MISSISSIPPI LEGISLATURE
2021 Regular Session
To: Medicaid; Appropriations
By: Representative Lamar
AN ACT TO AMEND SECTION 43-13-107, MISSISSIPPI CODE OF 1972, TO CREATE THE MISSISSIPPI MEDICAID COMMISSION TO ADMINISTER THE MEDICAID PROGRAM; TO PROVIDE FOR THE MEMBERSHIP AND APPOINTMENT OF THE COMMISSION; TO PROVIDE THAT THE EXECUTIVE DIRECTOR OF THE COMMISSION SHALL BE APPOINTED BY THE COMMISSION; TO ABOLISH THE DIVISION OF MEDICAID AND TRANSFER THE POWERS, DUTIES, PROPERTY AND EMPLOYEES OF THE DIVISION TO THE MEDICAID COMMISSION; TO AMEND SECTIONS 43-13-103, 43-13-105, 43-13-109, 43-13-113, 43-13-116, 43-13-117, 43-13-120, 43-13-121, 43-13-123, 43-13-125, 43-13-139 AND 43-13-145, MISSISSIPPI CODE OF 1972, TO CONFORM TO THE PRECEDING PROVISIONS; 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) (a)
The * * *
Mississippi Medicaid Commission is created * * *
to administer this article and perform such other duties as are prescribed by
law. The commission shall consist of seven (7) members, with three (3)
members appointed by the Governor and four (4) members appointed by the
Lieutenant Governor. All initial and later appointments to the commission
shall be with the advice and consent of the Senate.
(b) All members of the commission shall be persons who have some knowledge or practical experience in matters under the jurisdiction of the commission. No member of the commission shall be a provider or representative of any provider of Medicaid services or have any financial or other interest in any provider of Medicaid services, and no member of the commission shall be an elected official of the State of Mississippi or a political subdivision of the state.
(c) The Governor shall appoint one (1) member from each Supreme Court district as constituted on January 1, 2021, and the Lieutenant Governor shall appoint one (1) member from each congressional district as constituted on January 1, 2021. The initial members shall be appointed for staggered terms, as follows: one (1) member appointed by the Governor and one (1) member appointed by the Lieutenant Governor shall be appointed for terms that end on June 30, 2022; one (1) member appointed by the Governor and two (2) members appointed by the Lieutenant Governor shall be appointed for terms that end on June 30, 2024; and one (1) member appointed by the Governor and one (1) member appointed by the Lieutenant Governor shall be appointed for terms that end on June 30, 2026. All later appointments to the commission shall be made by the respective appointing authorities for terms of six (6) years from the expiration date of the previous term, and the appointments shall be subject to the same qualifications and geographical districts as the initial members. No person shall be appointed to the commission for more than two (2) consecutive terms.
(d) Two (2) of the members to be appointed by the Lieutenant Governor shall be appointed only after consideration of recommendations for those appointments made by the Speaker of the House of Representatives to the Lieutenant Governor.
(e) Any vacancy on the commission before the expiration of a term shall be filled by appointment of the original appointing authority for that position, with the advice and consent of the Senate. The person appointed to fill the vacancy shall serve for the remainder of the unexpired term.
(f) The members of the commission shall select one (1) member to serve as chairman of the commission. The commission shall select a chairman once every two (2) years, and any person who has previously served as chairman may be reelected as chairman.
(g) Four (4) members of the commission shall constitute a quorum for the transaction of any business of the commission. The commission shall hold regular monthly meetings, and other meetings as may be necessary for the purpose of conducting any business as may be required. All meetings shall be called by the chairman or by a majority of the members of the commission, except the first meeting, which shall be called by the Governor. Any member who does not attend three (3) consecutive regular meetings of the commission, except for illness, shall be subject to removal by a majority vote of the members of the commission.
(h) Members of the commission shall receive the per diem authorized under Section 25-3-69 for each day spent actually discharging their official duties, and shall receive reimbursement for mileage and necessary travel expenses incurred as provided in Section 25-3-41.
(i) Each member of the commission, before entering upon the discharge of the duties of the office, shall take and subscribe to the oath of office prescribed by the Mississippi Constitution and shall file the oath in the Office of the Secretary of State, and shall execute a bond in some surety company authorized to do business in the state in the penal sum of One Hundred Thousand Dollars ($100,000.00), conditioned for the faithful and impartial discharge of the duties of the office. The bonds shall be filed in the Office of the Secretary of State, and the premium on the bonds shall be paid as provided by law out of funds appropriated to the commission.
(2) (a) The * * * commission shall appoint a full-time
executive director, * * * who shall be either (i) a
physician with administrative experience in a medical care or health program,
or (ii) a person holding a graduate degree in medical care administration,
public health, hospital administration, or the equivalent, or (iii) a person
holding a bachelor's degree with at least three (3) years' experience in
management-level administration of, or policy development for, Medicaid
programs, and who shall serve at the will and pleasure of the commission.
* * *
No one who has been a member of the Mississippi Legislature during the previous
three (3) years may be executive director. The executive director shall be the
official secretary and legal custodian of the records of the * * * commission; shall be the agent
of the * * *
commission for the purpose of receiving all service of process, summons
and notices directed to the * * * commission; shall perform such
other duties as the * * *
commission may prescribe from time to time; and shall perform all other
duties that are now or may be imposed upon him or her by law.
* * *
( * * *b) The executive director shall,
before entering upon the discharge of the duties of the office, take and
subscribe to the oath of office prescribed by the Mississippi Constitution and
shall file the same in the Office of the Secretary of State, and shall execute
a bond in some surety company authorized to do business in the state in the
penal sum of One Hundred Thousand Dollars ($100,000.00), conditioned for the
faithful and impartial discharge of the duties of the office. The premium on
the bond shall be paid as provided by law out of funds appropriated to the * * * commission.
( * * *c) The executive director, * * * with
the approval of the commission and subject to 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 for those persons, all in accordance with a state merit system
meeting federal requirements. When the salary of the executive director is not
set by law, that salary shall be set by the State Personnel Board. * * *
The provisions of Section 25-9-107(c)(xv) shall apply to the executive
director and other administrative heads of the * * * commission.
(d) The provision of paragraph (a) of this subsection providing that the executive director shall be appointed by the commission shall not be applicable until the executive director who holds the office on July 1, 2021, has vacated the office, or January 1, 2024, whichever is earlier.
(3) (a) There is
established a Medical Care Advisory Committee, which shall be the committee
that is required by federal regulation to advise the * * * commission about
health and medical care services.
(b) The advisory 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 and one (1) from the state at large;
(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 Medicaid Committee, the House Public Health and Human Services Committee, the House Appropriations Committee, the Senate Medicaid 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 of the advisory committee.
(d) In addition to the committee members required by paragraph (b), the advisory committee shall consist of such other members as are necessary to meet the requirements of the federal regulation applicable to the advisory committee, who shall be appointed as provided in the federal regulation.
(e) The chairmanship of the advisory committee shall be elected by the voting members of the committee annually and shall not serve more than two (2) consecutive years as chairman.
(f) The members of the advisory 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 advisory committee. The members of the advisory 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 advisory committee shall meet not less than quarterly, and advisory committee members shall be furnished written notice of the meetings at least ten (10) days before the date of the meeting.
(h) The * * * commission shall
submit to the advisory committee all amendments, modifications and changes to
the state plan for the operation of the Medicaid program, for review by the
advisory committee before the amendments, modifications or changes may be
implemented by the * * *
commission.
(i) The advisory committee, among its duties and responsibilities, shall:
(i) Advise the * * * commission with respect to
amendments, modifications and changes to the state plan for the operation of
the Medicaid program;
(ii) Advise the * * * commission with respect to
issues concerning receipt and disbursement of funds and eligibility for
Medicaid;
(iii) Advise the * * * commission 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 * * * commission and communicate the
views of the * * *
commission 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 * * * commission 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 appointed by the * * * commission.
(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 members of the Legislature in the same manner, and shall be made available to others for a reasonable fee for copying. However, patient confidentiality and provider confidentiality shall be protected by blinding patient names and provider names with numerical or other anonymous identifiers. The board meetings shall be subject to the Open Meetings Act (Sections 25-41-1 through 25-41-17). 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 appointed by
the * * * commission.
(b) The committee shall meet as often as needed to fulfill its responsibilities and obligations as set forth in this section, and committee members shall be furnished written notice of the meetings at least ten (10) days before the date of the meeting.
(c) 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 members of the Legislature in the same manner, and shall be made available to others for a reasonable fee for copying. However, patient confidentiality and provider confidentiality shall be protected by blinding patient names and provider names with numerical or other anonymous identifiers. The committee meetings shall be subject to the Open Meetings Act (Sections 25-41-1 through 25-41-17). Committee meetings conducted in violation of this section shall be deemed unlawful.
(d) After a thirty-day
public notice, * * * the commission shall present its recommendation regarding prior
approval for a therapeutic class of drugs to the committee. However, in
circumstances where the * * *division commission deems it necessary for the health
and safety of Medicaid beneficiaries, the * * * commission may present to the
committee its recommendations regarding a particular drug without a thirty-day
public notice. In making that presentation, the * * * commission shall state to the
committee the circumstances that precipitate the need for the committee to
review the status of a particular drug without a thirty-day public notice. The
committee may determine whether or not to review the particular drug under the
circumstances stated by the * * * commission without a thirty-day
public notice. If the committee determines to review the status of the
particular drug, it shall make its recommendations to the * * * commission, after which the * * * commission shall file those
recommendations for a thirty-day public comment under Section 25-43-7(1).
(e) Upon reviewing the
information and recommendations, the committee shall forward a written
recommendation approved by a majority of the committee to the * * *
commission. 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.
(f) Upon reviewing and
considering all recommendations including recommendations of the committee,
comments, and data, the * * * commission 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.
(g) At least thirty
(30) days before the * * * commission
implements new or amended prior authorization decisions, written notice of the * * * commission's
decision shall be provided to all prescribing Medicaid providers, all Medicaid
enrolled pharmacies, and any other party who has requested the notification.
However, notice given under Section 25-43-7(1) will substitute for and meet the
requirement for notice under this subsection.
(h) Members of the committee shall dispose of matters before the committee in an unbiased and professional manner. If a matter being considered by the committee presents a real or apparent conflict of interest for any member of the committee, that member shall disclose the conflict in writing to the committee chair and recuse himself or herself from any discussions and/or actions on the matter.
SECTION 2. (1) The Division of Medicaid in the Office of the Governor is abolished, and all powers, duties and functions of the Division of Medicaid shall be transferred to the Mississippi Medicaid Commission created in Section 1 of this act. All records, property and contractual rights and obligations of, and unexpended balances of appropriations or other allocations to, the Division of Medicaid shall be transferred to the Mississippi Medicaid Commission on July 1, 2021. All employees of the Division of Medicaid on June 30, 2021, shall become employees of the Mississippi Medicaid Commission on July 1, 2021. The Division of Medicaid shall assist and cooperate with the Mississippi Medicaid Commission in order to accomplish an orderly transition under this act.
(2) Whenever the term "Governor's Office-Division of Medicaid", "Division of Medicaid" or "division," when referring to the Division of Medicaid in the Office of the Governor, is used in any statute, rule, regulation or document, it shall mean the Mississippi Medicaid Commission.
SECTION 3. Section 43-13-103, Mississippi Code of 1972, is amended as follows:
43-13-103. For the purpose
of affording health care and remedial and institutional services in accordance
with the requirements for federal grants and other assistance under Titles
XVIII, XIX and XXI of the Social Security Act, as amended, a statewide system
of medical assistance is established and shall be in effect in all political
subdivisions of the state, to be financed by state appropriations and federal
matching funds therefor, and to be administered by the * * * Mississippi Medicaid
Commission as * * *
provided in this article.
SECTION 4. Section 43-13-105, Mississippi Code of 1972, is amended as follows:
43-13-105. When used in this article, the following definitions shall apply, unless the context requires otherwise:
(a)
"Administering agency" means the * * *
Mississippi Medicaid Commission as created by this article.
(b) "Commission" or "Medicaid Commission" means the Mississippi Medicaid Commission.
(c)
"Division", * * * "Division of Medicaid" or
Governor's Office-Division of Medicaid means the * * *
Mississippi Medicaid Commission.
( * * *d) "Medical assistance"
means payment of part or all of the costs of medical and remedial care provided
under the terms of this article and in accordance with provisions of Titles XIX
and XXI of the Social Security Act, as amended.
( * * *e) "Applicant" means a
person who applies for assistance under Titles IV, XVI, XIX or XXI of the
Social Security Act, as amended, and under the terms of this article.
( * * *f) "Recipient" means a
person who is eligible for assistance under Title XIX or XXI of the Social
Security Act, as amended and under the terms of this article.
( * * *g) "State health agency"
means any agency, department, institution, board or commission of the State of
Mississippi, except the University of Mississippi Medical School, which is
supported in whole or in part by any public funds, including funds directly
appropriated from the State Treasury, funds derived by taxes, fees levied or
collected by statutory authority, or any other funds used by "state health
agencies" derived from federal sources, when any funds available to such
agency are expended either directly or indirectly in connection with, or in
support of, any public health, hospital, hospitalization or other public
programs for the preventive treatment or actual medical treatment of persons
with a physical disability, mental illness or an intellectual disability.
(h) "Executive director" or "director" means the Executive Director of the Mississippi Medicaid Commission.
* * *
SECTION 5. Section 43-13-109, Mississippi Code of 1972, is amended as follows:
43-13-109. The * * * commission, under the rules and regulations of the State
Personnel Board, may adopt reasonable rules and regulations to provide for an
open, competitive or qualifying examination for all employees of the * * * commission other than the executive
director, part-time consultants and professional staff members.
SECTION 6. Section 43-13-113, Mississippi Code of 1972, is amended as follows:
43-13-113. (1) The State
Treasurer shall receive on behalf of the state, and execute all instruments
incidental thereto, federal and other funds to be used for financing the
medical assistance plan or program adopted pursuant to this article, and place
all such funds in a special account to the credit of the * * * Mississippi
Medicaid Commission, which funds shall be expended by the * * * commission for the purposes and
under the provisions of this article, and shall be paid out by the State
Treasurer as funds appropriated to carry out the provisions of this article are
paid out by him.
The * * * commission shall issue all
checks or electronic transfers for administrative expenses, and for medical
assistance under the provisions of this article. All such checks or electronic
transfers shall be drawn upon funds made available to the * * * commission by the State * * * Fiscal Officer, upon requisition
of the executive director. It is the purpose of this section to provide
that the State * * *
Fiscal Officer shall transfer, in lump sums, amounts to the * * * commission for disbursement
under the regulations which shall be made by the * * * commission.
However, the * * *
commission, or its fiscal agent in behalf of the * * * commission, shall be authorized
in maintaining separate accounts with a Mississippi bank to handle claim
payments, refund recoveries and related Medicaid program financial
transactions, to aggressively manage the float in these accounts while awaiting
clearance of checks or electronic transfers and/or other disposition so as to
accrue maximum interest advantage of the funds in the account, and to retain
all earned interest on these funds to be applied to match federal funds for
Medicaid program operations.
(2) The * * * commission is authorized to
obtain a line of credit through the State Treasurer from the Working Cash-Stabilization
Fund or any other special source funds maintained in the State Treasury in an
amount not exceeding One Hundred Fifty Million Dollars ($150,000,000.00) to
fund shortfalls which, from time to time, may occur due to decreases in state
matching fund cash flow. The length of indebtedness under this provision shall
not carry past the end of the quarter following the loan origination. Loan
proceeds shall be received by the State Treasurer and shall be placed in a
Medicaid designated special fund account. Loan proceeds shall be expended only
for health care services provided under the Medicaid program. The * * * commission may pledge as
security for such interim financing future funds that will be received by the * * * commission. Any such loans
shall be repaid from the first available funds received by the * * * commission in the manner of and
subject to the same terms provided in this section.
* * * If the State Treasurer
makes a determination that special source funds are not sufficient to cover a
line of credit for the * * * commission, the * * * commission is authorized to
obtain a line of credit, in an amount not exceeding One Hundred Fifty Million
Dollars ($150,000,000.00), from a commercial lender or a consortium of
lenders. The length of indebtedness under this provision shall not carry past
the end of the quarter following the loan origination. The * * * commission shall obtain a
minimum of two (2) written quotes that shall be presented to the State Fiscal
Officer and State Treasurer, who shall jointly select a lender. Loan proceeds
shall be received by the State Treasurer and shall be placed in a Medicaid
designated special fund account. Loan proceeds shall be expended only for health
care services provided under the Medicaid program. The * * * commission may pledge as
security for such interim financing future funds that will be received by the * * * commission. Any such loans
shall be repaid from the first available funds received by the * * * commission in the manner of and
subject to the same terms provided in this section.
(3) Disbursement of funds to providers shall be made as follows:
(a) All providers must
submit all claims to the * * *Division of Medicaid commission's fiscal agent no later
than twelve (12) months from the date of service.
(b) The * * * commission's fiscal
agent must pay ninety percent (90%) of all clean claims within thirty (30) days
of the date of receipt.
(c) The * * * commission's fiscal
agent must pay ninety-nine percent (99%) of all clean claims within ninety (90)
days of the date of receipt.
(d) The * * * commission's fiscal
agent must pay all other claims within twelve (12) months of the date of
receipt.
(e) If a claim is
neither paid nor denied for valid and proper reasons by the end of the time
periods as specified above, the * * * commission's fiscal
agent must pay the provider interest on the claim at the rate of one and one-half
percent (1-1/2%) per month on the amount of such claim until it is finally
settled or adjudicated.
(4) The date of receipt is the date the fiscal agent receives the claim as indicated by its date stamp on the claim or, for those claims filed electronically, the date of receipt is the date of transmission.
(5) The date of payment is the date of the check or, for those claims paid by electronic funds transfer, the date of the transfer.
(6) The above specified time limitations do not apply in the following circumstances:
(a) Retroactive adjustments paid to providers reimbursed under a retrospective payment system;
(b) If a claim for payment under Medicare has been filed in a timely manner, the fiscal agent may pay a Medicaid claim relating to the same services within six (6) months after it, or the provider, receives notice of the disposition of the Medicare claim;
(c) Claims from providers under investigation for fraud or abuse; and
(d) The * * * commission and/or
its fiscal agent may make payments at any time in accordance with a court
order, to carry out hearing decisions or corrective actions taken to resolve a
dispute, or to extend the benefits of a hearing decision, corrective action, or
court order to others in the same situation as those directly affected by it.
* * *
SECTION 7. Section 43-13-116, Mississippi Code of 1972, is amended as follows:
43-13-116. (1) It shall be
the duty of the * * * commission to fully implement and carry out the
administrative functions of determining the eligibility of those persons who
qualify for medical assistance under Section 43-13-115.
(2) In determining Medicaid
eligibility, the * * * commission is authorized to enter into an
agreement with the Secretary of the Department of Health and Human Services for
the purpose of securing the transfer of eligibility information from the Social
Security Administration on those individuals receiving supplemental security
income benefits under the federal Social Security Act and any other information
necessary in determining Medicaid eligibility. The * * * commission is
further empowered to enter into contractual arrangements with its fiscal agent
or with the State Department of Human Services in securing electronic data
processing support as may be necessary.
(3) Administrative hearings
shall be available to any applicant who requests it because his or her claim of
eligibility for services is denied or is not acted upon with reasonable
promptness or by any recipient who requests it because he or she believes the
agency has erroneously taken action to deny, reduce, or terminate benefits.
The agency need not grant a hearing if the sole issue is a federal or state law
requiring an automatic change adversely affecting some or all recipients. Eligibility
determinations that are made by other agencies and certified to the * * * commission pursuant
to Section 43-13-115 are not subject to the administrative hearing procedures
of the * * * commission but are subject to the administrative
hearing procedures of the agency that determined eligibility.
(a) A request may be made either for a local regional office hearing or a state office hearing when the local regional office has made the initial decision that the claimant seeks to appeal or when the regional office has not acted with reasonable promptness in making a decision on a claim for eligibility or services. The only exception to requesting a local hearing is when the issue under appeal involves either (i) a disability or blindness denial, or termination, or (ii) a level of care denial or termination for a disabled child living at home. An appeal involving disability, blindness or level of care must be handled as a state level hearing. The decision from the local hearing may be appealed to the state office for a state hearing. A decision to deny, reduce or terminate benefits that is initially made at the state office may be appealed by requesting a state hearing.
(b) A request for a hearing, either state or local, must be made in writing by the claimant or claimant's legal representative. "Legal representative" includes the claimant's authorized representative, an attorney retained by the claimant or claimant's family to represent the claimant, a paralegal representative with a legal aid services, a parent of a minor child if the claimant is a child, a legal guardian or conservator or an individual with power of attorney for the claimant. The claimant may also be represented by anyone that he or she so designates but must give the designation to the Medicaid regional office or state office in writing, if the person is not the legal representative, legal guardian, or authorized representative.
(c) The claimant may make a request for a hearing in person at the regional office but an oral request must be put into written form. Regional office staff will determine from the claimant if a local or state hearing is requested and assist the claimant in completing and signing the appropriate form. Regional office staff may forward a state hearing request to the appropriate division in the state office or the claimant may mail the form to the address listed on the form. The claimant may make a written request for a hearing by letter. A simple statement requesting a hearing that is signed by the claimant or legal representative is sufficient; however, if possible, the claimant should state the reason for the request. The letter may be mailed to the regional office or it may be mailed to the state office. If the letter does not specify the type of hearing desired, local or state, Medicaid staff will attempt to contact the claimant to determine the level of hearing desired. If contact cannot be made within three (3) days of receipt of the request, the request will be assumed to be for a local hearing and scheduled accordingly. A hearing will not be scheduled until either a letter or the appropriate form is received by the regional or state office.
(d) When both members of a couple wish to appeal an action or inaction by the agency that affects both applications or cases similarly and arose from the same issue, one or both may file the request for hearing, both may present evidence at the hearing, and the agency's decision will be applicable to both. If both file a request for hearing, two (2) hearings will be registered but they will be conducted on the same day and in the same place, either consecutively or jointly, as the couple wishes. If they so desire, only one of the couple need attend the hearing.
(e) The procedure for administrative hearings shall be as follows:
(i) The claimant has thirty (30) days from the date the agency mails the appropriate notice to the claimant of its decision regarding eligibility, services, or benefits to request either a state or local hearing. This time period may be extended if the claimant can show good cause for not filing within thirty (30) days. Good cause includes, but may not be limited to, illness, failure to receive the notice, being out of state, or some other reasonable explanation. If good cause can be shown, a late request may be accepted provided the facts in the case remain the same. If a claimant's circumstances have changed or if good cause for filing a request beyond thirty (30) days is not shown, a hearing request will not be accepted. If the claimant wishes to have eligibility reconsidered, he or she may reapply.
(ii) If a claimant or representative requests a hearing in writing during the advance notice period before benefits are reduced or terminated, benefits must be continued or reinstated to the benefit level in effect before the effective date of the adverse action. Benefits will continue at the original level until the final hearing decision is rendered. Any hearing requested after the advance notice period will not be accepted as a timely request in order for continuation of benefits to apply.
(iii) Upon receipt of a written request for a hearing, the request will be acknowledged in writing within twenty (20) days and a hearing scheduled. The claimant or representative will be given at least five (5) days' advance notice of the hearing date. The local and/or state level hearings will be held by telephone unless, at the hearing officer's discretion, it is determined that an in-person hearing is necessary. If a local hearing is requested, the regional office will notify the claimant or representative in writing of the time of the local hearing. If a state hearing is requested, the state office will notify the claimant or representative in writing of the time of the state hearing. If an in-person hearing is necessary, local hearings will be held at the regional office and state hearings will be held at the state office unless other arrangements are necessitated by the claimant's inability to travel.
(iv) All persons
attending a hearing will attend for the purpose of giving information on behalf
of the claimant or rendering the claimant assistance in some other way, or for
the purpose of representing the * * * commission.
(v) A state or local hearing request may be withdrawn at any time before the scheduled hearing, or after the hearing is held but before a decision is rendered. The withdrawal must be in writing and signed by the claimant or representative. A hearing request will be considered abandoned if the claimant or representative fails to appear at a scheduled hearing without good cause. If no one appears for a hearing, the appropriate office will notify the claimant in writing that the hearing is dismissed unless good cause is shown for not attending. The proposed agency action will be taken on the case following failure to appear for a hearing if the action has not already been effected.
(vi) The claimant or his representative has the following rights in connection with a local or state hearing:
(A) The right to examine at a reasonable time before the date of the hearing and during the hearing the content of the claimant's case record;
(B) The right to have legal representation at the hearing and to bring witnesses;
(C) The right to produce documentary evidence and establish all facts and circumstances concerning eligibility, services, or benefits;
(D) The right to present an argument without undue interference;
(E) The right to question or refute any testimony or evidence including an opportunity to confront and cross-examine adverse witnesses.
(vii) When a request for a local hearing is received by the regional office or if the regional office is notified by the state office that a local hearing has been requested, the Medicaid specialist supervisor in the regional office will review the case record, reexamine the action taken on the case, and determine if policy and procedures have been followed. If any adjustments or corrections should be made, the Medicaid specialist supervisor will ensure that corrective action is taken. If the request for hearing was timely made such that continuation of benefits applies, the Medicaid specialist supervisor will ensure that benefits continue at the level before the proposed adverse action that is the subject of the appeal. The Medicaid specialist supervisor will also ensure that all needed information, verification, and evidence is in the case record for the hearing.
(viii) When a state hearing is requested that appeals the action or inaction of a regional office, the regional office will prepare copies of the case record and forward it to the appropriate division in the state office no later than five (5) days after receipt of the request for a state hearing. The original case record will remain in the regional office. Either the original case record in the regional office or the copy forwarded to the state office will be available for inspection by the claimant or claimant's representative a reasonable time before the date of the hearing.
(ix) The Medicaid specialist supervisor will serve as the hearing officer for a local hearing unless the Medicaid specialist supervisor actually participated in the eligibility, benefits, or services decision under appeal, in which case the Medicaid specialist supervisor must appoint a Medicaid specialist in the regional office who did not actually participate in the decision under appeal to serve as hearing officer. The local hearing will be an informal proceeding in which the claimant or representative may present new or additional information, may question the action taken on the client's case, and will hear an explanation from agency staff as to the regulations and requirements that were applied to claimant's case in making the decision.
(x) After the hearing, the hearing officer will prepare a written summary of the hearing procedure and file it with the case record. The hearing officer will consider the facts presented at the local hearing in reaching a decision. The claimant will be notified of the local hearing decision on the appropriate form that will state clearly the reason for the decision, the policy that governs the decision, the claimant's right to appeal the decision to the state office, and, if the original adverse action is upheld, the new effective date of the reduction or termination of benefits or services if continuation of benefits applied during the hearing process. The new effective date of the reduction or termination of benefits or services must be at the end of the fifteen-day advance notice period from the mailing date of the notice of hearing decision. The notice to claimant will be made part of the case record.
(xi) The claimant has the right to appeal a local hearing decision by requesting a state hearing in writing within fifteen (15) days of the mailing date of the notice of local hearing decision. The state hearing request should be made to the regional office. If benefits have been continued pending the local hearing process, then benefits will continue throughout the fifteen-day advance notice period for an adverse local hearing decision. If a state hearing is timely requested within the fifteen-day period, then benefits will continue pending the state hearing process. State hearings requested after the fifteen-day local hearing advance notice period will not be accepted unless the initial thirty-day period for filing a hearing request has not expired because the local hearing was held early, in which case a state hearing request will be accepted as timely within the number of days remaining of the unexpired initial thirty-day period in addition to the fifteen-day time period. Continuation of benefits during the state hearing process, however, will only apply if the state hearing request is received within the fifteen-day advance notice period.
(xii) When a request for a state hearing is received in the regional office, the request will be made part of the case record and the regional office will prepare the case record and forward it to the appropriate division in the state office within five (5) days of receipt of the state hearing request. A request for a state hearing received in the state office will be forwarded to the regional office for inclusion in the case record and the regional office will prepare the case record and forward it to the appropriate division in the state office within five (5) days of receipt of the state hearing request.
(xiii) Upon
receipt of the hearing record, an impartial hearing officer will be assigned to
hear the case * * * by the commission. Hearing officers
will be individuals with appropriate expertise employed by the * * * commission and who have not
been involved in any way with the action or decision on appeal in the case.
The hearing officer will review the case record and if the review shows that an
error was made in the action of the agency or in the interpretation of policy,
or that a change of policy has been made, the hearing officer will discuss
these matters with the appropriate agency personnel and request that an
appropriate adjustment be made. Appropriate agency personnel will discuss the
matter with the claimant and if the claimant is agreeable to the adjustment of
the claim, then agency personnel will request in writing dismissal of the
hearing and the reason therefor, to be placed in the case record. If the
hearing is to go forward, it shall be scheduled by the hearing officer in the
manner set forth in subparagraph (iii) of this paragraph (e).
(xiv) In conducting the hearing, the state hearing officer will inform those present of the following:
(A) That the hearing will be recorded on tape and that a transcript of the proceedings will be typed for the record;
(B) The action taken by the agency which prompted the appeal;
(C) An explanation of the claimant's rights during the hearing as outlined in subparagraph (vi) of this paragraph (e);
(D) That the purpose of the hearing is for the claimant to express dissatisfaction and present additional information or evidence;
(E) That the case record is available for review by the claimant or representative during the hearing;
(F) That the
final hearing decision will be rendered by the * * * commission * * * on the basis of
facts presented at the hearing and the case record and that the claimant will
be notified by letter of the final decision.
(xv) During the
hearing, the claimant and/or representative will be allowed an opportunity to
make a full statement concerning the appeal and will be assisted, if necessary,
in disclosing all information on which the claim is based. All persons
representing the claimant and those representing the * * * commission will
have the opportunity to state all facts pertinent to the appeal. The hearing
officer may recess or continue the hearing for a reasonable time should
additional information or facts be required or if some change in the claimant's
circumstances occurs during the hearing process which impacts the appeal. When
all information has been presented, the hearing officer will close the hearing
and stop the recorder.
(xvi) Immediately
following the hearing the hearing tape will be transcribed and a copy of the
transcription forwarded to the regional office for filing in the case record.
As soon as possible, the hearing officer shall review the evidence and record
of the proceedings, testimony, exhibits, and other supporting documents,
prepare a written summary of the facts as the hearing officer finds them, and
prepare a written recommendation of action to be taken by the agency, citing
appropriate policy and regulations that govern the recommendation. The decision
cannot be based on any material, oral or written, not available to the claimant
before or during the hearing. The hearing officer's recommendation will become
part of the case record which will be submitted to the * * * commission * * * for further review
and decision.
(xvii) The * * * commission * * *, upon review of
the recommendation, proceedings and the record, may sustain the recommendation
of the hearing officer, reject the same, or remand the matter to the hearing
officer to take additional testimony and evidence, in which case, the hearing
officer thereafter shall submit to the * * * commission a new
recommendation. The * * * commission shall
prepare a written decision summarizing the facts and identifying policies and
regulations that support the decision, which shall be mailed to the claimant
and the representative, with a copy to the regional office if appropriate, as
soon as possible after submission of a recommendation by the hearing officer.
The decision notice will specify any action to be taken by the agency, specify
any revised eligibility dates or, if continuation of benefits applies, will
notify the claimant of the new effective date of reduction or termination of
benefits or services, which will be fifteen (15) days from the mailing date of
the notice of decision. The decision rendered by the * * * commission * * * is final and
binding. The claimant is entitled to seek judicial review in a court of proper
jurisdiction.
(xviii) The * * * commission must
take final administrative action on a hearing, whether state or local, within
ninety (90) days from the date of the initial request for a hearing.
(xix) A group hearing may be held for a number of claimants under the following circumstances:
(A) The * * * commission may
consolidate the cases and conduct a single group hearing when the only issue
involved is one (1) of a single law or agency policy;
(B) The claimants may request a group hearing when there is one (1) issue of agency policy common to all of them.
In all group hearings,
whether initiated by the * * *Division of Medicaid commission or by the claimants,
the policies governing fair hearings must be followed. Each claimant in a
group hearing must be permitted to present his or her own case and be
represented by his or her own representative, or to withdraw from the group
hearing and have his or her appeal heard individually. As in individual
hearings, the hearing will be conducted only on the issue being appealed, and
each claimant will be expected to keep individual testimony within a reasonable
time frame as a matter of consideration to the other claimants involved.
(xx) Any specific matter necessitating an administrative hearing not otherwise provided under this article or agency policy shall be afforded under the hearing procedures as outlined above. If the specific time frames of such a unique matter relating to requesting, granting, and concluding of the hearing is contrary to the time frames as set out in the hearing procedures above, the specific time frames will govern over the time frames as set out within these procedures.
(4) The executive director * * *, with the approval of the
commission and subject to the rules and regulations of the State Personnel
Board, shall be authorized to employ eligibility,
technical, clerical and supportive staff as may be required in carrying out and
fully implementing the determination of Medicaid eligibility, including conducting
quality control reviews and the investigation of the improper receipt of
medical assistance. Staffing needs will be set forth in the annual
appropriation act for the * * *division commission. Additional office space as needed
in performing eligibility, quality control and investigative functions shall be
obtained by the * * *
commission.
SECTION 8. Section 43-13-117, Mississippi Code of 1972, is amended as follows:
43-13-117. (A) Medicaid as
authorized by this article shall include payment of part or all of the costs,
at the discretion of the * * *division commission, with approval of * * * 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.
(a) The * * * commission shall allow thirty
(30) days of inpatient hospital care annually for all Medicaid recipients.
Medicaid recipients requiring transplants shall not have those days included in
the transplant hospital stay count against the thirty-day limit for inpatient
hospital care. Precertification of inpatient days must be obtained as required
by the * * *
commission.
(b) From and after
July 1, 1994, the * * * executive director commission * * * shall amend the
Mississippi Title XIX Inpatient Hospital Reimbursement Plan to remove the
occupancy rate penalty from the calculation of the Medicaid Capital Cost
Component utilized to determine total hospital costs allocated to the Medicaid
program.
(c) Hospitals may receive an additional payment for the implantable programmable baclofen drug pump used to treat spasticity that is implanted on an inpatient basis. The payment pursuant to written invoice will be in addition to the facility's per diem reimbursement and will represent a reduction of costs on the facility's annual cost report, and shall not exceed Ten Thousand Dollars ($10,000.00) per year per recipient.
(d) The * * * commission is authorized to
implement an All Patient Refined Diagnosis Related Groups (APR-DRG)
reimbursement methodology for inpatient hospital services.
(e) No service
benefits or reimbursement limitations in this section shall apply to payments
under an APR-DRG or Ambulatory Payment Classification (APC) model or a managed
care program or similar model described in subsection (H) of this section
unless specifically authorized by the * * * commission.
(2) Outpatient hospital services.
(a) Emergency services.
(b) Other
outpatient hospital services. The * * * commission shall allow benefits
for other medically necessary outpatient hospital services (such as
chemotherapy, radiation, surgery and therapy), including outpatient services in
a clinic or other facility that is not located inside the hospital, but that
has been designated as an outpatient facility by the hospital, and that was in
operation or under construction on July 1, 2009, provided that the costs and
charges associated with the operation of the hospital clinic are included in
the hospital's cost report. In addition, the Medicare thirty-five-mile rule
will apply to those hospital clinics not located inside the hospital that are
constructed after July 1, 2009. Where the same services are reimbursed as
clinic services, the * * *
commission may revise the rate or methodology of outpatient
reimbursement to maintain consistency, efficiency, economy and quality of care.
(c) The * * * commission is authorized to
implement an Ambulatory Payment Classification (APC) methodology for outpatient
hospital services. The * * *division commission may give rural hospitals that have
fifty (50) or fewer licensed beds the option to not be reimbursed for
outpatient hospital services using the APC methodology, but reimbursement for
outpatient hospital services provided by those hospitals shall be based on one
hundred one percent (101%) of the rate established under Medicare for
outpatient hospital services. Those hospitals choosing to not be reimbursed
under the APC methodology shall remain under cost-based reimbursement for a two-year
period.
(d) No service benefits or reimbursement limitations in this section shall apply to payments under an APR-DRG or APC model or a managed care program or similar model described in subsection (H) of this section.
(3) Laboratory and x-ray services.
(4) Nursing facility services.
(a) The * * * commission shall make full
payment to nursing facilities for each day, not exceeding forty-two (42) 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 forty-two-day
limitation: Christmas, the day before Christmas, the day after Christmas,
Thanksgiving, the day before Thanksgiving and the day after Thanksgiving.
(b) From
and after July 1, 1997, the * * * commission shall implement the
integrated case-mix payment and quality monitoring system, which includes the
fair rental system for property costs and in which recapture of depreciation is
eliminated. The * * *
commission may reduce the payment for hospital leave and therapeutic
home leave days to the lower of the case-mix category as computed for the
resident on leave using the assessment being utilized for payment at that point
in time, or a case-mix score of 1.000 for nursing facilities, and shall compute
case-mix scores of residents so that only services provided at the nursing
facility are considered in calculating a facility's per diem.
(c) From and after July 1, 1997, all state-owned nursing facilities shall be reimbursed on a full reasonable cost basis.
(d) On or after
January 1, 2015, the * * *
commission shall update the case-mix payment system resource utilization
grouper and classifications and fair rental reimbursement system. The * * * commission shall develop and
implement a payment add-on to reimburse nursing facilities for ventilator-dependent
resident services.
(e) The * * * commission 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 * * * commission 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.
(f) The * * * commission shall develop and
implement an assessment process for long-term care services. The * * * commission may provide the
assessment and related functions directly or through contract with the area
agencies on aging.
The * * * commission 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 * * *
commission 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 * * * commission, 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 * * * commission. The * * * commission, 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 * * * commission.
(6) Physician's
services. Physician visits as determined by the * * * commission and in accordance
with federal laws and regulations. The * * * commission may develop and
implement a different reimbursement model or schedule for physician's services
provided by physicians based at an academic health care center and by
physicians at rural health centers that are associated with an academic health
care center. From and after January 1, 2010, all fees for physician's services
that are covered only by Medicaid shall be increased to ninety percent (90%) of
the rate established on January 1, 2018, and as may be adjusted each July
thereafter, under Medicare. The * * * commission 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 * * * commission. The * * * commission may reimburse
eligible providers as determined by the Patient Protection and Affordable Care
Act for certain primary care services as defined by the act at one hundred
percent (100%) of the rate established under Medicare. Additionally, the * * * commission shall reimburse
obstetricians and gynecologists for certain primary care services as defined by
the * * *
commission 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 * * *
commission.
(b) [Repealed]
(8) Emergency medical
transportation services as determined by the * * * commission.
(9) Prescription drugs
and other covered drugs and services as may be determined by the * * * commission.
The * * * commission 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 * * *
commission.
The * * * commission 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 * * *
commission 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 * * * commission 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 * * * commission 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 * * * commission 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 commission but are not used by a resident in
any of those facilities shall be returned to the billing pharmacy for credit to
the * * *
commission, 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 * * *
commission shall develop a methodology for reimbursing for restocked
drugs, which shall include a restock fee as determined by the * * * commission not exceeding Seven
Dollars and Eighty-two Cents ($7.82).
Except for those specific
maintenance drugs approved by the * * * commission, the * * * commission 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 * * * commission is authorized to
develop and implement a program of payment for additional pharmacist services
as may be determined by the * * * commission.
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 * * * commission's online payment
system.
The * * * commission 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 * * * commission shall develop and
implement a method or methods by which the * * * commission 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 * * * commission 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 * * *
commission, shall be not less than Three Dollars and Ninety-one Cents
($3.91), as determined by the * * * commission.
The * * * commission 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 * * * commission 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 * * * commission.
Notwithstanding any other
provision of this article, the * * * commission shall allow
physician–administered drugs to be billed and reimbursed as either a medical
claim or pharmacy point-of-sale to allow greater access to care.
It is the intent of the
Legislature that the * * *
commission 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 * * * commission.
This dental services program under this paragraph shall be known as the "James Russell Dumas Medicaid Dental Services Program."
The Medical Care Advisory
Committee * * *
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 * * * commission 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 * * * commission, or (b) one (1) pair
every five (5) years and in accordance with policies established by the * * * commission. 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 * * * commission shall make full
payment 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.
(c) Effective
January 1, 2015, the * * *
commission shall update the fair rental reimbursement system for
intermediate care facilities for individuals with intellectual disabilities.
(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.
Such diagnostic, preventive, therapeutic, rehabilitative or palliative services
furnished to an outpatient by or under the supervision of a physician or
dentist in a facility that is not a part of a hospital but that is organized
and operated to provide medical care to outpatients. Clinic services shall
include any services reimbursed as outpatient hospital services that may be
rendered in such a facility, including those that become so after July 1,
1991. On July 1, 1999, all fees for physicians' services reimbursed under
authority of this paragraph (14) shall be reimbursed at ninety percent (90%) of
the rate established on January 1, 1999, and as may be adjusted each July
thereafter, under Medicare (Title XVIII of the federal Social Security Act, as
amended). The * * *
commission may develop and implement a different reimbursement model or
schedule for physician's services provided by physicians based at an academic
health care center and by physicians at rural health centers that are
associated with an academic health care center. The * * * commission may provide for a
reimbursement rate for physician's clinic 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 * * * commission.
(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.
The * * * commission is
directed to apply for a waiver amendment to increase payments for all adult day
care facilities based on acuity of individual patients, with a maximum of
Seventy-five Dollars ($75.00) per day for the most acute patients.
(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 * * *
commission 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 * * * commission 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 * * * commission. The * * * commission 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 * * *
commission 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 * * *
commission 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 * * * commission 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, and may establish a Medicare Upper Payment Limits Program for
nursing facilities, and may establish a Medicare Upper Payment Limits Program
for physicians employed or contracted by public hospitals. Upon successful
implementation of a Medicare Upper Payment Limits Program for physicians
employed by public hospitals, the * * * commission may develop a plan
for implementing an Upper Payment Limits Program for physicians employed by
other classes of hospitals. The * * * commission shall assess each
hospital and, if the program is established for nursing facilities, shall
assess each nursing facility, 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) and the nursing facility
assessment, if established, shall be based on Medicaid utilization or other
appropriate method 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 * * * commission 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 * * * commission 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. Further, the * * * commission, in consultation
with the Mississippi Hospital Association and a governmental hospital located
in a county bordering the Gulf of Mexico and the State of Alabama shall develop
alternative models for distribution of medical claims and supplemental payments
for inpatient and outpatient hospital services, and such models may include,
but shall not be limited to the following: increasing rates for inpatient and
outpatient services; creating a low-income utilization pool of funds to
reimburse hospitals for the costs of uncompensated care, charity care and bad
debts as permitted and approved pursuant to federal regulations and the Centers
for Medicare and Medicaid Services; supplemental payments based upon Medicaid
utilization, quality, service lines and/or costs of providing such services to
Medicaid beneficiaries and to uninsured patients. The goals of such payment
models shall be to ensure access to inpatient and outpatient care and to
maximize any federal funds that are available to reimburse hospitals for
services provided. Any such documents required to achieve the goals described
in this paragraph shall be submitted to the Centers for Medicare and Medicaid
Services, with a proposed effective date of July 1, 2019, to the extent
possible, but in no event shall the effective date of such payment models be
later than July 1, 2020. The Chairmen of the Senate and House Medicaid
Committees shall be provided a copy of the proposed payment model(s) prior to
submission. Effective July 1, 2018, and until such time as any payment model(s)
as described above become effective, the * * * commission, in consultation
with the Mississippi Hospital Association and a governmental hospital located
in a county bordering the Gulf of Mexico and the State of Alabama is authorized
to implement a transitional program for inpatient and outpatient payments
and/or supplemental payments (including, but not limited to, MHAP
and directed payments), to redistribute available supplemental funds among
hospital providers, provided that when compared to a hospital's prior year
supplemental payments, supplemental payments made pursuant to any such
transitional program shall not result in a decrease of more than five percent
(5%) and shall not increase by more than the amount needed to maximize the distribution
of the available funds.
(c) (i) Not later
than December l, 2015, the * * * commission 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
only to approval by the Centers for Medicare and Medicaid Services (CMS) where
required, the MHAP shall provide increased inpatient capitation (PMPM) payments
to managed care entities contracting with the * * * commission 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 * * * commission 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 * * * commission 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 * * * commission 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 * * * commission 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 * * * commission shall be
reimbursed on a full reasonable cost basis.
(b) Early
intervention system services. The * * * commission 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 * * * commission 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 * * * commission.
(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 * * *
commission and the department, provided that funds for these services
are specifically appropriated to the Department of Rehabilitation Services.
(21) Nurse
practitioner services. Services furnished by a registered nurse who is
licensed and certified by the Mississippi Board of Nursing as a nurse
practitioner, including, but not limited to, nurse anesthetists, nurse
midwives, family nurse practitioners, family planning nurse practitioners,
pediatric nurse practitioners, obstetrics-gynecology nurse practitioners and
neonatal nurse practitioners, under regulations adopted by the * * * commission. Reimbursement for
those services shall not exceed ninety percent (90%) of the reimbursement rate
for comparable services rendered by a physician. The * * * commission 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 * * *
commission.
(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 * * * commission. 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. Inpatient psychiatric services to be determined by the * * * commission for recipients under
age twenty-one (21) that are provided under the direction of a physician in an
inpatient program in a licensed acute care psychiatric facility or in a
licensed psychiatric residential treatment facility, before the recipient
reaches age twenty-one (21) or, if the recipient was receiving the services
immediately before he or she reached age twenty-one (21), before the earlier of
the date he or she no longer requires the services or the date he or she
reaches age twenty-two (22), as provided by federal regulations. From and
after January 1, 2015, the * * * commission shall update the
fair rental reimbursement system for psychiatric residential treatment
facilities. Precertification of inpatient days and residential treatment days
must be obtained as required by the * * * commission. From and after
July 1, 2009, all state-owned and state-operated facilities that provide
inpatient psychiatric services to persons under age twenty-one (21) who are
eligible for Medicaid reimbursement shall be reimbursed for those services on a
full reasonable cost basis.
(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 * * * commission 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 * * * commission 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 for eligible persons under twenty-one (21) years of age.
(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 * * *
commission 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 * * *
commission and the department.
(36) Nonemergency
transportation services for Medicaid-eligible persons, to be provided by the * * * commission. The * * * commission may contract with
additional entities to administer nonemergency transportation services as it
deems necessary. All providers shall have a valid driver's license, valid
vehicle license tags and a standard liability insurance policy covering the
vehicle. The * * *
commission may pay providers a flat fee based on mileage tiers, or in
the alternative, may reimburse on actual miles traveled. The * * * commission may apply to the
Center for Medicare and Medicaid Services (CMS) for a waiver to draw federal
matching funds for nonemergency transportation services as a covered service
instead of an administrative cost. 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 * * * commission shall pay the
Medicare deductible and coinsurance amounts for services available under
Medicare, as determined by the * * * commission. From and after
July 1, 2009, the * * *
commission shall reimburse crossover claims for inpatient hospital
services and crossover claims covered under Medicare Part B in the same manner
that was in effect on January 1, 2008, unless specifically authorized by the
Legislature to change this method.
(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 * * * commission and the department.
(42) [Deleted]
(43) The * * * commission shall provide
reimbursement, according to a payment schedule developed by the * * * commission, 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. Services furnished by a physician assistant who is
licensed by the State Board of Medical Licensure and is practicing with
physician supervision under regulations adopted by the board, under regulations
adopted by the * * *
commission. Reimbursement for those services shall not exceed ninety
percent (90%) of the reimbursement rate for comparable services rendered by a
physician. The * * *
commission 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 * * * commission.
(46) The * * * commission 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 * * *
commission 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 * * * commission 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 * * * commission shall establish
copayments and/or coinsurance for all 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 * * * commission 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 * * * commission may pay enhanced
reimbursement fees related to trauma care, as determined by the * * * commission 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 * * * commission and the State
Department of Health. The * * * commission, in conjunction with
the State Department of Health, may use grants, waivers, demonstrations, 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 * * * commission 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 * * * commission 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 * * *
commission.
(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 * * *
commission is authorized to reimburse eligible providers for treatment
of opioid dependency and other highly addictive substance use disorders, as
determined by the * * *
commission. Treatment related to these conditions shall not count
against any physician visit limit imposed under this section.
(59) The * * * commission shall allow
beneficiaries between the ages of ten (10) and eighteen (18) years to receive
vaccines through a pharmacy venue.
(B) Notwithstanding any
other provision of this article to the contrary, the * * * commission shall reduce the
rate of reimbursement to providers for any service provided under this section
by five percent (5%) of the allowed amount for that service. However, the
reduction in the reimbursement rates required by this subsection (B) shall not
apply to inpatient hospital services, outpatient hospital services, nursing
facility services, intermediate care facility services, psychiatric residential
treatment facility services, pharmacy services provided under subsection (A)(9)
of this section, or any service provided by the University of Mississippi
Medical Center or a state agency, a state facility or a public agency that
either provides its own state match through intergovernmental transfer or
certification of funds to the * * * commission, or a service for
which the federal government sets the reimbursement methodology and rate. From
and after January 1, 2010, the reduction in the reimbursement rates required by
this subsection (B) shall not apply to physicians' services. In addition, the
reduction in the reimbursement rates required by this subsection (B) shall not
apply to case management services and home-delivered meals provided under the
home- and community-based services program for the elderly and disabled by a
planning and development district (PDD). Planning and development districts
participating in the home- and community-based services program for the elderly
and disabled as case management providers shall be reimbursed for case
management services at the maximum rate approved by the Centers for Medicare
and Medicaid Services (CMS). The Medical Care Advisory Committee established
in Section 43-13-107(3)(a) shall develop a study and advise the * * * commission with respect to (1)
determining the effect of any across-the-board five percent (5%) reduction in
the rate of reimbursement to providers authorized under this subsection (B),
and (2) comparing provider reimbursement rates to those applicable in other
states in order to establish a fair and equitable provider reimbursement
structure that encourages participation in the Medicaid program, and (3)
comparing dental and orthodontic services reimbursement rates to those
applicable in other states in fee-for-service and in managed care programs in
order to establish a fair and equitable dental provider reimbursement structure
that encourages participation in the Medicaid program, and (4) make a report
thereon with any legislative recommendations to the Chairmen of the Senate and
House Medicaid Committees prior to January 1, 2019.
(C) The * * * commission may pay to those
providers who participate in and accept patient referrals from the * * * commission's emergency room
redirection program a percentage, as determined by the * * * commission, 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 * * * commission 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 * * * commission 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 * * *
commission 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 * * * commission are reasonably
anticipated to exceed the amount of funds appropriated to the * * * commission for any fiscal year,
the * * *
commission * * *, 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 * * * commission.
Beginning in fiscal year
2010 and in fiscal years thereafter, when Medicaid expenditures are projected
to exceed funds available for the fiscal year, the * * * commission 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 commission 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 * * * commission in
substantiation of its cost reports for a period of three (3) years after the
date of submission to the * * *Division of Medicaid commission of an original cost
report, or three (3) years after the date of submission to the * * * commission of an
amended cost report.
(H) (1) Notwithstanding
any other provision of this article, the * * * commission 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. Managed care programs, coordinated care
programs, coordinated care organization programs, health maintenance
organization programs, patient-centered medical home programs, accountable care
organization programs, provider-sponsored health plans, or any combination of
the above programs or other similar programs implemented by the * * * commission under this section
shall be limited to the greater of (i) forty-five percent (45%) of the total
enrollment of Medicaid beneficiaries, or (ii) the categories of beneficiaries
participating in the program as of January 1, 2014, plus the categories of
beneficiaries composed primarily of persons younger than nineteen (19) years of
age, and the * * *
commission is authorized to enroll categories of beneficiaries in such
program(s) as long as the appropriate limitations are not exceeded in the aggregate.
As a condition for the approval of any program under this subsection (H)(1),
the * * *
commission shall require that no program may:
(a) Pay providers at a rate that is less than the Medicaid All Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement rate;
(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. It is the
intent of the Legislature that all managed care entities described in this
subsection (H), in collaboration with the * * * commission, develop and
implement innovative payment models that incentivize improvements in health
care quality, outcomes, or value, as determined by the * * * commission. 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 * * * commission 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 commission 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. All Medicaid beneficiaries with hemophilia shall receive unrestricted access to anti-hemophilia factor products through noncapitated reimbursement programs.
(2) Notwithstanding
any provision of this section, no expansion of Medicaid managed care program
contracts may be implemented by the * * * commission without enabling
legislation from the Mississippi Legislature. * * *
(3) Any contractors
providing direct patient care under a managed care program established in this
section shall provide to the Legislature and the * * * commission 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. The * * *
commission and the contractors participating in the managed care
program, a coordinated care program or a provider-sponsored health plan shall
be subject to annual program audits performed by the Office of the State
Auditor, the PEER Committee and/or an independent third party that has no
existing contractual relationship with the * * * commission. Those audits shall
determine among other items, the financial benefit to the State of Mississippi
of the managed care program, the difference between the premiums paid to the
managed care contractors and the payments made by those contractors to health
care providers, compliance with performance measures required under the contracts,
and whether costs have been contained due to improved health care outcomes. In
addition, the audit shall review the most common claim denial codes to
determine the reasons for the denials. This audit report shall be considered a
public document and shall be posted in its entirety on the * * * commission's website.
(4) All health
maintenance organizations, coordinated care organizations, provider-sponsored
health plans, or other organizations paid for services on a capitated basis by
the * * *
commission under any managed care program or coordinated care program
implemented by the * * *
commission under this section shall reimburse all providers in those
organizations at rates no lower than those provided under this section for
beneficiaries who are not participating in those programs.
(5) No health
maintenance organization, coordinated care organization, provider-sponsored
health plan, or other organization paid for services on a capitated basis by
the * * *
commission under any managed care program or coordinated care program
implemented by the * * *
commission 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) No health
maintenance organization, coordinated care organization, provider-sponsored
health plan, or other organization paid for services on a capitated basis by
the * * *
commission under any managed care program or coordinated care program
implemented by the * * *
commission 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 of the
providers by the * * *
commission.
(I) [Deleted]
(J) There shall be no cuts in inpatient and outpatient hospital payments, or allowable days or volumes, as long as the hospital assessment provided in Section 43-13-145 is in effect. This subsection (J) shall not apply to decreases in payments that are a result of: reduced hospital admissions, audits or payments under the APR-DRG or APC models, or a managed care program or similar model described in subsection (H) of this section.
(K) This section shall stand repealed on July 1, 2021.
SECTION 9. Section 43-13-120, Mississippi Code of 1972, is amended as follows:
43-13-120. (1) Any person
who is a Medicaid recipient and is receiving medical assistance for services
provided in a long-term care facility under the provisions of Section 43-13-117 * * *, who dies intestate and leaves no known heirs, shall have
deemed, through his acceptance of such medical assistance, the * * * commission as his
beneficiary to all such funds in an amount not to exceed Two Hundred Fifty
Dollars ($250.00) which are in his possession at the time of his death. Such
funds, together with any accrued interest thereon, shall be reported by the
long-term care facility to the State Treasurer in the manner provided in
subsection (2).
(2) The report of such funds shall be verified, shall be on a form prescribed or approved by the Treasurer, and shall include (a) the name of the deceased person and his last known address prior to entering the long-term care facility; (b) the name and last known address of each person who may possess an interest in such funds; and (c) any other information which the Treasurer prescribes by regulation as necessary for the administration of this section. The report shall be filed with the Treasurer prior to November 1 of each year in which the long-term care facility has provided services to a person or persons having funds to which this section applies.
(3) Within one hundred
twenty (120) days from November 1 of each year in which a report is made
pursuant to subsection (2), the Treasurer shall cause notice to be published in
a newspaper having general circulation in the county of this state in which is
located the last known address of the person or persons named in the report who
may possess an interest in such funds, or if no such person is named in the
report, in the county in which is located the last known address of the
deceased person prior to entering the long-term care facility. If no address
is given in the report or if the address is outside of this state, the notice
shall be published in a newspaper having general circulation in the county in
which the facility is located. The notice shall contain (a) the name of the
deceased person; (b) his last known address prior to entering the facility; (c)
the name and last known address of each person named in the report who may
possess an interest in such funds; and (d) a statement that any person possessing
an interest in such funds must make a claim therefor to the Treasurer within
ninety (90) days after such publication date or the funds will become the
property of the State of Mississippi. In any year in which the Treasurer
publishes a notice of abandoned property under Section 89-12-27, the Treasurer
may combine the notice required by this section with the notice of abandoned
property. The cost to the Treasurer of publishing the notice required by this
section shall be paid by the * * * commission.
(4) Each long-term care
facility that makes a report of funds of a deceased person under this section
shall pay over and deliver such funds, together with any accrued interest
thereon, to the Treasurer not later than ten (10) days after notice of such
funds has been published by the Treasurer as provided in subsection (3). If a
claim to such funds is not made by any person having an interest therein within
ninety (90) days of the published notice, the Treasurer shall place such funds
in the special account in the State Treasury to the credit of the * * *
commission to be expended by the * * * commission for the
purposes provided under Mississippi Medicaid Law.
(5) This section shall not be applicable to any Medicaid patient in a long-term care facility of a state institution listed in Section 41-7-73, who has a personal deposit fund as provided for in Section 41-7-90.
SECTION 10. Section 43-13-121, Mississippi Code of 1972, is amended as follows:
43-13-121. (1) The * * * commission shall administer the
Medicaid program under the provisions of this article, and may do the
following:
(a) Adopt and
promulgate reasonable rules, regulations and standards * * * in
accordance with the Administrative Procedures Law, Section 25-43-1.101 et seq.:
(i) Establishing methods and procedures as may be necessary for the proper and efficient administration of this article;
(ii) Providing
Medicaid to all qualified recipients under the provisions of this article as
the * * *
commission may determine and within the limits of appropriated funds;
(iii) Establishing
reasonable fees, charges and rates for medical services and drugs; in doing so,
the * * *
commission shall fix all of those fees, charges and rates at the minimum
levels absolutely necessary to provide the medical assistance authorized by
this article, and shall not change any of those fees, charges or rates except
as may be authorized in Section 43-13-117;
(iv) Providing for fair and impartial hearings;
(v) Providing safeguards for preserving the confidentiality of records; and
(vi) For detecting and processing fraudulent practices and abuses of the program;
(b) Receive and expend
state, federal and other funds in accordance with court judgments or
settlements and agreements between the State of Mississippi and the federal
government, the rules and regulations promulgated by the * * * commission, * * * within
the limitations and restrictions of this article and within the limits of funds
available for that purpose;
(c) Subject to the limits imposed by this article, to submit a Medicaid plan to the United States Department of Health and Human Services for approval under the provisions of the federal Social Security Act, to act for the state in making negotiations relative to the submission and approval of that plan, to make such arrangements, not inconsistent with the law, as may be required by or under federal law to obtain and retain that approval and to secure for the state the benefits of the provisions of that law.
No agreements, specifically
including the general plan for the operation of the Medicaid program in this
state, shall be made by and between the * * * commission and the United
States Department of Health and Human Services unless the Attorney General of
the State of Mississippi has reviewed the agreements, specifically including
the operational plan, and has certified in writing to the * * *
commission that the agreements, including the plan of operation, have
been drawn strictly in accordance with the terms and requirements of this
article;
(d) In accordance with the purposes and intent of this article and in compliance with its provisions, provide for aged persons otherwise eligible for the benefits provided under Title XVIII of the federal Social Security Act by expenditure of funds available for those purposes;
(e) To make reports to the United States Department of Health and Human Services as from time to time may be required by that federal department and to the Mississippi Legislature as provided in this section;
(f) Define and determine the scope, duration and amount of Medicaid that may be provided in accordance with this article and establish priorities therefor in conformity with this article;
(g) Cooperate and contract with other state agencies for the purpose of coordinating Medicaid provided under this article and eliminating duplication and inefficiency in the Medicaid program;
(h) Adopt and use an
official seal of the * * *
commission;
(i) Sue in its own name on behalf of the State of Mississippi and employ legal counsel on a contingency basis with the approval of the Attorney General;
(j) To recover any and
all payments incorrectly made by the * * * commission to a recipient or
provider from the recipient or provider receiving the payments. The * * * commission shall be authorized
to collect any overpayments to providers sixty (60) days after the conclusion
of any administrative appeal unless the matter is appealed to a court of proper
jurisdiction and bond is posted. Any appeal filed after July 1, 2015, shall be
to the Chancery Court of the First Judicial District of Hinds County,
Mississippi, within sixty (60) days after the date that the * * * commission has notified the
provider by certified mail sent to the proper address of the provider on file
with the * * *
commission and the provider has signed for the certified mail notice, or
sixty (60) days after the date of the final decision if the provider does not
sign for the certified mail notice. To recover those payments, the * * * commission may use the
following methods, in addition to any other methods available to the * * * commission:
(i) The * * * commission shall report to the
Department of Revenue the name of any current or former Medicaid recipient who
has received medical services rendered during a period of established Medicaid
ineligibility and who has not reimbursed the * * * commission for the related
medical service payment(s). The Department of Revenue shall withhold from the
state tax refund of the individual, and pay to the * * * commission, the amount of the
payment(s) for medical services rendered to the ineligible individual that have
not been reimbursed to the * * * commission for the related
medical service payment(s).
(ii) The * * * commission shall report to the
Department of Revenue the name of any Medicaid provider to whom payments were
incorrectly made that the * * *division commission has not been able to recover by
other methods available to the * * * commission. The Department of
Revenue shall withhold from the state tax refund of the provider, and pay to
the * * *
commission, the amount of the payments that were incorrectly made to the
provider that have not been recovered by other available methods;
(k) To recover any and
all payments by the * * *
commission fraudulently obtained by a recipient or provider.
Additionally, if recovery of any payments fraudulently obtained by a recipient
or provider is made in any court, then, upon motion of the * * * commission, the judge of the
court may award twice the payments recovered as damages;
(l) Have full,
complete and plenary power and authority to conduct such investigations as it
may deem necessary and requisite of alleged or suspected violations or abuses
of the provisions of this article or of the regulations adopted under this
article, including, but not limited to, fraudulent or unlawful act or deed by
applicants for Medicaid or other benefits, or payments made to any person, firm
or corporation under the terms, conditions and authority of this article, to
suspend or disqualify any provider of services, applicant or recipient for
gross abuse, fraudulent or unlawful acts for such periods, including
permanently, and under such conditions as the * * * commission deems proper and
just, including the imposition of a legal rate of interest on the amount
improperly or incorrectly paid. Recipients who are found to have misused or
abused Medicaid benefits may be locked into one (1) physician and/or one (1)
pharmacy of the recipient's choice for a reasonable amount of time in order to
educate and promote appropriate use of medical services, in accordance with
federal regulations. If an administrative hearing becomes necessary, the * * * commission may, if the provider
does not succeed in his or her defense, tax the costs of the administrative
hearing, including the costs of the court reporter or stenographer and transcript,
to the provider. The convictions of a recipient or a provider in a state or
federal court for abuse, fraudulent or unlawful acts under this chapter shall
constitute an automatic disqualification of the recipient or automatic
disqualification of the provider from participation under the Medicaid program.
A conviction, for the purposes of this chapter, shall include a judgment entered on a plea of nolo contendere or a nonadjudicated guilty plea and shall have the same force as a judgment entered pursuant to a guilty plea or a conviction following trial. A certified copy of the judgment of the court of competent jurisdiction of the conviction shall constitute prima facie evidence of the conviction for disqualification purposes;
(m) Establish and provide
such methods of administration as may be necessary for the proper and efficient
operation of the Medicaid program, fully utilizing computer equipment as may be
necessary to oversee and control all current expenditures for purposes of this
article, and to closely monitor and supervise all recipient payments and
vendors rendering services under this article. Notwithstanding any
other provision of state law, the * * * commission is authorized to
enter into a ten-year contract(s) with a vendor(s) to provide services
described in this paragraph (m). Notwithstanding any provision of law to the
contrary, the * * *
commission is authorized to extend its Medicaid Management Information
System, including all related components and services, and Decision Support
System, including all related components and services, contracts in effect on
June 30, 2020, for a period not to exceed two (2) years without complying with
state procurement regulations;
(n) To cooperate and contract with the federal government for the purpose of providing Medicaid to Vietnamese and Cambodian refugees, under the provisions of Public Law 94-23 and Public Law 94-24, including any amendments to those laws, only to the extent that the Medicaid assistance and the administrative cost related thereto are one hundred percent (100%) reimbursable by the federal government. For the purposes of Section 43-13-117, persons receiving Medicaid under Public Law 94-23 and Public Law 94-24, including any amendments to those laws, shall not be considered a new group or category of recipient; and
(o) The * * * commission shall impose
penalties upon Medicaid only, Title XIX participating long-term care facilities
found to be in noncompliance with * * * commission and certification
standards in accordance with federal and state regulations, including interest
at the same rate calculated by the United States Department of Health and Human
Services and/or the Centers for Medicare and Medicaid Services (CMS) under
federal regulations.
(2) The * * * commission also shall exercise
such additional powers and perform such other duties as may be conferred upon
the * * *
commission by act of the Legislature.
(3) The * * * commission, and the State
Department of Health as the agency for licensure of health care facilities and
certification and inspection for the Medicaid and/or Medicare programs, shall
contract for or otherwise provide for the consolidation of on-site inspections
of health care facilities that are necessitated by the respective programs and
functions of the * * *
commission and the department.
(4) The * * * commission and its hearing
officers shall have power to preserve and enforce order during hearings; to
issue subpoenas for, to administer oaths to and to compel the attendance and
testimony of witnesses, or the production of books, papers, documents and other
evidence, or the taking of depositions before any designated individual
competent to administer oaths; to examine witnesses; and to do all things
conformable to law that may be necessary to enable them effectively to
discharge the duties of their office. In compelling the attendance and
testimony of witnesses, or the production of books, papers, documents and other
evidence, or the taking of depositions, as authorized by this section, the * * * commission or its hearing
officers may designate an individual employed by the * * * commission or some other
suitable person to execute and return that process, whose action in executing
and returning that process shall be as lawful as if done by the sheriff or some
other proper officer authorized to execute and return process in the county
where the witness may reside. In carrying out the investigatory powers under
the provisions of this article, the executive director or * * * other
person or persons designated by the commission may examine, obtain, copy or
reproduce the books, papers, documents, medical charts, prescriptions and other
records relating to medical care and services furnished by the provider to a
recipient or designated recipients of Medicaid services under investigation.
In the absence of the voluntary submission of the books, papers, documents,
medical charts, prescriptions and other records, * * * the * * * commission may issue and serve subpoenas
instantly upon the provider, his or her agent, servant or employee for the
production of the books, papers, documents, medical charts, prescriptions or
other records during an audit or investigation of the provider. If any
provider or his or her agent, servant or employee refuses to produce the
records after being duly subpoenaed, the * * * commission may
certify those facts and institute contempt proceedings in the manner, time and
place as authorized by law for administrative proceedings. As an additional
remedy, the * * *
commission may recover all amounts paid to the provider covering the
period of the audit or investigation, inclusive of a legal rate of interest and
a reasonable attorney's fee and costs of court if suit becomes necessary. * * * Commission staff shall have
immediate access to the provider's physical location, facilities, records,
documents, books, and any other records relating to medical care and services
rendered to recipients during regular business hours.
(5) If any person in
proceedings before the * * *
commission disobeys or resists any lawful order or process, or
misbehaves during a hearing or so near the place thereof as to obstruct the
hearing, or neglects to produce, after having been ordered to do so, any
pertinent book, paper or document, or refuses to appear after having been subpoenaed,
or upon appearing refuses to take the oath as a witness, or after having taken
the oath refuses to be examined according to law, the * * * commission shall
certify the facts to any court having jurisdiction in the place in which it is
sitting, and the court shall thereupon, in a summary manner, hear the evidence
as to the acts complained of, and if the evidence so warrants, punish that
person in the same manner and to the same extent as for a contempt committed
before the court, or commit that person upon the same condition as if the doing
of the forbidden act had occurred with reference to the process of, or in the
presence of, the court.
(6) In suspending or
terminating any provider from participation in the Medicaid program, the * * * commission shall preclude the
provider from submitting claims for payment, either personally or through any
clinic, group, corporation or other association to the * * * commission or its fiscal agents
for any services or supplies provided under the Medicaid program except for
those services or supplies provided before the suspension or termination. No
clinic, group, corporation or other association that is a provider of services
shall submit claims for payment to the * * * commission or its fiscal agents
for any services or supplies provided by a person within that organization who
has been suspended or terminated from participation in the Medicaid program
except for those services or supplies provided before the suspension or
termination. When this provision is violated by a provider of services that is
a clinic, group, corporation or other association, the * * * commission may suspend or
terminate that organization from participation. Suspension may be applied by
the * * *
commission to all known affiliates of a provider, provided that each
decision to include an affiliate is made on a case-by-case basis after giving
due regard to all relevant facts and circumstances. The violation, failure or
inadequacy of performance may be imputed to a person with whom the provider is
affiliated where that conduct was accomplished within the course of his or her
official duty or was effectuated by him or her with the knowledge or approval
of that person.
(7) The * * * commission may deny or revoke
enrollment in the Medicaid program to a provider if any of the following are
found to be applicable to the provider, his or her agent, a managing employee
or any person having an ownership interest equal to five percent (5%) or
greater in the provider:
(a) Failure to
truthfully or fully disclose any and all information required, or the
concealment of any and all information required, on a claim, a provider
application or a provider agreement, or the making of a false or misleading
statement to the * * *
commission relative to the Medicaid program.
(b) Previous or
current exclusion, suspension, termination from or the involuntary withdrawing
from participation in the Medicaid program, any other state's Medicaid program,
Medicare or any other public or private health or health insurance program. If
the * * *
commission ascertains that a provider has been convicted of a felony
under federal or state law for an offense that the * * * commission determines is
detrimental to the best interest of the program or of Medicaid beneficiaries,
the * * *
commission may refuse to enter into an agreement with that provider, or
may terminate or refuse to renew an existing agreement.
(c) Conviction under federal or state law of a criminal offense relating to the delivery of any goods, services or supplies, including the performance of management or administrative services relating to the delivery of the goods, services or supplies, under the Medicaid program, any other state's Medicaid program, Medicare or any other public or private health or health insurance program.
(d) Conviction under federal or state law of a criminal offense relating to the neglect or abuse of a patient in connection with the delivery of any goods, services or supplies.
(e) Conviction under federal or state law of a criminal offense relating to the unlawful manufacture, distribution, prescription or dispensing of a controlled substance.
(f) Conviction under federal or state law of a criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct.
(g) Conviction under federal or state law of a criminal offense punishable by imprisonment of a year or more that involves moral turpitude, or acts against the elderly, children or infirm.
(h) Conviction under federal or state law of a criminal offense in connection with the interference or obstruction of any investigation into any criminal offense listed in paragraphs (c) through (i) of this subsection.
(i) Sanction for a violation of federal or state laws or rules relative to the Medicaid program, any other state's Medicaid program, Medicare or any other public health care or health insurance program.
(j) Revocation of license or certification.
(k) Failure to pay recovery properly assessed or pursuant to an approved repayment schedule under the Medicaid program.
(l) Failure to meet any condition of enrollment.
SECTION 11. Section 43-13-123, Mississippi Code of 1972, is amended as follows:
43-13-123. The
determination of the method of providing payment of claims under this article
shall be made by the * * *
commission, * * * which methods may be:
(a) By contract with insurance companies licensed to do business in the State of Mississippi or with nonprofit hospital service corporations, medical or dental service corporations, authorized to do business in Mississippi to underwrite on an insured premium approach, such medical assistance benefits as may be available, and any carrier selected under the provisions of this article is expressly authorized and empowered to undertake the performance of the requirements of that contract.
(b) By contract with an insurance company licensed to do business in the State of Mississippi or with nonprofit hospital service, medical or dental service organizations, or other organizations including data processing companies, authorized to do business in Mississippi to act as fiscal agent.
The * * * commission shall obtain
services to be provided under either of the above-described provisions in
accordance with the * * * Public Procurement Review Board procurement
regulations.
The authorization of the foregoing methods shall not preclude other methods of providing payment of claims through direct operation of the program by the state or its agencies.
SECTION 12. Section 43-13-125, Mississippi Code of 1972, is amended as follows:
43-13-125. (1) If Medicaid
is provided to a recipient under this article for injuries, disease or sickness
caused under circumstances creating a cause of action in favor of the recipient
against any person, firm, corporation, political subdivision or other state
agency, then the * * *
commission shall be entitled to recover the proceeds that may result
from the exercise of any rights of recovery that the recipient may have against
any such person, firm, corporation, political subdivision or other state
agency, to the extent of the * * * commission's
interest on behalf of the recipient. The recipient shall execute and deliver
instruments and papers to do whatever is necessary to secure those rights and
shall do nothing after Medicaid is provided to prejudice the subrogation rights
of the * * *
commission. Court orders or agreements for reimbursement of Medicaid's
interest shall direct those payments to the * * * commission, which
shall be authorized to endorse any and all, including, but not limited to,
multipayee checks, drafts, money orders, or other negotiable instruments
representing Medicaid payment recoveries that are received. In accordance with
Section 43-13-305, endorsement of multipayee checks, drafts, money orders or
other negotiable instruments by the * * * commission shall be
deemed endorsed by the recipient. All payments must be remitted to the * * * commission within sixty (60)
days from the date of a settlement or the entry of a final judgment; failure to
do so hereby authorizes the * * * commission to assert its rights
under Sections 43-13-307 and 43-13-315, plus interest.
The * * * commission
may compromise or settle any such claim and execute a release of any claim it
has by virtue of this section at the * * * commission's sole discretion.
Nothing in this section shall be construed to require the * * * commission to
compromise any such claim.
(2) The acceptance of
Medicaid under this article or the making of a claim under this article shall
not affect the right of a recipient or his or her legal representative to
recover Medicaid's interest as an element of damages in any action at law; however,
a copy of the pleadings shall be certified to the * * * commission at the time of the
institution of suit, and proof of that notice shall be filed of record in that
action. The * * *
commission may, at any time before the trial on the facts, join in that
action or may intervene in that action. Any amount recovered by a recipient or
his or her legal representative shall be applied as follows:
(a) The reasonable
costs of the collection, including attorney's fees, as approved and allowed by
the court in which that action is pending, or in case of settlement without
suit, by the legal representative of the * * * commission;
(b) The amount of
Medicaid's interest on behalf of the recipient; or such amount as may be
arrived at by the legal representative of the * * * commission and the recipient's
attorney; and
(c) Any excess shall be awarded to the recipient.
(3) No compromise of any
claim by the recipient or his or her legal representative shall be binding upon
or affect the rights of the * * * commission against the third
party unless the * * * commission has entered
into the compromise in writing. The recipient or his or her legal
representative maintain the absolute duty to notify the * * * commission of the institution
of legal proceedings, and the third party and his or her insurer maintain the
absolute duty to notify the * * * commission of a proposed
compromise for which the * * *division commission has an interest. The
aforementioned absolute duties may not be delegated or assigned by contract or
otherwise. Any compromise effected by the recipient or his or her legal
representative with the third party in the absence of advance notification to
and approved by the * * *
commission shall constitute conclusive evidence of the liability of the
third party, and the * * *
commission, in litigating its claim against the third party, shall be
required only to prove the amount and correctness of its claim relating to the
injury, disease or sickness. If the recipient or his or her legal
representative fails to notify the * * * commission of the institution
of legal proceedings against a third party for which the * * * commission has a cause of
action, the facts relating to negligence and the liability of the third party,
if judgment is rendered for the recipient, shall constitute conclusive evidence
of liability in a subsequent action maintained by the * * * commission and only the amount
and correctness of the * * *
commission's claim relating to injuries, disease or sickness shall be
tried before the court. The * * * commission shall be authorized
in bringing that action against the third party and his or her insurer jointly
or against the insurer alone.
(4) Nothing in this section
shall be construed to diminish or otherwise restrict the subrogation rights of
the * * * commission against a third party for Medicaid
provided by the * * * commission to the recipient as a result of
injuries, disease or sickness caused under circumstances creating a cause of
action in favor of the recipient against such a third party.
(5) Any amounts recovered
by the * * *
commission under this section shall, by the * * * commission, be placed to the
credit of the funds appropriated for benefits under this article proportionate
to the amounts provided by the state and federal governments respectively.
SECTION 13. Section 43-13-139, Mississippi Code of 1972, is amended as follows:
43-13-139. Nothing
contained in this article shall be construed to prevent the * * * commission, in * * * its discretion, from discontinuing
or limiting medical assistance to any individuals who are classified or deemed
to be within any optional group or optional category of recipients as
prescribed under Title XIX of the federal Social Security Act or the
implementing federal regulations. If the Congress or the United States
Department of Health and Human Services ceases to provide federal matching
funds for any group or category of recipients or any type of care and services,
the * * *
commission shall cease state funding for such group or category or such
type of care and services, notwithstanding any provision of this article.
SECTION 14. Section 43-13-145, Mississippi Code of 1972, is amended as follows:
43-13-145. (1) (a) Upon
each nursing facility licensed by the State of Mississippi, there is levied an
assessment in an amount set by the * * * commission, equal to the
maximum rate allowed by federal law or regulation, for each licensed and
occupied bed of the facility.
(b) A nursing facility is exempt from the assessment levied under this subsection if the facility is operated under the direction and control of:
(i) The United States Veterans Administration or other agency or department of the United States government;
(ii) The State Veterans Affairs Board; or
(iii) The University of Mississippi Medical Center.
(2) (a) Upon each
intermediate care facility for individuals with intellectual disabilities
licensed by the State of Mississippi, there is levied an assessment in an
amount set by the * * *
commission, equal to the maximum rate allowed by federal law or
regulation, for each licensed and occupied bed of the facility.
(b) An intermediate care facility for individuals with intellectual disabilities is exempt from the assessment levied under this subsection if the facility is operated under the direction and control of:
(i) The United States Veterans Administration or other agency or department of the United States government;
(ii) The State Veterans Affairs Board; or
(iii) The University of Mississippi Medical Center.
(3) (a) Upon each
psychiatric residential treatment facility licensed by the State of
Mississippi, there is levied an assessment in an amount set by the * * * commission, equal to the
maximum rate allowed by federal law or regulation, for each licensed and
occupied bed of the facility.
(b) A psychiatric residential treatment facility is exempt from the assessment levied under this subsection if the facility is operated under the direction and control of:
(i) The United States Veterans Administration or other agency or department of the United States government;
(ii) The University of Mississippi Medical Center; or
(iii) A state
agency or a state facility that either provides its own state match through
intergovernmental transfer or certification of funds to the * * * commission.
(4) Hospital assessment.
(a) (i) Subject to
and upon fulfillment of the requirements and conditions of paragraph (f) below,
and notwithstanding any other provisions of this section, effective for state
fiscal years 2016 through fiscal year 2021, an annual assessment on each
hospital licensed in the state is imposed on each non-Medicare hospital
inpatient day as defined below at a rate that is determined by dividing the sum
prescribed in this subparagraph (i), plus the nonfederal share necessary to
maximize the Disproportionate Share Hospital (DSH) and Medicare Upper Payment
Limits (UPL) Program payments and hospital access payments and such other
supplemental payments as may be developed pursuant to Section 43-13-117(A)(18),
by the total number of non-Medicare hospital inpatient days as defined below
for all licensed Mississippi hospitals, except as provided in paragraph (d)
below. If the state matching funds percentage for the Mississippi Medicaid
program is sixteen percent (16%) or less, the sum used in the formula under
this subparagraph (i) shall be Seventy-four Million Dollars ($74,000,000.00).
If the state matching funds percentage for the Mississippi Medicaid program is
twenty-four percent (24%) or higher, the sum used in the formula under this
subparagraph (i) shall be One Hundred Four Million Dollars ($104,000,000.00).
If the state matching funds percentage for the Mississippi Medicaid program is
between sixteen percent (16%) and twenty-four percent (24%), the sum used in
the formula under this subparagraph (i) shall be a pro rata amount determined
as follows: the current state matching funds percentage rate minus sixteen
percent (16%) divided by eight percent (8%) multiplied by Thirty Million
Dollars ($30,000,000.00) and add that amount to Seventy-four Million Dollars
($74,000,000.00). However, no assessment in a quarter under this subparagraph
(i) may exceed the assessment in the previous quarter by more than Three Million
Seven Hundred Fifty Thousand Dollars ($3,750,000.00) (which would be Fifteen
Million Dollars ($15,000,000.00) on an annualized basis). The * * * commission shall publish the
state matching funds percentage rate applicable to the Mississippi Medicaid
program on the tenth day of the first month of each quarter and the assessment
determined under the formula prescribed above shall be applicable in the
quarter following any adjustment in that state matching funds percentage rate.
The * * *
commission shall notify each hospital licensed in the state as to any
projected increases or decreases in the assessment determined under this
subparagraph (i). However, if the Centers for Medicare and Medicaid Services
(CMS) does not approve the provision in Section 43-13-117(39) requiring the * * * commission to reimburse
crossover claims for inpatient hospital services and crossover claims covered
under Medicare Part B for dually eligible beneficiaries in the same manner that
was in effect on January 1, 2008, the sum that otherwise would have been used
in the formula under this subparagraph (i) shall be reduced by Seven Million
Dollars ($7,000,000.00).
(ii) In addition to the assessment provided under subparagraph (i), effective for state fiscal years 2016 through fiscal year 2021, an additional annual assessment on each hospital licensed in the state is imposed on each non-Medicare hospital inpatient day as defined below at a rate that is determined by dividing twenty-five percent (25%) of any provider reductions in the Medicaid program as authorized in Section 43-13-117(F) for that fiscal year up to the following maximum amount, plus the nonfederal share necessary to maximize the Disproportionate Share Hospital (DSH) and inpatient Medicare Upper Payment Limits (UPL) Program payments and inpatient hospital access payments, by the total number of non-Medicare hospital inpatient days as defined below for all licensed Mississippi hospitals: in fiscal year 2010, the maximum amount shall be Twenty-four Million Dollars ($24,000,000.00); in fiscal year 2011, the maximum amount shall be Thirty-two Million Dollars ($32,000,000.00); and in fiscal year 2012 and thereafter, the maximum amount shall be Forty Million Dollars ($40,000,000.00). Any such deficit in the Medicaid program shall be reviewed by the PEER Committee as provided in Section 43-13-117(F).
(iii) In addition
to the assessments provided in subparagraphs (i) and (ii), effective for state
fiscal years 2016 through fiscal year 2021, an additional annual assessment on
each hospital licensed in the state is imposed pursuant to the provisions of
Section 43-13-117(F) if the cost containment measures described therein have
been implemented and there are insufficient funds in the Health Care Trust Fund
to reconcile any remaining deficit in any fiscal year. If the * * * commission institutes any other
additional cost containment measures on any program or programs authorized
under the Medicaid program pursuant to Section 43-13-117(F), hospitals shall be
responsible for twenty-five percent (25%) of any such additional imposed
provider cuts, which shall be in the form of an additional assessment not to
exceed the twenty-five percent (25%) of provider expenditure reductions. Such
additional assessment shall be imposed on each non-Medicare hospital inpatient
day in the same manner as assessments are imposed under subparagraphs (i) and
(ii).
(b) Payment and definitions.
(i) The hospital
assessment as described in this subsection (4) shall be assessed and collected
monthly no later than the fifteenth calendar day of each month; provided,
however, that the first three (3) monthly payments shall be assessed but not be
collected until collection is satisfied for the third monthly (September) payment
and the second three (3) monthly payments shall be assessed but not be
collected until collection is satisfied for the sixth monthly (December)
payment and provided that the portion of the assessment related to the DSH
payments shall be paid in three (3) one-third (1/3) installments due no later
than the fifteenth calendar day of the payment month of the DSH payments
required by Section 43-13-117(A)(18), which shall be paid during the second,
third and fourth quarters of the state fiscal year, and provided that the
assessment related to any UPL payment(s) shall be paid no later than the
fifteenth calendar day of the payment month of the UPL payment(s) and provided
assessments related to hospital access payments will be collected beginning the
initial month that the * * *
commission funds MHAP.
(ii) Definitions. For purposes of this subsection (4):
1. "Non-Medicare
hospital inpatient day" means total hospital inpatient days including
subcomponent days less Medicare inpatient days including subcomponent days from
the hospital's most recent Medicare cost report for the second calendar year
preceding the beginning of the state fiscal year, on file with CMS per the CMS
HCRIS database, or cost report submitted to the * * * commission if the HCRIS
database is not available to the * * * commission, as of June 1 of
each year.
a. Total hospital inpatient days shall be the sum of Worksheet S-3, Part 1, column 8 row 14, column 8 row 16, and column 8 row 17, excluding column 8 rows 5 and 6.
b. Hospital Medicare inpatient days shall be the sum of Worksheet S-3, Part 1, column 6 row 14, column 6 row 16.00, and column 6 row 17, excluding column 6 rows 5 and 6.
c. Inpatient days shall not include residential treatment or long-term care days.
2. "Subcomponent inpatient day" means the number of days of care charged to a beneficiary for inpatient hospital rehabilitation and psychiatric care services in units of full days. A day begins at midnight and ends twenty-four (24) hours later. A part of a day, including the day of admission and day on which a patient returns from leave of absence, counts as a full day. However, the day of discharge, death, or a day on which a patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of admission. If admission and discharge or death occur on the same day, the day is considered a day of admission and counts as one (1) subcomponent inpatient day.
(c) The assessment provided in this subsection is intended to satisfy and not be in addition to the assessment and intergovernmental transfers provided in Section 43-13-117(A)(18). Nothing in this section shall be construed to authorize any state agency, division or department, or county, municipality or other local governmental unit to license for revenue, levy or impose any other tax, fee or assessment upon hospitals in this state not authorized by a specific statute.
(d) Hospitals operated by the United States Department of Veterans Affairs and state-operated facilities that provide only inpatient and outpatient psychiatric services shall not be subject to the hospital assessment provided in this subsection.
(e) Multihospital systems, closure, merger, change of ownership and new hospitals.
(i) If a hospital conducts, operates or maintains more than one (1) hospital licensed by the State Department of Health, the provider shall pay the hospital assessment for each hospital separately.
(ii) Notwithstanding any other provision in this section, if a hospital subject to this assessment operates or conducts business only for a portion of a fiscal year, the assessment for the state fiscal year shall be adjusted by multiplying the assessment by a fraction, the numerator of which is the number of days in the year during which the hospital operates, and the denominator of which is three hundred sixty-five (365). Immediately upon ceasing to operate, the hospital shall pay the assessment for the year as so adjusted (to the extent not previously paid).
(iii) The * * * commission shall determine the
tax for new hospitals and hospitals that undergo a change of ownership in
accordance with this section, using the best available information, as
determined by the * * *
commission.
(f) Applicability.
The hospital assessment imposed by this subsection shall not take effect and/or shall cease to be imposed if:
(i) The assessment is determined to be an impermissible tax under Title XIX of the Social Security Act; or
(ii) CMS revokes
its approval of the * * *
commission's 2009 Medicaid State Plan Amendment for the methodology for
DSH payments to hospitals under Section 43-13-117(A)(18).
This subsection (4) is repealed on July 1, 2024.
(5) Each health care
facility that is subject to the provisions of this section shall keep and
preserve such suitable books and records as may be necessary to determine the
amount of assessment for which it is liable under this section. The books and
records shall be kept and preserved for a period of not less than five (5)
years, during which time those books and records shall be open for examination
during business hours by the * * * commission, the Department of
Revenue, the Office of the Attorney General and the State Department of Health.
(6) Except as provided in
subsection (4) of this section, the assessment levied under this section shall
be collected by the * * *
commission each month.
(7) All assessments collected under this section shall be deposited in the Medical Care Fund created by Section 43-13-143.
(8) The assessment levied under this section shall be in addition to any other assessments, taxes or fees levied by law, and the assessment shall constitute a debt due the State of Mississippi from the time the assessment is due until it is paid.
(9) (a) If a health care
facility that is liable for payment of an assessment levied by the * * * commission does not pay the
assessment when it is due, the * * * commission shall give written notice
to the health care facility by certified or registered mail demanding payment
of the assessment within ten (10) days from the date of delivery of the
notice. If the health care facility fails or refuses to pay the assessment
after receiving the notice and demand from the * * * commission, the * * * commission shall withhold from
any Medicaid reimbursement payments that are due to the health care facility
the amount of the unpaid assessment and a penalty of ten percent (10%) of the
amount of the assessment, plus the legal rate of interest until the assessment
is paid in full. If the health care facility does not participate in the
Medicaid program, the * * *
commission shall turn over to the Office of the Attorney General the collection
of the unpaid assessment by civil action. In any such civil action, the Office
of the Attorney General shall collect the amount of the unpaid assessment and a
penalty of ten percent (10%) of the amount of the assessment, plus the legal
rate of interest until the assessment is paid in full.
(b) As an additional
or alternative method for collecting unpaid assessments levied by the * * * commission, if a health care
facility fails or refuses to pay the assessment after receiving notice and
demand from the * * *
commission, the * * *
commission may file a notice of a tax lien with the chancery clerk of
the county in which the health care facility is located, for the amount of the
unpaid assessment and a penalty of ten percent (10%) of the amount of the
assessment, plus the legal rate of interest until the assessment is paid in
full. Immediately upon receipt of notice of the tax lien for the assessment,
the chancery clerk shall forward the notice to the circuit clerk who shall
enter the notice of the tax lien as a judgment upon the judgment roll and show
in the appropriate columns the name of the health care facility as judgment
debtor, the name of the * * *division commission as judgment creditor, the amount of
the unpaid assessment, and the date and time of enrollment. The judgment shall
be valid as against mortgagees, pledgees, entrusters, purchasers, judgment
creditors and other persons from the time of filing with the clerk. The amount
of the judgment shall be a debt due the State of Mississippi and remain a lien
upon the tangible property of the health care facility until the judgment is
satisfied. The judgment shall be the equivalent of any enrolled judgment of a
court of record and shall serve as authority for the issuance of writs of
execution, writs of attachment or other remedial writs.
(10) (a) To further the
provisions of Section 43-13-117(A)(18), the * * * commission shall
submit to the Centers for Medicare and Medicaid Services (CMS) any documents
regarding the hospital assessment established under subsection (4) of this
section. In addition to defining the assessment established in subsection (4)
of this section if necessary, the documents shall describe any supplement
payment programs and/or payment methodologies as authorized in Section 43-13-117(A)(18)
if necessary.
(b) All hospitals satisfying the minimum federal DSH eligibility requirements (Section 1923(d) of the Social Security Act) may, subject to OBRA 1993 payment limitations, receive a DSH payment. This DSH payment shall expend the balance of the federal DSH allotment and associated state share not utilized in DSH payments to state-owned institutions for treatment of mental diseases. The payment to each hospital shall be calculated by applying a uniform percentage to the uninsured costs of each eligible hospital, excluding state-owned institutions for treatment of mental diseases; however, that percentage for a state-owned teaching hospital located in Hinds County shall be multiplied by a factor of two (2).
(11) The * * * commission shall implement DSH
and supplemental payment calculation methodologies that result in the
maximization of available federal funds.
(12) The DSH payments shall be paid on or before December 31, March 31, and June 30 of each fiscal year, in increments of one-third (1/3) of the total calculated DSH amounts. Supplemental payments developed pursuant to Section 43-13-117(A)(18) shall be paid monthly.
(13) The hospital assessment as described in subsection (4) above shall be assessed and collected monthly no later than the fifteenth calendar day of each month; provided, however, that the first three (3) monthly payments shall be assessed but not be collected until collection is satisfied for the third monthly (September) payment and the second three (3) monthly payments shall be assessed but not be collected until collection is satisfied for the sixth monthly (December) payment and provided that the portion of the assessment related to the DSH payments shall be paid in three (3) one-third (1/3) installments due no later than the fifteenth calendar day of the payment month of the DSH payments required by Section 43-13-117(A)(18), which shall be paid during the second, third and fourth quarters of the state fiscal year, and provided that the assessment related to any supplemental payment programs developed pursuant to Section 43-13-117(A)(18) shall be paid no later than the fifteenth calendar day of the payment month of the payment(s).
(14) If for any reason any part of the plan for annual DSH and supplemental payment programs to hospitals provided under subsection (10) of this section and/or developed pursuant to Section 43-13-117(A)(18) is not approved by CMS, the remainder of the plan shall remain in full force and effect.
(15) Nothing in this
section shall prevent the * * *Division of Medicaid commission from facilitating
participation in Medicaid supplemental hospital payment programs by a hospital
located in a county contiguous to the State of Mississippi that is also
authorized by federal law to submit intergovernmental transfers (IGTs) to the
State of Mississippi to fund the state share of the hospital's supplemental
and/or MHAP payments.
(16) Subsections (10) through (15) of this section shall stand repealed on July 1, 2024.
SECTION 15. This act shall take effect and be in force from and after July 1, 2021.