Health benefit plans and Medicaid; require to offer coverage for biomarker testing., the official text

MISSISSIPPI LEGISLATURE

2026 Regular Session

To: Public Health and Human Services; Insurance

By: Representatives Creekmore IV, Bell (65th), Felsher,
Owen, Eure, McKnight, Currie, Scott

House Bill 565

(As Sent to Governor)

AN ACT TO BE KNOWN AS THE "JILL GARY EURE ACT"
OR "JILL'S LAW"; TO REQUIRE EACH HEALTH BENEFIT PLAN, CONTRACT OR
AGREEMENT THAT IS ENTERED INTO OR RENEWED ON OR AFTER JULY 1, 2026, INCLUDING
THE MEDICAID PROGRAM AND THE STATE AND SCHOOL EMPLOYEES HEALTH INSURANCE PLAN,
TO OFFER COVERAGE FOR BIOMARKER TESTING FOR THE PURPOSES OF DIAGNOSIS,
TREATMENT, APPROPRIATE MANAGEMENT, OR ONGOING MONITORING OF AN ENROLLEE'S
DISEASE OR CONDITION WHEN USE OF THE TEST IS SUPPORTED BY MEDICAL AND
SCIENTIFIC EVIDENCE; TO AMEND SECTIONS 43-13-117 AND 83-5-907, MISSISSIPPI CODE
OF 1972, TO CONFORM TO THE PROVISIONS OF THIS ACT; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE
LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1.  This
act shall be known and may be cited as the "Jill Gary Eure Act" or
"Jill's Law".

SECTION 2.
As used in Sections 2 and 3 of this act, the following terms
shall be defined as provided in this section:

(a)
"Biomarker" means a characteristic that is objectively measured and
evaluated as an indicator of normal biological processes, pathogenic processes
or pharmacologic responses to a specific therapeutic intervention, including
known gene-drug interactions for medications being considered for use or
already being administered.  Biomarkers include, but are not limited to, gene
mutations, characteristics of genes, or protein expression.

(b)  "Biomarker
testing" means the analysis of a patient's tissue, blood or other
biospecimen for the presence of a biomarker.  Biomarker testing includes, but
is not limited to, single-analyte tests, multi-plex panel tests, protein
expression, whole exome, whole genome, and whole transcriptome sequencing and
other genomic or molecular sequencing.

(c)  "Consensus
statement" means a statement developed by an independent,
multidisciplinary panel of experts using a transparent methodology and
reporting structure and with a conflict of interest policy.  A consensus
statement is aimed at specific clinical circumstances and the statement is
based on the best available evidence for the purpose of optimizing the outcomes
of clinical care.

(d)  "Health
benefit plan" has the meaning given to that term in Section 83-9-6.3, and
also includes nonprofit health service plans and the State and School Employees
Health Insurance Plan.

(e)  "Health
insurance issuer" has the meaning given to that term in Section 83-9-6.3.

(f)  "Nationally
recognized clinical practice guidelines" means evidence-based clinical
practice guidelines developed by independent organizations or medical professional
societies using a transparent methodology and reporting structure and with a
conflict of interest policy.  Clinical practice guidelines establish standards
of care informed by a systematic review of evidence and an assessment of the
benefits and risks of alternative care options and include recommendations
intended to optimize patient care.

SECTION 3.
(1)  All health benefit plans and any third-party contractor or agent of such
entities shall provide coverage for biomarker testing for the purposes of
diagnosis, treatment, appropriate management, or ongoing monitoring of an
enrollee's disease or condition when use of the test is supported by medical
and scientific evidence, including, but not limited to, any one of the
following:

(a)  Labeled indications
for an FDA-approved or -cleared test;

(b)  Indicated tests
for an FDA-approved drug;

(c)  Warnings and
precautions on FDA-approved drug labels;

(d)  Centers for
Medicare and Medicaid Services (CMS) National Coverage Determinations or any
Medicare Administrative Contractor (MAC) Local Coverage Determinations and
associated Local Coverage Articles, regardless of jurisdiction; or

(e)  Testing
recommendations or considerations from a:

(i)  Nationally
recognized clinical practice guideline; or

(ii)  Consensus
statement.

(2)  All health benefit
plans shall ensure that coverage as required in subsection (1) of this section
is provided in a manner that limits disruptions in care including the need for
multiple biopsies or biospecimen samples.

(3)  Health benefit plans
and health insurance issuers subject to this section shall update and make
publicly available medical policies and coverage guidelines within sixty (60)
days after enactment.  Any updates or changes to medical policies impacting
coverage of biomarker testing must be made publicly available thirty (30) days
in advance of the effective date of the updated policy.

(4)  If a health benefit
plan or health insurance issuer denies a claim for coverage of testing
that is supported by any evidence in subsection (1) of this section, the health
benefit plan or health insurance issuer shall provide to the requesting entity,
whether it is the provider, individual or laboratory, specific written
justification explaining in detail why the claim for coverage was denied as it
pertains to the individual for whom the test was ordered.

(5)  If utilization review,
including, but not limited to, prior authorization, is required, the health
benefit plan, utilization review entity or any third party acting on behalf of
an organization or entity subject to Sections 2 and 3 of this act
shall approve or deny a prior authorization request and notify the enrollee,
the enrollee's health care provider, and any entity requesting authorization of
the service within the timeframe established in Section 83-5-913 for nonurgent
requests and Section 83-5-915 for urgent requests.

(6)  If prior authorization
is required, requests for biomarker tests may be submitted by:

(a)  The ordering or
treating provider;

(b)  The rendering
laboratory provider; or

(c)  The enrollee or
enrollee's representative.

(7)  In addition to the
provisions of Section 83-5-901 et seq., a patient and prescribing practitioner
shall have access to a clear, readily accessible, and convenient process to
request an exception to a coverage policy or an adverse utilization review
determination of a health benefit plan or health insurance issuer.  The process
shall be made readily accessible on the health benefit plan's or health
insurance issuer's website.

(8)  The Department of
Insurance may conduct periodic audits and reviews to ensure entity compliance
with Sections 2 and 3 of this act.

(9)  Sections 2 and 3
of this act shall apply to all health benefit plans, contracts or agreements
that are entered into or renewed on or after July 1, 2026.

SECTION 4.
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, with approval of the Governor and the
Centers for Medicare and Medicaid Services, of the following types of care and
services rendered to eligible applicants who have been determined to be
eligible for that care and services, within the limits of state appropriations
and federal matching funds:

(1)  Inpatient hospital
services.

(a)  The division
is authorized to implement an All Patient Refined Diagnosis Related Groups (APR-DRG)
reimbursement methodology for inpatient hospital services.

(b)  No service
benefits or reimbursement limitations in this subsection (A)(1) 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 division.

(2)  Outpatient
hospital services.

(a)  Emergency
services.

(b)  Other
outpatient hospital services.  The division 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 division may revise the rate or methodology of outpatient reimbursement to
maintain consistency, efficiency, economy and quality of care.

(c)  The division
is authorized to implement an Ambulatory Payment Classification (APC)
methodology for outpatient hospital services.  The division shall 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 subsection (A)(2) 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 unless specifically
authorized by the division.

(3)  Laboratory and x-ray
services.

(4)  Nursing facility
services.

(a)  The division
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 division 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
division 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 division shall update the case-mix payment system resource
utilization grouper and classifications and fair rental reimbursement system.
The division shall develop and implement a payment add-on to reimburse nursing
facilities for ventilator-dependent resident services.

(e)  The division
shall develop and implement, not later than January 1, 2001, a case-mix payment
add-on determined by time studies and other valid statistical data that will
reimburse a nursing facility for the additional cost of caring for a resident
who has a diagnosis of Alzheimer's or other related dementia and exhibits
symptoms that require special care.  Any such case-mix add-on payment shall be
supported by a determination of additional cost.  The division shall also
develop and implement as part of the fair rental reimbursement system for
nursing facility beds, an Alzheimer's resident bed depreciation enhanced
reimbursement system that will provide an incentive to encourage nursing
facilities to convert or construct beds for residents with Alzheimer's or other
related dementia.

(f)  The division
shall develop and implement an assessment process for long-term care services.
The division may provide the assessment and related functions directly or
through contract with the area agencies on aging.

The division shall apply for
necessary federal waivers to assure that additional services providing
alternatives to nursing facility care are made available to applicants for
nursing facility care.

(5)  Periodic screening
and diagnostic services for individuals under age twenty-one (21) years as are
needed to identify physical and mental defects and to provide health care
treatment and other measures designed to correct or ameliorate defects and
physical and mental illness and conditions discovered by the screening
services, regardless of whether these services are included in the state plan.
The division may include in its periodic screening and diagnostic program those
discretionary services authorized under the federal regulations adopted to implement
Title XIX of the federal Social Security Act, as amended.  The division, in
obtaining physical therapy services, occupational therapy services, and
services for individuals with speech, hearing and language disorders, may enter
into a cooperative agreement with the State Department of Education for the
provision of those services to handicapped students by public school districts
using state funds that are provided from the appropriation to the Department of
Education to obtain federal matching funds through the division.  The division,
in obtaining medical and mental health assessments, treatment, care and
services for children who are in, or at risk of being put in, the custody of
the Mississippi Department of Human Services may enter into a cooperative
agreement with the Mississippi Department of Human Services for the provision
of those services using state funds that are provided from the appropriation to
the Department of Human Services to obtain federal matching funds through the
division.

(6)  Physician
services.  Fees for physician's services that are covered only by Medicaid
shall be reimbursed at ninety percent (90%) of the rate established on January
1, 2018, and as may be adjusted each July thereafter, under Medicare.  The
division may provide for a reimbursement rate for physician's services of up to
one hundred percent (100%) of the rate established under Medicare for
physician's services that are provided after the normal working hours of the
physician, as determined in accordance with regulations of the division.  The
division may reimburse eligible providers, as determined by the division, for
certain primary care services at one hundred percent (100%) of the rate
established under Medicare.  The division shall reimburse obstetricians and
gynecologists for certain primary care services as defined by the division at
one hundred percent (100%) of the rate established under Medicare.

(7)  (a)  Home health
services for eligible persons, not to exceed in cost the prevailing cost of
nursing facility services.  All home health visits must be precertified as
required by the division.  In addition to physicians, certified registered
nurse practitioners, physician assistants and clinical nurse specialists are
authorized to prescribe or order home health services and plans of care, sign
home health plans of care, certify and recertify eligibility for home health
services and conduct the required initial face-to-face visit with the recipient
of the services.

(b)  [Repealed]

(8)  Emergency medical
transportation services as determined by the division.

(9)  Prescription drugs
and other covered drugs and services as determined by the division.

The division shall establish
a mandatory preferred drug list.  Drugs not on the mandatory preferred drug
list shall be made available by utilizing prior authorization procedures
established by the division.

The division may seek to
establish relationships with other states in order to lower acquisition costs
of prescription drugs to include single-source and innovator multiple-source
drugs or generic drugs.  In addition, if allowed by federal law or regulation,
the division may seek to establish relationships with and negotiate with other
countries to facilitate the acquisition of prescription drugs to include single-source
and innovator multiple-source drugs or generic drugs, if that will lower the
acquisition costs of those prescription drugs.

The division may allow for a
combination of prescriptions for single-source and innovator multiple-source
drugs and generic drugs to meet the needs of the beneficiaries.

The executive director may
approve specific maintenance drugs for beneficiaries with certain medical
conditions, which may be prescribed and dispensed in three-month supply
increments.

Drugs prescribed for a
resident of a psychiatric residential treatment facility must be provided in
true unit doses when available.  The division may require that drugs not
covered by Medicare Part D for a resident of a long-term care facility be
provided in true unit doses when available.  Those drugs that were originally
billed to the division but are not used by a resident in any of those
facilities shall be returned to the billing pharmacy for credit to the
division, in accordance with the guidelines of the State Board of Pharmacy and
any requirements of federal law and regulation.  Drugs shall be dispensed to a
recipient and only one (1) dispensing fee per month may be charged.  The
division shall develop a methodology for reimbursing for restocked drugs, which
shall include a restock fee as determined by the division not exceeding Seven
Dollars and Eighty-two Cents ($7.82).

Except for those specific
maintenance drugs approved by the executive director, the division shall not
reimburse for any portion of a prescription that exceeds a thirty-one-day
supply of the drug based on the daily dosage.

The division is authorized
to develop and implement a program of payment for additional pharmacist
services as determined by the division.

All claims for drugs for
dually eligible Medicare/Medicaid beneficiaries that are paid for by Medicare
must be submitted to Medicare for payment before they may be processed by the
division's online payment system.

The division shall develop a
pharmacy policy in which drugs in tamper-resistant packaging that are
prescribed for a resident of a nursing facility but are not dispensed to the
resident shall be returned to the pharmacy and not billed to Medicaid, in
accordance with guidelines of the State Board of Pharmacy.

The division shall develop
and implement a method or methods by which the division will provide on a
regular basis to Medicaid providers who are authorized to prescribe drugs,
information about the costs to the Medicaid program of single-source drugs and
innovator multiple-source drugs, and information about other drugs that may be
prescribed as alternatives to those single-source drugs and innovator multiple-source
drugs and the costs to the Medicaid program of those alternative drugs.

Notwithstanding any law or
regulation, information obtained or maintained by the division regarding the
prescription drug program, including trade secrets and manufacturer or labeler
pricing, is confidential and not subject to disclosure except to other state
agencies.

The dispensing fee for each
new or refill prescription, including nonlegend or over-the-counter drugs
covered by the division, shall be not less than Three Dollars and Ninety-one
Cents ($3.91), as determined by the division.

The division shall not
reimburse for single-source or innovator multiple-source drugs if there are
equally effective generic equivalents available and if the generic equivalents
are the least expensive.

It is the intent of
the Legislature that the pharmacists providers be reimbursed for the reasonable
costs of filling and dispensing prescriptions for Medicaid beneficiaries.

The division shall allow
certain drugs, including physician-administered drugs, and implantable drug
system devices, and medical supplies, with limited distribution or limited
access for beneficiaries and administered in an appropriate clinical setting,
to be reimbursed as either a medical claim or pharmacy claim, as determined by
the division.

It is the intent of the
Legislature that the division and any managed care entity described in
subsection (H) of this section encourage the use of Alpha-Hydroxyprogesterone
Caproate (17P) to prevent recurrent preterm birth.

(10)  Dental and orthodontic
services to be determined by the division.

The division shall increase
the amount of the reimbursement rate for diagnostic and preventative dental
services for each of the fiscal years 2022, 2023 and 2024 by five percent (5%)
above the amount of the reimbursement rate for the previous fiscal year.  The
division shall increase the amount of the reimbursement rate for restorative
dental services for each of the fiscal years 2023, 2024 and 2025 by five
percent (5%) above the amount of the reimbursement rate for the previous fiscal
year.  It is the intent of the Legislature that the reimbursement rate revision
for preventative dental services will be an incentive to increase the number of
dentists who actively provide Medicaid services.  This dental services
reimbursement rate revision shall be known as the "James Russell Dumas
Medicaid Dental Services Incentive Program."

The Medical Care Advisory
Committee, assisted by the Division of Medicaid, shall annually determine the
effect of this incentive by evaluating the number of dentists who are Medicaid
providers, the number who and the degree to which they are actively billing
Medicaid, the geographic trends of where dentists are offering what types of
Medicaid services and other statistics pertinent to the goals of this
legislative intent.  This data shall annually be presented to the Chair of the
Senate Medicaid Committee and the Chair of the House Medicaid Committee.

The division shall include
dental services as a necessary component of overall health services provided to
children who are eligible for services.

(11)  Eyeglasses for
all Medicaid beneficiaries who have (a) had surgery on the eyeball or ocular
muscle that results in a vision change for which eyeglasses or a change in
eyeglasses is medically indicated within six (6) months of the surgery and is
in accordance with policies established by the division, or (b) one (1) pair
every five (5) years and in accordance with policies established by the
division.  In either instance, the eyeglasses must be prescribed by a physician
skilled in diseases of the eye or an optometrist, whichever the beneficiary
may select.

(12)  Intermediate care
facility services.

(a)  The division
shall make 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 division 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.
Preventive, diagnostic, therapeutic, rehabilitative or palliative services that
are furnished by a facility that is not part of a hospital but is organized and
operated to provide medical care to outpatients.  Clinic services include, but
are not limited to:

(a)  Services
provided by ambulatory surgical centers (ASCs) as defined in Section 41-75-1(a);
and

(b)  Dialysis
center services.

(15)  Home- and
community-based services for the elderly and disabled, as provided under Title
XIX of the federal Social Security Act, as amended, under waivers, subject to
the availability of funds specifically appropriated for that purpose by the
Legislature.

(16)  Mental health
services.  Certain services provided by a psychiatrist shall be reimbursed at
up to one hundred percent (100%) of the Medicare rate.  Approved therapeutic
and case management services (a) provided by an approved regional mental
health/intellectual disability center established under Sections 41-19-31 through
41-19-39, or by another community mental health service provider meeting the
requirements of the Department of Mental Health to be an approved mental
health/intellectual disability center if determined necessary by the Department
of Mental Health, using state funds that are provided in the appropriation to
the division to match federal funds, or (b) provided by a facility that is
certified by the State Department of Mental Health to provide therapeutic and
case management services, to be reimbursed on a fee for service basis, or (c)
provided in the community by a facility or program operated by the Department
of Mental Health.  Any such services provided by a facility described in
subparagraph (b) must have the prior approval of the division to be reimbursable
under this section.

(17)  Durable medical
equipment services and medical supplies.  Precertification of durable medical
equipment and medical supplies must be obtained as required by the division.
The Division of Medicaid may require durable medical equipment providers to
obtain a surety bond in the amount and to the specifications as established by
the Balanced Budget Act of 1997.  A maximum dollar amount of reimbursement for
noninvasive ventilators or ventilation treatments properly ordered and being
used in an appropriate care setting shall not be set by any health maintenance
organization, coordinated care organization, provider-sponsored health plan, or
other organization paid for services on a capitated basis by the division under
any managed care program or coordinated care program implemented by the
division under this section.  Reimbursement by these organizations to durable
medical equipment suppliers for home use of noninvasive and invasive
ventilators shall be on a continuous monthly payment basis for the duration of
medical need throughout a patient's valid prescription period.

(18)  (a)
Notwithstanding any other provision of this section to the contrary, as
provided in the Medicaid state plan amendment or amendments as defined in Section
43-13-145(10), the division shall make additional reimbursement to hospitals
that serve a disproportionate share of low-income patients and that meet the
federal requirements for those payments as provided in Section 1923 of the
federal Social Security Act and any applicable regulations.  It is the intent
of the Legislature that the division shall draw down all available federal
funds allotted to the state for disproportionate share hospitals.  However,
from and after January 1, 1999, public hospitals participating in the Medicaid
disproportionate share program may be required to participate in an
intergovernmental transfer program as provided in Section 1903 of the federal
Social Security Act and any applicable regulations.

(b)  (i)  1.  The
division may establish a Medicare Upper Payment Limits Program, as defined in
Section 1902(a)(30) of the federal Social Security Act and any applicable
federal regulations, or an allowable delivery system or provider payment
initiative authorized under 42 CFR 438.6(c), for hospitals, nursing facilities
and physicians employed or contracted by hospitals.

2.  The
division shall establish a Medicaid Supplemental Payment Program, as permitted
by the federal Social Security Act and a comparable allowable delivery system
or provider payment initiative authorized under 42 CFR 438.6(c), for emergency
ambulance transportation providers in accordance with this subsection
(A)(18)(b).

(ii)  The
division shall assess each hospital, nursing facility, and emergency ambulance
transportation provider for the sole purpose of financing the state portion of
the Medicare Upper Payment Limits Program or other program(s) authorized under
this subsection (A)(18)(b).  The hospital assessment shall be as provided in
Section 43-13-145(4)(a), and the nursing facility and the emergency ambulance
transportation assessments, if established, shall be based on Medicaid
utilization or other appropriate method, as determined by the division,
consistent with federal regulations.  The assessments will remain in effect as
long as the state participates in the Medicare Upper Payment Limits Program or
other program(s) authorized under this subsection (A)(18)(b).  In addition to
the hospital assessment provided in Section 43-13-145(4)(a), hospitals with
physicians participating in the Medicare Upper Payment Limits Program or other
program(s) authorized under this subsection (A)(18)(b) shall be required to
participate in an intergovernmental transfer or assessment, as determined by
the division, for the purpose of financing the state portion of the physician
UPL payments or other payment(s) authorized under this subsection (A)(18)(b).

(iii)  Subject
to approval by the Centers for Medicare and Medicaid Services (CMS) and the
provisions of this subsection (A)(18)(b), the division shall make additional
reimbursement to hospitals, nursing facilities, and emergency ambulance
transportation providers for the Medicare Upper Payment Limits Program or other
program(s) authorized under this subsection (A)(18)(b), 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, provided the assessment in this subsection
(A)(18)(b) is in effect.

(iv)
Notwithstanding any other provision of this article to the contrary, effective
upon implementation of the Mississippi Hospital Access Program (MHAP) provided
in subparagraph (c)(i) below, the hospital portion of the inpatient Upper
Payment Limits Program shall transition into and be replaced by the MHAP
program.  However, the division is authorized to develop and implement an
alternative fee-for-service Upper Payment Limits model in accordance with
federal laws and regulations if necessary to preserve supplemental funding.
Further, the division, in consultation with the hospital industry 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 division, in consultation
with the hospital industry, 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.

(v)  1.  To preserve
and improve access to ambulance transportation provider services, the division
shall seek CMS approval to make ambulance service access payments as set forth
in this subsection (A)(18)(b) for all covered emergency ambulance services
rendered on or after July 1, 2022, and shall make such ambulance service access
payments for all covered services rendered on or after the effective date of
CMS approval.

2.  The
division shall calculate the ambulance service access payment amount as the
balance of the portion of the Medical Care Fund related to ambulance
transportation service provider assessments plus any federal matching funds
earned on the balance, up to, but not to exceed, the upper payment limit gap
for all emergency ambulance service providers.

3.  a.
Except for ambulance services exempt from the assessment provided in this
paragraph (18)(b), all ambulance transportation service providers shall be
eligible for ambulance service access payments each state fiscal year as set
forth in this paragraph (18)(b).

b.
In addition to any other funds paid to ambulance transportation service providers
for emergency medical services provided to Medicaid beneficiaries, each
eligible ambulance transportation service provider shall receive ambulance
service access payments each state fiscal year equal to the ambulance
transportation service provider's upper payment limit gap.  Subject to approval
by the Centers for Medicare and Medicaid Services, ambulance service access
payments shall be made no less than on a quarterly basis.

c.
As used in this paragraph (18)(b)(v), the term "upper payment limit
gap" means the difference between the total amount that the ambulance
transportation service provider received from Medicaid and the average amount
that the ambulance transportation service provider would have received from
commercial insurers for those services reimbursed by Medicaid.

4.  An
ambulance service access payment shall not be used to offset any other payment
by the division for emergency or nonemergency services to Medicaid
beneficiaries.

(c)  (i)  Not later
than December l, 2015, the division shall, subject to approval by the Centers
for Medicare and Medicaid Services (CMS), establish, implement and operate a
Mississippi Hospital Access Program (MHAP) for the purpose of protecting
patient access to hospital care through hospital inpatient reimbursement
programs provided in this section designed to maintain total hospital
reimbursement for inpatient services rendered by in-state hospitals and the out-of-state
hospital that is authorized by federal law to submit intergovernmental transfers
(IGTs) to the State of Mississippi and is classified as Level I trauma center
located in a county contiguous to the state line at the maximum levels
permissible under applicable federal statutes and regulations, at which time
the current inpatient Medicare Upper Payment Limits (UPL) Program for hospital
inpatient services shall transition to the MHAP.

(ii)  Subject
to approval by the Centers for Medicare and Medicaid Services (CMS), the MHAP
shall provide increased inpatient capitation (PMPM) payments to managed care
entities contracting with the division pursuant to subsection (H) of this
section to support availability of hospital services or such other payments
permissible under federal law necessary to accomplish the intent of this
subsection.

(iii)  The
intent of this subparagraph (c) is that effective for all inpatient hospital
Medicaid services during state fiscal year 2016, and so long as this provision
shall remain in effect hereafter, the division shall to the fullest extent
feasible replace the additional reimbursement for hospital inpatient services
under the inpatient Medicare Upper Payment Limits (UPL) Program with additional
reimbursement under the MHAP and other payment programs for inpatient and/or
outpatient payments which may be developed under the authority of this
paragraph.

(iv)  The
division shall assess each hospital as provided in Section 43-13-145(4)(a) for
the purpose of financing the state portion of the MHAP, supplemental payments
and such other purposes as specified in Section 43-13-145.  The assessment will
remain in effect as long as the MHAP and supplemental payments are in
effect.

(19)  (a)  Perinatal
risk management services.  The division shall promulgate regulations to be
effective from and after October 1, 1988, to establish a comprehensive
perinatal system for risk assessment of all pregnant and infant Medicaid
recipients and for management, education and follow-up for those who are
determined to be at risk.  Services to be performed include case management, nutrition
assessment/counseling, psychosocial assessment/counseling and health
education.  The division shall contract with the State Department of Health to
provide services within this paragraph (Perinatal High Risk Management/Infant
Services System (PHRM/ISS)).  The State Department of Health shall be
reimbursed on a full reasonable cost basis for services provided under this
subparagraph (a).

(b)  Early
intervention system services.  The division shall cooperate with the State
Department of Health, acting as lead agency, in the development and
implementation of a statewide system of delivery of early intervention
services, under Part C of the Individuals with Disabilities Education Act
(IDEA).  The State Department of Health shall certify annually in writing to
the executive director of the division the dollar amount of state early
intervention funds available that will be utilized as a certified match for
Medicaid matching funds.  Those funds then shall be used to provide expanded
targeted case management services for Medicaid eligible children with special
needs who are eligible for the state's early intervention system.
Qualifications for persons providing service coordination shall be determined
by the State Department of Health and the Division of Medicaid.

(20)  Home- and
community-based services for physically disabled approved services as allowed
by a waiver from the United States Department of Health and Human Services for
home- and community-based services for physically disabled people using state
funds that are provided from the appropriation to the State Department of
Rehabilitation Services and used to match federal funds under a cooperative
agreement between the division and the department, provided that funds for
these services are specifically appropriated to the Department of
Rehabilitation Services.

(21)  Nurse
practitioner services.  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 division.
Reimbursement for those services shall not exceed ninety percent (90%) of the
reimbursement rate for comparable services rendered by a physician.  The
division may provide for a reimbursement rate for nurse practitioner services
of up to one hundred percent (100%) of the reimbursement rate for comparable
services rendered by a physician for nurse practitioner services that are
provided after the normal working hours of the nurse practitioner, as
determined in accordance with regulations of the division.

(22)  Ambulatory
services delivered in federally qualified health centers, rural health centers
and clinics of the local health departments of the State Department of Health
for individuals eligible for Medicaid under this article based on reasonable
costs as determined by the division.  Federally qualified health centers shall
be reimbursed by the Medicaid prospective payment system as approved by the
Centers for Medicare and Medicaid Services.  The division shall recognize
federally qualified health centers (FQHCs), rural health clinics (RHCs) and
community mental health centers (CMHCs) as both an originating and distant site
provider for the purposes of telehealth reimbursement.  The division is further
authorized and directed to reimburse FQHCs, RHCs and CMHCs for both distant
site and originating site services when such services are appropriately
provided by the same organization.

(23)  Inpatient
psychiatric services.

(a)  Inpatient
psychiatric services to be determined by the division 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 division 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 division.  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.

(b)  The division
may reimburse for services provided by a licensed freestanding psychiatric
hospital to Medicaid recipients over the age of twenty-one (21) in a method and
manner consistent with the provisions of Section 43-13-117.5.

(24)  [Deleted]

(25)  [Deleted]

(26)  Hospice care.  As
used in this paragraph, the term "hospice care" means a coordinated
program of active professional medical attention within the home and outpatient
and inpatient care that treats the terminally ill patient and family as a unit,
employing a medically directed interdisciplinary team.  The program provides
relief of severe pain or other physical symptoms and supportive care to meet
the special needs arising out of physical, psychological, spiritual, social and
economic stresses that are experienced during the final stages of illness and
during dying and bereavement and meets the Medicare requirements for
participation as a hospice as provided in federal regulations.

(27)  Group health plan
premiums and cost-sharing if it is cost-effective as defined by the United
States Secretary of Health and Human Services.

(28)  Other health
insurance premiums that are cost-effective as defined by the United States
Secretary of Health and Human Services.  Medicare eligible must have Medicare
Part B before other insurance premiums can be paid.

(29)  The Division of
Medicaid may apply for a waiver from the United States Department of Health and
Human Services for home- and community-based services for developmentally
disabled people using state funds that are provided from the appropriation to
the State Department of Mental Health and/or funds transferred to the
department by a political subdivision or instrumentality of the state and used
to match federal funds under a cooperative agreement between the division and
the department, provided that funds for these services are specifically
appropriated to the Department of Mental Health and/or transferred to the
department by a political subdivision or instrumentality of the state.

(30)  Pediatric skilled
nursing services as determined by the division and in a manner consistent with
regulations promulgated by the Mississippi State Department of Health.

(31)  Targeted case
management services for children with special needs, under waivers from the
United States Department of Health and Human Services, using state funds that
are provided from the appropriation to the Mississippi Department of Human
Services and used to match federal funds under a cooperative agreement between
the division and the department.

(32)  Care and services
provided in Christian Science Sanatoria listed and certified by the Commission
for Accreditation of Christian Science Nursing Organizations/Facilities, Inc.,
rendered in connection with treatment by prayer or spiritual means to the
extent that those services are subject to reimbursement under Section 1903 of
the federal Social Security Act.

(33)  Podiatrist
services.

(34)  Assisted living
services as provided through  home- and community-based services under Title
XIX of the federal Social Security Act, as amended, subject to the availability
of funds specifically appropriated for that purpose by the Legislature.

(35)  Services and
activities authorized in Sections 43-27-101 and 43-27-103, using state funds
that are provided from the appropriation to the Mississippi Department of Human
Services and used to match federal funds under a cooperative agreement between
the division and the department.

(36)  Nonemergency
transportation services for Medicaid-eligible persons as determined by the
division.  The PEER Committee shall conduct a performance evaluation of the
nonemergency transportation program to evaluate the administration of the
program and the providers of transportation services to determine the most cost-effective
ways of providing nonemergency transportation services to the patients served
under the program.  The performance evaluation shall be completed and provided
to the members of the Senate Medicaid Committee and the House Medicaid
Committee not later than January 1, 2019, and every two (2) years thereafter.

(37)  [Deleted]

(38)  Chiropractic
services.  A chiropractor's manual manipulation of the spine to correct a
subluxation, if x-ray demonstrates that a subluxation exists and if the
subluxation has resulted in a neuromusculoskeletal condition for which
manipulation is appropriate treatment, and related spinal x-rays performed to
document these conditions.  Reimbursement for chiropractic services shall not
exceed Seven Hundred Dollars ($700.00) per year per beneficiary.

(39)  Dually eligible
Medicare/Medicaid beneficiaries.  The division shall pay the Medicare
deductible and coinsurance amounts for services available under Medicare, as
determined by the division.  From and after July 1, 2009, the division 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 division and the
department.

(42)  [Deleted]

(43)  The division
shall provide reimbursement, according to a payment schedule developed by the
division, for smoking cessation medications for pregnant women during their
pregnancy and other Medicaid-eligible women who are of child-bearing age.

(44)  Nursing facility
services for the severely disabled.

(a)  Severe
disabilities include, but are not limited to, spinal cord injuries, closed-head
injuries and ventilator-dependent patients.

(b)  Those services
must be provided in a long-term care nursing facility dedicated to the care and
treatment of persons with severe disabilities.

(45)  Physician assistant
services.  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
division.  Reimbursement for those services shall not exceed ninety percent
(90%) of the reimbursement rate for comparable services rendered by a
physician.  The division may provide for a reimbursement rate for physician
assistant services of up to one hundred percent (100%) or the reimbursement
rate for comparable services rendered by a physician for physician assistant
services that are provided after the normal working hours of the physician
assistant, as determined in accordance with regulations of the division.

(46)  The division
shall make application to the federal  Centers for Medicare and Medicaid
Services (CMS) for a waiver to develop and provide services for children with
serious emotional disturbances as defined in Section 43-14-1(1), which may
include home- and community-based services, case management services or managed
care services through mental health providers certified by the Department of
Mental Health.  The division may implement and provide services under this
waivered program only if funds for these services are specifically appropriated
for this purpose by the Legislature, or if funds are voluntarily provided by
affected agencies.

(47)  (a)  The division
may develop and implement disease management programs for individuals with high-cost
chronic diseases and conditions, including the use of grants, waivers,
demonstrations or other projects as necessary.

(b)  Participation
in any disease management program implemented under this paragraph (47) is
optional with the individual.  An individual must affirmatively elect to
participate in the disease management program in order to participate, and may
elect to discontinue participation in the program at any time.

(48)  Pediatric long-term
acute care hospital services.

(a)  Pediatric long-term
acute care hospital services means services provided to eligible persons under
twenty-one (21) years of age by a freestanding Medicare-certified hospital that
has an average length of inpatient stay greater than twenty-five (25) days and
that is primarily engaged in providing chronic or long-term medical care to
persons under twenty-one (21) years of age.

(b)  The services
under this paragraph (48) shall be reimbursed as a separate category of
hospital services.

(49)  The division may
establish copayments and/or coinsurance for any Medicaid services for which
copayments and/or coinsurance are allowable under federal law or regulation.

(50)  Services provided
by the State Department of Rehabilitation Services for the care and
rehabilitation of persons who are deaf and blind, as allowed under waivers from
the United States Department of Health and Human Services to provide home- and
community-based services using state funds that are provided from the
appropriation to the State Department of Rehabilitation Services or if funds
are voluntarily provided by another agency.

(51)  Upon
determination of Medicaid eligibility and in association with annual
redetermination of Medicaid eligibility, beneficiaries shall be encouraged to
undertake a physical examination that will establish a base-line level of
health and identification of a usual and customary source of care (a medical
home) to aid utilization of disease management tools.  This physical
examination and utilization of these disease management tools shall be
consistent with current United States Preventive Services Task Force or other
recognized authority recommendations.

For persons who are
determined ineligible for Medicaid, the division will provide information and
direction for accessing medical care and services in the area of their
residence.

(52)  Notwithstanding
any provisions of this article, the division may pay enhanced reimbursement
fees related to trauma care, as determined by the division in conjunction with
the State Department of Health, using funds appropriated to the State
Department of Health for trauma care and services and used to match federal
funds under a cooperative agreement between the division and the State
Department of Health.  The division, in conjunction with the State Department
of Health, may use grants, waivers, demonstrations, enhanced reimbursements,
Upper Payment Limits Programs, supplemental payments, or other projects as
necessary in the development and implementation of this reimbursement program.

(53)  Targeted case
management services for high-cost beneficiaries may be developed by the
division for all services under this section.

(54)  [Deleted]

(55)  Therapy
services.  The plan of care for therapy services may be developed to cover a
period of treatment for up to six (6) months, but in no event shall the plan of
care exceed a six-month period of treatment.  The projected period of treatment
must be indicated on the initial plan of care and must be updated with each
subsequent revised plan of care.  Based on medical necessity, the division
shall approve certification periods for less than or up to six (6) months, but
in no event shall the certification period exceed the period of treatment
indicated on the plan of care.  The appeal process for any reduction in therapy
services shall be consistent with the appeal process in federal regulations.

(56)  Prescribed
pediatric extended care centers services for medically dependent or
technologically dependent children with complex medical conditions that require
continual care as prescribed by the child's attending physician, as determined
by the division.

(57)  No Medicaid
benefit shall restrict coverage for medically appropriate treatment prescribed
by a physician and agreed to by a fully informed individual, or if the
individual lacks legal capacity to consent by a person who has legal authority
to consent on his or her behalf, based on an individual's diagnosis with a
terminal condition.  As used in this paragraph (57), "terminal
condition" means any aggressive malignancy, chronic end-stage
cardiovascular or cerebral vascular disease, or any other disease, illness or
condition which a physician diagnoses as terminal.

(58)  Treatment
services for persons with opioid dependency or other highly addictive substance
use disorders.  The division is authorized to reimburse eligible providers for
treatment of opioid dependency and other highly addictive substance use disorders,
as determined by the division.  Treatment related to these conditions shall not
count against any physician visit limit imposed under this section.

(59)  The division
shall allow beneficiaries between the ages of ten (10) and eighteen (18) years
to receive vaccines through a pharmacy venue.  The division and the State
Department of Health shall coordinate and notify OB-GYN providers that the
Vaccines for Children program is available to providers free of charge.

(60)  Border city
university-affiliated pediatric teaching hospital.

(a)  Payments may
only be made to a border city university-affiliated pediatric teaching hospital
if the Centers for Medicare and Medicaid Services (CMS) approve an increase in
the annual request for the provider payment initiative authorized under 42 CFR
Section 438.6(c) in an amount equal to or greater than the estimated annual
payment to be made to the border city university-affiliated pediatric teaching
hospital.  The estimate shall be based on the hospital's prior year Mississippi
managed care utilization.

(b)  As used in
this paragraph (60), the term "border city university-affiliated pediatric
teaching hospital" means an out-of-state hospital located within a city
bordering the eastern bank of the Mississippi River and the State of
Mississippi that submits to the division a copy of a current and effective
affiliation agreement with an accredited university and other documentation
establishing that the hospital is university-affiliated, is licensed and
designated as a pediatric hospital or pediatric primary hospital within its
home state, maintains at least five (5) different pediatric specialty training
programs, and maintains at least one hundred (100) operated beds dedicated
exclusively for the treatment of patients under the age of twenty-one (21)
years.

(c)  The cost of providing
services to Mississippi Medicaid beneficiaries under the age of twenty-one (21)
years who are treated by a border city university-affiliated pediatric teaching
hospital shall not exceed the cost of providing the same services to
individuals in hospitals in the state.

(d)  It is the
intent of the Legislature that payments shall not result in any in-state
hospital receiving payments lower than they would otherwise receive if not for
the payments made to any border city university-affiliated pediatric teaching
hospital.

(e)  This paragraph
(60) shall stand repealed on July 1, 2024.

(61)  Services
described in Section 41-140-3 that are provided by certified community health
workers employed and supervised by a Medicaid provider.  Reimbursement for
these services shall be provided only if the division has received approval
from the Centers for Medicare and Medicaid Services for a state plan amendment,
waiver or alternative payment model for services delivered by certified
community health workers.

(62)  Biomarker
testing in accordance with the provisions of Sections 2 and 3 of this act.
With respect to biomarker testing, the division shall, within sixty (60) days
after the effective date of this act, update the fee schedule for Medicaid
services to include the appropriate current procedural terminology (CPT) and
proprietary laboratory analysis (PLA) codes for all biomarker tests coverage
that is mandated under Sections 2 and 3 of this act.

(B)  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).

(C)  The division may pay to
those providers who participate in and accept patient referrals from the
division's emergency room redirection program a percentage, as determined by
the division, of savings achieved according to the performance measures and reduction
of costs required of that program.  Federally qualified health centers may
participate in the emergency room redirection program, and the division may pay
those centers a percentage of any savings to the Medicaid program achieved by
the centers' accepting patient referrals through the program, as provided in
this subsection (C).

(D)  (1)  As used in this
subsection (D), the following terms shall be defined as provided in this
paragraph, except as otherwise provided in this subsection:

(a)  "Committees"
means the Medicaid Committees of the House of Representatives and the Senate,
and "committee" means either one of those committees.

(b)  "Rate change"
means an increase, decrease or other change in the payments or rates of
reimbursement, or a change in any payment methodology that results in an
increase, decrease or other change in the payments or rates of reimbursement,
to any Medicaid provider that renders any services authorized to be provided to
Medicaid recipients under this article.

(2)  Whenever the
Division of Medicaid proposes a rate change, the division shall give notice to
the chairmen of the committees at least thirty (30) calendar days before the
proposed rate change is scheduled to take effect.  The division shall furnish
the chairmen with a concise summary of each proposed rate change along with the
notice, and shall furnish the chairmen with a copy of any proposed rate change
upon request.  The division also shall provide a summary and copy of any
proposed rate change to any other member of the Legislature upon request.

(3)  If the chairman of
either committee or both chairmen jointly object to the proposed rate change or
any part thereof, the chairman or chairmen shall notify the division and
provide the reasons for their objection in writing not later than seven (7)
calendar days after receipt of the notice from the division.  The chairman or
chairmen may make written recommendations to the division for changes to be
made to a proposed rate change.

(4)  (a)  The chairman
of either committee or both chairmen jointly may hold a committee meeting to
review a proposed rate change.  If either chairman or both chairmen decide to
hold a meeting, they shall notify the division of their intention in writing
within seven (7) calendar days after receipt of the notice from the division,
and shall set the date and time for the meeting in their notice to the
division, which shall not be later than fourteen (14) calendar days after
receipt of the notice from the division.

(b)  After the
committee meeting, the committee or committees may object to the proposed rate
change or any part thereof.  The committee or committees shall notify the division
and the reasons for their objection in writing not later than seven (7)
calendar days after the meeting.  The committee or committees may make written
recommendations to the division for changes to be made to a proposed rate
change.

(5)  If both chairmen
notify the division in writing within seven (7) calendar days after receipt of
the notice from the division that they do not object to the proposed rate
change and will not be holding a meeting to review the proposed rate change,
the proposed rate change will take effect on the original date as scheduled by
the division or on such other date as specified by the division.

(6)  (a)  If there are
any objections to a proposed rate change or any part thereof from either or
both of the chairmen or the committees, the division may withdraw the proposed
rate change, make any of the recommended changes to the proposed rate change,
or not make any changes to the proposed rate change.

(b)  If the
division does not make any changes to the proposed rate change, it shall notify
the chairmen of that fact in writing, and the proposed rate change shall take
effect on the original date as scheduled by the division or on such other date
as specified by the division.

(c)  If the
division makes any changes to the proposed rate change, the division shall
notify the chairmen of its actions in writing, and the revised proposed rate
change shall take effect on the date as specified by the division.

(7)  Nothing in this
subsection (D) shall be construed as giving the chairmen or the committees any
authority to veto, nullify or revise any rate change proposed by the division.
The authority of the chairmen or the committees under this subsection shall be
limited to reviewing, making objections to and making recommendations for
changes to rate changes proposed by the division.

(E)  Notwithstanding any
provision of this article, no new groups or categories of recipients and new
types of care and services may be added without enabling legislation from the
Mississippi Legislature, except that the division may authorize those changes
without enabling legislation when the addition of recipients or services is
ordered by a court of proper authority.

(F)  The executive director
shall keep the Governor advised on a timely basis of the funds available for
expenditure and the projected expenditures.  Notwithstanding any other provisions
of this article, if current or projected expenditures of the division are
reasonably anticipated to exceed the amount of funds appropriated to the division
for any fiscal year, the Governor, after consultation with the executive
director, shall take all appropriate measures to reduce costs, which may
include, but are not limited to:

(1)  Reducing or
discontinuing any or all services that are deemed to be optional under Title
XIX of the Social Security Act;

(2)  Reducing
reimbursement rates for any or all service types;

(3)  Imposing
additional assessments on health care providers; or

(4)  Any additional
cost-containment measures deemed appropriate by the Governor.

To the extent allowed under
federal law, any reduction to services or reimbursement rates under this
subsection (F) shall be accompanied by a reduction, to the fullest allowable
amount, to the profit margin and administrative fee portions of capitated
payments to organizations described in paragraph (1) of subsection (H).

Beginning in fiscal year
2010 and in fiscal years thereafter, when Medicaid expenditures are projected
to exceed funds available for the fiscal year, the division shall submit the
expected shortfall information to the PEER Committee not later than December 1
of the year in which the shortfall is projected to occur.  PEER shall review
the computations of the division and report its findings to the Legislative
Budget Office not later than January 7 in any year.

(G)  Notwithstanding any
other provision of this article, it shall be the duty of each provider
participating in the Medicaid program to keep and maintain books, documents and
other records as prescribed by the Division of Medicaid in accordance with
federal laws and regulations.

(H)  (1)  Notwithstanding
any other provision of this article, the division is authorized to implement
(a) a managed care program, (b) a coordinated care program, (c) a coordinated
care organization program, (d) a health maintenance organization program, (e) a
patient-centered medical home program, (f) an accountable care organization
program, (g) provider-sponsored health plan, or (h) any combination of the
above programs.  As a condition for the approval of any program under this
subsection (H)(1), the division shall require that no managed care program,
coordinated care program, coordinated care organization program, health
maintenance organization program, or provider-sponsored health plan 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 division, develop and implement
innovative payment models that incentivize improvements in health care quality,
outcomes, or value, as determined by the division.  Participation in the
provider network of any managed care, coordinated care, provider-sponsored
health plan, or similar contractor shall not be conditioned on the provider's
agreement to accept such alternative payment models;

(d)  Implement a
prior authorization and utilization review program for medical services,
transportation services and prescription drugs that is more stringent than the
prior authorization processes used by the division in its administration of the
Medicaid program.  Not later than December 2, 2021, the contractors that are
receiving capitated payments under a managed care delivery system established
under this subsection (H) shall submit a report to the Chairmen of the House
and Senate Medicaid Committees on the status of the prior authorization and
utilization review program for medical services, transportation services and
prescription drugs that is required to be implemented under this subparagraph
(d);

(e)  [Deleted]

(f)  Implement a
preferred drug list that is more stringent than the mandatory preferred drug
list established by the division under subsection (A)(9) of this section;

(g)  Implement a
policy which denies beneficiaries with hemophilia access to the federally
funded hemophilia treatment centers as part of the Medicaid Managed Care
network of providers.

Each health maintenance
organization, coordinated care organization, provider-sponsored health plan, or
other organization paid for services on a capitated basis by the division under
any managed care program or coordinated care program implemented by the
division under this section shall use a clear set of level of care guidelines
in the determination of medical necessity and in all utilization management
practices, including the prior authorization process, concurrent reviews,
retrospective reviews and payments, that are consistent with widely accepted
professional standards of care.  Organizations participating in a managed care
program or coordinated care program implemented by the division may not use any
additional criteria that would result in denial of care that would be
determined appropriate and, therefore, medically necessary under those levels
of care guidelines.

(2)  Notwithstanding
any provision of this section, the recipients eligible for enrollment into a
Medicaid Managed Care Program authorized under this subsection (H) may include
only those categories of recipients eligible for participation in the Medicaid
Managed Care Program as of January 1, 2021, the Children's Health Insurance
Program (CHIP), and the CMS-approved Section 1115 demonstration waivers in
operation as of January 1, 2021.  No expansion of Medicaid Managed Care Program
contracts may be implemented by the division without enabling legislation from
the Mississippi Legislature.

(3)  (a)  Any
contractors receiving capitated payments under a managed care delivery system
established in this section shall provide to the Legislature and the division
statistical data to be shared with provider groups in order to improve patient
access, appropriate utilization, cost savings and health outcomes not later
than October 1 of each year.  Additionally, each contractor shall disclose to
the Chairmen of the Senate and House Medicaid Committees the administrative
expenses costs for the prior calendar year, and the number of full-equivalent
employees located in the State of Mississippi dedicated to the Medicaid and
CHIP lines of business as of June 30 of the current year.

(b)  The division
and the contractors participating in the managed care program, a coordinated
care program or a provider-sponsored health plan shall be subject to annual
program reviews or audits performed by the Office of the State Auditor, the
PEER Committee, the Department of Insurance and/or independent third parties.

(c)  Those reviews
shall include, but not be limited to, at least two (2) of the following items:

(i)  The
financial benefit to the State of Mississippi of the managed care program,

(ii)  The
difference between the premiums paid to the managed care contractors and the
payments made by those contractors to health care providers,

(iii)
Compliance with performance measures required under the contracts,

(iv)
Administrative expense allocation methodologies,

(v)  Whether
nonprovider payments assigned as medical expenses are appropriate,

(vi)
Capitated arrangements with related party subcontractors,

(vii)
Reasonableness of corporate allocations,

(viii)  Value-added
benefits and the extent to which they are used,

(ix)  The
effectiveness of subcontractor oversight, including subcontractor review,

(x)  Whether
health care outcomes have been improved, and

(xi)  The most
common claim denial codes to determine the reasons for the denials.

The audit reports shall be
considered public documents and shall be posted in their entirety on the
division's website.

(4)  All health
maintenance organizations, coordinated care organizations, provider-sponsored
health plans, or other organizations paid for services on a capitated basis by
the division under any managed care program or coordinated care program
implemented by the division under this section shall 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 division under any managed care program or coordinated care program
implemented by the division under this section shall require its providers or
beneficiaries to use any pharmacy that ships, mails or delivers prescription
drugs or legend drugs or devices.

(6)  (a)  Not later
than December 1, 2021, the contractors who are receiving capitated payments
under a managed care delivery system established under this subsection (H)
shall develop and implement a uniform credentialing process for providers.
Under that uniform credentialing process, a provider who meets the criteria for
credentialing will be credentialed with all of those contractors and no such
provider will have to be separately credentialed by any individual contractor
in order to receive reimbursement from the contractor.  Not later than December
2, 2021, those contractors shall submit a report to the Chairmen of the House
and Senate Medicaid Committees on the status of the uniform credentialing
process for providers that is required under this subparagraph (a).

(b)  If those
contractors have not implemented a uniform credentialing process as described
in subparagraph (a) by December 1, 2021, the division shall develop and implement,
not later than July 1, 2022, a single, consolidated credentialing process by
which all providers will be credentialed.  Under the division's single,
consolidated credentialing process, no such contractor shall require its
providers to be separately credentialed by the contractor in order to receive
reimbursement from the contractor, but those contractors shall recognize the
credentialing of the providers by the division's credentialing process.

(c)  The division
shall require a uniform provider credentialing application that shall be used
in the credentialing process that is established under subparagraph (a) or
(b).  If the contractor or division, as applicable, has not approved or denied
the provider credentialing application within sixty (60) days of receipt of the
completed application that includes all required information necessary for
credentialing, then the contractor or division, upon receipt of a written
request from the applicant and within five (5) business days of its receipt,
shall issue a temporary provider credential/enrollment to the applicant if the
applicant has a valid Mississippi professional or occupational license to
provide the health care services to which the credential/enrollment would
apply.  The contractor or the division shall not issue a temporary
credential/enrollment if the applicant has reported on the application a
history of medical or other professional or occupational malpractice claims, a
history of substance abuse or mental health issues, a criminal record, or a
history of medical or other licensing board, state or federal disciplinary
action, including any suspension from participation in a federal or state program.
The temporary credential/enrollment shall be effective upon issuance and shall
remain in effect until the provider's credentialing/enrollment application is
approved or denied by the contractor or division.  The contractor or division
shall render a final decision regarding credentialing/enrollment of the
provider within sixty (60) days from the date that the temporary provider
credential/enrollment is issued to the applicant.

(d)  If the
contractor or division does not render a final decision regarding
credentialing/enrollment of the provider within the time required in
subparagraph (c), the provider shall be deemed to be credentialed by and
enrolled with all of the contractors and eligible to receive reimbursement from
the contractors.

(7)  (a)  Each
contractor that is receiving capitated payments under a managed care delivery
system established under this subsection (H) shall provide to each provider for
whom the contractor has denied the coverage of a procedure that was ordered or
requested by the provider for or on behalf of a patient, a letter that provides
a detailed explanation of the reasons for the denial of coverage of the
procedure and the name and the credentials of the person who denied the
coverage.  The letter shall be sent to the provider in electronic format.

(b)  After a
contractor that is receiving capitated payments under a managed care delivery
system established under this subsection (H) has denied coverage for a claim
submitted by a provider, the contractor shall issue to the provider within
sixty (60) days a final ruling of denial of the claim that allows the provider
to have a state fair hearing and/or agency appeal with the division.  If a
contractor does not issue a final ruling of denial within sixty (60) days as
required by this subparagraph (b), the provider's claim shall be deemed to be
automatically approved and the contractor shall pay the amount of the claim to
the provider.

(c)  After a
contractor has issued a final ruling of denial of a claim submitted by a provider,
the division shall conduct a state fair hearing and/or agency appeal on the
matter of the disputed claim between the contractor and the provider within
sixty (60) days, and shall render a decision on the matter within thirty (30)
days after the date of the hearing and/or appeal.

(8)  It is the
intention of the Legislature that the division evaluate the feasibility of
using a single vendor to administer pharmacy benefits provided under a managed
care delivery system established under this subsection (H).  Providers of
pharmacy benefits shall cooperate with the division in any transition to a
carve-out of pharmacy benefits under managed care.

(9)  The division shall
evaluate the feasibility of using a single vendor to administer dental benefits
provided under a managed care delivery system established in this subsection
(H).  Providers of dental benefits shall cooperate with the division in any
transition to a carve-out of dental benefits under managed care.

(10)  It is the intent
of the Legislature that any contractor receiving capitated payments under a
managed care delivery system established in this section shall implement
innovative programs to improve the health and well-being of members diagnosed
with prediabetes and diabetes.

(11)  It is the intent
of the Legislature that any contractors receiving capitated payments under a
managed care delivery system established under this subsection (H) shall work
with providers of Medicaid services to improve the utilization of long-acting
reversible contraceptives (LARCs).  Not later than December 1, 2021, any
contractors receiving capitated payments under a managed care delivery system
established under this subsection (H) shall provide to the Chairmen of the
House and Senate Medicaid Committees and House and Senate Public Health
Committees a report of LARC utilization for State Fiscal Years 2018 through
2020 as well as any programs, initiatives, or efforts made by the contractors
and providers to increase LARC utilization.  This report shall be updated
annually to include information for subsequent state fiscal years.

(12)  The division is
authorized to make not more than one (1) emergency extension of the contracts
that are in effect on July 1, 2021, with contractors who are receiving
capitated payments under a managed care delivery system established under this
subsection (H), as provided in this paragraph (12).  The maximum period of any
such extension shall be one (1) year, and under any such extensions, the
contractors shall be subject to all of the provisions of this subsection (H).
The extended contracts shall be revised to incorporate any provisions of this
subsection (H).

(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)  In the negotiation and
execution of such contracts involving services performed by actuarial firms,
the Executive Director of the Division of Medicaid may negotiate a limitation
on liability to the state of prospective contractors.

(L)  The Division of
Medicaid shall reimburse for services  provided to eligible Medicaid
beneficiaries by a licensed birthing center in a method and manner to be
determined by the division in accordance with federal laws and federal
regulations.  The division shall seek any necessary waivers, make any required
amendments to its State Plan or revise any contracts authorized under
subsection (H) of this section as necessary to provide the services authorized
under this subsection.  As used in this subsection, the term "birthing
centers" shall have the meaning as defined in Section 41-77-1(a), which is
a publicly or privately owned facility, place or institution constructed,
renovated, leased or otherwise established where nonemergency births are
planned to occur away from the mother's usual residence following a documented
period of prenatal care for a normal uncomplicated pregnancy which has been
determined to be low risk through a formal risk-scoring examination.

(M)  This section shall
stand repealed on July 1, 2028.

SECTION 5.
Section 83-5-907, Mississippi Code of 1972, is amended as follows:

83-5-907.  Definitions.
For purposes of this article, unless the context requires otherwise, the following
terms shall have the meanings as defined in this section:

(a)  "Adverse
determination" means a determination by a health insurance issuer that,
based on the information provided, a request for a benefit under the health
insurance issuer's health benefit plan upon application of any utilization
review technique does not meet the health insurance issuer's requirements for
medical necessity, appropriateness, health care setting, level of care, or
effectiveness or is determined to be experimental or investigational and the
requested benefit is therefore denied, reduced, or terminated or payment is not
provided or made, in whole or in part, for the benefit; the denial, reduction,
or termination of or failure to provide or make payment, in whole or in part,
for a benefit based on a determination by a health insurance issuer that a
preexisting condition was present before the effective date of coverage; or a
rescission of coverage determination, which does not include a cancellation or
discontinuance of coverage that is attributable to a failure to timely pay
required premiums or contributions toward the cost of coverage.

(b)  "Appeal"
means a formal request, either orally or in writing, to reconsider an adverse
determination.

(c)
"Approval" means a determination by a health insurance issuer that a
health care service has been reviewed and, based on the information provided,
satisfies the health insurance issuer's requirements for medical necessity and
appropriateness.

(d)  "Clinical
review criteria" means the written screening procedures, decision
abstracts, clinical protocols and practice guidelines used by a health
insurance issuer to determine the necessity and appropriateness of health care
services.

(e)
"Department" means the Mississippi State Department of Insurance.

(f)  "Emergency
medical condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity, including, but not limited to, severe pain,
such that a prudent layperson who possesses an average knowledge of health and
medicine could reasonably expect the absence of immediate medical attention to
result in:

(i)  Placing the
health of the individual or, with respect to a pregnant woman, the health of
the woman or her unborn child, in serious jeopardy;

(ii)  Serious
impairment to bodily functions; or

(iii)  Serious
dysfunction of any bodily organ or part.

(g)  "Emergency
services" means health care items and services furnished or required to
evaluate and treat an emergency medical condition.

(h)
"Enrollee" means any person and his or her dependents enrolled in or
covered by a health care plan.

(i)  "Health care
professional" means a physician, a registered professional nurse or other
individual appropriately licensed or registered to provide health care
services.

(j)  "Health care
provider" means any physician, hospital, ambulatory surgery center, or
other person or facility that is licensed or otherwise authorized to deliver
health care services.

(k)  "Health care
service" means any services or level of services included in the
furnishing to an individual of medical care or the hospitalization incident to
the furnishing of such care, as well as the furnishing to any person of any
other services for the purpose of preventing, alleviating, curing, diagnosing,
screening for, or healing human illness or injury, including behavioral
health, mental health, home health and pharmaceutical services and products.

(l)  "Health
insurance issuer" has the meaning given to that term in Section 83-9-6.3.
Any provision of this article that applies to a "health insurance
issuer" also applies to any person or entity covered under the scope of
this article in Section 83-5-905.

(m)  "Medically
necessary" means a health care professional exercising prudent clinical
judgment would provide care to a patient for the purpose of preventing,
diagnosing, or treating an illness, injury, disease or its symptoms and that
are:

(i)  In accordance
with generally accepted standards of medical practice; and

(ii)  Clinically
appropriate in terms of type, frequency, extent, site and duration and are
considered effective for the patient's illness, injury or disease; and not
primarily for the convenience of the patient, treating physician, other health
care professional, caregiver, family member or other interested party, but
focused on what is best for the patient's health outcome.

(n)
"Physician" means any person with a valid doctor of medicine, doctor
of osteopathy or doctor of podiatry degree.

(o)  "Prior
authorization" means the process by which a health insurance issuer
determines the medical necessity and medical appropriateness of an otherwise
covered health care service before the rendering of such health care service.
"Prior authorization" includes any health insurance issuer's
requirement that an enrollee, health care professional or health care provider
notify the health insurance issuer before, at the time of, or concurrent to
providing a health care service.

(p)  "Urgent
health care service" means a health care service with respect to which the
application of the time periods for making a nonexpedited prior authorization
that in the opinion of a treating health care professional or health care
provider with knowledge of the enrollee's medical condition:

(i)  Could
seriously jeopardize the life or health of the enrollee or the ability of the
enrollee to regain maximum function;

(ii)  Could subject
the enrollee to severe pain that cannot be adequately managed without the care
or treatment that is the subject of the utilization review; or

(iii)  Could lead
to likely onset of an emergency medical condition if the service is not
rendered during the time period to render a prior authorization determination
for an urgent medical service.

(q)  "Urgent
health care service" does not include emergency services.

(r)  "Private
review agent" has the meaning given to that term in Section 41-83-1.

SECTION 6.
This act shall take effect and be in force from and after July 1, 2026.