on each non-Medicare 2230
hospital inpatient day in the same manner as assessments are 2231
imposed under subparagraphs (i) and (ii). 2232
(b) Definitions. 2233
(i) [Deleted] 2234
(ii) For purposes of this subsection (4): 2235
1. "Non-Medicare hospital inpatient day" 2236
means total hospital inpatient days including subcomponent days 2237
less Medicare inpatient days including subcomponent days from the 2238
hospital's most recent Medicare cost report for the second 2239
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calendar year preceding the beginning of the state fiscal year, on 2240
file with CMS per the CMS HCRIS database, or cost report submitted 2241
to the Division if the HCRIS database is not available to the 2242
division, as of June 1 of each year. 2243
a. Total hospital inpatient days shall 2244
be the sum of Worksheet S-3, Part 1, column 8 row 14, column 8 row 2245
16, and column 8 row 17, excluding column 8 rows 5 and 6. 2246
b. Hospital Medicare inpatient days 2247
shall be the sum of Worksheet S-3, Part 1, column 6 row 14, column 2248
6 row 16.00, and column 6 row 17, excluding column 6 rows 5 and 6. 2249
c. Inpatient days shall not include 2250
residential treatment or long-term care days. 2251
2. "Subcomponent inpatient day" means the 2252
number of days of care charged to a beneficiary for inpatient 2253
hospital rehabilitation and psychiatric care services in units of 2254
full days. A day begins at midnight and ends twenty-four (24) 2255
hours later. A part of a day, including the day of admission and 2256
day on which a patient returns from leave of absence, counts as a 2257
full day. However, the day of discharge, death, or a day on which 2258
a patient begins a leave of absence is not counted as a day unless 2259
discharge or death occur on the day of admission. If admission 2260
and discharge or death occur on the same day, the day is 2261
considered a day of admission and counts as one (1) subcomponent 2262
inpatient day. 2263
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(c) The assessment provided in this subsection is 2264
intended to satisfy and not be in addition to the assessment and 2265
intergovernmental transfers provided in Section 43-13-117(A)(18). 2266
Nothing in this section shall be construed to authorize any state 2267
agency, division or department, or county, municipality or other 2268
local governmental unit to license for revenue, levy or impose any 2269
other tax, fee or assessment upon hospitals in this state not 2270
authorized by a specific statute. 2271
(d) Hospitals operated by the United States Department 2272
of Veterans Affairs and state-operated facilities that provide 2273
only inpatient and outpatient psychiatric services shall not be 2274
subject to the hospital assessment provided in this subsection. 2275
(e) Multihospital systems, closure, merger, change of 2276
ownership and new hospitals. 2277
(i) If a hospital conducts, operates or maintains 2278
more than one (1) hospital licensed by the State Department of 2279
Health, the provider shall pay the hospital assessment for each 2280
hospital separately. 2281
(ii) Notwithstanding any other provision in this 2282
section, if a hospital subject to this assessment operates or 2283
conducts business only for a portion of a fiscal year, the 2284
assessment for the state fiscal year shall be adjusted by 2285
multiplying the assessment by a fraction, the numerator of which 2286
is the number of days in the year during which the hospital 2287
operates, and the denominator of which is three hundred sixty-five 2288
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(365). Immediately upon ceasing to operate, the hospital shall 2289
pay the assessment for the year as so adjusted (to the extent not 2290
previously paid). 2291
(iii) The division shall determine the tax for new 2292
hospitals and hospitals that undergo a change of ownership in 2293
accordance with this section, using the best available 2294
information, as determined by the division. 2295
(f) Applicability. 2296
The hospital assessment imposed by this subsection shall not 2297
take effect and/or shall cease to be imposed if: 2298
(i) The assessment is determined to be an 2299
impermissible tax under Title XIX of the Social Security Act; or 2300
(ii) CMS revokes its approval of the division's 2301
2009 Medicaid State Plan Amendment for the methodology for DSH 2302
payments to hospitals under Section 43-13-117(A)(18). 2303
(5) Each health care facility that is subject to the 2304
provisions of this section shall keep and preserve such suitable 2305
books and records as may be necessary to determine the amount of 2306
assessment for which it is liable under this section. The books 2307
and records shall be kept and preserved for a period of not less 2308
than five (5) years, during which time those books and records 2309
shall be open for examination during business hours by the 2310
division, the Department of Revenue, the Office of the Attorney 2311
General and the State Department of Health. 2312
(6) [Deleted] 2313
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(7) All assessments collected under this section shall be 2314
deposited in the Medical Care Fund created by Section 43-13-143. 2315
(8) The assessment levied under this section shall be in 2316
addition to any other assessments, taxes or fees levied by law, 2317
and the assessment shall constitute a debt due the State of 2318
Mississippi from the time the assessment is due until it is paid. 2319
(9) (a) If a health care facility that is liable for 2320
payment of an assessment levied by the division does not pay the 2321
assessment when it is due, the division shall give written notice 2322
to the health care facility demanding payment of the assessment 2323
within ten (10) days from the date of delivery of the notice. If 2324
the health care facility fails or refuses to pay the assessment 2325
after receiving the notice and demand from the division, the 2326
division shall withhold from any Medicaid reimbursement payments 2327
that are due to the health care facility the amount of the unpaid 2328
assessment and a penalty of ten percent (10%) of the amount of the 2329
assessment, plus the legal rate of interest until the assessment 2330
is paid in full. If the health care facility does not participate 2331
in the Medicaid program, the division shall turn over to the 2332
Office of the Attorney General the collection of the unpaid 2333
assessment by civil action. In any such civil action, the Office 2334
of the Attorney General shall collect the amount of the unpaid 2335
assessment and a penalty of ten percent (10%) of the amount of the 2336
assessment, plus the legal rate of interest until the assessment 2337
is paid in full. 2338
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(b) As an additional or alternative method for 2339
collecting unpaid assessments levied by the division, if a health 2340
care facility fails or refuses to pay the assessment after 2341
receiving notice and demand from the division, the division may 2342
file a notice of a tax lien with the chancery clerk of the county 2343
in which the health care facility is located, for the amount of 2344
the unpaid assessment and a penalty of ten percent (10%) of the 2345
amount of the assessment, plus the legal rate of interest until 2346
the assessment is paid in full. Immediately upon receipt of 2347
notice of the tax lien for the assessment, the chancery clerk 2348
shall forward the notice to the circuit clerk who shall enter the 2349
notice of the tax lien as a judgment upon the judgment roll and 2350
show in the appropriate columns the name of the health care 2351
facility as judgment debtor, the name of the division as judgment 2352
creditor, the amount of the unpaid assessment, and the date and 2353
time of enrollment. The judgment shall be valid as against 2354
mortgagees, pledgees, entrusters, purchasers, judgment creditors 2355
and other persons from the time of filing with the clerk. The 2356
amount of the judgment shall be a debt due the State of 2357
Mississippi and remain a lien upon the tangible property of the 2358
health care facility until the judgment is satisfied. The 2359
judgment shall be the equivalent of any enrolled judgment of a 2360
court of record and shall serve as authority for the issuance of 2361
writs of execution, writs of attachment or other remedial writs. 2362
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(10) (a) To further the provisions of Section 2363
43-13-117(A)(18), the Division of Medicaid shall submit to the 2364
Centers for Medicare and Medicaid Services (CMS) any documents 2365
regarding the hospital assessment established under subsection (4) 2366
of this section. In addition to defining the assessment 2367
established in subsection (4) of this section if necessary, the 2368
documents shall describe any supplement payment programs and/or 2369
payment methodologies as authorized in Section 43-13-117(A)(18) if 2370
necessary. 2371
(b) All hospitals satisfying the minimum federal DSH 2372
eligibility requirements (Section 1923(d) of the Social Security 2373
Act) may, subject to OBRA 1993 payment limitations, receive a DSH 2374
payment. This DSH payment shall expend the balance of the federal 2375
DSH allotment and associated state share not utilized in DSH 2376
payments to state-owned institutions for treatment of mental 2377
diseases. The payment to each hospital shall be calculated by 2378
applying a uniform percentage to the uninsured costs of each 2379
eligible hospital, excluding state-owned institutions for 2380
treatment of mental diseases; however, that percentage for a 2381
state-owned teaching hospital located in Hinds County shall be 2382
multiplied by a factor of two (2). 2383
(11) The division shall implement DSH and supplemental 2384
payment calculation methodologies that result in the maximization 2385
of available federal funds. 2386
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(12) The DSH payments shall be paid on or before December 2387
31, March 31, and June 30 of each fiscal year, in increments of 2388
one-third (1/3) of the total calculated DSH amounts. Supplemental 2389
payments developed pursuant to Section 43-13-117(A)(18) shall be 2390
paid monthly. 2391
(13) Payment. 2392
(a) The hospital assessment as described in subsection 2393
(4) for the nonfederal share necessary to maximize the Medicare 2394
Upper Payments Limits (UPL) Program payments and hospital access 2395
payments and such other supplemental payments as may be developed 2396
pursuant to Section 43-3-117(A)(18) shall be assessed and 2397
collected monthly no later than the fifteenth calendar day of each 2398
month. 2399
(b) The hospital assessment as described in subsection 2400
(4) for the nonfederal share necessary to maximize the 2401
Disproportionate Share Hospital (DSH) payments shall be assessed 2402
and collected on December 15, March 15 and June 15. 2403
(c) The annual hospital assessment and any additional 2404
hospital assessment as described in subsection (4) shall be 2405
assessed and collected on September 15 and on the 15th of each 2406
month from December through June. 2407
(14) If for any reason any part of the plan for annual DSH 2408
and supplemental payment programs to hospitals provided under 2409
subsection (10) of this section and/or developed pursuant to 2410
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Section 43-13-117(A)(18) is not approved by CMS, the remainder of 2411
the plan shall remain in full force and effect. 2412
(15) Nothing in this section shall prevent the Division of 2413
Medicaid from facilitating participation in Medicaid supplemental 2414
hospital payment programs by a hospital located in a county 2415
contiguous to the State of Mississippi that is also authorized by 2416
federal law to submit intergovernmental transfers (IGTs) to the 2417
State of Mississippi to fund the state share of the hospital's 2418
supplemental and/or MHAP payments. 2419
(16) This section shall stand repealed on July 1, 2028. 2420
SECTION 7. Section 43-13-107, Mississippi Code of 1972, is 2421
amended as follows: 2422
43-13-107. (1) The Division of Medicaid is created in the 2423
Office of the Governor and established to administer this article 2424
and perform such other duties as are prescribed by law. 2425
(2) (a) The Governor shall appoint a full-time executive 2426
director, with the advice and consent of the Senate, who shall be 2427
either (i) a physician with administrative experience in a medical 2428
care or health program, or (ii) a person holding a graduate degree 2429
in medical care administration, public health, hospital 2430
administration, or the equivalent, or (iii) a person holding a 2431
bachelor's degree with at least three (3) years' experience in 2432
management-level administration of, or policy development for, 2433
Medicaid programs. Provided, however, no one who has been a 2434
member of the Mississippi Legislature during the previous three 2435
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(3) years may be executive director. The executive director shall 2436
be the official secretary and legal custodian of the records of 2437
the division; shall be the agent of the division for the purpose 2438
of receiving all service of process, summons and notices directed 2439
to the division; shall perform such other duties as the Governor 2440
may prescribe from time to time; and shall perform all other 2441
duties that are now or may be imposed upon him or her by law. 2442
(b) The executive director shall serve at the will and 2443
pleasure of the Governor. 2444
(c) The executive director shall, before entering upon 2445
the discharge of the duties of the office, take and subscribe to 2446
the oath of office prescribed by the Mississippi Constitution and 2447
shall file the same in the Office of the Secretary of State, and 2448
shall execute a bond in some surety company authorized to do 2449
business in the state in the penal sum of One Hundred Thousand 2450
Dollars ($100,000.00), conditioned for the faithful and impartial 2451
discharge of the duties of the office. The premium on the bond 2452
shall be paid as provided by law out of funds appropriated to the 2453
Division of Medicaid for contractual services. 2454
(d) The executive director, with the approval of the 2455
Governor and subject to the rules and regulations of the State 2456
Personnel Board, shall employ such professional, administrative, 2457
stenographic, secretarial, clerical and technical assistance as 2458
may be necessary to perform the duties required in administering 2459
this article and fix the compensation for those persons, all in 2460
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accordance with a state merit system meeting federal requirements. 2461
When the salary of the executive director is not set by law, that 2462
salary shall be set by the State Personnel Board. No employees of 2463
the Division of Medicaid shall be considered to be staff members 2464
of the immediate Office of the Governor; however, Section 2465
25-9-107(c)(xv) shall apply to the executive director and other 2466
administrative heads of the division. 2467
(3) (a) * * * There is established a Medicaid Advisory 2468
Committee and Beneficiary Advisory Committee in accordance with 2469
federal law. The Medicaid Advisory Committee shall consist of no 2470
more than twenty (20) members. All members of the Medical Care 2471
Advisory Committee serving on January 1, 2026, shall be selected 2472
to serve on the Medicaid Advisory Committee, and such members 2473
shall serve until July 1, 2029. Such members shall not be 2474
reappointed for immediately successive and consecutive terms. If 2475
any such member resigns, then the division shall replace the 2476
member for the remainder of the term. Other members of the 2477
Medicaid Advisory Committee and Beneficiary Advisory Council shall 2478
be selected by the division consistent with federal regulations. 2479
A member's terms shall not be followed immediately by a 2480
consecutive term for the same member, on a rotating and continuous 2481
basis. 2482
* * * 2483
( * * *b) The executive director shall submit to the 2484
advisory committee all amendments, modifications and changes to 2485
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the state plan for the operation of the Medicaid program, for 2486
review by the advisory committee before the amendments, 2487
modifications or changes may be implemented by the division. 2488
( * * *c) The advisory committee, among its duties and 2489
responsibilities, shall: 2490
(i) Advise the division with respect to 2491
amendments, modifications and changes to the state plan for the 2492
operation of the Medicaid program; 2493
(ii) Advise the division with respect to issues 2494
concerning receipt and disbursement of funds and eligibility for 2495
Medicaid; 2496
(iii) Advise the division with respect to 2497
determining the quantity, quality and extent of medical care 2498
provided under this article; 2499
(iv) Communicate the views of the medical care 2500
professions to the division and communicate the views of the 2501
division to the medical care professions; 2502
(v) Gather information on reasons that medical 2503
care providers do not participate in the Medicaid program and 2504
changes that could be made in the program to encourage more 2505
providers to participate in the Medicaid program, and advise the 2506
division with respect to encouraging physicians and other medical 2507
care providers to participate in the Medicaid program; 2508
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(vi) Provide a written report on or before 2509
November 30 of each year to the Governor, Lieutenant Governor and 2510
Speaker of the House of Representatives. 2511
(4) (a) There is established a Drug Use Review Board, which 2512
shall be the board that is required by federal law to: 2513
(i) Review and initiate retrospective drug use, 2514
review including ongoing periodic examination of claims data and 2515
other records in order to identify patterns of fraud, abuse, gross 2516
overuse, or inappropriate or medically unnecessary care, among 2517
physicians, pharmacists and individuals receiving Medicaid 2518
benefits or associated with specific drugs or groups of drugs. 2519
(ii) Review and initiate ongoing interventions for 2520
physicians and pharmacists, targeted toward therapy problems or 2521
individuals identified in the course of retrospective drug use 2522
reviews. 2523
(iii) On an ongoing basis, assess data on drug use 2524
against explicit predetermined standards using the compendia and 2525
literature set forth in federal law and regulations. 2526
(b) The board shall consist of not less than twelve 2527
(12) members appointed by the Governor, or his designee. 2528
(c) The board shall meet at least quarterly, and board 2529
members shall be furnished written notice of the meetings at least 2530
ten (10) days before the date of the meeting. 2531
(d) The board meetings shall be open to the public, 2532
members of the press, legislators and consumers. Additionally, 2533
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all documents provided to board members shall be available to 2534
members of the Legislature in the same manner, and shall be made 2535
available to others for a reasonable fee for copying. However, 2536
patient confidentiality and provider confidentiality shall be 2537
protected by blinding patient names and provider names with 2538
numerical or other anonymous identifiers. The board meetings 2539
shall be subject to the Open Meetings Act (Sections 25-41-1 2540
through 25-41-17). Board meetings conducted in violation of this 2541
section shall be deemed unlawful. 2542
(5) (a) There is established a Pharmacy and Therapeutics 2543
Committee, which shall be appointed by the Governor, or his 2544
designee. 2545
(b) The committee shall meet as often as needed to 2546
fulfill its responsibilities and obligations as set forth in this 2547
section, and committee members shall be furnished written notice 2548
of the meetings at least ten (10) days before the date of the 2549
meeting. 2550
(c) The committee meetings shall be open to the public, 2551
members of the press, legislators and consumers. Additionally, 2552
all documents provided to committee members shall be available to 2553
members of the Legislature in the same manner, and shall be made 2554
available to others for a reasonable fee for copying. However, 2555
patient confidentiality and provider confidentiality shall be 2556
protected by blinding patient names and provider names with 2557
numerical or other anonymous identifiers. The committee meetings 2558
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shall be subject to the Open Meetings Act (Sections 25-41-1 2559
through 25-41-17). Committee meetings conducted in violation of 2560
this section shall be deemed unlawful. 2561
(d) After a thirty-day public notice, the executive 2562
director, or his or her designee, shall present the division's 2563
recommendation regarding prior approval for a therapeutic class of 2564
drugs to the committee. However, in circumstances where the 2565
division deems it necessary for the health and safety of Medicaid 2566
beneficiaries, the division may present to the committee its 2567
recommendations regarding a particular drug without a thirty-day 2568
public notice. In making that presentation, the division shall 2569
state to the committee the circumstances that precipitate the need 2570
for the committee to review the status of a particular drug 2571
without a thirty-day public notice. The committee may determine 2572
whether or not to review the particular drug under the 2573
circumstances stated by the division without a thirty-day public 2574
notice. If the committee determines to review the status of the 2575
particular drug, it shall make its recommendations to the 2576
division, after which the division shall file those 2577
recommendations for a thirty-day public comment under Section 2578
25-43-7(1). 2579
(e) Upon reviewing the information and recommendations, 2580
the committee shall forward a written recommendation approved by a 2581
majority of the committee to the executive director, or his or her 2582
designee. The decisions of the committee regarding any 2583
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limitations to be imposed on any drug or its use for a specified 2584
indication shall be based on sound clinical evidence found in 2585
labeling, drug compendia, and peer-reviewed clinical literature 2586
pertaining to use of the drug in the relevant population. 2587
(f) Upon reviewing and considering all recommendations 2588
including recommendations of the committee, comments, and data, 2589
the executive director shall make a final determination whether to 2590
require prior approval of a therapeutic class of drugs, or modify 2591
existing prior approval requirements for a therapeutic class of 2592
drugs. 2593
(g) At least thirty (30) days before the executive 2594
director implements new or amended prior authorization decisions, 2595
written notice of the executive director's decision shall be 2596
provided to all prescribing Medicaid providers, all Medicaid 2597
enrolled pharmacies, and any other party who has requested the 2598
notification. However, notice given under Section 25-43-7(1) will 2599
substitute for and meet the requirement for notice under this 2600
subsection. 2601
(h) Members of the committee shall dispose of matters 2602
before the committee in an unbiased and professional manner. If a 2603
matter being considered by the committee presents a real or 2604
apparent conflict of interest for any member of the committee, 2605
that member shall disclose the conflict in writing to the 2606
committee chair and recuse himself or herself from any discussions 2607
and/or actions on the matter. 2608
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SECTION 8. This act shall take effect and be in force from 2609
and after July 1, 2026. 2610