MISSISSIPPI LEGISLATURE
2002 Regular Session
To: Public Health and Welfare
By: Senator(s) Huggins
AN ACT TO AMEND SECTION 43-13-107, MISSISSIPPI CODE OF 1972, TO ESTABLISH WITHIN THE DIVISION OF MEDICAID A DRUG USE REVIEW BOARD TO CONDUCT RECIPIENT DRUG USE REVIEW, AND TO ESTABLISH A PHARMACY AND THERAPEUTICS COMMITTEE TO DESIGN A FORMULARY OR PREFERRED/NON-PREFERRED DRUG LIST FOR MEDICAID RECIPIENTS; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. Section 43-13-107, Mississippi Code of 1972, is amended as follows:
43-13-107. (1) The Division of Medicaid iscreated in the Office of the Governor and established to administer this article and perform such other duties as are prescribed by law.
(2) The Governor shall appoint a full-time director, with the advice and consent of the Senate, who shall be either (a) a physician with administrative experience in a medical care or health program, or (b) a person holding a graduate degree in medical care administration, public health, hospital administration, or the equivalent, or (c) a person holding a bachelor's degree in business administration or hospital administration, with at least ten (10) years' experience in management-level administration of Medicaid programs, and who shall serve at the will and pleasure of the Governor. The director shall be the official secretary and legal custodian of the records of the division; shall be the agent of the division for the purpose of receiving all service of process, summons and notices directed to the division; and shall perform such other duties as the Governor shall, from time to time, prescribe. The director, with the approval of the Governor and the rules and regulations of the State Personnel Board, shall employ such professional, administrative, stenographic, secretarial, clerical and technical assistance as may be necessary to perform the duties required in administering this article and fix the compensation therefor, all in accordance with a state merit system meeting federal requirements, except that when the salary of the director is not set by law, such salary shall be set by the State Personnel Board. No employees of the Division of Medicaid shall be considered to be staff members of the immediate Office of the Governor; however, the provisions of Section 25-9-107 (c) (xv) shall apply to the director and other administrative heads of the division.
(3) (a) There is established a Medical Care Advisory Committee, which shall be the committee that is required by federal regulation to advise the Division of Medicaid about health and medical care services.
(b) The committee shall consist of not less than eleven (11) members, as follows:
(i) The Governor shall appoint five (5) members, one (1) from each congressional district as presently constituted; (ii) The Lieutenant Governor shall appoint three (3) members, one (1) from each Supreme Court district;
(iii) The Speaker of the House of Representatives shall appoint three (3) members, one (1) from each Supreme Court district.
All members appointed under this paragraph shall either be health care providers or consumers of health care services. One (1) member appointed by each of the appointing authorities shall be a board certified physician.
(c) The respective chairmen of the House Public Health and Welfare Committee, the House Appropriations Committee, the Senate Public Health and Welfare Committee and the Senate Appropriations Committee, or their designees, one (1) member of the State Senate appointed by the Lieutenant Governor and one (1) member of the House of Representatives appointed by the Speaker of the House, shall serve as ex officio nonvoting members.
(d) In addition to the committee members required by paragraph (b), the committee shall consist of such other members as are necessary to meet the requirements of the federal regulation applicable to the Medical Care Advisory Committee, who shall be appointed as provided in the federal regulation.
(e) The chairmanship of the Medical Care Advisory Committee shall alternate for twelve-month periods between the chairmen of the House and Senate Public Health and Welfare Committees, with the Chairman of the House Public Health and Welfare Committee serving as the first chairman.
(f) The members of the committee specified in paragraph (b) shall serve for terms that are concurrent with the terms of members of the Legislature, and any member appointed under paragraph (b) may be reappointed to the committee. The members of the committee specified in paragraph (b) shall serve without compensation, but shall receive reimbursement to defray actual expenses incurred in the performance of committee business as authorized by law. Legislators shall receive per diem and expenses which may be paid from the contingent expense funds of their respective houses in the same amounts as provided for committee meetings when the Legislature is not in session.
(g) The committee shall meet not less than quarterly, and committee members shall be furnished written notice of the meetings at least ten (10) days before the date of the meeting.
(h) The Executive Director of the Division of Medicaid shall submit to the committee all amendments, modifications and changes to the state plan for the operation of the Medicaid program, for review by the committee before the amendments, modifications or changes may be implemented by the division.
(i) The committee, among its duties and responsibilities, shall:
(i) Advise the division with respect to amendments, modifications and changes to the state plan for the operation of the Medicaid program;
(ii) Advise the division with respect to issues concerning receipt and disbursement of funds and eligibility for medical assistance;
(iii) Advise the division with respect to determining the quantity, quality and extent of medical care provided under this article;
(iv) Communicate the views of the medical care professions to the division and communicate the views of the division to the medical care professions;
(v) Gather information on reasons that medical care providers do not participate in the Medicaid program and changes that could be made in the program to encourage more providers to participate in the Medicaid program, and advise the division with respect to encouraging physicians and other medical care providers to participate in the Medicaid program;
(vi) Provide a written report on or before November 30 of each year to the Governor, Lieutenant Governor and Speaker of the House of Representatives.
(4) (a) There is established a Drug Use Review Board which shall be the board that is required by federal law to:
(i) Review and initiate retrospective drug use, review including ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals receiving Medicaid benefits or associated with specific drugs or groups of drugs.
(ii) Review and initiate ongoing interventions for physicians and pharmacists, targeted toward therapy problems or individuals identified in the course of retrospective drug use reviews.
(iii) On an ongoing basis, assess data on drug use against explicit predetermined standards using the compendia and literature set forth in federal law and regulations.
(b) The board shall consist of not less than twelve (12) members, as follows:
(i) The Governor shall appoint six (6) Mississippi licensed and actively practicing physicians from a list of eight (8) such physicians provided by the Mississippi State Medical Association. The physicians shall be independent of the Medicaid division and have expertise in the care of the Medicaid population;
(ii) The Governor shall appoint four (4) Mississippi licensed and actively practicing pharmacists from a list of six (6) such pharmacists provided by the Mississippi Pharmacists Association;
(iii) The Governor shall appoint one (1) consumer advocate from a list of two (2) such persons submitted by the health care taskforce set forth in Mississippi Code Annotated Section 41-103-1;
(iv) The Governor shall appoint one (1) person from a list of two (2) such persons submitted by a nonprofit organization representing entities required to pay Medicaid rebates required under Section 1927 (42 USC 1396 r-8).
(c) The board shall meet at least quarterly, and board members shall be furnished written notice of the meetings at least ten (10) days before the date of the meeting.
(d) The board meetings shall be open to the public, members of the press, legislators and consumers. Additionally, all documents provided to board members shall be available to the public, members of the press, legislators and consumers in the same manner. However, patient confidentiality and provider confidentiality shall be protected by blinding patient names and provider names with numerical or other anonymous identifiers. Board meetings conducted in violation of this section shall be deemed unlawful.
(5) (a) There is established a Pharmacy and Therapeutics Committee which shall be the committee that is required by federal law should the Medicaid Agency choose to design a formulary or should the Medicaid Agency choose to create a preferred or nonpreferred drug list.
(b) The committee shall consist of twelve (12) to fifteen (15) members, as follows:
(i) The Governor shall appoint seven (7) Mississippi licensed and actively practicing physicians from a list of nine (9) such physicians provided by the Mississippi State Medical Association. The physicians shall be independent of the Medicaid division and have expertise in the care of the Medicaid population;
(ii) The Governor shall appoint three (3) Mississippi licensed and actively practicing pharmacists from a list of five (5) such pharmacists provided by the Mississippi Pharmacists Association;
(iii) The Governor shall appoint one (1) consumer advocate from a list of two (2) such persons submitted by the health care taskforce set forth in Mississippi Code Annotated Section 41-103-1;
(iv) The Governor shall appoint one (1) person from a list of two (2) such persons submitted by a nonprofit organization representing entities required to pay to Medicaid rebates required under Section 1927 (42 USC 1396 r-8).
(c) The committee shall meet at least quarterly, and committee members shall be furnished written notice of the meetings at least ten (10) days before the date of the meeting.
(d) The committee meetings shall be open to the public, members of the press, legislators and consumers. Additionally, all documents provided to committee members shall be available to the public, members of the press, legislators, and consumers in the same manner. However, patient confidentiality and provider confidentiality shall be protected by blinding patient names and provider names with numerical or other anonymous identifiers. Committee meetings conducted in violation of this section shall be deemed unlawful.
(e) After a thirty-day public notice, the Medicaid director or designee shall present the division's recommendation regarding prior approval for a therapeutic class of drugs to the committee. The written documentation shall include:
(i) The original recommendation from any source to require prior approval or modify existing prior approval requirements.
(ii) Supporting justification for such recommendation including summaries of any guidance, assistance or research provided by physicians or pharmacists or others with expertise in the clinical use of the drug or category of drugs.
(iii) Utilization data for the class of drugs including, but not limited to, information outlining any inappropriate use, misuse, abuse or inappropriate prescribing of the class.
(iv) The division's recommendation regarding specifics of prior authorization of the drug including one (1) specific medical protocol or one (1) specific clinical criterion per drug or per drug therapeutic class, available to physicians and patients, specifying when that drug is authorized for reimbursement without completion of prior authorization requirements.
(v) Any written comments received from interested parties pertaining to the proposed prior authorization.
(vi) Upon reviewing the information and recommendations, the committee shall forward a written recommendation approved by a majority of the committee to the Medicaid director, or designee. The decisions of the committee regarding any limitations to be imposed on any drug or its use for a specified indication shall be based on sound clinical evidence found in labeling, drug compendia, and peer reviewed clinical literature pertaining to use of the drug in the relevant population.
(vii) Upon reviewing and considering all recommendations including recommendation of the Pharmacy and Therapeutic Committee, comments, and data, the Medicaid director shall make a final determination whether to require prior approval of a therapeutic class of drugs, or modify existing prior approval requirements for a therapeutic class of drugs.
(viii) At least thirty (30) days before the administrator implements new or amended prior authorization decisions, written notice of the director's decision shall be provided to all prescribing Medicaid providers, all Medicaid enrolled pharmacies, and any other party who has requested such notification.
(ix) Upon completion of the written notification, drugs that are subject to prior approval will not be reimbursed by Medicaid unless the prescriber or pharmacist receives authorization prior to dispensing. However, it is unlawful for Medicaid, or its designee, to request or require physicians, pharmacies and/or covered beneficiaries to participate in the prior approval process unless:
1. The prior authorization system provides for real-time receipts of requests, by voice mail, fax or electronic transmission, on a twenty-four-hour basis, seven (7) days a week;
2. Any request for authorization or approval of a drug that the prescriber indicates is for an acute condition, including infection or exposure requiring treatment with antibiotics, acute pain, or life threatening symptoms, shall be answered in no more than four (4) hours of the time that authorization is requested by the prescriber or pharmacy;
3. Any request or approval of a drug that the prescriber indicates is for a chronic or nonacute condition shall be answered in no more than twenty-four (24)_hours of the time that authorization is requested by the prescriber or pharmacy; and
4. In an emergency or, with respect to an acute condition, a failure (after an initial denial) to authorize a prescribed course of therapy within the same business day in which the request is commenced, the patient shall receive coverage of an initial course of therapy for an acute condition, or a fourteen (14) days' supply for a chronic condition.
SECTION 2. This act shall take effect and be in force from and after July 1, 2002.