Bill Amendment: MS SB2836 | 2018 | Regular Session
Bill Title: Mississippi Medicaid program; revise services, provider reimbursement rates and extend repealer.
Status: 2018-04-12 - Approved by Governor [SB2836 Detail]
Download: Mississippi-2018-SB2836-House_Committee_Amendment_No_1.html
Pending
COMMITTEE AMENDMENT NO 1 PROPOSED TO
Senate Bill No. 2836
BY: Committee
Amend by striking all after the enacting clause and inserting in lieu thereof the following:
SECTION 1. 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 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 division.
(b) From and after July 1, 1994, the Executive Director of the Division of Medicaid 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 division 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 division.
(f) The division shall develop and implement a hospital readmissions reduction program designed to reduce potentially preventable readmissions. Notwithstanding any other provisions of this article to the contrary, the division shall work with any managed care program or other program as specified in subsection (H) of this section in implementing and successfully operating such a program.
(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 is authorized to 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 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's services. * * * The
division 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, * * * 2018, 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, 2010, 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 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 division may reimburse obstetricians and gynecologists for certain primary
care services as defined by the division at one hundred percent (100%) of the
rate established under Medicare.
(7)
(a) Home health services for eligible persons, not to exceed in cost the
prevailing cost of nursing facility services * * *.
All home health visits must be precertified as required by the division.
(b) [Repealed]
(8)
Emergency medical transportation services as determined by the division.
* * *
(9) (a) Legend and other drugs as may be 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 shall 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).
The voluntary preferred drug list shall be expanded to function in the interim in order to have a manageable prior authorization system, thereby minimizing disruption of service to beneficiaries.
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 shall develop and implement a program of payment for additional pharmacist services, with payment to be based on demonstrated savings, but in no case shall the total payment exceed twice the amount of the dispensing fee.
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.
(b) Payment by the division for covered multisource drugs shall be limited to the lower of the upper limits established and published by the Centers for Medicare and Medicaid Services (CMS) plus a dispensing fee, or the estimated acquisition cost (EAC) as determined by the division, plus a dispensing fee, or the providers' usual and customary charge to the general public.
Payment for other covered drugs, other than multisource drugs with CMS upper limits, shall not exceed the lower of the estimated acquisition cost as determined by the division, plus a dispensing fee or the providers' usual and customary charge to the general public.
Payment for nonlegend or over-the-counter drugs covered by the division shall be reimbursed at the lower of the division's estimated shelf price or the providers' usual and customary charge to the general public.
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.
Notwithstanding any other provision of this article, the division 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.
(10)
* * *
Dental * * * and orthodontic services to be
determined by the division. The dental services * * * program under this paragraph
shall be known as the "James Russell Dumas Medicaid Dental * * * Services Program."
* * *
(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. 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 division 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 division 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 division.
(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 Division of Medicaid 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 may be reimbursed at up to one hundred
percent (100%) of the Medicare rate.
Approved therapeutic and case management
services (a) provided by an approved regional mental health/intellectual
disability center established under Sections 41-19-31 through 41-19-39, or by
another community mental health service provider meeting the requirements of
the Department of Mental Health to be an approved mental health/intellectual
disability center if determined necessary by the Department of Mental Health,
using state funds that are provided in the appropriation to the division to
match federal funds, or (b) provided by a facility that is certified by the
State Department of Mental Health to provide therapeutic and case management
services, to be reimbursed on a fee for service basis, or (c) provided in the
community by a facility or program operated by the Department of Mental
Health. Any such services provided by a facility described in subparagraph (b)
must have the prior approval of the division to be reimbursable under this
section. * * *
(17) Durable medical equipment services and medical supplies. Precertification of durable medical equipment and medical supplies must be obtained as required by the division. The Division of Medicaid may require durable medical equipment providers to obtain a surety bond in the amount and to the specifications as established by the Balanced Budget Act of 1997.
(18) (a) Notwithstanding any other provision of this section to the contrary, as provided in the Medicaid state plan amendment or amendments as defined in Section 43-13-145(10), the division shall make additional reimbursement to hospitals that serve a disproportionate share of low-income patients and that meet the federal requirements for those payments as provided in Section 1923 of the federal Social Security Act and any applicable regulations. It is the intent of the Legislature that the division shall draw down all available federal funds allotted to the state for disproportionate share hospitals. However, from and after January 1, 1999, public hospitals participating in the Medicaid disproportionate share program may be required to participate in an intergovernmental transfer program as provided in Section 1903 of the federal Social Security Act and any applicable regulations.
(b) The division shall 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 division may develop a plan for implementing an Upper Payment Limits Program for physicians employed by other classes of hospitals. The division shall assess each hospital 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. As provided in the Medicaid state plan amendment or amendments as defined in Section 43-13-145(10), the division shall make additional reimbursement to hospitals and, if the program is established for nursing facilities, shall make additional reimbursement to nursing facilities, for the Medicare Upper Payment Limits, and, if the program is established for physicians, shall make additional reimbursement for physicians, as defined in Section 1902(a)(30) of the federal Social Security Act and any applicable federal regulations. Notwithstanding any other provision of this article to the contrary, effective upon implementation of the Mississippi Hospital Access Program (MHAP) provided in subparagraph (c)(i) below, the hospital portion of the inpatient Upper Payment Limits Program shall transition into and be replaced by the MHAP program. However, the division is authorized to develop and implement an alternative fee for service Upper Payment Limits model in accordance with federal laws and regulations if necessary to preserve supplemental funding.
(c) (i) Not later than December l, 2015, the division shall, subject to approval by the Centers for Medicare and Medicaid Services (CMS), establish, implement and operate a Mississippi Hospital Access Program (MHAP) for the purpose of protecting patient access to hospital care through hospital inpatient reimbursement programs provided in this section designed to maintain total hospital reimbursement for inpatient services rendered by in-state hospitals and the out-of-state hospital that is authorized by federal law to submit intergovernmental transfers (IGTs) to the State of Mississippi and is classified as Level I trauma center located in a county contiguous to the state line at the maximum levels permissible under applicable federal statutes and regulations, at which time the current inpatient Medicare Upper Payment Limits (UPL) Program for hospital inpatient services shall transition to the MHAP.
(ii)
Subject 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 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.
(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 and such other purposes as specified in Section 43-13-145. The assessment will remain in effect as long as the MHAP is in effect.
* * *
(19) (a) Perinatal risk management services. The division shall promulgate regulations to be effective from and after October 1, 1988, to establish a comprehensive perinatal system for risk assessment of all pregnant and infant Medicaid recipients and for management, education and follow-up for those who are determined to be at risk. Services to be performed include case management, nutrition assessment/counseling, psychosocial assessment/counseling and health education. The division shall contract with the State Department of Health to provide the services within this paragraph (Perinatal High Risk Management/Infant Services System (PHRM/ISS)). The State Department of Health as the agency for PHRM/ISS for the Division of Medicaid shall be reimbursed on a full reasonable cost basis.
(b) Early intervention system services. The division shall cooperate with the State Department of Health, acting as lead agency, in the development and implementation of a statewide system of delivery of early intervention services, under Part C of the Individuals with Disabilities Education Act (IDEA). The State Department of Health shall certify annually in writing to the executive director of the division the dollar amount of state early intervention funds available that will be utilized as a certified match for Medicaid matching funds. Those funds then shall be used to provide expanded targeted case management services for Medicaid eligible children with special needs who are eligible for the state's early intervention system. Qualifications for persons providing service coordination shall be determined by the State Department of Health and the Division of Medicaid.
(20) Home- and community-based services for physically disabled approved services as allowed by a waiver from the United States Department of Health and Human Services for home- and community-based services for physically disabled people using state funds that are provided from the appropriation to the State Department of Rehabilitation Services and used to match federal funds under a cooperative agreement between the division and the department, provided that funds for these services are specifically appropriated to the Department of Rehabilitation Services.
(21) Nurse practitioner services. 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.
(23) Inpatient psychiatric services. 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.
(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 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 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, to be
provided by the Division of Medicaid. The division 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 division may pay providers a flat fee based on mileage tiers, or in the
alternative, may reimburse on actual miles traveled. The division 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 Public Health and
Welfare 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 shall establish copayments and/or coinsurance for all Medicaid services for which copayments and/or coinsurance are allowable under federal law or regulation, and shall set the amount of the copayment and/or coinsurance for each of those services at the maximum amount 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, 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) Adult foster care services pilot program. Social and protective services on a pilot program basis in an approved foster care facility for vulnerable adults who would otherwise need care in a long-term care facility, to be implemented in an area of the state with the greatest need for such program, under the Medicaid Waivers for the Elderly and Disabled program or an assisted living waiver. The division may use grants, waivers, demonstrations or other projects as necessary in the development and implementation of this adult foster care services pilot program.
(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) Medication-assisted comprehensive treatment services for persons diagnosed with an opioid use disorder or other highly addictive substance use disorder as determined by a licensed physician. Opioid or other highly addictive substance treatment services may include medical maintenance, medically supervised withdrawal and detoxification, various levels of medical, psychosocial and other types of care, detoxification treatment, and maintenance treatment. Opioid or other highly addictive substance treatment services may be provided through outpatient, residential, hospital, certified Opiate Treatment Program (OTP) or other certified substance abuse treatment program. Medication-assisted treatment programs shall be eligible for, and not prohibited from, enrollment with the division. As used in this paragraph:
(a) "Medication" means any medication approved by the Federal Drug Administration for the treatment of opiate use disorders or other highly addictive substance use disorders.
(b) "Opioid" means any drug having an addiction-forming liability similar to morphine or being capable of conversion into a drug having such addiction-forming or addiction-sustaining liability.
(c) "Highly addictive substance" means a controlled substance in Schedule I or Schedule II having a high potential for abuse that may lead to severe psychological or physical dependence.
(d) "Certified" means holding a certification provided by the State Department of Mental Health and licensed by the State Board of Pharmacy.
(59) The division 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 division 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 division, or a service for which the federal government sets the reimbursement methodology and rate, unless current or projected expenditures of the division are reasonably anticipated by the division to exceed the amount of funds appropriated to the division for any fiscal year. 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).
(C) The division may pay to those providers who participate in and accept patient referrals from the division's emergency room redirection program a percentage, as determined by the division, of savings achieved according to the performance measures and reduction of costs required of that program. Federally qualified health centers may participate in the emergency room redirection program, and the division may pay those centers a percentage of any savings to the Medicaid program achieved by the centers' accepting patient referrals through the program, as provided in this subsection (C).
(D)
* * * [Deleted]
(E) Notwithstanding any provision of this article, no new groups or categories of recipients and new types of care and services may be added without enabling legislation from the Mississippi Legislature, except that the division may authorize those changes without enabling legislation when the addition of recipients or services is ordered by a court of proper authority.
(F)
The executive director shall keep the Governor advised on a timely basis of the
funds available for expenditure and the projected expenditures. Notwithstanding
any other provisions of this article, if current or projected expenditures
of the division are reasonably anticipated to exceed the amount of funds
appropriated to the division for any fiscal year, the Governor, after
consultation with the executive director, shall * * * take all appropriate measures to reduce costs, which
may include, but are not limited to:
(1) Reducing or discontinuing any or all services that are deemed to be optional under Title XIX of the Social Security Act;
(2) Reducing reimbursement rates for any or all service types;
(3) Imposing additional assessments on health care providers; or
(4) Any additional cost containment measures deemed appropriate by the Governor.
Beginning
in fiscal year 2010 and in fiscal years thereafter, when Medicaid expenditures
are projected to exceed funds available for * * * the fiscal year, the division
shall submit the expected shortfall information to the PEER Committee * * * not later than December 1 of the
year in which the shortfall is projected to occur. PEER shall review the
computations of the division and report its findings to the Legislative Budget
Office * * * not later than
January 7 in any year. * * * If expenditure reductions or cost containments are implemented, the
Governor may implement a maximum amount of state share expenditure reductions
to providers, of which hospitals will be responsible for twenty‑five
percent (25%) of provider reductions as follows: 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). However, instead of
implementing cuts, the hospital share shall be in the form of an additional
assessment not to exceed Ten Million Dollars ($10,000,000.00) as provided in
Section 43‑13‑145(4)(a)(ii). If Medicaid expenditures are
projected to exceed the amount of funds appropriated to the division in any
fiscal year in excess of the expenditure reductions to providers, then funds
shall be transferred by the State Fiscal Officer from the Health Care Trust
Fund into the Health Care Expendable Fund and to the Governor's Office,
Division of Medicaid, from the Health Care Expendable Fund, in the amount and
at such time as requested by the Governor to reconcile the deficit. If the
cost containment measures described above have been implemented and there are
insufficient funds in the Health Care Trust Fund to reconcile any remaining deficit
in any fiscal year, the Governor shall institute any other additional cost
containment measures on any program or programs authorized under this article
to the extent allowed under federal law. Hospitals shall be responsible for
twenty‑five percent (25%) of any additional imposed provider cuts.
However, instead of implementing hospital expenditure reductions, the hospital
reductions shall be in the form of an additional assessment not to exceed
twenty‑five percent (25%) of provider expenditure reductions as provided
in Section 43‑13‑145(4)(a)(ii). It is the intent of the
Legislature that the expenditures of the division during any fiscal year shall
not exceed the amounts appropriated to the division for that fiscal year.
(G) Notwithstanding any other provision of this article, it shall be the duty of each nursing facility, intermediate care facility for individuals with intellectual disabilities, psychiatric residential treatment facility, and nursing facility for the severely disabled that is participating in the Medicaid program to keep and maintain books, documents and other records as prescribed by the Division of Medicaid in substantiation of its cost reports for a period of three (3) years after the date of submission to the Division of Medicaid of an original cost report, or three (3) years after the date of submission to the Division of Medicaid of an amended cost report.
(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. 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 division 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 division 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 division 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; however, the division may approve use of innovative payment models that recognize alternative payment models, including quality and value-based payments, provided both parties mutually agree and the Division of Medicaid approves of said models. Participation in the provider network of any managed care, coordinated care, provider-sponsored health plan, or similar contractor shall not be conditioned on the provider's agreement to accept such alternative payment models;
(d) Implement a prior authorization program for prescription drugs that is more stringent than the prior authorization processes used by the division in its administration of the Medicaid program;
(e) Implement a policy that does not comply with the prescription drugs payment requirements established in subsection (A)(9) of this section;
(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. All Medicaid beneficiaries with hemophilia shall receive unrestricted access to anti-hemophilia factor products through noncapitated reimbursement programs.
(2) Any contractors providing direct patient care under a managed care program 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. 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 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 division. 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 division's website.
(3) 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.
(4) 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.
(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 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 division.
(6) From and after July 1, 2019, the Legislature shall not appropriate any funds for (a) the contracts that were in effect as of January 1, 2017, between the division and the managed care entities with which the division has contracted to provide Medicaid services on a capitated basis under a managed care program or coordinated care program implemented by the division under this subsection (H); and (b) the contracts that were in effect as of January 1, 2018, between the division and the managed care entities with which the division has contracted to provide Medicaid services on a capitated basis under a managed care program or coordinated care program implemented by the division under this subsection (H) after the expiration of the contracts described in paragraph (a); and the division shall terminate the contracts described in paragraphs (a) and (b) with those managed care entities on July 1, 2019. In order to provide Medicaid services on a capitated basis under a managed care program or coordinated care program under this subsection (H) after July 1, 2019, the division shall issue a request for proposals (RFP) to select not less than three (3) managed care entities to provide those services, with such specifications, terms and conditions as determined by the division. Any provider sponsored health plan licensed and established pursuant to Section 83-5-601 et seq. shall not be penalized in the procurement process for lack of experience. The division shall select the managed care entities that submit the best proposals that meet the criteria specified by the division.
(7) Not later than July 1, 2019, the Division of Medicaid may establish a pilot program that will begin on or before January 1, 2020, and operate for a period of three (3) years, to evaluate an alternative managed care payment model for medically complex children.
(a) The program authorized by this paragraph (6) shall provide care, coordination of care, and/or case management services for all beneficiaries younger than nineteen (19) years of age who require treatment for: (i) cardiac conditions requiring inpatient care or surgery; (ii) behavioral or developmental issues; or (iii) significant chronic conditions in two (2) or more body systems or a single dominant chronic condition, under guidelines developed by the Children's Hospital Association for medically complex children. Each qualifying beneficiary shall participate in this pilot program only for the duration of his or her qualifying condition(s).
(b) For the duration of the pilot program, the division shall select one (1) provider to deliver the services offered. In order to qualify for selection, the provider must be licensed by the State Department of Health as a hospital, must be located in Mississippi, and must operate a hospital principally dedicated to the care and treatment of children, as of the effective date of this act. The provider selected may provide the services authorized by this pilot program and may do so through any form through which it is authorized by Mississippi law to deliver health care services, including but not limited to Section 37-115-31 or 83-5-601 et seq., or may enter into a joint venture or other arrangement with one or more other entities authorized by Section 37-115-50.1.
(c) The division shall not pay the medically complex children provider at a rate that is less than the normal Medicaid reimbursement rate or the Medicaid All-Patient Refined-Diagnosis Related Groups (APR-DRG) reimbursement rate for covered services; however, notwithstanding the foregoing, the provider and the division may implement an innovative payment model, as authorized in subsection (H)(1)(c) of this section, as an alternative to or in addition to fee-for-service reimbursement to provide a cost-effective, actuarially sound and quality health care delivery system that shares with the division the savings produced.
(d) All beneficiaries participating in this pilot program shall be allowed to choose from among all the available providers in the beneficiary's managed care organization's network to the extent possible, reasonable and appropriate. The medically complex children provider shall have the option to release any beneficiary from participation in the pilot program if it determines, in its discretion, that it is in the best interests of the beneficiary to do so or if the beneficiary, parent or legal guardian chooses to opt out of the program.
(e) The purpose of this pilot program is to compare the performance of this program in the treatment of medically complex children to other plans in the following areas: improving health outcomes for covered lives, administrative costs and beneficiary satisfaction. In December 2019 and each December thereafter for the duration of the pilot program, the division shall provide a report to the Chairman of the House Medicaid Committee and the Chairman of the Senate Medicaid Committee detailing comparative results in these areas.
(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 2. This act shall take effect and be in force from and after June 30, 2018.
Further, amend by striking the title in its entirety and inserting in lieu thereof the following:
AN ACT TO AMEND SECTION 43-13-117, MISSISSIPPI CODE OF 1972, TO EXTEND THE DATE OF THE REPEALER ON THE COMPREHENSIVE LIST OF THE TYPES OF CARE AND SERVICES COVERED BY MEDICAID; TO DIRECT THE DIVISION OF MEDICAID TO DEVELOP AND IMPLEMENT A HOSPITAL READMISSIONS REDUCTION PROGRAM DESIGNED TO REDUCE POTENTIALLY PREVENTABLE READMISSIONS; TO PROVIDE THAT RURAL HOSPITALS THAT HAVE FIFTY OR FEWER LICENSED BEDS SHALL BE GIVEN THE OPTION TO BE REIMBURSED UNDER MEDICAID FOR OUTPATIENT HOSPITAL SERVICES BASED ON 101% OF THE MEDICARE RATE FOR THOSE SERVICES INSTEAD OF USING THE AMBULATORY PAYMENT CLASSIFICATION (APC) METHODOLOGY; TO REDUCE THE ANNUAL NUMBER OF HOME LEAVE DAYS FOR PATIENTS IN NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES; TO DELETE THE ANNUAL LIMIT ON PHYSICIAN VISITS; TO DIRECT THE DIVISION TO INCREASE THE FEES FOR PHYSICIAN'S SERVICES; TO AUTHORIZE THE DIVISION TO REIMBURSE OBSTETRICIANS AND GYNECOLOGISTS FOR CERTAIN PRIMARY CARE SERVICES AS DEFINED BY THE DIVISION AT 100% OF THE RATE ESTABLISHED UNDER MEDICARE; TO DELETE THE ANNUAL LIMITS ON HOME HEALTH SERVICES VISITS; TO DELETE THE RESTRICTION ON THE REIMBURSEMENT RATE FOR EMERGENCY MEDICAL TRANSPORTATION SERVICES; TO DELETE THE MONTHLY PRESCRIPTION LIMIT FOR MEDICAID BENEFICIARIES; TO DIRECT THE DIVISION TO 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; TO PROVIDE THAT THE COVERAGE OF DENTAL AND ORTHODONTIC SERVICES WILL BE DETERMINED BY THE DIVISION; TO PROVIDE THAT CERTAIN SERVICES PROVIDED BY A PSYCHIATRIST MAY BE REIMBURSED AT UP TO 100% OF THE MEDICARE RATE; TO AUTHORIZE THE DIVISION 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; TO PROVIDE THAT FEDERALLY QUALIFIED HEALTH CENTERS PROVIDING AMBULATORY SERVICES SHALL BE REIMBURSED BY THE MEDICAID PROSPECTIVE PAYMENT SYSTEM AS APPROVED BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES; TO AUTHORIZE INSTEAD OF REQUIRE THAT TARGETED CASE MANAGEMENT SERVICES FOR HIGH-COST BENEFICIARIES BE DEVELOPED FOR ALL SERVICES COVERED BY THIS SECTION; TO PROVIDE THAT MEDICATION-ASSISTED COMPREHENSIVE TREATMENT SERVICES FOR PERSONS DIAGNOSED WITH AN OPIOID SUBSTANCE USE DISORDER OR OTHER HIGHLY ADDICTIVE SUBSTANCE USE DISORDER WILL BE COVERED UNDER MEDICAID; TO DIRECT THE DIVISION TO ALLOW BENEFICIARIES BETWEEN THE AGES OF TEN AND EIGHTEEN YEARS TO RECEIVE VACCINES THROUGH A PHARMACY VENUE; TO INCLUDE OUTPATIENT HOSPITAL SERVICES IN THE LIST OF SERVICES THAT ARE EXEMPT FROM THE FIVE PERCENT REDUCTION IN THE PROVIDER REIMBURSEMENT RATE; TO PROVIDE THAT THE EXEMPTIONS FROM THE FIVE PERCENT REDUCTION IN THE PROVIDER REIMBURSEMENT RATE APPLICABLE TO CERTAIN SERVICES PROVIDED UNDER THIS SECTION WILL NOT BE IN EFFECT IF CURRENT OR PROJECTED EXPENDITURES OF THE DIVISION ARE REASONABLY ANTICIPATED BY THE DIVISION TO EXCEED THE AMOUNT OF FUNDS APPROPRIATED TO THE DIVISION FOR ANY FISCAL YEAR; TO DELETE THE PROHIBITION ON THE DIVISION FROM MAKING CERTAIN CHANGES TO THE SERVICES AUTHORIZED UNDER THIS SECTION WITHOUT AN AMENDMENT TO THIS SECTION BY THE LEGISLATURE; TO REVISE THE ACTIONS THAT THE DIVISION MAY TAKE TO REDUCE COSTS IF CURRENT OR PROJECTED EXPENDITURES OF THE DIVISION ARE REASONABLY ANTICIPATED BY THE DIVISION TO EXCEED THE AMOUNT OF FUNDS APPROPRIATED TO THE DIVISION FOR ANY FISCAL YEAR; TO PROVIDE THAT 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 AUDITS PERFORMED BY THE OFFICE OF THE STATE AUDITOR, THE PEER COMMITTEE AND/OR AN INDEPENDENT THIRD PARTY; TO PROHIBIT MANAGED CARE ORGANIZATIONS FROM REQUIRING THEIR PROVIDERS TO BE CREDENTIALED BY THE ORGANIZATION IN ORDER TO RECEIVE REIMBURSEMENT; TO PROVIDE THAT FROM AND AFTER JULY 1, 2019, THE LEGISLATURE SHALL NOT APPROPRIATE ANY FUNDS FOR CERTAIN CONTRACTS BETWEEN THE DIVISION AND THE MANAGED CARE ENTITIES WITH WHICH THE DIVISION HAS CONTRACTED TO PROVIDE MEDICAID SERVICES ON A CAPITATED BASIS UNDER A MANAGED CARE PROGRAM IMPLEMENTED BY THE DIVISION; TO PROVIDE THAT THE DIVISION SHALL TERMINATE THOSE CONTRACTS WITH THE MANAGED CARE ENTITIES ON JULY 1, 2019, AND SHALL ISSUE A REQUEST FOR PROPOSALS TO SELECT NOT LESS THAN THREE MANAGED CARE ENTITIES TO PROVIDE MEDICAID SERVICES ON A CAPITATED BASIS UNDER A MANAGED CARE PROGRAM AFTER JULY 1, 2019; TO AUTHORIZE THE DIVISION TO ESTABLISH A PILOT PROGRAM FOR THREE YEARS TO EVALUATE AN ALTERNATIVE MANAGED CARE PAYMENT MODEL FOR MEDICALLY COMPLEX CHILDREN; AND FOR RELATED PURPOSES.
