MISSISSIPPI LEGISLATURE
2021 Regular Session
To: Medicaid
By: Senator(s) Blackwell
AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, RELATING TO REIMBURSEMENT FOR CARE AND SERVICES UNDER THE MEDICAID PROGRAM, TO PROVIDE THAT MEDICAID IS AUTHORIZED TO INCLUDE PAYMENTS OF PART OR ALL OF COSTS FOR CERTAIN SERVICES AND CARE; TO DELETE CERTAIN PROVISIONS RELATING TO REIMBURSEMENT OF INPATIENT HOSPITAL SERVICES; TO DELETE CERTAIN PROVISIONS RELATING TO THE REIMBURSEMENT OF OUTPATIENT HOSPITAL SERVICES; TO PROVIDE FOR NURSING FACILITY REIMBURSEMENT FOR HOME LEAVE DAYS; TO DELETE CERTAIN PROVISIONS RELATING TO REIMBURSEMENT OF NURSING FACILITY SERVICES; TO PROVIDE FOR REIMBURSEMENT FOR FEES FOR PHYSICIAN SERVICES COVERED ONLY BY MEDICAID; TO DELETE THE PROVISION THAT REQUIRES THE DIVISION TO ALLOW PHYSICIAN-ADMINISTERED DRUGS TO BE BILLED AND REIMBURSED AS A MEDICAL CLAIM OR PHARMACY POINT-OF-SALE; TO PROVIDE THAT THE DIVISION SHALL MAKE PARTIAL PAYMENTS, AS DETERMINED BY THE DIVISION, TO INTERMEDIATE CARE FACILITY SERVICES; TO DEFINE CLINIC SERVICES AS IT RELATES TO THE REIMBURSEMENTS BY MEDICAID FOR THOSE SERVICES; TO PROVIDE THAT MEDICAID MAY ESTABLISH AN UPPER PAYMENT LIMITS PROGRAM FOR AMBULANCE TRANSPORTATION; TO DELETE THE PROVISIONS RELATING TO MEDICAID'S DEVELOPMENT OF AN ALTERNATIVE MODEL FOR DISTRIBUTION OF MEDICAL CLAIMS AND SUPPLEMENTAL PAYMENTS FOR SERVICES; TO DELETE THE CERTAIN PROVISIONS RELATING TO REIMBURSEMENT OF NURSE PRACTITIONER SERVICES; TO PROVIDE THAT THE REIMBURSEMENT OF PEDIATRIC SKILLED NURSING SERVICES, INPATIENT PSYCHIATRIST SERVICES AND NONEMERGENCY TRANSPORTATION SERVICES SHALL BE DETERMINED BY THE DIRECTOR OF MEDICAID; TO DELETE THE PROVISION THAT REQUIRES MEDICAID TO REIMBURSE CROSSOVER CLAIMS FOR INPATIENT HOSPITAL SERVICES AND THOSE UNDER MEDICARE PART B; TO DELETE CERTAIN PROVISIONS RELATING TO THE REIMBURSEMENT OF PHYSICIAN ASSISTANT SERVICES; TO PROVIDE THAT THE DIVISION MAY ESTABLISH COPAYMENTS AND COINSURANCE FOR ANY MEDICAID SERVICES; TO ALLOW THE DIVISION TO USE ENHANCED REIMBURSEMENTS AND UPPER PAYMENT LIMIT PROGRAMS FOR ITS REIMBURSEMENT PROGRAM; TO DELETE THE PROVISION THAT REQUIRES MEDICAID TO REDUCE THE RATE OF REIMBURSEMENT TO CERTAIN PROVIDERS FOR SERVICES BY 5% OF THE ALLOWED AMOUNT FOR THAT SERVICE; TO REQUIRE PROVIDERS TO MAINTAIN RECORDS AS PRESCRIBED BY THE DIVISION AND IN ACCORDANCE WITH FEDERAL LAW; TO REQUIRE THE DIVISION TO REIMBURSE OBSTETRICIANS AND GYNECOLOGISTS FOR CERTAIN PRIMARY CARE SERVICES AT 100% OF THE MEDICARE RATE; TO DELETE CERTAIN ENROLLMENT LIMITATIONS AND PROVISIONS RELATING TO MANAGED CARE PROGRAMS; TO ALLOW THE DIVISION OF MEDICAID TO APPROVE THE USE OF ALTERNATIVE PAYMENT MODELS FOR REIMBURSEMENT RATES; TO CLARIFY MEDICAID ELIGIBILITY FOR ENROLLMENT IN MANAGED CARE PROGRAMS; TO DELETE THE PROVISIONS THAT PROVIDE FOR THE COMMISSION ON EXPANDING MEDICAID MANAGED CARE; TO REQUIRE CONTRACTORS RECEIVING PAYMENTS UNDER A MANAGED CARE DELIVERY SYSTEM TO DISCLOSE TO THE CHAIRMEN OF THE SENATE AND HOUSE MEDICAID COMMITTEES THE ADMINISTRATIVE EXPENSES FOR THE PRIOR YEAR, AND THE NUMBER OF EMPLOYEES IN MISSISSIPPI THAT ARE DEDICATED TO MEDICAID AND CHIP LINES OF BUSINESS AS OF JUNE 30 OF EACH YEAR; TO PROVIDE FOR REVIEWS OF THE MANAGED CARE PROGRAMS BY THE STATE AUDITOR; TO REQUIRE THAT ALL MANAGED CARE CONTRACTORS SHALL DEVELOP AND IMPLEMENT A UNIFORM CREDENTIALING PROCESS BY WHICH ALL PROVIDERS ARE CREDENTIALED BY JULY 1, 2022; TO DELETE THE PROVISION THAT THERE SHALL NOT BE CUTS TO INPATIENT AND OUTPATIENT HOSPITAL PAYMENTS; TO REQUIRE CERTAIN REPORTS RELATING TO EXTENDING MEDICAID COVERAGE FOR POSTPARTUM CARE; TO EXTEND THE AUTOMATIC REPEALER; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. Section 43-13-117, Mississippi Code of 1972, is amended as follows:
43-13-117. (A) Medicaid * * * is authorized * * * to include
payment of part or all of the costs, at the discretion of the division, with
approval of the Governor and the Centers for Medicare and Medicaid Services, of
the following types of care and services rendered to eligible applicants who
have been determined to be eligible for that care and services, within the
limits of state appropriations and federal matching funds:
(1) Inpatient hospital services.
* * *
(2) Outpatient hospital services.
* * *
(3) Laboratory and x-ray services.
(4) Nursing facility services.
(a) The division
shall make * * *
partial payment, as determined by the division, to nursing
facilities for each day, not exceeding * * * thirty-two (32)
days per year, that a patient is absent from the facility on home leave.
Payment may be made for the following home leave days in addition to the * * * thirty-two-day limitation:
Christmas, the day before Christmas, the day after Christmas, Thanksgiving, the
day before Thanksgiving and the day after Thanksgiving.
* * *
( * * *b) The division shall develop and
implement, not later than January 1, 2001, a case-mix payment add-on determined
by time studies and other valid statistical data that will reimburse a nursing
facility for the additional cost of caring for a resident who has a diagnosis
of Alzheimer's or other related dementia and exhibits symptoms that require
special care. Any such case-mix add-on payment shall be supported by a
determination of additional cost. The division shall also develop and
implement as part of the fair rental reimbursement system for nursing facility
beds, an Alzheimer's resident bed depreciation enhanced reimbursement system
that will provide an incentive to encourage nursing facilities to convert or
construct beds for residents with Alzheimer's or other related dementia.
( * * *c) The division shall develop and
implement an assessment process for long-term care services. The division may
provide the assessment and related functions directly or through contract with
the area agencies on aging.
The division shall apply for necessary federal waivers to assure that additional services providing alternatives to nursing facility care are made available to applicants for nursing facility care.
(5) Periodic screening and diagnostic services for individuals under age twenty-one (21) years as are needed to identify physical and mental defects and to provide health care treatment and other measures designed to correct or ameliorate defects and physical and mental illness and conditions discovered by the screening services, regardless of whether these services are included in the state plan. The division may include in its periodic screening and diagnostic program those discretionary services authorized under the federal regulations adopted to implement Title XIX of the federal Social Security Act, as amended. The division, in obtaining physical therapy services, occupational therapy services, and services for individuals with speech, hearing and language disorders, may enter into a cooperative agreement with the State Department of Education for the provision of those services to handicapped students by public school districts using state funds that are provided from the appropriation to the Department of Education to obtain federal matching funds through the division. The division, in obtaining medical and mental health assessments, treatment, care and services for children who are in, or at risk of being put in, the custody of the Mississippi Department of Human Services may enter into a cooperative agreement with the Mississippi Department of Human Services for the provision of those services using state funds that are provided from the appropriation to the Department of Human Services to obtain federal matching funds through the division.
(6) Physician * * * services. * * * Effective
January 1, 2021, all fees for physician services that are covered only by
Medicaid shall not exceed ninety percent (90%) of the rate established on
January 1, * * *
2020, and as may be adjusted each July thereafter, under Medicare. The
division may provide for a reimbursement rate for physician's services of up to
one hundred percent (100%) of the rate established under Medicare for
physician's services that are provided after the normal working hours of the
physician, as determined in accordance with regulations of the division. The
division may reimburse eligible providers, as determined by the * * * division,
for certain primary care services * * * at one hundred percent
(100%) of the rate established under Medicare. * * * The division * * * may reimburse obstetricians and
gynecologists for certain primary care services as defined by the division at
one hundred percent (100%) of the rate established under Medicare.
(7) (a) Home health services for eligible persons, not to exceed in cost the prevailing cost of nursing facility services. All home health visits must be precertified as required by the division.
(b) [Repealed]
(8) Emergency medical transportation services as determined by the division.
(9) Prescription drugs
and other covered drugs and services as * * * determined by the division.
The division shall establish a mandatory preferred drug list. Drugs not on the mandatory preferred drug list shall be made available by utilizing prior authorization procedures established by the division.
The division may seek to establish relationships with other states in order to lower acquisition costs of prescription drugs to include single-source and innovator multiple-source drugs or generic drugs. In addition, if allowed by federal law or regulation, the division may seek to establish relationships with and negotiate with other countries to facilitate the acquisition of prescription drugs to include single-source and innovator multiple-source drugs or generic drugs, if that will lower the acquisition costs of those prescription drugs.
The division may allow for a combination of prescriptions for single-source and innovator multiple-source drugs and generic drugs to meet the needs of the beneficiaries.
The executive director may approve specific maintenance drugs for beneficiaries with certain medical conditions, which may be prescribed and dispensed in three-month supply increments.
Drugs prescribed for a resident of a psychiatric residential treatment facility must be provided in true unit doses when available. The division may require that drugs not covered by Medicare Part D for a resident of a long-term care facility be provided in true unit doses when available. Those drugs that were originally billed to the division but are not used by a resident in any of those facilities shall be returned to the billing pharmacy for credit to the division, in accordance with the guidelines of the State Board of Pharmacy and any requirements of federal law and regulation. Drugs shall be dispensed to a recipient and only one (1) dispensing fee per month may be charged. The division shall develop a methodology for reimbursing for restocked drugs, which shall include a restock fee as determined by the division not exceeding Seven Dollars and Eighty-two Cents ($7.82).
Except for those specific maintenance drugs approved by the executive director, the division shall not reimburse for any portion of a prescription that exceeds a thirty-one-day supply of the drug based on the daily dosage.
The division is authorized
to develop and implement a program of payment for additional pharmacist
services as * * *
determined by the division.
All claims for drugs for dually eligible Medicare/Medicaid beneficiaries that are paid for by Medicare must be submitted to Medicare for payment before they may be processed by the division's online payment system.
The division shall develop a pharmacy policy in which drugs in tamper-resistant packaging that are prescribed for a resident of a nursing facility but are not dispensed to the resident shall be returned to the pharmacy and not billed to Medicaid, in accordance with guidelines of the State Board of Pharmacy.
The division shall develop and implement a method or methods by which the division will provide on a regular basis to Medicaid providers who are authorized to prescribe drugs, information about the costs to the Medicaid program of single-source drugs and innovator multiple-source drugs, and information about other drugs that may be prescribed as alternatives to those single-source drugs and innovator multiple-source drugs and the costs to the Medicaid program of those alternative drugs.
Notwithstanding any law or regulation, information obtained or maintained by the division regarding the prescription drug program, including trade secrets and manufacturer or labeler pricing, is confidential and not subject to disclosure except to other state agencies.
The dispensing fee for each new or refill prescription, including nonlegend or over-the-counter drugs covered by the division, shall be not less than Three Dollars and Ninety-one Cents ($3.91), as determined by the division.
The division shall not reimburse for single-source or innovator multiple-source drugs if there are equally effective generic equivalents available and if the generic equivalents are the least expensive.
It is the intent of the Legislature that the pharmacists providers be reimbursed for the reasonable costs of filling and dispensing prescriptions for Medicaid beneficiaries.
The division may allow certain drugs, implantable drug system devices, and medical supplies, with limited distribution or limited access for beneficiaries and administered in an appropriate clinical setting, to be reimbursed as either a medical claim or pharmacy claim, as determined by the division.
* * *
It is the intent of the Legislature that the division and any managed care entity described in subsection (H) of this section encourage the use of Alpha-Hydroxyprogesterone Caproate (17P) to prevent recurrent preterm birth.
(10) Dental and orthodontic services to be determined by the division.
This dental services program under this paragraph shall be known as the "James Russell Dumas Medicaid Dental Services Program."
The Medical Care Advisory Committee, assisted by the Division of Medicaid, shall annually determine the effect of this incentive by evaluating the number of dentists who are Medicaid providers, the number who and the degree to which they are actively billing Medicaid, the geographic trends of where dentists are offering what types of Medicaid services and other statistics pertinent to the goals of this legislative intent. This data shall annually be presented to the Chair of the Senate Medicaid Committee and the Chair of the House Medicaid Committee.
The division shall include dental services as a necessary component of overall health services provided to children who are eligible for services.
(11) Eyeglasses for all Medicaid beneficiaries who have (a) had surgery on the eyeball or ocular muscle that results in a vision change for which eyeglasses or a change in eyeglasses is medically indicated within six (6) months of the surgery and is in accordance with policies established by the division, or (b) one (1) pair every five (5) years and in accordance with policies established by the division. In either instance, the eyeglasses must be prescribed by a physician skilled in diseases of the eye or an optometrist, whichever the beneficiary may select.
(12) Intermediate care facility services.
(a) The division
shall make * * *
partial payment, as determined by the division, to all
intermediate care facilities for individuals with intellectual disabilities for
each day, not exceeding sixty-three (63) days per year, that a patient is
absent from the facility on home leave. Payment may be made for the following
home leave days in addition to the sixty-three-day limitation: Christmas, the
day before Christmas, the day after Christmas, Thanksgiving, the day before
Thanksgiving and the day after Thanksgiving.
(b) All state-owned intermediate care facilities for individuals with intellectual disabilities shall be reimbursed on a full reasonable cost basis.
* * *
(13) Family planning services, including drugs, supplies and devices, when those services are under the supervision of a physician or nurse practitioner.
(14) Clinic services * * *, which means preventive, diagnostic, therapeutic,
rehabilitative or palliative services that are furnished by a facility that is
not part of a hospital but is organized and operated to provide medical care to
outpatients.
(15) Home- and community-based services for the elderly and disabled, as provided under Title XIX of the federal Social Security Act, as amended, under waivers, subject to the availability of funds specifically appropriated for that purpose by the Legislature.
* * *
(16) Mental health services. Certain services provided by a psychiatrist shall be reimbursed at up to one hundred percent (100%) of the Medicare rate. Approved therapeutic and case management services (a) provided by an approved regional mental health/intellectual disability center established under Sections 41-19-31 through 41-19-39, or by another community mental health service provider meeting the requirements of the Department of Mental Health to be an approved mental health/intellectual disability center if determined necessary by the Department of Mental Health, using state funds that are provided in the appropriation to the division to match federal funds, or (b) provided by a facility that is certified by the State Department of Mental Health to provide therapeutic and case management services, to be reimbursed on a fee for service basis, or (c) provided in the community by a facility or program operated by the Department of Mental Health. Any such services provided by a facility described in subparagraph (b) must have the prior approval of the division to be reimbursable under this section.
(17) Durable medical equipment services and medical supplies. Precertification of durable medical equipment and medical supplies must be obtained as required by the division. The Division of Medicaid may require durable medical equipment providers to obtain a surety bond in the amount and to the specifications as established by the Balanced Budget Act of 1997.
(18) (a) Notwithstanding any other provision of this section to the contrary, as provided in the Medicaid state plan amendment or amendments as defined in Section 43-13-145(10), the division shall make additional reimbursement to hospitals that serve a disproportionate share of low-income patients and that meet the federal requirements for those payments as provided in Section 1923 of the federal Social Security Act and any applicable regulations. It is the intent of the Legislature that the division shall draw down all available federal funds allotted to the state for disproportionate share hospitals. However, from and after January 1, 1999, public hospitals participating in the Medicaid disproportionate share program may be required to participate in an intergovernmental transfer program as provided in Section 1903 of the federal Social Security Act and any applicable regulations.
(b) The division
may establish a Medicare Upper Payment Limits Program, as defined in Section
1902(a)(30) of the federal Social Security Act and any applicable federal
regulations, for hospitals, * * * nursing facilities, * * * physicians employed or contracted by public hospitals, and
ambulance transportation. Upon successful implementation of a Medicare
Upper Payment Limits Program for physicians employed by public hospitals, the
division may develop a plan for implementing an Upper Payment Limits Program
for physicians employed by other classes of hospitals. The division shall
assess each hospital * * *, * * *
nursing facility, and ambulance transportation provider for the sole
purpose of financing the state portion of the Medicare Upper Payment Limits
Program. The hospital assessment shall be as provided in Section 43-13-145(4)(a) * * *, the nursing facility assessment, and
the ambulance transportation assessment, if established, shall be based on
Medicaid utilization or other appropriate method, as determined by the
division, consistent with federal regulations. The assessment will remain
in effect as long as the state participates in the Medicare Upper Payment
Limits Program. Public hospitals with physicians participating in the Medicare
Upper Payment Limits Program shall be required to participate in an intergovernmental
transfer program for the purpose of financing the state portion of the
physician UPL payments. As provided in the Medicaid state plan amendment or
amendments as defined in Section 43-13-145(10), the division shall make
additional reimbursement to hospitals and, if the program is established for
nursing facilities, shall make additional reimbursement to nursing facilities,
for the Medicare Upper Payment Limits, and, if the program is established for
physicians, shall make additional reimbursement for physicians, as defined in
Section 1902(a)(30) of the federal Social Security Act and any applicable
federal regulations. Notwithstanding any other provision of this article to
the contrary, effective upon implementation of the Mississippi Hospital Access
Program (MHAP) provided in subparagraph (c)(i) below, the hospital portion of
the inpatient Upper Payment Limits Program shall transition into and be
replaced by the MHAP program. However, the division is authorized to develop
and implement an alternative fee-for-service Upper Payment Limits model in
accordance with federal laws and regulations if necessary to preserve
supplemental funding. * * *
(c) (i) Not later than December l, 2015, the division shall, subject to approval by the Centers for Medicare and Medicaid Services (CMS), establish, implement and operate a Mississippi Hospital Access Program (MHAP) for the purpose of protecting patient access to hospital care through hospital inpatient reimbursement programs provided in this section designed to maintain total hospital reimbursement for inpatient services rendered by in-state hospitals and the out-of-state hospital that is authorized by federal law to submit intergovernmental transfers (IGTs) to the State of Mississippi and is classified as Level I trauma center located in a county contiguous to the state line at the maximum levels permissible under applicable federal statutes and regulations, at which time the current inpatient Medicare Upper Payment Limits (UPL) Program for hospital inpatient services shall transition to the MHAP.
(ii) Subject * * * to approval by the Centers for Medicare
and Medicaid Services (CMS) * * *, the MHAP shall provide
increased inpatient capitation (PMPM) payments to managed care entities
contracting with the division pursuant to subsection (H) of this section to
support availability of hospital services or such other payments permissible
under federal law necessary to accomplish the intent of this subsection.
(iii) The intent of this subparagraph (c) is that effective for all inpatient hospital Medicaid services during state fiscal year 2016, and so long as this provision shall remain in effect hereafter, the division shall to the fullest extent feasible replace the additional reimbursement for hospital inpatient services under the inpatient Medicare Upper Payment Limits (UPL) Program with additional reimbursement under the MHAP and other payment programs for inpatient and/or outpatient payments which may be developed under the authority of this paragraph.
(iv) The division shall assess each hospital as provided in Section 43-13-145(4)(a) for the purpose of financing the state portion of the MHAP, supplemental payments and such other purposes as specified in Section 43-13-145. The assessment will remain in effect as long as the MHAP and supplemental payments are in effect.
(19) (a) Perinatal risk management services. The division shall promulgate regulations to be effective from and after October 1, 1988, to establish a comprehensive perinatal system for risk assessment of all pregnant and infant Medicaid recipients and for management, education and follow-up for those who are determined to be at risk. Services to be performed include case management, nutrition assessment/counseling, psychosocial assessment/counseling and health education. The division shall contract with the State Department of Health to provide the services within this paragraph (Perinatal High Risk Management/Infant Services System (PHRM/ISS)). The State Department of Health as the agency for PHRM/ISS for the Division of Medicaid shall be reimbursed on a full reasonable cost basis.
(b) Early intervention system services. The division shall cooperate with the State Department of Health, acting as lead agency, in the development and implementation of a statewide system of delivery of early intervention services, under Part C of the Individuals with Disabilities Education Act (IDEA). The State Department of Health shall certify annually in writing to the executive director of the division the dollar amount of state early intervention funds available that will be utilized as a certified match for Medicaid matching funds. Those funds then shall be used to provide expanded targeted case management services for Medicaid eligible children with special needs who are eligible for the state's early intervention system. Qualifications for persons providing service coordination shall be determined by the State Department of Health and the Division of Medicaid.
(20) Home- and community-based services for physically disabled approved services as allowed by a waiver from the United States Department of Health and Human Services for home- and community-based services for physically disabled people using state funds that are provided from the appropriation to the State Department of Rehabilitation Services and used to match federal funds under a cooperative agreement between the division and the department, provided that funds for these services are specifically appropriated to the Department of Rehabilitation Services.
(21) Nurse
practitioner services. * * * The division may provide for a reimbursement rate for nurse
practitioner services of up to one hundred percent (100%) of the reimbursement
rate for comparable services rendered by a physician for nurse practitioner
services that are provided after the normal working hours of the nurse
practitioner, as determined in accordance with regulations of the division.
(22) Ambulatory services delivered in federally qualified health centers, rural health centers and clinics of the local health departments of the State Department of Health for individuals eligible for Medicaid under this article based on reasonable costs as determined by the division. Federally qualified health centers shall be reimbursed by the Medicaid prospective payment system as approved by the Centers for Medicare and Medicaid Services.
(23) Inpatient
psychiatric services as determined by the division. * * *
(24) [Deleted]
(25) [Deleted]
(26) Hospice care. As used in this paragraph, the term "hospice care" means a coordinated program of active professional medical attention within the home and outpatient and inpatient care that treats the terminally ill patient and family as a unit, employing a medically directed interdisciplinary team. The program provides relief of severe pain or other physical symptoms and supportive care to meet the special needs arising out of physical, psychological, spiritual, social and economic stresses that are experienced during the final stages of illness and during dying and bereavement and meets the Medicare requirements for participation as a hospice as provided in federal regulations.
(27) Group health plan premiums and cost-sharing if it is cost-effective as defined by the United States Secretary of Health and Human Services.
(28) Other health insurance premiums that are cost-effective as defined by the United States Secretary of Health and Human Services. Medicare eligible must have Medicare Part B before other insurance premiums can be paid.
(29) The Division of Medicaid may apply for a waiver from the United States Department of Health and Human Services for home- and community-based services for developmentally disabled people using state funds that are provided from the appropriation to the State Department of Mental Health and/or funds transferred to the department by a political subdivision or instrumentality of the state and used to match federal funds under a cooperative agreement between the division and the department, provided that funds for these services are specifically appropriated to the Department of Mental Health and/or transferred to the department by a political subdivision or instrumentality of the state.
(30) Pediatric skilled
nursing services * * * as
determined by the division.
(31) Targeted case management services for children with special needs, under waivers from the United States Department of Health and Human Services, using state funds that are provided from the appropriation to the Mississippi Department of Human Services and used to match federal funds under a cooperative agreement between the division and the department.
(32) Care and services provided in Christian Science Sanatoria listed and certified by the Commission for Accreditation of Christian Science Nursing Organizations/Facilities, Inc., rendered in connection with treatment by prayer or spiritual means to the extent that those services are subject to reimbursement under Section 1903 of the federal Social Security Act.
(33) Podiatrist services.
(34) Assisted living services as provided through home- and community-based services under Title XIX of the federal Social Security Act, as amended, subject to the availability of funds specifically appropriated for that purpose by the Legislature.
(35) Services and activities authorized in Sections 43-27-101 and 43-27-103, using state funds that are provided from the appropriation to the Mississippi Department of Human Services and used to match federal funds under a cooperative agreement between the division and the department.
(36) Nonemergency
transportation services for Medicaid-eligible persons * * * as
determined by the division. The PEER Committee shall conduct a performance
evaluation of the nonemergency transportation program to evaluate the
administration of the program and the providers of transportation services to
determine the most cost-effective ways of providing nonemergency transportation
services to the patients served under the program. The performance evaluation
shall be completed and provided to the members of the Senate Medicaid Committee
and the House Medicaid Committee not later than January 1, 2019, and every two
(2) years thereafter.
(37) [Deleted]
(38) Chiropractic services. A chiropractor's manual manipulation of the spine to correct a subluxation, if x-ray demonstrates that a subluxation exists and if the subluxation has resulted in a neuromusculoskeletal condition for which manipulation is appropriate treatment, and related spinal x-rays performed to document these conditions. Reimbursement for chiropractic services shall not exceed Seven Hundred Dollars ($700.00) per year per beneficiary.
(39) Dually eligible
Medicare/Medicaid beneficiaries. The division shall pay the Medicare
deductible and coinsurance amounts for services available under Medicare, as
determined by the division. * * *
(40) [Deleted]
(41) Services provided by the State Department of Rehabilitation Services for the care and rehabilitation of persons with spinal cord injuries or traumatic brain injuries, as allowed under waivers from the United States Department of Health and Human Services, using up to seventy-five percent (75%) of the funds that are appropriated to the Department of Rehabilitation Services from the Spinal Cord and Head Injury Trust Fund established under Section 37-33-261 and used to match federal funds under a cooperative agreement between the division and the department.
(42) [Deleted]
(43) The division shall provide reimbursement, according to a payment schedule developed by the division, for smoking cessation medications for pregnant women during their pregnancy and other Medicaid-eligible women who are of child-bearing age.
(44) Nursing facility services for the severely disabled.
(a) Severe disabilities include, but are not limited to, spinal cord injuries, closed-head injuries and ventilator-dependent patients.
(b) Those services must be provided in a long-term care nursing facility dedicated to the care and treatment of persons with severe disabilities.
(45) Physician
assistant services. * * *
The division may provide for a reimbursement rate for physician assistant
services of up to one hundred percent (100%) or the reimbursement rate for
comparable services rendered by a physician for physician assistant services
that are provided after the normal working hours of the physician assistant, as
determined in accordance with regulations of the division.
(46) The division shall make application to the federal Centers for Medicare and Medicaid Services (CMS) for a waiver to develop and provide services for children with serious emotional disturbances as defined in Section 43-14-1(1), which may include home- and community-based services, case management services or managed care services through mental health providers certified by the Department of Mental Health. The division may implement and provide services under this waivered program only if funds for these services are specifically appropriated for this purpose by the Legislature, or if funds are voluntarily provided by affected agencies.
(47) (a) The division may develop and implement disease management programs for individuals with high-cost chronic diseases and conditions, including the use of grants, waivers, demonstrations or other projects as necessary.
(b) Participation in any disease management program implemented under this paragraph (47) is optional with the individual. An individual must affirmatively elect to participate in the disease management program in order to participate, and may elect to discontinue participation in the program at any time.
(48) Pediatric long-term acute care hospital services.
(a) Pediatric long-term acute care hospital services means services provided to eligible persons under twenty-one (21) years of age by a freestanding Medicare-certified hospital that has an average length of inpatient stay greater than twenty-five (25) days and that is primarily engaged in providing chronic or long-term medical care to persons under twenty-one (21) years of age.
(b) The services under this paragraph (48) shall be reimbursed as a separate category of hospital services.
(49) The division * * * may establish copayments and/or
coinsurance for * * *
any Medicaid services for which copayments and/or coinsurance are
allowable under federal law or regulation.
(50) Services provided by the State Department of Rehabilitation Services for the care and rehabilitation of persons who are deaf and blind, as allowed under waivers from the United States Department of Health and Human Services to provide home- and community-based services using state funds that are provided from the appropriation to the State Department of Rehabilitation Services or if funds are voluntarily provided by another agency.
(51) Upon determination of Medicaid eligibility and in association with annual redetermination of Medicaid eligibility, beneficiaries shall be encouraged to undertake a physical examination that will establish a base-line level of health and identification of a usual and customary source of care (a medical home) to aid utilization of disease management tools. This physical examination and utilization of these disease management tools shall be consistent with current United States Preventive Services Task Force or other recognized authority recommendations.
For persons who are determined ineligible for Medicaid, the division will provide information and direction for accessing medical care and services in the area of their residence.
(52) Notwithstanding any provisions of this article, the division may pay enhanced reimbursement fees related to trauma care, as determined by the division in conjunction with the State Department of Health, using funds appropriated to the State Department of Health for trauma care and services and used to match federal funds under a cooperative agreement between the division and the State Department of Health. The division, in conjunction with the State Department of Health, may use grants, waivers, demonstrations, enhanced reimbursements, Upper Payment Limits Programs, or other projects as necessary in the development and implementation of this reimbursement program.
(53) Targeted case management services for high-cost beneficiaries may be developed by the division for all services under this section.
(54) [Deleted]
(55) Therapy services. The plan of care for therapy services may be developed to cover a period of treatment for up to six (6) months, but in no event shall the plan of care exceed a six-month period of treatment. The projected period of treatment must be indicated on the initial plan of care and must be updated with each subsequent revised plan of care. Based on medical necessity, the division shall approve certification periods for less than or up to six (6) months, but in no event shall the certification period exceed the period of treatment indicated on the plan of care. The appeal process for any reduction in therapy services shall be consistent with the appeal process in federal regulations.
(56) Prescribed pediatric extended care centers services for medically dependent or technologically dependent children with complex medical conditions that require continual care as prescribed by the child's attending physician, as determined by the division.
(57) No Medicaid benefit shall restrict coverage for medically appropriate treatment prescribed by a physician and agreed to by a fully informed individual, or if the individual lacks legal capacity to consent by a person who has legal authority to consent on his or her behalf, based on an individual's diagnosis with a terminal condition. As used in this paragraph (57), "terminal condition" means any aggressive malignancy, chronic end-stage cardiovascular or cerebral vascular disease, or any other disease, illness or condition which a physician diagnoses as terminal.
(58) Treatment services for persons with opioid dependency or other highly addictive substance use disorders. The division is authorized to reimburse eligible providers for treatment of opioid dependency and other highly addictive substance use disorders, as determined by the division. Treatment related to these conditions shall not count against any physician visit limit imposed under this section.
(59) The division shall allow beneficiaries between the ages of ten (10) and eighteen (18) years to receive vaccines through a pharmacy venue.
(B) * * *
[Deleted]
(C) The division may pay to those providers who participate in and accept patient referrals from the division's emergency room redirection program a percentage, as determined by the division, of savings achieved according to the performance measures and reduction of costs required of that program. Federally qualified health centers may participate in the emergency room redirection program, and the division may pay those centers a percentage of any savings to the Medicaid program achieved by the centers' accepting patient referrals through the program, as provided in this subsection (C).
(D) [Deleted]
(E) Notwithstanding any provision of this article, no new groups or categories of recipients and new types of care and services may be added without enabling legislation from the Mississippi Legislature, except that the division may authorize those changes without enabling legislation when the addition of recipients or services is ordered by a court of proper authority.
(F) The executive director shall keep the Governor advised on a timely basis of the funds available for expenditure and the projected expenditures. Notwithstanding any other provisions of this article, if current or projected expenditures of the division are reasonably anticipated to exceed the amount of funds appropriated to the division for any fiscal year, the Governor, after consultation with the executive director, shall take all appropriate measures to reduce costs, which may include, but are not limited to:
(1) Reducing or discontinuing any or all services that are deemed to be optional under Title XIX of the Social Security Act;
(2) Reducing reimbursement rates for any or all service types;
(3) Imposing additional assessments on health care providers; or
(4) Any additional cost-containment measures deemed appropriate by the Governor.
Beginning in fiscal year 2010 and in fiscal years thereafter, when Medicaid expenditures are projected to exceed funds available for the fiscal year, the division shall submit the expected shortfall information to the PEER Committee not later than December 1 of the year in which the shortfall is projected to occur. PEER shall review the computations of the division and report its findings to the Legislative Budget Office not later than January 7 in any year.
(G) Notwithstanding any
other provision of this article, it shall be the duty of each provider
participating in the Medicaid program to keep and maintain books, documents and
other records as prescribed by the Division of Medicaid in * * * accordance with
federal laws and regulations.
(H) (1) Notwithstanding
any other provision of this article, the division is authorized to implement
(a) a managed care program, (b) a coordinated care program, (c) a coordinated
care organization program, (d) a health maintenance organization program, (e) a
patient-centered medical home program, (f) an accountable care organization
program, (g) provider-sponsored health plan, or (h) any combination of the
above programs. * * *
As a condition for the approval of any program under this subsection (H)(1),
the division shall require that no managed care program may:
(a) * * * [Deleted]
(b) Override the medical decisions of hospital physicians or staff regarding patients admitted to a hospital for an emergency medical condition as defined by 42 US Code Section 1395dd. This restriction (b) does not prohibit the retrospective review of the appropriateness of the determination that an emergency medical condition exists by chart review or coding algorithm, nor does it prohibit prior authorization for nonemergency hospital admissions;
(c) Pay providers at a rate that is less than the normal Medicaid reimbursement rate. However, the division may approve use of alternative payment models, including quality and value-based payment arrangements, provided both parties mutually agree and the Division of Medicaid approves of said models. It is the intent of the Legislature that all managed care entities described in this subsection (H), in collaboration with the division, develop and implement innovative payment models that incentivize improvements in health care quality, outcomes, or value, as determined by the division. Participation in the provider network of any managed care, coordinated care, provider-sponsored health plan, or similar contractor shall not be conditioned on the provider's agreement to accept such alternative payment models;
(d) Implement a prior authorization program for prescription drugs that is more stringent than the prior authorization processes used by the division in its administration of the Medicaid program;
(e) [Deleted]
(f) Implement a preferred drug list that is more stringent than the mandatory preferred drug list established by the division under subsection (A)(9) of this section;
(g) Implement a
policy which denies beneficiaries with hemophilia access to the federally
funded hemophilia treatment centers as part of the Medicaid Managed Care
network of providers. * * *
(2) Notwithstanding
any provision of this section, the recipients eligible for enrollment into a
Medicaid managed care program authorized under this subsection (H) shall
include only those categories of recipients eligible for participation in the
Medicaid managed care program as of January 1, 2019, and categories of
recipients enrolled in the division's Healthier Mississippi Waiver, Family
Planning Waiver and Children's Health Insurance Program. No expansion of
Medicaid managed care program contracts may be implemented by the division
without enabling legislation from the Mississippi Legislature. * * *
* * *
(3) (a) Any
contractors * * * receiving capitated payments under a
managed care * * *
delivery system established in this section shall provide to the
Legislature and the division statistical data to be shared with provider groups
in order to improve patient access, appropriate utilization, cost savings and
health outcomes not later than October 1 of each year. Additionally, each
contractor shall disclose to the Chairmen of the Senate and House Medicaid
Committees the administrative expenses costs for the prior calendar year, and
the number of full-equivalent employees located in the State of Mississippi
dedicated to the Medicaid and CHIP lines of business as of June 30 of the
current year.
(b) The
division and the contractors participating in the managed care program, a
coordinated care program or a provider-sponsored health plan shall be subject
to * * *
program reviews or audits performed by the Office of the State Auditor,
the PEER Committee and/or * * * an independent third * * * parties.
(c) Those * * * reviews shall determine among
other items * * *:
(i) The financial benefit to the State of Mississippi of the managed care program,
(ii)
The difference between the premiums paid to the managed care contractors and
the payments made by those contractors to health care providers, * * *
(iii) Compliance with performance measures required under the contracts,
(iv) Administrative expense allocation methodologies,
(v) Whether nonprovider payments assigned as medical expenses are appropriate,
(vi) Capitated arrangements with related party subcontractors,
(vii) Reasonableness of corporate allocations,
(viii) Value-added benefits and the extent to which they are used,
(ix) The effectiveness of subcontractor oversight, including subcontractor review,
(x)
Whether * * * health care outcomes * * * have
been improved, and
(xi) The most common claim denial codes to determine the reasons for the denials.
* * * The audit reports shall be
considered * * *
public documents and shall be posted in * * * their entirety on the division's
website.
(4) * * * [Deleted]
(5) No health maintenance organization, coordinated care organization, provider-sponsored health plan, or other organization paid for services on a capitated basis by the division under any managed care program or coordinated care program implemented by the division under this section shall require its providers or beneficiaries to use any pharmacy that ships, mails or delivers prescription drugs or legend drugs or devices.
(6) Not later than July 1, 2022, any contractors receiving capitated payments under a managed care delivery system established in this section shall develop and implement a uniform credentialing process by which all providers will be credentialed. If the provisions of this subsection are not met by July 1, 2022, the division shall establish a uniform credentialing or screening process, and no health maintenance organization, coordinated care organization, provider-sponsored health plan, or other organization paid for services on a capitated basis by the division under any managed care program or coordinated care program implemented by the division under this section shall require its providers to be credentialed by the organization in order to receive reimbursement from the organization, but those organizations shall recognize the credentialing or screening of the providers by the division.
(I) [Deleted]
(J) * * * [Deleted]
(K) Not later than July 1, 2022, the division or its designee shall develop a report evaluating the cost effectiveness of extending Medicaid coverage for pregnant women from sixty (60) days postpartum to three hundred sixty-five (365) days postpartum.
( * * *L) This section shall stand repealed
on July 1, * * *
2025.
SECTION 2. This act shall take effect and be in force from and after July 1, 2021.