Miss. Admin. Code Title 23 — Medicaid

DIVISION OF MEDICAID DIVISION OF MEDICAID

Part 100 General Provisions

23 Miss. Admin. Code Pt. 100 General Provisions

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 100 General Provision

TABLE OF CONTENTS

Title 23: Division of Medicaid ....................................................................................................1 Part 100: General Provisions ............................................................................................................................... 1 Part 100 Chapter 1: Introduction...................................................................................................................... 1 Rule 1.1: History and Legal Base. ................................................................... Error! Bookmark not defined. Rule 1.2: SSI Program. ................................................................................... Error! Bookmark not defined. Rule 1.3: Current Structure.............................................................................. Error! Bookmark not defined. Part 100 Chapter 2: Agency Duties ................................................................... Error! Bookmark not defined. Rule 2.1: Duties of the Division of Medicaid .....................................................................2 Rule 2.2: Duties of the Department of Human Services (DHS)......................... Error! Bookmark not defined. Part 100 Chapter 3: Rights of Applicants and Recipients .............................. Error! Bookmark not defined. Rule 3.1: Opportunity to Apply. ..................................................................... Error! Bookmark not defined. Rule 3.2: Civil Rights and Non-Discrimination. .............................................. Error! Bookmark not defined. Rule 3.3: Access to Information. .................................................................... Error! Bookmark not defined. Rule 3.4: Release of Information to Legal Representative/Attorney. ................ Error! Bookmark not defined. Rule 3.5: Confidentiality of Information. ....................................................... Error! Bookmark not defined. Rule 3.6: Protected Information. ..................................................................... Error! Bookmark not defined. Rule 3.7: Release of Information Without Client Consent. ............................... Error! Bookmark not defined. Rule 3.8: Release of Program Information. ..................................................... Error! Bookmark not defined. Rule 3.9: Safeguarding Confidential Information. ........................................... Error! Bookmark not defined. Rule 3.10: Safeguard Awareness Training. ..................................................... Error! Bookmark not defined. Part 100 Chapter 4: Moved to Part 300 Part 100 Chapter 5: Moved to Part 300

Part 100 Chapter 6: Improper Payments [Refer to Part 305] ........................................................................ 21 Part 100 Chapter 7: Quality Control [Refer to Part 305] .............................................................................. 21 Part 100 Chapter 8: Revised and moved to Miss. Admin. Code Part 101, Chapter 1...............................21

Part 100 Chapter 9: Administrative Rules..................................................................................21 Rule 9.1 Public Notice......................................................................................................21 Rule 9.2 Public Records....................................................................................................22 Rule 9.3 Declaratory Opinions.............................................................................................25 Rule 9.4 Oral Proceedings.................................................................................................28 Rule 9.5 Public Hearings...................................................................................................29

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Title 23: Division of Medicaid

Part 100: General Provisions

Part 100 Chapter 1: Introduction

Rule 1.1: History and Legal Base

A. Title XIX of the Social Security Act, enacted in 1965, provides authority for states to establish Medicaid programs to provide medical assistance to needy individuals. The program is jointly financed by federal and state governments and administered by states. Within broad federal rules, each state decides eligible groups, types and range of services, payment levels for services, and administrative and operating procedures. Payments for services are made directly by the state to the providers that furnish the services.

B. The Mississippi Legislature passed enabling legislation for the Medicaid program during a special session in 1969. Funds were appropriated, and the Mississippi Medicaid Commission was designated as the single state agency to administer the program.

C. From 1969 to 1973, the State Department of Public Welfare (DPW) determined Medicaid eligibility. During this period, DPW authorized money payments for the aged, blind and disabled (ABD) as well as dependent children.

Source: Miss. Code Ann. § 43-13-101 et. seq.

History: Revised eff. 08/01/2020.

Rule 1.2: Supplemental Security Income (SSI) Program

A. In 1972, the United States Congress passed amendments to the Social Security Act establishing the Supplemental Security Income (SSI) Program for the aged, blind and disabled (ABD) individuals. The Missisisppi Legislature amended its code to specify that State Department of Public Welfare (DPW) would no longer determine eligibility for a monthly payment for ABD-designated recipients beneficiaries..

B. Under the Social Security Act amendments, states had the option to either grant Medicaid to all persons receiving SSI or to grant Medicaid to persons who met more restrictive criteria as determined individually by states. The Mississippi Legislature voted to limit Medicaid eligibility to persons who met more restrictive criteria and to designate the DPW as the certifying agency for Medicaid.

C. During the l980 Session, the Mississippi Legislature extended Medicaid coverage to all individuals receiving SSI. In addition, SSI criteria would be used to determine eligibility for all ABD individuals. During the 1981 Session, the Mississippi Legislature designated the Mississippi Medicaid Commission to make Medicaid determinations for ABD individuals.

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Regional Medicaid offices opened in July 1981 to assess eligibility of ABD individuals who did not receive SSI.

Source: 42 U.S.C. § 1382 et seq., Pub. L. 92-603, Miss. Code Ann. § 43-13-115.

History: Revised eff. 08/01/2020.

Rule 1.3: Current Structure

A. During the 1984 Session, the Mississippi Legislature designated the Division of Medicaid in the Office of the Governor as the single state agency authorized to administer the Medicaid Program.

B. After the Division of Medicaid’s designation, the Mississippi Department of Human Services (MDHS, formerly known as Department of Public Welfare) continued to determine eligibility for Medicaid Programs for children and families. In 1999, MDHS acquired the authority to determine eligibility for the Children’s Health Insurance Program (CHIP).

C. During the 2004 Session, the Mississippi Legislature expanded the Division of Medicaid’s eligibility jurisdiction, making the Division of Medicaid additionally responsible for determining initial and ongoing eligibility for all children, families, and pregnant women. The transition of the Families, Children and CHIP (FCC) programs from MDHS to the Division of Medicaid was effective January 1, 2005. MDHS remained the certifying agency for children under Title IV-E services and other related custody and adoption assistance programs and those eligible for Medicaid coverage under the Refugee Resettlement Program.

D. During the 2012 Session, the Mississippi Legislature transferred the existing contract for insurance services for CHIP from the State and School Employees Health Insurance Management Board to the Division of Medicaid effective January 1, 2013.

E. The Mississippi Legislature created the Department of Child Protection Services (CPS) during the 2016 Session, making CPS Mississippi’s lead child welfare agency. Effective July 1, 2016, CPS became responsible for Medicaid certifications for children in its custody who qualify for Medicaid, and children under Title IV-E services and other related custody and adoption assistance programs and those eligible for Medicaid coverage under the Refugee Resettlement Program.

F. During the 2018 Session, the Mississippi Legislature made CPS a sub-agency of MDHS. CPS remains independent of MDHS, but was housed within DHS to increase efficiency through the sharing of resources, such as system support and other related administrative functions.

Source: Miss. Code Ann. §§ 41-86-9, 41-86-15, 43-13-101 et seq., 43-13-115, 43-26-1 .

History: Revised eff. 08/01/2020.

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Chapter 2: Agency Duties

Rule 2.1: Duties of the Division of Medicaid.

The duties of the Division of Medicaid Agency are set out by State and Federal legislation and the approved Mississippi State Plan include, but are not limited to:

A. Setting regulations and standards for the administration of the Medicaid programs, with approval from the Governor, and in accordance with the Administrative Procedures Law. [Refer to Miss. Admin. Code Part 100, Rule 9.3]

B. Providing Medicaid coverage to all qualified beneficiaries under the provisions of state law and within appropriated funds.

C. Establishing reasonable fees, charges and rates for medical services, drugs, equipment and supplies

D. Conducting fair and impartial hearings.

E. Safeguarding the confidentiality of records.

F. Detecting and investigating alleged violations, and addressing fraudulent practices and abuses of the program.

G. Receiving and expending funds for the program.

H. Submitting a state plan for Medicaid in accordance with state and federal regulations.

I. Preparing and distributing required reports to the state and federal government.

J. Defining and determining the scope, duration, and amount of Medicaid coverage.

K. Cooperating and contracting with other state agencies for the purpose of administrating the Medicaid program.

L. Bringing suit in its own name.

M. Recovering incorrect beneficiary or provider payments including recovery of beneficiary or provider state tax refunds of beneficiaries or providers.

N. Establishing and providing methods of administration for the operation of the Medicaid program.

O. Contracting with the federal government to provide Medicaid coverage for certain refugees.

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P. Entering into an agreement with the federal health insurance marketplace as necessary to fulfill the requirements of federal healthcare laws relating to insurance affordability programs that include Medicaid, CHIP and subsidies for insurance coverage through a federal marketplace, effective January, 2014.

Source: 42 C.F.R. § 435.1200; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2020; Revised eff. 09/01/2014.

Rule 2.2: Duties of the Department of Child Protection Services (CPS)

A. The duties of the Child Protection Services (CPS) with regard to Medicaid include, but are not limited to:

1. Providing the opportunity for persons to apply for Medicaid benefits through all foster care and refugee programs.

2. Determining eligibility for foster children and adoption assistance-related Medicaid applicants, certifying eligible children, and notifying the appropriate individuals of eligibility decisions certified by CPS

3. Renewing foster care and adoption assistance Medicaid eligibility at required intervals.

4. Providing the opportunity for filing appeals.

5. Identifying and reporting third-party resources for foster care and adoption assistance beneficiaries to the Division of Medicaid.

Source: Miss. Code Ann. §§ 43-13-115, 43-26-1. .

History: Revised eff. 08/01/2020.

Chapter 3: Rights of Applicants and Beneficiaries

Rule 3.1: Opportunity to Apply

Any individual, who requests assistance, including those who are clearly ineligible, must be allowed to apply without delay. The Division of Medicaid must make a reasonable effort to assist the applicant in establishing eligibility.

Source: 42 C.F.R. §§ 435.906, 435.908 (Rev. .

History: Revised eff. 08/01/2020.

Rule 3.2: Civil Rights and Non-Discrimination.

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The Division of Medicaid complies with all state and federal policies which prohibit discrimination on the basis of race, age, sex, national origin, handicap or disability as defined through the Americans with Disabilities Act of 1990, the Rehabilitation Act of 1973 and the Civil Rights Act of 1964. All complaints of discrimination will be investigated in accordance with state and federal laws and regulations.

Source: 42 C.F.R. § 435.901.

History: Revised eff. 08/01/2020.

Rule 3.3: Access to Information

A. The beneficiary or their authorized representative may have access to information in the eligibility case record to either review the file or request copies of information from the file, in certain situations and under specified conditions as required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The privacy restrictions for protected health information (PHI) under HIPAA are specific regarding the disclosure of information to and on behalf of a Medicaid beneficiary. Privacy policies and procedures for all disclosures and the authorization forms required prior to the release of case record information are located in the HIPAA Privacy Policies Manual and the HIPAA Privacy Procedures Manual.

B. The HIPAA Privacy Procedures Manual outlines requirements for the release of information, with or without consent of the beneficiary, and the type and amount of information that is allowed to be released to or for:

1. A Medicaid beneficiary.

2. A Personal Representative of a beneficiary as defined by HIPAA.

3. A legal representative of a beneficiary.

4. A parent or guardian of a minor child.

5. Law enforcement agencies or officials.

6. Public authorities.

7. A judicial or administrative hearing.

8. Federal or state agencies.

9. Audits or compliance reviews.

10. Legislators or elected officials.

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11.Providers and their contractors.

Source: 45 C.F.R. Parts 160,164; Miss. Code Ann. §§ 43-12-17, 43-13-121.

History: Revised eff. 08/01/2020.

Rule 3.4: Confidentiality of Information

All individuals have the right to a confidential relationship with the Division of Medicaid. All information maintained about current and former beneficiaries and current and denied applicants is confidential and must be safeguarded. The Division of Medicaid adheres to state laws and federal regulations regarding the protection of the confidentiality of information about applicants and beneficiaries. Protected information may only be disclosed without the individual’s authorization in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Source: 42 C.F.R. § 431. 300 et seq.; 45 C.F.R. Parts 160, 164. Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2025; Revised eff. 08/01/2020.

Rule 3.5: Protected Health Information

A. Protected Health Information (PHI) is information created or received by the Division of Medicaid that identifies an individual or for which there is a reasonable basis to believe an individual can be identified, is transmitted or maintained by electronic media or in any other form, with the exception of any such records held by the Division of Medicaid in its role as an employer or regarding a person who has been deceased for more than 50 years, and relates to the following:

1. The past, present, or future physical or mental health or condition of an individual,

2. The provision of health care to an individual, or

3. The past, present, or future payment for the provision of health care to an individual;

B. Protected Health Information (PHI) consists of eligibility/financial and/or medical information and includes, but is not limited to, the following information:

1. Eligibility information:

a) Name and address of applicants and beneficiaries,

b) Social and economic conditions or circumstances,

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c) Evaluation of personal information such as financial status, citizenship, residence, age and other demographic characteristics,

d) Information received in connection with the identification of legally liable third-party resources,

e) Information received for verifying income eligibility and benefit level and

f) Income information verifying income eligibility and benefit level received from the Social Security Administration, the Veteran’s Administration, State Retirement Board, or Medicare. Information provided by these agencies must be safeguarded according to the requirements of the agency that furnished the data.

2. Medical information:

a) Medical data, including diagnosis and past history of disease or disability,

b) Medical services provided,

c) Medical status, psychobehavioral status, and functional ability,

d) Results of laboratory tests, and

e) Medication records.

Source: 42 C.F.R. §§ 160.103, 435.901, Miss. Code Ann.§ 43-13-121.

History: Revised eff. 08/01/2020.

Rule 3.6: Release of Program Information

The Division of Medicaid releases program information for the purposes of informing the public and conducting necessary business in accordance with all applicable privacy laws. The release of such information includes, but is not limited to:

A. The annual report of the Division of Medicaid, published pursuant to state law, containing the total number of beneficiaries, the total amount paid for medical assistance and care, the total number of applications, the total number of applications approved and denied, and similar data.

B. Pamphlets, brochures and other documents prepared for distribution to the public.

C. Information exchanged with other state or federal agencies pursuant to a contract or written agreement.

Source: Miss. Code Ann. § 43-13-121.

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History: Revised eff. 08/01/2020.

Rule 3.7: Safeguarding Confidential Information

A. Privacy laws protect electronic records, paper records and oral communication. Employees of the Division of Medicaid are responsible for safeguarding the confidentiality of applicant and beneficiary information in all forms to prevent unauthorized disclosure.

B. Failure to abide by the policies and procedures regarding confidentiality of applicant and beneficiary information, either intentionally or unintentionally, can result in disciplinary action. In addition, any violation of privacy and security policies and procedures may be referred to state and/or federal agencies for prosecution.

Source: 42 C.F.R. § 435.901; 45 C.F.R. Parts 160, 164. .

History: Revised eff. 08/01/2020.

Rule 3.8: Privacy and Security Training

A. The Division of Medicaid ensures that all workforce members receive training regarding the privacy and security requirements of applicable state and federal laws, as well as the privacy and security policies and procedures of the the Division. In addition, all workforce members are trained how to identify, report, and prevent potential privacy and security incidents.

B. Privacy and security training is ongoing throughout an employe’s tenure with the Division of Medicaid and includes, but is not limited to, training in relevant Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates and periodic security reminders.

Source: 45 C.F.R Parts 160, 164.

History: Revised eff. 08/01/2019.

Part 100 Chapter 4: Moved to Part 300

Part 100 Chapter 5: Moved to Part 300

Part 100 Chapter 6: Improper Payments [Refer to Part 305]

Part 100 Chapter 7: Quality Control [Refer to Part 305]

Part 100 Chapter 8: [Revised and moved to Miss. Admin. Code Part 101, Chapter 1]

Part 100 Chapter 9: Administrative Rules

Rule 9.1: Public Notice

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The Division of Medicaid provides public notice of any:

A. Significant proposed change in methods and standards for setting payment rates for State Plan services, except when a change is:

1. Being made to conform to Medicare methods or levels of reimbursement,

2. Required by a court order, or

3. Based on changes in wholesalers’ or manufactures’ prices of drugs or materials, if the Division of Medicaid's reimbursement system is based on material cost plus a professional fee.

B. Significant proposed change in methods and standards for setting payment rates and an opportunity for public input on substantive changes to services and operations of a 1915 Waiver.

C. Submission of an application or extension of an 1115 Demonstration Waiver.

D. Proposed change to eligibility or benefits for the Children's Health Insurance Program (CHIP).

E. Proposed significant modifications to existing premiums or cost sharing, including any change in the consequences for non-payment.

F. Requests for bids or proposals as required by state law.

G. Proposed changes to the MississippiCAN program.

Source: 42 CFR §§ 431.400, 431.404, 431.408, 438.50, 438.202, 441.301, 441.304, 447.57, 447.205, 447.253, 457.65; Miss. Code Ann. §§ 25-9-120, 31-7-13, 43-13-121.

History: New Rule eff. 07/01/2015.

Rule 9.2: Public Records

A. The Division of Medicaid defines "public records" as all books, records, papers, accounts, letters, maps, photographs, films, cards, tapes, recordings or reproductions thereof, and any other documentary materials, regardless of physical form or characteristics, having been used, being in use, or prepared, possessed or retained for use in the conduct, transaction or performance of any business, transaction, work, duty or function of the Division of Medicaid or required to be maintained by the Division of Medicaid.

B. The Division of Medicaid allows any person the right to inspect, copy, mechanically reproduce or obtain a reproduction of any public record of the Division of Medicaid, unless the record is exempt from public inspection as specified by federal and/or state law, during

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the Division of Medicaid's normal business hours, Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding legal holidays.

1. Public records must be inspected or reproduced at the central or regional office(s) of the Division of Medicaid, depending on the type of public records requested.

2. The Division of Medicaid may have a staff member observe the inspection or reproduction of public records by the requestor.

3. The Division of Medicaid will provide reasonable space for the inspection and/or reproduction of public records.

4. Requested public records and/or information will be provided by a Division of Medicaid staff member.

5. Public records subject to inspection and/or reproduction may not be destroyed, altered, marked upon, or disassembled in any manner by the requestor.

6. The time, place and manner of inspection and/or reproduction of public records cannot interfere with other essential duties or unreasonably disrupt operations of the Division of Medicaid.

7. The time, place and manner of inspection and/or reproduction of public records must be mutually agreed upon by the Division of Medicaid and the requestor.

C. The requestor must claim or review the assembled records within thirty (30) days of the Division of Medicaid's notification to him or her that the records are available for inspection or reproduction.

1. The Division of Medicaid will notify the requestor in writing of this requirement and inform the requestor that he or she should contact the Division of Medicaid to make arrangements to claim or review the records.

2. If the requestor or a representative of the requestor fails to claim or review the records within the thirty (30) day period or make other arrangements, the Division of Medicaid may close the request and refile the assembled records.

D. Any person requesting to inspect, copy, mechanically reproduce or obtain a reproduction of public records of the Division of Medicaid must make the request in writing by email, fax or letter addressed to the Division of Medicaid's public records officer and must include the following information:

1. Name of requestor,

2. Address of requestor,

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3. Other requestor contact information, including telephone number and an email address,

4. Identification of the requested public records, by individual item or by category with reasonable particularity, so that the public records officer or designee can locate the public records, and

5. Date of request.

E. Within seven (7) business days of receipt of the request, the public records officer will:

1. Make the public records available for inspection and/or reproduction,

2. Deliver requested copies to the requestor if terms of payment are agreed upon,

3. Request clarification from the requestor via telephone, letter or email, or

4. Deny the request and give the specific exemption or other authority and/or provide a brief explanation.

F. If the Division of Medicaid cannot produce the requested public records within seven (7) business days of the request, the public records officer will:

1. Provide the requestor with notification specifying the reason why the requested public records cannot be produced within seven (7) business days, and

2. Obtain a mutually agreed upon delivery date for the public records to be released.

G. The Division of Medicaid may charge for the processing, retrieval/searching, reviewing and duplicating of information and/or public records not readily available, unless the information and/or public records are requested by a federal agency, institution of higher learning, or a Medicaid beneficiary, as follows:

1. The actual cost of searching for, reviewing and redacting exempt information from public records, which is based on the hourly rate of compensation for the lowest paid agency employee qualified to perform the tasks multiplied by the actual time to complete the task according to the Division of Medicaid's fee schedule,

2. The cost of any associated computer run time or database processing time related to the retrieval of data according to the Division of Medicaid's fee schedule,

3. The cost of electronic copies of public records being placed on a data storage device. There is no charge for e-mailing electronic public records to a requestor, unless another cost applies such as a scanning fee or system costs according to the Division of Medicaid's fee schedule,

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4. Fifty Cents ($0.50) per page for standard black and white and/or color copies of any public record made on a Division of Medicaid copier, and

5. The actual cost of mailing, including the cost of the shipping container.

H. The Division of Medicaid requires payment, by check or money order, to the Division of Medicaid in the amount of the estimated cost of processing or retrieval of public records and/or information prior to the completion of the request.

Source: Miss. Code Ann. §§ 25-61-1, et seq., 43-13-121.

History: New Rule eff. 07/01/2015.

Rule 9.3: Declaratory Opinions

A. This rule sets forth the Mississippi Division of Medicaid’s rules governing the form, content, and filing of requests for declaratory opinions, the procedural rights of persons in relation to the written requests, and the Mississippi Division of Medicaid’s procedures regarding the disposition of requests as required by Miss. Code Ann. § 25-43-2.103.

B. The Mississippi Division of Medicaid will issue declaratory opinions regarding the applicability to specified facts of:

1. A statute administered or enforceable by the Mississippi Division of Medicaid;

2. A rule promulgated by the Mississippi Division of Medicaid; or

3. An order issued by the Mississippi Division of Medicaid.

C. A request must be limited to a single transaction or occurrence.

D. When a person with substantial interest, as required by Miss. Code Ann. § 25-43-2.103, requests a declaratory opinion, the requestor must submit a printed, typewritten, or legibly handwritten request.

1. Each request must be submitted on 8-1/2” x 11” white paper.

2. The request may be in the form of a letter addressed to the Executive Director of the Mississippi Division of Medicaid or in the form of a pleading as if filed with a court.

3. Each request must include the full name, telephone numbers, and mailing address of the requestor(s).

4. All requests shall be signed by the person filing the request, unless represented by an attorney, in which case the attorney may sign the request.

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5. Each request must clearly state that it is a request for a declaratory opinion.

E. Any party who signs the request shall attest that the request complies with the requirements set forth in these rules, including but not limited to a full, complete, and accurate statement of relevant facts and that there are no related proceedings pending before any agency, administrative, or judicial tribunal.

F. Each request must contain the following:

1. A clear identification of the statute, rule, or order at issue;

2. The question for the declaratory opinion;

3. A clear and concise statement of all facts relevant to the question presented;

4. The identity of all other known persons involved in or impacted by the facts giving rise to the request including their relationship to the facts, and their name, mailing address, and telephone number; and

5. A statement sufficient to show that the requestor has a substantial interest in the subject matter of the request.

G. The Mississippi Division of Medicaid may, for good cause, refuse to issue a declaratory opinion. The circumstances in which declaratory opinions will not be issued include, but are not necessarily limited to the following:

1. The matter is outside the primary jurisdiction of the Mississippi Division of Medicaid;

2. There is a lack of clarity concerning the question presented;

3. There is pending or anticipated litigation, administrative action or anticipated administrative action, or other adjudication which may either answer the question presented by the request or otherwise make an answer unnecessary;

4. The statute, rule, or order on which a declaratory opinion is sought is clear and not in need of interpretation to answer the question presented by the request;

5. The facts presented in the request are not sufficient to answer the question presented;

6. The request fails to contain information required by these rules or the requestor failed to follow the procedure set forth in these rules;

7. The request seeks to resolve issues which have become moot or are abstract or hypothetical such that the requestor is not substantially affected by the rule, statute, or order on which a declaratory opinion is sought;

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8. No controversy exists or is certain to arise which raises a question concerning the application of the statute, rule, or order;

9. The question presented by the request concerns the legal validity of a statute, rule, or order;

10. The request is not based upon facts calculated to aid in the planning of future conduct, but is, instead, based on past conduct in an effort to establish the effect of that conduct;

11. No clear answer is determinable;

12. The question presented by the request involves the application of a criminal statute or sets forth facts which may constitute a crime;

13. The answer to the question presented would require the disclosure of information which is privileged or otherwise protected by law from disclosure;

14. The question is currently the subject of an Attorney General’s opinion request;

15. The question has been answered by an Attorney General’s opinion;

16. One or more requestors have standing to seek an Attorney General’s opinion on the proffered question;

17. A similar request is pending before this agency, or any other agency, or a proceeding is pending on the same subject matter before any agency, administrative or judicial tribunal, or where such an opinion would constitute the unauthorized practice of law; or

18. The question involves eligibility for a license, permit, certificate, or other approval by the Mississippi Division of Medicaid or some other agency and there is a statutory or regulatory application process by which eligibility for said license, permit, or certificate or other approval may be determined.

H. Within forty-five (45) days after the receipt of a request for a declaratory opinion which complies with the requirements of these rules, the Mississippi Division of Medicaid shall, in writing:

1. Issue an opinion declaring the applicability of the statute, rule, or order to the specified circumstances;

2. Agree to issue a declaratory opinion by a specified time but no later than ninety (90) days after receipt of the written request; or

3. Decline to issue a declaratory opinion, stating the reasons for its action.

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4. The forty-five (45) day period shall begin on the first business day after which the request is received by the Mississippi Division of Medicaid.

I. Declaratory opinions and requests for declaratory opinions shall be available for public inspection and copying at the expense of the viewer during normal business hours. All declaratory opinion and requests shall be indexed by name, subject, and date of issue. Declaratory opinions and requests which contain information which is confidential or exempt from disclosure under the Mississippi Public Records Act or other laws shall be exempt from this requirement and shall remain confidential.

Source: Miss. Code Ann. §§ 25-43-2.103; 43-13-121.

History: New eff. 09/01/2014.

Rule 9.4: Oral Proceedings

A. This rule applies to all oral proceedings held for the purpose of providing the public with an opportunity to make oral presentations or written input on proposed new rules, amendments to rules, and proposed repeal of existing rules before the Mississippi Division of Medicaid pursuant to the Administrative Procedures Act, specifically Miss. Code Ann. § 25-43-3.104.

B. When a political subdivision, an agency, or ten (10) persons request an oral proceeding in regards to a proposed rule adoption, the requestor must submit a printed, typewritten, or legibly handwritten request.

1. Each request must be submitted on 8-1/2” x 11” white paper.

2. The request may be in the form of a letter addressed to the Executive Director of the Mississippi Division of Medicaid or in the form of a pleading as if filed with a court.

3. Each request must include the full name, telephone numbers, and mailing address of the requestor(s).

4. All requests shall be signed by the person filing the request, unless represented by an attorney, in which case the attorney may sign the request.

C. Notice of the date, time, and place of all oral proceedings shall be filed with the Secretary of State’s Office for publication in the Administrative Bulletin. The agency providing the notice shall provide notice of oral proceedings to all persons requesting notification of proposed rule adoptions. The oral proceedings will be scheduled no earlier than twenty (20) days from the filing of the notice with the Secretary of State. The Executive Director of the Mississippi Division of Medicaid or designee who is familiar with the substance of the proposed rule shall preside at the oral proceeding on a proposed rule.

D. Public participation shall be permitted at oral proceedings, as follows:

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1. At an oral proceeding on a proposed rule, persons may make statements and present documentary and physical submissions concerning the proposed rule.

2. Persons wishing to make oral presentations at such a proceeding shall notify the Executive Director of the Mississippi Division of Medicaid at least three (3) business days prior to the proceeding and indicate the general subject of their presentations. The presiding officer in his or her discretion may allow individuals to participate that have not contacted the Mississippi Division of Medicaid prior to the proceeding.

3. At the proceeding, those who participate shall indicate their names and addresses, identify any persons or organizations they may represent, and provide any other information relating to their participation deemed appropriate by the presiding officer.

4. The presiding officer may place time limitations on individual presentations when necessary to assure the orderly and expeditious conduct of the oral proceeding. To encourage joint presentations and to avoid repetition, additional time may be provided for persons whose presentations represent the views of other individuals as well as their own views.

5. Persons making presentations are encouraged to avoid restating matters that have already been submitted in writing. Written materials may be submitted at the oral proceeding.

6. Where time permits and to facilitate the exchange of information, the presiding officer may open the floor to questions or general discussion. The presiding officer may question participants and permit the questioning of participants by other participants about any matter relating to that rule-making proceeding, including any prior written submissions made by those participants in that proceeding. No participant shall be required to answer any question.

E. Physical and documentary submissions presented by participants in an oral proceeding shall be submitted to the presiding officer. Such submissions become the property of the Mississippi Division of Medicaid, part of the rulemaking record, and are subject to the Mississippi Division of Medicaid’s public records request procedure. The Mississippi Division of Medicaid may record oral proceedings by stenographic or electronic means.

Source: Miss. Code Ann. §§ 25-43-2.103; 43-13-121.

History: New eff. 09/01/2014.

Rule 9.5: Public Hearings

A. This rule applies to all public hearings held for the purpose of providing the public with an opportunity for input on the Division of Medicaid's submissions to the Centers for Medicare and Medicaid Services (CMS).

B. The date, time, and place of a public hearing will be published as part of a public notice.

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C. Public hearings held by the Division of Medicaid will allow for a reasonable time for the public to provide input.

D. The presiding officer may place time limitations on individual presentations when necessary to assure the orderly and expeditious administration of the public hearing.

E. The Division of Medicaid is not required to respond to public comments or questions during a public hearing.

F. Physical and documentary submissions presented by participants of a public hearing are to be submitted to the presiding officer and become property of the Division of Medicaid, subject to the public records request procedure.

G. The Division of Medicaid may record public hearings by stenographic or electronic means.

Source: 42 CFR § 447.205; Miss. Code Ann. § 43-13-121.

History: New Rule eff. 07/01/2015.

Part 101 Coverage Groups and Processing Applications and Reviews Redetermination Processes

Chapter 4 Filing the Application

23 Miss. Admin. Code Pt. 101, R. 4.5 Out of State Applicants

A. Applications received from individuals residing in another state will be denied with a notice mailed to them explaining that the applicants need to reapply upon arrival in Mississippi with the intent to permanently reside.

B. Individuals who are in Mississippi for a temporary purpose, such as a visit, who intend to return to their home out of state are not eligible for Mississippi Medicaid or the Children’s Health Insurance Program (CHIP).

C. Individuals always have the right to make an application if they wish to do so and receive a decision on their case.

History: Revised eff. 04/01/2018.

Rule 4.6: Residence Change During the Application Process

A. If the applicant reports moving to another location within Mississippi during the application process, the application must be completed by the first regional office, and if approved, transferred to the regional office applicable to the new location. If the application is denied, the record is not transferred until the applicant reapplies in the second location.

B. If the applicant reports moving out of Mississippi during the application process, the date of the move must be determined. If otherwise eligible, the applicant may be approved for Medicaid for any requested retroactive months through the month of the move. If the applicant will be eligible for Children’s Health Insurance Program (CHIP), eligibility can be established

for the month following the month of application or any subsequent month(s) when the applicant lived in Mississippi.

C. If only some members of the applicant family are moving from Mississippi, the children and adults who remain in Mississippi will be identified and the case will be handled on their ongoing eligibility accordingly.

History: Revised eff. 04/01/2018.

Rule 4.7: Where to File the Application

A. Applications submitted via any acceptable method listed in Miss. Admin. Code Part 101, Rule 4.2 should be filed with the regional office that serves the applicant’s county of residence.

1. Applications for individuals living in another regional office’s service area will be accepted by any regional office.

2. Each regional office must review each application upon receipt and confirm the accuracy of the address if there is a question about the responsible office.

B. Combination modified adjusted gross income (MAGI) and aged, blind, disabled (ABD) households are the responsibility of the regional office that serves the county of residence of the household; however, if one of the ABD household members is institutionalized, the regional office that serves the county where the long-term care facility is located is responsible for both ABD and MAGI cases.

C. Applications filed with the Federally Facilitated Marketplace (FFM) are evaluated for coverage in either Medicaid, the Children’s Health Insurance Program (CHIP) or for enrollment in a qualified health plan, i.e., insurance affordability programs.

1. If an individual or family appears to be eligible for Medicaid or CHIP based on data verified by the FFM, the electronic account of the individual or family is transferred to the Division of Medicaid for completion of the application.

a) The Account Transfer (AT) received from the FFM is evaluated for MAGI-related coverage initially, but if any applying household member indicates that a disability exists or if the household member is age sixty-five (65) or older, that household member is evaluated for ABD coverage.

b) The AT record received from the FFM is the responsibility of the regional office that serves the county of residence of the applicant household unless one (1) member of the applying household is in an institution.

2. Insurance affordability programs include Medicaid, CHIP and coverage in a qualified

health plan through the FFM that provides advance payments of the premium tax credit or cost-sharing reductions to qualified individuals.

3. MAGI-related denied applications that are filed with the Division of Medicaid that do not indicate ABD coverage is possible are automatically referred to the FFM for an evaluation of coverage in a qualified health plan.

4. Non-Medicare ABD denials are referred to the FFM for an evaluation of coverage in a qualified health plan. However, if a MAGI-related or ABD application is denied for failure to comply with application requirements or if the application is voluntarily withdrawn, no referral is made to the FFM.

History: Revised eff. 4/01/2018.

Rule 4.8: Voter Registration

A. The Division of Medicaid offers the opportunity to register to vote or update voter registration to applicants, recipients and adults applying for children at the time of application, at the time of review or whenever an address change is reported.

B. Voter registration forms are available at regional offices and out-stationed sites for those applying in person, offered to those applying by phone and available on-line for those applying or submitting applications on-line.

C. Completed forms returned to the regional office are transmitted to the Circuit Clerk’s office in the county of residency, according to established timelines.

History: New eff. 04/01/2018.

Rule 4.9: Medicaid Applications Filed Through Another Agency or Entity

Certain applications for Medicaid are filed through other agencies or entities as follows:

A. Supplemental Security Income (SSI) applications are filed with the Social Security Administration (SSA). No separate application for Medicaid is necessary unless the SSI applicant needs to apply separately for retroactive Medicaid or for Medicaid to evaluate coverage for any missing month(s) of SSI coverage.

B. Children in the custody of the Mississippi Department of Child Protection Services (DCPS) who are certified as Medicaid-eligible by DCPS receive Medicaid with no separate application required.

C. Applications filed with the Federally Facilitated Marketplace (FFM) are reviewed for possible Medicaid or the Children’s Health Insurance Program (CHIP) eligibility before enrolling the applicant in a qualified health plan.

1. If applicants are potentially eligible for Medicaid or CHIP, their FFM account is transferred to the Division of Medicaid for further development and a decision regarding eligibility.

2 Referrals from the FFM require a Division of Medicaid decision to approve or deny eligibility for Medicaid or CHIP.

D. Low-Income Subsidy (LIS) applications are filed as part of an application for Medicare coverage through the SSA. LIS applications referred to the Division of Medicaid by SSA require a decision to approve or deny eligibility for one of the Medicare cost-sharing coverage groups Qualified Medicare Beneficiary (QMB), Specified Low - Income Medicare Beneficiary (SLMB), or a Qualifying Individual (QI).

E. Hospital Presumptive Eligibility (HPE) applications are filed by qualified hospitals to place time-limited Medicaid eligibility on file for certain individuals qualifying for HPE. The Division of Medicaid places the presumptive eligibility on file and monitors the submission of a full Medicaid application that can shorten the HPE eligibility originally placed on file or, if eligibility is approved, place full eligibility on file.

F. Presumptive Eligibility for Pregnant Women (PEPW) applications are filed by qualified providers.

1. Providers must inform the Division of Medicaid within five (5) working days after the determination is made.

2. Providers must inform the woman that a full application must be submitted prior to the end of the presumptive period.

G. Applications submitted by individuals through the Common Web Portal (CWP) are loaded directly into the information processing system to be processed by the Division of Medicaid. Applications from the CWP require a decision to approve or deny eligibility for Medicaid or CHIP from DOM.

History: Revised to correspond with MS SPA 24-0010 (eff. 07/01/2024), eff. 01/01/2026; Revised eff. 09/01/2025; New eff. 04/01/2018.

History

• Source: 42 C.F.R. § 435.403.
• Source: 42 C.F.R. § 435.403.
• Source: Miss. Code Ann. § 43-13-121.
• Source: 52 U.S.C § 20501- 52.
• Source: 42 U.S.C. § 1396p; 42 C.F.R. §§ 423.774, 423.904, 435.120, 435.201, 435.1110, 435.1200; Miss. Code Ann. § 43-13-115.1.

Chapter 14 Reinstatements and Corrective Action

23 Miss. Admin. Code Pt. 101, R. 15.2 Changing to a Reduced Service Coverage Group

A. Changing from a full service coverage group to a reduced service coverage group requires advance notice before the change can be effective the following month.

B. An active full service case is not changed to a reduced service coverage group such as Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Individual (QI) for the following month unless there are at least fifteen (15) days remaining in the current month.

History: Revised eff. 04/01/2018.

History

• Source: 42 C.F.R. § 431.211.

Part 102 Non-Financial Requirements

Chapter 9 Residents of an Institution

23 Miss. Admin. Code Pt. 102, R. 9.9 State Residency of Inmates

Inmates are generally state residents of the state in which they are living. Residency is otherwise determined under the following conditions:

A. If the inmate is placed in an out-of-state institution by the home state, the home state remains the state of residence for purposes of Medicaid eligibility and reimbursement of inpatient services.

B. Individuals who commit a crime outside their home state and are placed in a correctional facility in and by the state in which the crime was committed are considered to be residents of that state while incarcerated. The state in which the individual is incarcerated determines how eligibility is established.

C. Prior to release, an inmate may apply for Medicaid in a different state if the inmate intends to reside in that state after release. The effective date of eligibility can be no earlier than the month the former inmate arrives in the new state of residence.

History: Revised eff. 08/01/2020.

History

• Source: 42 U.S.C. § 435.403

Part 103 Resources

23 Miss. Admin. Code Pt. 103, R. 2.1 Significance of Ownership

...................................................................................19 Rule 2.2 Sole Ownership. ....................................................................................................20 Rule 2.3 Shared Ownership. ................................................................................................20 Rule 2.4 Fee Simple Ownership. .........................................................................................21 Rule 2.5 Less Than Fee Simple Ownership. ........................................................................21 Rule 2.6 Property Rights With No Ownership. ...................................................................25 Rule 2.7 Other Rights to Use of Real Property. ...................................................................27 Rule 2.8 Evidence of Real Property Ownership. .................................................................27 Rule 2.9 Verifying Current Market Value (CMV). .............................................................28 Part 103 Chapter 3: Non-Countable Resources...................................................................... 29 Rule 3.1 Retirement Funds. .................................................................................................29 Rule 3.2 Treatment of Retirement Funds. ............................................................................30 Rule 3.3 Loans, Promissory Notes & Property Agreements – General. ..............................31 Rule 3.4 Treatment of Loans, Promissory Notes & Property Agreements (SSI). ...............32 Rule 3.5 Treatment of Loans, Promissory Notes and Property Agreements (Liberalized). 33 Rule 3.6 Inheritances and Unprobated Estates. ...................................................................35 Rule 3.7 Real Property Exclusions. .....................................................................................36 Rule 3.8 Interests of Individual Indians in Trust or Restricted Lands. ................................44 Rule 3.9 Exclusion of Personal Property. ............................................................................46 Rule 3.10 Exclusion of Property Essential for Self-Support. .............................................65 Rule 3.11 Resources Set Aside As Part of A Plan To Achieve Self-Support (Pass). ..........71 Rule 3.12 Exclusion of Retained Cash Payments. ...............................................................71 Rule 3.13 Treatment of Excluded Funds Co-Mingled with Non-Excluded Funds..............75 Part 103 Chapter 4:Countable Resources ............................................................................... 78 Rule 4.1 Cash. ......................................................................................................................78 Rule 4.2 Checking/Savings Accounts. .................................................................................78 Rule 4.3 Joint Checking/Savings Accounts. ........................................................................79 Rule 4.4 Funds Held in Another Individual’s Account. ......................................................80 Rule 4.5 Time Deposits........................................................................................................81 Rule 4.6 Conservator Accounts. ..........................................................................................82 Rule 4.7 Patient Accounts. ...................................................................................................82 Rule 4.8 Charitable Funds Bank Accounts. ........................................................................83 Rule 4.9 Contents of Safety Deposit Box. ...........................................................................83 Rule 4.10 Non-Home Real Property. ..................................................................................83

23 Miss. Admin. Code Pt. 103, R. 4.11 529 Plan

.............................................................................................................83 Rule 4.12 Stocks. ................................................................................................................84 Rule 4.13 Mutual Fund Shares.............................................................................................84 Rule 4.14 US Savimgs Bonds. .............................................................................................85 Rule 4.15 Corporate Bonds. .................................................................................................85 Rule 4.16 Municipal Bonds. ................................................................................................86 Rule 4.17 Government Bonds/US Securities. ......................................................................87 Rule 4.18 Cash to Purchase Medical or Social Services. ...................................................87 Rule 4.19 Retroactive in-home Supportive Services. ..........................................................88 Rule 4.20 Uniform Gifts to Minors Act. ..............................................................................88 Rule 4.21: Entrance Fees to Continuing Care Retirement Communities ...........................90 Rule 4.22: Disqualification for Long Term Care Assistance for Individuals with Substantial Home Equity .....................................................................................................91 Part 103 Chapter 5: Trust Provisions ..................................................................................... 91 Rule 5.1: Classification of Trusts.........................................................................................92 Rule 5.2: Clearing Trusts, Guardianships, and Conservatorships .......................................92 Rule 5.3: General Trust Definitions .....................................................................................93 Rule 5.4: General Trust Definitions - OBRA-93 and DRA Trust Policy ............................94 Rule 5.5: Medicaid Trust Provision .....................................................................................96 Rule 5.6: Treatment of Revocable Trusts ............................................................................97 Rule 5.7: Treatment of Irrevocable Trusts ...........................................................................97 Rule 5.8: Payments Made From Revocable or Irrevocable Trusts ......................................98 Rule 5.9: Circumstances Under Which Payments Can/Cannot Be Made. ..........................99 Rule 5.10: Placement of Excluded Assets in Trust ..............................................................99 Rule 5.11: Undue Hardship Provision ...............................................................................100 Rule 5.12: Reviewing Trust Documents ............................................................................101 Rule 5.13: Trust Exceptions ...............................................................................................101 Rule 5.14 Special Needs Trusts (SNT) ..............................................................................102 Rule 5.15: Pooled Trusts ....................................................................................................103 Rule 5.16: SNT and Pooled Trust Guidelines and Restrictions ........................................100 Rule 5.17: Income Trusts ...................................................................................................105 Part 103 Chapter 6: Annuities ............................................................................................. 107 Rule 6.1: Annuities Defined for Medicaid Purposes ........................................................107 Rule 6.2: Treatment of Annuities Purchased prior to 2/8/2006. ........................................109

Rule 6.3: Calculating the Uncompensated Value of Annuities Purchased prior to 0/08/06 02/08/2006. ........................................................................................................................110 Rule 6.4: Treatment of Annuities Purchased on or after 2/8/2006. ...................................110 Rule 6.5: Determining Whether an Annuity (Purchased After 02/08/2006) is Actuarially Sound .................................................................................................................................115 Part 103 Chapter 7: OBRA-93 and DRA Transfer Policy .................................................. 116 Rule 7.1: OBRA-93 and DRA Transfer Policy Principles. ...............................................116 Part 103 Chapter 8: Medicaid Qualifying Trusts (MQT) ..................................................... 133 Rule 8.1 Treatment of Medicaid Qualifying Trusts (MQT). .............................................133 Part 103 Chapter 9: Standard Trusts .................................................................................... 136 Rule 9.1 Treatment of Standard Trusts. .............................................................................136 Part 103 Chapter 10: Conservatorships Prior to 3/1/1987.................................................... 138 Rule 10.1 Treatment of Conservatorships Prior to 03/01/1987. ........................................138 Part 103 Chapter 11: Medicare Catastrophic Coverage Act Transfer Policy ...................... 140 Rule 11.1 Treatment of Medicare Catastrophic Coverage Act Transfer Policy. ...............140 Part 103 Chapter 12: Encumbrance of a Liquid Resource .................................................. 145 Rule 12.1 Treatment of the Encumbrance of a Liquid Resource. ......................................145 Part 103 Chapter 13: Resource Spenddown (Liberalized Policy) ........................................ 146 Rule 13.1 Treatment of Resource Spenddown Under Liberalized Policy. ........................147 Part 103 Chapter 14: Deeming of Resources ....................................................................... 148 Rule 14.1 Treatment of Resource Deeming. .....................................................................148 Part 103 Chapter 15: General Verification Requirements ................................................... 151 Rule 15.1 General Verification Requirements. ..................................................................151

Chapter 1 Introduction to Resources

23 Miss. Admin. Code Pt. 103, R. 1.2 Aged, Blind and Disabled Programs

A. Medicaid uses the value of a person’s resources as a factor in determining eligibility. It is generally expected that individuals or couples whose resources exceed the limit will use the excess to meet their needs before becoming eligible for Medicaid.

B. As a 1634 state, Mississippi is required to use SSI resource rules for ABD eligibility determinations. However, as indicated previously, the state is allowed to apply income and resource rules to certain ABD coverage groups that are more liberal than the SSI program. The Division of Medicaid requested and received approval to liberalize resource policies for some ABD coverage groups.

C. Some coverage groups are exempt from liberalization under 1902(r)(2) because they are considered “deemed” cash assistance groups. These coverage groups continue to follow SSI resource rules. The remainder of this section describes the treatment of resources in determining eligibility in the Aged, Blind and Disabled programs and discusses the use of strict SSI rules or liberalized resource policy, as applicable.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.3 General Resource Principles

A. The following general principles about resources should be noted:

1. Not everything a person owns is a resource.

2. Not all resources count against the limit.

3. The Social Security Act and other Federal laws require certain types and amounts of resources to be excluded.

a) If a resource is not specifically excluded, it is countable.

4. In certain situations, federal law requires other people to share financial responsibility for an individual or couple.

a) In those situations, Medicaid considers the resources of the person(s) along with those actually belonging to the individual couple. If countable resources exceed the limit, an individual or couple is not eligible.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.4 Resource Limits

A. Federal law establishes a limit on the value of resources an individual or couple may own and still be eligible for Medicaid.

B. Countable resources must not exceed the limit in effect for the applicable time period.

C. Beginning 07-01-2000 ongoing:

1. The indivdual limit is $4,000; and

2. The couple limit is $6,000.

a) The increased limits above are applicable to most coverage groups subject to liberalized resource policies.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b).

23 Miss. Admin. Code Pt. 103, R. 1.5 SSI Resource Limits

A. The individual/couple limits for groups subject to SSI resource limits remain $2,000/$3,000.

Rule 1.6: Coverage Groups Subject to SSI Resource Limits

A. SSI resource limits apply to the following coverage groups:

1. SSI Retro Determinations, a) Unless the client must be placed in a liberalized coverage group for the retroactive period.

2. Former SSI Recipient Coverage Groups, which include:

a) Disabled Adult Child (DAC),

b) Cost of Living (COL) and

c) OBRA widows/widowers.

3. Katie Beckett group, and

4. Qualified Working Disabled Individuals (QWDI),

a) QWDI is a reduced coverage group which has resource limits that are twice SSI limits.

History: Revised eff. 07/01/2025.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).
• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.7 Coverage Groups Subject to Liberalized Resource Limits

A. Liberalized resource limits apply to the following coverage groups:

1. Long Term Care coverage groups (LTC);

2. Home and Community Based Waiver groups (HCBS);

3. Poverty Level Aged and Disabled (PLAD);

a) Program ended December 31, 2005.

4. Healthier Mississippi Waiver (HM);

5. Working Disabled (WD) and

6. Medicare Savings Programs (MSP)

a) See discussion on these reduced coverage groups below.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.8 Reduced Coverage Groups

A. The reduced coverage groups for non-institutional individuals have or had a resource limit that is twice the SSI-related resource limit. 1. Under liberalized policy, the Medicare Savings Programs (QMB, SLMB, and QI) have no assets test.

2. The individual/couple limit for QWDI remains twice the SSI-related resource limit or $4,000/$6,000.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.9 Resource Limits Applicable to Institutional Groups

A. For Medicaid coverage groups considered to be “institutional” coverage groups, the following set of resource limits apply:

1. Effective 10-01-1989, Spousal Impoverishment resource rules apply to married couples whereby one spouse is in a medical facility while the other spouse remains at home.

2. The Community Spouse is allowed a higher resource limit set by federal law and subject to increase each year.

3. Effective 04-01-1993 until the coverage group ended 04-30-2005, Spousal Impoverish rules applied to Hospice Coverage group.

4. Effective 01-01-1994, Spousal Impoverishment resource rules began to be applied to the HCBS Waiver programs.

Rule 1.10: Liberalized Resource Policy Overview

A. The following briefly describes the liberalized resource policies currently in effect. The liberalizations are described in greater detail in the discussion of each resource type:

1. Spend down of resources within a month to become eligible in that month, i.e., eligibility may be established effective the first day of the month if countable resources fall below the applicable limit within the month.

2. Excess resources earmarked for payment of private pay in a nursing facility in month(s) prior to Medicaid eligibility are not considered countable resources.

3. Income that accumulates pending Medicaid approval that results in excess resources can be excluded if this income is obligated for Medicaid income purposes.

4. Certain property and types of ownership are totally excluded, regardless of value:

a) Home property located in Mississippi, life estate and remainder interests in any property, sixteenth (16 th ) Section land leaseholds, mineral rights or timber rights that are not under production and housing on government-owned land are excluded under liberalized policy,

b) Income producing property is excluded if it produces at least six percent (6%) of the equity value of the property,

c) Promissory notes, loans and property agreements are excluded if the note produces a net annual return of six percent (6%) of the principal balance,

d) Up to two (2) automobiles may be excluded for applicants or recipients under the age of nineteen (19),

e) Household goods are totally excluded and personal property up to five thousand dollars ($5,000.00) in equity value is excluded,

f) The cash value of whole life insurance is excluded if the combined face value of all life insurance policies on any one individual is ten thousand dollars ($10,000.00) or less,

g) Burial spaces for family members are excluded as resources, and

h) Burial funds set aside in a revocable arrangement are subject to a six thousand dollar ($6,000.00) limit effective April 1, 2001.

5. The current market value of real property is established using the county tax assessed true value as shown or calculated using the appropriate county property tax assessment notice.

History: Revised to correspond with SPA 19-0018 (eff. 07/01/2019) eff. 12/01/2025; Revised to correspond to SPA 16-0009 (eff. 01/01/2016) eff. 01/01/2017.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).
• Source: 42 U.S.C. § 1396a; 42 C.F.R. § 435.601.

23 Miss. Admin. Code Pt. 103, R. 1.11 SSI Resource Policy Overview

A. SSI policy specifies different exclusion limits or different ways to determine countable resources. If the resource policy has not been liberalized, SSI policy is applicable unless a subsequently issued federal statue or Medicaid regulation supersedes SSI policy.

B. SSI policies include:

1. Eligibility is based on the individual’s countable resources as of the first moment of the first day of the month and is applicable to the entire month.

a) If resources exceed the limit as of the first moment of the first day of the month, the individual or couple is not eligible for that month.

b) It is not possible to “spenddown” resources within a month to establish eligibility for that month under SSI resource policy.

2. One automobile is automatically excluded regardless of value.

3. The value of life estates and remainder interest in real property is a countable resource.

4. The cash value of whole life insurance is excluded, if the combined face value of all policies on any individual is $1,500 or less.

a) The combined face value of these excluded policies is used as an offset in determining burial fund exclusion.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.12 First of the Month Rule for Making Resource Determinations

A. In the programs using SSI policy, resource determinations are made as of the first moment of a calendar month.

B. Any increase or decrease in the value of resources during a month is considered as of the first moment of the month following the month the change occurred.

1. Example; Tom Lee applies for assistance on March 30 th . His only resource is 20 shares of XYZ stock that are worth $800.00 on the date he applied. On April 30 th , the value increased to $1,000.00. His countable resource amount for April is $800.00. The countable value for May is $1,000.00.

2. Example; Rhonda Mooney applies for assistance on April 5 th . On April 1 st , her resources were $500 in checking and $700 in savings. On April 5 th , her son gave her money and she purchases a CD worth $1,800. Her savings balance increased to $750 on April 30 th , but her checking balance dropped to $350. For April, countable resources are $1,200 ($500 + $700). For May, they are $2,900 ($1,800 + $750 + $350). The CD is not considered until May since it was acquired in the middle of the month.

C. Do not consider as a resource any advance dated checks or advance posted direct deposit checks received prior to the month of normal receipt. If retained, funds from such checks will be considered a resource as of the first moment of the first day of the month following the month in which the check is normally paid.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.13 Resource Definitions

A. Resources (General Definition): All assets, including real and personal property which an individual or couple:

1. Owns;

2. Can apply toward basic needs of food, clothing and shelter, either directly or by conversion to cash, (if not already cash); and

3. Are not legally restricted from use for support or maintenance.

a) Examples of resources include, but are not limited to:

1. Home,

2. Land,

3. Bank Accounts,

4. Burial Assets,

5. Life Insurance,

6. Automobiles, and

7. Investments.

B. Liquid Resources:

1. Cash or items that are readily converted to cash (within 20 workdays).

2. Liquidity or nonliquidity of a resource has no effect on a resource’s countability.

3. Absent evidence to the contrary, assume the following types of resources to be liquid:

a) Stocks, bonds and mutual fund shares;

b) Checking and savings accounts, time deposits, CDs;

c) US Savings Bonds, treasury bills;

d) Mortgages and promissory notes;

e) This is not an all-inclusive list of liquid resources.

C. Non-liquid Resources:

1. Are not cash and are not readily convertible to cash;

2. Liquidity or non-liquidity of a resource has no effect on a resource’s countability; and

3. Absent evidence to the contrary, assume the following resources to be non-liquid:

a) Buildings, land and other real property rights,

b) Vehicles,

c) Farm machinery and livestock,

d) Household goods and personal effects, and

e) Non-cash business property.

f) This is not an all-inclusive list of non-liquid resources.

D. Real Property:

1. Land, including buildings or immovable object attached permanently to the land.

E. Personal Property:

1. Any property that is not real property.

2. Personal property includes such items as:

a) Cash,

b) Jewelry,

c) Household goods,

d) Tools,

e) Life insurance policies, and

f) Automobiles

F. Exclusion:

1. A resource, or part of a resource’s value, that is not considered in the eligibility determination.

G. Countable Resources:

1. Resources remaining after all exclusions are applied.

2. The value of a resource is the amount of an individual’s or couple’s equity in it. The current market value and debt on a resource must be verified to determine the equity value.

H. Current Market Value (CMV):

1. The amount a resource can reasonably be expected to sell for on the open market in the particular geographical area involved or the sale price, if sold for a higher amount.

I. Equity Value:

1. The current market value (CMV) minus any encumbrance (payoff amount), i.e., a piece of property has a CMV of $35,000. The mortgage payoff is $20,000. The equity value is $15,000.

J. Encumbrance:

1. An encumbrance is a legally binding debt against a specific property.

2. The debt reduces the value of the encumbered property, but does not prevent the owner from transferring ownership (selling) to a third party.

a) However, if the owner does sell it, the creditor will nearly always require payment from the proceeds of a sale.

K. Conserved Funds:

1. Funds or property being held for an individual by another person, such as a daughter has $30,000 in a bank in her name but it is verified to be her parent’s money and is used for their needs.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.14 Income vs Resources

A. It is important to distinguish between resources and income to know which counting rules to use for any given month. The same item is not evaluated under two sets of counting rules for

the same month; that is, one item cannot be counted as both income and a resource in the same month:

B. Income Counting Rules. Items received in cash or in-kind during a month are evaluated under the income rules.

C. Resource Counting Rules. Items retained for use in the month following the month of receipt are subject to evaluation under resource rules, as are all other items not defined as income.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.15 Distinguishing Resources from Income

A. If an individual sells, exchanges, or replaces a resource, what he receives in return is not income; rather, it is a different form of resource.

B. In order to distinguish resources from income, a determination must be on what has occurred and the monetary gain.

C. The monetary gain would be considered a resource when it:

1. Was an increase in value of an existing resource;

2. Was for the receipt or replacement of a resource;

3. Was from the conversion or sale of a resource; or

4. Was a cash or in-kind item for the replacement or repair of an excluded resource which is lost, damaged or stolen. (This is discussed further later in this chapter.)

D. Dividends and interest are defined as returns on investments, stocks, bonds, and savings accounts, etc. Refer to the income section for handling.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.16 Converted Resources

A. If an individual sells, exchanges or replaces a resource, what he receives in return is a resource that has been converted from one type of resource to another.

B. Examples of converted resources are:

1. A lot with equity value of $5,000.00 is sold and the money is deposited into a money market account.

2. A life insurance policy is cashed in and the proceeds are used to purchase a pre-need burial contract.

C. Handling Changes in a Converted Resource. When a resource changes form, it may also change:

1. From an excluded resource to a countable one,

2. From a countable resource to an excluded one or

3. To something that is not considered a resource for Medicaid purposes.

a) Example: An excluded vehicle is sold and proceeds are deposited into a checking account. The money received is a countable resource, rather than income.

b) Example: A life insurance policy with a face value of $15,000.00 and a countable cash surrender value of $1,000.00 is cashed in and the proceeds are used to purchase a cemetery plot which is excluded in the resource determination.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.17 Evaluation of Receipt of Property as Income

A. When an individual first receives property (as a gift or inheritance, for instance, and not as a purchase or trade of one resource for another), the new property is subject to evaluation under the income rules for the month of receipt and under resource rules thereafter.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.18 Factors That Make Property a Resource

A. Property of any kind, including cash, is a resource only if it meets all three criteria listed below by resource criteria and description:

1. Ownership Interest.

a) An individual must have some form of ownership in property in order for the property to be considered a resource. The fact that an individual has access to property, or has a legal right to use it, does not make it a resource if there is no ownership interest.

2. Legal Right to Access (spend or convert) Property.

a) An individual must have a legal right to access property. Even with ownership interest, property cannot be a resource if the owner lacks the legal ability to access funds to spend or convert non-cash property into cash. The fact that an owner does not have physical possession of property does not mean it is not his resource. It is a

resource if the owner still has the legal ability to spend it or convert it into cash. An individual has free access to, and unrestricted use of, property even when he can take actions only through an agent (such as a representative payee or conservator).

3. Legal Ability to Use for Personal Support and Maintenance.

a) Even with ownership interest and legal ability to access property, a legal restriction against the property’s use for the owner’s own support and maintenance means the property is not a resource.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.19 Access to Resources

A. Unless an individual has been declared legally incompetent, he is assumed capable of managing his own affairs and his resources are considered. Competency does not affect consideration of resources.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.20 Individuals Declared Legally Incompetent

A. The following is applicable to individuals who have been declared legally incompetent:

1. Court Appointed Guardian or Conservator or Conservator. If the court has appointed a guardian or conservator, resources owned by the individual are considered available.

a) Seeking court approval is not a legal restriction to the sale or disposal of the property and does not change the property’s status as a countable resource to the individual.

B. No Court Appointed Guardian. If the court has not yet appointed a guardian or conservator, resources owned by the individual are not considered available.

1. The individual does not have access to the resource until a guardian or conservator has been appointed.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.21 Types of Access

A. Resources are accessible through an agent, litigation or a petition-conservatorship account under SSI and liberalized resource policy:

1. Access Via an Agent. An individual is considered to have free access to, and unrestricted use of, property even when he can take those actions only through an agent, such as a representative payee or guardian.

a) Example: Joan Shoto receives Social Security. Her mother, Laura Shoto, is her representative payee and has Power of Attorney. The bank account is a countable resource to Joan because she has unlimited access through her mother.

2. Access Only Via Litigation. If there is a legal restriction, or a bar, to the sale or use of property, such as a co-owner legally blocks the sale of jointly-owned property, an individual is not required to undertake litigation to accomplish the sale or access. The property is not a resource under such circumstances in a month if a legal bar exists any time in the month.

a) Example: Shelley Lumpkin and her sister, Susan Smith, co-own a piece of property they inherited from their parents. Last year Susan took legal action to prevent Shelley from selling. Shelley is not required to enter into litigation to gain the ability to sell, so the property is not a resource to her.

3. Access Via Petition. Petitioning a court is different from undertaking litigation, and:

a) Seeking court approval is not a legal restriction against use.

b) Although the individual does not have access to the asset, the conservator does. Therefore, it is available for the individual’s support and maintenance and is, therefore, that individual’s resource. This is true despite the fact that the individual or his agent is required to petition the court to withdraw funds for the individual’s support and maintenance.

c) The conservator will be allowed a period of time to petition the court. Once the conservator has verified a petition has been filed with the court, the regional office will follow-up to determine the outcome.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.22 Assets vs Resources

A. Not everything a person owns (assets) are resources for Medicaid purposes. As previously indicated, a resource is cash or other real or personal property that an individual (or spouse, if any):

1. Owns,

2. Has the right, authority or power to convert to cash, (if not already cash),

3. Is not legally restricted from using for his support or maintenance.

B. In certain situations, an asset that is not a resource may become one at a later date or vice versa. The distinction is important since:

1. An asset that is not a resource does not count against the resource limit (while a resource may count); and

2. Proceeds from the sale or trade of a resource, i.e., the amount representing conversion of principal from one form to another, are also resources; however,

3. What a person receives from a non-resource is subject to evaluation as income at the time of receipt. For example, an individual is the beneficiary of a trust which is not his resource; therefore, when the trust pays him his monthly allowance, he receives income.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.23 Resources With Zero Value

A. Property does not cease to be a resource simply because it has no current market value. Even though there is no value to count, the property remains a resource for as long as it meets the definition of a resource. If the property develops market value at a later time, this will be an increase in the value of a resource rather than receipt of income.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.24 Property That Is Not a Resource

A. Any property (asset) that does not meet the above definition of a resource is not a resource, e.g., an individual who has an ownership interest in property, but is not legally able to transfer that interest to anyone else does not have a resource.

B. Example: An individual owns a block of stock with his brother. Although the form of ownership is one which would permit either to sell the property without the other’s consent, the brothers have a legally binding agreement that one will not sell without consent of the other. The individual’s brother refuses his consent, making the stock a non-resource for the individual. If the brother subsequently agrees to sell, the stock would be evaluated under resource-counting rules beginning with the month following the month of consent. The value of the stock would not be counted as income to the individual in the month consent is given.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.25 Unknown Assets

A. An individual may be unaware of his ownership of an asset. If this is the case, the asset is not a resource for the period during which the individual is unaware of his ownership.

B. Once the asset is discovered by the individual, the value, including any monies accumulated on it through the month of discovery, must be treated as follows:

1. Month of discovery. The value of the unknown asset, including any monies (such as interest) that have accumulated on it through the month of discovery, is evaluated under regular income-counting rules.

2. Months after month of discovery. For months after the month of discovery, the previously unknown asset is a resource and subject to usual resource counting rules.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 1.26 Valuation of Resources

A. The value of a resource is the amount of an individual’s or couple’s equity in it. As indicated in the definitions section, the equity value (EV) of a resource is its current market value (CMV) less any encumbrance(s). The pay-off amount for each encumbrance on the property is used in the calculation of its equity value.

Rule 1.27: Whose Resources to Count

A. When eligibility is determined or re-determined, the resources of the following must be considered:

1. Applicant/recipient; and

2. Spouse of the applicant/recipient;

a) If the spouse is included in the household;

b) Even if the spouse is not applying or is ineligible;

c) An exception exists for institutionalized individuals.

3. Parent(s) of an applicant/recipient who is a child under age 18 living in the same household.

a) There is no deeming of parental resources to the eligible child in the Katie Beckett group or in any institutional group for the month of entry.

History: Revised eff. 07/01/2025.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).
• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

Chapter 2 Ownership Interest

23 Miss. Admin. Code Pt. 103, R. 2.1 Significance of Ownership

A. Since the type and form of ownership may affect the value of real or personal property and even its status as a resource, ownership interests are significant in determining resource eligibility.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.2 Sole Ownership

A. Only one person owns the property (real or personal) and may sell, transfer or dispose of the property. However, sole ownership may be subject to conditions imposed by others, such as sole ownership of a remainder interest in property.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.3 Shared Ownership

A. Two or more people own the property (real or personal) together. The different types of shared ownership are discussed below.

1. Tenancy in Common.

a) Two or more people have an undivided fractional interest in the whole property for the duration of the tenancy. These interests are not necessarily equal, i.e., two joint tenants do not necessarily each owns half of the property.

b) One owner may dispose of his share without permission of the other owner(s), but cannot take these actions with respect to the entire property.

c) When one owner dies, his interest passes to his heirs or estate.

d) There is no automatic right to survivorship for the surviving tenants-in-common.

e) Example, Don, Charles and Fred Evans own property as tenants-in-common. Charles and Fred each own an undivided ¼ interest while Don owns the remaining ½ interest. If Don Evans were to sell his ½ interest to Stan Long, Mr. Long would be a tenant-in- common with Charles and Fred. If Mr. Long were then were then to die so that property passed to his 4 children, each of them would own 1/8 interest as tenants-in– common with Charles and Fred, who would each continue to own ¼ interest.

2. Joint Tenancy

a) Each person has an undivided ownership interest and possession of the whole property for the duration of the tenancy. In effect, each owns all of the property.

b) Right to survivorship applies to the other owner(s).Upon the death of one of only two joint tenants, the survivor becomes the sole owner. On the death of one of three or more joint tenants, the survivors become joint tenants of the entire interest.

3. Tenancy by the Entirety.

a) Exists only with married couples. b) While married, the wife and husband own the property as a unit and the property can only be disposed of if both give consent;

c) If divorced, the former spouses become tenants-in-common and each can sell his/her share without the other’s consent.

d) Right to survivorship applies upon the death of one tenant by the entirety, the survivor takes the whole.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.4 Fee Simple Ownership

A. Relates only to real property;

B. Means absolute and unqualified legal title to real property;

C. Fee simple ownership is completely free of conditions imposed by others.

D. The owner has the unconditional power of disposition during his lifetime.

E. Upon the owner’s death, property held in fee simple can always pass to the owner’s heirs.

F. May exist with respect to property owned jointly or solely.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.5 Less Than Fee Simple Ownership

A. Equitable Ownership.

1. Exists without legal title to property;

2. Legal title may belong to another or to no one;

3. Examples of equitable ownership include ownership in unprobated estates or trust property.

a) Unprobated Estate. An individual may have an equitable ownership in an unprobated estate if he is an heir or relative of the deceased, receives income from the property or acquires rights through intestacy laws. Under liberalized policy, estates in process of probation are excluded. Under SSI resource policy an unprobated estate becomes a resource the month following the month it meets the definition of income.

b) Trust Property. A trust is a right of property, established by a trustor or grantor. A Trustee holds legal title and manages the property for the benefit of a beneficiary. The beneficiary does not have legal title, but does have an equitable ownership interest. Clearance procedures must be followed in determining how the trust affects eligibility

B. Life Estate Interest.

1. Individual has certain property rights during his life or someone else’s life.

2. May be conditional. See instructions below for handling a conditional life estate.

3. Legal document is required (such as will or deed).

4. Unless the legal document restricts rights, the life estate owner has the right to possess, use, and obtain profits from the property (such as rents).

5. Life estate interest can be sold.

6. Life estates do not descend to heirs.

7. Example: Mr. Heath, now deceased, willed his daughter a life estate in property which he owned fee simple. The will also designated Mr. Heath’s two sons as remaindermen. The daughter has the right to live on the property until her death at which time, under the terms of her father’s will, the property will pass to her brothers as joint tenants.

8. If there are joint owners of a life estate, the CMV is divided by the number of owners to determine an individual’s share.

9. When one joint owner of the life estate dies, the surviving owner(s) increases their interest. If a couple has a life estate and one spouse dies, the remaining spouse is the sole owner of the life estate. When the remaining spouse dies, the person holding the remainder interest then has the right to possess and use the property.

10. It is possible to have a life estate interest in a structure (house) and not surrounding land. The CMV of the structure or whatever the tenant has the right to use as established by the deed or a will would be determined.

11. Under liberalized policy, a life estate is an excluded resource. The exclusion is not limited to property located in Mississippi. In addition, if the individual has a life estate

interest in more than one piece of property, all are excluded. However, there are some exceptions to excluding a life estate:

a) If a life estate is transferred or sold, eligibility for vendor payment or HCBS waiver services may be affected. A transfer of a life estate is sanctionable.

1. When the value of a life estate interest needs to be determined for a potential transfer, follow the procedures below, using the age of the individual as of their last birthday at the time of the transfer. Verify the Current Market Value (CMV) of the property. Use the Unisex Life Estate and Remainder Interest Table for the following steps:

(a) Find the age of life estate owner as of their last birthday at the time of the transfer.

(b) Locate the factor in the Life Estate column that corresponds to the age.

(c) Multiply the CMV of the property by the life estate factor to obtain the value of the life estate. (CMV of the property X Life Estate Factor = CMV of the life estate).

(i) Example: Jane Ayers took a life estate in her home in 1988. Now at age 97, she is applying for nursing home care. It is discovered she transferred her life estate interest to her son two years ago. Her age as of her last birthday at the time of the transfer was 95 and at that time the property had a CMV of $250,000. The uncompensated value is determined as follows:

$250,000 (CMV) x .22887 (Life Estate Factor for Age 95) = $52,217.50 (Uncompensated Value).

12. Conditional Life Estate.

a) A conditional clause establishes limitations on the life estate. For example, the grantor may reserve a life estate for as long as the grantor lives and maintains a home on the property.

b) For deeds dated on or after February 8, 2006, consider the entire property transferred if the deed contains a conditional life estate clause. The transfer date will be the date of the deed.

c) The life estate can be corrected if a revised deed is prepared removing the conditional clause with the grantor reserving a life estate without limitations. However, the transfer of the remainder interest, if it occurred within the 5-year look back period, must be considered if the grantor enters long term care. Therefore, removing the conditional life estate clause may only shorten the transfer period.

13. Under the DRA the purchase of a life estate in another individual’s home on or after February 8, 2006, is a transfer of assets unless the purchaser resides in the home for at least 12 consecutive months after the date of purchase.

a) Do not deduct vacations, overnight visits, and hospital stays from the one-year period as long as the home continued to be the individual’s legal residence. Count the entire purchase price as an uncompensated transfer if the purchaser resides in the home for any period less than one year.

b) Also the DRA provides that even if the life estate purchaser lives in the home for 12 consecutive months, the purchaser must not pay more than CMV for the life estate. Any amount paid above CMV is considered a transfer and should be penalized according to the transfer policy. Verify the purchase price and calculate the CMV of the life estate. Any amount paid over the CMV of the life estate is considered a transfer.

14. Under strict SSI policy, the value of a life estate is a countable resource unless an exclusion exists.

a) Verify the Current Market Value (CMV) of the property.

b) Use the Unisex Life Estate and Remainder Interest Table for the following steps:

1. Find the age of life estate owner as of their last birthday.

2. Locate the factor in the Life Estate column that corresponds to the age.

3. Multiply the CMV of the property by the life estate factor to obtain the value of the life estate. (CMV of the property X Life Estate Factor = CMV of the life estate).

c) If there is joint ownership of a life estate, first determine the CMV of the entire property. Divide the CMV by the sharer of joint owners to determine the individual’s share and then calculate the individual’s life estate value as described above.

1. Example. 75 year-old Harry Thomas has a life estate in non-homestead property with a current market value of $80,000. An exclusion for the property cannot be developed. Using the table, his life estate interest is valued as follows: $80,000 (CMV) x .52149 (factor for age 75) = $41,719.20 (value of the life estate)

2. Example. 75 year-old Max Berry is living with his daughter due to illness, but states he intends to return home when health permits. Ten years ago, he transferred his home to his children retaining a life estate interest. An exclusion can be developed for the home property since his desire is to be able to return home.

C. Ownership by Will or Descent.

1. An individual may have ownership interest in an unprobated estate acquired through a will or through the death of a relative who died intestate (without a will). The heir(s) may be the sole owner or joint or common owners, etc.

2. Heirs by Will.

a) Have ownership or control of the property or their joint or common share.

b) If the will has not been filed with the proper court and has not been probated, there is question of whether the will is legally binding. Legally, wills are supposed to be filed for probate; however, there is no time limit.

c) Absent evidence to the contrary, assume the client owns the property in proportion, whereby he has the right to the will’s directives.

3. Heirs by Descent.

a) Acquire ownership interest to property by virtue of the heir’s relationship to the deceased. Intestate property of a deceased person with a spouse and children is shared equally by the surviving spouse and children. Grandchildren become involved in ownership interest only when their parent, who was a child of the original owner, is deceased. The grandchildren’s interest is only in the share that their deceased parent held in interest.

b) Intestate property of an individual with no spouse or children at the time of death descends equally to his parents and brothers and sisters. If the deceased’s parents are also deceased, the property descends to his brothers and sisters. Nieces and nephews become involved only if their parent who was a brother or sister to the deceased is also deceased. Their ownership interest is only in the share that their deceased parent held an interest in.

c) Absent evidence to the contrary assume an heir inherited property based on their laws of descent where the property is located.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.6 Property Rights With No Ownership

A. Leasehold.

1. Does not designate rights of ownership, but conveys an individual control of the property so that he has use and possession for a specific period of time and usually for a specified rent, such as 16 th section land leases.

a) 16 th Section Land. 16 th section land or land acquired in lieu of 16 th section land is land controlled by the State Board of Education under the general supervision of the State Land Commissioner. Generally each county Board of Supervisors has the authority to approve or renew leases on the land. An individual who leases such land does not own the property and has limited rights. The value of the lease decreases as the expiration date nears. Lease rights to 16th section or lieu lands are negotiable. These rights may be sold to another person provided the governing authority which approves such leases is agreeable to such a sale.

B. Incorporeal Interests.

1. No ownership of the physical property;

2. The owner has certain rights to use the property without the right to dispose of property;

3. Applies to mineral rights, timber rights and easements, which may be sold by the owner.

a) Mineral Rights. Ownership in natural resources, usually obtained from the ground, such as coal, oil, sulphur, sand or natural gas, etc., coming from the property.

b) Timber Rights. These rights permit one party to cut and remove trees from property owned by another, as designated by a contract with the owner of the land on which the timber stands.

c) Easements. Property right whereby one has the right to use the land of another person for a special purpose.

C. Valuation of leaseholds and incorporeal interests.

1. They may be countable resources under both SSI and liberalized resource policy if they have a cash value available to the individual upon disposition.

2. However, in some cases these property rights are not saleable and would not be a countable resource:

a) An individual may own an easement to pass through another person’s property to get to his own property. There would be little or no market for the sale of this property right.

b) Timber rights to land which has been stripped of its trees or mineral rights to land with no viable natural resources would have little or no market value.

3. To verify the value of property ownerships such as mineral rights or timber rights, determine the CMV from a knowledgeable source. If the property right is under

production, it is necessary to obtain a copy of the land lease to determine if the lease is transferrable in order to determine if the property right is a countable resource.

4. Under liberalized policy, 16th Section land leases and mineral rights, timber rights and leaseholds that are not under production are excluded in the resource determination regardless of value. If one of these types of ownership is income-producing, net annual return is tested against the 6% income-producing rule when applicable.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.7 Other Rights to Use of Real Property

A. Homestead Rights

1. Under state law a surviving spouse (widow or widower) is entitled to the homestead on the real property used as the home at the time of the death of the spouse and to receive income from it for his lifetime. This is not a life estate interest in the property, but is quite similar.This situation occurs when spouses jointly or commonly own property without the right of survivorship clause in the property.The surviving spouse has homestead rights to the portion of the property that belonged to the deceased spouse. The surviving spouse would also own his/her own interest in the property. A homestead right does not have value and cannot be sold.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 2.8 Evidence of Real Property Ownership

A. Property ownership must be verified. Obtain a copy of the official document used to verify ownership and file it in the case record. The following official records may be used to establish real property ownership:

1. Current Deed. If the client does not have a copy of the current deed, a copy may be obtained from records in the Chancery Clerk’s office in the county where the property is located. Any discrepancies which exist between a deed and a tax receipt must be resolved in order to determine the true ownership situation. A deed must be recorded in the appropriate county office to be considered a true deed documenting ownership.

2. Tax Assessment Notice or Most Recent Tax Receipt. Tax records and receipts describe the property. Phrases such as “Et al” and “Et ux” beside the name on a tax receipt indicate joint or common ownership in some form. Current Mortgage Statement. Mortgages are recorded in the Chancery Clerk’s office; however, the name of the mortgage holder must be known. Report of Title Search Wills, Court Records or Relationship Document.- Which show rights of an heir to the property after death of the former owner.

History

• Source: Miss. Code Ann. 43-13-121.1 (Rev. 2005).

23 Miss. Admin. Code Pt. 103, R. 2.9 Verifying Current Market Value (CMV)

A. Once ownership or ownership interest in property has been verified, the current market value (CMV) of the client’s ownership interest is determined based on the coverage group of the applicant or beneficiary and whether Supplemental Security Income (SSI) or liberalized resource policy is applicable.

B. Under liberalized resource policy, the CMV is established using the most recent county property tax assessment notice unless a tax assessment for a prior time period is needed, such as to establish CMV when a transfer of assets occurred.

1. The true value of the property as shown on the county property tax assessment notice is used to establish CMV. If the true value is not shown, the property tax assessed true value is calculated as follows:

a) A tax assessed value divided by the county tax assessment ratio is the CMV based on the assessment. Class 1 property is home property and Class 2 property is non- home property. Class 2 property may adjoin home property and therefore be included in the definition of home property.

b) Property in Mississippi is assessed at ten percent (10%) for Class 1 (home) property and fifteen percent (15%) for Class 2 (non-home) property.

c) The assessed value divided by the applicable assessment ratio is used to arrive at the true value of property. For example, Class 1 (home) property has an assessed value of five thousand dollars ($5,000.00). Divide five thousand dollars ($5,000.00) by ten percent (10%). The true value is fifty thousand dollars ($50,000.00) based on the county tax assessment.

2. If the individual disagrees with the true value as shown on the appropriate county property tax assessment notice or calculated using the county property tax assessed value, the individual must obtain a knowledgeable source estimate to establish CMV as required under SSI policy.

C. SSI Policy requires obtaining a knowledgeable source estimate to establish the CMV of real property. Knowledgeable sources include, but are not limited to:

1. Real estate brokers,

2. Local office of the Farmer’s Home Administration (for rural land),

3. Local office of the Agricultural Stabilization and Conservation Service (for rural land),

4. Banks, savings and loan associations, mortgage companies and similar lending institutions, and

5. An official of the local property tax jurisdiction (must obtain an estimate rather than the office’s assessment).

6. Licensed Mississippi real estate appraisers.

D. When CMV has an impact on eligibility and applicants or beneficiaries disagree with the CMV evidence submitted or obtained by the Medicaid specialist, a rebuttal determination must be made.

1. The rebuttal determination must take into account:

a) All the evidence previously in the file including, but not limited to, the individual’s original allegation, any tax assessment notices and any estimates from knowledgeable sources, b) Any additional evidence the individual wishes to submit including, but not limited to, evidence that the individual’s ownership interest in the property is worth less than the CMV determined total value of the property divided by the number of owners, and

c) Any other facts about the property or about market conditions where it is located.

2. The rebuttal must be supported by a preponderance of the evidence which may require one (1) or more additional estimates from knowledgeable sources.

E. For both SSI and liberalized policy, the CMV less any legally binding debts against the property is the countable equity value for real property that cannot be excluded under any real property exclusion.

History: Revised to correspond to SPA 16-0009 (eff. 01/01/2016) eff. 01/01/2017.

History

• Source: Miss. Code Ann. § 43-13-121.

Chapter 3 Non-Countable Resources

23 Miss. Admin. Code Pt. 103, R. 3.1 Retirement Funds

A. Retirement funds are annuities or work-related plans that are designed to provide income when employment ends. These funds can be held with a company or held privately at a bank or other financial institution. Listed below are some examples:

1. Pensions, disability, or retirement plans administered by an employer or union 401K;

2. Individual Retirement Account (IRA);

3. Keogh plans (plans for self-employed individuals); and

4. Some profit sharing plans

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.2 Treatment of Retirement Funds

A. The terms IRA and Keogh refer only to the type of retirement account and do not identify the underlying investment vehicle for the account, which may be a bank account, Certificate of Deposit, mutual fund, etc.

1. If retirement benefits are being received out of such accounts, the principal is not considered a resource.

2. Otherwise, IRAs and Keogh accounts are developed according to the resource policy applicable to the underlying investment vehicle.

B. Retirement benefits are payments made at some regular interval (i.e., monthly) and result from entitlement to a retirement fund. Periodic payments must be of uniform rate, principal and interest (principal must equal or exceed amount of interest) and are counted as unearned income.

C. If an individual owns a retirement fund and is not eligible for periodic payments, determine whether he can make a lump sum withdrawal. If he can withdraw any of the retirement fund, the value of the fund is a resource in the month the funds become available for withdrawal.

D. The value of the retirement fund is the amount that can currently be withdrawn. If there is a penalty for early withdrawal, the fund’s value is the amount available after the penalty is deducted. However, any taxes which may be due are not deductible in determining the fund’s value.

E. A retirement fund is a resource when the individual has the option of withdrawing a lump sum, even if he is not eligible for periodic payments. When this is the case:

1. If the individual applies for periodic payments and is denied, the value of the fund becomes a countable resource the month after the month periodic payments are denied.

2. A delay in payment beyond the individual’s control (e.g., an organization’s processing time) does not mean the fund is not a resource since the individual is legally able to obtain the money.

F. A retirement fund is not a resource when a person must terminate employment to obtain payment or when a person is eligible for and receiving periodic payments.

G. Retirement funds owned by an ineligible spouse or parent are excluded from resources for deeming purposes.

H. A previously unavailable retirement fund is subject to resource rules in the month after the month the funds first become available.

History: Revised eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.3 Loans, Promissory Notes & Property Agreements – General

A. This section provides resource policies that primarily apply when the client or spouse is the creditor (lender or seller) and is, therefore, the owner of a loan agreement, promissory note or a property agreement. The principal amounts of these items are evaluated under appropriate SSI or liberalized resource policy.

B. Definitions.

1. Bona Fide Agreement. An agreement which is legally valid and made in good faith.

2. Negotiable Agreement. A type of agreement where legal title or the amount of the agreement can be transferred (sold) to another party.

a) Generally, promissory notes, loan agreements and personal and real property agreements can be sold to a third party.

b) An agreement may be assumed to be non-negotiable if there is a legal bar to its sale.

3. Loan. A transaction in which one party advances money to, or on behalf of another party, who promises to repay the lender in full, with or without interest.

a) The loan agreement must be enforceable under state law and be in writing.

b) A written loan agreement is a form of promissory note.

4. Informal Loan. With formal loans (e.g., commercial), there is rarely a question about whether the loan agreement is bona fide. An informal loan is a loan between individuals who are not in the business of lending money or providing credit. An informal loan must be written and is bona fide if:

a) It is legally binding under state law;

b) It was in effect at the time of the transaction (money given with no obligation to repay cannot become a loan at a later date) ;

c) There is an acknowledgement of an obligation to repay, with or without interest, by the lender and the borrower;

d) There is a plan or schedule for repayment and the borrower’s express intent to repay by pledging real or anticipated future income; and

e) The repayment plan is feasible.

5. Promissory Note. Written, unconditional agreement where one person promises to pay another party a specific amount at a specific time (or on demand). It can be repayment for goods, money loaned or services rendered.

6. Property Agreement. A piece of property is used to secure payment of a debt or performance of services within a specified period of time. Other names for property agreements include:

a) Mortgages;

b) Real estate or land contracts;

c) Contracts for deed;

d) Deeds of trust;

e) Personal property agreements, e.g., pledges of crops, fixtures, inventory, etc., are known as chattel mortgages.

C. Property Agreements Prior to Settlement. A person holding a contract for sale of real estate (seller or creditor) owns two items until the settlement of the sale is completed:

1. The real estate, which is not a resource since it cannot be sold while encumbered by the contract, and

2. The value of the contractual agreement.

D. Determining the Value of a Contract. The status and value of a contract, i.e., loan agreement, promissory note or property agreement, must be evaluated to determine if it is a resource under appropriate SSI or liberalized resource policy.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.4 Treatment of Loans, Promissory Notes & Property Agreements (SSI)

A. SSI policy when the individual is the seller or creditor:

1. Obtain a copy of the agreement and assume, absent evidence to the contrary, that the written agreement is bona fide and negotiable.

2. A bona fide, negotiable agreement is a resource. The goods or money represented in the agreement are not a resource because they are not accessible.

3. The debtor’s payments against the principal are a conversion of a resource, not income.

4. The interest portion received by the lender is unearned income.

5. If retained, principal and interest are counted as the lender’s resource the month following the month of receipt.

a) Example: Debtor pays $500 per month - $350 toward principal and $150 in interest. The $350 is a converted resource. The $150 is unearned income.

6. If including the original principal balance (the amount owed to the creditor when the agreement was established) causes ineligibility on resources, obtain verification of the outstanding principal balance, i.e., the balance in the month for which a determination is being made.

7. If including the outstanding principal balance causes ineligibility on resources use the outstanding principal balance in determining resources unless one of the following is submitted:

a) Evidence of a legal bar to the sale of the agreement ; or

b) An estimate from a knowledgeable source (in the business of making estimates, such as banks, other financial institutions, private investors, real estate brokers, etc.) showing that the CMV of the agreement is less than its outstanding principal balance.

1. The estimate must show name, title, and address of the source.

8. For agreements determined to be Non-Bona Fide or Non-Negotiable:

a) A non-bona fide or non-negotiable agreement is not a resource under SSI policy;

b) The principal and interest paid to the lender are income, not a resource ; and

c) The goods or money represented in the agreement may be a resource to the seller if the seller/creditor has access for his own use

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.5 Treatment of Loans, Promissory Notes and Property Agreements (Liberalized)

A. For the borrower under both SSI and liberalized resource policy, if the agreement is bona fide and negotiable:

1. Cash paid by the lender to the borrower is not income;

2. However, cash retained (or property received) may be a resource to the borrower the month following the month of receipt.

B. Liberalized policy when individual is the seller or creditor:

1. Obtain a copy of the agreemen and assume, absent evidence to the contrary, that the written agreement is bona fide and negotiable.

2. Determine if the bona fide, negotiable note or agreement produces at least 6% net annual return of the principal balance.

a) Loans, promissory notes and property agreements can be excluded as a resource if the note, loan or agreement produces at least a 6% net annual return of the principal balance.

b) The income must be received by the client/spouse and counted as income in order for the exclusion to apply.

c) If the above criteria are not met, the note or agreement cannot be excluded as a resource.

C. Policy for institutionalized individuals in SSI or liberalized programs.

1. Even though the 6% rule is in effect and establishes a minimum acceptable payment when compared to the principal balance, the following conditions must also be met for a resource exclusion for all institutionalized individuals in either SSI or Liberalized programs:

a) The repayment terms of the agreement must be actuarially sound;

b) The payments must be of uniform rate, principal and interest, during the term of the agreement, with no deferred or balloon payments; and

c) The agreement must prohibit cancellation of the debt upon the death of the lender. d) The institutional client or spouse must reasonably expect to receive full payoff of the note or loan during his/her lifetime. As with annuities, the average number of years of life expectancy remaining based on the Annuity Life Expectancy Charts must coincide with the payout of the promissory note or loan.

D. Agreements which do not meet requirements.

1. For non-institutional cases assessed under liberalized resource policy, a non-bona fide or non-negotiable agreement is not a resource. Principal and interest payments are income to the seller/creditor. The goods or money represented in the agreement may be a resource if the seller/creditor has access for his own use.

2. For institutional cases, funds used to purchase promissory notes, loans or mortgages that do not meet the 6% rule, are not actuarially sound or are not bona fide or negotiable will be considered a transfer of assets valued as the entire outstanding balance due as of the date of the application for long term care for contracts dated on or after February 8, 2006.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.6 Inheritances and Unprobated Estates

A. Unprobated Estates.

1. Under SSI resource policy, an ownership interest in an unprobated state may be a resource if an individual:

a) Is an heir of the deceased; or

b) Receives income from the property; or

c) Under state intestacy laws has acquired rights in the property due to the death of the deceased.

2. An ownership interest in an unprobated estate exists if:

a) Documents such as a will or court records indicate an individual is an heir; or

b) An individual has the use of, or income from, a deceased person’s property; or

c) Documents verify, or the individual alleges, a relationship to the deceased that awards him a share under the state’s intestacy laws; or

d) The inheritance, use of income and distributions are not contested.

3. Under liberalized policy, estates in the process of probation are excluded from the resource determination.

B. Inheritances.

1. An inheritance is cash, a right, or a noncash item(s), received as the result of a person’s death.

2. Treatment under liberalized resource policy.

a) An inheritance is not a resource until the month following the month it meets the definition of income i.e., it has a value and can be used, either directly or by sale or conversion to meet basic needs. Thereafter, if retained, the property is evaluated as a resource.

b) If an applicant or recipient in a long term care program refuses or transfers an inheritance, the individual may be subject to penalty under the transfer of assets provisions.

Rule 3.7: Real Property Exclusions

A. Home Property Exclusion.

1. An individual’s home is property he has ownership interest in and is his principal place of residence; and

2. It may include the shelter he lives in, the land on which the shelter is located, and all buildings on the land.

a) A principal place of residence is the dwelling that an individual considers his/her principal home. It may be:

1. Real or personal property;

2. Fixed or mobile;

3. Located on land or water.

b) Example: If a person owns and resides in a houseboat on a lake, the boat may qualify as home property.

3. If a person owns land and intends to reside on it, it may be considered home property if there is no other principal place of residence. If a person owns the land, but not the shelter, the land is considered the residence.

a) Example: A person owns the land he lives on, but lives in a mobile home owned by his parents. If a person owns the shelter, but not the land, the shelter is the residence.

b) Example: A person owns the mobile home, but rents the lot on which it is located.

4. Applying the home exclusion.

a) The home exclusion applies to:

1. The shelter in which the individual lives;

2. All buildings on the property;

3. The land on which the shelter is located; and

4. Any land adjoining it as long as it is not separated by land that neither the individual nor spouse has an ownership interest in.

(a) Easements and public rights of way (utility lines, roads, etc) do not separate other land from the home plot.

5. Home Out-Of-State.

a) If an applicant’s home property is located out-of-state, policy governing state residency applies.

b) It is not permissible for the individual to intend to return to his principal place of residence out-of-state and at the same time intend to reside in Mississippi.

c) If the applicant intends to return home to another state, he cannot be considered a Mississippi resident for Medicaid eligibility purposes.

d) If the applicant intends to reside in Mississippi, home out-of-state cannot be excluded as his principal place of residence.

6. Treatment of Home Property Under Supplemental Security Income (SSI) Resource Policy.

a) An individual’s home, regardless of value, is an excluded resource if the individual:

1. Resides in the home; or

2. Is absent and intends to return to the home.

(a) An individual is residing with her children due to an illness, but intends to go home when health permits The intent is based on the person’s desire to return home.

(b) If the individual leaves the home and does not intend to return home to it, it is no longer considered the person’s principal place of residence.

(i) The home exclusion no longer applies as of the date the individual leaves with the intent not to return or the date the individual no longer intends to return.

(ii) The month after there is no intent to return, the property will be considered a countable resource unless another exclusion develops.

b) A home can be excluded without intent to return, if:

1. A spouse or dependent relative of an institutionalized individual continues to reside in the home while the individual is institutionalized;

(a) Dependency may be financial or medical;

(b) Relatives may include child, step-child, grandchild, parent, step-parent, grandparent, sibling, step-sibling, half sibling, aunt, uncle, cousin niece, nephew, in-laws;

2. Sale of the home would cause an undue hardship to a co-owner due to loss of housing.

(a) Obtain a statement from the dependent relative or the co-owner to apply either of the above exclusions.

c) Multiple Residences.

1. Only one residence can be excluded as home property.

2. If there are multiple residences, the principal place of residence must be determined, considering such points as how much time is spent at each residence; where the individual is registered to vote; and which address the individual uses for mail and tax purposes.

7. Treatment of Home Property Under Liberalized Resource Policy.

a) Home property can be excluded regardless of intent to return home or whether a dependent relative lives on the property.

b) Each client is allowed one home that can be excluded regardless of its use.

c) If more than one residence is owned, exclude the property that would be most advantageous to the client.

d) For long term care applications filed on or after January 1, 2006, there is a disqualification period for individuals with equity interest in their home of greater than $500,000. This provision will not prevent an individual from using a reverse mortgage or home equity loan to reduce the total equity interest in the home.

1. This disqualification period means that the homeowner who is in long term care can qualify for all Medicaid services except vendor payment of nursing facility services as long as equity interest exceeds the $500,000 limit.

2. The home equity limit will increase yearly based on the percentage increase in the urban consumer price index rounded to the nearest $1,000.

3. If Medicaid eligibility is dependent upon participation in the Home and Community Based Services (HCBS) waiver, the individual is ineligible for full Medicaid services as long as equity in the home exceeds the limit; however, a Medicare Savings Program can be approved if criteria are met.

4. Undue hardship can be found to exist if a lien or legal impediment exists causing the individual to be unable to access the equity.

8. Reverse Mortgages.

a) A reverse mortgage is an agreement in which a lending company:

1. Makes a lump sum (subject to being counted as a resource the month following month of receipt);

2. Available line of credit (subject to being counted as a resource the month following month of receipt; or

3. Regular payments (treated as loan proceeds) to a homeowner during a specific period of time.

b) The amount of payment is determined by the amount of equity the homeowner has in the home.

c) The homeowner is allowed to remain in the home until his/her death. At that time, the home is sold and/or the lender is repaid.

d) Reverse mortgages are available to homeowners age 62 or older who own a debt-free or nearly debt-free home. e) Funds received from a reverse mortgage in any form that are transferred, either in the month of receipt or subsequent months, are subject to a transfer penalty unless an allowable exception applies (such as spousal transfers).

B. Exclusion of Home Replacement Funds. If an individual sells an excluded home, the proceeds may be an excluded resource if he:

1. Plans to buy another excluded home; and

2. Buys the home within 3 full calendar months following the month the proceeds are received.

C. Exclusion of Installment Sales Contracts.

1. If the proceeds from the sale of an excluded home are received under an installment sales contract, the contract is excluded if the individual:

a) Plans to use the entire down payment and the entire principal portion of a given installment payment to buy another excluded home; and

b) Purchases the new home within 3 full calendar months following the month the down payment or installment payment is received.

2. The proceeds of the sale include the following:

a) Lump sum. The net amount the seller receives at closing/settlement;

b) Installments. Down payment and principal portion of any installment payment.

3. Use of Proceeds. Use of the proceeds to buy another excluded home includes payment of any costs that stem from the purchase. These include, but are not limited to:

a) Down payment;

b) Closing/settlement costs;

c) Moving expenses;

d) Loan processing fees and points;

e) Necessary repairs and replacement of the new home’s structures and fixtures costs, if identified and documented before the new home is occupied and stem directly from the purchase or occupancy of the new home.

1. This may include: roof, heating and cooling, plumbing, built-in appliances, etc.

f) Mortgage payments;

g) Use of proceeds to pay other costs will warrant their exclusion if such costs are identified and documented prior to occupancy and stem directly from the purchase or occupancy of the new home.

4. Proceeds Not Re-Invested in a Timely Manner.

a) If the home is not replaced within the allowable 3-month period, the unused proceeds are a countable resource retroactive to the month following the month of receipt as follows:

1. Lump sum. The exclusion of the unused funds is revoked retroactively to the date of receipt;

2. Installment contract. The exclusion of the contract itself and the unused portion of any installments received are revoked retroactively to the date the unused proceeds were received.

3. The exclusion of an installment contract, once revoked, will be reinstated if the individual intends to and does use the entire principal portion of a subsequent installment payment toward the purchase of another excluded home within 3 full calendar months of receiving such installment payment.

(a) The exclusion does not apply to that portion of the proceed of the sale of the original home that is in excess of the costs of the purchase and occupancy of the new home.

5. Exclusion of Jointly Owned Property Whose Sale Would Cause Undue Hardship.

a) The value of an individual’s ownership interest in the jointly-owned property is an excluded resource for as long as the sale of the property would cause an undue hardship, due to loss of housing, to a co-owner.

b) Undue hardship would result if the co-owner:

1. Uses the property as his principal place of residence;

2. Would have to move if the property were sold;

3. Has no other readily available housing.

c) The exclusion ends when any one of the above conditions no longer exists.

1. Example: Mr. Allen and his son jointly own a piece of land. The son and his family live on the property and have no other place to live. Mr. Allen applies for Medicaid. The property is excluded because the sale would cause an undue hardship to his son. However, if the son owned another house nearby which was vacant and habitable, there would be other available housing. Under these circumstances, undue hardship would not exist and the value of Mr. Allen’s interest would be countable.

D. Exclusion of Real Property Due to Reasonable Efforts to Sell.

1. Real property may be excluded from resources if the owner is making reasonable efforts to sell it and those efforts have been unsuccessful.

2. The individual must maintain their efforts to sell unless good cause, i.e., circumstances beyond the individual’s control prevent his taking the required actions to accomplish reasonable efforts to sell, exists.

3. In addition, the individual must accept a reasonable offer for the property. The specific requirements listed below must be met in order for this exclusion to apply:

a) Reasonable Efforts To Sell.

1. Reasonable efforts to sell real property consist of taking all necessary steps to sell it through media serving the geographic area in which the property is located.

2. Reasonable efforts specifically mean that within 30 days of signing the Agreement to Sell Property, the owner(s) must:

(a) List the property with an agent; or

(b) Begin to advertise in at least one of the appropriate local media, place “For Sale” signs on the property (if permitted),

(c) Begin to conduct open houses or otherwise show the property to interested parties on a continuing basis and attempt any other appropriate methods of sale; and

(d) Except for gaps of no more than 1 week, the owner must maintain efforts the type listed above; and

(e) The owner does not reject any reasonable offer to buy the property and accepts the burden of demonstrating to Medicaid’s satisfaction that an offer was rejected because it was not reasonable.

b) Reasonable Offer To Buy.

1. Assume that an offer to buy the property at a particular price is reasonable if it is at least two-thirds of the estimated current market value (CMV), as evidenced by the tax receipt. If the owner disagrees with CMV as evidenced by the tax receipt, he must provide convincing evidence of a different CMV. Verification presented by the owner to support a CMV other than that evidenced by the tax receipt must be submitted to state office for review.

c) Good Cause.

1. Good cause exists when circumstances beyond an individual’s control prevents the required action to accomplish reasonable efforts to sell. If good cause exists for failure to meet any of the criteria specified above, the exclusion can continue provided action is taken to resume efforts to sell.

2. Good cause includes:

(a) No offer to buy is received;

(b) A legitimate offer does not result in a sale;

(c) Escrow begins, but closing does not take place within the disposal period; and

(d) Incapacitating illness or injury, such as the individual becomes homebound or hospitalized for a prolonged period due to illness or injury and cannot take steps necessary to sell the property or to arrange for someone to sell it on his behalf.

(e) Eample: Sandy Patterson is a Medicaid recipient whose property has been excluded due to a bona fide effort to sell. She accepted a reasonable offer for the property; however, the buyer backed out of the deal at closing. Ms. Patterson immediately started sales efforts again. Good cause exists.

d) Failure To Make Reasonable Efforts.

1. Unless there is good cause, failure to meet any of the criteria specified above means that:

(a) An individual is not making reasonable efforts to sell the property and is not accepting a reasonable offer to buy;

(b) The individual’s countable resources include the value of the property beginning with the month following the month in which reasonable efforts to sell stop or the month following the month the owner failed to accept a reasonable offer to buy; and

(c) The individual will be charged with an improper payment, if applicable.

e) Initial Verification of Efforts To Sell.

1. The effort to sell must be documented in the case record within the 30-day time period for applying the exclusion by requiring all proof such as:

(a) Copy of the listing agreement with the real estate agent in current use;

(b) Dated advertisement(s) indicating the property is for sale;

(c) Contracts with local media to advertise the property;

(d) A photograph of the “For Sale” sign on the property, in conjunction with other efforts; or

(e) Any other relevant items.

f) Effective Date of Exclusion.

1. If the appropriate proof is submitted, the exclusion is applied back to the first of the month in which the effort to sell as initiated.

2. If a reasonable effort to sell was in existence prior to the date of application, the exclusion can be applied retroactively provided the effort is documented and DOM-320A is signed.

3. If the effort to sell is just beginning, the exclusion applies effective with the first month DOM-320A is signed (provided it is signed within thirty (30) days). If not signed within thirty (30) days, the exclusion applies as of the first month a reasonable effort to sell is initiated.

g) Follow-Up Contacts.

1. Contacts must be scheduled at ninety (90) day intervals until the property is sold or the exclusion ends.

2. Follow-up contacts may be by telephone to determine efforts being made to accomplish the sale and to document whether there has been any offer to buy since the prior contact.

3. If an offer to buy has been refused, a statement must be submitted explaining the refusal.

4. The refusal of an offer to buy must be evaluated under the “Reasonable Offer to Buy” guidelines. If the refusal is unacceptable, the exclusion ends beginning with or retroactive to the month after the month of the refusal to sell.

5. If the reasonable efforts to sell are not continuing at each follow-up contact, determine if good cause exists. If good cause does not exist, the exclusion ends beginning with or retroactive to the month after the month the reasonable efforts stopped.

History: Revised eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).
• Source: Social Security Act §1902 (r) (2); 42 U.S.C. § 1396p(f)(1)(C); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.8 Interests of Individual Indians in Trust or Restricted Lands

A. Certain types of Indian-specific property are excluded from being considered as resources in determining Medicaid eligibility for an individual who is an Indian. These excluded resources include the following:

1. Property Connected to the Political Relationship between Indian Tribes and the Federal Government;

a) This exclusion includes any Indian trust or restricted land, or any other property under the supervision of the Secretary of the Interior located on a reservation, including any federally-recognized Indian Tribe’s reservation, pueblo or colony, and including Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior; and

b) Individual Indian Monies (IIM) accounts, which are under the supervision of the Secretary of the Interior, and considered to be inaccessible; and

c) Property located within the most recent boundaries of a prior Federal reservation including former reservations in Oklahoma and Alaska Native regions established by the Alaska Native Claims Settlement Act;

d) Ownership interest in rents, leases, royalties or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally-protected rights Monies received from the lease or sale of these natural resources remain excluded while in an IIM account.

2. Property with Unique Indian Significance, such as:

a) Ownership interest in or usage rights to items not covered under the above provisions that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or traditional lifestyle according to Tribal law or custom.

b) While the above identified assets are excluded in determining eligibility, if the assets are converted to a non-excluded asset, they become countable.

1. For instance money in an IIM account is excluded; however, once the money is removed from the IIM account it becomes a countable asset.

2. Money received by Indians from the lease or sale of natural resources, and rent or lease income, resulting from the exercise of federally-protected rights on excluded Indian property, is considered an asset conversion. Therefore, this money is not considered income, but is an excluded resource in the month the money is received (This is true even if the money is taken out of the IIM account in the same month it was deposited into the account). If some or all of the money is retained at the end of the month in which received, it is either counted or excluded based on the type of resource in which the money is retained after month of receipt.

3. Distributions of per capita judgment funds or property earnings held in trust for a Tribe by the Secretary of the Interior.

a) However, this does not include local Tribal funds that a Tribe distributes to individuals on a per capita basis, but which have not been held in trust by the Secretary of the Interior (e.g., tribally managed gaming revenues, which are countable income).

Rule 3.9: Exclusion of Personal Property

A. Personal property includes automobiles, life insurance, household goods and personal effects and burial funds and certain burial arrangments and items, which may be subject to a full or partial exclusion. The exclusion applicable to each is discussed under this rule.

1. Exclusion of Automobiles.

a) An automobile is any registered or unregistered vehicle used for transportation. Vehicles used for transportation can be motorized, animal drawn or even an animal. A vehicle not used for transportation is not an automobile, but may be a countable resource. A temporarily inoperable vehicle normally used for transportation meets the definition of an automobile.

b) If an exclusion cannot be developed for a vehicle the current market value (CMV) must be determined. The CMV is the average price an automobile of that particular year, make and model and condition would sell for on the open market (to a private individual) in the particular geographic area involved. The most recent NADA Official Car Guide or Older Car Guide may be used to determine the average trade-in value. If there is debt on the vehicle, determine the equity value.

1. If the client states the CMV is not representative of the value of the vehicle, he must be given the opportunity to provide a value rebuttal from another knowledgeable source, such as a used car/truck dealer, automobile insurance company, classic car appraiser, etc.

c) Examples of Automobiles:

1. Car or truck;

2. Boat;

3. Motorcycle;

4. All-terrain vehicle;

5. Horse-drawn carriage;

6. Horse.

d) The following are not vehicles for purposes of this exclusion:

1. Permanently inoperable (junk) vehicle;

2. Vehicle used exclusively for recreation, such as boats, motorcycles, RVs, dirt bikes, golf carts, etc.;

3. Leased vehicles are not considered in the resource determination, as the individual does not own the vehicle.

e) Treatment of Vehicles Under Supplemental Security Income (SSI) Resource Policy.

1. Effective April 2005, one automobile may be excluded, regardless of value, if is used for transportation of the individual, spouse and/or a household member.

(a) Unless there is evidence to the contrary, assume the vehicle is used for transportation.

(b) If multiple vehicles are involved, apply the exclusion in a way that is most advantageous to the applicant/recipient. That is, apply the exclusion to the vehicle with the greater value.

(c) For any vehicle that cannot be excluded wholly under this provision or another provision (e.g., property essential to self-support, etc.), the equity value is countable toward the resource limit.

(d) The equity value of junk cars and vehicles used only for recreation is a resource. The personal effects exclusion does not apply to such vehicles.

f) Treatment of Vehicles Under Liberalized Resource Policy.

1. Two vehicles may be excluded, regardless of value, if used for transportation of the applicant or recipient under the age of nineteen (19).

2. Unless there is evidence to the contrary, assume the vehicles are used for transportation.

3. If multiple vehicles are involved. apply the exclusions in a way that is most advantageous to the applicant or recipient. That is, apply the exclusions to the vehicles with the greater equity value.

4. For any vehicle that cannot be excluded wholly under this provision or another provision (e.g., property essential to self-support, etc.), the equity value is countable toward the resource limit.

5. Any vehicle not used for transporation that is permanently inoperable (junk vehicle) can be totally excluded as a resource.

6. Recreational vehicles are treated as personal property. The personal effects exclusion does not apply to such vehicles.

2. Exclusion of Life Insurance.

a) A life insurance policy is a contract. The purchaser (owner) pays premiums to the company (insurer). In return, the insurer agrees to pay a specified sum to a designated person(s), known as a beneficiary, upon the death of the insured individual. The owner and the insured may or may not be the same person. The policy should state the owner’s name, if different from the insured.

b) Below are some common terms associated with life insurance:

1. Face Value (FV) is the amount of basic death benefit contracted for at the time the policy is purchased. The face page of the policy may show it as such or as the “amount of insurance”, “the amount of this policy”, “the sum insured”, etc. A policy’s FV does not include:

(a) The FV of any dividend addition, which is added after the policy is issued;

(b) Additional sums payable in the event of accidental death or because of other special provisions; or

(c) The amount(s) of term insurance, when a policy provides whole life coverage for one family member and term coverage for others.

2. Cash Surrender Value (CSV) is a form of equity value that it acquires over time. The owner of the policy can obtain in its CSV only by turning the policy in for cancellation before it matures or the insured dies. A loan against a policy reduces its CSV.

3. Dividends are shares of any surplus insurance company earnings, which can be applied to premiums due or paid by check or by an addition or accumulation to an existing policy.

4. Dividend Additions are the amount of insurance purchased with dividends added to the policy, increasing its death benefit and CSV. The table of CSVs that comes with a policy does not reflect the added CSV of any dividends.

5. Dividend Accumulations are dividends that the policy owner has constructively received, but left in the custody of the insurer to accumulate at interest. They are not a value of the policy; the policy owner can obtain them without affecting FV or CSV.

(a) Dividend accumulations cannot be excluded from resources under the life insurance exclusion, even if the policy that pays the accumulations is excluded from resources. Unless they can be excluded under another provision (e.g., as set aside for burial), they are a countable resource.

c) Verification of Life Insurance.

1. Documentary evidence is obtained to verify the value of life insurance when the client/spouse reports ownership of whole life insurance(s) on any individual with a total FV exceeding the appropriate program exclusion limit: $1500 (SSI) or $10,000 (Liberalized).

2. The individual or authorized representative must provide a copy of all the life insurance policies and the most recent dividend statement for each one.

3. After exclusions are developed, any remaining cash value must be considered in the eligibility determination. The cash surrender value of any policy that cannot be excluded is countable toward the resource limit.

d) Types of Life Insurance.

1. Term Life Insurance is usually in effect for a specific length of time such as 20 years or length of employment. It does not accrue cash value;

2. Whole Life Insurance remains in effect unless the premiums are not paid or the policy matures; and accrues cash value;

3. Burial Insurance contracts prevent the proceeds from being used for anything other than the burial expenses of the insured.

e) Owner versus Beneficiary.

1. The owner is the one who has control of the policy. An individual may own life insurance on himself or another person. The owner may take such actions as cash in a policy, take out a loan against cash value, etc. The value of life insurance policies owned must be considered in the eligibility process.

2. The beneficiary is the individual(s) who receive the proceeds of the policy at the insured individual’s death. One person may be both the owner and the beneficiary.

(a) Example: Jim Jones purchases a $10,000 life insurance policy on his mother, Jane Williams, and is the beneficiary upon her death.

f) Treatment of Life Insurance Under SSI Resource Policy.

1. Term life insurance policies do not have cash value and are excluded.

2. Burial policies are excluded.

3. For all other policies determine the total Face Value (FV) of the policies owned by the individual. Do not include the Face Value of any dividend additions in determining whether a policy is a countable or excluded resource.

4. A life insurance policy is excluded if its’ Face Value and the FV of any other life insurance policies the individual owns on the same insured person total $1,500 or less.

5. Even if a policy is excluded, any accumulated dividends are countable toward the resource limit unless they are excluded under another provision such as set aside for burial.

6. If the policy is a countable resource, the cash surrender values (CSV), dividend additions, dividend accumulations, outstanding loan amounts reducing the (CSV) of the policies must be verified and considered in the eligibility determination.

7. The countable cash surrender values of the policies and accumulations are countable toward the resource limit unless they can be excluded as burial assets.

8. The following are examples:

(a) Lyn Reno is the owner of four life insurance policies. Two have Face Values of $500 and two have Face Values of $250. The total of all FVs is $1500 so the policies are excluded.

(b) Jerry Mann is the owner of three life insurance policies insuring his spouse. The Face Value of each one is $750. The total Face Value is $2,250. The specialist must determine the cash values of the policies and count them toward the resource limit unless a burial exclusion is developed.

(c) Roger West is the owner of two life insurance policies on his spouse. One is whole life with a Face Value of $1,200 and the other is term life with a Face Value of $10,000. The term life policy has no cash value and is excluded. The whole life policy is excluded because the Face Value is less than $1,500.

g) Treatment of Life Insurance Under Liberalized Resource Policy.

1. Term life insurance policies do not have cash value and are excluded.

2. Burial policies are excluded.

3. For all other policies determine the total Face Value (FV) of the policies owned by the individual. Do not include the Face Value of any dividend additions in determining whether a policy is a countable or excluded resource.

4. A life insurance policy is excluded if its Face Value and the FV of any other life insurance policies the individual owns on the same insured person total $10,000 or less.

5. Even if a policy is excluded, any accumulated dividends are countable toward the resource limit unless they are excluded under another provision such as set aside for burial.

6. If the policy is a countable resource, the cash surrender values (CSV, dividend additions, dividend accumulations, outstanding loan amounts reducing the CSV) of the policies must be verified and considered in the eligibility determination.

7. The countable cash surrender values of the policies and accumulations are countable toward the resource limit unless they can be excluded as a burial asset.

8. The following are examples:

(a) Lane Ryan is the owner of four life insurance policies. Two have Face Values of $1,500 and two have Face Values of $750. The total Face Value is $4,500 so the policies are excluded.

(b) Jennifer Madison is the owner of three life insurance policies on her spouse, with Face Values of $750, $2,500 and $12,000. The total Face Values are $15,250. The specialist must determine the cash surrender values of the policies and count them toward the resource limit unless a burial exclusion is developed.

(c) Roberta Warren is the owner of two life insurance policies on her spouse. One is whole life with a Face Value of $8,500 and the other is term life with a Face Value of $25,000. The term life policy has no cash surrender value and is excluded. The whole life policy is excluded because the Face Value is less than $10,000.

h) Accelerated Life Insurance Payments.

1. Proceeds paid to a policyholder before death.

2. Plans vary from company to company; however, all involve early payout of some or all of the proceeds of the policy.

3. Most of the plans fall into three basic types depending on the circumstances that cause the payments to be accelerated:

(a) Long Term Care Model. Allows payments if the policyholder requires an extended stay in a care facility or, in some instances, healthcare services at home.

(b) Dread Disease or Catastrophic Illness Model. Allows payments if the policyholder suffers from a specified covered disease or illness such as cancer or AIDS.

(c) Terminal Illness Model. Allows payments following the diagnosis of a terminal illness where death is likely to occur within a specified timeframe.

4. These payments are also called “living needs” or “accelerated death” payments.

5. Depending on the plan, the receipt of payments may reduce the FV of the policy by the amount of the payments and may reduce the CSV in a proportionate manner. In other cases, a lien may be attached to the policy in the amount of the payments that results in a proportionate reduction in the CSV.

6. If an individual has a life insurance policy that allows them to receive their death benefit while living and the individual meets the requirements set by the insurance company to receive such proceeds, they are not required to file for the proceeds.

(a) If the individual does file and receives the benefits, the payment will be considered as follows:

(i) Consider as income in the month of receipt.

(ii) Any money remaining the following month is considered a resource.

i) Life Insurance Endowment Policies.

1. A life insurance policy’s primary function is to pay out upon the death of the insured.

2. A life insurance endowment policy does not do that; rather it serves as an investment medium with a maturity date or date certain payout, i.e., 5 years from purchase, at which time a benefit is paid to a designated beneficiary. The possible death of the “insured” individual before the maturity date is a secondary consideration.

3. These policies should be treated as annuities.

3. Exclusion of Household Goods and Personal Effects.

a) Household goods are personal property found in the home and used in connection with normal maintenance, use and residency of a home. They include:

1. Furniture; 2) Appliances; 3) Television sets; 4) Carpets; 5) Cooking and eating utensils; 6) Dishes. b) Personal effects are personal property that is worn or carried by an individual or that have an intimate relation to him or her. They include:

2. Clothing; 2) Jewelry; 3) Personal care items; 4) Prosthetic devices; 5) Educational or recreational items; (a) Books; (b) Musical instruments.

c) Treatment under SSI Resource Policy.

1. Household goods and personal effects as defined above, are excluded in resource determinations, regardless of their dollar value.

2. Prior to April 2005, a general exclusion of up to $2,000 applies to the total equity value of household goods and personal effects, other than those excluded regardless of value: one wedding ring, one engagement ring and prosthetic devices, wheelchairs, hospital beds, dialysis machines and other items required by a person’s physical condition.

3. Personal property that an individual acquires or holds because of its value or as an investment is:

(a) A countable resource; and

(b) Not considered as household goods or personal effects for purposes of exclusion.

4. When ownership of other personal property is alleged and the property is not excludable as household goods or personal effects, the Current Market Value (CMV) or Equity Value (EV), as appropriate, of the item must be verified.

5. Example: A recreational vehicle (RV) used for vacations and other recreational activities is classified as personal property. It does not meet criteria to be an automobile or meet the definition of household goods or personal effects for exclusion. If the CMV of the RV is $10,000 and the payoff is $5,000, under SSI resource policy the equity value of $5,000 is counted as a resource.

d) Treatment Under Liberalized Resource Policy.

1. Under liberalized policy, household goods and personal effects, as defined above, are excluded in resource determinations regardless of their dollar value.

2. Personal property that an individual acquires or holds because of its value or as an investment:

(a) Is a countable resource when its equity value exceeds $5,000; and

(b) Is not considered to be household goods or personal effects for purposes of exclusion.

3. When ownership of other personal property is alleged and the property is not excludable as household goods or personal effects, under liberalized resource policy, up to $5,000 in EV is excluded for other personal property.

4. The Current Market Value (CMV) or Equity Value (EV), as appropriate, must be verified.

5. Example: A recreational vehicle (RV) used for vacations and other recreational activities is classified as personal property. The RV does not meet criteria to be an automobile, nor does it meet the definition of household goods or personal effects for exclusion. If the CMV of the RV is $12,000 and the payoff is $7,500, the RV can be excluded as a resource under liberalized policy since its equity value is $5,000 or less.

4. Exclusion of Death Benefits for Last Illness and Burial Expenses.

a) Death benefits are received because of another person’s death. Examples include:

1. Life insurance proceeds;

2. Social Security death benefits;

3. Burial benefits from the Railroad or Veterans Administration;

4. Inheritances;

5. Gifts from relatives, friends or the community to help with expenses.

b) Recurring survivor benefits from a pension or retirement plan or the Social Security Administration are not death benefits.

c) Last illness and burial expenses include related hospital and medical expenses; funeral, burial plot and interment expenses; and other related expenses.

d) Death benefits provided to an individual are income to the extent that the total amount exceeds the expenses of the deceased’s last illness and burial expenses paid by the individual.

e) Death benefits which are not income are also not a resource for one month following the month of receipt. If retained, the second month following receipt, death benefits are resources.

f) If death benefits are not considered income, under both SSI and Liberalized Resource policy, treatment is as follows:

1. Month of receipt. Excluded.

2. Month after receipt. Excluded.

3. Second Month following receipt/ Countable resource, if retained.

4. Exception: If the death benefits are repayment for expenses already paid, they are considered resources the month after receipt, if retained.

(a) Example: When her uncle passed away, Beth Smith received 4,000 as Beneficiary of his life insurance policy. She received it in July and anticipates spending the entire amount on his last illness and burial expenses. She has already received bills totaling $900 that she paid. On August 1, she received a funeral bill for $2,900 and a few days later received a cash gift of $500 which she also intends to apply toward last illness and burial expenses. She pays the

$2,900 funeral bill in August and intends to use the remainder of the life insurance to pay some hospital expenses.

(i) Treatment: Neither the $4,000 received in July nor the $500 received in August is unearned income since it is all expected to be used for burial or last illness expenses. She used $900 of the $4,000 in July. As of August 1, she had $3,100 that is not a resource for August. During August she paid the $2,900 bill and then had $200 left. However, the $500 she receives in August gives her $700 to use for hospital expenses. She must spend $200 in August for burial or last illness expenses; otherwise, the $200 will count as a resource September 1. Any portion of the $500 remaining as of October 1 will be counted as a resource.

(b) Jane Smith has total countable resources of $1,980 consisting of a $1,000 savings account and $980 in checking. Her brother died in late October. In November she receives $3,000 as beneficiary of her brother’s life insurance. She has last illness and burial expenses of $2,750 to pay. There are no other bills.

(i) Treatment: Of the $3,000 Ms. Smith received, $250 is unearned income in November because the last illness and burial expenses are only $2,750. The $2,750 is not considered unearned income and will not be a resource until January 1, if she still has it at that time. Any of the $250 remaining will be a resource for December.

5. Exclusion of Burial Spaces.

a) Burial spaces are spaces or items that are used to contain the remains of a deceased person. These include:

1. Cemetery plots, crypts, mausoleums, cremation niches;

2. Caskets, urns;

3. Headstones or other grave markers;

4. Burial containers (burial vaults or grave liners);

5. Expenses related to the opening and closing of the grave sites; and

6. Perpetual care expenses

b) Treament of Burial Spaces Under SSI and Liberalized Resource Policy.

1. A burial space or an agreement which represents the purchase of a burial space held for the burial of the individual, his or her spouse, or a member of his or her

immediate family is an excluded resource, regardless of value. The burial space exclusion is in addition to, and has no effect on, the burial funds exclusion.

2. Under SSI policy, burial spaces may be excluded if intended for use of the individual, spouse or immediate family, as defined.

3. Liberalized policy includes all of the relatives in the SSI definition and extends to family members of any degree of relationship.

4. To be “held for” the burial of an individual , the item must be paid for in full and if not paid for in full, the amount paid is considered a burial fund rather than a burial space.

5. Only one item serving the same purpose may be excluded per person. For example, exclude a casket and vault for the same person, but not a casket and an urn.

6. No limit exists on the value that may be excluded.

7. Taxes paid on burial spaces are also excluded.

8. If a burial space is being held by a funeral provider in accordance with a burial agreement, whether revocable or irrevocable, then the value of the burial space(s) is excluded under the burial space exclusion

6. Exclusion of Burial Funds.

a) Burial funds are items clearly designated for an individual’s burial. They include:

1. Revocable burial contracts;

2. Revocable burial trusts;

3. Other revocable burial arrangements (Including installment sales contracts for burial spaces);

4. Cash;

5. Financial accounts such as checking, saving or CDs;

6. Stocks or bonds; and

7. Life insurance cash value.

b) Burial funds must be clearly designated for the eligible individual’s burial, cremation or other burial-related expenses, i.e., flowers, clothing, transportation, etc.

c) Property other than that listed above will not be considered burial funds and may not be excluded under the burial funds provision. For example, a car, real property, livestock, etc., are not burial funds.

d) Burial funds may be designated by:

1. An indication on the burial funds document, such as a revocable burial contract or the title on a bank account. Whenever burial funds are already clearly set aside as burial funds, no separate signed statement or further designation is required.

2. Completion of DOM-321B, Designation of Burial Funds, provides the information required to document a burial fund, i.e., owner, value and form of funds, date set aside for burial, etc.

3. Once a fund is designated, it remains a burial fund until eligibility terminates or the individual uses the funds for another purpose, in which case a penalty may apply. See discussion of Misuse of Burial Funds later in this section.

e) The burial fund may be excluded retroactively to the date the individual originally designated the funds for burial. The individual’s allegation of the date the funds were first considered set aside for burial (even prior to application) is accepted unless there is evidence the funds were used and replaced after that date.

1. Example: Mr. Hoover applies on May 1 and signs DOM-321B designating a CD for burial. He set the account up two (2) years ago for his burial. He is seeking coverage for February, March and April. The exclusion may be given for those months.

f) Burial funds cannot be commingled with other resources which are not intended for burial. The burial fund exclusion applies only if funds set aside for burial expenses are kept separate from non-burial funds. If excluded burial funds are mixed with resources not intended for burial, the exclusion will not apply to any portion of the funds.

1. It is possible to have excluded and non-excluded funds commingled provided all funds are intended for burial. It is not permissible, however, to have burial and non-burial funds commingled.

(a) Example: Mr. Brennan has a bank account with a balance of $2,000. He plans to use $1,500 for burial and the remaining $500 for other non-burial expenses. The burial exclusion may not be applied to this bank account. Mr. Brennan may want to consider opening another account for the $500. If he does so, he must provide verification and DOM-321B must be completed to document the burial exclusion.

g) Any amount may be designated for burial; however, only the amount up to the applicable maximum exclusion may be excluded. Once the amount of the designated burial funds equals the applicable maximum, the only additions to it that can be excluded are appreciation and interest. However, until the maximum has been reached, additional amounts can be excluded if the individual designates them for burial expenses. Interest is not included in determining if the maximum has been reached.

h) SSI policy allows up to $1,500 in funds set aside for the burial of the individual and up to an additional $1,500 in funds set aside for burial of the individual’s eligible or ineligible spouse.

1. Example: Mr. Brown designates $1,500 in a bank account for burial. The entire amount may be excluded. Mr. Brown designates an account with a $2,000 balance for burial. Since $1,500 is the maximum exclusion, the remaining designated funds are not excluded and count toward the resource limit.

i) Under liberalized policy, the maximum that can be excluded for burial of the individual is $6,000. In addition, up to $6,000 is allowed for burial of the eligible or ineligible spouse.

j) The $1,500 or $6,000 maximum exclusion is reduced by:

1. Any amount held in an irrevocable trust or burial contract or other revocable arrangement for the individual or spouse, if applicable, except to the extent it represents excludable burial spaces.

2. Face Value of any excluded life insurance policy on the individual or spouse, if applicable

(a) Example (SSI): Greta Mann has a savings account designated for burial. It has a balance of $2,000. She also has an irrevocable burial contract with Hartfield Funeral Home that represents burial space items worth $2,500 and burial funds of $1,500. The burial fund portion of the burial contact totally offsets the $1,500 SSI burial exclusion: $1,500-$1,500 = 0; therefore, the entire $2,000 balance in the savings account is not excluded and counts toward the resource limit.

(b) Example (Liberalized): Greta Mann has an excluded life insurance policy with a Face Value of $5,000. She also has a savings account with a balance of $4,000 that she designates for burial. The $6,000 burial exclusion is partially offset by the Face Value of her policy: $6,000-$5,000 = $1,000. Therefore, $1,000 of her savings may be excluded and the remaining $3,000 in non- excluded burial funds is a countable resource.

k) Irrevocable burial arrangements are not resources and are not subject to the $1,500 or

$6,000 maximums; however, as indicated above, they do reduce the amount of the burial fund exclusion allowed. Burial insurance is considered an irrevocable arrangement.

l) The value of the irrevocable burial arrangements purchased by the individual must be equal to the value of the funding source used to make the purchase, e.g., cash prepayment, life insurance or annuity irrevocably assigned to the funeral home. If the value of the burial arrangement is not equal to the value of the prepayment, a penalty may be assessed under the transfer of assets provision for institutionalized clients.

m) The maximum amount that can be excluded when a burial fund is initially designated is $1,500 under SSI resource rules or $6,000 under liberalized policy. Interest earned on excluded burial funds and appreciation in the value of excluded burial arrangements are excluded as income and resources if left to accumulate and become part of the separate burial fund.

n) Changes in the individual’s circumstances may raise or lower the amount that can be excluded for burial, such as:

1. The purchase of additional life insurance with cash surrender value may change the allowable exclusion. In addition, cashing in life insurance may raise or lower the allowable exclusion.

2. The face amount of life insurance may change, thereby changing the allowable exclusion.

3. An irrevocable burial contract may be purchased, thereby reducing the allowable burial exclusion.

4. Deposits made to bank accounts designated for burial will change the allowable exclusion.

5. If the amount designated is less than the maximum exclusion, the individual may add additional funds to the burial fund to bring up the original amount to the maximum exclusion amount.

o) The burial fund exclusion once applied must be reevaluated whenever a change bcomes becomes known that would affect the exclusion amount or at each redetermination.

p) If the fund contains both excluded and non-excluded amounts, use the formula below to determine the excludable portion:

1. Original exclusion amount ÷ Original fund amount x Present fund amount = Excluded Portion;

2. Example: An individual, subject to SSI rules, designated $2000 (original fund amount) as a burial fund, $1500 (original exclusion amount) was excluded and $500 is non-excluded. At the most recent review, the account had grown to $2200 (present fund amount) due to accumulated interest. The excluded amount is $1650. (1500 ÷ 2000 x 2200 = 1650)

q) If funds, including interest, that were excluded under the burial fund exclusion are used for any purpose other than burial expenses for the designated individual, a penalty for misuse is imposed only if the client would have excess resources without the burial exclusion. Upon discovery of the misuse of excluded burial funds, verification must be obtained (which may be in the form of a statement from the client or representative) that all or a portion of the funds have been used for another purpose other than burial to determine the effect the misuse will have on eligibility.

1. If the client would have excess resources without the burial fund exclusion, the amount used inappropriately is counted as income the next possible month after the month in which the misuse is discovered.

2. The misused funds will be included as income in the eligibility computation; however, misused burial funds are not counted as income in the Medicaid Income computation for the institutionalized individual unless the funds are available to the recipient.

3. If the misused funds include non-excluded burial funds, assume the funds were used in this order: non-excluded interest; non-excluded designated amount; excluded interest and excluded designated amount. The penalty only applies to excluded interest and designated amounts.

4. If ineligibility results, the case will be closed in accordance with ongoing policy, i.e., advance notice issued, etc.

5. If the misuse of burial funds does not result in excess income because the client’s resources would not exceed limit even if the burial funds were not excluded or if applicable, the funds are not available to the client to include in the Medicaid Income computation, no action is required other than documenting the case record.

6. There must be a new redesignation of funds when there is a change in the amount of funds originally designated, not including accumulated interest or appreciation.

7. If eligibility is lost, the burial fund exclusion must be developed if the individual reapplies later.

(a) Example: Jennifer Shows originally designated $1,500 as a burial fund. Interest accumulated and the account grew to $1,750. In May, she withdrew $500 to repair her car. If her other resources plus the $1750 burial fund, which

is now non-excluded, exceed the program resource limit, the penalty applies. In addition, she must redesignate the amount of funds for burial because the amount in the account ($1,250) is now below the original amount designated. In the alternative, she could add $250 to the account and the original designation would be accurate; however, any penalty would still apply.

7. Exclusion of Pre-Need Burial Contracts.

a) A pre-need burial contract is an agreement between an individual and a funeral home where the buyer pays in advance for his or another person’s burial arrangements.

b) If an applicant’s resources exceed the allowable limit, he is allowed to establish a pre- need contract to reduce his resources below the limit.

c) Many pre-need contracts include both burial space and burial fund items:

1. Expenses related to the burial space include: casket, vault, opening/closing costs at the cemetery; and

2. Expenses related to the burial fund include: embalming, clothing, visitation room, transportation, flowers.

d) Payment for a contract has taken place when an applicant/recipient transfers a liquid resource to the funeral provider or when specific life insurance policies have been designated on the pre-need burial contract.

e) A liquid resource designated, but not transferred to the funeral provider as payment for a contract, is counted as an available resource.

f) A resource cannot be designated for future payment of a pre-need contract and that resource be excluded as a resource.

g) There are two types of pre-need burial contracts: revocable and irrevocable.

1. Revocable contracts may be sold or the money may be refunded. They are considered resources; however, a full or partial exclusion may be developed.

(a) Revocable Contracts That Are Paid in Full.

(i) If the value of all the items is provided, both the burial space and the burial fund exclusion may be developed. If the value of the burial space items is not provided, only the burial fund exclusion may be developed.

(b) Revocable Contracts That Are Not Paid In Full.

(i) Only the burial fund exclusion may be developed unless the contract verifies the burial space items are paid for and the burial funds items are being paid on.

(c) Under SSI and Liberalized Resource Policy, revocable pre-need burial contracts are considered a resource; however, a burial exclusion may be developed.

(d) If the revocable contract is paid in full:

(i) Any portion of the contract clearly representing burial spaces may be excluded entirely, regardless of value

(ii) Up to $1,500 (SSI) or $6,000 (Liberalized) of the remaining portion of the contract may be excluded as a burial fund

(e) If the contract is not paid in full, it should be treated as a burial fund unless it is verified that the burial spaces themselves are paid in full and considered “held for” the individual

(f) Example: Mr. Allen applies for Medicaid. He has just purchased a revocable contract at Land of Lakes Funeral Home. The contract verifies it is paid in full and includes the following:

$1,500 Casket $1,000 Vault $1,000 Headstone $500 Opening/closing costs $200 Embalming $300 Visitation Room $1,000 Funeral service

Because the contract is paid in full, the first four items, which are burial space items, may be excluded under the burial space exclusion. The remaining $1,500 may be excluded under the burial fund exclusion.

2. Irrevocable pre-need contracts under SSI and liberalized resource policy are not a resource since the money cannot be refunded or the contract sold without significant hardship. If the contract is irrevocable, it is not a resource retroactive to the date of purchase. The portion that represents burial funds offsets that exclusion. If the contract is not paid in full, the portion paid represents burial funds up to the maximum.

3. Life Insurance Funded Burial Contracts.

(a) A life insurance funded burial contract involves an individual purchasing a life insurance policy on his own and then assigning, revocably or irrevocably,

either the proceeds or ownership of the policy to a funeral provider. The purpose of the assignment is to fund a burial contract. Life insurance funded burial contracts are not considered burial insurance.

8. Effect of the Assignment of Ownership on Burial Exclusion.

a) Revocable Assignment.

1. The burial space exclusion does not apply because the items are not paid for until the death of the individual and therefore are not being “held for” the individual. The burial fund exclusion may apply.

2. The resource value of the burial contract is equal to the Cash Surrender Value of the life insurance, subject to the maximum burial funds exclusion amount.

b) Irrevocable Assignment.

1. The burial space exclusion may apply if the values of the items are provided.

2. The life insurance policy is not a resource because the individual no longer owns it.

3. The contract is not a resource because the individual no longer owns it.

4. The value of the burial fund items offsets the value of any other burial funds items up to the allowable maximum

9. Effect of the Assignment of Proceeds on Burial Exclusion.

a) When life insurance proceeds are assigned, the burial space exclusion does not apply because the provider will not be paid until the death of the individual and spaces are not being “held for” the individual.

b) The resource value of the contract is the cash surrender value of the life insurance policy.

1. If the Face Value of all life insurance policies for the individual total $1,500/$6,000 or less, exclude the CSV under the life insurance exclusion.

2. If the FVs total more the $1,500/$6,000, verify and count the CSV toward the resource limit. The burial fund exclusion may apply.

History: Revised to correspond with SPA 19-0018 (eff. 07/01/2019) eff. 12/01/2025.

History

• Source: P.L. 111-5 American Recovery and Reinvestment Act of 2009 § 5006.
• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 3.10 Exclusion of Property Essential for Self-Support

A. The exclusion of property essential to self-support may apply to real or personal property.

1. All property must be in current use or, if not in use for reasons beyond the individual’s control, there must be a reasonable expectation that the required use will resume.

2. The income generated by income-producing property is not excluded under this provision. Income is either earned or unearned, depending on the type of income- producing property involved.

B. Resources excluded under this provision generally fall into four categories:

1. Property Essential to Self Support;

2. Property Used to Produce Goods and Services;

3. Non-Business, Income-Producing Property; and

4. Essential Property Exclusion under Liberalized Policy.

C. For exclusion under this provision, the property must be in current use in the type of activity that qualifies it for exclusion.

1. Current use is evaluated on a monthly basis.

2. Property not in current use may be excluded only if it has been in use and

3. There is expectation that the use will resume within 12 months of last use.

a) This 12-month period can be extended for an additional 12 months if non-use is due to a disabling condition and resumption of the self-support activity can reasonably be expected to occur within that time.

1. If the individual does not intend to resume the self-support activity, the property is a countable resource for the month after the month of last use.

2. If there is a change of intent after the exclusion has been applied, the exclusion no longer applies as of the date of the change of intent. The property becomes a resource for the following month unless a different exclusion is met.

D. Exclusion Principles and Types of Property.

1. Properties essential to self-support which are excluded regardless of value or rate of return are discussed in this section.

2. The properties essential to self-support described in this section include necessary capital and operating assets of a business, e.g., real property, buildings, inventory, equipment, machinery, livestock, motor vehicles, etc.

3. The properties must be in current use or if not in current use due to circumstances beyond the individual’s control, there must be a reasonable expectation that the required use will resume.

4. The following types of properties essential to self-support are excluded regardless of value or rate of return:

a) Property used in a trade or business;

b) Government permits which represent authority to engage in an income- producing activity; and

c ) Personal property used by an employee in his work

5. Property essential to self-support used in a trade or business is excluded from resources, regardless of the value or rate of return. This is applicable to programs subject to both SSI and liberalized resource policy.

a) When the individual alleges owning a trade or business property, a statement must be obtained in regard to:

1. Description of the trade or business;

2. Description of the assets of the trade or business;

3. The number of years the business has been operated;

4. Names of any co-owners; and

5. Estimated gross and net earnings of the trade or business for the current tax year.

b) A copy of the current year tax return (Form 1040 with schedules and attachments) must also be obtained.

1. The tax forms are used to determine net self employment earnings and validity of the trade or business.

2. If the current year return is not available, obtain the latest return available.

6. Government permits represent authority granted by a government agency to engage in an income-producing activity. They are excluded regardless of value or rate of return. This is applicable to programs subject to both SSI and liberalized resource policy.

a) Examples are commercial fishing permits or tobacco crop allotments.

b) When the individual alleges owning a government license, permit or other property which represents government authority to engage in an income producing activity, and which has value as a resource, the following information is needed:

1. Type of license, permit or other property;

2. Name of the issuing agency, if appropriate;

3. If license is required for engaging in this activity;

4. How the license, permit or property is being used; or

5. If not being used, why not.

c) A copy of the license, permit and/or other applicable documents is required.

7. Personal property used by an employee for work is excluded from resources. This is applicable to programs subject to both SSI and liberalized resource policy.

a) Excluded items include tools, safety equipment, uniforms, etc.

b) If the individual alleges owning items that are used in his work as an employee, obtain a statement regarding the following:

1. Name, address and telephone number of employer;

2. General description of the job duties and the items; and

3. Whether the items are currently in use

c) Absent evidence to the contrary, the individual’s statement may be accepted.

8. Non-business property, real or personal property (but not cash or bank accounts), used to produce goods or services essential to daily living is excluded as follows:

a) No specified rate of return is required.

b) Property must be in use or, if not in use for reasons beyond the individual’s control, there must be a reasonable expectation that the required use will return.

c) If the equity value of the property exceeds $6000, the excess is not excluded; it is countable toward the resource limit.

1. Example: If the resource is valued at $7000, then $6000 is excluded and $1000 is counted.

d) Non-Business Property, real or personal, includes:

1. Property used to grow produce or livestock raised solely for personal consumption in the individual’s household;

2. Property used in activities essential to the production of food for home consumption, such as a tractor used for plowing or a boat for subsistence fishing.

(a) This does not include any vehicle that qualifies as an automobile.

e) When an individual alleges owning property that he uses to produce goods or services necessary for daily activities, the following must be obtained:

1. A description of the property;

2. How it is used; and

3. Estimate of the CMV; and

4. Any legal encumbrances.

f) The client’s statement may be accepted regarding use of the property.

9. Non-business, income-producing property is excluded as follows:

a) This property is defined as property which includes land that produces rents or other land-use fees (e.g., non-liquid notes or mortgages, ownership or timber rights, mineral or oil exploration) or other non-liquid property which provides rental or other income, but is not used as part of a trade or business.

b) When an individual alleges owning non-business real property that produces income, the following must be documented:

1. The number of years he has owned the property;

2. Any co-owners of the property;

3. A description of the property;

4. The estimated CMV of the property;

5. Any encumbrances; and

c) The estimated net and gross income from the property for the current tax year. Must be obtained to establish that the property is producing income.

1. If available, a copy of the tax return for the year must be obtained.

2. When no tax returns are available, other evidence may be obtained, e.g., a person leasing land for mineral or oil exploration should have a copy of the lease agreement for the period in question.

d) The equity value of the property must be verified.

e) Under SSI policy, treat as follows:

1. This exclusion applies to non-business, income-producing property.

2. Up to $6000 of the equity value can be excluded from resources if the property produces a net annual return equal to at least 6% of the excluded equity value.

3. Any equity that exceeds $6000 counts toward the resource limit.

4. If the net annual return is less than 6%, the entire equity value is counted.

5. Example: At review, Mr. Cameron reports that he lives in an apartment and is renting out his formerly excluded home, which has an equity value of $13,000. Even if the property produces a 6% net annual return, $7000 of his equity cannot be excluded and counts as a resource under SSI policy.

6. Exceptions: If the property produces less than a 6% net annual return, the exclusion may be allowed only if the following apply; otherwise, none of the EV is excluded under this provision:

(a) Lower return that is beyond the individual’s control, such as:

(i) Crop failure;

(ii) Fire;

(iii) Illness; and

(b) There is a reasonable expectation that the property will again produce a 6% Return.

7. If earnings decline for reasons beyond the client’s control, up to 24 months is allowed for resumption of a 6% net annual rate of return.

(a) This 24-month period begins with the first day of the tax year following the one in which the rate dropped below 6%.

(b) The individual’s progress with the business must be checked.

(c) The individual can have the additional 12 months to achieve the 6% net annual rate of return if he is actively pursuing the activity.

(d) If the individual has stopped actively pursuing the activity, the value of the property counts as a resource the month following the review.

(e) If the property is still not producing at least a 6 percent net annual return at the end of the 24-month period, the exclusion is discontinued.

(f) The value of the property counts as a resource the month following the month the 24-month period ends.

8. If an individual owns more than one piece of property, the 6% return rule applies individually to each piece.

(a) The $6000 equity value limit applies to the combined equity values of properties meeting the 6% return rule.

(b) If all the properties meet the 6% test, but total EV exceeds $6000, that portion of the total in excess of $6000 is not excluded under this provision.

(i) Example: Mr. Green has a piece of land on which he grows corn for sale at market. The equity value of the land is $7000. He nets $500 per year in sales. $500 ÷ $7000 = 7.14%; therefore, $6000 of the EV is excluded and $1000 counts as a resource. Last year his crop was struck by lightning and caught on fire. He made no money, but expects to plant and sell again next year at the regular rate. The $6000 may still be excluded because Mr. Green had no control over the fire. His 24-month period begins January 1 of the tax year following the year in which the loss occurred. A tickler is set to check on his progress in 12 months.

(ii) Example: Mr. Green owns three non-connected acres of pastureland. He rents them to different horse and cattle owners for $500 per year each. The land has equity values of $2000, $3500 and $1200 for a total of $6700. The 6% rule is met: $500 ÷ $2000 = 25% return; $500 ÷ $3500 = 14% return; $500 ÷ $1200 = 42% return. Since the 6% rule is met, $6000 is excluded and $700 is countable

10. The essential property exclusion is applied using liberalized policy as follows:

a) Property essential to self-support, defined as property used in a trade or business, government permits and personal property used by an employee for his job, is excluded regardless of value or rate of return.

b) The $6000 exclusion cap is lifted under liberalized policy; therefore, property used to produce goods or services essential to daily living is also excluded regardless of value or rate of return.

c) With the $6000 exclusion cap lifted under liberalized policy, non-business, income- producing property must produce a net annual return of 6% of the EV of each property.

d) If multiple properties are involved, each must be evaluated under the 6% rule.

e) Property that a client sells via a property settlement agreement must meet the 6% net annual return criteria and the agreement must be actuarially sound in order to avoid a possible transfer of resources penalty for the institutional client.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994)

23 Miss. Admin. Code Pt. 103, R. 3.11 Resources Set Aside As Part of A Plan To Achieve Self-Support (Pass)

A. The Social Security Act authorizes the exclusion of income and resources of an individual who has a disability or is blind (but not aged) when the individual needs the income and resources to fulfill a Plan to Achieve Self-Support (PASS) approved by the Social Security Administration.

B. Resources set aside as part of an approved PASS are excluded.

Rule 3.12: Exclusion of Retained Cash Payments

A. The treatment of the following types of retained cash payments is discussed below:

1. Retroactive Supplemental Security Income (SSI) and Retirement, Survivors and Disability Insurance (RSDI).

a) The unspent portion of retroactive SSI benefits and RSDI benefits is excluded from resources for nine (9) calendar months following the month in which the individual receives the benefits.

b) Retroactive SSI benefits are SSI benefits issued in any month after the calendar month for which they are paid.

1. Benefits for January that are issued in February are retroactive.

c) Retroactive RSDI benefits are those issued in any month that is at least two calendar months after the calendar month for which they are paid.

2. Disaster Assistance.

a) Disaster Assistance includes assistance received from the following sources:

1. The Disaster Relief and Emergency Act (PL 100-707);

2. Another federal statute because of a presidentially-declared major disaster;

3. A state or local government’s comparable assistance; or

4. A disaster assistance organization.

b) If the disaster assistance funds are excluded from income, the unspent amount is also excluded from resources.

c) Interest earned on funds excluded in this provision is excluded from income and resources.

3. Presidentially-Declared Major Disasters.

a) Some catastrophes (such as hurricanes) cause such wide-spread destruction that the President of the United States declares them major disasters.

b) The exclusion period may be extended for individuals who incurred damage or loss of excluded resources under certain circumstances.

1. The eighteen (18) month period (nine (9) month initial period plus the nine (9) month good cause extension) may be extended up to an additional twelve (12) months.

2. Such an extension may be granted if the excluded resource is located within the geographical area of the disaster area (this area is defined in the presidential order); the individual intends to repair or replace the excluded resource or the individual presents evidence of good cause.

4. Netherland WUV Payments to Victims of Persecution.

a) The Netherlands Act on Benefits for Victims of Persecution 1940 – 1945, WUV (Wet Uitkering Vervlgingsslachtoffers) provides payments to individuals who were victims

of persecution during World War I during German and Japanese occupation of the Netherlands and the Netherlands East Indies (now the Republic of Indonesia).

b) The unspent WUV payments made by the Dutch government are excluded from resources and the interest earned on unspent WUV payments is excluded from income.

5. German Reparation Payments.

a) German reparations payments are made to certain survivors of the Holocaust under the:

1. Federal Republic of Germany’s laws for compensation of National Socialist Persecution (German Restitution Act); or

2. German Reunification Act of 1990.

b) These payments may be made periodically or in a lump sum.

c) Unspent German reparations payments are excluded from income and resources. Interest earned on unspent payments is excluded from income.

6. Austrian Social Insurance Payments.

a) The nationwide class action law suit, Bondy v. Sullivan, involved Austrian social insurance payments that were based on wage credits granted under Paragraphs 500- 506 of the Austrian General Social Insurance Act.

b) These paragraphs grant credits to individuals who suffered a loss; that is, were imprisoned, unemployed or forced to flee Austria, during the period of March 1933 to May 1945 for political, religious or ethnic reasons.

c) Unspent Austrian social insurance payments based, in whole or in part, on wage credits granted under Paragraphs 500-506 of the Austrian General Social Insurance Act are excluded from resources and the interest earned on unspent Austrian social insurance payments is excluded from income.

d) Austrian social insurance payments not based on wage credits granted under these paragraphs are not excluded from resources under this provision.

7. Benefits Excluded from Both Income and Resources by a Federal Statute other than Title XVI.

a) Federal statutes other than Title XVI specify many income and resources exclusions. Examples of these are discussed below:

1. Agent Orange Settlement Payments.

(a) There is no limit to the length of time unspent Agent Orange settlement funds are excluded from resources. Interest earned on conserved payments is excluded as income.

2. Victims Compensation.

(a) Some states establish funds to assist victims of crimes.

(b) Unspent payments received from such a fund are excluded for nine (9) months if received for expenses incurred or losses suffered because of crime, e.g., lost wages, medical expenses incurred due to injuries, etc.

(c) Interest earned on unspent victims’ compensation payments is not excluded from income or resources.

3. Relocation assistance.

(a) This type of assistance is sometimes provided to persons displaced by projects which acquire real property.

(b) Relocation assistance may be provided under local, state or federal programs. Such payments may be excluded for certain lengths of time. The length of the exclusion depends on the source:

(i) State and Local Program Assistance – unspent funds are excluded from resources for 9 months;

(ii) Federal Assistance – There is no time limit on the exclusion for assistance provided under the Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970

(c) Interest earned on unspent payments is not excluded from income or resources.

8. Tax Advances, Tax Credits and Refunds.

a) Unspent federal tax refunds and advance tax credits are excluded from resources for twelve (12) calendar months following the month the refund or payment is received.

b) Interest earned on any unspent tax funds related to Earned Income Tax Credits (EITC) or Child Tax Credits (CTC) is not excluded as income or a resource.

9. Radiation Exposure Compensation Trust Fund Payments.

a) The Radiation Exposure Compensation Trust Fund (RECTF) authorized the Department of Justice to make compensation payments to individuals (or their survivors) that were found to have contracted certain diseases after exposure.

b) The payments will be made as a one-time lump sum.

c) Unspent payments are excluded from resources. Interest earned on unspent payments is excluded income.

10. Gifts of Domestic Airline Tickets.

a) The value of a ticket for domestic travel received by an individual (or spouse) is not a resource if the ticket is:

1. Received as a gift,

2. Not converted to cash, i.e., cashed in, sold, etc., and

3. Excluded from income.

11. Cash and in-kind items received for the repair or replacement of lost, damaged, or stolen excluded resources are not considered resources for nine (9) months from the date or receipt, This may be extended up to nine (9) more months if the individual verifies good cause for the repair or replacement not being completed within the first nine (9) month period.

History: Revised eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994)
• Source: Social Security Act §1902 (r) (2); 20 CFR § 416.1232; 42 CFR § 435.601(b) (Rev 1994); American Taxpayer Relief Act of 2012, Pub. L. No. 112-240, H.R. 8, 112th Cong. (2013).

23 Miss. Admin. Code Pt. 103, R. 3.13 Treatment of Excluded Funds Co-Mingled with Non-Excluded Funds

A. Otherwise excludable funds must be identifiable in order to be excluded.

B. This does not require them to be separate from other funds (such as in a separate bank account).

C. When withdrawals are made from co-mingled funds, the assumption is non-excludable funds are withdrawn first, leaving as much of the excluded funds in the account as possible.

D. If excluded funds are withdrawn, the excluded funds left in the account can only be added to by deposits of subsequent funds excluded under the same provision and excluded interest

E. Example: An individual deposits an $800 retroactive RSDI check in a checking account. The account already contains $300 in non-excluded funds.

1. Of the new $1,100 balance, $800 is an excluded retroactive RSDI payment;

2. The individual withdraws $300. The remaining $800 is still excluded;

3. The individual withdraws another $300, leaving the $500 balance excluded;

4. The individual deposits $500, creating a new $1000 balance. Only $500 of the new balance is excluded.

F. Example: An individual deposits $200 in excluded funds in a non-interest bearing checking account that already contains $300 in non-excluded funds.

1. The individual withdraws $400. The remaining $100 is excluded;

2. The individual then deposits $100 in non-excluded funds. Of the resulting $200 balance, $100 remains excluded;

3. The individual next deposits $100 in excludable funds. Of the resulting $300 balance, $200 is now excluded.

Rule 3.14: Achieving a Better Life Experience (ABLE) Accounts

A. An ABLE account is a type of tax-advantaged account that enables eligible individuals with disabilities to:

1. Save money that is tax-exempt,

2. Withdraw the funds to use for certain qualified disability expenses, and

3. Experience Limited impact on eligibility for Medicaid and Supplemental Security Income (SSI).

B. The Mississippi Department if Rehabilitation Services (MDRS) has full responsibility for administering the ABLE program, including making the assessment on whether the individual is eligible to open an ABLE account.

C. The designated beneficiary is the eligible individual who establishes and owns the ABLE account.

D. The designated beneficiary is the owner of an ABLE account, regardless of whether someone else has signatury authority over the account.

E. An eligible individual can open an ABLE account through an ABLE Program in any state that has a qualified ABLE program; however, the eligible individual can be the designated beneficiary of only one ABLE account.

F. Contributions to an ABLE account and earnings (interest, dividends, etc.) an ABLE account receives are excluded as income to the designated beneficiary. This includes income distributions from a Special Needs Trust or Pooled Trust that is deposited into an ABLE account of the SNT or pooled trust beneficiary.

G. ABLE account balances are fully excluded as a resource for Medicaid purposes.

H. Distributions from an ABLE account do not count as income of the designated beneficiary for ABD; instead, they are a conversion of a non-countable resource to another form of resource that is counted or excluded as follows:

1. Qualified Disability Expenses (QDE’s) are related to the blindness or disability of the designated beneficiary and are for the benefit of the designated beneficiary. In general, a QDE includes, but is not limited to, the types of expenses shown below:

a) Education,

b) Housing (mortgage, property insurance, property taxes, rent and utilities, i.e., heating, fuel, gas, electricity, water, sewer and garbage removal),

c) Transportation,

d) Employment training and support,

e) Assistive technology and related services,

f) Health, prevention and wellness,

2. Distribution from an ABLE account are not countable as a resource for ABD purposes if used for QDEs in the month of the distribution.

3. Distributions retained after the month of distribution are not counted as resource unless they are spent on a non-QDE.

4. Distributions spent on a non-QDE are a resource in the month they were spent.

I. Distributions from an ABLE account that are used for QDEs are not included in the beneficiary’s taxable income for MAGI. However, the taxable portion of a distribution used for a non-QDE is countable as income for MAGI determinations.

J. ABLE account distributions that are used for a QDE are disregarded from an individual’s total income used to calculate Medicaid Income. If the distribution is not used for a QDE, it is a resource in the month the funds are misspent.

K. The Mississippi Division of Medicaid does not seek direct recovery of medical expenses paid for the beneficiary from an ABLE account at the beneficiary’s death. However, funds in an ABLE account at the beneficiary’s death may become part of the beneficiary’s probate estate for purposes of estate recovery.

History: New Rule eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).
• Source: Miss. Code Ann. § 43-28-1; Pub. L. 113-295.

Chapter 4 Countable Resources

23 Miss. Admin. Code Pt. 103, R. 4.1 Cash

A. Cash is a countable resource.

B. Cash is defined as money on hand that is in the form of coin or currency.

1. Foreign currency or coins are cash to the extent they can be exchanged for U.S. currency.

2. Coin collections are not considered cash, even though they are a resource.

a) The value of coin collections is based on a collector’s value and determined by knowledgeable source estimate.

1. Treat a coin collection as other personal property.

Rule 4.2: Checking/Savings Accounts

A. Funds maintained in checking and savings accounts are usually payable on demand.

B. When an individual has unrestricted access to an account, all of the funds in the account are considered as a resource to the owner of the account, regardless of who deposited the funds.

C. A fiduciary or trustee is authorized to act on behalf of or for the benefit of another person. A fiduciary’s right to withdraw funds is the same as the account owner’s right to withdraw them.

D. Bank accounts must be verified either from the client’s own records (statements, print-outs, etc.) or agency verification to establish activity on the account and account balances.

1. DOM uses an asset verification system to request electronic verification of liquid assets held in financial institutions for purposes of determining Medicaid eligibility for applicants and recipients in programs with an asset test.

2. The applicant or recipient, their spouse, and any other person whose resources are required by law to be disclosed to determine eligibility, shall authorize the use of the asset verification system.

3. The responses from the asset verification system are compared to the client’s attestation and the resource limit to determine if they are reasonably compatible. If they are not, the client must provide verification.

4. The person designated as the owner in the account title is assumed to own all the funds in the account.

5. Absent evidence to the contrary, the person shown as the owner in the account title is assumed to have the legal right to withdraw funds and use them for support and maintenance.

a) Example: An account is titled “In trust for John Jones and Mary Smith, subject to sole order of John Jones, balance at death of either to belong to survivor”. Since John alone has unrestricted access, none of the funds in the account could be considered Mary’s resources unless John is her fiduciary or his resources are deemed available to her.

b) Example: An account is titled” George Dahey, restricted Individual Indian Money Account”. Mr. Dahy cannot withdraw funds from the account without the authorization of the Bureau of Indian Affairs. Therefore, the account is not his resource.

History: Revised eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994)
• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994); Miss. Code Ann.§ 43-13-116.1.

23 Miss. Admin. Code Pt. 103, R. 4.3 Joint Checking/Savings Accounts

A. Except for account ownership, all instructions in the above rule also apply to joint bank accounts. The information in this section pertains only to ownership of joint bank accounts.

B. Ownership Assumptions for Joint Accounts.

1. Ownership is assumed as follows when the individual has unrestricted access to the account as follows:

a) Ownership When Medicaid Client is Joint Owner with an Ineligible Individual(s):

1. Count the total value of the account when the Medicaid applicant/recipient holds funds jointly with an ineligible individual(s), regardless of the source of the funds.

b) Ownership When More Than One Medicaid Client is an Account Holder:

1. Count an equal share of the account if two or more Medicaid applicants/recipients are holders of the same joint account, regardless of the source of the funds.

2. If the account is also jointly-held with ineligible individuals, do not allow a share of the funds to ineligible individuals.

c) Deemors.

1. If one or more account holders is a deemor and none of the account holders is a client, all of the funds in the account are assumed belong to the deemor or in equal shares if more than one deemor.

2. Rebuttal of Joint Checking/Savings Accounts.

a) An applicant or recipient may rebut ownership of part or all of the funds in a jointly- held account and must provide verification surrounding establishment of the account and ownership and expenditure of funds to support this claim.

b) Any funds that the evidence establishes were owned by the other account holder(s), and that the client can no longer withdraw from the account, were not and are not the client’s resources. Rebuttal is both retrospective and prospective.

c) The funds can be deemed to be available to the client if the account holder to whom the funds belong is a deemor.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.4 Funds Held in Another Individual’s Account

A. The value of funds deposited or held for an applicant/recipient in an account that does not have the client’s name on it are countable if:

1. The holder(s) of the account agrees that the funds on deposit, or a portion thereof, belong to the applicant/recipient, and

2. The funds are available to the client.

B. If some or all of the funds are acknowledged as belonging to the client and are available, the account is treated as a countable resource to the extent the funds belong to the client.

C. Documentation will include written statements from the client and the holder(s) of the account.

D. Entitlement income deposited into an account which is not owned by the client does not alter the fact that the income belongs to the client and is used to determine eligibility and Medicaid Income (if applicable).

E. Funds belonging to the client (including non-entitlement income) deposited into another person’s account and not accessible to the client are subject to a transfer penalty, if applicable.

1. A transfer may exist even if the funds are not acknowledged as belonging to the client when evidence indicates the client’s funds are deposited and retained in the account.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.5 Time Deposits

A. A time deposit is a contract between an individual and a financial institution whereby the individual agrees to leave funds on deposit for a specified period of time (six months, two years, five years, etc.) and the financial institution agrees to pay interest at a specified rate for that period.

1. Certificates of Deposit and savings certificates are common forms of time deposits.

2. The ownership assumptions regarding ownership of bank accounts apply to time deposits.

B. Withdrawal of a time deposit before the specified period expires incurs a penalty which is usually imposed against the principal. The penalty does not prevent the time deposit from being a resource, but it does reduce its value as a resource.

1. The resource value of a time deposit at any given time is the amount the owner would receive upon withdrawing it at that time, excluding interest paid that month. Generally this is:

a) Amount originally deposited;

b) Plus accrued interest for all but the current month; and

c) Minus any penalty for early withdrawal.

C. On rare occasions, the terms of a time deposit may prohibit early withdrawal altogether. When early withdrawal is prohibited, principal and interest are treated as follows:

1. Principal.

a) If the owner of a time deposit cannot under any circumstances withdraw the principal before it matures, the principal is not a resource. It becomes a resource (not income) on the date it matures and may affect countable resources for the following month.

2. Interest.

a) If the owner has no access to the interest before the deposit matures, accrued interest is also not a resource. The interest is not counted as income in the month the deposit matures, but as a resource the month after maturity.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.6 Conservator Accounts

A. The term “conservatorship account” refers to a financial account in which a person or institution has been appointed by a court to manage and preserve the assets of an individual which are held in the account.

B. Absent evidence to the contrary, the funds are available for the individual’s support and maintenance and are countable as that person’s resource.

C. The court order establishing the account verifies it.

1. The fact that an individual has to petition the court for withdrawal of funds does not mean the funds may be assumed to be unavailable.

2. The denial of a request for withdrawal of funds by the court does not necessarily mean the funds in the account are unavailable for the individual’s support or maintenance.

a) A history of the petitions for and approvals and denials of funds may reveal the court approves petitions to withdraw funds to provide maintenance and support and only denies non-essential items; or

b) The court’s denial of a request is the exception rather than the rule. In either instance, the funds are considered an available resource.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.7 Patient Accounts

A. A nursing home patient account is a financial account set up by the nursing home for the convenience of the patient.

B. These accounts are similar to a checking and/or savings account. The facility holds funds belonging to the patient for the patient’s use.

C. For Medicaid purposes, a patient account is treated in the same manner as a checking or savings account.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.8 Charitable Funds Bank Accounts

A. The value of funds in an account set up to receive and hold charitable contributions (fundraisers) is counted if the name of the applicant/recipient is on the account and the funds are available to the applicant/recipient for support and maintenance.

Rule 4.9: Contents of Safety Deposit Box

A. Some or all of the contents of a safety deposit box may be countable as resources based on the appropriate policy applicable to the type of resource, i.e., stock certificated, coins, jewelry, life insurance policy, etc.

B. If a recipient’s possessions are stored in another person’s’ safety deposit box, access to the contents must be determined. Access would be determined from the owner’s statement.

C. Contents are determined from statements of the applicant/recipient, spouse or authorized representative.

History: Revised eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).
• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.10 Non-Home Real Property

A. This type of property is land and any permanent buildings/immovable objects attached to it that are not considered a principal place of residence.

B. Generally, this type of property is a countable resource; however, an exclusion may be developed if there is a bona fide effort to sell.

C. Ownership and Current Market Value must be determined.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.11 529 Plan

A. This is a state-sponsored investment program in which parents may fund accounts to pay for a child’s college education.

B. Parents are owners and the account is considered a resource.

1. Withdrawal for reasons other than to pay for qualified college education is subject to income tax and an additional 10% penalty.

2. Account statements may be used to verify ownership and value of a 529 Plan..

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.12 Stocks

A. General.

1. Shares of stocks represent ownership in a business corporation. The term “stock” includes:

a) Preferred stock,

b) Warrants and rights; and

c) Options to purchase stock:

B. Treatment.

1. To determine value:

a) Absent evidence to the contrary, assume each owner of a stock owns an equal share of stock; and

b) Can sell the stock at will, at current value.

1. Broker fees do not reduce the value that stocks have as a resource.

2. Ownership is determined using the stock certificate or most recent account statement (including dividend account) from the brokerage firm that issued or is holding the stock.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.13 Mutual Fund Shares

A. General.

1. A mutual fund is a company whose primary business is buying and selling securities and other investments.

2. Types of mutual funds include growth funds, income funds, balance funds, municipal bonds, money market funds, load funds, no load funds.

B. Treatment

1. Shares in a mutual fund represent ownership in the investments held by the fund and their value is a countable resource.

2. Such investments may be pooled assets (such as stocks or bonds, managed by an investment company). In this event, a mutual fund share represents ownership interest in this pool as opposed to a specific stock.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.14 US Savimgs Bonds

A. General.

1. A US Savings Bond is an obligation of the federal government, is not transferable and can only be sold back to the federal government.

B. Treatment.

1. Ownership Determination.

a) The individual(s) in whose name the bond is registered is the owner and retains sole ownership rights during his lifetime, even if a beneficiary is also named.

2. Valuation.

a) The redemption value of US bonds must be determined through the US Treasury and counts as a resource.

1. If there are joint owners, each individual owns equal shares of the bond’s redemption value.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.15 Corporate Bonds

A. General.

1. Corporate bonds are the obligation of a private corporation. Corporations sell bonds to raise capital.

2. There are two type of corporate bonds:

a) Debentures are backed by the issuer’s full faith and credit; and

b) Mortgage-Backed bonds are backed by a lien on the company’s assets.

3. Corporate bonds are issued in two forms:

a) Registered bonds pay interest to their registered owner; and

b) Bearer or coupon bonds pay interest to whomever holds the bond.

B. Treatment.

1. Ownership is determined by the receipt of purchase.

2. The bond value is obtained from the issuer, i.e., broker, securities dealer, etc., and is a countable resource.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.16 Municipal Bonds

A. General.

1. Municipal bonds are to city, county and state governments what corporate bonds are to corporations.

2. Most municipal bonds are of two types:

a) General Obligation Bonds are backed by the full faith and credit of the issuing municipality and supported by the taxing power; and

b) Revenue Bonds are backed by the project being financed and the revenue or user fees it generates.

c) Other types of municipals are limited-tax bonds, anticipation notes, industrial development bonds and life-care bonds.

B. Treatment.

1. Ownership is determined by the receipt of purchase.

2. The bond value is obtained from the issuer, i.e, broker, securities dealer, etc., and is a countable resource.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.17 Government Bonds/US Securities

A. General.

1. A government bond, distinct from a US Savings Bond, is a transferable obligation issued or backed by the federal government.

2. Examples are:

a) Treasury Bills are short-term obligations that require a minimum investment of $10,000 and can be sold before maturity.

b) Treasury Notes and Bonds are similar to T-Bills but they have longer maturities and lower minimum investment requirements. They have been registered in book form since July 1986, but were sometimes issued as bearer bonds before then.

c) TIGER (Treasury Investors Growth Receipt) and CATS (Certificate of Accrual on Treasury Securities) are government securities issued with a zero coupon concept and can be sold before maturity. y. d) Some Federal Agencies have charters to issue securities known as Federal Agency Securities. Minimum investments range from $1,000 to $25,000. Some of these federal agencies are: the Federal Home Loan Bank Board, Federal Home Loan Mortgage Corporation (FREDDIE MAC), the Export-Import Bank and the Government National Mortgage Association (GINNIE MAE).

B. Treatment.

1. The government securities discussed above are countable resources.

2. Ownership is determined from the receipt of purchase.

3. The value is determined from the issuer and counts as a resource.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.18 Cash to Purchase Medical or Social Services

A. General.

1. An individual cannot always disburse cash given to him/her to purchase medical or social services in the month of receipt.

2. To permit use of the funds as intended, it is reasonable to assume, for a limited time, that the individual will use them to pay for approved services and, therefore, that they are not available for support and maintenance.

B. Treatment.

1. A cash payment for medical or social services that is not income also is not a resource for the month following month of receipt.

2. Exception: Even though it is not income, cash received as repayment for bills an individual has already paid is a resource and if retained, is counted the month after receipt.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.19 Retroactive in-home Supportive Services

A. General.

1. In limited circumstances, governmental programs will pay a spouse or parent to provide a disabled spouse or child with certain in-home supportive (attendant, homemaker) services (IHSS). IHSS payments are income when received by the ineligible spouse or parent, but are not included as income for deeming purposes. In addition, a period of time is allowed during which retroactive IHSS payments are not considered resources.

B. Treatment.

1. A payment is considered retroactive if the payment is made after the month it was due.

a) If payment is made in the month due, but following the month services were rendered, the payment is not retroactive.

2. An IHSS retroactive payment is excluded as a resource the month of receipt and the calendar month after receipt.

3. Beginning the second calendar month after receipt, it is a resource and subject to resources deeming.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).

23 Miss. Admin. Code Pt. 103, R. 4.20 Uniform Gifts to Minors Act

A. General.

1. Most states have adopted the Uniform Gifts to Minors Act (UGMA) that permits making gifts that are tax free to minors. The UGMA is sometimes called the Uniform Transfers to Minors Act.

2. Under the UGMA legislation:

a) An individual (donor) makes an irrevocable gift of money or other property to a minor (the donee);

b) The gift plus any earnings it generates is under the control of a custodian until the donee reaches the age of majority established by state law; c) The custodian has discretion to provide to the minor or spend for the minor’s support, maintenance, benefit or education as much of the assets as he/she deems equitable; and

d) The donee automatically receives control of the assets when he/she reaches the age of majority established by state law (age 21 in Mississippi).

3. A custodian of UGMA assets cannot legally use any of the funds for his/her own personal benefit. Therefore, the assets are not the custodian’s resources and additions to, or earnings on the principal are not income to the custodian who has no right to use them for his/her own support and maintenance.

4. According to Mississippi state law, gifts that are valid under the Mississippi Uniform Transfer to Minors Act must reflect that the gift is being made under this Act. This means the gift(s), e.g., annuity, CD, property, life insurance, etc., must be assigned in writing and substantially worded to show the custodian’s name, minor’s name and the designation that the gift is authorized under the Uniform Transfer to Minors Act (in Mississippi, MS Code Ann., Section 91-20-19).

B. Treatment.

1. Additions to principal may be income to the donor before becoming part of the UGMA principal.

a) Example: If the donor is a deemor who receives rental income and adds it to a child’s UGMA funds, consider the rental income as income for deeming purposes.

2. Gifts made under the UGMA may involve a countable transfer of resources to the donor, if applicable.

3. For minor donee, consider as income:

a) Custodian’s disbursements to the minor; and

b) Disbursements on behalf of the minor used to make certain third party vendor payments. 4. For the minor donee, the following is not income to the minor: : a) The UGMA property; and

b) Any additions or earnings. 5. For the donee at age 21, the following is applicable:

a) All UGMA property will become available to him/her; and

b) All funds in the UGMA will count as income the month the minor reaches age 21 and is a resource thereafter. 6. The document designating a UGMA transfer and ownership assigned in writing and complying with the requirements of state law must be provided. If there is no document designating a UGMA transfer, treat as though there is no UGMA.

Rule 4.21: Entrance Fees to Continuing Care Retirement Communities

A. Continuing Care Retirement Communities (CCRC) or life care communities provide a range of living arrangements from independent living assistance to skilled nursing care.

1. Some CCRC’s include Medicaid certified nursing facilities while others do not participate in Medicaid.

2. An individual or couple may be required to pay substantial entrance fees and sign detailed contracts before moving into the CCRC.

3. The entrance fee paid to a CCRC is treated as a resource under certain circumstances for the purpose of determining Medicaid eligibility.

B. The entrance fee paid to a CCRC is a countable resource if all of the following conditions are met:

1. The entrance fee can be used to pay for care under the terms of the entrance contract if other resources of the individual become insufficient. If only a portion of the fee is refundable, this condition is met.

2. The entrance fee is refundable when the individual dies or terminates the contract and leaves the CCRC. If the individual is eligible for a refund of any remaining entrance fee, this condition is met.

3. The entrance fee does not confer an ownership interest in the CCRC.

History: New to correspond with the Deficit Reduction Act of 2005 (eff. 07/01/2008), eff. 09/01/2014.

Rule 4.22: Disqualification for Long Term Care Assistance for Individuals with Substantial Home Equity

A. Reimbursement for nursing facility services and other long term care services must be denied for an individual who has substantial home equity. In 2009, equity interest in home property could not exceed $500,000. This amount is subject to increase based on the annual percentage increase in the urban component of the consumer price index beginning in 2011, rounded to the nearest $1,000.

B. The disqualification for substantial home equity will not apply to an individual who has a spouse, child under age 21 or adult blind or disabled child residing in the individual’s home.

C. The substantial home equity limitation provision can be waived in cases of undue hardship as defined in Miss. Admin. Code, Part 103, Chapter 7.

History: New to correspond with SPA 2008-003 (eff. 07/01/2008), eff. 09/01/2014.

Rule 4.23: Virtual Currencies and other Digital Tokens

A. Digital tokens are forms of digital assests that represent ownership of digital items. There are two types of digital token:

1. Fungible Tokens – Fungible tokens are interchangeable with and exchangeable for equivalent digital tokens and are divisible into smaller units. Fungible tokens are also known as Virtual Currencies or Cryptocurrencies.

2. Non-Fungible Tokens (NFTs) – NFTs are digital assests that signify ownership of a unique or scarce property that is not interchangeable with other token and cannot be divided into smaller units.

B. The current market value of a virtual currency or other digital token is a countable resource.

C. Virtual currencies and digital tokens that can only be exchanged for virtual goods and services within a limited virtual economy are not countable resources.

History: New Rule eff. 12/01/2025.

History

• Source: Social Security Act §1902 (r) (2); 42 CFR § 435.601(b) (Rev 1994).
• Source: Social Security Act § 1917(g); The Deficit Reduction Act of 2005.
• Source: Social Security Act § 1917(f); Title XVI; Deficit Reduction Act; Omnibus Budget Reconciliation Act of 1993.
• Source: 42 CFR § 435.601(b); Social Security Act § 1902 (r)(2)

Chapter 5 Trust Provisions

23 Miss. Admin. Code Pt. 103, R. 5.14 Special Needs Trusts (SNT)

A. A Special Needs Trust (SNT) contains the assets of an individual under age sixty-five (65) who is disabled and which is established for the sole benefit of the disabled individual by a parent, grandparent, legal guardian of the individual, or a court.

B. To qualify for an exception to the rules governing trusts, the SNT must contain a provision stating that, upon the death of the individual or upon termination of the trust for any other reason, the MS Division of Medicaid receives all amounts remaining in the trust, up to an amount equal to the total amount of medical assistance paid on behalf of the individual.

C. When a SNT is established for a disabled individual under age sixty-five (65), the SNT exception for the trust continues even after the individual becomes age sixty-five (65). However, a SNT cannot be added to or otherwise augmented after the disabled individual reaches age sixty-five (65). Any such addition or augmentation after age sixty-five (65) involves assets that were not the assets of an individual under age sixty-five (65) and therefore, those assets are not subject to the SNT exception.

D. A SNT must be established for a disabled individual, as defined under the SSI Program in section 1614(a)(3). When the individual in question is receiving either Title II or SSI benefits as a disabled individual, the disability determination made for those programs is accepted. If the individual is not receiving SSI or title II based on disability, a determination concerning the individual’s disability must be made. If disability is not established using SSI criteria, the SNT exception cannot apply.

E. Establishment of a SNT as described above does not constitute a transfer of assets for less than fair market value if the transfer is made into a trust established solely for the benefit of a disabled individual under age sixty-five (65). However, if the trust is not solely for the benefit of the disabled person or if the disabled person is over age sixty-five (65) at the time the SNT is established, transfer penalties may apply.

History: Revised eff. 11/01/2014.

Rule 5.15: Pooled Trusts

A. A pooled trust is a trust containing the assets of a disabled individual that meets the following conditions:

1. The trust is established and managed by a non-profit entity that has been granted that status by the Internal Revenue Service (IRS);

2. A separate account is maintained for each beneficiary of the trust but for purposes of investment and management of funds the trust pools the funds in these accounts;

3. Accounts in the trust are established solely for the benefit of disabled individuals by the individual, by the parent, grandparent, legal guardian of the individual, or by a court; and

4. To the extent that any amounts remaining in the beneficiary’s account upon the death of the beneficiary or upon the termination of the trust for any other reason are not retained by the trust, the trust pays to the MS Division of Medicaid the amount remaining in the account up to the amount equal to the total amount of medical assistance paid on behalf of the beneficiary. To meet this requirement, the trust must include a provision specifically providing for such payment.

B. To qualify as an excepted trust, the trust account must be established for a disabled individual, as defined in Section 1614(a)(3) of the Act. When the individual in question is receiving either Title II or SSI benefits as a disabled individual, the disability determination made for those programs is accepted. If the individual is not receiving SSI or title II benefits based on disability, a determination concerning the individual’s disability must be made. If disability is not established using SSI criteria, the pooled trust exception cannot apply.

History: Revised eff. 11/01/2014.

Rule 5.16: Special Needs Trust (SNT) and Pooled Trust Guidelines and Restrictions

The MS Division of Medicaid has established guidelines and restrictions regarding payments and distributions from a SNT or pooled trust that must be followed in order for either type of trust to meet or continue to meet the conditions for exception. Medicaid eligibility of the disabled individual may be affected if these guidelines are not followed.

A. Payments for medical expenses that are not paid by Medicaid are allowed to be made from the trust. One exception is the cost differential between that of a private room and a semi- private room in an institutional setting is not an allowable expense.

B. Gifts must not be made from either type of trust.

C. Compensation paid to a family member from either type of trust for services rendered as a trustee must be reasonable under the circumstances.

D. Compensation paid to a family member from either type of trust for services rendered as a caretaker to the beneficiary must be reasonable under the circumstances and not exceed rates charged by agencies in the geographic area for the same or similar services. For a parent, the services must be over and above normal parental responsibilities.

E. The purchase of residential real property by the trust is allowable if the residence serves as the beneficiary’s place of residence. The trust must be the owner of any real property purchased by the trust. Additions or improvements to existing property owned by another individual will be allowed if made for the benefit of the beneficiary. The trust must have a lien on the property for the cost of the additions or improvements.

F. The purchase of a vehicle by the trust is allowed only if it is the only household vehicle or is specially equipped to allow the beneficiary to operate the vehicle or to be transported in the vehicle. If the vehicle will be used for other than the beneficiary, all expenses relating to the vehicle must be prorated between the trust and anyone other than the beneficiary that uses the vehicle. If the vehicle is placed in the name of anyone other than the beneficiary, the trust must have a lien on the vehicle title.

G. Payments for vacations and other non-medical trips for the beneficiary must be reasonable under the circumstances and considering the size of the trust.

H. Payments for recreational opportunities, family visits or visits to friends for the beneficiary must be reasonable under the circumstances. Payments for family members to visit the beneficiary may be made if the visit is for purposes of ensuring the safety and well-being of the beneficiary.

I. Payments for non-medical expenses such as radios, televisions, audio or video equipment, computer equipment or other electronic devices and/or equipment must be made for the primary benefit of the beneficiary and reasonable under the circumstances and considering the size of the trust.

J. The pre-need payment of burial expenses, the purchase of pre-need burial contracts or the payment of burial insurance premiums are allowable, but if such arrangements have not been made prior to the passing of the beneficiary, they must not be paid until after reimbursement has been made to Medicaid.

K. Payments for the following items will produce In Kind Support and Maintenance (ISM) for the beneficiary: food, rent, mortgage payments (including property insurance required by the mortgage holder), real property taxes (less any tax rebate/credit), heating fuel, gas electricity, water, sewer, garbage removal. ISM is considered income and may affect eligibility for Medicaid-only beneficiaries or reduce SSI benefits.

L. Distributions from either type of trust directly to the beneficiary or to the beneficiary’s bank account will be considered income to the beneficiary in the month in which the distribution is made. Direct distributions must be reported and may result in loss of coverage for Medicaid- only beneficiaries or reduction and possible loss of SSI benefits.

History: Revised eff. 06/01/2024; Revised eff. 11/01/2014.

Rule 5.17: Income Trusts

A. The purpose of an Income Trust is to allow an individual with excess income who has exhausted all available resources to become eligible for Medicaid. The trust may be used only for income belonging to the individual. No resources (assets) may be used to establish or augment the trust. Inclusion of resources voids the trust exception. It is intended to assist individuals with excess recurring monthly income who have income that exceeds the Medicaid institutional limit in effect at the time eligibility is requested but have insufficient income to pay the private cost of institutional care. Individuals with income above the private pay rate for the facility in which the individual resides will not be eligible for Medicaid under the Income Trust provision.

B. This type of trust established for the benefit of the individual is limited to institutionalized individuals, not those in an acute care hospital setting. Persons participating in the home and community-based services (HCBS) waiver may also utilize an Income Trust for eligibility purposes.

C. An Income Trust must meet all the following requirements:

1. The trust is composed only of the pension(s), Social Security, and other income due the individual from all sources, including accumulated interest in the trust. Total income does not include income that is not countable under Medicaid rules, such as payments from the Veterans’ Administration for Aid and Attendance (A&A) and payments for unreimbursed medical expenses.

2. Income Trusts, once accepted by the Division of Medicaid, cannot be modified without the Division of Medicaid’s approval. An Income Trust must specify that the trust will terminate at the individual’s death, when Medicaid eligibility is terminated, when the trust is no longer necessary or in the event the trust is otherwise terminated. Trusts may need to be terminated prior to an individual’s death due to changes in the individual’s income or changes in Medicaid policy regarding how certain income must be counted or in the event the individual is discharged from the nursing facility.

3. A portion of the individual’s income may be protected in the month of entry into a nursing facility. When income protection is applicable, there is no cost of care payable to the nursing facility for beneficiaries whose income is less than the institutional income

limit. However, income above the amount that is one dollar ($1.00) less than the Medicaid institutional limit is payable to the Division of Medicaid for beneficiaries eligible under an Income Trust within thirty (30) days after receipt of the notice approving eligibility issued by the Division of Medicaid. The approval notice informs the Trustee of the amount payable for the month of entry.

4. For all subsequent month(s), if income of the individual is less than the individual’s cost of care at the nursing facility, all income of the individual, less authorized deductions, must be paid directly to the nursing facility. In that case no funds will be retained in the trust. If the income of the individual exceeds the cost of care at the nursing facility in any month the individual is eligible under an Income Trust, the trust must retain the income in excess of the cost of care until such time that payment of the accumulated Income Trust fund is requested by the Division of Medicaid.

5. Income Trusts for HCBS Waiver enrollees require that the trust must distribute to the individual, or for his/her benefit, an amount equal to not more than one dollar ($1.00) less than the then current Medicaid income limit as approved by the Division of Medicaid. The trust should not specify the amount of the individual’s income as this amount may change each year and the amount to be released from the trust will change to an amount equal to one dollar ($1.00) less than the current Medicaid income limit.

6. At the dissolution or termination of an Income Trust, the death of the individual, loss of the individual's Medicaid eligibility or in the event that the individual's income no longer exceeds the current Medicaid income limits, the trust agreement must provide that all amounts remaining in the trust up to an amount equal to the total medical assistance paid by the Division of Medicaid on behalf of the individual that has not previously been repaid will be paid to the Division of Medicaid.

7. The trust agreement must provide that at the time of each review of the individual's Medicaid eligibility (at least annually) while this trust is in existence, when notified by the Division of Medicaid, the Trustee must pay to the Division of Medicaid the amount that should be accumulated in the trust up to the amount expended by the Division of Medicaid on behalf of the individual that has not previously been repaid. Failure to make the requested payments will result in the loss of Medicaid eligibility for the individual.

8. The trust agreement must provide for an accounting of all receipts and disbursements of the trust during the prior calendar year when requested by the Division of Medicaid.

9. No fees are allowed to be paid to the Trustee for their service. In the event funds are retained in the trust, administrative fees are limited to ten dollars ($10.00) per month and are intended to cover any bank charges required to maintain the trust account.

10. Any disbursements not approved by the Division of Medicaid or provided for by the trust agreement will result in a loss of the trust exemption.

11. The trust agreement must specify an effective date. Unless the applicant is requesting retroactive eligibility of up to ninety (90) days, which will require that the applicant have the funds necessary to fund the trust for that period, the effective date will be the date of execution. If a retroactive date is being sought, the effective date will be determined through consultation with the Division of Medicaid's Regional Office. In that case the Regional Office should be consulted to determine the effective date prior to execution of the agreement.

D. An Income Trust will not be allowed on a temporary or intermittent basis except in instances when monthly excess income will be reduced at a future date. In such a case, an Income Trust will be allowed until such time as the excess monthly income no longer requires an Income Trust to allow eligibility. Income received less than monthly does not qualify as recurring excess monthly income that allows the use of an Income Trust. Income received irregularly or infrequently must be converted to monthly income before evaluating the need for an Income Trust.

E. The Division of Medicaid will provide model Income Trust agreements for individuals in need of an Income Trust. Model agreements are provided for individuals in institutional care and for individuals enrolled in an HCBS waiver that need an Income Trust in order to qualify for Medicaid based on income. The only changes to these legally binding documents that the Division of Medicaid will accept are to add language regarding a successor trustee or co- trustee. Changes must be approved by the Division of Medicaid prior to execution of the trust. In completing the Income Trust document, the individual cannot be the Trustee of the Income Trust.

F. It is possible to have an Income Trust during the time a transfer of assets penalty is in effect. Although the Division of Medicaid will not pay for an individual’s room and board during a transfer penalty period, the Income Trust will allow an individual with excess income who otherwise requires an Income Trust in order to be eligible to qualify for all Medicaid covered services other than payment of room and board and will allow the penalty period to be implemented.

G. An applicant or beneficiary requiring an Income Trust who has a court appointed conservator must furnish a copy of the Chancery Court Order authorizing the conservator to establish the Income Trust. The court must be made aware of the Income Trust requirement to pay the Division of Medicaid any accumulated trust funds up to an amount expended by the Division of Medicaid under the terms of the trust.

History: Revised to correspond to SPA 16-0009 (eff. 01/01/2016) eff. 01/01/2017; Revised eff. 11/01/2014.

History

• Source: 42 U.S.C. § 1396p(d)(4).
• Source: 42 U.S.C. §1396p(d)(4); Social Security Act §1614(a).
• Source: 42 U.S.C. §1396p(d); Miss. Code Ann. § 43-13-121.
• Source: 42 U.S.C. § 1396p; Miss. Code Ann. § 43-13-121.

Chapter 8 Medicaid Qualifying Trusts (MQT)

23 Miss. Admin. Code Pt. 103, R. 8.1 Treatment of Medicaid Qualifying Trusts (MQT)

A. The provisions in this section are applicable to any trust or similar legal device established on or after March 1, 1987, through August 10, 1993, that meet MQT criteria. If MQT criteria are not met, defer to Standard Trust policy.

1. A Medicaid Qualifying Trust is a trust or similar device, which:

a) Is established (other than by will) with the applicant/recipient’s own funds, by the applicant/recipient (or spouse);

b) Names the applicant/recipient as the trust beneficiary for all or part of the payments from the trus; and

c) Permits the trustee to exercise any discretion with respect to the distribution of such payments to the individual.

2. The MQT provision is applied without regard to whether or not:

a) The MQT is revocable or irrevocable; or

b) The MQT is established for purposes other than to qualify for Medicaid; or

c) The discretion of the trustee is actually exercised.

3. In determining whether an MQT exists, look for 3 main components:

a) The grantor is the Medicaid client or his representative (e.g., spouse, parent, guardian, conservator or anyone holding power of attorney for the client);

b) The trust was established with property belonging to the client; and

c) The client is at least one of the beneficiaries of the trust.

4. In addition, the following principles must be considered:

a) The client is considered the grantor even if the trust was established pursuant to court order issued upon the petition of the client or his representative. In this situation, the court acts as the client’s agent in establishing the trust.

b) It is not necessary that there be a trust agreement, as defined by state law, for MQT trust policies to apply. MQT trust policies apply to “similar legal devices” or arrangements having all of the characteristics of an MQT, except there is no actual trust instrument.

1. Examples are:

(a) Escrow accounts;

(b) Savings accounts;

(c) Pension funds;

(d) Annuities;

(e) Investment accounts; and

(f) Other accounts managed by agent with fiduciary obligations, such as conservatorships or guardianships.

c) The MQT provision does not apply to trust agreements established by will. These trusts are treated as standard trusts. However, if a client inherits resources and in turn establishes a trust, the MQT provision could apply.

5. Each trust document must be reviewed individually to determine the resource treatment of the trust, but in general use the following criteria to determine resource treatment:

a) Revocable MQT.

1. The entire corpus of the trust is an available resource to the client. Resources comprising the corpus are subject to individual resource exclusions, if applicable, since the client can access these resources. An exception is exclusion of the home

for institutionalized recipients. Home property loses its excluded status when transferred into an MQT.

b) Irrevocable MQT.

1. The countable amount of the corpus is the maximum amount the trustee can disburse to (or for the benefit of) the client, using his full discretionary power under the terms of the trust. Resources transferred to an irrevocable MQT lose individual resource consideration.

(a) Example: Home property transferred to such a trust can no longer be excluded as home property but is included in the value of the corpus.

2. If the trustee has unrestricted access to the corpus and has discretionary power to disburse the entire corpus to the client (or to use it for the client’s benefit), then the entire corpus is an available resource to the client.

3. If the trust does not specify an amount for distribution from the corpus of the trust or from income produced by the corpus, but the trustee has access to and use of both corpus and income, the entire amount is an available resource to the client.

4. If the trust permits a specified amount of trust income to be distributed to the client (or to be used for his benefit), but these distributions are not made, then client’s countable resources increase cumulatively by the undistributed amount.

6. In general use the following criteria to determine treatment of income from an MQT:

a) Amounts of trust income distributed to the client are counted as income when distributed.

b) Amounts of trust income distributed to third parties for the client’s benefit (including payments for medical services) are countable income when distributed.

c) Exculpatory Clauses which limit the authority of the trustee to distribute funds from a trust if such distribution would jeopardize eligibility for government programs are ignored for MQT purposes if the language explicitly or implicitly links the trustee’s discretion to Medicaid requirements.

7. Handle a transfer of assets under this policy as follows:

a) If the MQT is irrevocable, a transfer of assets has occurred if the resources are no longer available to the client.

1. Resources rendered unavailable are subject to the transfer penalty based on the value of the unavailable resources without consideration of whether the resource would have been excluded under ongoing policy.

8. The MQT provision may be waived if an undue hardship is determined to exist: .

a) This means Medicaid should not be denied to an individual under this provision if the individual would be forced to go without life-sustaining services because the trust funds cannot be released.

1. This does not include situations where the trustee simple chooses not to make the trust funds available.

History

• Source: Social Security Act §1917(c); Medicare Catastrophic Coverage Act (MCCA) of 1988 (P.L. 100-360).

Chapter 10 Conservatorships Prior to 3/1/1987

23 Miss. Admin. Code Pt. 103, R. 10.1 Treatment of Conservatorships Prior to 03/01/1987

A. Conservators and legal guardians are court appointed and are usually court controlled. These types of legal arrangements are initiated when the competence of an individual is at issue. Technically, a legal guardian is appointed to serve over an individual and the individual’s resources, whereas a conservator is appointed only to handle an individual’s resources. Regardless of the legal term used, an application or active case involving a conservator or legal guardian is handled as outlined below.

1. In the absence of evidence to the contrary, conserved liquid and non-liquid resources held by a guardian or conservator on behalf of a Medicaid applicant or recipient are countable resources to that client.

a) The fact that the guardian/conservator manages and controls the funds, (e.g., makes the actual (withdrawals), does not alter the attribution of the resource to the client. Since the guardian/conservator legally acts on behalf of the incompetent individual, it is the same as if the individual is controlling or managing the resource.

b) “Evidence to the contrary” that may indicate a client does not have total access to conserved resources held by a guardian or conservator is a court order which specifies the disbursement of funds and/or disposal of assets.

1. If the court order or decree specifies the amount and frequency of funds which may be disbursed or restricts the disposal of resources, the court’s decision in such matters determines the client’s access.

2. However, a “silent” court order, which does not specify disposition and/or availability of conserved resources, is not considered evidence to the contrary. Therefore, conserved funds controlled by a silent court order are considered available to the client.

2. The fact that a guardian/conservator must first petition the court in order to dispose of resources or disburse funds does not constitute “evidence to the contrary”.

a) State law requires such a petition in guardian/conservator cases making petitioning a standard practice.

b) In all cases where petitioning is required, the conserved resources are considered available to the client unless or until the court is petitioned and rules as to the availability/disposition of assets.

c) When a signed and dated petition is presented as evidence that a court has been petitioned for disbursement of funds and/or disposal of resources, the petition is sufficient to exclude the resources in question until the court renders a decision in the matter.

3. Eligibility Determinations Involving Conservatorship.

a) To determine how to handle a case involving a legal guardian or conservator, it is necessary to obtain a copy of the original decree appointing an individual as guardian or conservator and any legal documents which may subsequently have been issued by the court to amend or change the original decree, if any. If a guardianship or conservatorship is in the process of being established, the client’s resources are considered available until court documents are presented as outlined below:

1. If the court order specifies disbursement of funds, any payments made to or on behalf of the client count as unearned income to the client.

2. If the court order does not specify the disbursement of any non-liquid resources conserved by the court, consider the funds as a countable resource.

3. If the court order specifies that conserved non-liquid resources, such as property, may be disposed of for the benefit of the client, consider the property, etc., as a countable resource.

4. If the court order is silent on the subject of disposal of non-liquid resources, consider the resources countable unless or until the court is petitioned for disposal.

5. A court order may specify the disbursement of liquid resources and not mention disposal of any conserved non-liquid resources or vice versa.

(a) In such a case, abide by the court’s decision regarding the disbursement or disposal issue specified and count as a resource the unspecified resource.

(i) Example: A conservatorship court order specifies the release of $100 per month from a savings account with a $5000 balance and fails to mention the disposal of 50 acres of property owned by the client. The $100 is counted as income while the balance of the account is excluded as a

resource. The property is countable until the court is petitioned for the purpose of disposing of the property.

6. Court orders that are not specific on the availability of conserved resources result in the availability of the conserved resource to the client until the month the court is petitioned for use of the conserved funds or resources.

(a) A valid petition will exclude the resource provided the petition requests the court to rule as to the disposal and/or disbursement of conserved resources. The exclusion will apply until the court rules in the matter at which time the case must be reviewed in light of the court decision.

History

• Source: 42 CFR § 435.601(b) (Rev 1994); CMS Transmittal 64, State Medicaid Manual §3257-3259.

Chapter 12 Encumbrance of a Liquid Resource

23 Miss. Admin. Code Pt. 103, R. 12.1 Treatment of the Encumbrance of a Liquid Resource

A. An encumbrance is defined as a legal obligation to pay a debt.

1. If an applicant/recipient’s combined resources exceed the resource limit, the amount of any encumbrances is deducted from the Current Market Value (CMV) to determine the equity value of a resource.

2. The equity value is countable toward the resource limit.

B. Under SSI policy, an encumbrance may occur when the applicant/recipient in an SSI-related coverage group has alleged a check has been written from a bank account, and it has not yet cleared the bank. If the individual has alleged a check has been written from a bank account and it has not cleared:

1. Examine evidence that the check was written, therefore legally obligating the funds from the bank account.

2. Verification must be obtained before allowing a reduced equity value of the bank account. Once verification, is received, the equity value of the bank account can be established by deducting the amount of the check written.

3. Verifications needed are a paid receipt, cancelled check, etc.

a) Example: Mr. Timmons’ bank statement shows a checking account balance of $1,250 as of May 1, which combined with other countable resources, exceeds $2000 as of the first day of the month. Mr. Timmons alleges that the balance includes his rent check of $500 which he wrote and gave to the landlord on April 25, but his landlord has not yet cashed the check.

The specialist examines Mr. Timmons’ check register and finds an annotation for check number 1345 written on 4/25 for $500. He also notes that check 1346 has already cleared the bank and has been deducted from his account according to the bank statement. Next the specialist notes Mr. Timmons has written a $500 check to his landlord for rent on or around the 25 th of each month for the last six months.

Since there is evidence that Mr. Timmons has written the check and legally obligated those funds in his account, and his records provide a complete and consistent picture of the account, the specialist can deduct the amount of the uncashed check from the 5/1 first of the month balance. The uncashed check can be deducted because SSI equity value rules state that in determining equity value, we deduct encumbrances from the CMV. The new balance of $850 permits eligibility on resources.

C. Under liberalized resource policy, an encumbrance may occur when the applicant/recipient has alleged a check has been written from a bank account, and it has not yet cleared the bank. If the individual has alleged a check has been written from a bank account and it has not cleared:

1. Examine evidence that the check was written, therefore legally obligating the funds from the bank account.

2. Verification must be obtained before allowing a reduced equity value of the bank account. Once verification, is received, the equity value of the bank account can be established by deducting the amount of the check written.

3. Verifications needed are a paid receipt, cancelled check, etc.

a) Example: Mr. Jon Doe applied for Medicaid on January 4. As of January 31, Mr. Doe’s bank statement shows a checking account balance of $2,350, which combined with other countable resources, exceeds $4000. Mr. Doe alleges that the balance includes his rent check of $500 which he wrote and gave to the landlord on January 22, but his landlord has not yet cashed the check.

b) The specialist examines Mr. Doe’s check register and finds an annotation for check number 1345 written on January 22 for $500. Since there is evidence Mr. Doe has written the check from the account, the specialist can deduct the amount of the uncashed check since it is an encumbrance.

c) In determining equity value of the bank account, the encumbrance of $500 is deducted from the $2,350 in the bank account. Eligibility can be established for Mr. Doe for January if he is otherwise eligible.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

Chapter 13 Resource Spenddown (Liberalized Policy)

23 Miss. Admin. Code Pt. 103, R. 13.1 Treatment of Resource Spenddown Under Liberalized Policy

A. Effective October 1, 1989, eligibility can exist for an entire month when an individual or couple, subject to liberalized resource policy, meets the resource test during the month.

B. The applicant is allowed to “spenddown” resources in a month to become eligible for that month.

C. Under the liberalized spenddown provisions, resources can be reduced within the applicable limit and as long as resources remain within the limit for that month, eligibility can be established. The following are considered in making the determination:

1. Do not allow payment of expenses that will be returned, refunded or reimbursed as legitimate spenddown expenses when calculating resources for a given month. Client- owned resources spent for reimbursable expenses count as an available resource in the month paid.

2. Allow outstanding checks/payments as an expense if proof is provided that the payment was authorized during the spenddown month and the expense is non- reimbursable.

3. The spenddown provision implies that an individual spends down to the resource limit and remains at or below the limit for the remainder of the month. When determining eligibility for a prior period and reviewing the resource situation for a full month, the individual or couple must have depleted resources to acceptable level and remained eligible for that month for a true spenddown to have occurred.

a) Example: An individual had $5,000 in a bank account on the first of the month and spent $3,000 on a pre-paid burial contract on the 5 th of the month. However, on the

th , he sold his car, which was excluded as a resource for $2,500. The $2,500 then becomes a resource (conversion of a resource) in the same month and unless the individual spends the excess $2,500 by the end of the month, eligibility cannot be established for that month.

D. Under liberalized resource policy, if excess liquid resources are earmarked for payment of private pay expenses for month(s) prior to a month of Medicaid eligibility, these excess resources can be excluded as a resource for any potential Medicaid months since the funds are obligated. If Medicaid will cover any months that have been paid as private pay by the client, the amount subject to reimbursement is a resource in the month paid.

1. Example: A LTC applicant enters a nursing home in June and applies for Medicaid in August. The applicant’s bank account is $6,000, but $4,500 is earmarked for private pay for June/July. Medicaid is needed for August 1. Since the $4,500 is obligated for months prior to Medicaid eligibility, it can be excluded as a resource in determining eligibility for

August forward, provided the earmarked funds are used to pay for the intended private pay expenses.

E. Under liberalized resource policy, income that accumulates while a Medicaid application is in process and that is obligated for payment of Medicaid income for months that will be covered by Medicaid can be excluded as a resource if excess resources result from accumulating income.

1. Example: A LTC applicant enters a nursing home in August and applies for Medicaid in October requesting benefits retroactive to August. The client’s income is $1,200 per month. In November when the case is being worked up, the bank balance is $5,000. Medicaid Income for September and October would be $2,312 ($1,200 - $44 = $1,156 x 2).

2. November’s income of $1,200 can be backed out of the balance plus the $2,312 obligated for September and October Medicaid Income, thus leaving $1,488 as a countable resource for November.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

Chapter 14 Deeming of Resources

23 Miss. Admin. Code Pt. 103, R. 14.1 Treatment of Resource Deeming

A. For SSI and Medicaid purposes, an individual’s resources are deemed to include any resources of an ineligible spouse or ineligible parent(s).

1. Resources are deemed whether or not they are actually available.

2. Deeming only applies in household situations, i.e., it only applies to an eligible with an ineligible spouse or parent(s).

a) In deeming resources from one spouse to the other, consider only the resources of those two individuals.

b) In deeming resources from a parent to a child, consider only the resources of the parent.

c) Where there is more than one eligible child, the resources available for deeming are shared equally among the children.

1. Eample: If there are two eligible children and $500 in parental resources must be deemed, deem $250 to each child.

d) Do not include the resources of a stepparent who is not legally liable for support of the child under state law in the deeming process.

B. Effective September 1, 1987, pension funds owned by an ineligible spouse or parent(s) are excluded from resources for deeming purposes.

1. This exclusion applies in order for an ineligible spouse or parent(s) to provide for their own future support.

2. Pension funds are defined as monies held in a retirement fund under a plan administered by an employer or union, or an individual retirement account (IRA) or Keogh account as described by Internal Revenue Code.

C. When deeming spouse to spouse:

1. The ineligible spouse’s resources must be verified and documented as required for the eligible spouse.

2. Total countable resources are the combination of the resources of the eligible individual and ineligible spouse after all applicable resource exclusions are applied.

3. Total countable resources are compared to the resource limit for a couple.

4. If the amount of the resources does not exceed the limit, the applicant/recipient meets the resource eligibility requirement.

5. If countable resources exceed the limit for a couple, the applicant/recipient is ineligible.

6. Eligible Spouses Not Living Together.

a) If an eligible individual and eligible spouse are not living together, the resources of both members (whether owned separately by each or jointly by both) are combined only for the month of separation.

b) Each member of the couple is treated as an eligible individual beginning with the month after the month of separation, i.e., no longer living in the same household, and the resource limit for each is the individual resource limit.

7. When a change occurs in marital status, a new resource limit is established and a new resource determination is made for the first month in which the new resource limit (individual or couple) is effective as a result of the change.

a) Make a new resource determination for the first month in which a new resource limit (individual or couple) is effective as a result of the change in marital status.

1. Example: If two eligible individuals marry in February, a new resource determination would be required for March since the individuals became a couple effective on the first day of March as a result of the marriage. For SSI or

Medicaid purposes, the marital relationship of a couple can be ended by death, divorce or annulment:

(a) If a marriage ends by death, divorce or annulment in the same month the marriage begins, treat the marriage as though it had not occurred.

(b) Beginning with the month following the month of the death of one member of a couple, the surviving member will be an eligible individual if all other eligibility criteria are met. (c) If the marital relationship of a couple terminates by divorce or annulment, each member of the couple should be treated as an individual effective the first day of the month following the month the couple no longer lives in the same household.

D. When deeming from Parent to Child to determine elgibility for a child under age 18 (or under 21, if a student), who lives with his parent(s):

1. The resources of the child include the value of the countable resources of the parent(s) or parent/stepparent to the extent that the resources of the parent(s) or parent/stepparent exceed the resource limit of:

a) An individual, if one parent lives in the household; or

b) A couple, if two parents live in the household.

2. The following should be considered:

a) Do not include the resources of the stepparent in the deeming process.

b) The value of parental resources is subject to deeming whether or not those resources are available to the child.

c) If there is more than one eligible child under 18 or (under 21, if a student) in the household, equally divide the value of the deemed resources among those children.

1. If an eligible child is later determined ineligible for any reason or is no longer subject to deeming (e.g., after attainment of age 18), divide the value of the deemed resources among the remaining eligible children effective with the first month the child is ineligible or no longer subject to deeming.

3. A child’s total countable resources are the combination of the value of the deemed resources and the non-excluded resources of the child. A child’s countable resources are compared with the resource limit for an individual with no spouse. If the resources do not exceed the limit, the child meets the resource eligibility requirement. If countable resources exceed the limit, the child is ineligible because of the excess resources.

4. When more than one eligible individual lives in the same household and there is a parent- child relationship, a multiple deeming situation may exist:

a) If a child under age 18 (or under 21, if a student) lives in the same household with a parent(s) applying for Medicaid or an eligible parent(s), determine the countable resources of the parent(s).

b) If the parent(s) meets the resource eligibility requirement, do not deem the value of any parental resources to the child. c) If the parent(s) do not meet the resource eligibility requirements, follow the usual parent-to-child resource deeming rules to determine the value of the deemed parental resources.

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994).

Chapter 15 General Verification Requirements

23 Miss. Admin. Code Pt. 103, R. 15.1 General Verification Requirements

A. Generally, resources must be verified for any month for which you must determine eligibility. For the following types of action, verify as follows:

1. Applications.

a) Specifically, for initial applications, verify the value of resources for the month of application and each month(s) of possible retroactive eligibility. Verify months subsequent to the month of application as necessary.

2. Redeterminations.

a) For redeterminations, verify, as needed, the value of resources for up to 3 months prior to the review month. It is permissible for resources to be developed as of the most recent month for which verification is available for regular reviews, rather than requiring resource balances for the review month.

3. Appeals.

a) If a client appeals a denial related to a particular resource, the evidence in the file must clearly establish the value of that resource. If must do so even if the issue under appeal is not the value itself (e.g., when the issue under appeal is ownership). This requirement ensures that at each level in the appeals process, the file contains complete documentation of the resource in question.

B. There are some exceptions to the above. Do not verify the value of resources for a given month if:

1. The resource is totally excluded, regardless of its value;

2. The alleged value of total countable resources exceed the applicable limit for that month; or

3. The individual is ineligible that month for reasons other than excess resources

C. Develop the equity value of a resource (liquid or nonliquid) when an individual alleges a debt against it and the difference between equity and CMV could mean the difference between eligibility and ineligibility:

1. Verify, at a minimum, the outstanding principal balance (payoff), the rate of interest and the schedule and amount of payments (to permit the projection of increases in equity); and

2. Obtain a copy of the agreement or note that establishes the debt. If this does not provide all the information needed, use other records of the individual, the creditor or both.

D. At a minimum, resources owned by a client are verified at the time of application and at each regular review scheduled annually. However, circumstances may warrant re- verification of resource(s) at shorter intervals. The following describes situations which mandate re-verification of resources at shorter intervals than annually, but it is not an all- inclusive list. Any reported changes in resources or discovery of changes in resources may warrant verification or re-verification.

1. Individuals/couples determined eligible for Medicaid who own countable resources valued within $100 of the applicable limit must have resources renewed/verified every six months, rather than annually.

a) The purpose of the 6-month special review will be to verify the value of countable resources in order to determine if the individual/couple remains eligible based on resources.

b) A tickler must be utilized to control the timing of the required special review of cases with countable resources close to the resource limit.

2. Client cases, especially long term care cases that receive excess VA income that is not countable as income must be monitored closely for excess resources.

a) The amount of the monthly income that is not counted will determine the frequency review/re-verification is deemed necessary.

b) Long Term Care Recipients in Medicare Beds. Individuals who are placed in Medicare-certified nursing facilities are not required to pay any of their income toward the cost of their care which means that income may be allowed to accumulate

and result in excess resources during the first 100 days of possible Medicare coverage.

This means it is necessary to re-verify resources during the period of Medicare coverage to check for possible excess resources.

§43-13-121.1 (Rev. 2005).

History

• Source: Social Security Act §1902 (r)(2); 42 CFR § 435.601(b) (Rev 1994); Miss. Code Ann.

Part 104 Income

Chapter 13 Income That Counts Under IRS Rules – Modified Adjusted Gross Income (MAGI) Programs

23 Miss. Admin. Code Pt. 104, R. 13.1 – Income That Counts

A. The following is not an exhaustive list of the types of income that counts but is meant to cover the types most commonly encountered If not addressed herein, Internal Revenue Service (IRS) tax rules provide the governing policy.

1. Employee Compensation includes all things received in payment for personal services, such as wages, salaries, commissions, fees, bonuses, tips, severance pay, sick pay paid by an employer while out on sick leave and backpay awards. Employment income that counts is the gross income prior to any payroll deductions.

2. Volunteer Income. The treatment of income received as a volunteer is as follows:

a) Peace Corp – living allowances paid to the volunteer for housing, utilities, supplies, food and clothing are not counted as income. Countable wages include allowances paid to a spouse and minor children while the volunteer is a volunteer leader training in the U.S.; living allowances designated as basic compensation; leave allowances and readjustment allowances.

b) VISTA (Volunteers in Service to America) – meal and lodging allowances paid to the volunteer are counted as wages.

c) AmeriCorps education awards and living allowances are countable income.

d) National Senior Service Corps programs, include the RSVP or Retired Senior Volunteer Program, Foster Grandparent Program, and Senior Companion

Program. Income received for supportive services or reimbursements for out- of-pocket expenses are not counted as income.

3. Military Pay – payments received as a member of a military service are wages. Military retirement benefits are treated as pensions. Allowances, such as a basic allowance for housing or subsistence, are generally not taxable income and do not count as income.

4. Self-Employment – for IRS purposes, an individual is considered to be self-employed if the individual has a trade or business as a sole proprietor, an independent contractor, is a member of a partnership that carries on a trade or business or is otherwise in business for himself/herself, including a part-time business. Self-employment is business income less allowable business expenses that results in a net profit or loss. Net profit counts as income. Annualize the income to arrive at a monthly countable amount provided the business has been in existence for a twelve (12) month period. Annualize even if the income is received over a short period of time during the year unless the business is designed to be seasonal, such as a summer business that operates only three (3) months out of the year. Such business income would be averaged over the period of time the business covers. If a business has been in existence less than a full taxable year, average over the period of time the business has been in existence.

a) Partnership income – each partner’s distributive share of profit counts as self- employment income which is annualized.

5. Rental Income – countable income includes the net proceeds after allowing all IRS allowed deductions for rental income.

6. Farm Income – farm income that counts is the net earnings or profit that remains after allowing all IRS allowed business expenses involved in raising livestock, poultry or fish or from the growing of fruits or vegetables. Farm income is annualized or averaged over the time the farming business operates, as appropriate.

7. Royalties from copyrights, patents and oil, gas and mineral properties are taxable income and therefore countable.

8. Unemployment Compensation – all unemployment compensation benefits are countable as income.

9. Retirement, Survivors and Disability Insurance (RSDI) or benefits paid by the Social Security Administration are only partially taxable as income under certain conditions but are fully countable as income for insurance affordability programs.

10. Alimony payments received from divorce or separation agreements finalized on or before December 31, 2018, are countable as income to the divorced or separated spouse receiving the payment. Alimony payments received from divorce or separation agreements finalized after December 31, 2018, are not countable income.

11. Annuities – payments from annuities are countable as income.

12. Pensions and Retirement benefits are countable as income, including pensions paid by any private, municipal, county, state or federal plan.

13. Estate and trust income is countable income when distributed or when it should have been distributed, regardless of whether it was actually distributed.

14. Gambling, Lotteries and Raffle Winnings – cash winnings are countable income in the month received. Lottery and gambling winnings of eighty thousand dollars ($80,000) or greater that require lump sum winnings are not only counted as unearned income in the month received, but for the person receiving the lump sum (the winner), it is counted as income up to one hundred and twenty (120) months, depending on the amount of the winnings. The only person potentially impacted beyond the month of receipt of lump sum is the lottery or gambling winner. Otherwise, a lump sum received under this provision continues to count in month of receipt only for household members.

15. Jury duty pay is countable as income.

16. Alternative trade adjustment assistance (ATAA) payments received from a state agency under the Demonstration Project for Alternative Trade Adjustment Assistance for Older Workers is countable as income.

17. Interest income, including tax-exempt interest, is countable under MAGI rules.

18. Disability benefits received through an accident or health insurance plan – the IRS rules for counting such benefits are as follows:

a) If both the individual and the employer paid the premiums for the plan, only the amount received for disability that is due to the employer’s payments is countable as income,

b) If the individual paid the entire cost of the plan, the payments are not countable as income,

c) If the premiums of a plan were paid through a cafeteria plan and the amount of the premium was not taxable income to the individual, the premiums are considered paid by the employer and the disability payments are countable as income.

History: Revised eff. 05/01/2026.

History

• Source: 42 C.F.R. § 435.603 (Rev. 2012).

Chapter 14 Verification of Income – MAGI Programs

23 Miss. Admin. Code Pt. 104, R. 14.1 – Verification Requirements

A. The ACA mandates that states rely heavily on electronic data sources to verify income. Data sources include IRS tax return data for households that file taxes, the Social Security Administration (SSA) for benefits paid through SSA and state data sources such as the MS Department of Employment Security for wage and unemployment compensation verification. Other available state and federal data sources may be used as appropriate. B. Self-attested income reported on the application form must be compared to income verified through electronic data sources to determine if the various sources are reasonably compatible and allow a decision regarding eligibility or ineligibility for Medicaid, CHIP or other insurance affordability programs.

23 Miss. Admin. Code Pt. 104, R. 14.2 – Reasonable Compatibility Rules

A. Income verified from electronic data sources that is reasonably compatible with self-attested income allows a Medicaid or Children’s Health Insurance Program (CHIP) decision regarding eligibility without requesting paper verification from the applicant.

B. The first test of reasonable compatibility for income is the comparison of income reported from the Mississippi Department of Human Services Supplemental Nutrition Assistance Program (SNAP) program against income declared or self-attested on the application form. If both sources are at or below the appropriate Medicaid income limit for the household size, Medicaid approval is allowed for individuals in the household who otherwise qualify for Medicaid. If both sources are above the Medicaid limit, Medicaid is denied but CHIP eligibility for children in the household will be assessed and adults in the household will referred to the Federal Market Place as appropriate.

C. Discrepancies in income that result from comparing income from SNAP to self-attested income will result in a hierarchy of attempts to resolve the discrepancy prior to requesting that the applicant provide paper verification. Attempts include the comparison of income to a state- established threshold that would allow a decision and/or pending the decision awaiting secondary data sources to arrive for comparison purposes. A written request for paper verification will be requested only when:

1. The applicant fails to provide a reasonable explanation for the discrepancy when contacted.

2. Efforts to contact the individual to discuss reasons for any discrepancy fail.

3. Reported income is not available for verification through an electronic data source.

History: Revised eff. 05/01/2026.

History

• Source: 42 C.F.R. § 435.945 (rev. 2012).

Part 105 Budgeting

Chapter 4 Modified Adjusted Gross Income (MAGI) Requirements

23 Miss. Admin. Code Pt. 105, R. 4.5 Modified Adjusted Gross Income (MAGI) Coverage Under the Family Planning Waiver

A. Family Planning services are provided under Section 1115 waiver authority, as outlined in Miss. Admin. Code Title 23, Part 221, Chapter 2. Modified Adjusted Gross Income (MAGI) budgeting methodology, as specified in the waiver, is used to determine eligibility for women and men applying for services, with exceptions for applicants under the age of nineteen (19) who are budgeted as a single person household with parental income disregarded.

B. Applicants for waiver participation use a designated family planning application form to apply. The effective date of eligibility under the waiver is the first (1 st )day of the month in which the short form is received by the agency.

C. If an applicant wants to be evaluated for full Medicaid or CHIP coverage, the single, streamlined MAGI application form is used.

History: New rule eff._01/01/2022.

Rule 4.6: Modified Adjusted Gross Income (MAGI) Budget Types

A. Modified Adjusted Gross Income (MAGI) households are constructed for each individual applying for or renewing coverage. Eligibility is determined at the individual level. Different households may exist within a single family, depending on each household member’s family and tax relationship to each other.

B. Tax filer’s households are determined as follows:

1. A tax filer’s household includes the tax filer, spouse and all dependents that the tax filer claims or plans to claim in the tax year for which eligibility is requested.

2. Spouses whose tax filing status is married filing jointly are considered one (1) household whether living together or separately.

3. Spouses whose tax filing status is married filing separately are considered one (1) household if living together. If living apart, each is treated as two (2) households.

a) A tax filer household in any other tax filing status includes the tax filer and all dependents that the tax filer claims.

b) A tax filer’s household income includes all countable MAGI income received by household members except the income of a tax dependent does not count unless the dependent is required to file a federal tax return.

4. A tax dependent’s household is the same as the tax filer’s household, with certain exceptions as described in Miss. Admin. Code, Title 23, Part 105, Rule 4.6.C.

a) If a tax dependent is married and living with his/her spouse, but claimed by a parent as a tax dependent, the tax dependent’s household includes the parent tax filer’s household plus the tax dependent’s spouse.

b) The spouse’s household would be limited to the two (2) spouses unless both spouses are claimed by their separate parent(s).

c) A tax dependent who is also a parent of child(ren) living in the household must have his/her income counted toward his/her child(ren), regardless of whether the tax dependent parent is required to file a tax return.

C. Exceptions to using tax filer rules apply in the following situations:

1. A tax dependent of any age who is not the tax filer’s spouse or child is treated as a non- filer described in Miss. Admin. Code, Title 23, Part 105, Rule 4.6.D.

2. A tax dependent under age nineteen (19) living with two (2) parents who do not expect to file a joint tax return is treated as a non-filer described in Miss. Admin. Code, Title 23, Part 105, Rule 4.6.D. This exception does not apply to children age nineteen (19) and over.

3. A tax dependent under age nineteen (19) claimed as a tax dependent by a non-custodial parent is treated as a non-filer, described in Miss. Admin. Code, Title 23, Part 105, Rule 4.6.D. The child is not a member of the custodial parent’s household even though the child physically resides in the home. The child’s income does not count in the custodial parent’s household income. This exception does not apply to children age nineteen (19) and over.

D. Non-Filer households are determined as follows:

1. A non-filer is someone who neither files a federal tax return nor is claimed as a tax dependent. For individuals who are non-filers or exceptions to tax filer rules, budgeting rules depend on whether the individual is an adult or child under age nineteen (19) living in the same household.

2. A non-filer adult’s household includes the non-filer, the non-filer’s spouse and his/her children under age nineteen (19) living together. Income includes all countable Modified Adjusted Gross Income (MAGI) income received by the household members except the income of a child not required to file a federal tax return does not count as income to the household. If a child is also a parent of child(ren) living in the household, the child’s income must be counted toward his/her child(ren) regardless of the requirement to file a federal tax return.

3. A non-filer child’s household includes the non-filer child and the child’s parent(s) and siblings under age nineteen (19) living together.

History: New rule eff. 01/01/2022.

History

• Source: 42 U.S.C. §§ 1315, 1396; Miss. Code Ann. §§ 43-13-115, 43-13-117, 43-13-121.
• Source: 42 C.F.R. § 435.603

Chapter 5 Requirements for Foster and Adoption Assistance Children

23 Miss. Admin. Code Pt. 105, R. 5.1 Children in the Custody of the Department of Child Protection Services (DCPS)

A. Children in the custody of the Department of Child Protection Services (DCPS) are eligible for Medicaid as follows:

1. Foster children for whom DCPS assumes full or partial financial responsibility are eligible for Medicaid if the child is placed in a licensed foster care home or appropriate institution and the child meets Modified Adjusted Gross Income (MAGI) state set income limits.

2. Foster and adoption assistance children receiving IV-E financial assistance are Medicaid eligible using IV-E income limits.

3. Children in adoptions subsidized in full or part by DCPS are Medicaid eligible using MAGI state-set income limits.

4. Children for whom there is no IV-E adoption assistance agreement in effect are eligible for Medicaid without an income test if the child cannot be placed for adoption without Medicaid coverage because of special needs for medical or rehabilitative care.

B. The Department of Child Protection Services has Medicaid certification responsibilities for foster children and adoption assistance children that meet the above stated criteria. If a foster child or adoption assistance child is not eligible through DCPS, a separate application for Medicaid is filed at the Medicaid Regional Office by the appropriate DCPS staff person or foster parent or adopted parent.

C. As outlined in Miss. Admin. Code, Title 23, Part 101, Rule 1.8, former foster care children who were on Medicaid and in foster care when they turned age eighteen (18) or aged out of foster care after age eighteen (18) are covered by Medicaid until the end of the month in which they turn age twenty-six (26). Prior to the Affordable Care Act (ACA), foster children who were in foster care upon turning age eighteen (18) were granted Medicaid eligibility to age twenty-one (21)

History: New rule eff. 01/01/2022.

History

• Source: 42 C.F.R. §§ 435.145, 435.150, 435.222, 435.226 and 435.227

Part 200 General Provider Information

23 Miss. Admin. Code Pt. 200 General Provider Information

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 200 General Provider Information

Table of Content

Table of Contents Title 23: Division of Medicaid ........................................................................................................ 1 Part 200: General Provider Information ...................................................................................... 1 Part 200 Chapter 1: General Administrative Rules for Providers .......................................... 1 Rule 1.1: Disclosure of Confidential Information ............................................................ 1 Rule 1.2: Access to Public Information ........................................................................... 2 Rule 1.3: Maintenance of Records .................................. Error! Bookmark not defined. Rule 1.4: Fundraising ....................................................................................................... 3 Rule 1.5: Limited English Proficiency Plan (LEP) .......................................................... 7 Rule 1.6: Timely Filing............................................................................7 Rule 1.7: Timely Processing of Claims.........................................................8 Rule 1.8: Administrative Reviews for Claims..................................................9 Rule 1.9: Authorized Provider Representative .................................................10 Rule 1.10: Electronic Signature ..................................................................10 Rule 1.11: Provider Claim Submission Signatures .............................................12 Rule 1.12: National Correct Coding Initiative (NCCI) Edits.................................13 Part 200 Chapter 2: Benefits ................................................................................................. 18 Rule 2.1: Medicaid Services........................................................................................... 18 Rule 2.2: Non-Covered Services .................................................................................... 16 Rule 2.3: Medicaid Cost Sharing for Medicare/Medicaid Dually Eligibles .................. 24 Part 200 Chapter 3: Beneficiary Information ........................................................................ 25 Rule 3.1: Eligibility Groups ........................................................................................... 22 Rule 3.2: Newborn Child Eligibility .............................................................................. 22 Rule 3.3: Beneficiary Retroactive Eligibility ................................................................. 22 Rule 3.4: Eligibility for Medicare and Medicaid ........................................................... 23

Rule 3.5: Verification of Eligibility ............................................................................... 29 Rule 3.6: Freedom of Choice of Providers ..................................................................... 29 Rule 3.7: Beneficiary Cost Sharing ................................................................................ 25 Rule 3.8: Charges Not Beneficiary’s Responsibility ..................................................... 30 Rule 3.9: Charges Beneficiary’s Responsibility ............................................................ 30 Part 200 Chapter 4: Provider Enrollment ............................................................................. 32 Rule 4.1: Definitions ...................................................................................................... 30 Rule 4.2: Conditions of Participation ............................................................................ 32 Rule 4.3: Change of Ownership ..................................................................................... 36 Rule 4.4: Effective Date of Provider Agreement and Provider Agreement Termination . ........................................................................................................................................ 38 Rule 4.5: Licensure Expiration....................................................................................... 39 Rule 4.6: Advertising by Provider................................................................................. 40 Rule 4.7: Change of Tax ID ........................................... Error! Bookmark not defined. Rule 4.8: Requirements for All Providers ...................................................................... 41 Rule 4.9: Group Providers .............................................................................................. 44 Rule 4.10: 340B Providers.......................................................................45 Part 200 Chapter 5: General ................................................................................................. 48 Rule 5.1: Medically Necessary...................................................................................... 48 Rule 5.2: Consent for Minors ........................................................................................ 55 Rule 5.3: Wellness Program .......................................................................................... 49 Rule 5.4: Tobacco Cessation ......................................................................................... 52 Rule 5.5: Mobile Medical Units Other Than Independent Diagnostic Treatment Facilities ......................................................................................................................... 52 Rule 5.6: Diabetes Self-Management Training (DSM).....................................54

Rule 5.7: Electronic Health Record and Electronic Signature.............................56

Part 200 Chapter 6: Indian Health Services ......................................................................... 57

Rule 6.1: Provision of Indian Health Services ............................................................... 57 Rule 6.2: Beneficiary Enrollment................................................................................... 58 Rule 6.3: Provider Enrollment/Participation Requirements ........................................... 58 Rule 6.4: Covered Services ............................................................................................ 58 Rule 6.5: Reimbursement ............................................................................................... 59 Rule 6.6: Cost-Sharing ................................................................................59

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Title 23: Division of Medicaid

Part 200: General Provider Information

Part 200 Chapter 1: General Administrative Rules for Providers

Rule 1.1: Disclosure of Confidential Information

A. Records and information acquired in the administration of any part of the Social Security Act are confidential and may be disclosed only under the conditions prescribed in rules and regulations of the Department of Health and Human Services (DHHS) or when authorized by the Secretary of Health and Human Services.

B. A provider may disclose records or information acquired under the Medicaid program only when:

1. The record or information is to be used in connection with a claim, or

2. To verify the utilization of Medicaid benefits; and

3. The disclosure is necessary for the proper performance of the duties of any employee of:

a) The Division of Medicaid,

b) Any public or private agency or organization under an agreement with Division of Medicaid in regard to meeting requirements of the Medicaid program,

c) The Attorney General Medicaid Fraud Control Unit,

d) A duly authorized legal hearing, or

e) Representative of the Secretary of Health and Human Services office.

C. If a beneficiary or beneficiary’s attorney requests medical records, billing information, etc., these records should be released in accordance with the Third Party Procedures described in Part 300, Chapter 7.

D. Providers that are utilizing collection and/or billing agencies should know that the Division of Medicaid and its fiscal agent cannot release information to these companies without a signed release from the Medicaid beneficiary. Information can only be furnished to:

1. The provider that provided the service to the Medicaid beneficiary, or

2. To a provider’s business agent, billing service, or accounting firm that regularly handles claims filing for the provider,

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a) If, and only if the company has a written agreement with the provider, and

b) Has a confidentiality agreement with the Division of Medicaid that is on file with the fiscal agent.

E. State law requires that any medical information concerning a Medicaid beneficiary that is released by a provider must contain the following information:

1. The person is a Medicaid beneficiary,

2. His/her Medicaid identification number, and

3. The bill has been paid by Medicaid or will be submitted to Medicaid.

Source: Miss. Code Ann. § 43-13-121; Social Security Act Section 1902(a)(7); Title XIX Social Security Act

Rule 1.2: Access to Public Information

A. Public access to records maintained by the Division of Medicaid is described in Section 25- 61-1 et seq. of the Mississippi Code of 1972, as amended. An exception to this public access for Medicaid purposes is beneficiary specific information which must be kept confidential in accordance with 42 CFR 431.300 through 431.307 as discussed in Chapter 200, Rule 1.1, and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, 45 CFR 160 and 164.

B. Provider manuals/bulletins and other Division of Medicaid information including the complete Medicaid Eligibility Manual, the Title XIX State Plan for the Mississippi Division of Medicaid and certain fee schedules are available for viewing and/or printing.

C. Records furnished to the Division of Medicaid by third parties that may contain trade secrets or confidential commercial or financial information will not be released until notice to the third party has been given. Such records will be released within a reasonable period of time, unless the third party has obtained a court order protecting the records as confidential. If the third party notifies the Division of Medicaid that it will seek a court order to protect the records as confidential, the Division of Medicaid will notify the requestor.

D. Any person seeking a public record pursuant to the Mississippi Public Records Act, Section 25-61-1, et seq., should make the request in writing. The written request should include the following information:

1. Name of requestor,

2. Address of requestor,

3. Other contact information, including telephone number and any e-mail address,

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4. Identification of the public records adequate for the public records officer or designee to locate, and

5. The date and time of day of the request.

Source: Miss. Code Ann. § 43-13-121; Miss. Code Ann. § 25-61-1; 42 CFR 431.300 – 431.307; HIPAA 45 CFR 160 and 164

Rule 1.3: Maintenance of Records

A. All professional, institutional, and contractual providers, who are currently participating or at any time in the past have participated, in the Medicaid program must:

1. Maintain all records substantiating services rendered and/or billed under the program, and

2. Upon request, make such records available to representatives of the Department of Health and Human Services (DHHS), the Centers for Medicare and Medicaid Services (CMS), the Division of Medicaid, or the Mississippi Medicaid Fraud Control Unit (MFCU) in substantiation of any and all claims.

B. The Division of Medicaid defines medical records as documentation supporting medical services which fully disclose the extent of services, care and supplies furnished to a beneficiary and support claims billed.

1. Medical records must be legible, appropriate, and correct. All entries within a medical record should be written legibly to ensure beneficiary safety and appropriate billing and/or reviewing.

2. All information contained within a medical record must be written, entered or otherwise compiled on appropriate provider documentation forms.

3. All entries within the medical record must be made without a space between entries.

4. All entries must be made in a permanent form and cannot be in pencil.

5. Corrective tape, corrective liquid, erasers or other obliteration methods cannot be used to remove or change information in the medical record.

6. A medical record is a legal document and illegal to tamper with or falsify.

7. Entry corrections in the medical record must be documented as follows.

a) Draw a single line through the error, to ensure the error entry is still legible.

b) Document the current date and time the error was lined through and initials of who

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lined out the entry.

c) Document the correct information as a new entry on the next available line or in the next available space including:

1. The date and time of the new entry,

2. The date and time the correct information occurred, and

3. The details of the correct information.

d) Do not use corrective tape, corrective liquid or other obliteration methods to change or erase any part of the medical record.

8. Late entries are defined as entries that are not completed in the same business day as the date of service and must be documented as follows:

a) Identify the new entry as a “late entry” in the medical record.

b) Document the current date and time when the late entry is actually being written in the medical record and not the date and time the event/incident actually occurred.

c) Document the late entry event/incident and refer to the date and time the event/incident actually occurred within the late entry.

d) Document information as soon as possible.

e) Do not use corrective tape, corrective liquid or other obliteration methods to change or erase any part of the medical record.

C. All current and former Medicaid providers must maintain auditable records that substantiate the payment of claims submitted to the Division of Medicaid.

1. The Division of Medicaid's staff must have immediate access to the provider’s physical service location, facilities, records, documents, books, prescriptions, invoices, radiographs, and any other records relating to licensure, medical care, and services rendered to beneficiaries, and billings/claims during regular business hours, defined as 8 a.m. to 5 p.m., Monday – Friday, and all other hours when employees of the provider are normally available and conducting business of the provider.

2. The Division of Medicaid's staff must have immediate access to any administrative, maintenance, and storage locations within, or separate from, the service location.

3. The Division of Medicaid does not reimburse providers for the provision of or access to records substantiating claims submitted to the Division of Medicaid.

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D. If a provider’s records do not substantiate services paid under the Mississippi Medicaid program the provider must refund to the Division of Medicaid any money received from the Medicaid program for such unsubstantiated services. If a refund is not received within thirty (30) days, a sum equal to the amount paid for such services will be deducted from any future payments that are deemed to be due the provider.

E. All current and former Medicaid providers must retain medical records for a minimum of five (5) years or longer as required by federal or state law.

1. All providers required to file a cost report must 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.

2. All providers not required to submit a cost report must keep and maintain books, documents, and other records as prescribed by the Division of Medicaid in substantiation of its claim for services rendered to Medicaid beneficiaries, for a period of five (5) years from the date of service or until after the date all audit findings are resolved, whichever is later.

3. Providers whose cost reports are selected for audit must keep and maintain books, documents and other records as prescribed by the Division of Medicaid in substantiation of its cost reports until such time as the audit and/or any related appeals are finalized.

4. Providers who are required to pay assessments must keep and preserve books and records as necessary to determine the amount of the assessments for which it is liable for no less than five (5) years.

5. Coordinated Care Organizations (CCOs) must keep and maintain books, documents and other records as prescribed by the Division of Medicaid for a period of no less than ten (10) years or until all issues are finally resolved whichever is later.

6. The Division of Medicaid is entitled to full recoupment of the amount paid to any provider of a medical service who has failed to keep or maintain records as required.

7. A provider who knowingly or willfully makes, or causes to be made, false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under federal and state criminal laws. A false attestation can result in civil and monetary penalties as well as fines, and may automatically disqualify the provider as a provider of Medicaid services.

Source: 42 C.F.R. § 422.504; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121, 43-13- 129, 43-13-145.

History: Revised eff. 04/01/2026; Revised eff. 08/01/2018.

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Rule 1.4: Fundraising

A. Fundraising may only be used to obtain funds needed to pay for medical/treatment costs not normally covered by the Mississippi Medicaid program. Such costs include, but are not limited to the following:

1. Transportation for family members,

2. Food and lodging for the beneficiary and family,

3. Child care,

4. Non-covered medical equipment, or

5. Non-covered medical services.

B. Fundraising Criteria:

1. Prior to accepting donations, arrangements must be made to place donations in a trust fund/ special account.

2. The trust fund/special account must be established/administered in compliance with all applicable federal and state rules/regulations.

3. The trust fund/special account must be managed/administered by someone other than the beneficiary or the beneficiary’s family member/legal guardian (i.e., the beneficiary or the beneficiary’s family member/legal guardian may not have direct access to the fund/account).

4. The trust fund/special account must be maintained separate from personal monies belonging to the beneficiary or the beneficiary’s family member/legal guardian (i.e., mixed funds could be counted as income or an asset which could result in a loss or reduction of Medicaid benefits).

5. Legible documentation on income and expenditures must be maintained and must be made available to the Division of Medicaid, the fiscal agent, and/or the UM/QIO upon request.

C. All sources of income must be reported to the source of eligibility. Donated funds for the purpose of payment of medical services are considered a third party source. Refer to Part 306.

D. Provider/facilities must adhere to conditions of participation as a Medicaid provider and cannot participate in fundraising for beneficiaries to raise additional funds to pay for Medicaid covered procedures and/or related services. Refer to Part 200, Chapter 4.

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Source: Miss. Code Ann. § 43-13-121

Rule 1.5: Limited English Proficiency Plan (LEP)

For Division of Medicaid purposes, this plan is established to define the mandated compliance requirements pertinent to the provision of services to individuals with limited English proficiency (LEP), established procedures for requisitioning forms in Spanish and Vietnamese, and for accessing and/or hiring and utilizing qualified interpreters. This rule provides provisions to ensure awareness of the program by beneficiaries/applicants with limited English proficiency, employee training and requirements for reporting, records retention for the LEP program and monitoring oversight of the language assistance program to ensure LEP persons meaningful access to the program.

Source: Miss. Code Ann. § 43-13-121; Title VI Civil Rights Act 1964 USC Section 2000(d)

Rule 1.6: Timely Filing

A. The Division of Medicaid requires providers to submit claims no later than three hundred sixty-five (365) calendar days from the date of service.

B. Claims for services submitted by newly enrolled providers must be submitted within three hundred sixty-five (365) calendar days from the date of service and must be for services provided on or after the effective date of the provider's enrollment.

C. Claims originally submitted to and paid by a coordinated care organization (CCO) but which are subsequently recouped by the CCO retrospectively due to a change in the beneficiary’s enrollment from the CCO to fee-for-service (FFS), must be submitted to the Division of Medicaid within:

1. Three hundred sixty-five (365) calendar days from the date of service, or

2. Within ninety (90) calendar days of the CCO recoupment if the CCO recoupment date is after the timely filing period of three hundred sixty-five (365) calendar days from the date of service.

D. If a claim for payment under Medicare has been filed in a timely manner, the Division of Medicaid will process a Medicaid claim relating to the same services within one hundred eighty (180) calendar days after the agency or the provider receives notice of the disposition of the Medicare claim.

E. If a provider fails to meet the timely filing requirements, the beneficiary cannot be billed for those services.

Source: 42 C.F.R. § 447.45; Miss. Code Ann. §§ 43-13-113, 43-13-117, 43-13-121.

History: Revised eff. 12/01/2020; New rule eff. 07/01/2019.

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Rule 1.7: Timely Processing of Claims

A. The Division of Medicaid defines a clean claim as a claim that can be processed without obtaining additional information from the provider of the service or from a third party.

1. Claims with errors originating in the Division of Medicaid's claims system are considered clean claims.

2. The following are not considered clean claims:

a) Claims from providers under investigation for fraud or abuse, or

b) Claims under review for medical necessity.

B. The Division of Medicaid processes claims in accordance with federal and state timely processing requirements.

C. The Division of Medicaid processes all claims within three hundred sixty-five (365) calendar days from the date of receipt except:

1. If a claim for payment under Medicare has been filed in a timely manner, the Division of Medicaid will process a Medicaid claim relating to the same services within one hundred eighty (180) calendar days of the Medicare paid date.

2. Retroactive adjustments paid to providers who are reimbursed under a retrospective payment system.

3. When the claim is from a provider that is under investigation for fraud or abuse.

4. When payments are made to carry out:

a) A court order,

b) Hearing decision, or

c) Agency corrective actions taken to resolve a dispute.

5. To extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it.

D. The processing period begins on the date a claim is timely received by the Division of Medicaid and ends three hundred sixty-five (365) calendar days from the date the original claim is received by the Division of Medicaid.

E. Providers may submit a corrected claim during the processing period.

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F. If the Division of Medicaid adjusts claims after the processing period has ended, providers may submit a written request for an Administrative Review within ninety (90) calendar days of the date of the remittance advice (RA). Providers must submit additional documentation to support claims payment.

G. Providers may request an administrative hearing if they are dissatisfied with the disposition of their claim as described in Miss. Admin. Code, Title 23, Part 300, Rule 1.1.

Source: 42 C.F.R. § 447.45; Miss. Code Ann. §§ 43-13-113, 43-13-117, 43-13-121.

History: Added Miss. Admin. Code Rule 1.7.F. eff. 10/01/2019; New rule eff. 07/01/2019.

Rule 1.8: Administrative Reviews for Claims

A. Providers may request an Administrative Review regarding claims within ninety (90) calendar days of the denial of a claim when:

1. The provider is unable to meet the timely filing requirement due to retroactive beneficiary eligibility and has:

a) Received prior authorization, if required, from the Utilization Management/Quality Improvement Organization (UM/QIO) within 90 days of the system add date of the eligibility determination, and

b) Filed the claim within ninety (90) days of the system add date of the eligibility determination,

2. The Division of Medicaid adjusts claims after timely filing and timely processing deadlines have expired, or

3. A Medicare crossover claim has been filed within one hundred eighty (180) calendar days from the Medicare paid date and the provider is dissatisfied with the disposition of the Medicaid claim.

B. Requests for an Administrative Review must include:

1. Documentation of timely filing or documentation that the provider was unable to file the claim timely due to the beneficiary's retroactive eligibility,

2. Documentation that explains the facts that support the provider’s position as to how the denied claim meets one (1) or more of the requirements in Miss. Admin. Code, Title 23, Part 200, Rule 1.8.A. and the reasons the provider believes he/she complied with Medicaid regulations, and

3. Other documentation as required or requested by the Division of Medicaid.

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C. Providers may appeal certain decisions made by the Division of Medicaid as described in Miss. Admin. Code, Title 23, Part 300.

Source: Miss. Code Ann. §§ 43-13-113, 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised eff. 08/01/2020; New Rule eff. 07/01/2019.

Rule 1.9: Authorized Provider Representative

The Division of Medicaid defines an authorized provider representative as an employee or agent of a provider designated by the provider to act for the provider with the provider’s knowledge and written consent in order to manage and submit claims to the Division of Medicaid for payment.

A. An authorized provider representative must not have been convicted of or pleaded guilty to or nolo contendere to a felony or certain misdemeanors including, but not limited to, fraud, forgery, counterfeiting, embezzlement, identity theft, tax evasion, money laundering, or any other crime related to dishonesty or concealment. Reversal on appeal or a pardon granted for the conviction or plea of these crimes does not mitigate this requirement.

B. A provider designating an authorized provider representative or agent must use the Appointment of Authorized Provider Representative or Agent Form included in the Mississippi Medicaid Provider Billing Handbook. This form must be kept on file at the provider’s main office and be available to the Division of Medicaid upon request.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: New rule eff. 04/01/2020.

Rule 1.10: Electronic Signatures A. The Division of Medicaid defines an electronic signature (e-signature) as an electronic symbol attached to or logically associated with a document or communication to be transmitted or submitted to the Division of Medicaid.

1. The Division of Medicaid recognizes an electronic signature as an electronic symbol or process attached to, or logically associated with, a document or communication with the Division of Medicaid when executed or adopted by a person with the intent to electronically sign a document or communication when the application of the electronic signature:

a) Is made by the person whose electronic signature is being applied,

b) Identifies a person as the signer,

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3. Authenticates a person as the signer,
4. Includes the date and time of the application of the electronic signature, and
5. Indicates intent of approval of information contained in the electronically signed

document or communication.

2. The Division of Medicaid considers electronic signatures the equivalent of full

handwritten signatures or handwritten initials.

a) An electronic signature will not be denied solely on the grounds that it is in electronic form. b) A duplicative image of the original electronic signature or a signature stamp is not a valid electronic signature. c) A provider cannot refuse to accept a handwritten signature from a beneficiary. B. Providers must ensure that electronic signatures applied to an electronic health record EHR and/or medical document cannot be excised, copied, or otherwise transferred to falsify an EHR or medical document. C. Providers are permitted to use e-signatures in submissions to the Division of Medicaid including, but not limited to, Provider Enrollment Applications and claim forms.

1. Provider e-signatures must be created using e-signature software including, but not limited to, the following:

a) Right Signature TM , b) Adobe E-Sign, c) Electronic health record (EHR) software. [Refer to Miss. Admin. Code Part 200, Rule 5.7], or

d) Any technology solution provided by the Mississippi Division of Medicaid and utilized by providers to conduct business with the Mississippi Division of Medicaid.

2. An authorized provider representative may use a provider’s e-signature to make submissions for payment to the Division of Medicaid at the provider’s direction. The authorized provider representative must print their name next to the provider’s e- signature. [Refer to Miss. Admin. Code Part 200, Rule 1.9.]

3. Any e-signature appearing on an EHR must be made by the treating practitioner.

1. EHR e-signature-making authority may not be delegated to any other party.
2. E-signatures appearing on an EHR must comply with Division of Medicaid

requirements regarding EHR. [Refer to Miss. Admin. Code Part 200, Rule 5.7.]

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D. Beneficiaries are permitted to use e-signatures in submissions, including Medicaid applications, to the Division of Medicaid.

1. Beneficiaries may create e-signatures through touchscreen technology, online verification systems, and other methods regularly used for beneficiary applications and receipt of benefits in accordance with applicable state and federal laws.

2. Beneficiaries may use e-signatures in records that normally appear in an EHR including, but not limited to, consent for treatment. [Refer to Miss. Admin. Code Part 200, Rule 5.7.]

3. A beneficiary’s representative may use an e-signature for purposes of both application and receipt of benefits.

a) The representative must sign both the beneficiary’s name and the representative’s name when using an e-signature. b) A representative’s use of an e-signature must comply with Division of Medicaid requirements regarding applicant and beneficiary representatives. [Refer to Miss. Admin. Code Part 101, Rules 3.3 and 3.4.] Source: 12 C.F.R. § 609.910, 42 C.F.R § 435.907, Miss. Code Ann. §§ 43-13-117, 43-13-121, 75-12-3, 75-12-9. History: Revised eff. 06/01/2022; New Rule eff. 04/01/2020.

Rule 1.11: Provider Claim Submission Signatures

A. The Division of Medicaid allows providers’ signatures on claims to be applied using one (1) of four (4) different methods:

1. Electronic signature [Refer to Miss. Admin. Code Part 200, Rule 1.10],

2. Typed signature,

3. Signature stamp bearing the signature of the provider, or

4. Handwritten only by the provider. The ability to make a handwritten signature may not be delegated to another party.

B. A provider may delegate the ability to affix their electronic, typed, or stamped signature to an authorized provider representative when submitting claims on the provider’s behalf. The provider must complete and keep on file the Appointment of Authorized Provider Representative or Agent Form included in the Mississippi Medicaid Provider Billing Handbook. [Refer to Miss. Admin. Code part 200, Rule 1.9.]

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C. If there is no printed name accompanying an electronic, typed, or signature stamp, it is presumed that the provider affixed the signature to the claim.

Source: Miss. Code Ann. §§ 43-13-117, 43-17-121.

History: Revised eff. 04/01/2020.

Rule 1.12: National Correct Coding Initiative (NCCI) Edits

A. The Division of Medicaid defines National Correct Coding Initiative (NCCI) edits as edits implemented in the Medicaid Management Information System (MMIS) to control improper coding leading to inappropriate payments which includes:

1. NCCI procedure to procedure (PTP) edits defined as pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that cannot be billed together, and

2. NCCI medically unlikely edits (MUEs) defined for each HCPCS/CPT code utilizing the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

B. The Division of Medicaid requires providers to follow the Medicaid National Correct Coding Initiative (NCCI) policies and edits:

1. Medicaid NCCI and medically unlikely edit (MUE) values are reviewed with the quarterly file updates, and

2. Located at https://www.medicaid.gov/medicaid/program-integrity/national-correct- coding-initiative/medicaid-ncci-edit-files/index.html

C. Providers must append NCCI associated modifiers only when appropriate clinical circumstances are documented in accordance with the NCCI policies and the HCPCS/CPT Manual instructions/definitions for the modifier/procedure code combination. A modifier cannot be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use.

D. Providers are required to bill for services according to Medicaid NCCI coding policies, the Fee Schedules on the Division of Medicaid’s website and/or Administrative Code.

Source: 42 U.S.C. § 1396b; Miss. Code Ann. §§ 43-13-117, 43-17-121.

History: New Rule eff. 12/01/2020.

Rule 1.13: Rounding of Timed Codes

A. The Division of Medicaid requires providers to adhere to Current Procedural Terminology

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(CPT) and Healthcare Common Procedure Coding System (HCPCS) billing and coding guidelines when reporting timed-based services.

1. Providers are required to bill for services according to Medicaid National Correct Coding Initiative (NCCI) coding policies, the Fee Schedules on the Division of Medicaid’s website and Administrative Code.

2. Should a conflict arise between this rule and specific CPT/HCPCS coding guidelines, the CPT/HCPCS guidelines take precedence.

B. Documentation must support the level of service billed and the medical appropriateness of the service by providing a detailed description of services provided.

C. Providers may bill for CPT/HCPCS codes with 15-minute allotment as follows:

1. Providers may bill the first initial unit if direct patient contact time is at least eight (8) minutes.

2. Providers may bill for additional 15-minute increment units after completing the initial full fifteen (15) minutes of service, if at least eight (8) minutes of the next time block are used to perform direct patient services.

3. Providers may not round up to the next timed code if less than eight (8) minutes of direct patient services are performed of a 15-minute increment.

D. Providers may bill for units of service that are measured in minutes based on the following:

1. The provider must have provided services for more than half of the time allotment in the code description for the service to bill the unit of service.

2. Additional units may be billed in increments, provided that at least more than half of the time of each billable increment has been provided.

3. Providers are not permitted to bill for a unit of service if half or less than half the time requirement is met.

E. For time-based, evaluation and management services, providers must document the activities related to the beneficiary visit including the total time with start and end times of all procedures or services performed for time-based codes. Total time includes all activities related to the visit performed by the physician, physician assistant or nurse practitioner on the date of the visit and may comprise activities including, but not limited to the following:

1. Preparing to see the beneficiary, including review of previous documentation and test results,

2. Obtaining and/or reviewing separately obtained history,

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3. Ordering medications, tests, or procedures,

4. Documentation of clinical information in the health record or other records; and,

5. Communicating with the patient, family, or caregiver.

F. Providers may round CPT/HCPCS procedure codes with a one-hour allotment as follows:

1. Providers may bill one unit for one hour of service if at least forty-five (45) minutes but less than 60 minutes is spent with the beneficiary.

2. Providers may not round up to the next level of service if total time spent with the beneficiary is equal to or less than forty-five (45) minutes.

3. If a more appropriate time code is available according to Medicaid National Correct Coding Initiative (NCCI) coding policies, the provider must bill the available code.

G. The Division does not allow the billing of mixed remainder minutes across multiple codes.

H. The Division of Medicaid may conduct audits of provider billing to ensure compliance with rounding rules and recoup payments as necessary.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: New Rule eff. 03/01/2025.

Rule 1.14: Electronic Visit Verification (EVV) A. The Mississippi Division of Medicaid requires the use of electronic visit verification (EVV), as a part of personal care services and/or home health care services. EVV is a computer application system that records and electronically verifies the following:

1. Type of service performed;

2. Individual receiving the service;

3. Date of the service;

4. Location of service delivery;

5. Individual providing the service; and

6. Time the service begins and ends.

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B. The Mississippi Division of Medicaid requires EVV data to reimburse for the following programs and services:

1. 1915(c) Elderly and Disabled Waiver:

a) Personal Care Services and

b) In Home Respite Services.

2. 1915(c) Intellectual Disabilities/Developmental Disabilities Waiver:

a) Home and Community Supports Services,

b) Respite – In Home Nursing Services,

c) In Home Respite Services, and

d) Supported Living Services.

3. 1915(c) Independent Living Waiver:

a) Personal Care Attendant Services.

4. 1915(c) Traumatic Brain Injury/Spinal Cord Injury Waiver:

a) Personal Care Attendant Services,

b) In Home Companion Respite Services, and

c) In Home Nursing Respite Service.

5. 1915(i) Community Support Program:

a) Supported Living Services, and

b) In Home Respite Services.

6. State Plan Services:

a) Private Duty Nursing Services,

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b) Personal Care Services,

c) Home Health Physical Therapy Services,

d) Home Health Speech Language Pathology Services,

e) Home Health Skilled Nursing Services, and

f) Home Health Aide Services.

C. Providers of personal care and home health services must implement EVV under one of the following models to ensure compliance for all services rendered to Medicaid enrolled beneficiaries:

1. Utilize the state provided EVV provider portal via HHAeXchange to collect and maintain EVV data.

2. Utilize a Division of Medicaid approved provider contracted solution to collect and maintain EVV data and submit collected data via electronic integration with the state’s EVV aggregator within fourteen (14) days of the date of data collection.

D. Providers utilizing an EVV provider contracted solution must:

1. Ensure the contracted solution meets the minimum requirements established by the Division of Medicaid.

2. Maintain the data in an auditable format for the minimum period outlined in Miss. Admin. Code Title 23, Part 200, and which meets any specific federal requirements. Failure to maintain auditable data and records in required formats with required information and signatures may result in claims being denied, recouped, or otherwise repaid to the Division of Medicaid.

E. Service documentation must be maintained according to the appropriate administrative code part for the service being provided. Documentation shall be captured and maintained in one of the following formats:

1. Electronically captured in the state Medicaid provided EVV solution mobile application via HHAeXchange and stored in the associated provider portal.

2. Electronically captured in the Division of Medicaid approved provider contracted EVV solution mobile application and stored in the associated database. If data is captured and stored in the Division of Medicaid approved provider solution, the provider must:

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a) Ensure that electronic records reflect a clear audit trail for any edits/updates.

b) Grant system access to the Division of Medicaid, their contractors, and oversight entities for the purposes of auditing EVV data upon request.

3. Manually captured on paper and maintained in the beneficiary’s record for audit and review purposes by DOM, its contractors, and oversight entities. Visit data manually captured on paper must be entered in the provider’s selected EVV solution in order to submit claims for services.

F. Manual entry of visit data will only be utilized when the EVV system is unavailable or when exigent circumstances, documented by the provider agency, make usage of the system impossible. The provider agency will:

1. Provide justification documentation to support any instance of human error in EVV use and such errors must be readily identifiable. Repeated instances of human error are subject to audit.

2. Enter justification documentation into the EVV system.

3. Include the date and time of the manual entry, the reason for the entry, and the identification of the person making the entry.

G. Provider agencies must report any suspected falsification of EVV data to the Mississippi Medicaid Program Integrity Unit within two (2) business days of discovery.

H. In order to ensure that claims are substantiated by EVV data, claims for services rendered with required EVV data must be submitted to the fiscal agent via the state’s EVV system unless otherwise authorized in writing by the Division of Medicaid.

Source: 42 U.S.C. § 1396b.

History: New Rule eff. 12/01/2025.

Part 200 Chapter 2: Benefits

Rule 2.1: Medicaid Services

A. Federally Mandated Services - The following services are mandated for Mississippi Medicaid:

1. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) (Mississippi Cool Kids

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Program,

2. Expanded EPSDT,

3. Family Planning,

4. Federally Qualified Health Center (FQHC),

5. Home Health,

6. Hospital Inpatient,

7. Hospital Outpatient,

8. Laboratory,

9. Nurse Practitioner,

10. Nursing Facility,

11. Physician,

12. Radiology,

13. Rural Health Clinic, and

14. Transportation (including emergent/non-emergent ambulance, air ambulance & NET).

B. Optional services covered by State:

1. Ambulatory Surgical Center,

2. Chiropractic,

3. Community Mental Health,

4. Dental,

5. Dialysis,

6. Durable Medical Equipment,

7. Eyeglasses and Vision,

8. Freestanding Psychiatric Hospital,

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9. Hearing Services and Hearing Aids,

10. Hospice,

11. Intermediate Care Facilities for the Mentally Retarded (ICF/MR) Services,

12. Medical Supplies,

13. Occupational Therapy,

14. Physical Therapy,

15. Podiatry,

16. Prescription Drugs,

17. Psychiatric Residential Treatment Facilities,

18. Speech Therapy,

19. Hospital Swing Bed, and

20. MS State Department of Health Clinic.

C. Waivered services which are optional:

1. HCBS – Assisted Living Waiver,

2. HCBS – Elderly and Disabled Waiver,

3. HCBS – Independent Living Waiver,

4. HCBS – Intellectual Disabilities/Developmental Disabilities Waiver,

5. HCBS - Traumatic Brain Injury/Spinal Cord Injury Waiver,

6. Mississippi Youth Programs Around the Clock (MYPAC),

7. Family Planning Waiver, and

8. Healthier Mississippi 1115 Waiver.

Source: Miss. Code Ann. § 43-13-121; Social Security Act Section 1902(a); 42 CFR 440.1; 42 USC § 1396d; 440.210; 440.220

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Rule 2.2: Non-Covered Services

A. The Division of Medicaid does not cover certain items and services including, but not limited to, the following:

1. Items or services which are furnished gratuitously without regard to the beneficiary's ability to pay and without expectation of payment from any source, including, but not limited to:

a) Free diagnostic services provided by a health department, and

b) Services provided as part of a health fair.

2. Services provided by the following except as specified by the State Plan or a 1915(c) waiver:

a) Anyone legally responsible for a beneficiary/participant,

b) An individual, corporation, partnership or other organization which has assumed the responsibility for the care of a beneficiary, but does not include the Division of Medicaid, a licensed hospital, or a licensed nursing home within the state,

c) The following family members:

1. Spouse,

2. Parent, step-parent or foster parent,

3. Child, step-child, grandchild or step-grandchild,

4. Grandparent or step-grandparent,

5. Sibling or step-sibling, or

d) Anyone who resides in the home with the beneficiary regardless of relationship.

3. Services provided by a registered nurse (RN) or licensed practical nurse (LPN) to their family members, as defined in Miss. Admin. Code Part 200, Rule 2.2 A.2.c).

4. Services denied by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or a designated entity.

5. Services, procedures, supplies or drugs still in clinical trials deemed as investigational or experimental in nature.

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6. Procedures, products and services for conditions and indications not approved by the Federal Drug Administration (FDA) and/or that do not follow medically accepted indications and dosing limits supported by one (1) or more of the official compendia as designated by the Centers for Medicare and Medicaid Services (CMS) including, but not limited to:

a) Physician administered drugs and implantable drug system devices,

b) Skin and tissue substitutes, and/or

c) Implantable medical devices.

7. Any operative procedure, or any portion of a procedure, performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form.

8. Reconstructive breast procedures performed to produce a symmetrical appearance.

9. Infertility studies, procedures to enhance fertility including reversal of sterilization, artificial or intrauterine insemination, or in-vitro fertilization.

10. Gastric surgery techniques or procedures for the treatment of obesity or weight control, regardless of medical necessity.

11. Routine foot care in the absence of systemic conditions.

12. Prosthetic or orthotic devices and orthopedic shoes except crossover claims allowed by Medicare.

13. Services provided to Specified Low Income Medicare Beneficiaries (SLMB), Qualified Medicare Beneficiaries (QMB), and Qualifying Individuals (QI) except as described in Miss. Admin. Code Part 200, Rule 3.4.

B. The Division of Medicaid does not cover items or services not directly related to the treatment of an illness or injury, including, but not limited to:

1. Television except as described in Miss. Admin. Code Part 207,

2. Massage,

3. Haircuts except as described in Miss. Admin. Code Part 207,

4. Interest on late pay claims,

5. Telephone contacts/consultations,

6. Missed or cancelled appointments, or

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7. Wigs.

C. The Division of Medicaid does not reimburse for items and services ordered, prescribed, administered, supplied or provided by providers, entities, or financial institutions who:

1. Have been excluded by the Department of Health and Human Services (DHHS),

2. Have been excluded by Medicare,

3. Are no longer licensed by their governing board(s),

4. Are respiratory therapists requesting direct payment for services,

5. Are freestanding substance abuse rehabilitation centers,

6. Are free-standing psychiatric facilities,

7. Are located outside of the United States,

8. Are not currently enrolled as a Mississippi Medicaid provider, or

9. Have not conducted criminal history records checks on each employee of the entity hired since 1989 who provides, and/or would provide direct patient care or services to adults or vulnerable persons in accordance with the Mississippi Vulnerable Persons Act.

D. The Division of Medicaid does not cover the following three (3) Never Events in the inpatient hospital, outpatient hospital and other types of healthcare settings:

1. Wrong surgery or other invasive procedure performed on a beneficiary,

2. Surgical or other invasive procedure performed on the wrong body part, or

3. Surgical or other invasive procedure performed on the wrong beneficiary.

E. The Division of Medicaid does not cover inpatient hospital Health Care-Acquired Conditions (HCACs) as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric beneficiaries.

F. The Division of Medicaid does not cover nursing facility services or duplicative hospice services for persons enrolled in a Home and Community-Based Services (HCBS) waiver program or enrollment in more than one (1) HCBS waiver program including, but not limited to:

1. Elderly and Disabled (E&D) Waiver,

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2. Independent Living (IL) Waiver,

3. Assisted Living (AL) Waiver,

4. Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver, or

5. Intellectual Disabilities/Developmental Disabilities (ID/DD) Waiver.

G. Services not specifically listed or defined by the Division of Medicaid are not covered, unless part of the expanded Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit.

H. The Division of Medicaid does not reimburse for any exclusion listed elsewhere in the Miss. Admin. Code Title 23, Mississippi Medicaid Bulletins, or other Mississippi Medicaid publications.

Source: 29 USC § 1185b; 42 USC § 1396n; Miss. Code Ann. §§ 43-13-121, 43-47-7; SPA 2011-006, 2012-001; 30 Miss. Admin. Code Part 2820, Rule 1.2 S.2).

History: Revised Miss. Admin. Code Part 200, Rule 2.2.F. eff. 06/01/2016; Added a New Miss. Admin. Code Part 200, Rule 2.2 A.2.a)-d) and C.9., reformatted and revised Miss. Admin. Code Part 200, Rule 2.2 including removing duplicative language, effective 12/01/2015; Added Miss. Admin. Code Part 200, Rule 2.2 A. 36. and Rule 2.2 D. eff. 10/01/2014; Rule 2.2 B. and 2.2 C. added to correspond with approved SPA 2011-004 and 2011-006 effective 10/01/11 and SPA 2012-001 effective 06/01/2012.

Rule 2.3: Medicaid Cost Sharing for Medicare/Medicaid Dually Eligibles

A. A state is not required to cover any Medicare cost sharing expenses related to payment for deductibles, coinsurance, or co-payments for dual eligibles which exceed what the state’s Medicaid program would have paid for such service for a beneficiary who is not a dual eligible. When a state's payment for Medicare cost-sharing for a dual eligible is reduced or eliminated the Medicare payment plus the state's Medicaid payment is considered payment in full. The dually eligible beneficiary cannot be billed the difference between the provider's charge and the Medicare and Medicaid payment.

B. Medicare Part A crossover nursing facility, hospice and home health agency claims for dually eligible beneficiaries are reimbursed as listed below:

1. The Medicaid reimbursement combined with the Medicare reimbursement will not exceed what the Mississippi Medicaid program would have paid for such service for a beneficiary who is not dually eligible.

2. All service limits will be applied to beneficiaries who are dually eligible when reimbursement is made toward covered services with service limits. Once the service

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limits are reached each state fiscal year, no additional payments will be made for these services.

3. All providers must accept the Medicare and Medicaid payment as payment in full. The provider is prohibited from billing the beneficiary the balance between the provider’s charge and Medicare and Medicaid payments.

C. For Medicare Part A crossover claims from hospitals (inpatient) and all Part B crossover claims, Medicaid reimburses the full deductible and coinsurance amount for dual eligibles.

Source: Miss. Code Ann. § 43-13-121; Balanced Budget Act of 1997

Part 200 Chapter 3: Beneficiary Information

Rule 3.1: Coverage of Eligibility Groups

A. The Division of Medicaid covers full Medicaid benefits for the following eligibility groups:

1. Individuals receiving Supplemental Security Income (SSI),

2. Certain former SSI recipients specified in federal and/or state law,

3. Parents and caretaker relatives of minor children living at home whose income is at or below the applicable limit,

4. Pregnant beneficiaries,

5. Infants born to Medicaid eligible mothers,

6. Children up to age nineteen (19) whose household income is at or below the applicable limit,

7. Children receiving adoption assistance or foster care maintenance payments,

8. Former foster care children under twenty-six (26) years old who received Medicaid at age eighteen (18) prior to being released from foster care by the Department of Human Services (DHS),

9. Institutionalized beneficiaries,

10. Katie Beckett group,

11. Working disabled, and

12. Certain women with breast and/or cervical cancer screened by the Mississippi State Department of Health (MSDH).

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B. The Division of Medicaid covers:

1. Medicare Part A premiums for certain qualified working disabled persons,

2. Medicare Part B premiums for Specified Low Income Beneficiaries (SLMB) and Qualified Individuals (QI),

3. Medicare Part A and B cost sharing, including premiums, deductibles, coinsurance and any copays, for Qualified Medicare Beneficiaries (QMB) regardless of whether or not the service provided is covered by the Division of Medicaid, and

4. Medicare Part C coinsurance and deductible for beneficiaries in applicable Categories of Eligibility (COE).

C. The Division of Medicaid covers full Medicaid benefits for beneficiaries receiving Home and Community-Based Services (HCBS) and additional services as specified in Miss. Admin. Code Part 208 through the following 1915(c) waivers:

1. Assisted Living (AL) Waiver,

2. Elderly and Disabled (E&D) Waiver,

3. Intellectual Disabilities/Developmental Disabilities (ID/DD) Waiver,

4. Traumatic Bain/Spinal Cord Injury (TBI/SCI) Waiver, and

5. Independent Living (IL) Waiver.

D. The Division of Medicaid covers those services specified in Miss. Admin. Code Part 221 for beneficiaries enrolled in the 1115(a) Family Planning Waiver (FPW).

E. The Division of Medicaid covers full Medicaid benefits for beneficiaries enrolled in the 1115(a) Healthier Mississippi Waiver (HMW) excluding the following:

1. Long-term care services, including, but not limited to:

a) Nursing facility,

b) Swing bed,

c) Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or

d) Services provided by an HCBS waiver.

2. Maternity and newborn care services.

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F. The Division of Medicaid covers emergency services, excluding transplant services, for aliens who meet the requirements of Miss. Admin. Code Part 100, Rule 8.10.

Source: 42 USC § 1396a(a)(10)(E)(i); 42 USC § 1396a(a)(17); 42 USC § 1396d(p)(3); 42 CFR § 435.116; Miss. Code Ann. §§ 43-13-115, 43-13-121; SPA 13-0019.

History: Revised eff. 07/01/2025; Revised to correspond with SPA 13-0019 (eff. 01/01/14) and Healthier Mississippi Waiver (eff. 01/01/2015) and eff. 04/01/2016; Removed 3.c.2.d.v) to reflect CMS waiver (eff. 04/01/2004) eff. 12/01/2013.

Rule 3.2: Newborn Child Eligibility

A. The Division of Medicaid covers an infant:

1. Whose mother was eligible for Medicaid in the child’s birth month for the first year of life.

a. Deemed newborn Medicaid eligibility begins with the birth month and continues through the month of the child’s first (1 st ) birthday unless one (1) of the termination reasons in Miss Admin Code Part 101, Rule 11.2 is applicable.

b. There is no requirement that the newborn live with the biological mother in order for the continuous eligibility to apply for the infant.

2. Born to immigrant mothers who qualify for Medicaid on the basis of emergency medical services for the first (1 st ) year of the infant’s life.

3. If the mother is not eligible for Medicaid at the time her child is born, she may apply for Medicaid for herself and her newborn. An application must be filed by the end of the third (3 rd ) month following the birth to be considered for coverage and in order for the infant to be eligible for the first (1 st ) year of life.

Source: 42 U.S.C. 1396a; Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2018.

Rule 3.3: Beneficiary Retroactive Eligibility

A. Retroactive eligibility is available to individuals during all or part of a three (3) month period before application for Medicaid. Applicants must meet financial and need requirements.

B. Medicaid covered services paid for by a beneficiary during the three (3) month period may be refunded at the option of the provider of services and billed to Medicaid when eligibility is validated in accordance with timely filing requirements.

C. Medically necessary services rendered which require authorization during the period of retroactive eligibility cannot be denied due to failure to secure prior authorization. In

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accordance with timely filing requirements, authorization must be obtained and the claim must be filed within ninety (90) days of the system add date of eligibility determination.

Source: Miss. Code Ann. § 43-13-117.

History: Revised eff. 08/01/2020.

Rule 3.4: Eligibility for Medicare and Medicaid

Medicare is the primary payor for a beneficiary who is both Medicare and Medicaid eligible and has four (4) parts:

A. Medicare Part A

1. The Division of Medicaid pays for the Medicare Part A premium through a "buy-in" process for individuals who have income that does not exceed 100% of the poverty level and are classified as Qualified Medicare Beneficiaries (QMB) and QMB-dual recipients, meaning the recipient is dually eligible as both a QMB and has full Medicaid through other coverage.

2. The Centers for Medicare and Medicaid Services (CMS) and the Division of Medicaid work jointly to ensure that all eligible individuals are included in the "buy-in" process for Medicare coverage. Persons who may be Medicaid-eligible should apply at the appropriate certifying agency.

B. Medicare Part B

1. The Division of Medicaid pays the Medicare Part B premium through a "buy-in" agreement with the Social Security Administration (SSA) for all Medicaid eligible individuals who also qualify for Medicare Part B. CMS and the Division of Medicaid work jointly to ensure that all eligible individuals are included in the "buy-in" process.

2. The Division of Medicaid also pays Part B premiums for specified low-income Medicare beneficiaries (SLMBs) and certain qualifying individuals (QIs). SLMBs and QIs do not receive a Medicaid ID card or any other benefits.

C. Medicare Part C (Medicare Advantage Plans)

1. The Division of Medicaid pays for the Medicare Part C coinsurance and deductible for beneficiaries in applicable Categories of Eligibility (COE).

2. For purposes of reimbursement, co-payments charged by a Medicare Part C plan are considered to be coinsurance.

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D. Medicare Part D (Medicare Prescription Drug Plan)

1. When Medicaid beneficiaries have both Medicare and Medicaid coverage, pharmacy providers are required to bill Medicare for drugs covered by that program.

2. The Division of Medicaid considers the Medicare payment as payment in full for Medicare Part D pharmacy claims.

Source: 42 U.S.C. § 1396a; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/2015.

Rule 3.5: Verification of Eligibility

A. It is the responsibility of the Medicaid provider to verify a Medicaid beneficiary’s eligibility each time the beneficiary appears for a service. Evidence of eligibility is demonstrated by the Medicaid identification card issued to each Medicaid eligible member in a family. A beneficiary is expected to present his/her Medicaid identification card when services are rendered.

B. A picture ID such as a driver’s license or school ID card is required to confirm the identity of the person presenting for service. If no picture ID is available, verification must be made by verifying the social security number and/or date of birth.

C. If it is found that the person presenting for services was not the Medicaid beneficiary to whom the card was issued, the provider is responsible for refunding any monies paid by Medicaid to the provider for those services provided.

D. A plastic identification card is not a guarantee of Medicaid eligibility.

E. Medicaid providers may verify beneficiary eligibility status by one (1) of the following methods:

1. Calling the Automated Voice Response System (AVRS),

2. Using the point of service eligibility verification system, or

3. Calling the fiscal agent.

Source: Miss. Code Ann. § 43-13-121

Rule 3.6: Freedom of Choice of Providers

A. Medicaid beneficiaries have the right to freedom of choice of providers for Medicaid covered services. Any individual eligible for medical assistance, including drugs, may obtain such assistance from any institution, agency, community pharmacy, or person qualified to perform

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the service or services required.

B. Providers of Medicaid services agree to comply with this section of the Act in the Provider Agreement. This means that providers may not take any action to deny freedom of choice to individuals eligible for Medicaid by using systems, methods, or devices which would require persons eligible for Medicaid to obtain a service from a particular provider.

C. This also means that providers may not require any individuals eligible for Medicaid to sign a statement of waiver, if such statement would, in any manner, deny or restrict that individual's free choice of a provider of any services for which the individual may be eligible. Providers cannot use any method of inducement, including free transportation, refreshments, cash or gifts, to influence a beneficiary to select a certain provider.

D. Exception: Under a federal waiver or approved State Plan amendment, freedom of choice may be restricted for individuals enrolled in a managed care program. These individuals are required to receive primary care from a primary care provider (PCP) and have specialty care prior authorized by the PCP.

Source: Miss. Code Ann. § 43-13-121; Social Security 1902(a)(23)

Rule 3.7: Beneficiary Cost Sharing

A. The Division of Medicaid does not impose premiums on beneficiaries.

B. The Division of Medicaid does not impose cost sharing on beneficiaries.

Source: U.S.C § 1396a; 42 C.F.R. § 447.50 et seq.; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with SPA 23-0011 (eff. 5/01/2023) eff. 09/01/2023. Revised eff. 07/01/2021; Revised Miss. Admin. Code Part 200, Rule 3.7.B.h) to correspond with SPA 2012-008 (eff. 10/01/2012) eff. 05/01/2014.

Rule 3.8: Charges Not Beneficiary’s Responsibility

A. Providers who have agreed to be Medicaid providers are expected to bill Medicaid for Medicaid covered services and accept Medicaid payment as payment in full.

B. Some charges are not the beneficiary’s responsibility and must not be billed to the beneficiary. Those included, but not limited to:

1. The beneficiary may not be billed for Medicaid covered services except in the following situations:

a) If the person is ineligible; or

b) If person has chosen to receive and agreed to pay for care not covered by the

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Medicaid program.

2. The beneficiary may not be held liable for a claim or portion of a claim when a determination that the services were not medically necessary is made based on the professional opinion of appropriate and qualified persons performing peer review of Medicaid cases.

3. The beneficiary may not be held liable for billed charges above the Medicaid maximum allowable.

4. The beneficiary may not be billed for claims denied because of provider errors. It is the responsibility of the provider to file claims in a timely manner, to correct errors, and to provide essential information necessary to process the Medicaid claim.

5. The beneficiary may not be billed for claims denied because of errors made by DOM, the fiscal agent, or due to changes in federal or state mandates.

6. The beneficiary may not be billed for services denied because a provider failed to request required authorization for a service or failed to meet procedural requirements.

7. For dual eligibles, the beneficiary may not be billed for the portion of a claim remaining after Medicare and Medicaid have paid.

8. The beneficiary may not be billed for the completion and submission of a Medicaid claim form. If the provider agrees to accept the patient as a Medicaid beneficiary and agrees to bill Medicaid for the services rendered, the beneficiary may not be charged for this billing procedure.

9. The beneficiary may not be billed for telephone calls or missed/cancelled appointments.

10. The beneficiary may not be charged for the cost of copying medical records.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 447.15 Rule 3.9: Charges Beneficiary’s Responsibility

A. Medicaid beneficiaries may be charged for the following:

1. The beneficiary is responsible for all expenses for non-covered services, such as services that are not covered under the scope of the Medicaid program, or services received in excess of program benefit limitations. The beneficiary is responsible for services received during a period of ineligibility.

2. Any applicable cost-sharing amount applied by the Medicaid program is the responsibility of the beneficiary.

3. Beneficiaries enrolled in managed care programs that insist upon receiving services that

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are not authorized by the primary care provider (PCP) may be required to pay for such services. For example, if the beneficiary seeks care in a hospital emergency room (ER) for services that can be provided in the PCP’s office and are not authorized by the PCP for treatment in the ER; the beneficiary may be responsible for payment of the ER services beyond the medical assessment. The beneficiary sees a specialist for services that are not excluded from managed care and are not considered emergent/urgent, and the PCP has not made the referral or denies authorization; the beneficiary may be responsible for payment of such services.

4. The beneficiary, or responsible adult, is held accountable and responsible for knowingly allowing or continuing to allow an unauthorized person to use a Medicaid card or beneficiary’s identity to obtain benefits otherwise not allowed. Any charges to or payments by the Division of Medicaid for services requested and/or received in an attempt to defraud the provider of services and/or Medicaid are billable to the cardholder or his/her responsible party, or the imposter.

B. This list is not all-inclusive.

Source: Miss. Code Ann. § 43-13-121

Part 200 Chapter 4: Provider Enrollment

Rule 4.1: Definitions

A. Providers: All health care entities including individual practitioners, institutional providers, and providers of medical equipment or goods related to care that are currently enrolled in the Medicaid program.

B. National Provider Identifier (NPI): A Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers as noted in 45 C.F.R. § 162. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.

C. Sole Proprietor: A Sole Proprietor is a form of business in which one (1) person owns all of the assets of the business and is solely liable for all debts on an individual basis. As a result of the National Provider Identifier (NPI) requirements, a Sole Proprietor must apply for their NPI as individuals. Medicaid will no longer issue a group number to an individual effective with the adoption of this rule revision. The subpart concept does not apply to a sole proprietorship, even one (1) with multiple locations, because the sole proprietorship is not an organization as defined in the final NPI Rule. An individual Medicaid provider number and the appropriate NPI issued by the Centers for Medicare & Medicaid Services (CMS) are entered into the Medicaid system with the individual’s social security number (SSN); and if applicable, the Federal Employer Identification Number (FEIN) assigned to it. If this number is used as a Medicaid provider billing number, income or earnings information are reported to the IRS for this SSN or FEIN, as applicable. Deferred compensation is only available via

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a sole proprietor’s SSN.

D. Group/Organization: A Group/Organization provider is not an individual/sole proprietor. This may include hospitals, long-term care facilities, laboratories, home health agencies, ambulance companies, and group practices; suppliers of durable medical equipment or pharmacies. Any subpart of the group/organization must apply for a different Medicaid provider number as determined by the provider type per Medicaid rule. A group provider requesting individual providers/servicing providers to be affiliated to their billing provider number must be approved Medicaid providers. For monies to be reported to the IRS on its Tax Identification, the group provider should be the biller, unless otherwise restricted by the Division of Medicaid. Group providers that have various servicing locations should apply to Medicaid to become a provider according to their enumeration application with CMS. The provider should also apply to Medicaid to become a provider according to the conduct of their own standard transactions and as required by the Division of Medicaid‘s program rules.

E. Effective Date: The earliest date a provider may begin billing for services.

F. Officer: Any person whose position is listed as being that of an officer in the provider’s “articles of incorporation” or “corporate bylaws” or anyone who is appointed by the board of directors as an officer in accordance with the provider’s corporate bylaws.

G. Director: A member of the provider’s “board of directors.” It does not necessarily include a person who may have the word “director” in his/her job title. Moreover, where a provider has a governing body that does not use the term “board of directors,” the members of that governing body will still be considered “director”. Thus, if the provider has a governing body titled “board of trustees,” as opposed to “board of directors,” the individual trustees are considered “directors” for Medicaid enrollment purposes.

H. Managing/Directing Employee: A managing/directing employee may be a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of the entity, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee of the entity.

I. Authorized Official: An appointed official to whom the organization has granted the legal authority to enroll it in the Medicaid program, to make changes or updates to the organization’s status in the Medicaid program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicaid program. Examples include: chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner.

J. Delegated Official: An individual who is delegated by an authorized official with the authority to report changes and updates to the entity’s enrollment record. A delegated official must be an individual with an “ownership or control interest,” or be a W-2 managing employee of the entity. Documentation in the application or as an attachment must be included with the application. A change of a delegated official will only be made to the file

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with the appropriate documentation signed by a documented authorized official.

K. Majority Interest: Ownership interest greater than fifty percent (50%) of the voting interest in a business enterprise.

Source: 42 C.F.R. Part 455, Subpart E; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 12/01/2019.

Rule 4.2: Conditions of Participation

A. Providers must meet the following conditions to participate in the Mississippi Medicaid program:

1. All providers must complete provider agreements and/or provider enrollment application packages per the requirements of the Division of Medicaid.

2. The provider must be licensed and/or certified by the appropriate federal and/or state authority, as applicable.

3. Agree to furnish required documentation of the provider’s business transactions per 42 C.F.R. § 455.105(b) to the Division of Medicaid or to the Department of Health & Human Services (HHS) within thirty-five (35) days of the date on the request.

4. Agree to abide by the requirements of the Affordable Care Act (ACA) concerning the following:

a) Provider Screening Procedures (42 C.F.R. §§ 455.400-470), based on the category of the provider type, which includes license verifications, database checks of eligible professionals, owners, managing employees, etc., fingerprinting and criminal background checks, and/or unscheduled or unannounced site visits based on required screening rules.

1. Providers with an expired license will be denied enrollment.

2. Providers with any current disciplinary limitations on their license may be denied enrollment.

3. Providers that meet any of the exclusion requirements according to state and/or federal law will be denied enrollment.

b) Provider Application Fees (42 C.F.R. § 455.460).

c) Temporary Moratorium (42 C.F.R. § 455.470).

d) Provider Termination (42 C.F.R. § 455.416).

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e) Payment Suspensions (42 C.F.R. § 455.23).

5. The provider agrees to review, complete and submit a completed re-validation document as required by the policies of Division of Medicaid. All providers must undergo a revalidation screening process at least once every five years in accordance with 42 C.F.R. § 455.414.

6. All professional and institutional providers participating in the Medicaid program are required to keep records that fully disclose the extent of services rendered and billed under the program. These records must be retained for a minimum of five (5) years in order to comply with all federal and state regulations and laws. When there is a change of ownership or retirement, a provider must continue to maintain all Medicaid beneficiary records, unless an alternative method for maintaining the records has been established and approved by the Division of Medicaid. Upon request, providers are required to make such records available to representatives of the Division of Medicaid and others as provided by law in validation of any claims. The Division of Medicaid staff shall have immediate access to the provider’s physical location, facilities, records, documents, and any other records relating to medical care and services rendered to beneficiaries during regular business hours. Providers must maintain records as indicated in Part 200 Chapter 1, Rule 1.3: Maintenance of Records.

7. The provider must meet the requirements of the Social Security Act and federal regulations concerning: (a) disclosure by providers of ownership and control information; (b) disclosure of information by a provider’s owners of any persons with convictions of criminal offenses against Medicare, Medicaid, or the Title XXI services program; and (c) disclosure affiliations as described in Miss. Admin. Code Title 23, Part 200, Rule 4.8.A.9. If the Division of Medicaid ascertains that a provider has been convicted of a felony under federal or state law for an offense that the Division of Medicaid determines is detrimental to the best interests of the program or of Medicaid beneficiaries, the Division of Medicaid may refuse to enter into an agreement with such provider or may terminate or refuse to renew an existing agreement.

8. The provider must agree to accept payment for Medicaid covered services in accordance with the rules and regulations for reimbursement, as declared by the Secretary of Health and Human Services and by the state of Mississippi and established under the Mississippi Medicaid program.

9. The provider must agree to accept, as payment in full, the amount paid by the Medicaid program for all services covered under the Medicaid program within the beneficiary’s service limits with the exception of authorized deductibles, co-insurance, and co- payments. All services covered under the Medicaid program will be made available to the beneficiary. Beneficiaries will not be required to make deposits or payments on charges for services covered by Medicaid. A provider cannot pick and choose procedures for which the provider will accept Medicaid. At no time shall the provider be authorized to split services and require the beneficiary to pay for one type of service and Medicaid to

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pay for another. All services provided to Medicaid beneficiaries will be billed to Medicaid where Medicaid covers said services, unless some other resources, other than the beneficiary or the beneficiary’s family, will pay for the service.

10. For most medical services rendered, the provider must agree to take all reasonable measures to determine the legal liabilities of third parties including Medicare and private health insurance to pay for Medicaid covered services, and if third party liability is established, to bill the third party before filing a Medicaid claim. Exceptions to this rule are outlined in Part 306 Third Party Recovery. For the purpose of this provision, the term “third party” includes an individual, institution, corporation, or public or private agency that is or may be liable to pay all or part of the medical costs of injury, disease or disability of a Medicaid beneficiary and to report any such payments as third parties on claims filed for Medicaid payment.

11. Participating providers of services under the Medicaid program, i.e., physicians, dentists, hospitals, nursing facilities, pharmacies, etc., must comply with the requirements of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age of Discrimination Act of 1975. Under the terms of these Acts, a participating provider or vendor of services under any program using federal funds is prohibited from making a distinction in the provision of services to beneficiaries on the grounds of race, color, national origin or handicap. This includes, but is not limited to, distinctions made on the basis of race, color, national origin, age or handicap with respect to: (a) waiting rooms, (b) hours of appointment, (c) order of seeing patients, or (d) assignment of patients to beds, rooms or sections of a facility. The Division of Medicaid is responsible for routine and complaint investigations dealing with these three (3) Acts.

12. Participating providers are prohibited from making a distinction in the provision of services to Medicaid beneficiaries on the grounds of being Medicaid beneficiaries. This includes, but is not limited to, making distinctions with regard to waiting rooms, hours of appointment, or order of seeing patients, third party sources (pursuant to federal regulations), and quality of services provided, including those provided in a facility.

13. The provider must agree that claims submitted will accurately reflect both the nature of the service and who performed the service.

14. The provider must maintain a copy of the Administrative Code for Mississippi Medicaid and all revisions.

15. Participating providers must be eligible to participate in the Medicaid program as determined by DHHS-Office of Inspector General (DHHS-OIG). Certain individuals and entities are ineligible to participate in the Medicaid program on the basis of their exclusion as sanctioned by DHHS-OIG by authority contained in Sections 1128 and 1156 of the Social Security Act. The effect of exclusion is that no program payment will be made for any items or services, including administrative and management services, furnished, ordered or prescribed by an excluded individual or entity under the Medicare, Medicaid, and State Children’s Health Insurance Programs during the period of the

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exclusion. Program payments will not be made to an entity in which an excluded person is serving as an employee, administrator, operator, or in any other capacity, for any services including administrative and management services furnished, ordered, or prescribed on or after the effective date of the exclusion. In addition, no payment may be made to any business or facility that submits bills for payment of items or services provided by an excluded party. The exclusion remains in effect until the subject is reinstated by action of the DHHS-OIG. It is the responsibility of each Medicaid provider to assure that no excluded person or entity is employed in a capacity which would allow the excluded party to order, provide, prescribe, or supply services or medical care for beneficiaries, or allow the excluded party to hold an administrative, billing, or management position involving services or billing for beneficiaries.

16. The provider must verify with the NET Broker that all non-emergency transportation (NET) services are for a Medicaid covered service only. The provider is only required to verify the date, time, beneficiary’s Medicaid number, and provide confirmation that a Medicaid covered service will be provided at the appointment.

17. A provider that has not rendered services as evidenced on claims to the Division of Medicaid or coordinated care organization (CCO) for a one (1) year period will be disenrolled except for certain providers that are necessary to maintain access to covered services, as determined by the Division of Medicaid. Once disenrolled, the provider may reapply in accordance with the current enrollment policy.

B. Out-of-State Providers –

1. The Division of Medicaid may enroll an out-of-state provider to cover medical services if one (1) of the following conditions is met:

a) That are needed because of an emergency medical condition as defined in Miss. Admin. Code Title 23, Part 201, Rule 1.2.G.

b) That are needed because the beneficiary's health would be endangered if they were required to travel to their state of residence.

c) That the Division of Medicaid has determined, on the basis of medical advice, are needed and more readily available in the other state.

1. The provider must submit documentation supporting the need for out of state services, including, but not limited to:

(a) A description of how the provider’s enrollment will meet the needs of Mississippi Medicaid members and documentation of an insufficient existing provider base for the specified services in Mississippi.

(b) A description of how the provider’s enrollment will provide a unique service that is currently unavailable in Mississippi.

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2. Requests to cover specific procedure codes should not be submitted through provider enrollment and will not be reviewed.

d) The location of services provided is within:

1. Thirty (30) miles of the Mississippi state border for a pharmacy, or

2. Sixty (60) miles from the Mississippi state border for certain other provider types.

e) Or as determined by the Division of Medicaid.

2. The Division of Medicaid may use the results of the provider screenings performed by another state’s Medicaid or Children’s Health Insurance Program (CHIP) agency in the state in which the out-of-state provider is located or by a Medicare Contractor.

3. Out-of-state providers must adhere to the Division of Medicaid’s policies and procedures.

4. Out-of-State facilities must submit copies of outstanding claims, if applicable.

C. Providers that are closing, discontinuing a service, or otherwise stopping services for reasons unrelated to the beneficiary’s condition or medical necessity of the services must provide a thirty (30) day written notice to beneficiaries and the Division of Medicaid prior to ending the services:

1. Providers must assist with the transition of the beneficiary to another service provider.

2. Providers who fail to provide proper notice will not be reimbursed for services provided during the thirty (30) day period the beneficiary should have been notified unless the provider was prevented from making the notification due to causes beyond the reasonable control of the Provider, including but not limited to fire, floods, embargoes, war, acts of war, insurrections, riots, strikes, lockouts or other labor disturbances, or acts of God; provided, however, that a Provider so affected shall use reasonable commercial efforts to avoid or remove such causes of nonperformance, and shall provide proper notice hereunder immediately whenever such causes are removed. Changes to the scope of available services or reimbursement methodology for the provision of certain services through legislative or regulatory action shall not constitute an unforeseeable circumstance within the meaning of this section.

3. Facilities and/or entities that employ multiple enrolled providers are not required to provide the thirty (30) day notice when an enrolled provider that is employed leaves the facility and/or entity as long as the beneficiary has been transitioned to another provider within the same facility/entity and there is no interruption in services.

Source: 42 C.F.R. §§ 431.52, 431.107, 447.15, 455.101, 455.104-455.107, 455.412, 455.416, 455.460, 455.470; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121.

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History: Revised eff. 08/01/2026; Revised to correspond with MS SPA 24-0011 (eff. 10/01/24) eff. 06/01/2025; Revised eff. 01/01/2025; Revised eff. 11/01/2021; Revised eff. 04/01/2021; Revised eff. 10/01/2020; Revised eff. 04/01/2020; Revised Miss. Admin. Code Part 200, Rule 4.2.B. eff. 01/01/2020; Revised eff. 12/01/2019.

Rule 4.3: Change of Ownership

A. A change of ownership of a provider/facility as defined by the Division of Medicaid includes, but is not limited to: inter vivos gifts, purchases, transfers, lease arrangements, cash and/or stock transactions or other comparable arrangements whenever the person or entity acquires or controls a majority interest of the facility or service. The new owner, upon consummation of the transaction effecting the change of ownership, shall, as a condition of participation, assume liability, jointly and severally, with the prior owner for any and all amounts that may be due to the Medicaid program.

B. The new ownership agreement shall be subject to any restrictions, conditions, penalties, sanctions or other remedial actions taken by the Division of Medicaid, the state agency or the federal agency against the prior owner of the facility.

C. The agreement will also remain subject to all applicable statutes and regulations, including, but not limited to:

1. Any statement of deficiencies cited by the State Agency that are not in substantial compliance, including any existing plan of correction,

2. Any expiration date,

3. Compliance with applicable health and safety standards,

4. Compliance with ownership and financial disclosure requirements, and

5. Compliance with civil rights and the rights of individuals with developmental disability requirements.

D. A provider/facility that undergoes a change of ownership must:

1. Notify the Division of Medicaid within thirty-five (35) days after any change in ownership through the submission of:

a) A complete Mississippi Medicaid Provider Application Packet, and

b) Proof of change of ownership such as a bill-of-sale or Medicare Tie-In Notice.

2. Receive a new taxpayer identification segment for the new owner with the provider number remaining unchanged.

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3. Comply with all applicable Mississippi Department of Health requirements for changes of ownership [Refer to 15 Miss. Admin. Code. Pt 16, Subpart 1, Rule 49.2.6 and 15 Miss. Admin. Code Pt. 9, Subpart 91, Appendices.]

E. When there is a change of ownership or retirement/closure, a provider must continue to maintain all Medicaid beneficiary records for at least six (6) years, unless an alternative method for maintaining the records has been established in writing, and approved by the Division of Medicaid as required by Health Insurance Portability and Accountability Act of 1996 (HIPAA). [Refer to Part 200, Chapter 1, Rule 1.3, Maintenance of Records.]

F. The following are examples of changes of ownership. This list is not exhaustive. Providers who are unsure of whether a transaction constitutes a change of ownership should contact the Division of Medicaid’s Office of Provider Enrollment. Examples include:

1. Changes in type of organization (ex. Partnership to limited liability company, or single proprietorship to organization),

2. Mergers, when a new organization is formed and the merging companies are non- surviving,

3. Consolidation of two or more corporations resulting in a new corporate entity,

4. Changes in partnership, including the removal, addition, or substitution of one or more individuals as partners (under Mississippi law, these actions result in dissolution of an older partnership and creation of a new one),

5. Transfers between different levels of government, such as city to county, state to county, etc., and

6. Transfer (sale, gift, exchange of stock) that results in a fifty (50) percent or more change.

Source: 42 C.F.R. §§ 455.104, 489.18; Miss. Code Ann. §§ 41-7-173, 43-13-121.

History: Revised eff. 09/01/2020.

Rule 4.4: Effective Date of Provider Agreement and Provider Agreement Termination

A. Each provider or organization furnishing services under the Mississippi Medicaid State Plan must enter into a provider agreement with the Mississippi Division of Medicaid.

B. The effective date of the provider agreement is the earliest day of the following options:

1. The date all required screening has been completed by the Division of Medicaid if the Division of Medicaid cannot verify all required screenings have been completed by a:

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a) Medicare contractor, or

b) Medicaid agency or Children’s Health Insurance Program (CHIP) of another state,

2. Up to one hundred twenty (120) days prior to the date of the submission of a Mississippi Medicaid Enrollment application if the Division of Medicaid can verify that the provider had all required screenings completed by a:

a) Medicare contractor, or

b) Medicaid agency or Children’s Health Insurance Program (CHIP) of another state,

3. The date of Medicare certification, not to exceed three hundred and sixty-five (365) days from the date of application, if the provider requests enrollment in the Medicaid program within one hundred twenty (120) days from the date the Medicare Tie-in Notice was issued to the provider, or

4. The first day of the month in which the Division of Medicaid receives the provider’s enrollment application if the provider requests enrollment after one hundred twenty (120) days of the issuance of the Medicare Tie-in Notice.

C. For providers subject to survey and certification by the Centers for Medicare and Medicaid Services (CMS) or the State survey agency, the effective date is determined as follows:

1. The agreement is effective on the date the onsite survey is completed, if on that date the provider meets:

a) All applicable Federal requirements; and

b) Any other requirements imposed by the State for participation in the Medicaid program.

2. If on the date the survey is completed the provider fails to meet any of the requirements of the survey/accreditation, the following rules apply:

a) A Nursing Facility provider agreement is effective on the date the nursing facility is found to be in substantial compliance, and

b) CMS or the State survey agency receives from the Nursing Facility, if applicable, an approvable waiver request.

c) For an agreement with any other provider, the effective date is the earlier of the date on which the provider meets all requirements, or the date on which a provider is found to meet all conditions of participation but has lower level deficiencies, and CMS or the State survey agency receives from the provider an acceptable plan of correction for the lower level deficiencies, or an approvable waiver request, or both.

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The date of receipt is the effective date of the agreement, regardless of when CMS approves the plan of correction or waiver request, or both.

D. If a provider is currently accredited by a national accrediting organization whose program had CMS approval at the time of accreditation survey and accreditation decision, and on the basis of accreditation, CMS has deemed the provider to meet Federal requirements, the effective date depends on whether the provider is subject to requirements in addition to those included in the accrediting organization's approved program.

a) For a provider that is subject to additional requirements, Federal or State, or both, the effective date is the date on which the provider meets all requirements, including the additional requirements.

b) For a provider that is not subject to additional requirements, the effective date is the date of the provider's initial request for participation if on that date the provider met all Federal requirements.

c) If the provider meets the requirements in Miss. Admin. Code Title 23, Part 200, Rule 4.4, (C) (4) (a) or Rule 4.4, (C) (4) (b), the effective date may be retroactive for up to one hundred twenty (120) days.

E. For out-of-state providers, applications and claims must be submitted within one hundred twenty (120) days of the date of service. The effective date of the provider agreement will be:

1. The date of the service if the service was an emergency or if the beneficiary's health would be endangered if they were required to travel to their state of residence, or

2. The date determined in Miss. Admin. Code Part 200, Rule 4.4.B.

F. The Division of Medicaid does not make payments to any provider or organization prior to the date of a valid Medicaid provider agreement. This rule applies for any services rendered regardless of any time period provided for under any timely filing provision.

G. Timely filing requirements apply to all claims submitted by all providers. [Refer to Miss. Admin. Code Part 200, Rule 1.6]

H. Providers of the following state plan services will continue to receive payment for up to thirty (30) days after the effective date of termination of a provider agreement for services furnished to a beneficiary who was admitted before the effective date of the termination to permit time for an orderly transfer of Medicaid beneficiaries:

1. Inpatient hospital services,

2. Nursing facility (NF) services,

3. Psychiatric residential treatment facility services (PRTF),

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4. Intermediate care facilities for the intellectually and/or developmentally disabled (ICF/ IDD) facility services, and

5. Home health services and hospice services furnished under a plan established before the effective date of termination.

I. The facilities listed in Miss. Admin. Code Part 200, Rule 4.1.D. must:

1. Notify all Medicaid beneficiaries, families, and/or sponsors in writing within forty-eight (48) hours of notice of termination of Medicaid participation,

2. Submit to the Division of Medicaid a current list of Medicaid beneficiaries who are receiving Medicaid services along with the name, address and telephone number of the family and/or the sponsor, when available, and the beneficiary’s attending physician.

3. Assist the beneficiaries, families and the facility in making other facility arrangements for the beneficiaries.

J. Reinstatement may be granted after a provider has been terminated by the licensing or certification board, Office of Inspector General, the Centers for Medicare and Medicaid services (CMS), or the Division of Medicaid when conditions of reinstatement have been satisfied by the sanctioning entity. Notification of re-instatement from the appropriate entity must be provided with an application for re-instatement to participate in the Medicaid program.

Source: 42 C.F.R. §§ 431.108, 489.55, 489.57; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 08/01/2026. Added Miss. Admin. Code Part 200, Rule 4.4.C. eff. 01/01/2020; Revised eff. 12/01/2019.

Rule 4.5: Licensure, Specialty Certificates, Certification and Permits

A. Medicaid providers must maintain current information as required by the Division of Medicaid such as licensure, specialty certificates, permits, and/or certification from their governing entity, as applicable, on file with the Division of Medicaid at all times while enrolled as a Medicaid provider.

1. The provider is ineligible to provide services to Medicaid beneficiaries if the license, permit, or certification of the provider is suspended, revoked, surrendered, or expired, effective on the date of the suspension, revocation, surrender or expiration.

2. The provider is ineligible to provide services to Medicaid beneficiaries if the license, permit, or certification of an employee of the provider upon which provider eligibility results from, is suspended, revoked, surrendered, or expired, or the person ceases to be an

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agent/employee of the provider effective on the date of the suspension, revocation, surrender, expiration, or change in employment.

3. The provider is ineligible to provide services to Medicaid beneficiaries when their license, permit, or certification has been limited due to disciplinary action by the board or entity that issues the license, permit, or certification effective on the date of the limitation.

B. The Division of Medicaid will process license renewals to avoid any gap in provider eligibility if:

1. The license update is provided to the Division of Medicaid within one (1) year from the expiration of the license;

2. The provider submits a copy of their current license or current licensure information is obtained directly or indirectly from a licensing agency through an electronic data match including any necessary updates to information, and

3. The provider has remained in compliance with all other conditions of participation.

C. The provider must re-enroll as a Medicaid provider when the provider’s Medicaid number has been closed due to license expiration for more than one (1) year.

D. In lieu of a license or permit as identified in Miss. Admin. Code Title 23, Part 200, Rule 4.5 (A), speech-language pathology providers must provide evidence that such is not required in the state or territory in which they practice and have completed one of the following:

1. A certificate of clinical competence from the American Speech and Hearing Association (ASHA),

2. The equivalent educational requirements and work experience necessary for the certificate, or

3. The academic program in Miss. Admin Code Title 23, Part 213, Rule 4.5, D.1. above and is acquiring supervised work experience to qualify for the certificate.

E. In lieu of a license or permit as identified in Part 200, Rule 4.5 (A), an audiologist must provide evidence that such is not required in the state or territory in which they practice and have:

1. A Certificate of Clinical Competence in Audiology granted by the ASHA for licensure, or

2. Successfully completed a minimum of three hundred fifty (350) clock-hours of supervised clinical practicum, or is in the process of accumulating that supervised clinical experience under the supervision of a qualified master or doctor-level audiologist;

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performed at least nine (9) months of full-time audiology services under the supervision of a qualified master or doctoral-level audiologist after obtaining a master’s or doctoral degree in audiology, or a related field; and successfully completed a national examination in audiology approved by the Secretary.

F. A Clinical Laboratory Improvement Amendments (CLIA) certificate is required, as appropriate.

Source: 42 CFR §§ 455.412, 455.416, 455.450; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. Revised eff. 08/01/2025. Revised eff. 04/01/2021.

Rule 4.6: Advertising by Provider

A. No person may use, in connection with any item constituting an advertisement, solicitation, circular, book, pamphlet, or other communication, or a broadcast, telecast, or other production, alone or with other words, letters, symbols or emblems, the word “Medicaid” or “Division of Medicaid”, or “Medicaid program”, or “Mississippi Medicaid”, or “Mississippi Division of Medicaid” in a manner which such person knows or should know would convey, or in a manner which reasonably could be interpreted or construed as conveying, the false impression that such item is approved, endorsed, or authorized by the Mississippi Division of Medicaid.

B. Providers may list Medicaid as a pay source they will accept, e.g., most third-party insurance, Medicare, and Medicaid accepted.

Source: Miss. Code Ann. § 43-13-121

Rule 4.7: Change of Tax ID

Providers who change tax identification numbers under circumstances other than those described in Rule 4.3, Change of Ownership and Rule 4.8, Requirements for All Providers must:

1. Request the change and the effective date of change in writing,

2. The request must include the tax identification number;

3. The tax identification type (FEIN or SSN);

4. The legal name of the provider; and

5. Attestation that a change of ownership, as defined in Rule 4.3, has not occurred.

The provider does not need to submit a Provider Enrollment Change of Ownership application. The provider number is not changed; however, a new taxpayer identification segment will be established.

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Source: Miss. Code Ann. § 43-13-121

History: Revised eff. 08/01/2026.

Rule 4.8: Requirements for All Providers

A. All providers are required to submit the following information or documentation:

1. Mississippi Medicaid Provider Enrollment Application

a) Individuals and Sole Proprietor applications must be signed by the individual provider.

b) Business/Entity applications must be signed by the Authorized Official.

2. Medical Assistance Participation Agreement (Provider Agreement)

3. Direct Deposit Authorization/Agreement Form

a) Include a copy of a voided check, deposit slip, or letter from the bank noting the account number and transit routing number.

b) Starter checks and counter deposit slips are not acceptable.

4. Legal Name and Federal Tax Identification Number

a) For organizational providers, the legal business name and Federal Employer Identification Number (FEIN) must match the information on record with the Internal Revenue Service (IRS) and must correspond to the legal name and FEIN provided in the Mississippi Medicaid Provider Enrollment Application.

b) For individual providers enrolling as a sole proprietor using a FEIN, the name and FEIN must match IRS records and must align with the information provided in the Mississippi Medicaid Provider Enrollment Application.

c) For individual providers, the name and Social Security Number must match IRS records and be consistent with the information submitted in the Mississippi Medicaid Provider Enrollment Application.

d) A copy of written confirmation from the IRS must be made available, upon request, within sixty (60) days.

5. Electronic Data Interchange (EDI) Provider Agreement and Enrollment Form is required if the intent is to submit electronically.

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6. Civil Rights Compliance Attestation. The following documents are not required at the time of attestation but must be provided upon request within sixty (60) days, including but not limited to:

a) A copy of the provider’s Nondiscrimination Policy.

b) A copy of the provider’s Limited English Proficiency Policy.

c) A copy of the provider’s Sensory and Speech Impairment Policy.

d) A copy of the provider’s Notice of Program Accessibility Policy.

e) A copy of the Department of Health and Human Services (DHHS) Office of Civil Rights letter of compliance may be submitted in lieu of the listed policies.

f) A copy of the provider’s published non-discrimination policy, required only for healthcare facilities.

7. Providers who have changes of information which are not considered a change of ownership (CHOW) must submit the following information, if applicable:

a) Tax Identification Number and Legal Name,

b) Change of Address form for provider mailing and/or business addresses, e-mail contact information or telephone number changes,

c) Electronic Funds Transfer (EFT) form for provider banking information changes, and/or

d) Provider Disclosure Form for any other applicable changes.

8. Certain disclosures are required for participation as a provider in the Mississippi Division of Medicaid.

a) The Division of Medicaid requires use of the Mississippi Medicaid Provider Disclosure Form, signed by the Authorized Official, in the following instances:

1. Upon the provider’s submission of the provider enrollment application,

2. Upon request of the Division of Medicaid during the re-validation of enrollment process, and

3. Within thirty-five (35) days after any change in ownership of the provider.

b) Required disclosures include:

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1. The name and address of any individual or corporation with an ownership or control interest in the provider. The address for corporate entities must include an applicable primary business address, every business location, every P.O. Box address, and/or other mailing address.

2. Date of birth and Social Security Number (in the case of an individual).

3. Other tax identification number (in the case of an organization) with an ownership or control interest in the provider or in any subcontractor in which the disclosing entity has a five percent (5%) or more interest.

4. Whether the person (individual or corporation) with an ownership or control interest in the provider is related to another person with ownership or control interest in the provider as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity has a five percent (5%) or more ownership interest is related to another person with ownership or control interest in the provider as a spouse, parent, or sibling.

5. The name of any other provider in which the ownership of the provider has an ownership or control interest.

6. The name address, date of birth, and Social Security Number of any managing employee, authorized official, and delegated official of the provider.

7. Any additional disclosures as required and enumerated by state and/or federal law.

9. Certain disclosures are required upon request by the Division of Medicaid during initial enrollment and/or during the re-validation of enrollment process as follows:

a) Any and all affiliations that the provider or any of its owning or managing employees or organizations, consistent with the terms “person with an ownership or control interest” and “managing employee” as defined in § 455.101, has with a currently or formerly enrolled Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) provider or supplier that has a disclosable event, as defined in § 455.101.

b) Any and all affiliations that the provider or any of its owning or managing employees or organizations, consistent with the terms “person with an ownership or control interest” and “managing employee” as defined in § 455.101, had within the previous five (5) years with a currently or formerly enrolled Medicare, Medicaid, or CHIP provider or supplier that has a disclosable event, as defined in § 455.101.

10. Provide a National Provider Identifier (NPI), received from the National Plan and Provider Enumeration System (NPPES), unless receipt of an NPI is prohibited by NPPES.

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11. The following providers are required to attest that a collaborative agreement with a Mississippi Medicaid enrolled physician is on file with the appropriate licensing board:

a) Certified Registered Nurse Anesthetist (CRNA),

b) Nurse Practitioner (NP),

c) Certified Nurse Midwife (CNM), or

d) Physician Assistant (PA)

12. The abovementioned provider attestation must be available for review within sixty (60) days, upon request, unless collaboration or supervision is not required in the state in which the provider is practicing.

13. Any changes in the provider’s collaborating physician should be reported to the Division of Medicaid once approved by the appropriate licensing board.

B. Failure to comply with the terms of this rule may result in rejection of the Provider Enrollment Application, revocation of provider enrollment, or a suspension in the payment of claims.

Source: 42 C.F.R. §§ 455.101, 455.104-455.107, 455.414; Miss. Code Ann. §§ 43-13-117, 43- 13-121.

History: Revised eff. 08/01/2026. Revised eff. 01/01/2026. Revised to correspond with MS SPA 24-0011 (eff. 10/01/24) eff. 06/01/2025; Revised eff. 09/01/2020.

Rule 4.9: Group Providers

A. Business or entity enrolling as a group of providers so that all monies received shall report to the tax identification number of the business. The following criteria must apply:

1. The enrolling provider has a tax identification number.

2. The enrolling provider is not a sole proprietor.

3. The enrolling provider employs and notes an active individual servicing provider within their application.

B. Providers enrolling as a group must meet the requirements set forth in Part 200, Chapter 4, Rule 4.8 for all providers, the requirements for their individual provider type requirements outlined in the assigned chapters of this code and the requirements listed below for group providers:

1. National Provider Identifier (NPI), verification from National Plan and Provider

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Enumeration System (NPPES).

2. Provide your tax identification number and legal business name.

3. CLIA certificate and CLIA Certification form, if applicable.

4. At least one active individual provider is linked to the enrolling group.

C. This rule is applicable to all group enrollments, including but not limited to the following provider types:

1. CRNA,

2. Nurse Practitioner,

3. Dentist,

4. Physician Assistant,

5. Dietician/ Nutritionist,

6. Occupational therapist,

7. Physical therapist,

8. Speech Therapist,

9. Optometrist,

10. Audiologist,

11. Nurse Midwife,

12. Pharmacist Disease Management,

13. Physician,

14. Osteopath (DO),

15. Chiropractor,

16. Podiatrist,

17. Psychologist,

18. Licensed Certified Social Worker (LCSW),

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19. Licensed Marriage and Family Therapist (LMFT), and

20. Licensed Professional Counselor (LPC).

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026.

Rule 4.10: 340B Providers

A. The Division of Medicaid defines a 340B provider as a nonprofit healthcare organization that meets the requirements of, and is considered to be, a covered entity under Section 340B of the Public Health Service Act which has elected to enroll in the 340B program.

B. The Division of Medicaid defines 340B purchased drugs as those:

1. Produced by any manufacturer which has entered into and complies with an agreement under Section 1927 (a) of the Act which are prescribed for a medically acceptable indication,

2. Purchased and administered or dispensed by 340B covered entities under the rules of the 340B program, and

3. Dispensed and administered to a 340B eligible beneficiary as defined in Miss. Admin. Code Part 200, Rule 4.10.C.

C. The Division of Medicaid defines an individual as a 340B eligible beneficiary if:

1. The individual has established a relationship with the covered entity, such that the covered entity maintains records of the individual’s healthcare,

2. The individual received healthcare services from a healthcare professional who is either employed by the covered entity or provides healthcare under contractual or other arrangements such that responsibility for the care provided remains with the covered entity, and

3. The individual receives a healthcare service or range of services from the covered entity which is consistent with the service or range of services for which grant funding or federally qualified health center look-alike status has been provided to the entity. Disproportionate share hospitals are exempt from this requirement.

D. Covered entities:

1. Eligibility to participate in the 340B program includes, but is not limited to:

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a) Health Centers including, but not limited to:

1. Federally Qualified Health Centers,

2. Federally Qualified Health Center Look-Alikes, and

3. Tribal/Urban Indian Health Centers.

b) Hospitals including, but not limited to:

1. Children’s Hospitals,

2. Critical Access Hospitals,

3. Disproportionate Share Hospitals,

4. Free Standing Cancer Hospitals,

5. Rural Referral Centers, and

6. Sole Community Hospitals.

c) Specialized Clinics including, but not limited to:

1. Black Lung Clinics,

2. Comprehensive Hemophilia Diagnostic Treatment Centers,

3. Title X Family Planning Clinics,

4. Sexually Transmitted Disease Clinics, and

5. Tuberculosis Clinics.

2. Must comply with all Health Resources and Service Administration’s (HRSA’s) regulations and requirements.

3. Must maintain detailed and auditable records regarding the compliance with all the Division of Medicaid’s 340B program requirements and policies.

E. Covered entities:

1. Must notify the Division of Medicaid of their election to participate in or to terminate from the federal 340B program.

2. Who participate in the federal 340B drug program must notify the Division of Medicaid

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of their election to opt-in or opt-out of billing the Division of Medicaid for 340B purchased drugs and must comply with the following.

a) The Division of Medicaid defines opt-in as a provider electing to dispense and/or administer drugs which have been purchased under the rules of the 340B federal program, and billing the Division of Medicaid for eligible Medicaid beneficiaries enrolled in either fee-for-service (FFS) or in a coordinated care organization (CCO). These covered entities must:

1. Register, enroll and receive an identification number from HRSA.

2. Complete, sign and submit the Division of Medicaid’s 340B Covered Entity Attestation & Provider Enrollment Form to the Division of Medicaid indicating enrollment in the 340B program.

3. Recertify with HRSA annually and notify the Division of Medicaid in writing by submitting the 340B Covered Entity Attestation & Provider Enrollment Form of any changes in 340B election status.

4. Dispense/administer covered 340B drugs purchased under the 340B program only to eligible beneficiaries.

5. Bill the Division of Medicaid according to Miss. Admin. Code Part 200, Rule 4.10.F.

6. Submit drug invoices as required by the Division of Medicaid for auditing purposes.

b) The Division of Medicaid defines opt-out as a covered entity electing never to bill the Division of Medicaid for 340B purchased drugs. These covered entities must complete, sign and submit to the Division of Medicaid the 340B Covered Entity Attestation & Provider Enrollment Form indicating election to opt-out.

c) Covered entities must notify the Division of Medicaid immediately of any change in election in billing the Division of Medicaid for 340B purchased drugs.

F. 340B covered entities who have elected to opt-in must bill the Division of Medicaid for dispensed/administered 340B purchased drugs as follows:

1. For point-of-sale (POS) claims, pharmacy providers must bill the ingredient cost at the actual acquisition cost (AAC) in effect as of July 1, 2021, defined as the price the pharmacy paid the wholesaler or manufacturer for the 340B purchased drug with no mark-up plus the applicable professional dispensing fee. Providers must identify 340B purchased drugs dispensed or administered with the appropriate National Council for Prescription Drug Programs’ (NCPDP) field values as defined by the Division of Medicaid.

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2. For medical claims, providers must bill 340B purchased Physician Administered Drugs (PAD) at the same cost in effect for State Fiscal Year (SFY) 2021, with the appropriate modifier to identify the 340B purchased drug and the corresponding Healthcare Common Procedure Coding System (HCPCS) and National Drug Code (NDC).

G. Under Miss. Admin. Code Part 200, Rule 1.3, a provider who knowingly or willfully makes, or causes to be made, false statement or representation of a material fact in any application for Medicaid benefits or Medicaid payments may be prosecuted under Federal and State criminal laws.

H. A contract pharmacy, defined by the Division of Medicaid as an agent of a 340B covered entity and ineligible to be a freestanding 340B covered entity, cannot dispense and bill the Division of Medicaid for 340B outpatient drugs for Medicaid beneficiaries.

I. A covered entity found in violation of Miss. Admin. Code Part 200, Rule 4.10.D.2. and D.3. is liable to the manufacturer of the covered outpatient drug that is the subject of the violation in an amount equal to the reduction in the price of the drug provided under the agreement between the entity and the manufacturer.

Source: 42 U.S.C. § 256b; 42 C.F.R Part 10; 42 C.F.R. § 447.512; Miss. Code Ann §§ 43-13- 117, 43-13-121; SPA 17-0002.

History: Revised eff. 07/01/2021; Revised eff. 04/01/2019; Eff. 11/01/2018. Removed Miss. Admin. Code Part 200, Chapter 4, Rule 4.10, B, E, F, and J to correspond with the withdrawal of SPA 14-015 eff. 11/01/2014; New Rule eff. 07/01/2014 to correspond with SPA 14-015 (eff. 07/01/2014).

Part 200 Chapter 5: General

Rule 5.1: Medically Necessary

A. The Division of Medicaid will provide coverage for services when it is determined that the medically necessary criteria and guidelines listed below are met.

B. “Medically necessary” or “medical necessity” is defined as health care services that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

1. Appropriate and consistent with the diagnosis of the treating provider and the omission of which could adversely affect the patient’s medical condition,

2. Compatible with the standards of acceptable medical practice in the United States,

3. Provided in a safe, appropriate and cost-effective setting given the nature of the diagnosis and the severity of the symptoms,

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4. Not provided solely for the convenience of the beneficiary or family, or the convenience of any health care provider,

5. Not primarily custodial care

6. There is no other effective and more conservative or substantially less costly treatment service and setting available, and

7. The service is not experimental, investigational or cosmetic in nature.

C. All Mississippi Medicaid program policies, exclusions, limitations, and service limits, etc., apply. The fact that a service is medically necessary does not, of itself, qualify the service for reimbursement.

Source: Miss. Code Ann. § 43-13-121

Rule 5.2: Consent for Minors

A. Whenever a health care practitioner treats a Medicaid beneficiary, it is the responsibility of the practitioner to have a clear understanding of the legal framework within which care is to be provided to minors.

B. All Mississippi Medicaid providers are responsible for following and documenting compliance with their state law, federal laws, rules, policies, and/or guidance in the delivery of healthcare services to minors.

Source: Miss. Code Ann. § 43-13-121; § 41-41-3; 41-41-7; 41-41-13, 41-41-14; 41-41-13; §7129-81(h)(Supp. 1971)

Rule 5.3: Wellness Program

A. Wellness Services for Adults

1. Annual Health Screening/Physical Examinations for Beneficiaries for Adults (Age 21 and over)

a) The Division of Medicaid covers annual physical examinations for adults.

b) The annual physical examination will not be counted toward any physician visit limit.

c) Appropriate age-related screenings such as those listed below will be reimbursed separately when performed as part of the annual physical exam.

1. Cardiovascular Screening - The Division of Medicaid will pay for an annual screening of cholesterol, lipids, and triglyceride levels.

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2. Diabetes Screening - An annual screening for diabetes is covered. The screening may include appropriate laboratory and urine studies.

3. Cervical and Vaginal Cancer Screening - A Pap test and a pelvic exam are covered yearly for women.

4. Screening Mammography - The Division of Medicaid covers annual mammography for women beginning at age forty (40).

5. Colorectal Cancer Screening - A yearly screening for occult blood is covered for individuals beginning at age fifty (50), or individuals who are <50 and identified as high risk. A flexible sigmoidoscopy or barium enema is covered every five (5) years, or a colonoscopy is covered every ten (10) years. High risk individuals have one (1) or more of the following colorectal cancer risk factors:

d) A personal history of colorectal cancer or adenomatous polyps,

e) A personal history of chronic inflammatory bowel disease, either Crohn’s disease or ulcerative colitis,

f) A strong family history of colorectal cancer or polyps including cancer polyps in a 1st degree relative [parent, sibling, or child] younger than sixty (60) or in two (2) or more 1st degree relatives of any age, or

g) A known family history of hereditary colorectal cancer syndromes such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC).

1. Prostate Cancer Screening - A prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) are covered annually for men beginning at age fifty (50). Both screenings are covered annually beginning at age forty-five (45) for men of African-American descent.

2. Bone Density Studies are allowed every twenty-four (24) months for women age sixty-five (65) and older.

3. Vision and Glaucoma Screening eye exams are covered as specified in Part 217 Vision Services.

4. Influenza and Pneumonia Vaccines are covered services for both children and adults under Mississippi Medicaid as outlined in Part 224 Immunizations.

B. Wellness Services for Children (Under Age 21)

1. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, a mandatory service under Medicaid, provides preventive and comprehensive health

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services for Medicaid eligible children and youths up to age twenty-one (21). Children will access the mandatory periodic screening services through EPSDT providers. EPSDT providers will follow the Division of Medicaid’s rules for the EPSDT Program.

2. No co-payment is applicable for services to children under age eighteen (18). The provider must report the co-payment Exception Code “C” on claims for beneficiaries under age eighteen (18). The codes for the periodic screening examinations do not apply toward the physician visit limit per fiscal year.

C. Wellness Services for Dual Eligibles

1. Beneficiaries whose Medicare Part B coverage begins on or after January 1, 2005 will have Medicare coverage for a one time only “Welcome to Medicare” Physical Examination within the first six (6) months of the Medicare coverage.

2. If the beneficiary has both Medicare and Mississippi Medicaid, the routine annual physical examination is not covered under Medicaid if the beneficiary is eligible for or has already received the “Welcome to Medicare” physical examination. The Division of Medicaid will not duplicate benefits for routine annual physical examinations covered by Medicare and will not provide an annual physical examination until twelve (12) months has elapsed from the original effective date of the Medicare Part B coverage. For these instances, it is the sole responsibility of the provider to determine whether Medicare or Mississippi Medicaid is the appropriate billing source.

3. Dual eligibles whose Medicare Part B effective date is prior to January 1, 2005 will be eligible for the physical examination as outlined above for adults or children.

D. Diagnostic and/or Screening Procedures are radiology and laboratory procedures which are a standard part of a routine adult annual age/gender physical examination or well child periodic screening may be billed by the provider performing the procedure, and coverage will be determined based on current Mississippi Medicaid policies for the individual procedures.

E. The Division of Medicaid covers a physical exam for beneficiaries enrolled in the Family Planning Waiver. [Refer to Part 221]

F. The Division of Medicaid does not cover an annual physical examination for:

1. School entrance,

2. Sports,

3. Employment, or

4. Beneficiaries in an institutional setting including those that are in a nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF/IID).

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Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 03/01/2026. Revised to correspond with SPA 23-0011 (eff. 5/01/2023) eff. 09/01/2023. Revised eff. 04/01/2018.

Rule 5.4: Tobacco Cessation

A. The Division of Medicaid covers up to twelve (12) in-person or telehealth tobacco cessation counseling sessions per State Fiscal Year, when provided by:

1. A physician, or

2. Other licensed practitioner that has prescriptive authority, operating within their scope of practice.

B. Tobacco Cessation Medications - The following types of tobacco cessation medications are covered in the Mississippi Medicaid program:

1. Over-the-counter nicotine products,

2. Legend or prescription nicotine replacement products,

3. Bupropion Hydrochloride, and

4. Varenicline Tartrate.

B. A physician’s prescription will be required for all legend and over-the-counter tobacco cessation medications. Each prescription will count toward the monthly limit.

C. The Division of Medicaid will monitor the beneficiary’s utilization of tobacco cessation products for over utilization or misuse; and in instances where there are patterns suggesting over utilization or misuse, the prescribing physician(s) will be contacted for justification of medical necessity.

Source: Miss. Code Ann. § 43-13-121

History: Revised to correspond with MS SPA 23-0024 (eff. 07/01/2023) eff. 01/01/2024

Rule 5.5: Mobile Medical Units Other Than Independent Diagnostic Treatment Facilities

A. For Division of Medicaid purposes, a mobile medical unit is defined as a self-contained facility or unit that can be moved, towed, or transported from one location to another and provides prevention, screening, diagnostic, and treatment services. This rule and definition excludes services provided in an Independent Diagnostic Treatment Facility (IDTF). See Part 219, Rule 1.3.

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B. Mobile medical units must satisfy the following criteria:

1. Must be owned and operated by a current Medicaid provider that has a permanent fixed office location where healthcare services are provided during normal business hours on a daily basis and the fixed office location is available for contact twenty-four (24) hours a day, seven (7) days a week.

2. Must maintain fixed schedule for locations.

3. Must have a separate Medicaid provider number from the permanent fixed office location

4. Must have a physician, physician assistant, dentist, certified audiologist, chiropractor, pharmacist, optometrist, ophthalmologist, or nurse practitioner available to furnish direct patient care services at all times during business hours.

5. Must have a written procedure that includes emergency follow-up care for beneficiaries treated in the mobile medical unit and arrangements for treatment in a facility which is permanently established in the area.

6. Must have communication capabilities which will enable the staff to contact necessary emergency personnel in the event of an emergency.

7. Must ensure the driver of the mobile unit possesses a valid Mississippi driver’s license of the appropriate class, the vehicle has a current Mississippi motor vehicle tag, and the vehicle has had a current Mississippi motor vehicle inspection.

8. Must comply with all applicable federal, state, and local laws, regulations and ordinances governing biohazard waste, waste water (black and grey), construction, safety, sanitation, insurance, and zoning.

9. Must be accessible in accordance with the Americans with Disabilities Act.

10. Must have properly functioning sterilization system for sterilizing reusable medical equipment.

11. Must have access to an adequate supply of potable (suitable for drinking) and portable water, including hot water.

12. Must have access to toilets and sanitary hand washing facilities.

C. All service limits apply, and services are subject to all rules and regulations applied by the Mississippi Division of Medicaid for each program area.

D. Documentation

1. Beneficiary records must be maintained at the permanent fixed physical office location

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and a copy of the beneficiary’s record must be maintained in the mobile unit.

2. At a minimum, the records must contain the following on each beneficiary:

a) Date of service,

b) History taken on initial visit,

c) Chief complaint on each visit,

d) Tests, radiographs and results. Radiographs must be legible, contain the beneficiary’s name and the date, and must be maintained on file with the beneficiary’s records,

e) Diagnosis,

f) Treatment, including prescriptions,

g) Signature or initials of provider after each visit, and

h) Copies of hospital and/or emergency room records that are available.

3. Providers must maintain proper and complete documentation to verify the services. The provider has full responsibility for maintaining documentation to justify the services provided. Maintenance of all records should be in compliance with Part 200, Chapter 1, Rule 1.3.

Source: Miss. Code Ann. § 43-13-121; Americans with Disabilities Act

Rule 5.6: Diabetes Self-Management Training (DSMT)

A. The Division of Medicaid defines Diabetes Self-Management Training (DSMT) as an interactive and collaborative process through which beneficiaries with diabetes gain the knowledge and skills needed to modify their behavior and self-manage the disease and its related conditions.

B. The Division of Medicaid does not enroll a provider for the sole purpose of performing DSMT because DSMT is not a separately recognized provider type. The provider seeking reimbursement for DSMT must meet all of the required criteria set forth in Miss. Admin. Code Part 200, Rule 4.8 in addition to being:

1. A current Mississippi Medicaid provider,

2. Located in the State of Mississippi, and

3. Accredited by the American Diabetes Association (ADA) or the American Association of Diabetes Educators (AADE).

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C. The Division of Medicaid covers DSMT when medically necessary, ordered by a physician, physician assistant, or nurse practitioner who is actively managing the beneficiary’s diabetes, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or a designated entity and when all the following criteria are met:

1. The beneficiary has been diagnosed with diabetes by a physician,

2. The services are provided under the direct supervision of a physician, physician assistant, nurse practitioner, pharmacist or a registered nurse certified as a diabetes educator, and

3. The program meets the current ADA training standards.

D. The DSMT Plan of Care must include, but is not limited to:

1. An assessment of the beneficiary’s specific needs for training,

2. Identification of the beneficiary’s specific diabetes self-management goals,

3. Behavioral interventions directed toward helping the beneficiary achieve identified self- management goals, and

4. Evaluation of the beneficiary’s progress towards identified self-management goals.

E. DSMT includes:

1. One (1) initial training per lifetime which:

a) Must be provided within a continuous six (6) month period which begins with the initial individual assessment visit.

b) Cannot exceed a total of seven (7) hours, provided in increments no less than thirty (30) minutes, which:

1. May include up to one (1) hour of individual training for assessment of the beneficiary’s training needs.

2. Includes up to six (6) hours of training in a group setting consisting of two (2) or more individuals except when the ordering physician determines:

(a) A beneficiary would benefit from individual sessions instead of group sessions which the physician’s order must include a statement specifying DSMT training in individual sessions along with an explanation, or

(b) A medical condition prevents the beneficiary from completing the seven (7) hours of initial training within six (6) months. Prior authorization for an

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extension to the six (6) month time-frame must be obtained from the UM/QIO.

2. Follow-up training which:

a) Must be ordered by the physician actively managing the beneficiary’s diabetes, including documentation in the medical record of the specific medical condition that the follow-up training must address,

b) Is furnished any time in a year following the year in which the beneficiary completes the initial training,

c) Includes a maximum of two (2) hours each year,

d) Is furnished in increments of no less than thirty (30) minutes, and

e) Is provided in group sessions consisting of two (2) or more individuals unless the ordering physician determines a beneficiary would benefit from individual sessions instead of group sessions. The physician’s order must include a statement specifying DSMT training in individual sessions along with an explanation.

F. Beneficiaries under the age of eighteen (18) must be accompanied by a parent/guardian/legal representative.

G. The Division of Medicaid pays for all medically necessary services for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: 42 CFR § 410.141; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Moved from Miss. Admin. Code Part 202, Rule 2.11 and revised Miss. Admin. Code Part 200, Rule 5.6.C. eff. 12/01/2015; New Rule eff. 04/01/2015.

Rule 5.7: Electronic Health Records

A. The Division of Medicaid recognizes an electronic health record (EHR) as an electronic version of a beneficiary’s medical history and key administrative clinical data relevant to a beneficiary under the care of a particular provider, that is maintained by a provider over time, and may include, but is not limited to:

1. Demographics,

2. Progress notes,

3. Problems,

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4. Medications,

5. Vital signs,

6. Past medical history,

7. Immunizations,

8. Laboratory data, and

9. Imaging data.

B. A provider may use an electronic signature (e-signature) in an EHR. E-signatures in EHR must:

1. Meet certified electronic health record technology (CEHRT) criteria according to the National Institute of Standards and Technology (NIST) and the Office of the National Coordinator for Health Information Technology (ONC) standards,

2. Be in compliance with both Uniform Electronic Transactions Act (UETA) and Electronic Signatures in Global and National Commerce Act (ESIGN Act) standards, and

3. Maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) in regards to the access, transfer, storage and signing of EHRs.

4. Comply with Division of Medicaid requirements regarding e-signatures. [Refer to Miss. Admin. Code Part 200, Rule 1.10.]

C. A beneficiary may use an e-signature in an EHR. The beneficiary must:

1. Consent to the use of an electronic signature when completing necessary forms, including, but not limited to, the consent for treatment.

2. Be given the option to use an electronic or handwritten signature.

3. Be furnished an electronic or printed copies of all documents electronically signed.

4. Comply with Division of Medicaid requirements regarding e-signatures. [Refer to Miss. Admin. Code Part 200, Rule 1.10.]

Source: 42 C.F.R. § 435.907; Miss. Code Ann. §§ 43-13-117, 43-13-121, 75-12-1 et. seq.

History: Revised eff.04/01/2020; New eff. 07/01/2019.

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Part 200 Chapter 6: Indian Health Services

Rule 6.1: Provision of Indian Health Services

Governmental responsibility for the provision of health services to the American Indian/Alaskan Native (AI/NI) population evolved through numerous Supreme Court decisions, treaties, Executive Orders, and legislation. Principal legislation authorizing federal funds for health services came through the Snyder Act of 1921. The Transfer Act of 1954 transferred the responsibility for Indian health services from the Bureau of Indian Affairs to the Department of Health, Education and Welfare (HEW), now the Department of Health and Human Services (DHHS). The Indian Health Service (IHS), an agency within DHHS, was established as the agency responsible for providing federal health services to the American Indian/Alaskan Native (AI/AN) population. The Indian Self-Determination and Education Assistance Act (Public Law 93-638, as amended) gave Tribes the option of assuming the operation of health services and community programs from Indian Health Services (IHS) or remaining within the IHS administered system. Subsequently the Indian Health Care Improvement Act (Public Law 94-437) was enacted to provide the quality and quantity of health services needed to elevate the health status of American Indians/Alaska Natives and to encourage maximum participation of tribes in the planning/management of those services.

Source: Miss. Code Ann. § 43-13-121; Public Law 93-638; Public Law 94-437

Rule 6.2: Beneficiary Enrollment

Applicants of American Indian/Alaskan Native descent are subject to the same eligibility criteria as any other applicant. Refer to Part 200, Chapter 3, Rule 3.1.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 136.12

Rule 6.3: Provider Enrollment/Participation Requirements

A. Indian Health Service (IHS) Facilities/Tribal 638 Health Facilities - In accordance with Sec. 1911.[42 U.S.C. 1396j] (a) (b) the Division of Medicaid accepts Indian Health Service Facilities/Tribal 638 Health Facilities as Medicaid providers on the same basis as other qualified providers. IHS/Tribal 638 facilities must meet all applicable standards for state licensure but need not obtain a state license. Refer to Part 200 Chapter 4, Rule 4.2 for Conditions of Participation.

B. All Other Providers - All other providers must complete the enrollment requirements for their respective provider type. Refer to Part 200 Chapter 4, Rule 4.2.

Source: Miss. Code Ann. § 43-13-121; 42 USC 1396j(a)(b)

Rule 6.4: Covered Services

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American Indians/Alaskan Natives who meet the Division of Medicaid eligibility criteria receive the same benefits as any other beneficiary in the same category of eligibility. All limitations, exclusions, and prior authorization requirements apply.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 136.11

Rule 6.5: Reimbursement

A. Indian Health Service (IHS) Facilities/Tribal 638 Health Facilities/Providers

1. In accordance with Social Security Act, the Division of Medicaid will reimburse Indian Health Service Facilities/Tribal 638 Health Facilities/Providers as follows:

a) Inpatient Hospital - per diem rate

b) Outpatient Hospital, includes physician and clinic services – encounter rate

c) Dental Services – encounter rate

d) Other approved providers will be reimbursed according to the current payment methodology, e.g., fee for service, per diem, encounter etc., for the respective provider type.

2. The Social Security Act provides that one hundred (100) percent Federal Medical Percentages (FMAP) is available to states for amounts spent on medical assistance received through an Indian Health Service facility whether operated by the Indian Health Service or by an Indian tribe or tribal organization, as also defined in section 4 of the Indian Health Care Improvement Act.

B. Non-Indian Health/Tribal 638 Providers who are not Indian Health Service Facilities/Tribal 638 Facilities will be reimbursed according to the current payment methodology, e.g., fee for service, per diem, encounter, etc. for the respective provider type.

Source: Miss. Code Ann. § 43-13-121; Sec. 1911. [42 U.S.C. 1396j] (a)(b)(c)(d); Section 1905 (b)

Rule 6.6: Cost-Sharing

A. An American Indian/Alaska Native who is eligible to receive or has received an item or service by an Indian health care provider or through referral under contract health services is exempt from Medicaid premiums.

B. American Indians/Alaska Natives who are currently receiving or have ever received an item or service furnished by an Indian health care provider or through referral under contract health services are exempt from all Medicaid cost-sharing.

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Source: 42 C.F.R. § 447.56; Miss. Code. Ann. §§ 43-13-117, 43-13-121.

History: New Rule eff. 10/01/2019.

Part 201 Transportation Services

23 Miss. Admin. Code Pt. 201 Transportation Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 201 Transportation Services

Table of Contents

Table of Contents Title 23: Medicaid ........................................................................................................................... 1 Table of Contents ............................................................................................................................ 1 Title 23: Division of Medicaid .................................................................................................... 1 Part 201: Transportation Services ............................................................................................... 1 Part 201 Chapter 1: Emergency Transportation Services ........................................................ 1 Rule 1.1: Emergency Ambulance Provider Requirements............................................... 1 Rule 1.2: Definitions ........................................................................................................ 2 Rule 1.3: Covered Services .............................................................................................. 4 Rule 1.4: Non-Covered Emergency Ambulance Services .............................................. 6 Rule 1.5: Reimbursement ................................................................................................. 8 Rule 1.6: Documentation................................................................................................. 8 Rule 1.7: Ambulance Transport of Nursing Facility Residents by Ambulance ............. 10 Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 10 Part 201 Chapter 2: Non-Emergency Transportation (NET) Broker Program .................... 10 Rule 2.1: Non-Emergency Transportation (NET) Broker Program ............................... 10 Rule 2.2: Eligibility ........................................................................................................ 15 Rule 2.3: Non-Emergency Transportation (NET) Services ........................................... 16 Rule 2.4: Transport of Nursing Facility Residents by NET ........................................... 18 Rule 2.5: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 19 Rule 2.6: Non-Emergency Transportation (NET) Driver Requirements ....................... 19 Rule 2.7: Vehicle Requirements ................................................................................... 21 Chapter 3: Non-Emergency Transportation (NET) Services Not Covered Under the Broker Program ................................................................................................................................. 24 Rule 3.1: Non-Emergency Transportation (NET) Services Not Covered Under the Broker Program .............................................................................................................. 24

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Title 23: Division of Medicaid

Part 201: Transportation Services

Part 201 Chapter 1: Ambulance

Rule 1.1: Emergency Ambulance Provider Requirements

A. All Medicaid ambulance service providers whose origin, or site of pickup, is within the state of Mississippi must meet the applicable requirements described in Miss. Admin. Code Part 200, Chapter 4.

B. Ambulance service providers operating outside the state of Mississippi must comply with the licensing and/or permit requirements of the state where the services are provided and meet all other requirements in Miss. Admin. Code Part 201.

C. Ambulance service providers must perform criminal background checks as required by state and/or federal law and not employ persons or entities convicted of crimes as specified in state and/or federal law.

D. All personnel providing emergency ambulance services must be certified and/or licensed acting within the scope of their practice.

E. Advanced Life Support (ALS) ambulance service providers that are not hospital-based are required by the Drug Enforcement Administration (DEA) to have an off-line medical director obtain a Controlled Substances Registration Certificate in order to store, issue and prescribe controlled substances through designated ALS personnel.

F. The Division of Medicaid prohibits emergency ambulance service providers from selling subscriptions, memberships, or similar payment packages to cover copayment for a Medicaid beneficiary.

Source: Miss. Code Ann. §§ 41-59-9, 41-59-63, 43-13-117, 43-13-121; Miss. Admin. Code Title 15, Part 12.

History: Revised eff. 08/01/2026. Revised eff. 02/01/2024. Revised eff. 08/01/2018.

Rule 1.2: Definitions

A. Basic life support (BLS) services are defined as non-invasive emergency procedures and services at the level described in the Emergency Medical Technician (EMT) National Standard Training Curriculum (NSTC) including, but not limited to:

1. Initiation of basic airway maneuvers and procedures,

2. Cardio-pulmonary resuscitation (CPR),

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3. Automated and semi-automated defibrillation,

4. Hemorrhage control, including direct pressure and tourniquet,

5. Spinal immobilization and extremity stabilization,

6. Assistance with childbirth, and/or

7. Obtaining vital signs,

8. Other techniques as authorized by Bureau of Emergency Medical Services (BEMS).

B. Advanced Life Support (ALS) services are defined as a sophisticated level of prehospital and interhospital emergency care including, but not limited to:

1. Cardiac monitoring,

2. Cardiac defibrillation,

3. Telemetered electrocardiography,

4. Administration of antiarrhythmic agents,

5. Intravenous therapy,

6. Administration of specified medications, drugs, and solutions,

7. Use of adjunctive ventilation devices,

8. Trauma care, and/or

9. Other techniques and procedures authorized by BEMS.

C. An Appropriate Facility is defined as a facility or institution generally equipped and able to provide the needed treatment for the beneficiary's condition including, but not limited to:

1. Trauma Level I BEMS certified facilities,

2. Trauma Level II BEMS certified facilities,

3. Trauma Level III BEMS certified facilities,

4. Trauma Level IV BEMS certified facilities, and

5. Other facilities as designated by BEMS and/or the Mississippi Statewide Trauma Plan.

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D. Nearest appropriate facility is defined as one or more facilities closest to the location where the beneficiary is picked up by the ambulance that is generally equipped and able to provide the needed treatment for the beneficiary's condition.

E. Beneficiary Loaded Mileage is defined as the number of miles from the site where the beneficiary was loaded into the ambulance to the drop-off destination.

F. Medical Necessity for emergency ambulance transportation, is defined as:

1. The severity of the beneficiary’s emergency medical condition is such that the use of any other method of transportation is contraindicated, and

2. The beneficiary's emergency medical condition requires both the emergency ambulance transportation itself and the level of service provided.

G. Emergency Medical Condition is defined as a sudden onset of acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in the following:

1. Serious jeopardy to the health of the beneficiary,

2. Serious impairment to bodily functions, or

3. Serious dysfunction of any bodily organ or part.

H. Medical Control is defined as directions and advice provided from a centrally designated medical facility staffed by appropriate personnel, operating under medical supervision, supplying professional support through radio or telephonic communication for on-site and in- transit BLS and ALS services given by field and satellite facility personnel.

Source: 42 C.F.R. §§ 410.40, 414.605; Miss. Code Ann. §§ 43-13-117, 43-13-121; Miss. Admin. Code Title 15, Part 12.

History: Revised eff. 02/01/2024. Revised eff. 08/01/2018.

Rule 1.3: Covered Services

A. The Division of Medicaid covers medically necessary emergency ground ambulance services which meet the requirements of the Mississippi Bureau of Emergency Medical Services (BEMS) including, but not limited to:

1. Basic Life Support (BLS) Ground Ambulance Services which must include, but are not limited to:

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a) A BLS ambulance vehicle with a BEMS permit, staffed with at least one (1) individual certified by BEMS to provide services at or above the level of Emergency Medical Technician (EMT),

b) A driver with a valid Emergency Medical Services Driver Certificate from the state of Mississippi,

c) Equipment and supplies as required by BEMS,

d) Services provided by an EMT within the scope of their practice as determined by BEMS, and

e) Transportation from the pick-up site to the nearest appropriate facility.

2. Advanced Life Support (ALS) Ground Ambulance Services which must include, but are not limited to:

a) An ALS ambulance vehicle, with a BEMS permit, staffed with at least one (1) individual certified by BEMS to provide services at or above the level of Advanced EMT (AEMT),

b) A driver with a valid Emergency Medical Services Driver Certificate from the state of Mississippi,

c) Equipment and supplies as required by BEMS,

d) Services provided by an AEMT and/or higher-level medical professional within the scope of their practice(s) as determined by BEMS or the appropriate licensing and/or governing board, and

e) Transportation from the pick-up site to the nearest appropriate facility.

B. The Division of Medicaid covers medically necessary emergency air ambulance services in a rotary-wing aircraft that meet the requirements of BEMS which must include, but are not limited to:

1. An air ambulance aircraft, with a BEMS permit, staffed commensurate with the mission statement and scope of care of the medical transport service, as required and/or specified by BEMS.

2. A pilot who is certified in accordance with current Federal Aviation Regulations (FARs) and meets the appropriate BEMS requirements,

3. Equipment and supplies as required by BEMS,

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4. Services provided by an air medical paramedic, registered nurse, and/or licensed physician, or other air medical personnel as defined by BEMS, and

5. Transportation from the pick-up site to the nearest appropriate facility.

C. The Division of Medicaid covers emergency or urgent air ambulance services in a fixed-wing aircraft which are medically necessary and meet the requirements of BEMS including, but not limited to:

1. An air ambulance aircraft, with a BEMS permit, staffed commensurate with the mission statement and scope of care of the medical transport service, as required and/or specified by BEMS.

2. A pilot who is certified in accordance with current FARs and meets the appropriate BEMS requirements,

3. Equipment and supplies as required by BEMS,

4. Services provided by an air medical paramedic, registered nurse, and/or licensed physician, or other air medical personnel as defined by BEMS, and

5. Transportation from the pick-up site to the nearest appropriate facility.

D. The Division of Medicaid covers medically necessary neonatal emergency ambulance services that meet the requirements of BEMS.

E. The Division of Medicaid covers the following in addition to the emergency ambulance service base rate:

1. Ground ambulance mileage to the closest appropriate facility when appropriate documentation is provided.

2. Air ambulance mileage to the closest appropriate facility when appropriate documentation is provided.

3. Injectable drugs administered by licensed or certified personnel acting within their scope of practice under the direction of medical control, and/or

4. Discarded injectable drugs up to the dosage amount indicated on the single-use vial or package label minus the administered dose(s) if:

a) The drug or biological is supplied in a single use vial or single-use package,

b) The drug or biological is actually administered to the beneficiary to appropriately address his/her condition and any unused portion is discarded,

c) The amount wasted is recorded in the beneficiary’s medical record,

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d) The provider has written policies and procedures regarding single-use drugs and biologicals and bills all payers in the same manner, and

e) The amount billed to the Division of Medicaid as a discarded drug is not administered to another beneficiary or patient.

Source: 42 C.F.R. §§ 410.40, 414.605; Miss. Code Ann §§ 41-59-29, 41-59-101, 43-13-117, 43-13-121; Miss. Admin. Code Title 15, Part 12.

History: Revised eff. 02/01/2024. Revised to correspond with SPA 23-0004 (eff. 02/01/2023) eff. 05/01/2023; Revised eff. 08/01/2018.

Rule 1.4: Non-Covered Emergency Ambulance Services

The Division of Medicaid does not cover the following including, but not limited to:

A. Emergency ambulance transportation of a beneficiary:

1. To anywhere other than the nearest appropriate facility that is able to care for the beneficiary,

2. Pronounced dead prior to the dispatch of the ambulance by an individual who is licensed or otherwise authorized under state law to pronounce death in the state where such pronouncement is made,

3. To a funeral home,

4. Due to a lack of alternative means,

5. For the convenience of the beneficiary and/or beneficiary’s family, and/or

6. For which medical necessity criteria has not been satisfied.

B. Services that are not directly related to medically necessary emergency treatment of an illness or injury including, but not limited to:

1. Time spent waiting for the beneficiary,

2. Refusal of the beneficiary to be transported after the ambulance arrives in response to an emergency, and/or

3. First-aid or other medical type treatment provided by ambulance staff to a beneficiary who is not subsequently transported to the closest appropriate facility,

C. Services provided to an individual not eligible for Medicaid,

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D. Mileage beyond the nearest appropriate facility, or

E. Services not specifically listed as covered services.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised and moved to Miss. Admin. Code Part 201, Rule 1.6 except Miss. Admin. Code Part 201, Rule 1.1.4.A.4. moved to Miss. Admin, Code Part 201, Rule 2.3.B.1., eff. 08/01/2018.

Rule 1.5: Reimbursement

A. The Division of Medicaid reimburses emergency ground ambulance providers a base rate from a statewide uniform fee schedule in effect on July 1, 2021 based on one hundred percent (100%) of the rate established under Medicare on January 1, 2020:

1. For only beneficiary loaded trips,

2. For medically necessary emergency services to the closest appropriate facility for treatment, and

3. When provided in an appropriate ALS or BLS vehicle that has been licensed by the state that actually transports the beneficiary.

B. The Division of Medicaid reimburses emergency ambulance providers in addition to the base rate for the following:

1. Ground ambulance mileage to the nearest appropriate facility according to the methodology described in the State Plan,

2. Air ambulance mileage to the nearest appropriate facility,

3. The actual units administered of medically necessary injectable drugs, and

4. Discarded injectable drugs that meet the requirements of Miss. Admin. Code Part 201, Rule 1.3.F.

C. The Division of Medicaid does not separately reimburse for services and items which are included in the emergency ambulance service base rate including, but not limited to:

1. Assessment of the beneficiary's condition, including vital signs,

2. Charges for professional services including, but not limited to:

a) Physicians,

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b) Nurses,

c) Emergency Medical Technicians, or

d) Respiratory therapists,

3. Supplies,

4. Equipment,

5. Non-injectable drugs,

6. Crystalloid fluids and the administration thereof, and

D. The Division of Medicaid does not reimburse for emergency ambulance services provided by persons or entities convicted of certain crimes as specified in state or federal law.

E. The Division of Medicaid does not reimburse for an ALS ground ambulance if only BLS services are provided. The ambulance provider will be reimbursed at the BLS ground ambulance rate for services.

F. The provider must indicate on the claim the usual charge or charges divided by the number of persons transported when providing emergency services to more than one (1) person in one (1) vehicle or aircraft. [Revised and moved from Miss. Admin. Code Part 201, Rule 1.2.2]

G. The provider must bill the appropriate:

1. Code applicable to the service rendered, and

2. Modifier indicating the origin and destination of the trip.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with SPA 23-0004 (eff. 02/01/2023) eff. 05/01/2023; Revised eff. 07/01/2021; Revised to correspond with SPA 20-0016 (eff. 07/01/2020) eff. 10/01/2020; Revised and moved Miss. Admin. Code Part 201, Rule 1.1.5.A. to Miss. Admin. Code Part 201, Rule 1.3.F.1, eff. 08/01/2018.

Rule 1.6: Documentation

A. Providers must maintain required documentation in accordance with Miss. Admin. Code Part 200, Rule 1.3, and must maintain auditable records to substantiate claims submitted to the Division of Medicaid or designated entity.

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B. Ambulance providers must maintain documentation in the medical record including, but not limited to:

1. Time the emergency was reported,

2. The person reporting the emergency,

3. Nature of illness or injury,

4. Documentation of medical necessity of emergency ambulance services,

5. Documentation of medical necessity for the level of care provided,

6. Beneficiary’s condition including, but not limited to:

a) Vital signs,

b) Level of consciousness, and

c) Ability to sit, stand, and/or walk.

7. Location of pick-up, time of pick-up, location of destination, and time of arrival,

8. For ground ambulance providers, the recording of odometer reading at pick-up and point of destination or the mileage as documented by an onboard global positioning system (GPS) which can store and retrieve trip data,

9. Detailed record of all services and treatments administered to the beneficiary,

10. Documentation that the beneficiary was taken to the closest appropriate facility or the reason that nearest appropriate facility was unable to accept the beneficiary causing the beneficiary to be taken to another appropriate facility, and

11. Trip ticket that indicates the date, mileage, crew, origin, destination, and type and level of ambulance service provided.

C. Ground ambulance providers must document the following to receive reimbursement for mileage including, but not limited to, the following:

1. The vehicle's actual odometer readings at pick-up and destination sites or the mileage as documented by an onboard GPS system which can store and retrieve trip data, and

2. Documentation that the beneficiary was taken to the closest appropriate facility able to provide treatment.

Source: 42 C.F.R. § 422.113; Miss. Code Ann. §§ 41-59-41, 43-13-117, 43-13-121.

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History: Revised to correspond with SPA 23-0004 (eff. 02/01/2023) eff. 05/01/2023; Revised eff. 04/01/2020; Renamed and added Miss. Admin. Code Title 23, Part 201, Rule 1.1.5.A.-D., moved and revised Miss. Admin. Code Part 201, Rule 1.1.6.A. and B. to Miss. Admin Code Title 23, Part 201, Rule 1.5.B. and C. eff. 08/01/2018.

Rule 1.7: Ambulance Transport of Nursing Facility Residents by Ambulance [Refer to Miss Admin. Code, Title 23, Part 207 for non-emergency transportation of nursing facility residents. Refer to Miss Admin. Code, Title 23, Part 201, Chapter 1 for emergency transportation of nursing facility residents.]

Source: 42 C.F.R. § 431.53; Miss. Code Ann. § 43-13-121.

History: Revised eff. 09/09/2018; Revised rule number eff. 08/01/2018.

Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for early and periodic screening, diagnosis, and treatment (EPSDT)-eligible beneficiaries in accordance with Part 223 of this Title, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised rule number eff. 08/01/2018.

Part 201 Chapter 2: Non-Emergency Transportation (NET) Broker Program

Rule 2.1: Non-Emergency Transportation (NET) Broker Program

A. The Division of Medicaid contracts with a Broker to provide non-emergency transportation (NET) through a NET provider to Medicaid beneficiaries in appropriate vehicles, depending on the beneficiary’s mobility status and personal capabilities on the date of service.

1. Other non-Medicaid funded sources for non-emergency transportation services must be utilized first with the Medicaid NET program being the last resort.

2. Beneficiaries are not allowed to request a particular NET provider for transportation.

B. The NET Broker is responsible for administering and operating the NET program in accordance with the Division of Medicaid’s policy including, but not limited to, the authorization, coordination, scheduling, management, and reimbursement of NET services and must:

1. Operate statewide.

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2. Authorize and schedule NET services within the following set timeframes:

a) Ninety-eight percent (98%) of routine NET services within three (3) business days after receipt of the request, and

b) One hundred percent (100%) of routine NET services within ten (10) business days after receipt of the request.

3. Notify the Division of Medicaid prior to denying a request for transport to a medical provider not geographically closest to the beneficiary’s residence if the NET Broker is unable to obtain a medical certification from the medical provider certifying that the beneficiary is unable to be treated at a closer facility. A medical certification is not required if the transport is to the University of Mississippi Medical Center in Jackson, MS.

4. Allow long distance transportation for up to ninety (90) days, if necessary, if a beneficiary has recently moved to a new area to maintain continuity of care until the transition of the beneficiary’s care to a closer appropriate provider is completed. The NET Broker must monitor the frequency of these NET authorizations involving excessive distances per beneficiary.

5. Ensure NET providers arrive at the drop-off and pick-up destinations within the Division of Medicaid’s minimum requirements.

6. Perform post-transportation authorizations in instances when prior authorization was not obtainable.

7. Request additional information, if necessary, within twenty-four (24) hours of the initial receipt of a request and place the request on hold. The request must specify the date the additional information must be submitted. The request for transport can be denied if the information is not received by the date specified with the exception of NET service appointments for chemotherapy, dialysis, and high-risk pregnancy.

8. Provide education to beneficiaries and NET providers on NET services and procedures.

9. Maintain a current Division of Medicaid approved NET provider Manual/Operations Procedure Manual.

10. Perform criminal background checks on all NET drivers to ensure excluded persons or entities are not paid any state or federal funds in compliance with Mississippi law [Refer to Part 201, Rule 2.6.D.], and ensure NET drivers meet the Division of Medicaid minimum requirements.

a) The NET Broker must conduct criminal background checks upon initial hire including, but not limited to:

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1. A one-time criminal background check requiring fingerprinting,

2. National and state criminal background checks utilizing personal identification data, including, but not limited to:

(a) Name and date-of-birth,

(b) Social security number, or

(c) Driver’s license number.

3. A Mississippi Sex Offender Registry check, and

4. A Motor Vehicle Record check.

b) The NET Broker must conduct criminal background checks annually including, but not limited to:

1. National and state criminal background checks utilizing personal identification data, including, but not limited to:

(a) Name and date-of-birth,

(b) Social security number, or

(c) Driver’s license number.

2. A Mississippi Sex Offender Registry check, and

3. A Motor Vehicle Record check.

c) Effective April 01, 2015 the NET Broker must ensure the NET providers comply with the one-time fingerprinting check requirement as listed below:

1. The NET Broker must have all NET drivers’ fingerprinting checks on file. The NET Broker is prohibited from reimbursing the NET provider for transportation services by a NET driver whose fingerprinting check is not on file.

2. New NET providers must submit to the NET Broker all NET driver fingerprinting checks within ninety (90) days from the contracted start date.

3. NET providers must submit to the NET Broker all fingerprinting checks for newly hired NET drivers within ninety (90) days from the date of employment if hired after the contracted start date.

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4. The NET Broker may utilize the fingerprinting record obtained by a previous Medicaid NET provider to meet the one-time fingerprinting check requirement if the NET driver changes employment.

d) The NET Broker can not reimburse the NET provider for transportation services rendered if the NET provider fails to comply with any of the fingerprinting check requirements listed in Miss. Admin. Code Part 201, Rule 2.1.B.10.

e) The NET Broker must recoup any funds paid to the NET provider for services rendered by a NET driver who fails the fingerprinting check.

11. Ensure vehicles meet the Division of Medicaid's minimum requirements and ensure required vehicle inspections are performed and documented with submission of inspection reports to the Division of Medicaid no later than the fifteenth (15 th ) day of the month following the inspection.

12. Maintain an adequate number of NET providers and trained staff to provide scheduled transports in a given geographical area.

13. Maintain a file of current executed NET provider contracts and:

a) Require NET provider enrollment forms to include disclosure of complete ownership, control, and relationship information from all NET providers,

b) Include contract language requiring the NET Broker to notify the Division of Medicaid of such disclosures on a timely basis, and

c) Provide to the Division of Medicaid upon request.

14. Make timely payments to NET providers.

15. Meet quality assurance and monitoring requirements including, but not limited to:

a) On-street observations,

b) Accident and incident reporting,

c) Statistical reporting of transports,

d) Statistical reporting of transport call center operations,

e) Analysis of complaints,

f) Driver licensure, driving records, experience, training and annual random drug testing of all NET drivers,

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g) Participant assistance,

h) Completion of driver transport logs,

i) Driver communication with dispatcher, and

j) Routine scheduled vehicle inspections and maintenance.

16. Maintain all required up-to-date electronic and data systems.

17. Meet all of the Division of Medicaid’s call center requirements.

18. Conduct the following random validation checks of monthly requests to verify NET provider claims for reimbursement match authorized transports and to verify the transports actually occurred. The NET Broker must document the reason the NET provider failed to properly authorize or render the service.

a) Three percent (3%) of pre-transportation requests verifying that a beneficiary’s appointment with the medical service provider is for a covered medical service, and

b) Two percent (2%) of post-transportation services verifying a beneficiary’s appointment is for a covered medical service.

19. Submit reports, data or other materials by the date due as determined by the Division of Medicaid.

20. Obtain a medical certification statement from the beneficiary’s physician if an adult attendant is required to accompany the beneficiary.

C. The Division of Medicaid, at its sole discretion, may assess damages if the NET Broker fails to perform the responsibilities in Rule 2.1.B. resulting in additional administrative costs to the Division of Medicaid.

1. The Division of Medicaid must give written notice to the NET Broker of any unmet responsibility that could result in an assessment of damages and the proposed amount of the damages.

2. The NET Broker has fifteen (15) days from the date of the notice to dispute the determination.

D. Reporting

1. The NET Broker must report within three (3) business days all allegations of sexual harassment or physical abuse by a driver, beneficiary or other passenger to the Division of Medicaid and per state law to the Mississippi Department of Human Services (MDHS).

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a) NET providers must report all allegations of sexual harassment or physical abuse to the NET Broker.

b) Medicaid beneficiaries should report any incident of abuse or sexual harassment directly to the NET Broker.

2. The NET Broker must refer suspected Medicaid fraud, abuse or misuse by beneficiaries, NET providers or NET Broker staff to the Division of Medicaid’s Office of Program Integrity within three (3) business days after discovery of the suspected Medicaid fraud, abuse or misuse.

3. The NET Broker must document all accidents/incidents occurring on a scheduled transport when a beneficiary is present in the vehicle and submit the accident/incident report to the Division of Medicaid within forty-eight (48) hours of the accident/incident.

Source: 42 C.F.R. §§ 431.53, 440.170; Miss. Code Ann. §§ 41-125-19, 43-13-117, 43-13-121; Miss. Admin Code Title 15, Part 16, Subpart 1, Chapter 2, Subchapter 14.

History: Added Miss. Admin. Code Part 201, Rule 2.1.B.21. eff. 02/01/2019; Moved and revised Miss. Admin Code Part 201 Rule 2.1.E. and F. to Miss. Admin Code Part 201 Rule 2.3.E. and F. eff. 08/01/2018; Revised Miss. Admin. Code Part 201, Rule 2.1.B.10. eff. 04/01/2015; Revised eff. 04/01/2013.

Rule 2.2: Eligibility

A. Non-emergency transportation (NET) services are non-covered for beneficiaries enrolled in the following categories of eligibility:

1. Family Planning Waiver,

2. Qualified Medicare Beneficiary (QMB),

3. Specified Low-Income Medicare Beneficiary (SLMB),

4. Qualified Working Disabled Individuals (QWDI), and

5. Qualified Individual (QI-1).

B. Beneficiaries enrolled in the Mississippi Coordinated Access Network (MississippiCAN) will receive non-emergency transportation services through MississippiCAN that meet the requirements of Miss. Admin. Code Title 23, Part 201 Chapter 2.

Source: 42 C.F.R. § 431.53; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 08/01/2018; Revised eff. 04/01/2013.

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Rule 2.3: Non-Emergency Transportation (NET) Services

A. Non-emergency transportation (NET) services are covered if all the following criteria are met:

1. The service for which NET service is requested is a covered service provided by a Mississippi Medicaid enrolled provider.

2. The beneficiary:

a) Is eligible for NET services,

b) Has a medical need which requires NET services, and

c) Does not have access to NET from any other source.

3. The transport must be:

a) In a vehicle which meets the medical needs of the beneficiary given their mobility status and personal capabilities on the date of service,

b) The most economical mode of transportation. The NET Broker must document the reason in detail if the NET Broker authorizes a mode of transportation that is not the most economical,

c) Provided by a NET provider closest to the beneficiary. The NET Broker must document the reason in detail if a transport is authorized for a NET provider which is not the closest to the beneficiary’s residence or medical service provider,

d) For a single covered medical service appointment, and

e) Requested at least three (3) business days before the NET service is needed.

4. If an adult attendant is necessary the NET Broker must obtain a medical certification statement from the beneficiary’s physician prior to the transport.

B. NET ambulance services must meet the criteria in Miss. Admin. Code Part 201, Rule 2.3.A. in addition to the following including, but not limited to:

1. A Level of Need form must be completed and signed by the physician, nurse practitioner, or physician assistant and the original must be kept on file by the provider at all times,

2. The sole justification for ambulance transportation cannot be bed confinement defined as the inability to:

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a) Get up from a bed without assistance,

b) Ambulate, and

c) Sit in a chair or wheelchair.

2. The transport must be provided by a NET ambulance provider to or from the nearest appropriate facility for the beneficiary to receive non-emergency medical care that cannot be provided in their place of residence or medical facility, and

3. The use of other means of transportation must be medically contraindicated because it would endanger or be detrimental to the beneficiary's health.

C. NET services are non-covered if:

1. The beneficiary:

a) Is not eligible for NET services on the requested date of service,

b) Does not have a medical need requiring NET services,

c) Has access to available transportation,

d) Refuses the appropriate mode of transportation, or

e) Refuses the NET provider assigned to the transport and another appropriate NET provider is not available,

2. The medical service is not covered for NET services requested,

3. Transportation to the medical service is covered under another program,

4. The request for post-transportation authorization is not received in a timely manner as defined in the current NET broker contract and/or did not meet established criteria found in Miss. Admin. Code Title 23, Part 201, Rule 2.3.A. and B.

5. The medical appointment is not scheduled or was not kept,

6. NET Broker cannot confirm the medical appointment,

7. The transport is not requested in a timely manner as defined in the current NET broker contract and is unable to be scheduled for the requested date and time,

8. Additional documentation was requested by the NET Broker and not received timely, or

9. The provider of NET services does not have a contract with the NET Broker.

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D. The NET Broker must deny non-covered NET services and document the reason for the denial on the same business day and mail the denial letter to the beneficiary no later than the next business day following the date of the denial decision.

1. The denial letter must contain the beneficiary’s right to appeal.

2. The Division of Medicaid, in its sole discretion, may add, modify or delete denial reasons without additional payment to the NET Broker or a contract amendment.

E. The Division of Medicaid covers meals and lodging for beneficiaries through the NET Broker Program for medically necessary overnight stays:

1. If the medical service is only available in another county, city, or state requiring extensive travel time and distance, and

2. The medical treatment facility does not provide for meals and/or lodging.

F. The Division of Medicaid covers one (1) adult attendant, at least eighteen (18) years of age or older, to accompany a beneficiary during transport and certain related expenses during an overnight stay through the NET Broker Program as follows:

1. All the following conditions must be met:

a) The medical provider certifies prior to the transport that the beneficiary’s need for an adult attendant and type of assistance required is medically necessary,

b) The adult attendant is qualified to provide the type of assistance required, and

c) Travel with the adult attendant is prior authorized by the NET Broker.

2. The NET Broker must pay the following expenses for one (1) adult attendant, at least (18) years of age, to accompany a beneficiary to a medical provider for a covered service:

a) Cost of a ticket for day or overnight transports,

b) Lodging and meals for overnight stay(s) if the medical provider does not provide for lodging and/or meals.

3. All costs associated with an adult attendant must be documented with receipts and submitted to the NET Broker.

Source: 42 U.S.C. § 1396a; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Moved and revised Miss. Admin. Code Part 201, Subchapter 3 to Miss. Admin. Code Part 201, Rule 2.3.B. eff. 08/01/2018; Revised eff. 04/01/2013.

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Rule 2.4: Non-Emergency Transportation of Long-Term Care (LTC) Facility Residents

Refer to Miss. Admin. Code Part 207 for non-emergency transportation of long-term care (LTC) facility residents.

Source: 42 C.F.R. § 431.53; Miss. Code Ann. § 43-13-121.

History: Revised eff. 09/09/2018; Revised eff. 04/01/2013.

Rule 2.5: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of this Title, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121.

Rule 2.6: Non-Emergency Transportation (NET) Driver Requirements

A. The non-emergency transportation (NET) Broker must ensure that all NET drivers complete a criminal background check verifying the NET driver is not excluded per Miss. Code Ann. § 43-13-121. [Refer to Miss. Admin. Code Part 201, Rule 2.1.B.10.]

B. The NET Broker must ensure NET drivers:

1. Abide by federal, state, and local laws.

2. Be at least eighteen (18) years of age and have a current valid driver’s license to operate the assigned vehicle.

3. Be courteous, patient and helpful to all passengers and be neat and clean in appearance.

4. Wear a visible, easily read name tag which identifies the employee and the employer.

5. Provide an appropriate level of assistance to a beneficiary when requested or when necessitated by the beneficiary’s mobility status or personal condition, including curb-to- curb, door-to-door, and hand-to-hand assistance, as required.

a) The NET driver must confirm the beneficiary is safely inside the residence or facility before departing the drop-off point.

b) The NET driver is responsible for properly securing any mobility devices used by the beneficiary.

6. Assist beneficiaries in the process of being seated, confirm all seat belts are fastened

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properly and all passengers are safely and properly secured.

7. Park the vehicle:

a) In a safe location out of traffic if a beneficiary or other passenger’s behavior or any other condition impedes the safe operation of the vehicle, notify the dispatcher and request assistance.

b) To prevent the beneficiary from crossing streets to reach the entrance of their destination.

8. Must provide verbal directions to passengers as appropriate.

9. Notify the NET provider immediately ofan emergency such as an accident/ incident or vehicle breakdown to arrange for alternative transportation for the beneficiaries on board. The NET provider must report all accidents/incidents and breakdowns to the NET Broker.

10. Report all no-shows immediately to the NET provider and the NET provider must notify the NET Broker so the authorization can be cancelled.

C. The NET Broker must ensure NET drivers do not:

1. Leave a beneficiary unattended at any time.

2. Use alcohol, narcotics, illegal drugs, or prescription medications that impair their ability to perform.

3. Smoke in the vehicle, while assisting a beneficiary or in the presence of a beneficiary or allow beneficiaries or their adult attendant to smoke in the vehicle.

4. Wear any type of headphones while on duty, with the exception of hands-free headsets for mobile telephones which can only be used for communication with the NET provider or to call 911 in an emergency.

5. Touch any passenger except as appropriate and necessary to assist the passenger into or out of the vehicle, into a seat and to secure the seatbelt or as necessary to render first aid or assistance which the NET driver has been trained.

6. Provide NET services to Medicaid beneficiaries without completing a national and state background check.

D. The NET Broker must ensure a NET driver is removed from NET service if he/she:

1. Fails an annual random drug test.

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2. Is convicted of:

a) Two (2) moving violations or accidents related to transportation provided under the NET Broker Program, or

b) Any federal or state crime listed in Miss. Code Ann. § 43-13-121.

3. Has a suspended or revoked driver’s license for moving traffic violations in the previous five (5) years.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 08/01/2018; Revised Miss. Admin. Code Part 201, Rule 2.6.A., C.6., and D.2.b) eff. 04/01/2015. Revised Miss. Admin. Code Part 201, Rule 2.6 to include 04/01/2012 compilation omission eff. 04/01/2013.

Rule 2.7: Vehicle Requirements

A. All vehicles used for transport must:

1. Adhere to all federal, state, county or local laws and ordinances.

2. Not exceed the vehicle manufacturer’s approved seating capacity for number of persons in the vehicle, including the driver.

3. Have a functioning heating and air-conditioning system which maintains a temperature comfortable to the beneficiary at all times.

4. Have functioning seat belts and restraints as required by federal, state, county or local statute or ordinance and:

a) Have an easily visible interior sign in capital letters that reads, “All passengers must wear seat belts”,

b) Store seat belts off the floor when not in use,

c) Have at least two (2) seat belt extensions available, and

d) Be equipped with at least one (1) seat belt cutter within easy reach of the driver for use in emergency situations.

5. Have an accurate, operating speedometer and odometer.

6. Be operated within the manufacturer’s safe operating standards at all times.

7. Have two (2) exterior rear view mirrors, one (1) on each side of the vehicle.

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8. Be equipped with an interior mirror for monitoring the passenger compartment.

9. Have a clean exterior free of broken mirrors or windows, excessive grime, major dents or paint damage that detracts from the overall appearance of the vehicles.

10. Have a clean interior free of torn upholstery, including floor and ceiling coverings, damaged or broken seats, protruding sharp edges, dirt, oil, grease or litter, hazardous debris, or unsecured items.

11. Display the non-emergency transportation (NET) provider’s business name and telephone number in a minimum of three (3) inch high lettering in a color that contrasts with the surrounding background on at least both sides of the exterior of the vehicle and have:

a) No words displayed on the interior or exterior of the vehicle indicating Medicaid beneficiaries are being transported, or

b) A NET provider’s business name which does not imply Medicaid beneficiaries are being transported.

12. Have the NET Broker’s toll-free and local phone numbers prominently displayed in the interior of each vehicle with complaint procedures clearly visible and available in written format upon request.

13. Be non-smoking at all times with a visible interior sign in all capital letters that reads: “No smoking”.

14. Have a vehicle information packet containing vehicle registration, insurance card, and accident procedures and forms.

15. Be equipped with a first aid kit stocked with antiseptic cleansing wipes, antibiotic ointment, assorted sizes of adhesive and gauze bandages, tape, scissors, latex-free or other impermeable gloves and sterile eyewash.

16. Contain a current map of the applicable geographic area with sufficient detail to locate beneficiary and Medicaid provider addresses.

17. Be equipped with an appropriate working fire extinguisher stored in a safe, secure location.

18. Have insurance coverage for all vehicles at all times in compliance with state law and any county or city ordinance.

19. Be equipped with a “spill kit” that includes liquid spill absorbent, latex-free or other impermeable gloves, hazardous waste disposal bags, scrub brush, disinfectant and deodorizer.

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20. Be in compliance with applicable Americans with Disabilities Act (ADA) Accessibility Specifications for Transportation.

B. The NET Broker must:

1. Ensure all NET providers maintain all vehicles which meet or exceed local, state and federal requirements and the manufacturer’s safety mechanical operating, and maintenance standards.

2. Supply all NET providers with a copy of the ADA vehicle requirements and inspect the vehicles for compliance during the scheduled bi-annual vehicle inspections.

3. Have in its network NET providers with the capability to perform bariatric transports of beneficiaries up to eight hundred (800) pounds.

4. Maintain documentation on the lifting capacity of each vehicle in its network to timely schedule transports for beneficiaries requiring a lift.

5. Require every vehicle in a NET provider’s fleet has a real-time link via a phone or two- way radio. Pagers are not acceptable as a substitute.

6. Test all communication equipment during regularly scheduled vehicle inspections.

7. Inspect all NET provider vehicles prior to the Operations Start Date and at least every six (6) months thereafter.

8. Place the Medicaid approved inspection sticker on the outside of the passenger side rear window upon completion of a successful inspection.

9. Maintain records of inspections and make them available to the Division of Medicaid upon request.

C. Authorized employees of the Division of Medicaid or the NET Broker must immediately remove from service any vehicle or NET driver found to be out of compliance with Miss. Admin. Code Part 201, Rule 2.1 or with any federal or state regulations.

1. The vehicle or NET driver may be returned to service only after the NET Broker verifies the deficiencies have been corrected.

2. Any deficiencies and actions taken to remedy deficiencies must be documented and become a part of the vehicle’s and the NET driver’s permanent records.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

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History: Revised eff. 08/01/2018; Revised Miss. Admin. Code Part 201, Rule 2.7 to include 04/01/2012 compilation omission eff. 04/01/2013.

Chapter 3: Non-Emergency Transportation (NET) Services Not Covered Under the Broker Program

Rule 3.1: Non-Emergency Transportation (NET) Services Not Covered Under the Broker Program

A. The Division of Medicaid covers the following non-emergency transportation (NET) services outside of the Broker program:

1. NET ambulance hospital-to-hospital transports when medically necessary to the nearest appropriate facility that is able to care for the beneficiary, a certificate of medical necessity (CMN) is completed, and all services are provided in accordance with the requirements of the Bureau of Emergency Medical Services (BEMS), and

2. NET services covered as part of another benefit or service including, but not limited to, transportation provided:

a) To long-term care facility residents [Refer to Miss. Admin. Code Title 23, Part 207], and

b) By Prescribed Pediatric Extended Care (PPEC) centers.

B. The Division of Medicaid reimburses the following NET services outside of the Broker program:

1. NET ambulance hospital-to-hospital transports when medically necessary to the nearest appropriate facility that is able to care for the beneficiary, a certificate of medical necessity (CMN) is completed, and all services are provided in accordance with the requirements of the Bureau of Emergency Medical Services (BEMS), and

2. NET services covered as part of another benefit or service including, but not limited to, transportation provided:

a) To long-term care facility residents [Refer to Miss. Admin. Code Title 23, Part 207], and

b) By Prescribed Pediatric Extended Care (PPEC) centers.

Source: 42 C.F.R. § 440.170; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 02/01/2019; New Rule eff. 08/01/2018.

Part 202 Hospital Services

Chapter 5 Hospital Procedures

23 Miss. Admin. Code Pt. 202, R. 1.6 - Refer to Chapter 5, Rule 5.1

23 Miss. Admin. Code Pt. 202, R. 1.7 - Refer to Chapter 5, Rule 5.2

23 Miss. Admin. Code Pt. 202, R. 1.8 - Refer to Chapter 5, Rule 5.3 and Rule 5.6

23 Miss. Admin. Code Pt. 202, R. 1.9 - Refer to Chapter 5, Rule 5.4

23 Miss. Admin. Code Pt. 202, R. 1.10 - Refer to Chapter 5, Rule 5.5

Rule 1.11: Documentation Requirements

The hospital must maintain legible and auditable records that will substantiate the claim

submitted to Medicaid. At a minimum, the records must contain the following on each patient:

A. Date of service.

B. A comprehensive history and physical assessment/report, including the patient’s presenting complaint.

C. Diagnosis(es) to substantiate the hospitalization and all treatments/procedures rendered during the hospitalization.

D. The specific name/type of all diagnostic studies, including lab, x-ray, and the like, and the medical indication and results/finding of the studies.

E. Documentation and consult reports to substantiate treatment/procedures rendered, the patient’s response to the treatment/procedure; and the signature or initials of the appropriate health care worker providing the treatment/procedure, including but not limited to the physician, nurse, therapist, dietitian.

F. The name, strength, dosage, route, either IM, IV, PO, topical, enteral, intracatheter, date and time, indication for, and the administration of all medications administered to the patient.

G. Discharge planning and instructions, including the signature or initials of the health care worker performing the instruction; the name of the person being instructed; date and time of instruction; whether the instructions are given in writing, verbally, by telephone or other means; and how much instruction was comprehended by the beneficiary, including level of proficiency on return demonstration when a procedure is being taught.

H. Discharge orders for medications, treatments and procedures that indicate whether the orders/prescriptions are issued in writing, verbally, or by telephone, and to whom the orders are issued.

I. Signed physician orders for all medications, treatments, and procedures rendered to the patient.

J. All x-ray images, including films and digital images, films, and digital images must be of such quality that they can be clearly interpreted.

Rule 1.12: Disproportionate Share Hospital

The Disproportionate Share Hospital (DSH) program and the qualifications for participation in the DSH program are defined in Attachment 4.19-A of the Medicaid State Plan.

Rule 1.13: Out-of-State Facilities

A. Out-of-state hospitals are reimbursed under the APR-DRG payment methodology. The inpatient cost-to-charge ratios (CCRs) used to pay cost outlier payments for each out-of-state hospital are set using the Federal Register that applies to the federal fiscal year beginning October 1 issued prior to the reimbursement period. The inpatient CCR is calculated using the sum of the statewide average operating urban CCR plus the statewide average capital CCR for each state.

B. For transplants not available in Mississippi, payment for transplant services performed outside of Mississippi is made under the MS APR-DRG payment methodology including a policy adjustor. If access to quality services is unavailable under the MS APR-DRG payment methodology, a case rate may be set as described in Part 202, Chapter 4, Rule 4.7.

C. For specialized services not available in Mississippi, the Division of Medicaid will make payment using the MS APR-DRG payment methodology. If MS APR-DRG payment limits access to care, the Division will reimburse what the domicile state pays for the service or a comparable payment other states reimburse under APR-DRG.

Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 09/01/2024. Revised eff. 07/01/2021; Revised - 01/01/2013, 10/01/2012

Rule 1.14: Inpatient Hospital Payments

A. For admissions dated October 1, 2012, and after, the Division of Medicaid reimburses all hospitals a per stay rate based on All Patient Refined Diagnosis Related Groups (APR- DRGs). APR-DRGs classify each case based on information contained on the inpatient Medicaid claim including diagnosis, procedures performed, patient age, patient sex, and discharge status. The APR-DRG payment is determined by multiplying the APR-DRG relative weight by the APR-DRG base rate. Medicaid uses a prospective method of reimbursement and will not make retroactive adjustments except as specified in the Title XIX Inpatient Hospital Reimbursement Plan.

B. The Division of Medicaid may adjust APR-DRG rates pursuant to changes in federal and/or state laws or regulations or to obtain budget goals. All Plan changes must be authorized by the Mississippi Legislature and federal grantor agency,

C. Extraordinarily costly cases in relation to other cases within the same DRG because of the severity of the illness or complicating conditions may qualify for a cost outlier payment. This is an add-on payment for expenses that are not predictable by the diagnoses, procedures performed, and other statistical data captured by the DRG grouper.

1. The additional payment for a cost outlier is determined by calculating the hospital’s estimated loss. The estimated loss is determined by multiplying the covered charges by

the hospital’s inpatient cost-to-charge ratio minus the DRG base payment. If the estimated loss is greater than the DRG cost outlier threshold established by the Division of Medicaid, then the cost outlier payment equals the estimated loss minus the DRG cost outlier threshold multiplied by the DRG Marginal Cost Percentage. For purposes of this calculation, the DRG base payment is net of any applicable transfer adjustment.

2. Stays assigned to mental health DRGs are not eligible for cost outlier payments, but may qualify for a day outlier payment if the mental health stay exceeds the DRG Long Stay Threshold.

D. Cost-to-Charge Ratio (CCR) Used to Calculate Cost Outlier Payments

1. The Cost-to-Charge Ratios (CCRs) used to calculate cost outlier payments are calculated for each provider by performing a desk review program developed by the Division of Medicaid, using the most recent filed cost report. The Division accepts amended original cost reports if the cost report is submitted prior to the end of the reimbursement period in which the cost report is used for payment purposes. If the provider’s inpatient cost-to- charge ratio used to pay cost outlier payments is changed as a result of the amended cost report, no retroactive adjustments are made to cost outlier payments using the amended cost-to-charge ratio. After the amended desk review is completed and the thirty (30) day appeal option has been exhausted the new inpatient cost-to-charge ratio is entered into the Mississippi Medicaid Management Information System and is in effect from the date of entry through the end of the current reimbursement period.

2. Out-of-state hospitals are reimbursed under the APR-DRG payment methodology. The inpatient cost-to-charge ratios (CCRs) used to pay cost outlier payments for each out-of- state hospital are set using the Federal Register, that applies to the federal fiscal year beginning October 1of each year, issued prior to the reimbursement period. The inpatient CCR is calculated using the sum of the statewide average operating urban CCR plus the statewide average capital CCR for each state. 3. A Mississippi facility which undergoes a change of ownership must notify the Division of Medicaid in writing of the effective date of the sale. The seller must file a final cost report with the Division of Medicaid from the date of the last cost report to the effective date of the sale. The filing of a final cost report may be waived by the Division, if the cost report is not needed for reimbursement purposes. The new owner must file a cost report from the date of change of ownership through the end of the Medicare cost report year end. The new owner must submit provider enrollment information required under the Division of Medicaid policy.

3. The inpatient cost-to-charge ratio, of the old owner is used to pay cost outlier payments for the new owner. The new owner’s inpatient cost-to-charge ratio used to pay cost outlier payments is calculated for the first rate beginning October 1, for which the new owner’s cost report is available. There are no retroactive adjustments to a new owner’s inpatient cost-to-charge ratio used to pay cost outlier payments.

4. New Mississippi hospitals beginning operations during a reporting year must file an

initial cost report from the date of certification to the end of the cost report year end. Each rate year the inpatient cost-to-charge ratio used to pay outlier payments for each Mississippi hospital is grouped by bed class of facilities and an average inpatient cost-to- charge ratio is determined for each class. The initial inpatient cost-to-charge ratio used to pay cost outlier payments to a new hospital will be the average inpatient cost-to-charge ratio used for the bed class of Mississippi hospitals as of the effective date of the Medicaid provider agreement until the inpatient cost-to-charge ratio is recalculated based on the new hospital’s initial cost report. There are no retroactive adjustments to a new hospital’s inpatient cost-to-charge ratio used to pay cost outlier payments.

E. The Division of Medicaid reimburses for Graduate Medical Education (GME). Payment schedules and calculations are defined in Attachment 4.19-A of the Medicaid State Plan. The Division of Medicaid does not reimburse for indirect GME costs. To qualify for GME payments, Mississippi hospitals must meet the following criteria:

1. Be located in the state of Mississippi.

2. Have accreditation from the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) at the beginning of the state fiscal year in order to qualify for the quarterly payments during the payment year.

3. Have a Medicare approved teaching program for direct GME costs.

4. Be eligible for Medicare GME reimbursement.

5. Render services on the campus of the teaching hospital or at a participating hospital site.

a) The participating site must be listed on the ACGME website.

b) If the participating site uses the teaching hospital’s ACGME accreditation, there must be a current affiliation agreement in place with the teaching hospital as of July 1 st of the payment year.

c) Only the teaching hospital or the participating hospital site is eligible for GME reimbursement.

6. Have full-time equivalents (FTEs) reported on Worksheet E-4, line 6, line 15 or line 16 columns 1 and 2 of the most recent Medicare cost report filed with DOM for the calendar year immediately prior to the beginning of the fiscal year for sponsoring/participating hospitals.

7. Any hospital which is a newly accredited sponsoring/participating hospital or is within the five (5) year resident cap building period for the newly accredited sponsoring/participating hospital must be in operation as of July 1 of the payment year and must submit:

a) Documentation of accreditation,

b) Medicare’s most recent interim rate letter, and

(1) The number of residents used to calculate medical education payments during cap building years will be the number of FTEs as reported on the Medicare interim rate letter.

(2) If the number of FTEs reported on the Medicare interim rate letter does not cover the entire cost reporting period, the reported FTEs will be annualized and used to calculate medical education payments,

c) Start date of the GME accredited sponsoring/participating hospital prior to the July 1 calculation of the payments.

8. Has GME eligibility determined each year with the submission of the following annually:

a) Documentation of accreditation,

b) Medicare’s most recent interim rate letter,

c) Number of filled resident positions,

d) Start date of the GME program prior to the July 1 calculation of the payments, and

e) Documentation that the program was in operation as of July 1 of the payment year.

F. Outpatient services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or operated by the admitting hospital, within the three (3) days prior to an inpatient hospital admission that are related to the reason for the inpatient hospital stay must be included in the APR-DRG payment for the inpatient hospital stay. This is referred to as the three (3) day payment window rule.

1. The inpatient hospital claim must include the following:

a) Diagnostic services provided to a beneficiary within three (3) days prior to and including the date of an inpatient hospital admission, and

b) Therapeutic (non-diagnostic) services related to an inpatient hospital admission and provided to a beneficiary within three (3) days prior to and including the date of the inpatient admission.

2. If outpatient services are provided more than three (3) days prior to admission to a beneficiary by the admitting hospital, or an entity wholly owned or operated by the admitting hospital, and the outpatient service dates span to days outside of the three (3) day window the hospital must:

a) Split bill for the outpatient services provided outside of the three (3) day window on a claim separate from the inpatient claim, and

b) Include the outpatient services provided that are related to the reason for the inpatient hospital stay within the three (3) day window on the inpatient hospital claim.

3. Maintenance renal dialysis services are excluded from the three (3) day window payment rule.

4. Although the Division of Medicaid’s policy is based on Medicare policy, the Division of Medicaid’s policy applies if there is a difference.

SPA 20-0018; SPA 19-0019.

History: Revised eff. 09/01/2024. Revised eff. 07/01/2021; Revised to correspond with SPA 19- 0019 (eff. 10/01/2019) and SPA 20-0018 (eff. 07/01/2020) eff. 12/01/2020; Revised eff. 03/01/2019; Revised - 10/01/2012.

Rule 1.15: Cost Reports

A. Facilities must submit a Uniform Cost Report to Medicaid following the close of their Medicare Title XVIII approved year end. Any deviations to the reporting year, such as a Medicare approved change in fiscal year end should be submitted to Division of Medicaid in writing. In cases where there is a change in the fiscal year end, the most recent cost report is used to perform the desk review. All other filing requirements shall be the same as those for Title XVIII, unless specifically outlined in the Hospital State Plan.

B. Cost reports must be submitted on or before the last day of the fifth (5 th ) month following the close of the reporting period. Should the due date fall on a weekend, a State of Mississippi holiday, or a federal holiday, the due date shall be the first (1 st ) business day following such weekend or holiday. Medicaid does not grant routine extensions for cost reports. Extensions of time to file may be granted due to unusual situations or to match a Medicare filing. Extraordinary circumstances are considered on a case-by-case basis. Extensions may only be granted by the Executive Director of the Division of Medicaid.

C. Cost reports and related information must be uploaded electronically to the cost report data base as designated by the Division of Medicaid. Cost reports uploaded after the due date will be assessed a penalty in the amount of fifty dollars ($50.00) per day the cost report is delinquent.

D. Hospitals that do not file a cost report within six (6) calendar months after the close of its reporting period are subject to cancellation of its Provider Agreement at the discretion of Medicaid.

E. All cost reports are required to detail their entire reporting year making appropriate adjustments as required by the Hospital State Plan for determination of allowable costs. The cost report must be prepared in accordance with the methods of reimbursement and cost findings in accordance with Title XVIII (Medicare) Principles of Reimbursement except where further interpreted by the Provider Reimbursement Manual, Section 2414 or as modified by the State Plan.

F. All cost reports must be filed with DOM. When it is determined that a cost report has been submitted that is not complete enough to perform a desk review, the provider is notified. The provider must submit a complete cost report. When it is determined that certain information is missing, providers are allowed a specified amount of time to submit the requested information. For cost reports which are submitted by the due date, ten (10) working days from the date of the provider’s receipt of the request for additional information are allowed for the provider to submit the additional information. If requested additional information has not been submitted by the specified date, an additional request for the information is made. The provider is given five (5) working days from the date of the provider’s receipt of the second request for information. Information that is requested that is not submitted following either the first or the second request may not be submitted for reimbursement purposes. Providers are not be allowed to submit the information at a later date, the cost report may not be amended in order to submit the additional information, and an appeal of the disallowance of the costs associated with the requested information may not be made. Adjustments may be made to the cost report by the Division of Medicaid to disallow expenses for which required documentation, including cost findings, is omitted.

G. For cost reports submitted after the due date, five (5) working days from the date of the provider’s receipt of the request for additional information will be allowed for the provider to submit the additional information. If there is no response to the request, an additional five (5) working days will be allowed for submission of the requested information. Hospitals that do not respond will not be allowed to submit the information at a later date, the cost report may not be amended in order to submit the additional information, and an appeal of the disallowance of the costs associated with the requested information may not be made. Adjustments may be made to the cost report by the Division of Medicaid to disallow expenses for which required documentation, including cost findings, is omitted.

H. Cost reports that are incomplete will be subject to the penalty provisions for delinquent cost reports until the required additional information is submitted.

413.20, 413.24, 413.40; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised - 10/01/2012

Rule 1.17: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of this Title, without regard to service limitations and with prior authorization.

Rule 1.18: Review for Medical Necessity and/or Independent Verification and Validation (IV&V)

A. The Division of Medicaid defines Review for Medical Necessity and/or Independent Verification and Validation (IV&V) as the Utilization Management/Quality Improvement Organization (UM/QIO) or Division of Medicaid, or designee, review of services of Medicaid beneficiaries in the inpatient setting for including, but not limited to, the following:

1. Meeting clinical guidelines for medical necessity. [Refer to Part 200, Rule 5.1 for definition of medical necessity],

2. Appropriateness of setting and quality of care,

3. Appropriate lengths of stay and services, and

4. Correct All Patient Refined Diagnosis Related Groups (APR-DRG) assignment.

B. The inpatient hospital provider must submit the requested documentation to the UM/QIO or the Division of Medicaid, or designee, within the specified time frame in the Notice.

C. Inpatient hospital providers may request an Administrative Appeal when the provider is dissatisfied with final administrative decisions of the Division of Medicaid relating to disallowances as a result of a review for medical necessity or an IV&V decision described in Miss. Admin. Code Part 202, Rule 1.18.A.

D. Providers must comply with the appeal provisions in Miss. Admin. Code Part 300, Rule 1.1.

History: New eff. 09/01/2014.

History

• Source: 42 CFR § 424.13; Miss. Code Ann. § 43-13-121.
• Source: 42 CFR § 447.298; Miss. Code Ann. § 43-13-121.
• Source: 42 CFR § 431.52; 42 USC § 1395f, also known as, Social Security Act § 1814; Miss.
• Source: 42 U.S.C. § 1395f; 42 C.F.R. § 447.325; Miss. Code Ann. §§ 43-13-121, 43-13-117;
• Source: Social Security Act § 1886(f)(1)(A), § 1886(b), § 1815(a), § 1833(e); 42 CFR §§ 412.52;
• Source: Miss. Code Ann. § 43-13-121.
• Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

Part 203 Physician Services

23 Miss. Admin. Code Pt. 203 Physician Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 203 Physician Services

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 203: Physician Services ...................................................................................................... 1 Part 203 Chapter 1: General ................................................................................................... 1 Rule 1.1: Provider Enrollment Requirements for Physicians, Osteopaths, Chiropractors, Podiatrists ........................................................................ Error! Bookmark not defined. Rule 1.2: Physician Fees .................................................................................................. 1 Rule 1.3: Medical Visit Editing........................................................................................ 1 Rule 1.4: Physician Office Visits - Extended Hours ........................................................ 2 Rule 1.5: Hospital Inpatient Visits/ Consultations ........................................................... 3 Rule 1.6: Locum Tenens/Reciprocal Billing Arrangements ............................................ 3 Rule 1.7: Teaching Facilities’ Billing for Resident Services ........................................... 5 Rule 1.8: Casting, Splinting, or Strapping in Office Setting ............................................ 5 Rule 1.9: Removal of Impacted Cerumen ........................................................................ 6 Rule 1.10: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 6 Rule 1.11: Physician Verbal Orders ................................................................................. 6 Part 203 Chapter 2: Injectable Drugs ...................................................................................... 7 Rule 2.1: Covered Services .............................................................................................. 7 Rule 2.2: Drug Rebates .................................................................................................... 9 Rule 2.3:Refer to Part 203, Rule 2.1 .............................................................................. 10 Rule 2.4: Refer to Part 203, Rule 2.1 ............................................................................. 10 Rule 2.5: Refer to Part 203, Rule 201 ............................................................................ 10 Rule 2.6: Refer to Part 203, Rule 201 ............................................................................ 10 Rule 2.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 10 Part 203 Chapter 3: Anesthesia ............................................................................................. 10 Rule 3.1: Provider Enrollment ....................................................................................... 10

Rule 3.2: Covered Services ............................................................................................ 11 Rule 3.3: Criteria for Medical Direction of Resident ..................................................... 11 Rule 3.4: Billing for Procedures ..................................................................................... 12 Rule 3.5: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 13 Part 203 Chapter 4: Surgery .................................................................................................. 13 Rule 4.1: Definitions ...................................................................................................... 13 Rule 4.2: Assistant Surgeon ........................................................................................... 14 Rule 4.3: Co-Surgeons ................................................................................................... 15 Rule 4.4: Team Surgeons ............................................................................................... 16 Rule 4.5: Multiple Surgeries .......................................................................................... 16 Rule 4.6: Bilateral Procedures ........................................................................................ 17 Rule 4.7: Surgical Modifiers .......................................................................................... 18 Rule 4.8: Endoscopic Procedures ................................................................................... 18 Rule 4.9: Post-Operative Pain Management .................................................................. 19 Rule 4.10: Abdominal Panniculectomy ........................................................................ 20 Rule 4.11: Blepharoplasty ............................................................................................. 21 Rule 4.12: Circumcisions .............................................................................................. 23 Rule 4.13: Refer to Part 203, Rule 2.1 .......................................................................... 24 Rule 4.14: Refer to Part 203, Rule 2.1 .......................................................................... 24 Rule 4.15: Keloids ......................................................................................................... 24 Rule 4.16: Male Gynecomastia ..................................................................................... 25 Rule 4.17: Otoplasty ...................................................................................................... 27 Rule 4.18: Reduction Mammoplasty ............................................................................. 28 Rule 4.19: Skin Tag Removal ....................................................................................... 29 Rule 4.20: Uvulopalatopharyngoplasty (UPPP/UP3) ................................................... 30 Rule 4.21: Ventricular Assist Devices (VAD) .............................................................. 31 Rule 4.22: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ........... 32

Rule 4.23: Gastric Electrical Stimulation (GES).............................................32 Part 203 Chapter 5: Chiropractor ......................................................................................... 33 Rule 5.1: Covered Services ............................................................................................ 33 Rule 5.2: Reimbursement ............................................................................................... 33 Rule 5.3: Coverage Criteria ............................................................................................ 33 Rule 5.4: Dual Eligibles ................................................................................................. 34 Rule 5.5: Documentation Requirements ........................................................................ 34 Rule 5.6: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 35 Part 203 Chapter 6: Podiatry ................................................................................................. 35 Rule 6.1: Covered Services ............................................................................................ 35 Rule 6.2: Non-covered services ..................................................................................... 37 Rule 6.3: Anesthesia ....................................................................................................... 38 Rule 6.4: Documentation................................................................................................ 39 Rule 6.5: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 40 Part 203 Chapter 7: Nurse Practitioner................................................................................. 40 Rule 7.1: Provider Enrollment ....................................................................................... 40 Rule 7.2: Nurse Practitioner Services ............................................................................ 41 Rule 7.3: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 42 Part 203 Chapter 8: Physician Assistant .............................................................................. 42 Rule 8.1: Physician Assistant Enrollment Requirements ............................................... 42 Rule 8.2: Physician Assistant Reimbursement ............................................................... 43 Rule 8.3: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 43 Part 203 Chapter 9: Psychiatric Services ............................................................................. 43 Rule 9.1: Provider Qualifications ................................................................................... 43 Rule 9.2: General Requirements .................................................................................... 44 Rule 9.3: Covered Services ............................................................................................ 44 Rule 9.4: Non-Covered Services .................................................................................... 44

Rule 9.5: Service Limits ................................................................................................. 45 Rule 9.6: Documentation................................................................................................ 46 Rule 9.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 48 Part 203 Chapter 10: Implantable Medical Devices.....................................................48 Rule 10.1 Skin and Soft Tissue Substitutes..................................................48

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Title 23: Division of Medicaid

Part 203: Physician Services

Part 203 Chapter 1: General

Rule 1.1: Provider Enrollment Requirements for Physicians, Osteopaths, Chiropractors, Podiatrists

Physician providers may participate in the Medicaid program upon compliance with the applicable provider enrollment requirements outlined in Miss. Admin. Code Title 23, Part 200, Chapter 4. Source: Miss. Code Ann. § 43-13-121

History: Revised eff. 08/01/2026.

Rule 1.2: Physician Fees

Effective for dates of services on and after July 1, 2022, physicians’ services are reimbursed at ninety percent (90%) of the Medicare Physician Fee Schedule.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2022; Revised eff. 07/01/2021.

Rule 1.3: Medical Visit Editing

Medicaid does not provide separate reimbursement for most Evaluation and Management (E&M) services when a substantial diagnostic or therapeutic procedure is performed.

Source: Miss. Code Ann. § 43-13-121 Rule 1.4: Physician Office Visits

A. The Division of Medicaid covers a combined total of sixteen (16) non-psychiatric physician office and hospital outpatient department visits per state fiscal year whether occurring during or after office hours or provider established office hours. [Refer to Miss. Admin. Code, Part 203, Rule 9.5 for psychiatric physician office and hospital outpatient department visits.]

B. The Division of Medicaid:

1. Defines regularly scheduled office hours as the hours between 8:00 a.m. and 5:00 p.m., Monday through Friday, excluding Saturday, Sunday and federal and state holidays, referred to in Rule 1.4 as “office hours”.

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2. Permits providers to set regularly scheduled office hours outside of the Division of Medicaid’s definition of office hours, referred to in Rule 1.4 as “provider established office hours”.

3. Requires providers to maintain records indicating the provider’s established office hours and any changes including:

a) The date of the change,

b) The provider established office hours prior to the change, and

c) The new provider established office hours.

C. The Division of Medicaid reimburses a fee in addition to the appropriate Evaluation and Management (E&M) code for a physician office visit when the visit:

1. Occurs during the provider established office hours which are set outside of the Division of Medicaid’s definition of office hours, or

2. Occurs outside of office hours or provider established office hours only for a condition which is not life-threatening but warrants immediate attention and cannot wait to be treated until the next scheduled appointment during office hours or provider established office hours.

D. The Division of Medicaid reimburses only the appropriate E&M code for a physician office visit scheduled during office hours or provider established office hours but not occurring until after office hours or provider established office hours.

E. The Division of Medicaid reimburses physician visits related to opioid treatment as part of a monthly bundle.

1. Physicians that are providing office based opioid treatment must be appropriately licensed and operating within the scope of their practice.

2. Physician visits provided as part of the office based opioid treatment bundle do not count toward the physician visit limit.

Source: 42 C.F.R. § 440.230; Miss. Code Ann. § 43-13-117, 43-13-121.

History: Revised eff. 01/01/2026. Revised eff. 04/01/2022; Revised to correspond with SPA 18- 0020 (eff. 01/01/2019) eff. 06/01/2019; Removed Miss. Admin. Code Part 203, Rule 1.4.E. with the approval of SPA 2013-032 on 08/08/2014, and SPA 2013-033 on 08/05/2014, eff. 06/01/2015.

Rule 1.5: Hospital Inpatient Visits/ Consultations

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A. An initial hospital visit for the beneficiary’s attending physician is covered. A subsequent hospital visit by the attending physician is not covered on the same day as the initial visit.

B. Inpatient hospital physician visits are limited to one (1) per day, per specialty. An exception is made when the patient is in an Intensive Care Unit (ICU) or Coronary Care Unit (CCU) where the limit is two (2) visits per day, per specialty.

C. An initial inpatient consultation is covered for each consultant of a different specialty if the patient’s condition justifies the medical necessity for multiple consultations. Only one (1) initial consultation is allowed per beneficiary, per consultant, per admission.

D. A subsequent hospital visit and a hospital discharge visit on the same date of service are not both covered; only the hospital discharge visit is a covered service.

Source: Miss. Code Ann. § 43-13-121.

History: Revised to correspond with MS SPA 25-0009 (05/01/2025) eff. 01/01/2026.

Rule 1.6: Locum Tenens/Reciprocal Billing Arrangements

A. Locum Tenens: For purposes of this rule a “locum tenens” arrangement is defined when the regular physician retains a substitute physician to take over the practice during an absence. A regular physician is the physician that is normally scheduled to see a patient. The regular physician usually pays the substitute physician a fixed amount per diem, with the substitute physician being an independent contractor rather than an employee.

B. Reimbursement shall be made to the patient’s regular physician for covered services of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices when all the following criteria are met:

1. The regular physician is unavailable to provide the services,

2. The regular physician pays the locum tenens for the services on a per diem or similar fee- for-time basis,

3. The Medicaid beneficiary has arranged or sought to receive services from the regular physician,

4. The substitute physician does not provide the services to the Medicaid beneficiary over a continuous period of longer than sixty (60) days,

5. The locum tenens physician is an enrolled Mississippi Medicaid provider with a valid Mississippi Medicaid provider number,

6. The regular physician identifies the services as substitute physician services,

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7. The claim is billed with the National Provider Identifier (NPI) of the regular physician,

8. The regular physician keeps on file a record of each service provided by the substitute physician, and

9. The regular physician ensures that the locum tenens physician is properly licensed to practice medicine in the state of Mississippi; or, if the regular physician practices in another state, the state in which the regular physician is licensed to practice.

C. Reciprocal Billing Arrangement: Medicaid defines reciprocal billing arrangement when a regular physician or group has a substitute physician provide covered services to a Medicaid beneficiary on an occasional reciprocal basis. A physician can have reciprocal arrangements with more than one physician. The arrangements need not be in writing.

1. Medicaid covers reciprocal billing arrangements when the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis if all the following criteria are met:

a) The regular physician is unavailable to provide the services,

b) A reciprocal billing arrangement is typically an agreement among physicians that one will cover the other’s practice when the regular physician is absent. Physicians can have reciprocal arrangements with more than one physician,

c) The Medicaid beneficiary has arranged or sought services from the regular physician,

d) The substitute physician does not provide the services to a Medicaid beneficiary over a continuous period of longer than sixty (60) days,

e) The substitute physician is an enrolled Mississippi Medicaid provider with a valid Mississippi Medicaid provider number,

f) The regular physician identifies the services as substitute physician on the appropriate claim form,

g) The regular physician keeps on file a record of each service provided by the substitute physician, associated with the substitute physician’s National Provider Identifier (NPI), and

h) The regular physician ensures that the substitute physician is properly licensed to practice medicine in the state of Mississippi; or, if the regular physician practices in another state, the state in which the regular physician is licensed to practice.

2. Medicaid does not cover reciprocal services for substitution arrangements among physicians in the same medical group except when a group member provides services on

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behalf of another group member who is the designated attending physician for a hospice patient.

D. Covered Visit Service - Medicaid covers the submission of claims for a medical group under reciprocal billing arrangements for the covered visit services of a substitute physician who is not a member of the group. Medicaid defines a continuous period of covered visit services that begins with the first day on which the substitute physician provides covered visit services to patients of the regular physician, and it ends with the last day on which the substitute physician provides these services to these patients before the regular physician returns to work. This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or are furnished by some other substitute physician on behalf of the regular physician. A new period of covered visit services can begin after the regular physician has returned to work.

Source: Miss. Code Ann. § 43-13-121

Rule 1.7: Teaching Facilities’ Billing for Resident Services

A. Medicaid does not apply Medicare policy related to billing for services performed by residents in a teaching facility. Medicaid does not cover services provided under the direction of the teaching physician.

B. Medicaid covers teaching physicians, who are supervising residents, but requires the teaching physician to physically be present in the room with the beneficiary and requires documentation in the teaching physician medical record that they were physically present in the room with the beneficiary when services were rendered by the resident.

Source: Miss. Code Ann. § 43-13-121

Rule 1.8: Casting, Splinting, or Strapping in Office Setting

A. Physicians, physician assistants, or nurse practitioners must bill the appropriate procedure evaluation and management code, fracture or dislocation codes, or application of casts and strapping code to be reimbursed professional fees for application of casts, splints, or strapping performed in the office setting. Providers must follow the procedure coding guidelines for selection of the appropriate code.

B. For casting, splinting, or strapping supplies provided by a physician, physician assistant, or nurse practitioner in the office setting, the provider must bill the procedure codes for the cost of the supplies.

C. The coding criteria listed above apply to replacement casts, splints, or strapping.

Source: Miss. Code Ann. § 43-13-121

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Rule 1.9: Removal of Impacted Cerumen

A. Medicaid covers the removal of impacted cerumen only for symptoms directly related to the presence of impacted cerumen. Symptoms include, but are not limited to, the following:

1. Earache,

2. Itching of the ear,

3. Feeling that the ear is plugged,

4. Partial hearing loss,

5. Ringing in the ear, or

6. Otorrhea

B. Medicaid does not cover simple removal of non-impacted cerumen and is considered incidental to an evaluation and management service.

C. Medicaid requires documentation to support occlusion, impaction or blockage, of the external auditory canal secondary to cerumen. The presence of earwax, without symptoms, is not sufficient to support need for removal and symptoms of wax impaction.

Source: Miss. Code Ann. § 43-13-121

Rule 1.10: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Rule 1.11: Physician Verbal Orders

The Division of Medicaid defines physician verbal orders as physician orders that are verbally communicated by telephone, telehealth or face-to-face to authorized medical personnel regarding medications, treatments, interventions or other beneficiary care.

A. Providers are permitted to use physician verbal orders, as long as the verbal order is:

1. Dated,

2. Timed, and

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3. Promptly documented by authorized medical personnel that is responsible for the beneficiary’s care and authorized to receive verbal orders in accordance with State law.

B. Verbal orders must be signed by the ordering physician within fourteen (14) days of the date the verbal order was given except for:

1. Pharmacy verbal orders which must be signed in compliance with the Mississippi Pharmacy Practice Regulations.

2. Nursing facility verbal orders which must be signed:

a) Within thirty (30) days of the date the verbal order was given during the first ninety (90) days after admission.

b) Within sixty (60) days of the date the verbal order was given after the initial ninety (90) days from admission.

Source: 42 C.F.R. §§ 482.23, 482.24, 483.30; Miss. Code Ann. §§ 43-13-117, 43-13-121; Miss. Admin. Code Title 30, Part 3001.

History: New rule eff. 05/01/2020.

Part 203 Chapter 2: Physician-Administered Drugs and Implantable Drug System Devices

Rule 2.1: Covered Services

A. The Division of Medicaid covers medically necessary physician-administered drugs and implantable drug system devices defined as a drug other than vaccines, diagnostic or therapeutic radiopharmaceutical, contrast imaging agent, biological or implantable drug system device covered under the Social Security Act § 1927(k)(2) that:

1. Are administered by a medical professional in a physician’s office or other outpatient clinical setting,

2. Are incident to physician services that are separately billed to the Division of Medicaid,

3. Qualifies for rebate in accordance with 42 USC § 1396r-8,

4. Are Food and Drug Administration (FDA) approved or follows medically accepted indications and dosing limits supported by one (1) or more of the official compendia as designated by the Centers for Medicare and Medicaid Services (CMS), and

5. Are not considered cosmetic, investigational, experimental or unproven.

B. The Division of Medicaid requires prior authorization for certain physician-administered drugs and implantable drug system devices as determined by the Division of Medicaid.

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C. The Division of Medicaid reimburses for discarded drugs or biologicals up to the dosage amount indicated on the single-use vial or package label minus the administered dose(s) if:

1. The drug or biological is supplied in a single use vial or single–use package,

2. The drug or biological is actually administered to the beneficiary to appropriately address his/her condition and any unused portion is discarded,

3. The amount wasted is recorded in the beneficiary’s medical record,

4. The provider has written policy and procedures regarding single-use drugs and biologicals and bills all payers in the same manner, and

5. The amount billed to the Division of Medicaid as a discarded drug is not administered to another beneficiary or patient.

D. The Division of Medicaid does not reimburse for discarded drugs or biologicals when:

1. A beneficiary misses an appointment,

2. A multi-use vial or package is used,

3. The actual dose of the drug or biological administered is less than the billing unit,

4. The drug or biological is administered during an inpatient stay, or

5. The extra amount of the drug is provided to account for wastage in a syringe hub.

E. The Division of Medicaid defines an implantable drug system device as an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent or other similar or related article, including a component part, or accessory which is:

1. Recognized in the official National Formulary, the United States Pharmacopoeia or any supplement to one of these, or

2. Intended for use in the diagnosing of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease.

F. The Division of Medicaid covers the insertion and removal of a Food and Drug Administration (FDA) approved implantable drug system device if it:

1. Is medically necessary,

2. Is in compliance with its approved uses, specifications and restrictions, and

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3. Meets all other applicable coverage requirements.

G. The Division of Medicaid does not cover:

1. Services related to the use of a non-covered medical device, or

2. Implantable drug system devices that are considered experimental or investigational.

Source: 42 U.S.C. § 1396r-8; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 12/01/2019; Added Miss. Admin. Code Part 203, Rule 2.1.A.5. eff. 05/01/2016. Emergency Filing eff. 03/02/2016. Revised eff. 07/01/2014.

Rule 2.2: Drug Rebates

A. In accordance with federal regulations, the Division of Medicaid collects Medicaid drug rebates from manufacturers on physician-administered drugs per the following:

1. Effective for all drugs administered on and after January 1, 2008, providers must submit the National Drug Code (NDC) of the drug administered in addition to the appropriate drug code for physician-administered drugs on claims.

a) An NDC is not required for vaccines or other drugs as specified by CMS.

b) The NDC of the drug administered must contain eleven (11) digits in the five (5) four (4) two (2) grouping and, if applicable, include “leading zeros (0)” to constitute an eleven (11) digit NDC code.

c) The NDC of the drug administered must be matched against a database to ensure its validity.

2. Providers reimbursed based on a fee-for-service must submit the NDC of the drug administered with the appropriate code(s) including, but not limited to, ambulances, independent radiology clinics, free-standing and hospital based dialysis facilities, nurse practitioners, optometrists, individual physicians, physician groups, physician assistants, and podiatrists.

3. Providers reimbursed based on a per diem, encounter or other type of rate are not required to submit the NDC or appropriate code(s) for drugs administered/dispensed by providers including, but not limited, to outpatient hospitals, federally qualified health centers (FQHC), rural health clinics (RHC), ambulatory surgical centers (ASC), home health agencies, nursing homes or other long term-term care facilities.

4. The Division of Medicaid only reimburses for physician administered drugs that are:

a) Subject to the federal rebate program, and

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b) Not considered Drug Efficacy Study Implementation (DESI) drugs.

5. Providers participating in the 340B program must adhere to all the provisions in Miss. Admin. Code Part 200, Chapter 4, Rule 4.10.

B. The Division of Medicaid has the authority to recoup monies when an audit determines that the incorrect NDC number was billed.

Source: Deficit Reduction Act of 2005; 42 U.S.C. § 1396r–8; Miss. Code Ann. § 43-13-121.

History: Revised eff. 09/01/2015; Revised eff. 07/01/2014.

Rule 2.3: [Refer to Miss. Admin. Code Part 203, Rule 2.1]

Rule 2.4: [Refer to Miss. Admin. Code Part 203, Rule 2.1]

Rule 2.5: [Refer to Miss. Admin. Code Part 203, Rule 2.1]

Rule 2.6: [Refer to Miss. Admin. Code Part 203, Rule 2.1]

Rule 2.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 3: Anesthesia

Rule 3.1: Provider Enrollment

A. Providers of anesthesia services must meet the applicable requirements set forth in Part 200, Chapter 4.

B. Anesthesiologists must meet the physician requirements outlined in Part 203, Chapter 1, Rule 1.1.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026.

Rule 3.2: Covered Services

A. Medicaid covers anesthesia services provided by an anesthesiologist/certified registered

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nurse anesthetists (CRNA).

B. Medicaid covers CRNAs for anesthesia services for surgical procedures using the appropriate anesthesia codes.

C. Medicaid covers administration of anesthesia by a CRNA, without medical direction, at ninety percent (90%) of the calculated payment for anesthesiologists. The appropriate modifier must be used when billing for services that are not medically directed.

D. Medicaid covers medically directed CRNA services at fifty percent (50%) of the allowance for the anesthesiologist. The appropriate modifier should be used when billing for services that are medically directed.

Source: Miss. Code Ann. § 43-13-121

Rule 3.3: Criteria for Medical Direction of Resident

A. Medicaid covers an anesthesiologist who assumes full responsibility for a patient while the anesthesia is being administered by a resident in a teaching facility.

1. Medicaid only covers one anesthesiologist for the professional services.

2. Medicaid covers the appropriate modifier indicating that the anesthesiologist has assumed full responsibility for the patient while the anesthesia is being administered by a resident in a teaching facility.

3. The medical direction of residents is covered only in a teaching facility.

4. Medicaid covers the anesthesiologist to supervise no more than four (4) residents at any one time.

5. Medicaid does not cover medical direction by CRNAs.

B. Medicaid covers for the medical direction only if the following criteria are met:

1. Anesthesiologist must be present in the immediate area of the operating or delivery suite with the resident and available for immediate diagnosis and treatment.

2. Anesthesiologist must perform and assist the resident in a pre-anesthesia examination and evaluation.

3. Anesthesiologist must prescribe the anesthesia plan for/with the resident.

4. Anesthesiologist must personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence with the resident.

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5. Anesthesiologist must ensure that no procedures were performed by a non-qualified anesthetist.

6. Anesthesiologist must monitor the course of anesthesia with the resident.

7. Anesthesiologist must at all times supervise and assist the resident with any procedure being performed by the resident.

8. Anesthesiologist must provide indicated post-anesthesia care with the resident.

C. The anesthesiologist and the resident must sign the anesthesia report.

Source: Miss. Code Ann. § 43-13-121

Rule 3.4: Billing for Procedures

A. Medicaid defines one (1) anesthesia time unit as one (1) minute.

B. Medicaid defines anesthesia time as when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under post-operative supervision.

C. Medicaid does not cover additional modifying units for physical status, extreme age, utilization of total body hypothermia or controlled hypotension, or emergency conditions.

D. Medicaid covers additional coverage for the insertion of an arterial line, CVP line, or the insertion/placement of a flow directed catheter such as a Swan-Ganz when the procedures are personally performed by the anesthesiologist/CRNA in conjunction with anesthesia services for a surgical procedure.

Source: Miss. Code Ann. § 43-13-121

Rule 3.5: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 4: Surgery

Rule 4.1: Definitions

A. For purposes of this chapter Medicaid defines the following terms related to surgery as

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follows:

1. Add-on codes are procedures performed in addition to the primary service/procedure and are never reported as a stand-alone code.

a) Add-on codes describe additional intra-service work associated with the primary procedure.

b) Add-on codes are exempt from multiple surgery rules.

2. Assistant surgeon is a licensed physician who actively assists the physician in charge of a case in performing a surgical procedure.

3. Bilateral procedures are exact procedures identified by the same procedure codes which are performed on anatomically bilateral sides of the body during the same operative session.

4. Co-surgeons are two (2) surgeons, each usually in a different specialty, who are required to perform specific procedures during the same operative setting. Co-surgery also refers to surgical procedures involving two (2) surgeons performing the parts of the procedure simultaneously, such as bilateral knee replacements.

5. Endoscopic procedure is the performance of a procedure on interior organs and cavities of the body through an endoscope.

6. An endoscope is a flexible fiber optic instrument used to visualize the interior of a body cavity or organ.

7. Incidental procedure is a procedure carried out at the same time as a primary procedure, is clinically integral to the performance of the primary procedure or requires little additional physician resources.

8. Multiple deliveries are two (2) or more infants delivered from one (1) pregnancy.

9. Multiple surgeries are separate procedures performed by the same physician on the same patient at the same operative setting. Medicaid applies multiple surgery rules to certain procedure codes except for certain procedures exempt from multiple surgery rules.

10. Mutually exclusive procedures are the separate billing for two (2) or more procedures that are usually not performed for the same patient on the same date of service.

11. Team surgeon is a team of surgeons, more than two (2) surgeons of different specialties, required to perform a specific procedure.

12. Unbundled procedures are the use of two (2) or more procedure codes to describe a procedure or event when a single procedure code exists that comprehensively describes

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the surgery performed.

Source: Miss. Code Ann. § 43-13-121

Rule 4.2: Assistant Surgeon

A. Medicaid covers an assistant surgeon during major surgery, including all surgical cases performed under spinal or regional anesthesia if the nature of the surgery requires the assistance of a second physician or surgeon. Medicaid covers only one (1) assistant surgeon for any case.

B. Medicaid does not cover interns, residents, fellows, physician assistants, and nurses, including nurse practitioners, as an assistant surgeon.

C. Medicaid covers the services of an assistant surgeon when the following criteria are met:

1. The operation must be a covered surgical procedure, and

2. The operation must be of sufficient difficulty and complexity to require an assistant surgeon, and

3. The assistant surgeon must actively assist in the surgery.

a) Medicaid defines actively assist as the assistant surgeon must assist in the actual performance of the surgical procedure, and

b) The assistant surgeon, in the event the surgeon is unable to continue, must be able to complete the surgery.

D. Medicaid covers the assistant surgeon’s services at sixteen percent (16%) of the surgical fee for that particular surgery.

E. The appropriate modifier in conjunction with the procedure code for services rendered is required to identify an assistant surgeon’s services.

F. Medicaid does not cover an assistant surgeon in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and which has a qualified resident available, unless one (1) of the following circumstances exists:

1. The assistant surgeon certifies that his services were medically necessary and no qualified resident was available to perform the services. There may be some instances when no qualified residents are available to assist in surgery due to a number of factors that include, but are not limited to, involvement in other activities, complexity of the surgery, number of residents in the program, or other valid reasons.

2. Exceptional medical circumstances, including emergency, life-threatening situations such

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as multiple traumatic injuries requiring immediate treatment.

3. The primary surgeon has an across-the-board policy on never involving residents in the preoperative, operative, or postoperative cares of his/her patients.

Source: Miss. Code Ann. § 43-13-121

Rule 4.3: Co-Surgeons

A. Medicaid covers the individual skills of two (2) or more surgeons when required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery.

B. Medicaid covers co-surgeons at sixty two and one half percent (62.5%) of the Medicaid coverage for co-surgeon procedures.

C. Medicaid covers the services of two (2) surgeons of the same specialty without regard to the two (2) specialty requirement when the services are justified by medical documentation.

D. Medicaid covers the services of two (2) surgeons in different specialties when performing a specific procedure.

1. This is also applicable when the different procedures are performed through the same incision.

2. Each surgeon must report the procedure he/she performed.

E. The appropriate modifier in conjunction with the procedure code for services rendered is required to identify a co-surgeon’s services.

Source: Miss. Code Ann. § 43-13-121

Rule 4.4: Team Surgeons

A. Medicaid covers two (2) or more surgeons to perform surgery on the same patient during the same operative session.

B. Medicaid covers the surgeons of different specialties performing a different procedure, even if the procedures are performed through the same incision.

C. The appropriate modifier in conjunction with the procedure code for services rendered is required to identify a co-surgeon’s services.

Source: Miss. Code Ann. § 43-13-121

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Rule 4.5: Multiple Surgeries

A. Part 203, Chapter 4 Rule 4.5.A, B is applicable for assistant surgeon, team surgeon, or co- surgeon services.

B. Medicaid reimburses for the primary procedure at the highest reimbursement rate from the Medicaid Physician Fee Schedule. The primary surgical procedure must be billed first and other procedures must be billed on subsequent lines on the claim.

C. Medicaid covers multiple surgical procedures performed by the same surgeon on the same patient and on the same date of service. The surgical procedures must be billed together on the same claim unless one (1) claim does not accommodate all of the procedures.

D. For multiple surgeries performed on the same day, Medicaid covers the following:

1. Multiple surgical procedures performed at the same operative setting through a single opening are reimbursable at the Medicaid rate for the procedure with the greatest reimbursement. The additional surgeries through this same opening are not reimbursable unless a second surgical procedure adds significant time, risk, or complexity to patient care which Medicaid will reimburse as follows:

a) The surgery with the greater Medicaid allowed amount will be reimbursed at the full amount.

b) The second surgery will be reimbursed at one half the Medicaid allowance.

c) The secondary procedure must be billed with the appropriate modifier.

d) No additional benefits are paid toward incidental, mutually exclusive, or unbundled procedures.

2. Multiple surgical procedures performed at the same operative setting through separate incisions are covered as follows:

a) The surgery with the greater Medicaid allowance amount will be reimbursed at the full amount.

b) Secondary surgeries, will be paid at one half (1/2) of the Medicaid allowance.

1. These procedures must be identified with the appropriate modifier.

2. No benefits are provided for incidental, mutually exclusive, and unbundled procedures.

3. Secondary procedures must meet all of the following criteria:

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a) The secondary procedure is to correct a separate pathological condition,

b) That pathological condition would have required intervention had an incision not already been present, and

c) The degree of difficulty, operative time and risk were significantly increased by the secondary procedure.

4. If, after a surgical procedure has been completed, it becomes necessary to return and perform a subsequent surgical procedure that same day, Medicaid will cover the full- allowed amount for each surgical setting in accordance with multiple surgery criteria.

E. Medicaid covers designated add on codes and other exempt codes from multiple surgery rules and coverage for multiple surgeries do not apply to these codes.

Source: Miss. Code Ann. § 43-13-121

Rule 4.6: Bilateral Procedures

A. Medicaid covers bilateral procedures performed during an operative setting, when reported with the appropriate procedure code and modifier. One (1) procedure will be paid at one hundred percent (100%) of the Medicaid allowable and the second procedure will be paid at fifty percent (50%) of the Medicaid allowable.

B. If the bilateral procedures are both secondary procedures to a primary procedure, the bilateral secondary procedures will each be paid at fifty percent (50%) of the Medicaid allowable.

Source: Miss. Code Ann. § 43-13-121

Rule 4.7: Surgical Modifiers

A. The applicable modifiers for bilateral procedures, multiple procedures, co-surgeons, surgical teams, and assistant surgeons must be utilized on claims for surgery.

B. Medicaid reimburses for surgical care only at eighty-five percent (85%) of the Medicaid allowable. The applicable modifier for this service must be reported with the appropriate surgery procedure codes.

C. Medicaid reimburses for postoperative management only at fifteen percent (15%) of the Medicaid allowable. The applicable modifier for this service must be reported with the appropriate surgery procedure codes.

1. Medicaid requires a documented agreement for the transfer of care when one (1) physician performs a patient’s surgical service and another provides the postoperative management.

2. The agreement must be in the form of a letter, discharge summary, chart notation, or other

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written documentation and be retained in each physician’ beneficiary’s medical record.

D. No separate benefits are allowed for preoperative management as it is inclusive in the allowance for surgical care.

Source: Miss. Code Ann. § 43-13-121

Rule 4.8: Endoscopic Procedures

A. Medicaid considers the following incidental and not covered:

1. A diagnostic scope and a surgical scope in the same setting,

2. A diagnostic scope with biopsy and a surgical scope,

3. A diagnostic scope with or without biopsy done with an endoscope and an open surgical procedure in the same anatomic area, or

4. A diagnostic scope and diagnostic scope with biopsy unless the verbiage distinguishes the procedure as “with biopsy” versus “without biopsy”.

B. Mutually exclusive relationships to endoscopic procedures are based on the following:

1. Complete versus partial,

2. With versus without, and

3. Extensive versus limited.

C. If endoscopic and open surgical procedures are both performed at the same surgical setting, Medicaid covers the clinically more intense procedure.

1. An endoscopic and an open surgical procedure in the same anatomic area are not covered by Medicaid for separate reimbursement.

2. Medicaid covers endoscopic-assisted, open surgical procedures performed on the same anatomic area during the same operative session when additional time, skill, and physician resources are required with the two (2) approaches, rather than a longer, more invasive open procedure, that can minimize morbidity, patient recovery, and scarring.

D. If multiple endoscopic procedures are performed during the same operative session, Medicaid covers the most complex procedure.

Source: Miss. Code Ann. § 43-13-121

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Rule 4.9: Post-Operative Pain Management

A. The surgeon is responsible for daily post-operative pain management services except under extraordinary circumstances.

B. Medicaid covers post-operative pain management provided by several means, including, but not limited to:

1. Oral and parenteral administration,

2. Patient controlled analgesia (PCA), and

3. Epidural.

C. Providers must maintain proper and complete documentation to verify the services provided. The provider has full responsibility for maintaining documentation to justify the services provided.

1. At a minimum, the medical record must include, but is not limited to, the following:

a) The medical necessity of providing the service.

b) The daily services provided by the surgeon.

c) The name, strength, dosage, route, date and time, indication for, and the administration of medications administered to the patient.

d) Documentation supporting failure of conservative management.

e) Relevant clinical signs and symptoms.

2. Documentation must be legible and medical records must be available to Medicaid, the fiscal agent, and/or the Utilization Management/Quality Improvement Organization (UM/QIO) upon request.

Source: Miss. Code Ann. § 43-13-121

Rule 4.10: Abdominal Panniculectomy

A. Medicaid covers abdominal panniculectomy (abdominoplasty, abdominodermatolipectomy) only when there is medical documentation that demonstrates the procedure is:

1. Medically necessary,

2. Reconstructive,

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3. Performed to alleviate the patient’s symptomatology, and

4. Performed to improve function.

B. Abdominal panniculectomy performed in conjunction with a primary abdominal surgical procedure will be considered as part of the primary surgery. No additional reimbursement will be made toward the abdominal panniculectomy.

C. Medicaid recognizes the performance of abdominal panniculectomy as appropriate and medically necessary when performed to relieve clinical signs and symptoms resulting from redundant skin following a massive weight loss, symptomatology related to panniculitis, and/or the facilitation of abdominal surgery for those persons defined as morbidly obese. The surgeon’s documentation must include presenting or past occurrences of any of the following signs and symptoms including, but not limited to:

1. Pain to abdominal pannus and/or lower back,

2. Impaired ambulation,

3. Interference with personal hygiene,

4. Signs and symptoms of panniculitis,

5. Large redundant fold of skin and fat hanging below the groin,

6. Recurrent intertrigo to the overhanging pannus resulting in skin infections,

7. Body Mass Index greater than thirty (30),

8. Presence of lymphedema, abscesses or hernias, and

9. Documentation of size and configuration of pannus as evidenced in photographs.

D. Prior approval for abdominal panniculectomy is not required.

1. The surgeon must retain all documentation supporting medical necessity in the medical record.

2. The final determination of medical necessity will be made by the surgeon based on the criteria listed in this Rule.

Source: Miss. Code Ann. § 43-13-121

Rule 4.11: Blepharoplasty

A. Medicaid covers a surgical blepharoplasty when performed by a general surgeon, plastic

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surgeon or ophthalmologist in the physician’s office, inpatient or outpatient facility or an ambulatory surgical center.

B. Medicaid defines:

1. Blepharoplasty as any surgery of the eyelid performed to improve abnormal functions or reconstruct deformities.

2. Cosmetic blepharoplasty as surgery performed to reshape normal structures of, or surrounding, the eye solely for the purpose of improving the patient’s appearance or self- esteem.

3. Reconstructive blepharoplasty as surgery performed to correct visual impairment and/or restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia or developmental errors.

C. Prior authorization is not required. The determination of medical necessity will be made by the surgeon based on Medicaid’s coverage criteria. Documentation of visual fields showing un-taped upper vision at twenty-five (25) degrees or better is interpreted as normal and is considered cosmetic.

D. Medicaid covers blepharoplasty and/or repair of blepharoptosis procedures when performed for the following functional indications. Any indication other than the following are deemed not medically necessary and will be considered cosmetic and non-covered procedures.

1. Lower eyelid blepharoplasty is considered medically necessary when documentation:

a) Supports horizontal lower eyelid laxity of medial and lateral canthus resulting in ectropion, dacrystenosis and infection, and/or

b) Supports massive lower eyelid edema.

2. Upper eyelid blepharoplasty and/or brow lift is considered medically necessary when:

a) Clinical notes and visual field testing support a decrease in peripheral vision and/or upper field vision,

b) Photographs document obvious dermatochalasis, ptosis or brow ptosis compatible with the visual field determinations, and

c) Documentation of visual fields must show upper eyelid taped improvement to greater than twenty-five (25) degrees.

3. Repair of brow ptosis and blepharoptosis are considered medically necessary for the following functional indications:

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a) Clinical notes and visual field testing support a decrease in peripheral vision and/or upper field vision,

b) Photographs document obvious dermatochalasis, ptosis, or brow ptosis compatible with the visual field determinations, and

c) Documentation of visual fields must show upper eyelid taped improvement to greater than twenty five (25) degrees.

4. Ptosis Repair is considered medically necessary when:

a) Pre-operative ptosis results in an eyelid covering of one fourth (1/4) of the pupil or one (1) to two (2) millimeters (mm) above the midline of the pupil, and

b) Documentation of the visual fields must show upper eyelid taped improvement to greater than twenty five (25) degrees.

E. The medical record must, at a minimum, include:

1. Complete opthalmological history and physical.

2. Documentation of patient complaints which justify functional surgery and are commonly found in patients with ptosis, pseudoptosis or dermatochalasis.

a) This may include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin or chronic blepharitis.

b) Both photographic and visual field testing are required.

3. Photographs must demonstrate one or more of the following:

a) The upper eyelid margin approaches to within two and one half (2.5) mm (of the diameter of the visible iris) of the corneal light reflex,

b) The upper eyelid skin rests on the eyelashes, or

c) The upper eyelid indicates the presence of dermatitis.

4. Photographs must be prints, not slides, and must include a frontal and lateral view.

a) The head must be perpendicular, not tilted, to the focal plane of the camera to demonstrate a skin rash or position of the true eyelid margin or the pseudo-eyelid margin.

b) The photos must be of sufficient clarity to show a light on the cornea.

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c) If redundant skin coexists with true eyelid ptosis, additional photos must be taken with the upper eyelid skin retracted to show the actual position of the true eyelid margin.

d) Oblique photos may be needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.

5. Visual field testing must be recorded using either a Goldmann Perimeter (III 4-E object) or a programmable automated perimeter (equivalent to a screening field with a single intensity strategy using a 10db stimulus) to test a superior (vertical) extend of fifty (50) to sixty (60) degrees above fixation with targets presented at a minimum four (4) degree vertical separation starting at twenty four (24) degrees above fixation while using no wider than a ten (10) degree horizontal separation.

6. Each eye must be tested with the upper eyelid at rest and repeated with the eyelid elevated to demonstrate an expected surgical improvement meeting or exceeding the criteria.

Source: Miss. Code Ann. § 43-13-121

Rule 4.12: Circumcisions

A. Medicaid does not cover circumcisions unless medical necessity is documented in the medical record according to the criteria listed below.

1. A diagnosis which justifies the medical necessity for circumcision including, but not limited to, recurrent balanoposthitis or recurrent urinary tract infections; the diagnosis of phimosis alone is not sufficient documentation of medical necessity,

2. Failure of the patient to respond to conservative treatment; documentation of conservative treatment must include, but not limited to, teaching about appropriate hygiene and listing of appropriate drug therapy used to treat the condition, and

3. The recurrent nature of the medical condition.

C. The medical documentation must be included either in the surgeon’s report or a beneficiary’s attending physician records to justify medical necessity. A pathology report alone is not sufficient as documentation of medical necessity.

D. Documentation must be legible and available for review if requested.

E. Medically necessary circumcisions may be performed in the inpatient hospital setting subject to precertification of all inpatient days, the outpatient hospital setting, the ambulatory surgical center, or a physician’s office.

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F. Reimbursement for hospital inpatient procedures will be included in the per diem rate of the facility and may be included in the cost report.

1. Facility charges for procedures performed in the outpatient department of the hospital will be reimbursed according to established Medicaid rates for outpatient hospital services.

2. Facility charges for procedures performed in an ambulatory surgical center are paid according to the Medicaid Ambulatory Surgical Center procedure schedule.

3. Physician fees are reimbursed based on the Medicaid Physician Fee Schedule.

G. Appropriate anesthesia, which is considered the standard of care, is covered in accordance with the Division of Medicaid’s rules for anesthesia services. Refer to Part 203, Chapter 3.

Source: Miss. Code Ann. § 43-13-121

Rule 4.13: [Refer to Miss. Admin. Code Part 203, Rule 2.1]

Rule 4.14: [Refer to Miss. Admin. Code Part 203, Rule 2.1]

Rule 4.15: Keloids

A. Medicaid covers the initial evaluation consultation to diagnose the condition and/or develop a plan of treatment.

B. Medicaid covers treatment only when there is medical documentation that demonstrates any of the following signs and symptoms:

1. Pain,

2. Persistent itching and/or burning sensation,

3. Ulceration and bleeding,

4. Limitation of movement of the head or a digit or extremity,

5. Obstruction of a bodily orifice,

6. Infection, or

7. Fast growth.

C. Medicaid covered Keloid treatments include the following:

1. Intralesional injection, including cortisone injections,

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2. Topical treatment,

3. Excision (surgery), and

4. Radiation therapy.

D. Medicaid does not require prior approval for treatment of keloids.

1. The physician must retain all documentation supporting medical necessity in the record.

2. Documentation must include size, location and severity of symptoms.

3. Photographs may also be used to support medical necessity.

Source: Miss. Code Ann. § 43-13-121

Rule 4.16: Male Gynecomastia

A. Medicaid covers mastectomy, including reconstruction if necessary, for gynecomastia when considered medically necessary when the following criteria are met:

1. The tissue removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of a drug treatment which can be discontinued (this would include drug-induced gynecomastia remaining unresolved six (6) months after cessation of the causative drug therapy),

2. Appropriate diagnostic evaluation has been done for possible underlying etiology,

3. Pain or tenderness directly related to the breast tissue has been refractory to a trial of analgesics, anti-inflammatory agents, etc., for a time period adequate to assess therapeutic effects,

4. The excessive breast tissue development is not caused by non-covered therapies or illicit drug usage such as marijuana, anabolic steroids, etc.,

5. The beneficiary has a physician documented history of two (2) years or more of gynecomastia that has been refractory to conservative treatments,

6. Unclothed preoperative photographs from the chin to the waist, including standing frontal and side views with arms straight down at sides, and

7. The beneficiary is over eighteen (18) years of age, or eighteen (18) months after the end of puberty.

B. Medicaid does not consider mastectomy for gynecomastia to be medically necessary under

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certain circumstances. Examples of such circumstances Medicaid does not cover include, but are not limited to, the following:

1. The beneficiary has pseudogynecomastia, which is excess adipose tissue in the male breast, but with no increase in glandular tissue,

2. The procedure is for cosmetic purposes, or

3. Only liposuction is used as the surgical procedure.

C. Medical record documentation of medical necessity must include all of the following:

1. A summary of the medical history and last physical exam, including the information specified in Part 203, Chapter 4 Rule 4.15.A,

2. All prior treatments used to manage the beneficiary’s medical symptoms,

3. Results from any diagnostic tests pertinent to the diagnosis taken within the last six months,

4. Photo documentation confirming breast hypertrophy taken within the last six months with the beneficiary’s name and date on each photo,

5. A surgical treatment plan that outlines the amount of tissue to be removed from each breast and the prognosis for improvement of clinical signs and symptoms pertinent to the diagnosis, and

6. Other pertinent clinical information that Medicaid may request.

D. Providers must maintain proper and complete documentation to verify the services provided. The provider has full responsibility for maintaining documentation to justify the services provided.

Source: Miss. Code Ann. § 43-13-121

Rule 4.17: Otoplasty

A. Medicaid covers otoplasty for the correction of ears that protrude more than twenty (20) millimeters (mm) and at an angle greater than thirty five (35) degrees from the occipital scalp when the following criteria is meet:

1. For the correction of an external ear deformity associated with an abnormality of the external ear canal such as stenosis.

2. When the procedure is intended to improve a hearing impairment.

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3. When performed as part of a staged reconstruction for an absent or inadequate external ear.

4. When the reconstruction involves a cochlear implant and the procedure is required for proper functioning of the device.

B. Medicaid does not cover otoplasty when performed solely for the purpose of improving or altering appearance or self-esteem, or to treat psychological symptomatology or psychosocial complaints related to one’s appearance. Conditions for which Medicaid considers otoplasty cosmetic include:

1. Prominent/protruding ears defined by Medicaid as minor deformities that are considered an anatomic variance and do not meet the measurements listed under Part 203, Chapter 4, Rule 4.16.A.,

2. Lop ears,

3. Cupped ears, or

4. Constricted ears.

C. Medicaid does not cover otoplasty for children under the age of five (5).

D. The medical record must include the relevant history and physical finding indicating the coverage criteria, and must include the following:

1. Photographs of frontal, lateral, and oblique ear positions. The name of the patient and the date of the photograph must be marked on each photograph.

2. Detailed medical history,

3. Hearing evaluation and test results, if performed, and

4. Physical examination.

Source: Miss. Code Ann. § 43-13-121

Rule 4.18: Reduction Mammoplasty

A. The Division of Medicaid covers reduction mammoplasty only when there is medical documentation that demonstrates the procedure is:

1. Medically necessary,

2. Reconstructive, and

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3. Performed as a last means of attempting to alleviate a beneficiary’s symptomatology and dysfunction due to the excessive breast size.

B. The Division of Medicaid covers reduction mammoplasty only when there is documentation that the beneficiary meets all of the following:

1. If under the age of eighteen (18), and has been evaluated by the primary care provider,

2. The primary care provider has documented that the beneficiary:

a) Is appropriate for this procedure, and

b) Has reached the age of sixteen (16) and Tanner Stage V of the Tanner Staging of Sexual Maturity Rating.

3. The primary care provider agrees that the beneficiary is appropriate for a surgical evaluation for reduction mammoplasty.

C. Justification for reduction mammoplasty must be based on the probability of relieving clinical signs and symptoms of macromastia. The surgeon’s documentation must include the following criteria:

1. A complete and accurate beneficiary history that includes complaints of pain and restriction of normal activity for the past two (2) years.

2. Medical necessity for the removal of a minimum of five hundred (500) grams of tissue from each breast. If the removal of the amount of breast tissue is less than five hundred (500) grams, the surgeon must provide full documentation in the medical record that justifies reduction mammoplasty with removal of less than five hundred (500) grams.

3. Supra sternal notch to nipple measurement of twenty-eight (28) cm or greater.

D. In addition to the criteria listed in Miss. Admin. Code Part 203, Chapter 4, Rule 4.18.C., documentation of the following may support the determination of medical necessity:

1. A history of intertrigo under or between breasts,

2. A psychological assessment, and/or

3. Documentation of deep grooves over the shoulders from bra straps.

E. The surgeon must retain all documentation supporting medical necessity in the medical record.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

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History: Revised eff. 05/01/2026. Revised eff. 03/01/2019.

Rule 4.19: Skin Tag Removal

A. Medicaid does not cover removal of benign skin tags that do not pose a threat to health or function.

B. Medicaid covers the removal of skin tags when there is medical documentation that one or more of the following conditions exist:

1. The skin tag has one or more of the following characteristics: bleeding, itching, pain,

2. The skin tag has physical evidence of inflammation such as purulence, oozing, edema, erythema,

3. The skin tag obstructs an orifice,

4. The skin tag clinically restricts vision,

5. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the skin tag appearance, or

6. A prior biopsy suggests or is indicative of malignancy.

C. Medicaid requires documentation to include the patient’s signs and symptoms and skin tag physical findings including size, location, appearance, number, duration and changes over time, tissue diagnosis report, operative note with detail to support the surgical procedure performed.

Source: Miss. Code Ann. § 43-13-121

Rule 4.20: Uvulopalatopharyngoplasty (UPPP/UP3)

Medicaid covers uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea syndrome if all of the following are present:

A. Documented obstructed sleep apnea (OSA) with apnea hypopnea index (AHI) or respiratory disturbance index (RDI) which meets the following parameters in a) or b) below:

1. UPPP/UP3 as sole procedure: with AHI/RDI greater than fifteen (15) and less than forty (40), or AHI/RDI ten (10) to fifteen (15) with one (1) or more of the conditions listed below:

a) Hypertension,

b) Cardiac arrhythmias predominately during sleep,

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c) Pulmonary hypertension,

d) Documented ischemic heart disease,

e) Impaired cognition or mood disorders,

f) History of stroke, or

g) Excessive daytime sleepiness, as documented by either a score of greater than ten (10) on the Epworth Sleepiness Scale or inappropriate daytime napping such as during driving, conversation, or eating, or sleepiness that interferes with daily activities.

2. UPPP/UP3 as part of a planned staged or combined surgery aimed at also relieving retro lingual obstruction such as genioglossal advancement, hyoid myotomy and suspension: with AHI/RDI greater than fifteen (15), or AHI/RDI ten (10) to fifteen (15) with one (1) or more of the conditions listed below:

a) Hypertension,

b) Cardiac arrhythmias predominately during sleep,

c) Pulmonary hypertension,

d) Documented ischemic heart disease,

e) Impaired cognition or mood disorders,

f) History of stroke, or

g) Excessive daytime sleepiness, as documented by either a score of greater than ten (10) on the Epworth Sleepiness Scale or inappropriate daytime napping, (e.g., during driving, conversation, or eating) or sleepiness that interferes with daily activities.

B. Continuous positive airway pressure (CPAP) has been tried with well-supported follow-up and clearly failed or is not tolerated.

C. Pre-operative evaluation including fiber optic endoscopy suggest retro-palatal narrowing is the primary source of airway obstruction if UPPP/UP3 is the sole procedure or a combined surgery aimed at also relieving retro lingual obstruction.

Source: Miss. Code Ann. § 43-13-121

Rule 4.21: Ventricular Assist Devices (VAD)

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A. Medicaid covers medically necessary procedures for the insertion or removal of FDA- approved ventricular assist devices (VAD) in accordance with its FDA approved uses as follows:

1. Post-cardiotomy procedures for insertion/removal of a VAD performed during the period following open-heart surgery.

2. Bridge-to-transplant procedures for insertion/removal of a VAD performed during the period prior to heart transplant when the patient is at imminent risk of dying before donor heart procurement.

3. Destination therapy procedures for insertion/removal of a VAD performed as a permanent mechanical cardiac support for individuals with severe New York Heart Association (NYHA) Class IV heart failure, and who are not eligible for heart transplantation.

B. Medicaid does not cover procedures using non-FDA approved devices and/or done for indications other than those approved by the FDA including, but not limited to:

1. Procedures using devices that are considered experimental, investigational, or part of clinical trials.

2. Procedures for replacement of the human heart with an artificial heart.

C. Medicaid does not allow separate reimbursement for the ventricular devices.

Source: Miss. Code Ann. § 43-13-121

Rule 4.22: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Rule 4.23: Gastric Electrical Stimulation (GES)

A. The Division of Medicaid covers Gastric Electrical Stimulation (GES) when used for the treatment of chronic intractable (drug-refractory) nausea and vomiting secondary to gastro- paresis of diabetic or idiopathic etiology. The Food and Drug Administration has approved the GES device through a humanitarian exemption.

B. The beneficiary’s medical record must contain documentation that the implanting facility’s institutional review board (IRB) or equivalent governing body has approved the implantation of the GES for the specific indications listed in Rule 4.23 A.

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C. GES is considered medically necessary if a beneficiary has a diagnosis of gastroparesis and meets all of the following criteria:

1. Is refractory or intolerant of two (2) out of three (3) classes of prokinetic medications and two (2) out of three (3) antiemetic medications,

2. Has significantly delayed gastric emptying as documented by standard scintigraphic imaging of solid food,

3. Has a poor nutritional status and enteral feedings or total parental nutrition (TPN) is medically necessary, and

4. Is age eighteen (18) through seventy (70).

D. All other indications including, but not limited to, the treatment of obesity, are considered investigational and not medically necessary.

E. GES is not covered for beneficiaries who are:

1. Pregnant,

2. Suffering from chemical dependency,

3. Undergoing peritoneal dialysis, or

4. Terminal with a limited life expectancy based on a diagnosis of cancer.

F. Prior authorization by the UM/QIO is required.

Source: Miss. Code Ann. § 43-13-121

History: 04\01\2013

Part 203 Chapter 5: Chiropractor

Rule 5.1: Covered Services

A. Medicaid covers chiropractic services for manual manipulation of the spine to correct a subluxation.

B. An x-ray must demonstrate that a subluxation exists and if the subluxation has resulted in a neuromusculoskeletal condition for which manipulation is appropriate treatment.

Source: Miss. Code Ann. § 43-13-121

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Rule 5.2: Reimbursement

The fee for chiropractic manipulation shall be reimbursed per the fee schedule and shall not exceed seven hundred dollars ($700) per fiscal year (July 1 - June 30) per beneficiary.

Source: Miss. Code Ann. § 43-13-121

Rule 5.3: Coverage Criteria

A. A chiropractor must use the appropriate procedure code for manual manipulation of the spine to correct subluxation. Medicaid coverage will be provided for one (1) procedure code that encompasses the entire treatment for any given day.

B. Necessity of treatment must be documented by use of the appropriate diagnosis code to report all of the following:

1. Treatment area as denoted by the appropriate primary diagnosis code.

2. Symptoms associated with subluxation as denoted by the appropriate second diagnosis code.

3. Complicating factors as denoted by the appropriate third diagnosis code.

C. An x-ray is required to demonstrate that a subluxation exists unless the patient is:

1. Pregnant,

2. Suspects pregnancy which has not yet been confirmed, or

3. A child age twelve (12) years or less.

D. The date of the x-ray or the exception(s) must be properly documented in the medical record including the:

1. Date of the x-ray which must be within twelve (12) months of the date of service.

2. Expected date of delivery if the patient is pregnant.

3. Date of last menstrual period if pregnancy is suspected but not confirmed.

4. Child’s date of birth when the child is twelve (12) years of age or less. The x-ray is at the discretion of the chiropractor.

E. Medicaid applies the appropriate procedure codes for chiropractic services and x-ray procedures toward the seven hundred dollars ($700) per fiscal year (July 1 - June 30) per beneficiary.

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Source: Miss. Code Ann. § 43-13-121

Rule 5.4: Dual Eligibles

A. For beneficiaries covered under Medicare and Mississippi Medicaid (dual eligibles), chiropractic providers must not file a claim with Medicaid for the manipulation of the spine procedures not covered by Medicare. Mississippi Medicaid benefits are not available for services that do not satisfy Medicare’s medical necessity criteria.

B. For beneficiaries covered under Medicare and Medicaid (dual eligibles), chiropractic providers may file a claim with Medicaid for those specified codes not covered by Medicare.

C. The six (6) month timely filing limitation for filing crossover claims is applicable with no exceptions.

Source: Miss. Code Ann. § 43-13-121

Rule 5.5: Documentation Requirements

The chiropractor must maintain auditable records that substantiate the services provided. At a minimum, the records must contain the following on each patient:

A. The dates of services provided.

B. The patient’s presenting complaint.

C. Date of the x-ray which must be within twelve (12) months of the date of service.

D. Expected date of delivery if the patient is pregnant.

E. Date of last menstrual period if a pregnancy is suspected but not confirmed.

F. Child’s date of birth when the child is twelve (12) years of age or less. (The x-ray is at the discretion of the chiropractor).

G. The results/findings of all diagnostic studies.

H. The patient’s history and physical findings.

I. The treatment rendered, including:

1. Frequency,

2. Proposed length,

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3. Progress, and

4. Prognosis.

J. The chiropractor’s signature.

Source: Miss. Code Ann. § 43-13-121

Rule 5.6: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 6: Podiatry

Rule 6.1: Covered Services

Medicaid covers the following podiatry services:

A. Laboratory services required for care of a systemic condition are covered only to the MD/DO supervising the systemic condition or to a laboratory to which the MD/DO has referred the specimen.

B. Physical therapy services that are medically necessary and appropriate for the treatment of the foot condition.

C. Radiology services provided in an office setting that are medically necessary and include both the technical and professional components of the service if provided.

D. Foot care required as a result of or associated with systemic conditions limited to once every sixty (60) days.

E. Surgical treatment of ingrown toenails. Localized pathology of the soft tissue surrounding the nail must demonstrate that it is severe enough to require professional intervention.

F. Debridement if gross contamination requires prolonged cleansing.

G. Surgical debridement of mycotic nails with a manual or electric grinder method if the following conditions exists:

1. Clinical evidence of mycosis of the toenail.

2. Documentation of the severity of the condition and if patient ambulatory have marked

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limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate and for non-ambulatory patients must suffer pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

H. Debridement of mycotic nails once every sixty (60) days.

I. Correction of hammertoe.

J. Definitive treatment of viral or plantar warts.

K. Medical or surgical treatment of subluxation of the ankle joint (talocrural joint). Services that are medical or surgical, diagnosis, or treatment for medical conditions that have resulted from or associated with partial displacement of structures.

L. Treatment of paronychia for stages A and B when avulsion or debridement is provided.

M. Foot care in the presence of metabolic, peripheral, or neurological disease including the following:

1. Diabetes Mellitus,

2. Arteriosclerosis obligerans,

3. Buerger’s disease,

4. Chronic thrombophlebitis, or

5. Peripheral neuropathies involving feet that are associated with malnutrition, alcoholism, malabsorption, or pernicious anemia, peripheral neuropathies

Source: Miss. Code Ann. § 43-13-121

Rule 6.2: Non-covered services

Medicaid does not cover the following:

A. Identification of culture of fungi in the toenail clippings is not covered.

B. Local anesthesia, digital blocks, or topical anesthesia done with a specific surgical procedure.

C. Cast applications/strapping/splinting charged separately from the initial surgery or fracture care on same day as initial surgery or fracture care.

D. Removal of casts/straps/splints.

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E. Ultrasound on patients with diabetes.

F. Foot massage.

G. Whirlpool for mycotic nail treatment.

H. Surgical trays.

I. Supplies.

J. Biopsies performed in conjunction with a surgical procedure.

K. Services for treatment of flat foot.

L. Services not medically necessary for the diagnosis and treatment of the condition of the foot.

M. Laboratory services performed by the DPM (Doctor of Podiatric Medicine) or referred to an independent laboratory by the DPM.

N. Services performed for conditions above the ankle unless within the scope of the podiatrist license.

O. Office visits with routine foot care procedures.

P. Routine foot examinations on all patients in a skilled nursing facility on a routine basis for screening purposes.

Q. Orthopedic shoes, any other type shoe, and/or supportive devices.

R. Routine foot care with debridement of nails on same date of service. Routine foot care may not be substituted for debridement of nails when the once every sixty day limit has been utilized.

S. Doppler (other than hand held Doppler), non-vascular diagnostic testing pertaining to a systemic disease.

T. Evaluation and advice for proper care of feet when the only service rendered for the management of paronychia. Debridement and avulsion may not be done on the same date of service.

U. Surgical or nonsurgical treatments provided for the sole purpose of correcting a subluxated structure in the foot as an isolate entity.

V. Palliative treatment of viral or plantar warts.

W. Routine foot care, in the absence of systemic conditions, including the following:

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1. The cutting or removal or corns or calluses,

2. The trimming of nails, including the cutting, clipping, or debridement of ingrown toenails, club nails, or mycotic nails,

3. Fungal infections of the nail plates or mycotic nails with little or no symptomatology,

4. Avulsing small chips after trimming of the thickened/elongated nails that are painful, under the diagnosis of ingrown toenail,

5. Other hygienic and preventive maintenance care and any other service provided in the absence of localized illness, injury, or symptoms involving the foot, or

6. Routine soaking and application of topical medication.

Source: Miss. Code Ann. § 43-13-121

Rule 6.3: Anesthesia

A. Medicaid does not cover local infiltration, metacarpal/ metatarsal/ digital blocks, or topical anesthesia outside the specific surgical procedure performed.

B. Medicaid covers the cost of drugs used for IV sedation and must be billed with the appropriate HCPCS code

Source: Miss. Code Ann. § 43-13-121

Rule 6.4: Documentation

Medicaid requires podiatry providers to maintain auditable records that will substantiate the services provided. At a minimum, the records must contain the following on each patient:

A. Date(s) of service,

B. Patient’s presenting complaint(s),

C. Patient’s history and physical findings,

D. Treatment rendered, including: frequency of treatment, proposed length of treatment, and progress reports documenting the patient’s progress with the treatment, and prognosis,

E. Narrative or operative report specific for procedure, type of anesthesia used for the procedure,

F. Clinical evidence of all conditions,

G. Accurate diagnosis codes to reflect all conditions,

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H. X-rays ordered or obtained,

I. Full name and address of the MD/DO treating patient for a systemic condition and date of last visit with that MD/DO and must be within last six (6) months. Medical necessity must document the local pathology of the foot that requires professional intervention, identify complicating factors,

J. Full description of the clinical symptoms of the systemic condition,

K. Site of each wart, size, method of treatment or surgical removal,

L. Medical necessity of therapy, specific modality, or procedure, frequency of therapy, proposed length of therapy, and progress reports of patient’s therapy,

M. Complicating conditions of the nail that limits ambulation, pain, or secondary infection result in thickening and dystrophy of the infected toenail plate,

N. Warts removed by cautery must include the number of lesions removed, their location, size and type of cautery used. If removed by surgical excision the operative note and pathology report on the excised tissue including number of specimens, their location, size, and any/all microscopic findings,

O. Nerve block injections must be reasonable and medically necessary and must indicate that a more conservative therapy has not been effective, must describe patient’s clinical state, history , physical findings, laboratory and other tests, identification of the problem, including diagnosis, precipitating events, quantity and quality of pain, test results, response to previous therapy, the procedure performed, including area injected, the substance(s) injected, and the dosage of the substance(s),

P. Diagnosis(es) to substantiate all treatments/procedures,

Q. The name, strength, dosage, route (intramuscular, intravenous, subcutaneous, oral, and topical, etc.), date and time, indication for, and the administration of all medications administered to the patient,

R. Patient’s or guardian’s refusal of services, if applicable,

S. Photographs, if applicable, must be prints, not slides, and include the patient’s name and date of service, to document severe paronychia, persistent, recurrent infections, clinical evidence of systemic conditions related to the foot, mycotic nails, severity of ulcers of the foot and progression of ulcer(s), deformities such as hammertoe, traumatic injuries, severity of ingrown toenails or ingrown toenail condition on toes other than big toe,

T. Description(s) of wound(s), ulcer(s), etc., if applicable, including size, appearance, and location for each date of service, and

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U. Podiatrist signature.

Source: Miss. Code Ann. § 43-13-121

Rule 6.5: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 7: Nurse Practitioner

Rule 7.1: Provider Enrollment

A. Advanced Practice Registered Nurses (APRNs), also referred to as Nurse Practitioners (NPs), certified by the state in which they practice may participate in the Mississippi Medicaid Program upon compliance with the applicable provider enrollment requirements outlined in Part 200, Chapter 4.

Source: 42 C.F.R. Part 455, Subpart E; Miss. Code Ann. §§ 43-13-117, 43-13-121, 73-15-20.

History: Revised eff. 08/01/2026. Revised eff. 12/01/2019.

Rule 7.2: Nurse Practitioner Services and Reimbursement

The Division of Medicaid covers services provided by Advanced Practice Registered Nurses (APRNs), also referred to as Nurse Practitioners (NPs), certified by the state in which they practice, for services rendered within the scope of practice allowed by their protocol.

NPs must bill the appropriate Current Procedure Terminology (CPT) code for services rendered and follow the same rules and guidelines as physician services.

The Division of Medicaid reimburses NPs at ninety percent (90%) of the physician fee for the service.

The Division of Medicaid does not reimburse for:

1. An NP as an assistant surgeon,

2. Multiple providers when a service is performed simultaneously with another provider, or

3. NP services if the collaborating physician is not a Mississippi Medicaid enrolled provider or an Ordering, Referring or Prescribing (ORP) physician.

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Source: 42 C.F.R. § 440.166; Miss. Code Ann. §§ 43-13-117, 43-13-121, 73-15-20.

History: Revised eff. 12/01/2019

Rule 7.3: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 8: Physician Assistant

Rule 8.1: Physician Assistant Enrollment Requirements

A. Physician assistants (PAs), who are licensed by the Mississippi State Board of Medical Licensure and are practicing with physician supervision under regulations adopted by the board, may participate in the Mississippi Medicaid Program upon compliance with the applicable provider enrollment requirements outlined in Part 200, Chapter 4.

B. The PA's supervising/collaborating physician must be enrolled with Mississippi Medicaid as:

1. A Medicaid provider, or

2. An Ordering, Referring or Prescribing (ORP) physician.

Source: 42 C.F.R. Part 455, Subpart E; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 08/01/2026. Revised eff. 12/01/2019. Rule 8.2: Physician Assistant Services and Reimbursement

A. Physician assistants (PAs) may bill the Division of Medicaid for the covered services within the scope of practice allowed by their protocol.

B. PAs must bill the appropriate Current Procedure Terminology (CPT) code for services rendered and follow the same rules and guidelines as physician services.

C. The Division of Medicaid reimburses PAs at ninety percent (90%) of the physician fee for the service.

D. The Division of Medicaid does not reimburse for:

1. A PA as an assistant surgeon,

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2. Multiple providers when a service(s) is (are) performed simultaneously with another provider, or

3. PA services if the supervising physician is not a Mississippi Medicaid enrolled provider or an Ordering, Referring or Prescribing (ORP) physician.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 12/01/2019.

Rule 8.3: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 9: Psychiatric Services

Rule 9.1: Provider Qualifications

Psychiatric services described in this chapter must be provided by a licensed physician (medical doctor or doctor of osteopathy) who is board-certified in psychiatry or by a licensed Psychiatric Mental Health Nurse Practitioner (PMHNP). Rules included in this chapter do not apply to psychologists.

Source: Miss. Code Ann. § 43-13-121

Rule 9.2: General Requirements

A. All services must be personally and directly provided by the psychiatrist or PMHNP who requests reimbursement for the service.

B. Services must be based on beneficiary need and not the convenience of the beneficiary, the beneficiary’s family or the provider.

C. A provider may bill only for the actual time spent in service delivery.

Source: Miss. Code Ann. § 43-13-121

Rule 9.3: Covered Services

The following psychiatric services are eligible for reimbursement by Medicaid only when they have been personally and directly provided by a licensed physician (medical doctor or doctor of osteopathy) who is board-certified in psychiatry or by a licensed Psychiatric Mental Health

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Nurse Practitioner (PMHNP):

A. Evaluative Services which include a psychiatric interview ok an interactive psychiatric interview.

B. Therapeutic Services which include individual, family, and group psychotherapy.

C. Other psychiatric services/procedures including

1. Medication evaluation, and

2. Electroconvulsive therapy.

Source: Miss. Code Ann. § 43-13-121

Rule 9.4: Non-Covered Services

A. Services are not eligible for reimbursement unless they are personally and directly provided by the servicing provider.

B. Educational interventions of an academic nature are not eligible for Medicaid reimbursement.

C. Medicaid will not reimburse more than once for the same service provided to any beneficiary on any given date, regardless of the setting(s) in which the service was provided. It is the provider’s responsibility to coordinate services with the beneficiary and/or his/her family member to ensure that services are not duplicated.

Source: Miss. Code Ann. § 43-13-121

Rule 9.5: Service Limits

A. The Division of Medicaid defines service limits as the maximum quantity of services per beneficiary that are eligible for reimbursement by the Division of Medicaid within a given time frame, either daily or yearly.

B. Daily service limits apply to beneficiaries, regardless of the setting, hospital/residential or community-based, in which the services are provided.

C. The following yearly service limits apply to non-EPSDT-eligible beneficiaries:

1. The Division of Medicaid covers a combined total of sixteen (16) psychiatric physician office and hospital outpatient department visits per state fiscal year (July 1-June 30). [Refer to Miss. Admin. Code, Part 200, Rule 9.5 for non-psychiatric physician office and hospital outpatient department visits.]

2. Hospital Inpatient Services

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a) Inpatient hospital psychiatric services are reimbursed under the APR-DRG methodology and are available only if the services are determined to be medically necessary by the Utilization Management/Quality Improvement Organization (UM/QIO). Day outlier payments may be made for mental health long lengths of stay for exceptionally expensive cases.

b) Prior authorization is required upon admission and for lengths of stay greater than nineteen (19) days.

c) One (1) covered psychiatric service/procedure is eligible for reimbursement per beneficiary per certified day in a general hospital or acute freestanding psychiatric facility.

Source: 42 C.F.R. § 440.230; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 18-0020 (eff. 01/01/2019) eff. 06/01/2019; Revised - 10/01/2012.

Rule 9.6: Documentation

A. Physicians are required to maintain auditable records that will verify any or all services provided and billed under the Medicaid program.

1. Records must, be made available to representatives of the Division of Medicaid or Office of the Attorney General in substantiation of claims.

2. Records must be maintained for a minimum of five (5) years in order to comply with all state and federal regulations and laws. Refer to Maintenance of Records Part 200, Chapter 1, Rule 1.3.

B. It is expected that the initial psychiatric service provided to any beneficiary must be of an evaluative nature. Documentation of the evaluation must be in the case record and must include, at a minimum:

1. Dates, including beginning and ending session times, and the amount of time spent,

2. Chief complaint,

3. Referral source,

4. History of present illness,

5. Past psychiatric history,

6. Past medical history,

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7. List of the beneficiary’s current medications including prescription, non-prescription and over-the-counter,

8. Social and family history,

9. Comprehensive mental health status examination,

10. Treatment plan formulation/prognosis,

11. Assessment of the patient’s ability to adhere to the treatment plan,

12. A multi-axial diagnosis,

13. Identification of the clinical problems that are to be the focus of treatment,

14. Treatment modalities and/or strategies that will be employed or are recommended to address each problem. If medications are prescribed, documentation must include the name of the drug, strength and dosage. The method of administration must be included for injectable medications. Medication prescriptions must be identified as issued in writing, electronically, or by telephone, and

15. The signature of the person who provided and documented the service. Any note that is “signed” by computer must be initialed by hand.

C. A treatment plan must be developed and implemented for each beneficiary no later than the date of the third (3 rd ) therapy session.

1. The treatment plan must include, at a minimum:

a) A multi-axial diagnosis,

b) Identification of the beneficiaries’ and/or family’s strengths,

c) Identification of the clinical problems, or areas of need, that is to be the focus of treatment,

d) Treatment goals for each identified problem,

e) Treatment objectives that represent incremental progress towards goals, coupled with target dates for their achievement,

f) Specific treatment modalities and/or strategies that will be employed to reach each objective, and

g) Date of implementation and signatures of the provider and the beneficiary or

46

parent/legal guardian.

2. Treatment plans must be kept in the case record and must be reviewed and revised as needed, or at least every three (3) months. Each review must be verified by the dated signatures of the provider and beneficiary/parent/legal guardian. The physician, nurse practitioner, psychologist, and clinical social worker must sign the treatment plan for the services each will provide to the beneficiary.

D. A clinical note for each therapeutic service provided must be in the case record and must:

1. Include the date of service, type of service provided, the length of time spent delivering the service, who received or participated in it, as well as a brief summary of what transpired. If medications are prescribed, documentation must include the name of the drug, strength and dosage. The method of administration must be included for injectable medications. Medication prescriptions must be identified as issued in writing, electronically, or by telephone.

2. Indicate whether Evaluation and Management services are provided.

3. Relate to the problems identified in clinical record.

4. Identify whether the service occurs in an inpatient or outpatient setting.

5. Be authenticated by the signature of the person who provided and documented the service. Any note that is “signed” by computer must be initialed by hand.

Source: Miss. Code Ann. § 43-13-121

Rule 9.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 203 Chapter 10: Implantable Medical Devices

Rule 10.1: Skin and Soft Tissue Substitutes

A. The Division of Medicaid defines skin and soft tissue substitutes as types of wound coverage materials composed of human tissue, non-human tissue, synthetic materials, or a composite of these materials which mimic or substitute for some aspect of the skin’s structure, either permanently or temporarily, for the treatment of acute and chronic non-healing wounds and soft tissue grafting.

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B. The Division of Medicaid covers skin and soft tissue substitute procedures, products, and services for medically accepted conditions and indications approved by the Food and Drug Administration (FDA) when medically necessary and when the procedures, products, and services are:

1. Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs,

2. Safely applied within the scope of FDA indications and according to manufacturer’s instructions, and

3. No equally effective or more conservative or less costly treatment is available statewide.

C. The Division of Medicaid covers skin and soft tissue substitutes for the following, including, but not limited to:

1. Acute wounds,

2. Chronic non-healing wounds,

3. Soft tissue grafting,

4. Second and third degree burns,

5. Dermatological conditions which involve large areas of skin breakdown,

6. Post-surgical states in which skin coverage is inadequate or ability to heal is compromised,

7. Diabetic foot ulcers, and

8. Venous stasis ulcers.

D. The Division of Medicaid does not cover skin and soft tissue substitutes for experimental, investigational uses or clinical trials or for the following conditions or circumstances, including, but not limited to:

1. Infected ulcers,

2. Wounds or ulcers healing with traditional wound care dressings and treatment,

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3. Underlying osteomyelitis,

4. Surrounding cellulitis,

5. Uncontrolled diabetes,

6. Vasculitis,

7. Eschar or any necrotic material,

8. Wound bed with exposed bone,

9. Uncontrolled rheumatoid arthritis, rheumatoid ulcers, or both,

10. Known hypersensitivity to:

a) Collagen,

b) Bovine-derived products, or

c) Porcine-derived products,

11. Active Charcot’s arthropathy of the ulcer extremity,

12. Arterial disease with an ankle brachial index (ABI) of less than .65 in respect to venous stasis ulcers or a lack of pedal pulses in respect to diabetic foot ulcers,

13. Ulcers with sinus tracts or tunnels,

14. Uncontrolled collagen vascular diseases,

15. Radiation and/or chemotherapy treatment within the month immediately preceding proposed skin substitute treatment, or

16. Current treatment with high-dose corticosteroids or immunosuppressants.

E. The provider must maintain auditable records that substantiate the services provided which must include, but are not limited to, the following:

1. The diagnosis supporting medical necessity,

2. Previous conservative wound management which has failed to induce healing,

3. Exact location, size, including width, length, circumference, and depth, of the wound prior to initial treatment and prior to each subsequent treatment,

49

4. Response to wound treatment,

5. Appropriate adjunctive wound care measures,

6. The handling, application, and immobilization of the product in accordance with the manufacturer’s instructions,

7. Amount of skin or soft tissue product used and wasted, and

8. Manufacturer’s serial/lot/batch or other unit identification number of graft material, or documentation sufficient to demonstrate that the manufacturer does not supply unit identification.

Source: Social Security Act §§ 1862(a)(1)(A) and (D); 21 CFR Part 1271.

History: New Rule eff. 10/01/2014.

Part 204 Dental Services

23 Miss. Admin. Code Pt. 204 Dental Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 204 Dental Services

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 204: Dental Services ............................................................................................................ 1 Part 204 Chapter 1: General .................................................................................................... 1 Rule 1.1: Dental Programs ............................................................................................... 1 Rule 1.2: Provider Enrollment ......................................................................................... 1 Rule 1.3: Covered Services .............................................................................................. 1 Rule 1.4: Non-covered Services ....................................................................................... 2 Rule 1.5: Dental Benefit Limits ....................................................................................... 2 Rule 1.6: Prior Authorization ........................................................................................... 2 Rule 1.7: Laboratory Services, Diagnostic Casts and Photographs ................................. 4 Rule 1.8: Radiographs ...................................................................................................... 4 Rule 1.9: Periodontic Procedures ..................................................................................... 5 Rule 1.10: Injectable Medications .................................................................................... 5 Rule 1.11: Dental Services Provided in the Hospital or Ambulatory Surgical Center (SC) Setting ...................................................................................................................... 5 Rule 1.12: Oral Evaluations ............................................................................................. 6 Rule 1.13: Consultations .................................................................................................. 6 Rule 1.14: Anesthesia ....................................................................................................... 6 Rule 1.15: Bone Replacement Graph ............................................................................... 7 Rule 1.16: Documentation Requirements ........................................................................ 7 Rule 1.17: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 8 Rule 1.18: Dental Reimbursement ............................................................8 Part 204 Chapter 2: Oral Surgery ........................................................................................... 9 Rule 2.1: Simple Extractions ........................................................................................... 9

Rule 2.2: Supernumerary Tooth Extractions ................................................................... 9 Rule 2.3: Surgical Extractions ......................................................................................... 9 Rule 2.4: Alveoloplasty ................................................................................................. 10 Rule 2.5: Root Tips ....................................................................................................... 10 Rule 2.6: Complicated Sutures ...................................................................................... 10 Rule 2.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ............. 10

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Title 23: Division of Medicaid

Part 204: Dental Services

Part 204 Chapter 1: General

Rule 1.1: Dental Programs

The Division of Medicaid is authorized to furnish:

A. Dental care that is an adjunct to treatment of an acute medical or surgical condition,

B. Services of oral surgeons and dentists in connection with surgery related to the jaw or any structure contiguous to the jaw or the reduction of any fracture of the jaw or any facial bone, and

C. Emergency dental extractions and treatment related thereto. Medicaid defines a dental emergency as a condition that requires treatment and that causes pain and/or infection of the dental apparatus and/or contiguous structures.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.2: Provider Enrollment

Dentists must meet the applicable requirements set forth in Miss. Admin. Code Part 200, Chapter 4.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026.

Rule 1.3: Covered Services

A. Covered dental services include:

1. Limited oral evaluation, problem-focused,

2. Radiographs,

3. Gingivectomy and/or gingivoplasty for Dilantin therapy only,

4. Oral surgery,

5. Extractions, and

6. Alveoloplasty.

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Source: Miss. Code Ann. § 43-13-121.

Rule 1.4: Non-covered Services

A. Non-covered dental services include, but not limited to, the following:

1. Comprehensive oral evaluation,

2. Preventive services,

3. Amalgams, composites, and crowns,

4. Endodontics,

5. Dentures, and

6. Orthodontia.

B. The Division of Medicaid does not cover for scheduling/rescheduling for any dental or oral surgical procedure in any treatment setting.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.5: Dental Benefit Limits

A. The Division of Medicaid covers dental expenditures, excluding orthodontia-related services, up to twenty five hundred dollars ($2,500.00) per beneficiary per state fiscal year.

B. All American Dental Association (ADA) dental procedure codes, except orthodontia-related services, are applied to the $2,500 annual limit.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.6: Prior Authorization

A. The Division of Medicaid requires prior authorization, except for emergencies, from the Utilization Management/Quality Improvement Organization (UM/QIO) of the following dental services:

1. Surgical access of an unerupted tooth,

2. Radical resection of mandible with tooth bone graft,

3. Arthrotomy,

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4. Complicated suture greater than five (5) cm,

5. Osteoplasty – for orthognathic deformities,

6. Osteotomy – mandibular rami,

7. Osteotomy – mandibular rami with bone graft, includes obtaining the graft,

8. Osteotomy – segmented or subapical – per sextant or quadrant,

9. Osteotomy –body of mandible,

10. Lefort I (maxilla – total),

11. Lefort I (maxilla – segmented),

12. Lefort II or Lefort III (osteoplasty of facial bones for midface hypoplasia),

13. Repair of maxillofacial soft and hard tissue defect,

14. Closure of salivary fistula,

15. Coronoidectomy,

16. All procedures billed under unspecified dental procedure codes, and

17. The following types of analgesia and sedation for dental office-based procedures:

a. Analgesia, anxiolysis, inhalation of nitrous oxide,

b. Non-Intravenous conscious sedation,

c. Deep sedation/general anesthesia, and

d. Intravenous conscious sedation/analgesia.

B. In the case of an emergency, documentation justifying the medical necessity for the urgent or emergency procedure must be provided to the UM/QIO to receive a Treatment Authorization Number (TAN) for billing purposes.

C. The prior authorization will apply only to those procedures on the treatment plan which were approved.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Added Miss. Admin. Code Part 204, Rule 1.6.A.17. eff. 05/01/2014.

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Rule 1.7: Laboratory Services, Diagnostic Casts and Photographs

The Division of Medicaid covers lab and pathology services if the provider performs the service in their office and must have a Clinical Laboratory Improvement Amendment (CLIA) certificate number on file with Medicaid.

Source: Miss. Code Ann. §§ 43-13-171, 43-13-121.

Rule 1.8: Radiographs

A. The Division of Medicaid covers the following types of dental radiographs:

1. Intraoral - complete series, including bitewings,

2. Intraoral – periapical,

3. Bitewings, and

4. Panoramic film.

B. The Division of Medicaid requires radiographs be of sufficient quality to be readable.

C. The Division of Medicaid covers an intraoral complete series radiograph or panorex only once every two (2) years per beneficiary per provider.

1. The Division of Medicaid requires that two (2) years must have elapsed from the date the previous intraoral complete series radiograph or panorex was given before the same provider can be covered for the next intraoral complete series radiograph or panorex.

2. The Division of Medicaid requires an intraoral complete series radiograph to include fourteen (14) to twenty-two (22) periapical and posterior bitewing images.

3. The Division of Medicaid does not cover for both intraoral complete series radiograph and panorex on the same day.

4. The Division of Medicaid does not cover additional radiographs if an emergency extraction is performed on the day that an intraoral complete series radiograph or panorex is taken.

5. The Division of Medicaid covers the following exceptions to this limit if one (1) of the following conditions is documented:

a) Documented trauma to head or mouth area,

b) Orthodontic evaluation, or

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c) Rule out malignancy.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.9: Periodontic Procedures

The Division of Medicaid covers gingivectomy or gingivoplasty for beneficiaries only if the beneficiary is on Dilantin therapy. Documentation relating to the beneficiary’s Dilantin therapy must be retained in the dental record.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.10:

History: Removed eff. 05/01/2014.

Rule 1.11: Dental Services Provided in the Hospital or Ambulatory Surgical Center (ASC) Setting

A. The Division of Medicaid covers medically necessary dental treatment in the outpatient hospital or Ambulatory Surgical Center (ASC) setting when all the following are met:

1. Quality, safe, and effective treatment cannot be provided in an office setting,

2. Inpatient hospitalization is not medically necessary, [Refer to Miss. Admin. Code Part 204, Rule 1.11.B.] and

3. Certain dental procedures have been prior authorized by the Division of Medicaid or designee.

B. The Division of Medicaid covers medically necessary dental treatment in the inpatient hospital setting when:

1. The beneficiary’s age, medical or psychological needs, and the extent of treatment necessitate hospitalization, and

2. Prior authorized by the Division of Medicaid or designee.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 10/01/2019; Revised eff. 12/01/2018; Revised eff. 09/01/2015.

Rule 1.12: Oral Evaluations

The Division of Medicaid defines a limited oral evaluation as an evaluation or re-evaluation limited to a specific oral health problem.

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A. The Division of Medicaid covers limited oral evaluations four (4) times per state fiscal year.

B. This may require interpretation of information acquired through additional diagnostic procedures.

C. The Division of Medicaid covers definitive procedures to be performed on the same date as the evaluation according to this rule.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.13: Consultations

The Division of Medicaid covers consultation services for dentists or dental specialists.

A. The Division of Medicaid does not cover the visit or exam on the same day as the initial consultation by the consulting dentist or dental specialist.

B. The Division of Medicaid covers diagnostic and therapeutic procedures on the same or different dates of services as the consultation.

C. The appropriate dental procedure code is required for reimbursement.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.14: Anesthesia

A. The Division of Medicaid defines a topical anesthetic as an agent used to temporarily anesthetize or numb the tiny nerve endings located on the surfaces of the oral mucosa. The Division of Medicaid does not cover the cost of the topical anesthetic and the application of the topical anesthetic separately from the procedure performed.

B. The Division of Medicaid defines a local anesthetic as an agent used to temporarily prevent the conduction of sensory impulses such as pain, touch, and thermal change from a body part along nerve pathways to the brain. The Division of Medicaid does not cover local anesthesia separately from the procedure performed.

C. The Division of Medicaid defines conscious sedation as an anesthetic, including oral, intravenous and intramuscular, administered to place the beneficiary in a relaxed state, which helps control fear and anxiety, but the beneficiary can still respond to speech or touch. The Division of Medicaid covers conscious sedation for dental and oral procedures using the appropriate dental procedure code.

D. The Division of Medicaid defines deep sedation/general anesthesia as a controlled state of depressed consciousness induced by an anesthetic and accompanied by a partial or complete loss of protective reflexes, including the inability of the beneficiary to maintain an airway

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without assistance or support. The Division of Medicaid covers deep sedation/general anesthesia for dental and oral procedures using the appropriate dental code.

E. All forms of sedation and anesthesia administered in a dental office-based setting must comply pursuant to Miss. Code Ann. § 73-9-13 to insure that beneficiaries are provided with the benefits of anxiety and pain control in a safe and efficacious manner.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121, 73-9-13; MS State Board of Dental Examiners, Board Regulation 29.

History: Revised Miss. Admin. Code Part 204, Rule 1.14.C. and added D. and E.

Rule 1.15: Bone Replacement Graft

A. The Division of Medicaid defines a bone replacement graft as a procedure which involves the use of osseous autografts, osseous allografts, or non-osseous grafts to stimulate bone formation or periodontal regeneration when the disease process has led to a deformity of the bone. This procedure does not include flap entry and closure. The Division of Medicaid defines the following as:

1. Osseous autograft as a graft taken from one part of the body and placed in another site on the same individual.

2. Osseous allograft as a graft between two or more individuals allogenic at one or more loci.

3. Non-osseous as a graft not composed of bone such as tendon or ligament tissue, and the material can be artificial, synthetic or natural.

B. Providers must bill the appropriate dental procedure code when providing this service.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.16: Documentation Requirements

Dental providers must maintain auditable records containing documentation that substantiate the services provided in accordance with requirements set forth in Miss. Admin. Code Part 200, Chapter 1, Rule 1.3. including, but not limited to:

A. Date of service,

B. History taken on initial visit,

C. Chief complaint on each visit,

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D. Test, radiographs and results must have the beneficiary’s name, the date, must be legible, and must be maintained on file with the beneficiary’s dental records.

E. Diagnosis,

F. Treatment, including prescriptions,

G. Signature or initials of dentist after each visit, and

H. Copies of hospital and/or emergency room records if available.

Source: Miss. Code Ann. § 43-13-121

Rule 1.17: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for Early and Periodic Screening, Diagnosis and Treatment (EPSDT)-eligible beneficiaries in accordance with Miss. Admin. Code Part 223, without regard to service limitations and with prior authorization.

A. Orthodontic services are covered and prior authorized by the Division of Medicaid or designated entity for EPSDT eligible beneficiaries.

B. Orthodontia-related services are limited to $4,620 per beneficiary per lifetime.

C. Orthodontic services in excess of the $4,620 lifetime limit may be provided with prior authorization from the Division of Medicaid’s UM/QIO or a contracted CCO’s UM/QIO.

Source: Miss. Code Ann. § 43-13-121.

History: Revised to correspond with MS SPA 23-0030 (eff. 10/01/2023) eff. 08/01/2024.

Rule 1.18: Dental Reimbursement

A. The Division of Medicaid reimburses dental providers based on a statewide uniform fee schedule.

B. Dental providers must bill the procedure code that accurately reflects the services rendered as follows:

1. Dental procedures performed by a Mississippi licensed dentist must be billed with a Code on Dental Procedures and Nomenclature (CDT).

2. Dental procedures performed by a Mississippi licensed dentist who is also a Mississippi licensed physician can bill either a CDT code or a Current Procedural Terminology (CPT) code.

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Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: New Rule eff. 10/01/2019.

Part 204 Chapter 2: Oral Surgery

Rule 2.1: Simple Extractions

Medicaid covers for simple extractions and the fee includes local anesthesia and routine post- operative care.

A. Medicaid covers for alveoloplasties with the simple extraction of three (3) or more adjacent teeth in the same quadrant.

B. Medicaid requires for an alveolopasty by quadrant to be covered, a minimum of five (5) teeth in the quadrant must be done.

Source: Miss. Code Ann. § 43-13-121

Rule 2.2: Supernumerary Tooth Extractions

Medicaid requires prior authorization for the extraction of a supernumerary tooth.

Source: Miss. Code Ann. § 43-13-121

Rule 2.3: Surgical Extractions

A. The Division of Medicaid defines an impacted tooth as one where its eruption is partially or wholly obstructed by bone, soft tissue or other teeth.

B. The Division of Medicaid covers surgical extractions and removal of impacted teeth.

C. The Division of Medicaid does not cover for the extraction of an unerupted third molar unless medically necessary including, but not limited to:

1. Radiographic evidence that a third molar will be severely impacted, or

2. Evidence of infection.

D. The fee for all surgical extractions and removal of impacted teeth includes:

1. Local anesthesia,

2. Smoothing the socket site,

3. Suturing, and

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4. Routine post-operative care.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 12/01/15.

Rule 2.4: Alveoloplasty

The Division of Medicaid covers alveoloplasty as a separate procedure from extractions or in conjunction with extractions when there is a need for significant bone re-contouring in the quadrant to prepare the ridge for a prosthetic appliance if there:

A. Are three (3) or more tooth spaces present per quadrant, or three (3) or more teeth extracted per quadrant, or

B. Are less than three (3) tooth spaces present per quadrant, or less than three (3) teeth extracted per quadrant if prior authorized as medically necessary by the Utilization Management/Quality Improvement Organization (UM/QIO), or designee.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 02/01/2015.

Rule 2.5: Root Tips

Medicaid does not cover for the surgical removal of residual tooth roots with an extraction separately. The appropriate code for surgical removal of residual tooth roots (cutting procedures) must be used to bill the surgical removal of residual roots when a tooth has been broken off by natural means or when the beneficiary seeks follow-up care from a practitioner other than the dentist or oral surgeon who performed the original extraction.

Source: Miss. Code Ann. § 43-13-121

Rule 2.6: Complicated Sutures

Medicaid covers complicated suturing only in instances of trauma where simple sutures cannot be placed or simple suturing is not possible. Medicaid does not pay separately when done with extractions of unerupted teeth or when the dentist creates the flap or incision. Medicaid requires detailed documentation of the traumatic event in the dental record.

Source: Miss. Code Ann. § 43-13-121

Rule 2.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

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The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 205 Hospice Services

23 Miss. Admin. Code Pt. 205 Hospice Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 205 Hospice Services

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................... Error! Bookmark not defined. Part 205: Hospice Services ......................................................... Error! Bookmark not defined. Part 205 Chapter 1: Program Overview ................................. Error! Bookmark not defined. Rule 1.1: General Provisions and Definitions .................................................................. 1 Rule 1.2: Provider Enrollment Requirements .................................................................. 4 Rule 1.3: Certification and Re-Certification of Terminal Illness ..................................... 5 Rule 1.4: Hospice Eligibility, Election, Transfer, Revocation and Discharge ................. 7 Rule 1.5: Hospice Care of Plan (POC) ........................................................................... 11 Rule 1.6: Covered Services ............................................................................................ 13 Rule 1.7: Transportation ................................................................................................. 16 Rule 1.8: Reimbursement ............................................................................................... 17 Rule 1.9: Documentation Requirements ........................................................................ 19 Rule 1.10: Dual Eligibles ............................................................................................... 22 Rule 1.11: Prior Authorization..................................................................22

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Title 23: Division of Medicaid

Part 205: Hospice Services

Part 205 Chapter 1: Program Overview

Rule 1.1: General Provisions and Definitions

A. Admission to hospice and subsequent election periods must be prior authorized through a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity.

B. The hospice provider must provide all required services to meet the needs of the beneficiary related to the terminal illness and related conditions.

C. The Division of Medicaid covers medically necessary hospice services for beneficiaries when the following criteria are met:

1. A written certification specifying the beneficiary's medical prognosis is for a life expectancy of six (6) months or less if the terminal illness runs its normal course and the written certification is in accordance with 42 C.F.R. § 418.22 and the Mississippi State Department of Health (MSDH) Minimum Standards of Operation for Hospice,

2. A beneficiary or a beneficiary's guardian/legal representative has elected hospice care services for the palliation and management of a beneficiary's terminal illness and related conditions,

3. Services are reasonable and necessary for the palliation and management of a beneficiary's terminal illness and related conditions,

4. A plan of care (POC) is established, prior to hospice care services beginning, which requires periodic review by the attending physician, if any, the medical director, and the interdisciplinary group of the hospice program, and

5. The hospice care services are consistent with the beneficiary's established plan of care.

D. Hospice services are only covered for palliative management of a terminal illness except for Early and Periodic Screening, Diagnosis and Treatment (EPSDT)-eligible beneficiaries.

E. The hospice provider must develop and maintain a system of communication and integration. Therefore, the hospice’s own policies and procedures must:

1. Ensure that the interdisciplinary team/interdisciplinary group (IDT/IDG) maintains responsibility for directing, coordinating, and supervising the care and services provided.

2. Ensure that the care and services are provided in accordance with the POC.

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3. Ensure that the care and services provided are based on all assessments of the beneficiary and family needs.

4. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.

5. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.

F. Persons enrolled in Home and Community-Based Services (HCBS) waivers who elect to receive hospice care may not receive HCBS waiver services which are duplicative of any services rendered through hospice. Persons may receive non-duplicative HCBS waiver services in coordination with hospice services.

G. The Division of Medicaid holds the hospice provider liable for the following circumstances including, but not limited to:

1. Duplicative hospice and/or HCBS waiver services, and/or

2. Failure to fully utilize hospice benefits and palliative services related to the person’s terminal illness and related conditions prior to utilizing HCBS waiver services.

H. The Division of Medicaid defines:

1. Terminal illness as an illness/condition with a prognosis of life expectancy of six (6) months or less, if the illness/condition follows its normal course.

2. Hospice as a public agency or private organization or subdivision of either of these that is primarily engaged in providing hospice care to terminally ill beneficiaries and meets Medicare Conditions of Participation for hospices and has a valid Medicaid provider agreement.

3. Hospice care as a comprehensive set of services, described in section 1861(dd)(1) of the Social Security Act, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill beneficiary and/or family members as delineated in a specific plan of care for the beneficiary.

4. Palliative care as beneficiary and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate beneficiary autonomy, access to information, and choice.

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5. Hospice physician as a doctor of medicine or osteopathy who is legally authorized to practice medicine in the state of Mississippi and designated by the hospice to provide care to hospice beneficiaries in coordination with the beneficiary' s attending physician, if the beneficiary has an attending physician.

6. Attending physician as a doctor of medicine or osteopathy who is legally authorized to practice medicine in the state of Mississippi or a nurse practitioner who meets training, education, and experience requirements as described in 42 C.F.R. § 410.75 and in accordance with the Mississippi Nurse Practice Act. The attending physician is identified by the beneficiary, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the beneficiary's medical care.

7. False claims as a term used when a person knowingly makes an untrue statement or claim to gain a benefit or reward.

8. Election statement as a written statement electing hospice care filed by a beneficiary or the beneficiary's guardian/legal representative with a hospice provider.

9. Prior authorization as the process of reviewing a request for services and determining beneficiary eligibility, coverage, medical necessity, and appropriateness of services. Refer to Miss. Admin. Code Part 205, Rule 1.11 for required documentation.

10. Election period as a predetermined timeframe for which a beneficiary may elect to receive Medicaid coverage of hospice care during the beneficiary's lifetime. Election periods consist of:

a) An initial ninety (90)-day period once in a lifetime,

b) A subsequent ninety (90)-day period once in a lifetime, and

c) Subsequent sixty (60)-day periods with unlimited increments which require face-to- face encounters with a hospice physician or hospice nurse practitioner.

11. Reasonable and necessary as safe and effective services which are not experimental or investigational and are appropriate, including the duration and frequency in terms of whether the item or service is:

a) Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary's condition or to improve the function of a malformed body member,

b) Ordered and furnished in a setting appropriate to the beneficiary's medical needs and condition, and

c) One that meets, but does not exceed, the beneficiary's medical need.

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12. Period of crisis as a period in which a beneficiary requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms.

13. Bereavement counseling as emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment.

Source: 42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2018.

Rule 1.2: Provider Enrollment Requirements

Providers of hospice must comply with all federal, state, and local laws and regulations related to the health and safety of beneficiaries and:

A. Meet the conditions of participation set forth in 42 C.F.R. Part 418, Subpart D,

B. Be licensed and certified for participation by the Mississippi State Department of Health (MSDH), Division of Health Facilities Licensure and Certification (HFLC), and meet all requirements in accordance with the rules and regulations as defined in the Minimum Standards of Operation for Hospice per the MSDH,

C. Meet the applicable requirements set forth in Part 200, Chapter 4.

Source: 42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. Revised eff. 04/01/2018.

Rule 1.3: Certification and Recertification of Terminal Illness

A. Only a Medicaid enrolled medical doctor or doctor of osteopathy can certify or recertify a terminal illness.

B. A beneficiary who reaches a point of stability and no longer meets the definition of terminally ill must not be recertified and must return to Medicaid benefits, if eligible.

C. The physician(s) signing the written certification/recertification statement can be held liable for causing false claims to be submitted.

D. Certifications/recertifications of terminal illness are based on the clinical judgment of the certifying physician(s) regarding the normal course of the beneficiary's terminal illness and must conform to the following requirements:

1. The certification/recertification must specify that the beneficiary's prognosis is for a life expectancy of six (6) months or less if the terminal illness runs its normal course.

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2. Clinical information and other documentation that support the medical prognosis of six (6) months or less must accompany the certification including, but not limited to,

a) Terminal diagnosis and related diagnoses,

b) Specific clinical findings, prognostic indicators, functional ability scales, symptom management scales, and other pertinent medical documentation,

c) Coordinating national or local coverage determinations, if any,

d) Laboratory reports,

e) Radiology reports, and/or

f) Pathology reports.

3. The certifying physician must complete a brief narrative explanation of the clinical findings that supports a life expectancy of six (6) months or less on the certification/recertification form, or as an attachment to the certification/recertification form.

a) If the narrative exists as an attachment to the certification/recertification form, in addition to the physician's signature on the certification/recertification form, the physician must also sign immediately following the narrative in the addendum.

b) The narrative must include a statement directly above the physician signature attesting that by signing, the narrative is based on his/her review of the beneficiary's medical record or, if applicable, his/her examination of the beneficiary.

c) The narrative must reflect the beneficiary's individual clinical circumstance and cannot contain check boxes or standard language used for all beneficiaries.

d) The narrative associated with the third election period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of six (6) months or less.

4. The physician or nurse practitioner who performs the face-to-face encounter with the beneficiary must attest in writing that he or she had a face-to-face encounter with the beneficiary, including the date of the visit. The attestation of the nurse practitioner or a non-certifying hospice physician must state the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care.

5. All certifications/recertifications of terminal illness must be signed, dated, and must include the election period dates to which the certification or recertification applies.

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E. The hospice must obtain written certification of terminal illness for each election period, even if a single election continues in effect.

1. For the initial ninety (90) day election period, the hospice must obtain written certification statements from:

a) The medical director of the hospice or the physician member of the hospice interdisciplinary group, and

b) The beneficiary's attending physician, if the beneficiary has an attending physician.

2. For subsequent election periods, the only requirement is recertification by the hospice medical director or physician member of the hospice interdisciplinary group.

F. The hospice provider must obtain written certification of terminal illness within two (2) calendar days, after the initiation of hospice care.

1. If the hospice cannot obtain the written certification of terminal illness within two (2) calendar days, after the initiation of hospice care, the hospice must obtain a verbal certification of terminal illness within two (2) calendar days. The hospice must obtain the written certification/recertification of terminal illness no later than eight (8) days after care is initiated and before submitting a claim for payment.

2. For recertifications, the hospice must obtain, no later than two (2) calendar days after the beginning of that period, a written certification statement prepared by the medical director of the hospice or the physician member of the hospice’s interdisciplinary group.

G. Certifications/recertifications of terminal illness cannot be completed more than fifteen (15) calendar days prior to the effective date of the election period.

H. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to- face encounter to gather clinical findings to determine continued eligibility for hospice care services for each hospice beneficiary whose total stay across all hospices is anticipated to reach the third benefit period. The face-to-face encounter must:

1. Occur no more than thirty (30) calendar days prior to the third election period recertification, and

2. Occur every election period recertification, thereafter.

Source: 42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2018.

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Rule 1.4: Hospice Eligibility, Election, Transfer, Revocation, and Discharge

A. A beneficiary must meet eligibility requirements for hospice care services. For the duration of an election of hospice care services, a beneficiary waives all rights to Medicaid State Plan services for treatment related to the terminal illness and related conditions. In order to be eligible to elect hospice care services under Medicaid, a beneficiary must:

1. Be Medicaid eligible for full benefits,

2. Be certified by a physician as terminally ill in compliance with 42 C.F.R. § 418.22,

3. Require medically necessary treatment for the palliation and management of a terminal illness and related conditions,

4. The beneficiary or legal guardian/representative must elect hospice care in accordance with 42 C.F.R. § 418.24.

B. A beneficiary that meets hospice care eligibility requirements, and chooses the Medicaid hospice benefit must file an election statement with a Mississippi Medicaid enrolled hospice provider. For dual eligible beneficiaries, refer to Rule 1.10.

C. The Medicaid enrolled hospice provider must submit the following to the Utilization Management / Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity within five (5) calendar days of a beneficiary’s admission to hospice which includes the following:

1. The beneficiary’s election statement, which includes the following:

a) Identification of the particular hospice that will provide care to the beneficiary,

b) The beneficiary’s acknowledgment or legal guardian's/representative’s acknowledgment, if applicable, that the beneficiary has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment,

c) The beneficiary’s acknowledgement or legal guardian's/representative’s acknowledgment, if applicable, that the beneficiary understands that certain Medicaid State Plan services are waived by the election of hospice,

d) An effective date of the election period which cannot be earlier than the date of the election statement,

e) The name of the beneficiary's attending physician, if any, along with the following information including, but not limited to, the attending physician's:

1. Full name,

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2. Office address,

3. National Provider Identification (NPI) number, and

4. Other detailed identifying information.

f) The beneficiary's acknowledgement or legal guardian's/representative's acknowledgment, if applicable, that the designated attending physician is the beneficiary's or legal guardian's/representative's choice.

g) The signature of the beneficiary or signature of the legal guardian/representative, if applicable, and date signed.

2. Prior authorization requests must include the following for the initial ninety (90) day election period:

a) Signed notice of election form,

b) Signed Physician Certification/Recertification of Terminal Illness Form,

c) Clinical/medical information supporting terminal prognosis,

d) Physician orders,

e) Current medication list, and

f) Hospice provider plan of care.

D. The Medicaid hospice provider must submit prior authorization for any subsequent ninety (90) day election period and subsequent sixty (60) day hospice election periods five (5) calendar days prior to the end of the current election period.

1. The following prior authorization documentation is required:

a) Signed Physician Certification/Recertification of Terminal Illness Form (DOM 1165 C),

b) Updated clinical/medical information supporting terminal prognosis,

c) Updated physician orders,

d) Updated medication record,

e) Updated plan of care,

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f) Beneficiary's current weight, vital sign ranges, lab tests, and

g) Any other documentation supporting continuation of hospice services.

2. An election to receive hospice care services is considered to continue through the initial election period and through subsequent election periods without a break in service as long as the beneficiary:

a) Remains in the care of a hospice,

b) Does not revoke the election,

c) Is not discharged from the hospice, and

d) Continues to meet Medicaid eligibility requirements.

E. Additional documentation that is requested by the UM/QIO that is not received within the time period outlined in the Notice of Pending or Suspended Review will result in the effective date beginning when completed required documentation is received.

1. The Division of Medicaid may waive the consequences of failure to submit timely documentation for exceptional circumstances. Exceptions to notice within five (5) calendar days:

a) Fire,

b) Floods,

c) Embargoes,

d) War, acts of war, insurrections, riots,

e) Strikes, lockouts or other labor disturbances,

f) Or acts of God.

2. A provider so affected shall use reasonable commercial efforts to avoid or remove such causes of nonperformance, and shall provide proper notice hereunder immediately whenever such causes are removed. Changes to the scope of available services or reimbursement methodology for the provision of certain services through legislative or regulatory action shall not constitute an unforeseeable circumstance within the meaning of this section.

F. A beneficiary or legal guardian/representative may change, once per election period, the designation of the particular hospice from which hospice care will be received. The change

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of the designated hospice is not considered a revocation of the election or discharge from hospice services, but is a transfer.

1. The beneficiary or legal guardian/representative must file, with the hospice from which hospice care has been received and with the newly designated hospice, a signed statement that includes the following information:

a) The name of the hospice from which the beneficiary currently receives hospice care,

b) The name of the hospice the beneficiary chooses to transfer to, and

c) The effective date of the transfer.

2. The new hospice provider chosen by the beneficiary or legal guardian/representative must file the transfer notice and complete all assessments as required by the hospice Conditions of Participation and any federal and state laws.

G. A beneficiary or legal guardian/representative may revoke the election of hospice care services at any time which results in forfeiture of any remaining days in that election period.

1. The revocation must be in writing and filed with the hospice provider and must include:

a) A signed statement that the beneficiary revokes the election for hospice care services for the remainder of that election period, and

b) The effective date of the revocation which cannot be earlier than the date that the revocation is made.

2. Verbal revocation of hospice care services is not acceptable.

3. Upon revoking hospice care services, the beneficiary's waived Medicaid benefits will resume.

4. The provider must file a revocation of hospice services notice to the UM/QIO Division of Medicaid or designee within five (5) calendar days after the effective date of the revocation.

5. The beneficiary or legal guardian/representative may, at any time after a revocation, elect to receive hospice coverage for any other hospice election periods the beneficiary is eligible to receive.

H. The hospice provider must notify the Division of Medicaid of any discharge by filing a discharge notice within five (5) calendar days after the effective date of discharge.

1. A hospice provider can only discharge a beneficiary as a result of one (1) of the following:

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a) The beneficiary or guardian/legal representative transfers to another hospice provider,

b) The beneficiary moves out of the geographic area that the hospice defines in its service area,

c) The beneficiary's condition improves and he/she is no longer considered terminally ill,

d) Discharge for cause which is extraordinary circumstances in which the hospice provider would be unable to continue to provide hospice care services. Before seeking a discharge for cause of a beneficiary, the hospice provider must:

1. Advise the beneficiary that a discharge for cause is being considered,

2. Make a serious effort to resolve the problem(s) presented by the beneficiary's behavior or situation, and

3. Ascertain that the beneficiary's proposed discharge is not due to the beneficiary's use of necessary hospice services,

4. Document the problem(s) and efforts made to resolve the problem(s) in the beneficiary's medical records, and

5. Notify the UM/QIO Division of Medicaid or designee of the circumstances surrounding the impending discharge.

e) Beneficiary or guardian/legal representative decides to revoke the hospice benefit, or

f) The beneficiary dies,

2. The hospice provider, prior to discharging a beneficiary for any reason other than revocation, transfer, or death, must obtain a written physician's discharge order from the hospice medical director. If a beneficiary has an attending physician involved in his or her care, this physician should be consulted before discharge and the physician's review and decision included in the discharge note.

3. A beneficiary, upon discharge from a hospice provider during a particular election period for reasons other than immediate transfer to another hospice, is no longer covered under Medicaid for hospice care and:

a) Resumes Medicaid coverage of the benefits waived, if eligible, and

b) May at any time elect to receive hospice care if he or she is again eligible to receive the benefit.

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4. The hospice provider must have in place a discharge planning process that takes into account the prospect that a beneficiary's condition might stabilize or otherwise change such that the beneficiary cannot continue to be certified as terminally ill. Prior to discharging a beneficiary who is no longer certified as terminally ill, the discharge planning process must include planning for any necessary:

a) Family counseling,

b) Beneficiary education, and/or

c) Other services.

I. Hospice providers cannot automatically or routinely discharge a beneficiary at its discretion, even if the hospice care is costly or inconvenient.

Source: 42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

History: Revised eff. 01/01/2022; Revised eff. 04/01/2018; Revised Miss. Admin. Code Part 205, Rule 1.4.E. eff. 06/01/2016.

Rule 1.5: Hospice Plan of Care (POC)

A. The hospice provider must ensure each beneficiary has an individualized written plan of care (POC) established by the hospice interdisciplinary team/interdisciplinary group (IDT/IDG) in collaboration with the attending physician, if any, beneficiary, family and/or primary care giver that specifies the hospice care and services necessary to meet the beneficiary's and family's specific needs identified in the initial, comprehensive, and updated comprehensive assessments.

B. The hospice provider must ensure that each beneficiary and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the POC.

C. The IDT/IDG must be designated by the hospice and be composed of representatives from all the core services and include, at a minimum:

1. A doctor of medicine or osteopathy,

2. A registered nurse (RN) designated to provide coordination of care and to ensure continuous assessment of each beneficiary’s and family’s needs and implementation of the interdisciplinary POC,

3. A social worker, and

4. A pastoral or other counselor.

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D. The POC must be developed for each beneficiary/family by a minimum of two (2) IDT/IDG members and must be approved or revised by the full IDT/IDG and the hospice medical director at the next IDT/IDG meeting. The IDT/IDG is responsible for:

1. Participation in the establishment of the POC within forty-eight (48) hours of admission to hospice,

2. Periodic review and revision of the most current beneficiary/family assessment, evaluation of care needs and updating the POC as frequently as the beneficiary’s condition requires but no less than every:

a) Fourteen (14) calendar days for home care, and

b) Seven (7) calendar days for general inpatient care,

3. Direction, coordination and supervision of the hospice care and services provided in accordance with the POC and comprehensive assessments, and

4. Signing initial, periodic, and revisions of the POC.

D. The POC must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:

1. Interventions to manage pain and symptoms,

2. A detailed statement of the scope and frequency of services necessary to meet the specific beneficiary and family needs,

3. Measurable outcomes anticipated from implementing and coordinating the POC,

4. Drugs and treatment necessary to meet the needs of the beneficiary,

5. Medical supplies and appliances necessary to meet the needs of the beneficiary,

6. The IDT's/IDG's documentation of the beneficiary's or guardian's/legal representative's level of understanding, involvement, and agreement with the POC in accordance with the hospice’s own policies, in the medical record.

E. The POC of a resident of a long-term care facility receiving hospice care should be coordinated between the long-term care facility and the hospice provider to ensure continuity of care.

F. The POC of a waiver participant receiving hospice care should be coordinated between the hospice provider and the waiver provider to ensure continuity of care. Waiver participants who elect to receive hospice care may not receive waiver services which are duplicative of any services rendered through hospice.

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Source: 42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2018.

Rule 1.6: Covered Services

The Division of Medicaid covers hospice services in accordance with the hospice plan of care (POC), when prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity and provided in a manner that is consistent with accepted standards of practice and complies with all federal and state laws in addition to Medicare's Conditions of Participation and includes the following:

A. Core services, with the exception of physician services, must be provided directly by hospice employees on a routine basis. The following are hospice core services:

1. Physician services,

2. Nursing services by a registered nurse (RN),

3. Medical social services by a licensed social worker who has at least a bachelor's degree from a school accredited or approved by the Council on Social Work Education, and who is working under the direction of a physician,

4. Counseling services which includes, but not limited to:

a) Bereavement counseling services provided to the beneficiary’s family before and up to one (1) year after the beneficiary’s death and the hospice provider must:

1. Have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling.

2. Counsel residents of a skilled nursing facility/nursing facility (SNF/NF) or an intermediate care facility for individuals with intellectual disabilities (ICF/IID) when appropriate and identified in the bereavement plan of care (POC).

3. Ensure that bereavement services reflect the needs of the bereaved.

4. Develop a bereavement POC that notes the kind of bereavement services to be offered and the frequency of service delivery.

b) Spiritual counseling, and

c) Dietary counseling by a registered dietician, RN, or other qualified professionals.

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B. Non-core services which include:

1. Physical therapy, occupational therapy, and speech-language pathology services,

2. Hospice aide and homemaker services furnished by qualified personnel, and

3. Volunteer services used in defined roles and under the supervision of a designated hospice employee.

C. Routine Home Care (RHC) which is a day when a beneficiary who has elected to receive hospice care is at home and is not receiving Continuous Home Care.

D. Continuous Home Care which is a day when a beneficiary who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home.

1. The hospice must provide a minimum of eight (8) aggregate hours of care by an RN, hospice aide and/or homemaker during a twenty-four (24) hour day that begins and ends at midnight. Homemaker or hospice aide services or both may supplement the nursing care during periods of crisis but care during these periods must be predominantly nursing care provided by an RN, which means more than half of the hours of care are provided by an RN.

2. Continuous Home Care may not be provided when the hospice beneficiary is a long-term care facility resident or an inpatient of a free-standing hospice.

E. Inpatient Respite Care which is a day when a beneficiary who has elected hospice care receives care in an approved facility on a short-term basis for respite when necessary to relieve the family members or other persons who normally care for the beneficiary at home and must not be:

1. Greater than five (5) consecutive days at a time.

2. Long-term care facility resident, assisted living (AL) waiver participant, or an inpatient of a free-standing hospice, or

3. Provided when services are duplicated or any other like services are being delivered to the beneficiary.

F. General Inpatient Care which is a day when a beneficiary who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings and provided in a participating hospice inpatient unit, hospital, or a participating skilled nursing facility (SNF) or nursing facility (NF) that additionally meets the special hospice standards regarding patient and staffing areas.

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G. Medical supplies and appliances, drugs and biologicals related to the palliation and management of the beneficiary’s terminal illness and related conditions as identified in the hospice POC.

H. Concurrent hospice and home and community based-services (HCBS) waiver services only if:

1. Hospice benefits which address the person’s terminal illness are fully utilized prior to waiver service utilization in instances of potential duplication including, but not limited to:

a) Hospice aide/homemaker and HCBS waiver personal care attendant services,

b) Hospice in-patient respite and HCBS waiver institutional respite,

c) Hospice medical appliances/supplies and HCBS waiver specialized medical equipment/supplies,

d) Hospice physical therapy, speech-language pathology, occupational therapy and HCBS waiver physical therapy, speech therapy, occupational therapy, and

e) Hospice nursing care and HCBS waiver home health skilled nurse visits.

2. A face-to-face person centered planning (PCP) conference with both providers is held within five (5) business days of a person receiving concurrent services. If the face-to- face conference cannot be held within five (5) business days due to justifiable logistical reasons, a conference call must be held:

a) Within five (5) business days of a person receiving concurrent services, and

b) A face-to-face conference with both providers must be held within thirty (30) days of the person receiving concurrent services.

3. A face-to-face PCP conference is conducted within five (5) business days of a significant change in the person’s condition that warrants changes to the person’s services on the hospice POC and/or HCBS plan of services and supports (PSS).

4. The following persons are in attendance at the face-to-face PCP conference:

a) The person and/or the person's designated representative,

b) The hospice provider, and

c) The HCBS waiver case manager/support coordinator.

5. The hospice POC and an HCBS PSS:

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a) Are maintained by both providers in the medical record,

b) Identify the services the person receives,

c) Designate which provider is responsible for delivering each service,

d) Indicate the frequency of each service,

e) State a reason each service performed by a waiver is not covered by hospice,

f) Meet the standard requirements of the hospice POC and the applicable requirements of the HCBS waiver program's PSS,

g) Are signed by both the hospice provider and HCBS waiver case manager/support coordinator, and

h) Are approved by the Division of Medicaid.

Source: Miss. Code Ann. §§ 41-85-1 through 25, 43-13-121.

History: Revised eff. 04/01/2018.

Rule 1.7: Transportation

A. The hospice provider must:

1. Provide transportation for medical services relating to the terminal illness and related conditions after the admission to the hospice,

2. Provide transportation from the hospital to the beneficiary’s residence or to a freestanding hospice facility during a period of hospitalization after election of the hospice benefit.

3. Arrange for non-emergency transportation through the non-emergency transportation (NET) broker program when the hospice beneficiary requires or requests transportation for services that are not palliative in nature or for transportation services unrelated to the terminal illness and related conditions.

B. Transportation is not covered under the hospice benefit when:

1. The hospice beneficiary calls 911 for ambulance/medical assistance for the terminal illness or related conditions, or

2. The hospice beneficiary requires or requests transportation for medical services that are not palliative in nature or are unrelated to the terminal illness or related conditions.

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Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2018. Rule 1.8: Reimbursement

A. A hospice provider must obtain written certification/recertification of terminal illness before billing for hospice services.

B. The Division of Medicaid reimburses hospice providers at one (1) of the four (4) following predetermined rates for each day that the beneficiary is under the care of the hospice based on the level of care required to meet the beneficiary’s and family’s needs:

1. Routine Home Care (RHC):

a) Is reimbursed for each day the beneficiary is under the care of the hospice provider and not receiving one of the other categories of hospice care. This rate is reimbursed without regard to the volume or intensity of routine home care services provided on any given day, and is also reimbursed when the beneficiary is receiving outpatient hospital care for a condition unrelated to the terminal condition.

b) Beginning January 1, 2016 is reimbursed:

1. At a higher payment rate for the first sixty (60) days of hospice care, and

2. At a reduced payment rate for hospice care for sixty-one (61) days and over, and

c) Includes a service intensity add-on (SAI) payment in addition to the per-diem RHC rate for the actual direct patient care hours provided by a registered nurse (RN) or social worker, up to four (4) hours total per day, during the last seven (7) days of a beneficiary’s life when discharged due to death. The SAI payment is equal to the continuous home care hourly payment rate multiplied by the amount of direct care actually provided by an RN and/or social worker.

2. Continuous Home Care:

a) Is reimbursed only during a period of crisis, defined as a period in which the beneficiary requires continuous care to achieve palliation and management of acute medical symptoms, and only as necessary to maintain the terminally ill beneficiary at home.

b) Must be a minimum of eight (8) aggregate hours of predominantly nursing care during a twenty-four (24) hour day, which begins and ends at midnight, and:

1. Nursing care must be provided for more than half of the period of care, and

2. Must be provided by a registered nurse.

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c) Is reimbursed at the hourly rate up to twenty-four (24) hours per day.

d) Is not reimbursed during a hospital, long-term care facility, or inpatient free-standing hospice facility stay.

3. Inpatient Respite Care:

a) Is reimbursed on any day on which the beneficiary is an inpatient in an approved facility for inpatient respite care.

b) Is limited to a maximum of five (5) consecutive days at a time.

c) Is not reimbursed when the hospice beneficiary is a long-term care facility resident, assisted living (AL) waiver participant, or an inpatient of a free-standing hospice.

4. General Inpatient Care:

a) Is reimbursed at the general inpatient care rate for each day such care is consistent with the beneficiary's plan of care.

b) Is reimbursed on any day on which the beneficiary is an inpatient in an approved facility for general inpatient care.

c) Is reimbursed at the general inpatient care rate for the date of admission and all subsequent inpatient days, except the day on which the beneficiary is discharged.

C. The Division of Medicaid reimburses the hospice for respite and general inpatient days. The hospice must reimburse the facility that provides respite inpatient care.

D. The Division of Medicaid does not reimburse for the date of discharge or the date of death.

E. Payment for physician services provided in conjunction with the hospice benefit is based on the type of service performed.

F. Payment for physicians’ administrative and general supervisory activities is included in the hospice payment rates which include:

1. Participating in the establishment, review and updating of plans of care,

2. Supervising care and services, and

3. Establishing governing policies.

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G. The Division of Medicaid reimburses the hospice provider for beneficiaries in a long-term care facility at ninety-five percent (95%) of the long-term care facility’s Medicaid per-diem rate.

1. If the hospice provider fails to submit the required documentation to the UM/QIO within five (5) calendar days of the hospice election, the effective date will be the date when the completed documentation is received.

a) The Division of Medicaid will not reimburse the hospice or nursing facility providers for days prior to the effective date of the election statement.

b) The hospice and/or nursing facility cannot seek payment from the beneficiary.

2. The Division of Medicaid does not reimburse the hospice provider for long-term care bed-hold days.

H. Hospice providers must report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual.

I. The Division of Medicaid reimburses drugs not related to the beneficiary's terminal illness or related conditions to the dispensing pharmacy through the Medicaid Pharmacy Program.

J. The Division of Medicaid reimburses disease specific drugs as well as other drugs related to the palliation and management of the beneficiary’s terminal illness and related conditions in the hospice per diem rates and are not be reimbursed through the Medicaid Pharmacy Program.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 01/01/2022; Revised eff. 04/01/2018 Rule 1.9: Documentation Requirements

A. The hospice provider must maintain medical records for each beneficiary at the hospice site which corresponds to the address associated with the provider license and Division of Medicaid provider number and must include, but not limited to, the following:

1. The Division of Medicaid’s specific hospice related forms which must be complete and accurate:

a) Terminal illness certification/recertification form with supporting documentation,

b) Hospice notice of election form,

c) Hospice discharge/Hospice revocation form, if applicable,

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d) Hospice transfer form, if applicable,

e) Hospice discharge/Hospice revocation form including the discharge summary for a hospice beneficiary which must include the following:

1. A summary of the beneficiary's stay including treatments, symptoms, and pain management,

2. The beneficiary's current plan of care (POC),

3. The beneficiary's current physician orders, and

4. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

The hospice must forward to the receiving facility for any beneficiary transferred to another hospice provider, the following:

(1) The hospice discharge summary, and

(2) The beneficiary's clinical record, if requested.

(b) The hospice must forward to the beneficiary's attending physician for any beneficiary that revokes hospice election or is discharged the following:

(1) The hospice discharge summary, and

(2) The beneficiary's clinical record, if requested.

2. An interdisciplinary POC including the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes that support each hospice service rendered including needs, care, services and goals.

3. A copy of a waiver participant's plan of services and supports (PSS) when the hospice beneficiary is also receiving waiver services.

4. The certifying physician's election period face-to-face encounter and date of encounter with clinical findings to support a life expectancy of six months or less. If a non- certifying hospice physician or nurse practitioner performs the face-to-face encounter, documentation must show:

a) An attestation in writing of the face-to-face encounter that the clinical findings of the visit were provided to the certifying physician for use in determining continued eligibility for hospice care, and

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b) The date of the face-to-face encounter.

5. Treatment rendered including:

a) Each discipline’s visit or contact of the treatment or intervention rendered at the frequency ordered on the POC.

b) Documentation to show relationship of the treatment plan and medications to the terminal illness and related conditions,

c) Responses to medications, symptom management, treatments, and services, and

d) Appropriate discipline’s signature or initials on all medical records.

6. A current medication list for each month of certification that clearly indicates the medications the hospice paid related to the terminal illness and related conditions. The list must contain the name, strength, dosage, and route of the drugs administered to the hospice beneficiary and the name and address of the pharmacies that provided the medications to the hospice beneficiary.

7. A current list of medical appliances and supplies related to the terminal illness and related conditions paid for by the hospice and the names and address(s) of the providers paid.

B. Documentation must be maintained in accordance with requirements set forth in Part 200, Chapter 1, Rule 1.3. and all hospice providers must retain medical records for a minimum of six (6) years after death or discharge of a beneficiary, unless State law stipulates a longer period of time.

C. Concurrent providers of hospice services and home and community-based (HCBS) waiver services must maintain medical records in accordance with requirements set forth in Miss. Admin. Code Part 200, Rule 1.3 and must include, but not limited to:

1. Additional documentation requirements included in Miss. Admin. Code Part 205, Rule 1.8 for hospice providers and in Miss. Admin. Code Part 207 for HCBS waiver providers.

2. All person centered planning (PCP) conferences, including but not limited to:

a) Time and date of conference,

b) Persons in attendance,

c) Any applicable notes, and

d) Signatures of the hospice provider and HCBS case manager/support coordinator.

3. The hospice plan of care (POC) and the HCBS plan of services and supports (PSS) which

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must include, but not limited to:

a) A list of all hospice and HCBS waiver services the person receives,

b) The provider responsible for providing each listed service,

c) The frequency of each service, and

d) An explanation when a service is provided by a HCBS waiver provider instead of a hospice provider.

e) Monthly communication between the hospice provider and the HCBS waiver provider must be documented in the person’s medical record including, but not limited to:

1. Date and time of the communication,

2. Staff included in the communication,

3. Method of communication, and

4. Topics discussed.

Source: 42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2018.

Rule 1.10: Dual Eligibles

A. The hospice benefit must be used simultaneously under Medicare and Medicaid with Medicare providing primary coverage for dual eligible beneficiaries.

B. The Division of Medicaid requires the hospice provider to submit the Notice of Hospice Election or Discharge for Dual Eligible Beneficiaries (Form DOM 1166C) to the Division of Medicaid’s Utilization Management/Quality Improvement Organization (UM/QIO) within five (5) calendar days of the beneficiary’s hospice election or discharge date.

1. If the hospice provider fails to submit Form DOM 1166C to the UM/QIO within five (5) calendar days of the election period, the effective date will be the date when the completed Form DOM 1166C is received.

a) The Division of Medicaid will not reimburse the hospice or nursing facility providers for days prior to the effective date of the election statement.

b) The hospice and/or nursing facility cannot seek payment from the beneficiary.

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2. The UM/QIO will issue a prior authorization number once Form DOM 1166C is received to be notated on the claim by the hospice provider for nursing facility room and board reimbursement.

3. If the beneficiary elects the hospice benefit in a home setting, the UM/QIO will issue a prior authorization number once Form DOM 1166C is received.

C. The Division of Medicaid may waive the consequences of failure to submit timely documentation for exceptional circumstances.

1. Exceptions to notice within five (5) calendar days:

a) Fire,

b) Floods,

c) Embargoes,

d) War, acts of war, insurrections, riots,

e) Strikes, lockouts or other labor disturbances,

f) Or acts of God.

2. A provider so affected shall use reasonable commercial efforts to avoid or remove such causes of nonperformance, and shall provide proper notice hereunder immediately whenever such causes are removed. Changes to the scope of available services or reimbursement methodology for the provision of certain services through legislative or regulatory action shall not constitute an unforeseeable circumstance within the meaning of this section.

Source: 42 C.F.R. § 418.24; Miss. Code Ann. § 43-13-121.

History: Revised eff. 01/01/2022; Revised eff. 03/01/2021; Revised eff. 04/01/2018.

Part 206 Mental Health Services

23 Miss. Admin. Code Pt. 206 Mental Health Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 206 Mental Health Services

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 206: Mental Health Services ................................................................................................ 1 Part 206 Chapter 1: Community Mental Health Services ....................................................... 1 Rule 1.1 Provider Requirements ...................................................................................... 1 Rule 1.2 Definitions ......................................................................................................... 4 Rule 1.3 Covered Services ............................................................................................... 8 Rule 1.4 Non-Covered Services ..................................................................................... 17 Rule 1.5 Reimbursement ................................................................................................ 18 Rule 1.6 Documentation ................................................................................................. 18 Part 206 Chapter 2: Reserved ............................................................................................... 18 Chapter 3: Pre-Admission Screening and Resident Review (PASRR) Level II......................19 Rule 3.1: Pre=Admission Screening and Resident Review (PASSR) Level II............21 Rule 3.2: Appropriateness Review Committee (ARC).......................................22 Rule 3.3: Advanced Group Determinations by Category....................................23 3.4: Pre-Admission Screening and Resident Review (PASRR) Level II Process.. 23 Rule 3.5: Qualification Requirements for Pre-Admission Screening and Resident Review (PASRR) Level II Evaluators...........................................................24 Rule 3.6: Specialized Rehabilitative Services and Specialized Services..................25 Rule 3.7: Confidentiality Safeguards...........................................................28 Rule 3.8: Reconsideration and Appeal.........................................................30 Rule 3.9: Reimbursement for PASRR Level II Evaluations................................30

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Title 23: Division of Medicaid

Part 206: Mental Health Services

Part 206 Chapter 1: Community Mental Health Services

Rule 1.1: Provider Requirements

A. All providers of community mental health services must meet the applicable requirements described in Miss. Admin Code Title 23, Part 200, Chapter 4.

B. Rehabilitative services must be provided by the following licensed and enrolled providers acting within their scope of practice:

1. Board-certified or board-eligible psychiatrists licensed by the Mississippi Board of Medical Licensure.

2. Physicians licensed by the Mississippi Board of Medical Licensure acting within their scope of practice.

3. Physician Assistants (PA) must hold a Master’s degree in a health related or science field, be licensed by the Mississippi Board of Medical Licensure, and must be under the supervision of a psychiatrist or a physician.

4. Psychiatric Mental Health Nurse Practitioners (PMHNP) must hold a Master’s degree in nursing with a specialty in psychiatry, be licensed by the Mississippi Board of Nursing, and must practice within a collaborative/consultative relationship with a physician within an established protocol or practice guidelines.

5. Psychologists must hold a Ph.D. degree in psychology and be licensed by the Mississippi Board of Psychology.

6. Licensed Certified Social Workers (LCSW) must hold a Master’s degree in social work and be licensed by the Mississippi State Board of Examiners for Social Workers and Marriage and Family Therapists at the LCSW level.

7. Licensed Professional Counselors (LPC) must hold a Master’s degree in counseling and be licensed by the Mississippi State Board of Examiners for Licensed Professional Counselors. Provisionally Licensed Professional Counselors (P-LPC) may provide services within the scope of their provisional license.

8. Licensed Marriage and Family Therapists (LMFT) must hold a Master’s degree in marriage and family therapy and be licensed by the Mississippi State Board of Examiners for Social Workers and Marriage and Family Therapists. Provisionally Licensed Marriage and Family Therapists (LMFT) may provide services within the scope of their provisional license.

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9. Quasi-governmental Community Mental Health Center (CMHC) agencies and private mental health centers (PMHCs) certified according to Mississippi Code Ann. § 41-4-7 by the Mississippi Department of Mental Health (DMH).

a. DMH issues a four (4) year certification for CMHCs/PMHCs and the services provided unless stated otherwise at the time of certification.

b. DMH certification is based on the following:

1. Adherence to DMH standards, DMH grant requirement guidelines, contracts, memoranda of understanding, and memoranda of agreement;

2. Compliance with DMH fiscal management standards and practices outlined in the DMH Operational Standards based on a risk-based audit system;

3. Evidence of fiscal compliance with external funding sources;

4. Compliance with ethical practices and codes of conduct of professional licensing entities related to provision of services and management of the organization; and

5. Evidence of solid business and management practices.

c. Staff qualifications for CMHC/PMHC:

1. Qualifications for providers listed in Miss. Admin. Code Part 206, Rule 1.1.B.1. through B.8 above are applicable in CMHC/PMHC,

2. All CMHC/PMHC staff must operate within the scope of their practice.

3. Licensed Master Social Workers (MSW) must hold a Master’s degree, and be licensed by the Mississippi State Board of Examiners for Social Workers and Marriage and Family Therapists.

4. Professional Art Therapists (ATR-BC) must hold a Master’s degree in art therapy and be licensed by the Mississippi Department of Health.

5. Registered Nurses (RN) must be a graduate from an approved or accredited RN nursing program, be licensed by the Mississippi Board of Nursing, and must be under the supervision of a psychiatrist, physician, PMHNP, or PA.

6. Licensed Practical Nurses (LPN) must be a graduate from an approved or accredited LPN nursing program, be licensed by the Mississippi Board of Nursing and supervised by a psychiatrist, physician, PMHNP, PA or RN.

7. DMH certifies the following staff:

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(a) Certified Mental Health Therapists (CMHT), Certified Intellectual and Developmental Disabilities Therapists (CIDDT) and Certified Addiction Therapists (CAT) must hold a Master’s degree in mental health, human services, intellectual disabilities, addictions, or behavioral health related fields from an approved educational institution.

(1) Provisionally certified therapists are temporarily certified while fulfilling all the certification requirements, provide the same services as a CMHT, CIDDT and CAT and must be under the supervision of certified therapist of the same discipline. Provisional certification is valid for up to twenty- four (24) consecutive months from the date of issuance.

(2) The certified credential is full certification and renewable every four (4) years as long as renewal requirements are met.

(b) Community Support Specialists must hold a minimum of a Bachelor’s degree in a mental health field, be certified by DMH as a Community Support Specialist and must be under the supervision of staff listed Miss. Admin. Code Part 206, Rule in 1.1.B.1. and B.9.

(c) Peer Support Specialist Professionals must hold a minimum of a high school diploma or GED equivalent, be certified by DMH as a Certified Peer Support Specialist and must be under the supervision of a psychiatrist, physician, PMHNP, PA, LCSW, LPC, LMSW LMFT, CMHT, CIDDT, CAT or a Peer Support Specialist Supervisor who has been trained as a Peer Support Specialist with an emphasis on supervision.

(d) Peer Support Specialist supervisors must hold a minimum of a master’s degree in addictions, mental health, intellectual/developmental disabilities, or human or behavioral services field and either a 1) professional license or 2) a DMH credential as a Mental Health Therapist, Intellectual/Developmental Disability Therapist, or Addictions therapist prior to or immediately upon acceptance of a Peer Support Specialist Supervisory position and must also receive training specifically developed for Peer Support Specialist supervisors by DMH.

8. Staff members who are provisionally certified must be supervised by a licensed professional or a credentialed DMH Certified Mental Health Therapist, DMH Certified Intellectual and Development Disabilities Therapist or DMH Certified Addiction Therapist of the same discipline.

C. Opioid Treatment Programs must be certified by and meet all the requirements of DMH.

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D. Evidence–based practices (EBP) or evidence-informed best practices must be provided by a master’s degree therapist who holds a professional license or DMH certification and has completed appropriate training in that evidence-based practice.

Source: 42 C.F.R. §§ 440.130, 440.169; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 08/01/2026. Revised to correspond with MS SPA 20-0023 (eff. 10/1/20) eff. 02/01/2022; Revised eff. 07/01/2021 Revised and renumbered to correspond with MS SPA 20-0022 (eff. 09/01/20) eff. 11/01/2020.

Rule 1.2: Definitions

The Division of Medicaid defines:

A. Assessment as obtaining from the beneficiary, beneficiary’s family or others involved in the beneficiary’s care, the beneficiary’s family background/ educational/vocational achievement, presenting problem(s), problem history, history of previous treatment, medical history, current medication(s), source of referral and other pertinent information in order to determine the nature of the beneficiary’s or family’s problem(s), the factors contributing to the problem(s), and the most appropriate course of treatment for the beneficiary.

B. Acute Partial Hospitalization as a program that provides medical supervision, nursing services, structured therapeutic activities and intensive psychotherapy (individual, family and/or group) to beneficiaries who are experiencing a period of such acute distress that their ability to cope with normal life circumstances is severely impaired. Acute Partial Hospitalization is designed to provide an alternative to inpatient hospitalization for such beneficiaries or to serve as a bridge from inpatient hospital to outpatient hospital or community treatment. Program content may vary based on beneficiary need but must include close observation/supervision and intensive support with a focus on the reduction/elimination of acute symptoms.

C. A Brief Emotional/Behavioral Health Assessment as a brief screening used to assess a beneficiary’s emotional and/or behavioral health and covers a variety of standardized assessments aimed to identify the need for more in-depth evaluation for a number of mental/behavioral conditions.

D. Clinical Staff member as a staff member who holds, at a minimum, a master’s degree and professional license or who is a DMH Certified Mental Health Therapist (CMHT), DMH Certified Intellectual and Developmental Disabilities Therapist (CIDDT) or a DMH Certified Addiction Therapist (CAT) when appropriate.

E. Community Support Services as services that are specific, measurable, and individualized that focus on the mental health needs of the beneficiary while attempting to restore beneficiary’s ability to succeed in the community.

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1. Identification of strengths which aid the beneficiary in their recovery and the barriers that will challenge the development of skills necessary for independent functioning in the community.

2. Individual therapeutic interventions that directly increase the restoration of skills needed to accomplish the goals set forth in the Individual Service Plan.

3. Monitoring and evaluating the effectiveness of interventions that focus on restoring, retraining and reorienting, as evidenced by symptom reduction and program toward goals.

4. Psychoeducation regarding the identification and self-management of the prescribed medication regimen and communication with the prescribing provider.

5. Direct interventions in de-escalating situations to prevent crisis.

6. Relapse prevention.

7. Facilitation of the Individual Service Plan or Recovery Support Plan which includes the active involvement of the beneficiary and the people identified as important in the beneficiary’s life.

F. Crisis Residential Services as medically monitored residential short-term psychiatric stabilization services provided in a setting other than an acute care hospital or a long-term residential treatment facility which consist of no more than sixteen (16) beds.

G. Crisis Response Services as time-limited intensive intervention provided by trained crisis response staff, available twenty-four (24) hours a day, seven (7) days a week and includes the assessment of the crisis and ability to activate a mobile crisis team, crisis stabilization and treatment of a beneficiary to avoid inpatient hospitalization. Crisis Response Services are limited to less than 24 hours per episode.

H. Family Therapy as face-to-face psychotherapy between a mental health therapist and a beneficiary’s family members, with or without the presence of the beneficiary, which may also include others with whom the beneficiary lives or has a family-like relationship. Family Therapy includes family psychotherapy, psychoeducation, and family-to-family training.

I. Group Therapy as face-to-face psychotherapy addressing the needs of several individuals within a group.

J. Individual Therapy as face-to-face, one-on-one psychotherapy that takes place between a mental health therapist and a beneficiary.

K. Intensive Community Outreach and Recovery Team (ICORT) Services as a team-oriented assertive community treatment approach to mental health rehabilitation intervention and

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supports necessary to assist beneficiaries in achieving and maintaining rehabilitative, resiliency and recovery goals with a severe and persistent mental illness.

L. Interactive Complexity in:

1. Group therapy as psychotherapy using non-verbal communication and/or physical aids between a mental health therapist and no more than six (6) individuals under the age of twenty-one (21) at the same time.

2. Individual therapy as the one-on-one psychotherapy using non-verbal communication and/or physical aids between a mental health practitioner and a beneficiary who have not yet developed or have lost their expressive communication ability or do not have the cognitive ability to understand the mental health practitioner if ordinary language is used.

M. Medication Administration as the administering of a prescribed medication.

N. Medication Evaluation as regular and periodic monitoring of the therapeutic and side effects of psychotropic medications prescribed for the treatment of a mental illness.

O. Multifamily Group Therapy as therapy taking place between a licensed and enrolled provider or CMHC/PMHC staff and family members of at least two (2) different beneficiaries in a group setting.

P. Nursing assessment as an assessment of a beneficiary’s psychological, physiological and sociological history.

Q. Peer Support Services as person-centered services with a rehabilitation and recovery focus designed to promote skills for coping with and managing psychiatric symptoms while facilitating the utilization of natural resources and the enhancement of community living skills.

R. Program of Assertive Community Treatment (PACT) as therapeutic programs provided in the community in which beneficiaries live that would traditionally need inpatient care and treatment but can be maintained in a less restrictive/community-based setting.

S. Psychiatric Diagnostic Evaluation as an integrated biopsychosocial assessment, including history, mental status, and recommendations.

T. Psychological Evaluation as the assessment of a beneficiary’s cognitive, emotional, behavioral, and social functioning by a licensed psychologist using standardized tests, interviews, and behavioral observations.

U. Psychosocial Rehabilitation as an active treatment program designed to support and restore community functioning and well-being of a beneficiary who has been diagnosed with a serious and persistent mental illness by providing systematic, curriculum based interventions for skills redevelopment and to promote recovery in the beneficiary’s community by

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alleviating psychiatric decompensation, confusion, anxiety, feelings of low self-worth, isolation and withdrawal.

V. Psychotherapeutic Services as intentional, face-to-face interactions, conversations or non- verbal encounters between a mental health therapist and a beneficiary, an individual, family or group where a therapeutic relationship is established to help resolve symptoms of the beneficiary’s mental and/or emotional disturbance.

W. Quasi-governmental CMHCs are defined as entities operated under the supervision of regional commissions appointed by county boards of supervisors comprising their respective catchment areas.

X. Targeted Case Management as services furnished to assist chronically mentally ill or emotionally disturbed beneficiaries who reside in a community setting or are transitioning to a community setting, in gaining access to needed medical, social, educational, and other services

Y. Treatment Plan as the plan that directs the treatment of the beneficiary and may be referred to as the plan of care, individualized service plan, wraparound plan or person-centered plan depending on the services provided.

Z. Treatment Plan Development and Review as the development and review of an overall treatment plan that directs the treatment and support of the person receiving services by qualified mental health providers.

Source: 42 C.F.R. §§ 440.130, 440.169; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised and renumbered to correspond with MS SPA 20- 0022 (eff. 09/01/20) eff. 11/01/2020.

Rule 1.3: Covered Services

A. The Division of Medicaid covers four (4) medically necessary mental health assessments by a non-physician per fiscal year when:

1. Completed during the intake process and/or when there is a need for reassessment.

2. Provided by a staff member who holds a master’s degree and professional license or is one (1) of the following as appropriate:

a) A Department of Mental Health (DMH) Certified Mental Health Therapist (CMHT),

b) DMH Certified Intellectual and Developmental Disabilities Therapist (CIDDT), or

c) A DMH Certified Addiction Therapist (CAT).

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B. The Division of Medicaid covers up to twelve (12) brief emotional/behavioral health assessments when administered via a standardized behavioral or emotional assessment tool when medically necessary to identify emotional and/or behavioral conditions.

C. The Division of Medicaid covers four (4) medically necessary treatment plan development and reviews per state fiscal year when:

1. Part of a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code Title 23, Part 206, Rule 1.1.B.1 through B9., and

2. Provided by one of the providers listed in Miss. Admin. Code Title 23, Part 206, Rule 1.1 B.1 through B.9.

D. The Division of Medicaid covers medically necessary Targeted Case Management which must include:

1. Completion of a comprehensive assessment and periodic reassessments of beneficiary needs to determine the need for services, including:

a) Beneficiary history,

b) Identifying the needs of the beneficiary and completing related documentation, and

c) Gathering information from other sources to form a complete assessment/reassessment of the beneficiary.

2. Development and periodic revisions of a specific treatment plan that is based on the information collected through the assessment/reassessments that:

a) Specifies the goals and actions to address the medical, social, educational, and other services needed by the beneficiary,

b) Includes activities such as ensuring the active participation of the eligible beneficiary, and working with the beneficiary or the beneficiary’s authorized health care decision maker and others to develop those goals,

c) Identifies a course of action to respond to the assessed needs of the eligible beneficiary,

d) Provides referral and related activities, such as scheduling appointments for the beneficiary, to address any identified needs including medical, social, educational providers, or other programs and services to address identified needs and achieve goals specified in the treatment plan.

3. Monitoring and follow-up activities including:

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a) Activities and contacts necessary to ensure the treatment plan is implemented and adequately addresses the beneficiary’s needs, which may include with the family members, service providers, or other entities or individuals conducted as frequently as necessary including at least one (1) annual monitoring, to determine whether the following conditions are met:

b) Services are being furnished in accordance with the beneficiary’s treatment plan;

c) Services in the treatment plan are adequate; and

d) Changes in the needs or status of the beneficiaries are reflected in the treatment plan. Monitoring and follow-up activities at least annually include making necessary adjustments in the treatment plan and service arrangements with providers.

E. The Division of Medicaid covers medically necessary crisis response services that meet the DMH standards of operations.

1. Crisis response services include:

a) Assessment,

b) De-escalation, which include verbal and non-verbal techniques to reduce the emotional, mental, and/or physical stress level of a beneficiary and

c) Service coordination and facilitation, including determining what additional services are needed and assisting the beneficiary in obtaining those services.

2. Crisis response teams must include:

a) A Certified Peer Support Professional with specific roles and responsibilities,

b) A licensed and/or Credentialed Master's Level Therapist with experience and training in crisis response,

c) A Community Support Specialist with experience and training in crisis response,

d) A Crisis Response Coordinator for the provider's catchment area who is a licensed and/or credentialed master's level therapist with a minimum of two (2) years' experience and training in crisis response, and

e) At least one (1) employee with experience and training in crisis response to each population served by the provider.

F. The Division of Medicaid covers up to sixty (60) days of medically necessary crisis residential services per state fiscal year when ordered by a psychiatrist, physician, psychologist, psychiatric mental health nurse practitioner (PMHNP) or physician assistant

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(PA) and prior authorized by the Division of Medicaid, Utilization Management/Quality Improvement Organization (UM/QIO) or designee.

1. Crisis residential services must provide the following within twenty-four (24) hours of admission:

a) Initial assessment,

b) Medical screening,

c) Drug toxicology screening, and

d) Psychiatric consultation.

2. Crisis residential services include:

a) Treatment plan development and review,

b) Medication management, provided by a psychiatrist, physician, physician assistant (PA) or PMHNP.

c) Nursing assessment, provided by a PMHNP or RN.

d) Individual therapy, provided by master’s level staff,

e) Family therapy, provided by master’s level staff

f) Group therapy, provided by master’s level staff and

g) Skill building groups such as social skills training, self-esteem building, anger control, conflict resolution and daily living skills provided master’s level staff or other direct service staff under the direction of the Master’s level staff.

3. Crisis residential room and board is not covered by the Division of Medicaid.

4. Crisis residential providers must maintain staffing ratios according to DMH standards.

G. The Division of Medicaid covers up to four hundred (400) fifteen (15) minute units per state fiscal year of medically necessary community support services.

1. Community support services must include:

a) Resource coordination that directly increases the restoration of skills needed to accomplish the goals set forth in the treatment plan.

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b) Monitoring and evaluating the effectiveness of interventions that focus on restoring, retraining, and reorienting, as documented by symptom reduction and progress toward goals.

c) Psychoeducation regarding the identification and self-management of prescribed medication regimen and communication with the prescribing provider.

d) Direct interventions in de-escalating situations to prevent crisis.

e) Home and community visits for the purpose of monitoring the beneficiary's condition and orientation.

f) Assisting the beneficiary and natural supports in implementation of therapeutic interventions outlined in the treatment plan.

2. Community support services must be provided by a Certified Community Support Specialist professional.

H. The Division of Medicaid covers up to four (4) units of medically necessary psychiatric diagnostic evaluations per state fiscal year when prior authorized by the Division of Medicaid, UM/QIO or designee.

I. The Division of Medicaid covers up to eight (8) hours of medically necessary psychological diagnostic evaluations per state fiscal year when prior authorized by the Division of Medicaid, UM/QIO or designee and entirely completed by a psychologist.

J. The Division of Medicaid covers medically necessary medication evaluation and management services.

1. Medication evaluation and management services provided by community/private mental health centers are not limited.

2. Medication evaluation and management services provided by independent practitioners within their scope of practice are subject to the physician visit limits in Miss. Admin. Code Title 23, Part 203, Rule 9.5.C.1.

3. Medication evaluation and management must be provided by one (1) of the following:

a) Psychiatrist,

b) Physician,

c) PMHNP, or

d) PA.

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K. The Division of Medicaid covers medically necessary medication administration per state fiscal year when provide by one (1) of the following:

1. Psychiatrist,

2. Physician,

3. PMHNP,

4. PA,

5. RN, or

6. LPN.

L. The Division of Medicaid covers up to one hundred forty-four (144), fifteen (15) minute units of nursing assessments performed by an RN per state fiscal year.

M. The Division of Medicaid covers the following medically necessary psychotherapeutic services when part of a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code Part 206, Rule 1.1.B.1 through B.8. and provided by one of the providers listed in Miss. Admin. Code Part 206, Rule 1.1.B.1 through B.8. or B.9 as appropriate:

1. Up to thirty-six (36) individual therapy sessions per state fiscal year,

2. Up to twenty-four (24) family therapy sessions per state fiscal year,

3. A combined total of up to forty (40) group therapy or multi-family group therapy sessions per state fiscal year, and

4. Interactive complexity for individual and group therapy as appropriate within yearly limits.

N. The Division of Medicaid covers up to one hundred (100) days of medically necessary acute partial hospitalization services in the community setting when prior authorized by the Division of Medicaid, UM/QIO or designee. Services must be provided for a minimum of four (4) hours in one (1) day for at least three (3) days per week.

1. Acute partial hospitalization includes, but is not limited to:

a) Treatment plan development and review,

b) Medication management, provided by a psychiatrist, physician, PA or PMHNP,

c) Nursing assessment, provided by a PMHNP or RN,

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d) Individual therapy, provided by master’s level staff,

e) Group therapy, provided by master’s level staff, and

f) Family therapy, provided by master’s level staff.

2. Acute partial hospitalization programs must be provided by licensed/certified providers including, but not limited to:

a) CMHC/PMHC, or

b) A private psychiatric clinic.

O. The Division of Medicaid covers up to five (5) hours per day, five (5) days per week of medically necessary psychosocial rehabilitation when prior authorized by the Division of Medicaid, UM/QIO or designee.

1. Psychosocial rehabilitation services are not covered when provided on the same day as group therapy, senior psychosocial rehabilitation, crisis residential services or acute partial hospitalization.

2. Psychosocial rehabilitation services must be included in a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code Title 23, Rule 1.1.B.1 through B.9.

3. Psychosocial rehabilitation services must be provided according to DMH standards.

4. Psychosocial Rehabilitation Services are provided in a DMH approved Psychosocial Rehabilitation Program by bachelor’s level staff that provide active treatment through evidence-based curriculum.

P. The Division of Medicaid covers one thousand six hundred (1600) fifteen minute units per state fiscal year of medically necessary assertive community treatment services provided through Programs of Assertive Community Treatment (PACT) when prior authorized by the Division of Medicaid, UM/QIO or designee.

1. PACT is an all-inclusive service that includes, but is not limited to:

a) Treatment plan review and development,

b) Medication management, provided by a psychiatrist, physician, PA or PMHNP,

c) Individual therapy, provided by master’s level staff,

d) Family therapy, provided by master’s level staff,

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e) Group therapy, provided by master’s level staff,

f) Community support, and

g) Peer support.

2. The composition of the PACT team members must include, but is not limited to:

a) A team leader,

b) A Psychiatrist or PMHNP,

c) RN,

d) Master's level mental health professional,

e) Substance use disorder specialist,

f) Certified peer support specialist professional, and

g) Other clinical personnel as determined by DMH.

Q. The Division of Medicaid covers one thousand six hundred (1600) fifteen minute units of medically necessary intensive community outreach and recovery team (ICORT) assertive community treatment services when prior authorized by the Division of Medicaid, UM/QIO or designee.

1. ICORT services include:

a) Treatment plan development and review,

b) Medication management, provided by a psychiatrist, physician, PA, or PMHNP,

c) Individual therapy and family therapy in the home, provided by master’s level staff,

d) Group therapy, provided by master’s level staff,

e) Peer support services,

f) Community support services, and

g) Psychoeducation.

2. ICORT providers must have the following staff:

a) Team Leader which must be a full-time Master's Level Mental Health Therapist,

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b) A full-time registered nurse,

c) A full-time equivalent Certified Peer Support Specialist Professional, and

d) If deemed necessary by the DMH, a part-time Community Support Specialist must be added to ICORT.

3. ICORT services must be included in a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code. Title 23, Part 106, Rule 1.1.B.1. through B.9.

R. The Division of Medicaid covers up to two hundred (200) fifteen (15) minute units per state fiscal year of medically necessary peer support services.

1. Peer support services must include:

a) Development of a recovery support plan, and

b) Skill building for coping with and managing symptoms while utilizing natural resources, and the preservation and enhancement of community living skills.

2. Services must be provided by a certified Peer Support Specialist Professional.

S. The Division of Medicaid covers medically necessary opioid treatment services that comply with all state and federal requirements.

1. Opioid Treatment services include, but are not limited to:

a) Assessments,

b) Laboratory services,

c) Physician services including Medication Evaluation and Management,

d) Medication Administration,

e) Therapy Services,

f) Medical Services, and

g) Pharmacy Services.

2. Opioid treatment services are provided by professionals operating within their scope of practice as part of a DMH certified opioid treatment program.

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3. Physician visits provided as part of an opioid treatment program do not count toward the beneficiary’s physician visit annual limit.

Source: 42 C.F.R. §§ 440.130, 440.169; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with MS SPA 20-0023 (eff. 10/1/20) eff. 02/01/2022; Revised eff. 07/01/2021; Revised and renumbered to correspond with MS SPA 20-0022 (eff. 09/01/20) eff. 11/01/2020.

Rule 1.4: Non-Covered Services

A. The Division of Medicaid does not cover community mental health services that:

1. Are not medically necessary,

2. Are not prior authorized by the Division of Medicaid, Utilization Management/Quality Improvement Organization (UM/QIO) or designee, if required, and

3. Are not part of a plan of care or treatment plan approved by a team member qualified to approve the service being provided.

B. The Division of Medicaid does not cover the following activities and/or services:

1. Time spent completing paperwork,

2. Telephone contacts, unless included in the service definition,

3. Recreational activities,

4. Educational interventions,

5. Travel time,

6. Missed or canceled appointments,

7. Room and board, and/or

8 Services provided to a beneficiary during an inpatient stay, unless included in the service definition.

C. The Division of Medicaid does not cover services and/or programs that do not meet the standards of the licensing/certifying agency when applicable.

Source: 42 C.F.R. §§ 440.130, 440.169; Miss. Code Ann. §§ 43-13-117, 43-13-121.

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History: Revised eff. 07/01/2021; Revised and renumbered to correspond with MS SPA 20- 0022 (eff. 09/01/20) eff. 11/01/2020.

Rule 1.5: Reimbursement

A. The Division of Medicaid reimburses for covered mental health services according to a statewide uniform fee schedule.

B. Reimbursement for physician services provided outside of a Community or Private Mental health center are subject to the limits described in Miss. Admin. Code Title 23, Part 203.

Source: 42 C.F.R. §§ 440.130; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2022; Revised eff. 07/01/2021; Revised and renumbered to correspond with MS SPA 20-0022 (eff. 09/01/20) eff. 11/01/2020.

Rule 1.6: Documentation

A. All services must be documented on a treatment plan and approved, signed and dated by a licensed practitioner operating within their scope of practice.

B. The following must be documented in the beneficiary's case record for each service provided:

1. Type of service provided,

2. Date of service,

3. Length of time spent providing the service,

4. Start and end times of sessions,

5. Names of all individuals receiving or participating in the service,

6. Summary of session,

7. Explanation of how the service relates to the goals and objectives established in the treatment plan,

8. Name and title of servicing provider, and

9. Signature and credentials of servicing provider/practitioner.

C. Community mental health services subject to certification by the Department of Mental Health (DMH) must be documented according to the DMH Record Guide and any supplemental instructions provided by DMH in effect at the time the service is provided.

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Source: 42 C.F.R. §§ 440.130, 440.169; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised and renumbered to correspond with MS SPA 20- 0022 (eff. 09/01/20) eff. 11/01/2020

Part 206 Chapter 2: Reserved

Part 206 Chapter 3: Pre-Admission Screening and Resident Review (PASRR) Level II

Rule 3.1: Pre-Admission Screening and Resident Review (PASRR) Level II

A. The Pre-Admission Screening and Resident Review (PASRR) Level I must be performed prior to admission to a Medicaid certified nursing facility (NF) to: [Refer to Miss. Admin. Code Part 207 for PASRR Level I]

1. Assess the person’s clinical eligibility and need for nursing facility (NF) services,

2. Confirm whether or not the person has a mental illness (MI), an intellectual disability/developmental disability (ID/DD) and/or a related condition (RC), and/or

3. Assess whether the person requires specialized rehabilitative services or supplemental services and supports.

B. If the PASRR Level I confirms that a person has MI, ID/DD and/or a RC, or if specialized rehabilitative services or supplemental services and supports are required, then the person must complete a PASRR Level II.

C. A PASRR Level II ensures the appropriate placement of persons with MI, ID/DD, and/or a RC and the provision of needed services to persons who have been diagnosed with MI, ID/DD, and/or a RC.

1. RCs are defined as conditions that are not an intellectual disability, but which produce similar functional impairment and require similar treatment or services.

2. RCs:

a) Must emerge before the age of twenty-two (22),

b) Are expected to continue indefinitely, and

c) Must result in substantial functional limitations in three (3) or more of the following major life activities:

1. Self-care,

2. The understanding and use of language,

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3. Learning,

4. Mobility,

5. Self-direction,

6. Capacity for independent living, and/or

7. Economic sufficiency.

3. RCs include, but are not limited to,

a) Autism,

b) Cerebral palsy,

c) Down syndrome,

d) Fetal alcohol syndrome,

e) Muscular dystrophy,

f) Multiple sclerosis,

g) Seizure disorder, and

h) Traumatic brain injury (TBI).

B. A PASRR Level II consists of two (2) types:

1. An initial PASRR Level II is defined as the first PASRR Level II completed on a person whose PASRR Level I indicated MI, ID/DD and/or a RC so that appropriateness of NF placement can be determined and the need for specialized services be identified and recommended.

2. A subsequent PASRR Level II is defined as any PASRR Level II completed after an initial PASRR Level II when there is a significant change in the physical, mental, or emotional condition of a NF resident.

a) The significant change is for persons with previously identified MI, ID/DD and/or RC whose needs have changed as well as for persons with newly discovered or suspected MI, ID/DD and/or RC.

b) The purpose of a subsequent PASRR Level II is to assess whether or not the resident is still appropriate for the NF level of care and/or if a change in the need or type of

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specialized services is required.

C. The Division of Medicaid defines:

1. Specialized rehabilitative services as a subcategory of NF services which are individualized services and supports which a NF provides for persons who need them and are included in the NF per diem.

2. Supplemental services and supports, referred to as specialized services, as any services and supports for persons with MI or ID/DD, other than specialized rehabilitative services, for a particular NF person and not included in the NF per diem.

Source: 42 C.F.R. § 483; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.2: Appropriateness Review Committee (ARC)

A. The Appropriateness Review Committee (ARC), administered by the Mississippi Department of Mental Health (DMH), is responsible for:

1. Reviewing the PASRR Level II,

2. Determining the appropriateness of nursing facility (NF) placement for persons with mental illness (MI), an intellectual disability/developmental disability (ID/DD) and/or a related condition (RC), and

3. Assessing whether the person requires specialized rehabilitative services or supplemental services and supports.

B. The ARC members must have a current Mississippi license and practice within the scope of their license:

1. To review the PASRR Level II for MI:

a) A psychiatrist who serves as the designated State Mental Health Authority Representative, and

b) A registered nurse (RN).

2. To review the PASRR Level II for ID/DD:

a) A psychiatrist who serves as the designated State Intellectual Disabilities Authority Representative, and

b) A registered nurse (RN), and

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c) Healthcare professionals credentialed with a minimum of a Master’s degree in a health related field, such as a licensed clinical social worker (LCSW) or licensed medical social worker (LMSW).

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.3: Advanced Group Determinations by Category

A. Advanced group determinations by category permits the nursing facility (NF) to omit the PASRR Level II in certain circumstances that are time-limited or where the need for the NF is clear or the need for specialized services is unlikely provided that the person is not a danger to themselves or others, if their exempting conditions are documented, and the Appropriateness Review Committee (ARC), after reviewing this documentation, determines that a PASRR Level II is not required.

B. Examples of categories include, but are not limited to:

1. Terminal illness,

2. Severe physical illnesses including, but not limited to:

a) Coma, or

b) Ventilator dependent,

3. Provisional admission pending further assessment in cases of delirium where a diagnosis cannot be made until the delirium clears,

4. Emergency protective services with a stay lasting no longer than seven (7) days, or

5. Very brief and finite stays of up to a fixed number of days to provide respite to in-home caregivers to whom the person with MI or ID/DD is expected to return following the brief NF stay.

C. If the evaluator believes that the person would benefit from specialized services despite the presence of conditions considered to be in an exempted category, the evaluator must refer the person for a PASRR Level II.

D. Findings for an advanced group determination must be documented in the PASRR Level I and must, at a minimum:

1. Identify the name and professional title of the person recommending the determination and the date of the recommendation,

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2. Identify the specific condition(s) which qualifies the person for exemption from the PASRR Level II,

3. If applicable, describe the nature of any further assessment(s) needed to determine the most appropriate setting and/or specialized services for the person,

4. Identify, to the extent possible, based on the available information, NF services that may be needed, including any mental health, specialized services and/or specialized rehabilitative services, and

5. Include evidence to support the evaluator’s conclusions.

Source: 42 C.F.R. § 483.130; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.4: Pre-Admission Screening and Resident Review (PASRR) Level II Process

A. The Division of Medicaid requires any person admitted to a Medicaid certified nursing facility (NF) have a completed Pre-Admission Screening and Resident Review (PASRR) Level II prior to admission to the NF if the PASRR Level I indicated that the person had a mental illness (MI), intellectual disability/developmental disability (ID/DD), and/or a related condition (RC) unless that person has an approved documented advanced group determination.

B. The hospital transferring or nursing facility (NF) admitting the person must electronically complete and submit the PASRR Level I located in the Envision web portal prior to the NF admission. The completed PASRR must be faxed to the Division of Medicaid if the provider is not a Mississippi Medicaid Provider.

C. The Division of Medicaid’s PASRR Contractor is responsible for:

1. Reviewing all PASRR Level I which indicate MI, ID/DD and/or a RC,

2. For MI, determining if a face-to-face assessment or an on-the-record review is the most appropriate in completing the PASRR Level II and making a recommendation for NF placement and any specialized services required to the MI Appropriateness Review Committee (ARC) within five (5) business days,

3. For ID/DD, notifying the Department of Mental Health’s (DMH’s) ARC within five (5) business days of receiving a referral of any PASRR Level I which indicates an ID/DD and/or a RC.

4. Determining if a PASRR Level II is required for a change of condition.

D. DMH’s ARC is responsible for:

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1. Reviewing any PASRR Level I which indicates ID/DD and/or a RC,

2. Determining if a face-to-face assessment or an on-the-record review is the most appropriate in completing the PASRR Level II, and

3. Forwarding the final recommendations to the State PASRR Coordinator at the Mississippi State Hospital within two (2) business days of receipt.

E. The MI ARC is responsible for:

1. Reviewing the PASRR Level II recommendations from the Division of Medicaid’s PASRR Contractor,

2. Making any changes to the recommendations received, and

3. Forwarding the final recommendations to the State PASRR Coordinator at the Mississippi State Hospital within two (2) business days of receipt.

F. The State PASRR Coordinator is responsible for submitting the recommendations to the designated State Intellectual Disabilities Authority Representative for the final decision on NF placement and required specialized services who must make the final determination within seven (7) to nine (9) business days from the date of the original PASRR Level I submittal triggering a PASRR Level II.

G. The NF must complete and submit a PASRR Level II State Request Form to the Division of Medicaid’s PASRR Contractor when a significant change in the person’s physical, mental, and/or emotional condition becomes apparent.

Source: 42 C.F.R. § 483; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.5: Qualification Requirements for Pre-Admission Screening and Resident Review (PASRR) Level II Evaluators

The Pre-Admission Screening and Resident Review (PASRR) Level II for:

A. Mental illness (MI) must be completed by:

1. A qualified mental health professional, as designated by the Department of Mental Health (DMH),

2. A person duly licensed and/or certified as a Certified Mental Health Therapist (CMHT), Licensed Certified Mental Health Therapist (LCMHT), Licensed Certified Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC), psychologist or registered

24

nurse (RN) who must conduct the psychosocial assessment portion of the PASRR Level II, and

3. A psychiatrist, psychologist or psychiatric mental health nurse practitioners (PMHNP) who must complete the psychiatric history and evaluation.

B. ID/DD must be completed by an interdisciplinary team of Diagnostic and Evaluation (D&E) professionals who possess the following credentials, at a minimum:

1. A Certified Intellectual and Developmental Disability Therapist (CIDDT), Licensed Clinical Intellectual and Developmental Disability Therapist LCIDDT), LSW, psychologist, RN or other DMH approved personnel who must complete the social history and adaptive behavior assessment.

2. A psychologist who approves and signs the psychological assessment completed by DMH approved personnel and

3. A physician, nurse practitioner, or an RN who must complete the medical summary.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.6: Specialized Rehabilitative Services and Specialized Services

A. Specialized rehabilitative services are defined as rehabilitative services which a nursing facility (NF) is required to provide to meet the daily physical, social, functional or mental health needs of its persons and include, but are not limited to:

1. Physical therapy,

2. Speech/language therapy,

3. Occupational therapy, and

4. Mental Health Rehabilitative Services for mental illness (MI) and/or intellectual disability/development disability (ID/DD).

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B. The NF must provide the specialized rehabilitative services necessary for the well-being of its persons even if the specialized rehabilitative services are not specifically mentioned in the Medicaid State Plan and cannot charge the person a fee for the specialized rehabilitative services because they are covered NF services.

C. A NF is not obligated to provide specialized rehabilitative services if no current person requires the services but if a resident develops the need for a specialized rehabilitative service after admission, the NF must either provide the specialized rehabilitative service or obtain the service from an outside resource.

D. Mental health rehabilitative services for MI, ID/DD and/or a related condition (RC) are specialized rehabilitative services which the NF is required to provide to meet the daily mental health needs of its persons. These services include, but are not limited to:

1. Consistent implementation, during the person’s daily routine and across settings, of systematic plans which are designed to change inappropriate behaviors,

2. Administering and monitoring the effectiveness and side effects of medications which are prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness,

3. Provision of a structured environment for those persons who are determined to need structure such as structured socialization activities to diminish tendencies toward isolation and withdrawal,

4. Development, maintenance, and consistent implementation across settings of those programs designed to teach persons the daily living skills they need to be more independent and self-determining. Program focus may include but not be limited to grooming, personal hygiene, mobility, nutrition, health, medication management, mental health education, money management, and maintenance of the living environment,

5. Development of appropriate personal support networks, or

6. Formal behavior modification programs.

E. If mental health rehabilitative services for MI, ID/DD and/or RC services are needed by a person, they must be provided by the NF regardless of whether the need was identified through the PASRR process, and regardless of whether the person requires other specialized services through another Medicaid provider.

F. Specialized Services for persons with MI are the services specified by the ARC that include treatment other that routine nursing care, supportive therapies, and supportive counseling by NF staff. This includes services that, combined with services provided by the NF, result in the continuous and aggressive implementation of an individualized plan of care that will aid the person in attaining the highest practicable level of physical, mental and psychosocial well-being, and:

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1. Is developed and monitored by an interdisciplinary team, which includes a physician, qualified mental health professionals and, as appropriate, other professionals;

2. Prescribes specific therapies and activities for the treatment of person experiencing an acute episode of serious MI, which necessitates supervision by trained mental health personnel; and

3. Is directed toward the diagnosis and reduction of the person’s behavioral symptoms that necessitate institutionalization and that aid the person to improve his/her level of independent functioning, and achieve a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.

G. Specialized services for persons with MI provided by Community Mental Health Centers (CMHCs) or Private Mental Health Centers (PMHCs) include, but are not limited to:

1. Medication Evaluation and Monitoring defined as an intentional face-to-face interaction between a physician or a nurse practitioner and a person for the purpose of assessing the need for psychotropic medication, prescribing medications and regular periodic monitoring of the medications prescribed for therapeutic effect and medical safety,

2. Individual Therapy defined as one-on-one psychotherapy that takes place between a mental health therapist and a person,

3. Family Therapy defined as psychotherapy that takes place between a mental health therapist and a person’s family members, with or without the presence of the person. Family therapy may also include others with whom the resident has a family-like relationship. However, meetings with NF staff that do not include the person is not considered family therapy,

4. Group Therapy defined as psychotherapy that takes place between a mental health therapist and at least two (2), but no more that twelve (12) residents at the same time. Possibilities include, but are not limited to, groups that focus on coping with or overcoming depression, adaptation to changing life circumstances and self-esteem enhancement, and

5. Psychosocial Rehabilitation defined as a program of structured activities, designed to support and enhance the ability of NF persons to function at the highest possible level of independence. The structured activities target the specific needs and concerns of the NF persons and aim to improve reality orientation, social adaptation, physical coordination, daily living skills, time and resource management, task completion and other areas of competence that promote independence in daily life. Structured activities are designed to aid in alleviating such psychiatric symptoms as confusion, anxiety, disorientation, distraction, preoccupation, isolation, withdrawal and feelings of low self-worth.

H. Specialized services for persons with MI, ID/DD and/or RCs include, but are not limited to,

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specialized services that constitute a continuous active treatment program, that includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services directed toward:

1. The acquisition of the behaviors necessary for the person to function with as much self- determination and independence as possible.

2. The prevention or deceleration of regression or loss of current optimal functional status. Specialized services are not services provided to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.

3. Short-term provision of any one (1) or a combination of the following services for the person during the temporary acute and/or sub-acute need:

a) Inpatient psychiatric services,

b) Medication evaluation and monitoring by a psychiatrist or similarly credentialed professional, such as a Psychiatric Nurse Practitioner, to evaluate patient response to psychotropic medications and to modify medication orders,

c) Individual, family, and/or group therapy services, and

d) Psychosocial rehabilitation services, and

e) Senior psychosocial rehabilitation.

I. Specialized services provided by community service providers certified by DMH include, but are not limited to:

1. Training targeted toward amelioration of identified basic skill deficits and/or maladaptive behavior,

2. Priority training needed to achieve greater levels of independence and self-determination, and

3. Aggressive implementation of a systematic program of formal and informal techniques and competent interactions continuously targeted toward achieving a measurable level of skill competency specified in written objective, based on a comprehensive interdisciplinary evaluation, and conducted in all client settings and by all personnel involved with the person.

J. The Division of Medicaid considers specialized services as any disability related supports and services provided to a NF person with a PASRR condition that aids the person to attain the highest practicable level of physical, mental, and psychosocial well-being that includes, but is not limited to:

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1. A short-term intensive intervention for a maximum of six (6) months promoting the successful adaptation to the NF and/or to improve the resident’s quality of life during the NF stay.

2. A short-term intensive intervention, that promotes a successful NF discharge and community reintegration, for persons with a capacity for community reintegration, within the ensuing three (3) to six (6) month period. These services are provided to promote the mission of Olmstead and other similar reintegration and diversion initiatives promoting successful community reintegration through targeted, time-limited, and goal directed services for persons with ID/DD who have the capacity for such transition.

3. Services include short-term services for a maximum of six (6) months depending on the identified needs of the person with the provision of one (1) or a combination of the following services that include, but are not limited to:

a) Independent living skills development,

b) Community living/integration skills development,

c) Re-socialization skills development, and

d) Behavior support and intervention services.

Source: 42 C.F.R. §§ 483.45, 483.440; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revise eff. 06/01/19.

Rule 3.7: Confidentiality Safeguards

A. The Division of Medicaid’s Pre-Admission Screening and Resident Review (PASRR) Level II Contractor is responsible for notifying the person and the person’s legal and/or designated representative in writing that the person is suspected of having a mental illness (MI), an intellectual disability/developmental disability (ID/DD) and/or a related condition (RC), and that a PASRR Level II is required.

B. The Division of Medicaid’s PASRR Level II Contractor must involve the person being evaluated and include the person’s legal and/or designated representative, along with the person’s family, if possible.

1. The person and the person’s legal and/or designated representative must agree to family participation.

2. If the legal and/or designated representative is not able to attend the PASRR Level II, he or she may give consent for the PASRR Level II to proceed without his or her presence.

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C. The Division of Medicaid’s PASRR Level II Contractor must ensure all notices are adapted to the cultural background, language, ethnic origin and means of communication used by the person being evaluated and must interpret and explain the results of the PASRR Level II to the person and legal and/or designated representative.

D. Interdisciplinary coordination must occur and be documented when more than one (1) evaluator performs any portion of the PASRR Level II Evaluation.

E. The gathering of information necessary for determining whether it is appropriate for the person with MI, ID/DD and/or a RC to be placed in a NF or in another appropriate setting must occur throughout all applicable portions of the PASRR Level II process.

1. All information must be considered and recommendations must be based upon a comprehensive analysis of all data concerning the person.

2. Evaluators are allowed to use available data, obtained prior to initiation of the PASRR process, as long as the available data is considered valid, accurate, and appears to reflect the current functional status of the person.

3. To supplement and verify that the existing data is current and accurate, it may be necessary for the Division of Medicaid’s PASRR Level II Contractor or the Department of Mental Health’s (DMH’s) Regional Center IDD Program to gather additional information to assess proper placement and treatment.

4. Information is only allowed to be obtained and/or released with properly executed consents.

F. In accordance with State Law, all Appropriateness Review Committee (ARC) PASRR Level II determinations must be maintained by the PASRR State Coordinator’s Office.

1. All PASRR Level II determinations, and any relevant information, must be placed and remain in the person’s active medical chart at the NF they are admitted to and maintained in accordance with State Law.

2. The recommendations in the PASRR Level II Summary of Findings Report must be addressed in the NF plan of care.

3. The PASRR Level II determinations, and any relevant information, must be sent to any new NF if the person transfers to another NF.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.8: Reconsideration and Appeal

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A. If a person or his/her legal or designated representative does not agree with the Appropriateness Review Committee (ARC) Determination, he/she has a right to appeal the decision.

B. The person must first request a reconsideration of the ARC Determination within ten (10) days of the date of the ARC determination notice and must be made directly to the Division of Medicaid’s PASRR Level II Contractor for a mental illness (MI) determination or the Department of Mental Health’s (DMH’s) Regional Center Intellectual/Development Disability (IDD) Program for an ID/DD or a related condition (RC) determination.

C. If a person or his/her legal or designated representative does not agree with the outcome of the reconsideration, he/she has a right to request a fair hearing from the Division of Medicaid. [Refer to Miss. Admin. Code Part 300]

Source: 42 C.F.R. 431 Subpart E; 42 C.F.R. §§ 431.10, 483.108, 483.204; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Rule 3.9: Reimbursement for PASRR Level II Evaluations

A. The Division of Medicaid reimburses the Pre-Admission Screening and Resident Review (PASRR) Level II Contractor for services rendered when the Contractor:

1. Completes and sends a PASRR Level II Billing Summary for MI monthly to the State PASRR Coordinator for review, and

2. Submits an invoice via Paymode to be electronically processed for reimbursement.

B. The Division of Medicaid reimburses the Department of Mental Health (DMH) Regional Center Intellectual/Developmental Disability (IDD) Program when DMH:

1. Submits the PASRR Level II Roster for ID to the State PASRR Coordinator for review, and

2. Depending upon the person’s Medicaid eligibility status, reimbursement will be processed accordingly by the Division of Medicaid.

C. The Division of Medicaid only reimburses for PASRR Level IIs which are:

1. Complete, and

2. Signed by the appropriate personnel who completed the assessments that are part of the PASRR Level II.

D. The Division of Medicaid does not reimburse for:

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1. Incomplete PASRR Level IIs,

2. Therapeutic services provided by community mental health centers (CMHCs) or private community health centers (PMHCs) in a nursing facility (NF) to persons who do not have an Appropriateness Review Committee (ARC) determination recommending the service,

3. PASRR Level II for persons who have a primary diagnosis of Alzheimer’s disease or other dementia which prevents them from benefitting from specialized services or those deemed to be in an advanced determination category, or

4. Multiple services provided for a person conducted and/or billed simultaneously.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/19.

Part 207 Institutional Long Term Care

Chapter 4 Psychiatric Residential Treatment Facility

23 Miss. Admin. Code Pt. 207, R. 4.2 Provider Enrollment

Enrollment into the Medicaid program requires each provider to meet all of the applicable requirements outlined in Miss. Admin. Code Title 23, Part 200, Chapter 4.

History: Revised eff. 08/01/2026. Revised eff. 12/01/2025.

Rule 4.3: Staffing

The Division of Medicaid requires Psychiatric Residential Treatment Facilities (PRTF) have the following staff:

A. The governing body of the PRTF must appoint an administrator to be responsible for the overall management of the facility. The administrator must have appropriate academic credentials and administrative experience in child/adolescent psychiatric treatment. The administrator must be responsible for the fiscal and administrative support of the facility's clinical program.

B. The facility must appoint a medical director to be responsible for coordinating medical services and directing resident treatment. The medical director must be a board-certified child/adolescent psychiatrist or a psychiatrist who has successfully completed an approved residency in child/adolescent psychiatry.

C. The facility must appoint a full-time clinical director to be responsible for coordinating clinical services and implementing patient treatment. The clinical director must be one of the following:

1. A board-certified child/adolescent psychiatrist,

2. A psychiatrist who has successfully completed an approved residency in child/adolescent psychiatry,

3. A licensed psychologist who is experienced in child/adolescent mental health treatment,

4. A psychiatric mental health nurse practitioner (PMHNP) who is experienced in child/adolescent mental health treatment, or

5. A licensed certified social worker who is experienced in child/adolescent mental health

treatment.

D. A board-certified child/adolescent psychiatrist or a psychiatrist who has successfully completed an approved residency in child/adolescent psychiatry may serve as both medical director and clinical director provided that he/she is a full-time employee.

E. The facility must employ sufficient full-time professional staff to provide clinical assessments, therapeutic interventions, ongoing program evaluations, and adequate resident supervision twenty-four (24) hours a day. At least fifty percent (50%) of the professional staff hours must be provided by full-time employees. Professional staff must be appropriately licensed and trained/experienced in providing mental health treatment. These staff members will include, but not be limited to, the following:

1. A board-certified child/adolescent psychiatrist or a psychiatrist who has successfully completed an approved residency in child/adolescent psychiatry,

2. A licensed psychologist,

3. A registered nurse,

4. A licensed certified social worker,

5. A certified teacher, and

6. A recreation specialist.

F. The PRTF must have access, through full/part-time or contract employment, the services of each of the following:

1. A licensed occupational therapist or credentialed creative arts therapist,

2. A rehabilitation counselor, and

3. A licensed speech-language pathologist.

G. The PRTF must provide an adequate staff-to-resident ratio on all shifts to provide for resident and staff safety.

H. The PRTF must notify the Division of Medicaid of changes in the Administrator, Medical Director or Clinical Director. Division of Medicaid must receive the notification in writing within seventy-two (72) hours of the effective change.

Rule 4.4: Admission

The Division of Medicaid covers PRTF services when a child does not require emergency or acute psychiatric care but does require supervision and treatment on a twenty-four (24) hour basis.

A. A board-certified child/adolescent psychiatrist or a psychiatrist who has successfully completed an approved residency in child/adolescent psychiatry with admitting privileges must approve each admission.

B. The goal of PRTF treatment is to help the child reach a level of functioning where less restrictive treatment will be possible.

C. The need for PRTF admission must be supported by documentation that:

1. The child has a diagnosable psychiatric disorder.

2. The child can participate and process information as evidenced by an appropriate IQ for the program to which they have been admitted, unless there is substantial evidence that the IQ score is suppressed due to psychiatric illness.

3. The child's psychiatric symptoms are severe enough to warrant residential treatment under the direction of a psychiatrist.

4. The referring psychiatrist or psychologist advises that residential treatment is needed.

5. At least one (1) of the following:

a) The child has failed to respond to less restrictive treatment in the last three (3) months.

b) Adequate less restrictive options are not available in the child's community.

c) The child is currently in an acute care facility whose professional staff advise that residential treatment is needed.

6. The admission has been certified by the UM/QIO as medically and psychologically necessary.

D. The facility must provide the parent/guardian with contact information for the Disability Rights Mississippi, including the phone number and mailing address, and document in the record.

History

• Source: Miss. Code Ann. §§ 43-13-121; 43-13-117; 43-13-118; 43-13-129; 42 C.F.R. § 441, Subpart D; 42 C.F.R. § 441.151.
• Source: Miss. Code Ann. § 43-13-121; 42 CFR 441. Subpart D; 42 CFR 441.151 (a)(2)
• Source: Miss. Code Ann. § 43-13-121; 42 CFR 441.152 (a)(3); 456.180(b)(1); 441.152 (a)(2);

23 Miss. Admin. Code Pt. 207, R. 441.152 (a)(1); 483.356 (c); 483.366 (a); 483.356 (d)

Rule 4.5: Non-Covered Services

Division of Medicaid does not cover:

A. Admissions on the weekends. The Division of Medicaid defines weekend admissions as admission after 5:00 p.m. on a Friday. Covered days will not begin until the following Monday.

B. Non-covered days of stay.

C. Any days of stay not certified by the UM/QIO.

Rule 4.6: Reimbursement

A. Participating Mississippi facilities must prepare and submit a Medicaid cost report for reimbursement of long term care facilities.

1. All cost reports are due by the end of the fifth (5 th ) calendar month following the reporting period.

2. Failure to file a cost report by the due date or the extended due date will result in a penalty of fifty dollars ($50.00) per day and may result in the termination of the provider agreement.

B. The Division of Medicaid uses a prospective method of reimbursement.

1. The rates are determined from cost report data.

2. Standard rates are determined annually with an effective date of January first (1 st ).

3. In no case may the reimbursement rate for services provided exceed an individual facility’s customary charges to the general public for such services in the aggregate, except for those public facilities rendering such services free of charge or at a nominal charge.

4. Prospective rates may be adjusted by the Division of Medicaid pursuant to changes in federal and/or state laws or regulations when authorized by the state legislature.

5. Prospective rates may be adjusted by the Division of Medicaid based on revisions to allowable costs or to correct errors when authorized by the state legislature.

a) These revisions may result from amended cost reports, field visit reviews, or other corrections.

b) Facilities are notified in writing of amounts due to or from the Division of Medicaid as a result of these adjustments.

c) There is no time limit for requesting settlement of these amounts. This is applicable to claims for dates of service since July 1, 1993.

C. The Division of Medicaid conducts periodic field level cost report financial reviews of selected long term care facilities, including nursing facilities, intermediate care facilities for the mentally retarded, and psychiatric residential treatment facilities, to verify the accuracy and reasonableness of the financial and statistical information contained in the Medicaid cost reports. Adjustments will be made as necessary to the reviewed cost reports based on the results of the reviews.

D. Notwithstanding any other provision of this article, it shall be the duty of each nursing facility, intermediate care facility for the mentally retarded, 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. 1. Providers must maintain adequate documentation including, but not limited to, financial records and statistical data, for proper determination of costs payable under the Medicaid program.

a) The cost report must be based on the documentation maintained by the facility.

b) All non-governmental facilities must file cost reports based on the accrual method of accounting.

c) Governmental facilities have the option to use the cash basis of accounting for reporting.

2. Documentation of financial and statistical data should be maintained in a consistent manner from one period to another and must be current, accurate and in sufficient detail to support costs contained in the cost report.

3. Providers must make available to the Division of Medicaid all documentation that substantiates the information included in the facility cost report for the purpose of determining compliance.

a) These records must be made available as requested by the Division of Medicaid.

b) All documentation which substantiates the information included in the cost report, including any documentation relating to home office and/or management company costs must be made available to Division of Medicaid reviewers as requested by the Division.

E. Services and charges include the following:

1. The facility may charge any amount greater than or equal to the Medicaid rate for non- Medicaid residents for the provision of services under the State Medicaid Plan.

2. While the facility may set their basic per diem charge for non-Medicaid residents at any level, the services covered by that charge must be identical to the services provided to Medicaid residents and covered by the Medicaid per diem rate.

3. Any items and services available in the facility that are not covered under Title XVIII or the facility’s basic per diem rate or charge must be available and priced identically for all residents in the facility.

F. Medicaid allows payment for the date of admission to the PRTF. Medicaid does not cover the date of discharge from the facility. A Medicaid-eligible beneficiary cannot be charged for the date of discharge. If a beneficiary is discharged on the date of admission, the day is covered as the date of admission.

G. Private room coverage by Medicaid is as follows: 1. The overall average cost per day determined from the cost report includes the cost of private rooms.

2. The average cost per day is used to compute PRTF reimbursement rates. Therefore, the cost of a private room is included in the reimbursement rate and no extra charge can be made to the beneficiary, his/her family or the Medicaid program.

3. Medicaid reimbursement is considered as payment in full for the beneficiary.

H. The following rules apply to hospital leave:

1. A fifteen (15) day length of stay is allowed in a non-psychiatric unit of a hospital. The facility must reserve the hospitalized resident’s bed in anticipation of his/her return. The bed cannot be filled with another resident during the covered period of hospital leave.

2. A resident must be discharged from the facility if he/she remains in the hospital for over fifteen (15) days. A leave of absence for hospitalization is broken if the resident returns to the facility for twenty-four (24) hours.

3. Facilities cannot refuse to readmit a resident from hospital leave when the resident has not been hospitalized for more than fifteen (15) days and still requires PRTF services.

I. If a resident elopes from the facility and remains absent for twenty-four (24) hours or longer, he/she must be discharged from the facility. If further treatment at the same facility is desired after the end of the twenty-four (24) hours, the child/adolescent must go through a readmission process.

J. The following rules apply to therapeutic leave:

1. An absence from the facility for eight (8) hours or more within one calendar day constitutes a leave day.

2. Medicaid coverage of therapeutic leave days per fiscal year, July 1 – June 30, is eighteen (18) days for a PRTF.

3. Each therapeutic leave day taken each month must be reported on the billing mechanism.

4. The attending physician must approve all therapeutic leave days. Documentation must include goals to be achieved during the leave, the duration of leave, who participated in the leave, and the outcome of the leave.

K. Payment during therapeutic leave from the facility is as follows:

1. A temporary absence of a resident from a PRTF does not interrupt the monthly payments to the facility under the provisions as outlined in Part 207, Chapter 4 Rule 4.6 J.

2. Each facility is required to maintain leave records and indicate periods of therapeutic leave days.

3. Before a resident departs on therapeutic leave, the facility must provide each resident and family member or legal representative written information explaining leave policies. The information must define the period of time the resident is permitted to return and resume residence in the facility.

4. A refund of payment will be demanded for all leave days taken in excess of the allowable or authorized number of days.

L. The PRTF must provide non-emergency transportation.

1. Effective February 1, 2019, the PRTF cannot use the Non-Emergency Transportation (NET) Broker to arrange transportation for residents. PRTFs may use NET providers that also provide NET services for the NET Broker if:

a) The facility arranges the transportation, and

b) Pays the NET provider directly.

2. Prior to February 1, 2019, the PRTF must:

a) Arrange and pay for non-emergency transportation and place the cost on the cost report, or

b) Utilize the NET Broker to arrange non-emergency transportation for residents.

History: Revised to correspond with MS SPA 22-0006 (eff. 05/01/2022) eff. 07/01/2022; Revised eff. 07/01/2021; Added Miss. Admin. Code Rule 4.6.L. eff. 09/01/2018.

Rule 4.7: Active Treatment

The use of the term “treatment’ refers to the active treatment of the resident. The Division of Medicaid defines active treatment as a process comprising of the following:

A. Multi-disciplinary diagnostic assessment,

B. Interdisciplinary treatment planning,

C. Therapeutic intervention,

D. Treatment evaluation/revision, and

E. Discharge/aftercare planning.

Rule 4.8: Assessment and Evaluation

A. The diagnostic evaluation must document the need for the PRTF level of care.

B. Diagnostic evaluations must be completed within the first fourteen (14) days of admission. The assessment process must include, but is not limited to, the following:

1. A psychiatric evaluation.

2. A psychological evaluation signed by a licensed psychologist, which must have been completed in the sixty (60) days prior to admission. If no psychological evaluation has been conducted within the last twelve (12) months, one must be completed within fourteen (14) days following PRTF admission.

3. A medical history and examination.

4. A psychosocial assessment, which includes a psychological profile, a developmental profile, a behavioral assessment, and an assessment of the potential resources of the resident’s family.

5. A Child and Adolescent Needs and Strengths (CANS-MH) assessment.

6. An educational evaluation.

7. A nursing assessment.

8. A nutritional assessment, if indicated.

Rule 4.9: Treatment Planning

A. Treatment planning is defined by the Division of Medicaid as a collaborative venture which the members of various disciplines jointly develop a comprehensive, individualized plan for the treatment of each resident.

1. The treatment plan charts a course designed to help the resident move to a less restrictive level of care as quickly as possible.

2. An initial treatment plan must be in effect within seventy-two (72) hours after the resident’s admission to the facility.

3. The interdisciplinary treatment team must meet to discuss, approve and implement a more comprehensive treatment plan within fourteen (14) days after the resident’s admission, once at the conclusion of the first (1st) month of stay, and once a month thereafter.

4. The treatment plan document must contain evidence of the resident’s and his/her parent/guardian’s active participation in the treatment planning/review/revision process.

B. The treatment team should include as many staff as possible who are involved in the treatment of the resident.

1. At a minimum, the team must include, either:

a) A board-certified child/adolescent psychiatrist or a psychiatrist who has successfully completed an approved residency in child/adolescent psychiatry, or

b) A Psychiatric Mental Health Nurse Practitioner (PMHNP) and a physician licensed to practice medicine or osteopathy, or

c) A licensed psychologist and a physician licensed to practice medicine or osteopathy.

2. The team must also include one (1) of the following:

a) A licensed certified social worker who has a minimum of one (1) years’ experience in treating children with serious emotional disturbances (SED), or

b) A registered nurse who has a minimum of one (1) years’ experience in treating

individuals with SED.

C. The treatment plan delineates all aspects of the resident’s treatment and includes, at a minimum:

1. A multi-axial diagnosis.

2. An assessment of the resident’s immediate therapeutic needs.

3. An assessment of the resident’s long-range therapeutic needs.

4. An assessment of the resident’s personal strengths and liabilities.

5. Identification of the clinical problems that are to be the focus of treatment.

6. Measurable and realistic treatment goals for each identified problem.

7. Observable, measurable treatment objectives that represent incremental progress towards goals, coupled with target dates for their achievement.

8. Specific treatment modalities and/or strategies that will be employed to reach each objective.

a) Special procedures must not be included in the treatment plan unless justified by current or historical evidence of aggressive behavior which, cannot be controlled by less restrictive interventions.

b) If special procedures become necessary, the treatment plan must be amended or modified within one (1) working day of the first incident to reflect the use of the least restrictive necessary measures.

9. The clinician identified as responsible for each aspect of treatment.

10. Identification of goals, objectives and treatment strategies for the family as well as the resident, and identification of the clinician responsible for family treatment. If a geographically distant therapist will be utilized, this must be specified in the treatment plan.

11. An individualized discharge plan that includes:

a) Discharge criteria, indicating specific goals to be met,

b) An estimated discharge target date, and

c) No later than seven (7) days prior to discharge, the discharge plan must also include an aftercare plan that addresses coordination of family, school/vocational and

community resources to provide the greatest possible continuity of care for the resident.

D. The treatment team must meet to staff each resident and review/revise his/her treatment plan as often as necessary to provide optimum treatment. The treatment review team must assess the resident’s progress in treatment by:

1. Noting treatment successes, discussing which objectives and/or goals have been achieved and when, and explaining treatment failures.

2. Making changes in the treatment plan, as needed.

3. Re-assessing the child's need for continued residential care, as opposed to less restrictive treatment.

4. Noting the child's measurable progress towards discharge, reviewing/revising the discharge criteria and/or target date as needed.

441.156(b)(1)(3)(4)(5); 441.156(c)(1)(2); 144.156(d)(1)(2).

Rule 4.10: Therapeutic Interventions

A. Psychotherapy is defined as the intentional, face to face interaction between a mental health professional and a client, either an individual, family, or group, in which a therapeutic relationship is established to help resolve symptoms of the resident’s mental and/or emotional disturbance.

B. Individual therapy is defined as psychotherapy that takes place between a mental health therapist and a resident. Individual Therapy must be provided a minimum of one (1) hour each week unless its contraindication is documented in the treatment plan. Individual Therapy must be provided by master’s level mental health therapists.

C. Family therapy is defined as psychotherapy that takes place between a mental health therapist and a resident’s family members or guardians, with or without the presence of the resident. If a resident is in the custody of the Department of Human Services (DHS), family therapy may also include others, including DHS representatives and foster family members, acting in loco parentis. Family Therapy must be at least twice a month, unless its contraindication is documented in the treatment plan.

1. Each resident’s family, guardian, or person acting in loco parentis must participate in the family therapy sessions.

2. If the resident’s family is more than a two (2) hour drive from the PRTF, one (1) face-to- face family therapy session and one (1) therapeutic conference call is acceptable.

3. Family Therapy must be therapeutic in nature to include discussing the resident’s functioning, treatment progress, goals and objectives.

4. Social visits or phone calls are not considered family therapy.

5. Family Therapy must be provided by master’s level mental health therapists.

6. Residents who are in the custody of the Department of Human Services (DHS) must complete one (1) face-to-face family therapy session with the social worker in the county of the PRTF, unless the social worker in the home county is available, and complete the second (2nd) family therapy session via telephone with the social worker in the home county.

7. A geographically distant therapist may provide family therapy when there are family issues that must be resolved or ameliorated before face-to-face sessions that include the resident can be productive and therapeutic.

a) Distance alone is not justification for prescribing off-site therapy.

b) When off-site therapy is appropriate, the treatment plan must identify the off-site therapist, indicate the goals for such therapy, and specify how information will be exchanged between the PRTF and the off-site therapist.

c) Collaboration between therapists is the responsibility of the PRTF and must be documented in the clinical record.

D. Group therapy is defined as psychotherapy that takes place between a mental health therapist and at least two (2), but not more than eight (8) residents at the same time.

1. Possibilities for groups include, but are not limited to, those which focus on relaxation training, anger management and/or conflict resolution, social skills training, and self- esteem enhancement.

2. Each resident must participate in a minimum of three (3) hours of group therapy, provided in at least three (3) sessions, each week unless contraindication is documented in the treatment plan.

3. The length, frequency and timing of sessions in which services are delivered must be determined by what is developmentally appropriate for each resident.

4. Group therapy must be provided by master’s level mental health therapists although larger groups up to twelve (12) participants can be co-led by a person with a lesser level of training.

E. Psychotherapy notes must be documented for each therapy session and include the following essential elements:

1. The date and time in and time out of the session,

2. The type of therapy, either individual, family or group,

3. The person(s) participating in the session,

4. The length of the session,

5. Clinical observations about the resident including their demeanor, mood, affect, mental alertness, thought processes or risks,

6. The content of the session,

7. Therapeutic interventions attempted and the resident’s response to the intervention(s),

8. The resident’s response to any significant others who may be present in the session,

9. The outcome of the session,

10. A statement summarizing the resident’s degree of progress toward the treatment goals,

11. Reference at least monthly to the resident’s progress in relation to the discharge criteria and the estimated discharge date,

12. The signature and printed name, if needed for clarity, of the therapist, and

13. Monthly summaries are not acceptable in lieu of psychotherapy session notes.

F. Milieu therapy is defined as residential psychiatric treatment that occurs in the total environment of the closed setting, also referred to as the “therapeutic community.” Milieu therapy must be provided twenty-four (24) hours a day by all PRTF staff.

1. Emphasis is placed on clear, healthy, respectful communication between resident/resident, staff/staff, and staff/resident, and on shared problem-solving and decision-making.

2. The entire environment, not just the limited time spent with an identified therapist, is considered vital to the treatment process. The physical environment of the facility must reflect a warm, child-friendly atmosphere with treatment-oriented information including, but not limited to, motivational/educational posters, schedules of activities, requirements for level systems and rules for unit, written in positive terms and age appropriate language. Materials must be posted in a manner that is highly visible and easily accessible to residents.

3. Milieu notes must be documented daily and:

a) Present a clear picture of the resident’s participation and interactions in the therapeutic community.

b) Describe the resident’s actions, staff interventions, and the resident’s response to those interventions.

c) Are usually completed by direct care staff.

d) If a checklist is used, it must be accompanied by at least a brief narrative.

e) Must be behaviorally focused.

f) Behavior and events should be described rather than labeled.

g) Must reflect a pattern of clear, respectful communication between staff and resident, with emphasis on the resident’s involvement and collaboration in his/her own treatment.

4. The community meeting is a required element of milieu therapy. This is a time when all residents and most, if not all, professional and direct care staff meet together to discuss and solve problems that arise in community living, make community decisions, set goals, resolve conflicts and discuss ideas that may enhance treatment.

5. Documentation that community meetings are held at least daily and are attended by all residents and most, if not all, professional and direct care staff.

6. Documentation that the focus of community meetings is good communication and collaboration among residents and staff to solve problems, make community decisions, and introduce/discuss ideas/suggestions that will enhance treatment.

7. Documentation that residents are knowledgeable about their treatment and actively participate in goal-setting and treatment evaluation.

8. Community meeting notes must be clearly identifiable.

9. Each resident’s participation must be documented, or his/her absence justified, in a minimum of one (1) community meeting per day.

10. Notes must reflect that the community meetings are therapeutic in nature and address treatment issues including, but not limited to:

a) Problem identification,

b) Goal-setting,

c) Problem-solving,

d) Conflict resolution,

e) Behavioral observations/evaluation,

f) Problems in community living.

11. The nature of each resident’s participation must be described.

12. If a checklist is used, it must be accompanied by at least a brief narrative.

G. Therapeutic Pass/Therapeutic Leave is defined as those times when a resident is permitted time “away” from the PRTF to practice skills learned in treatment or to work on significant relationships in a setting that is less structured and controlled.

1. Therapeutic Pass refers to “away” time of less than eight (8) hours.

a) If a resident leaves the facility on a therapeutic pass accompanied by PRTF staff, no documentation is required.

b) If a resident leaves the facility on a therapeutic pass with anyone other than staff, including relatives or representatives of DHS, therapeutic goals for the pass must be identified and documented. At the conclusion of the pass, documentation must indicate whether or not the therapeutic goals were met.

2. Therapeutic Leave refers to “away” time of eight (8) hours or more in the same calendar day. A single day of therapeutic leave is determined by the resident’s absence from the facility for eight (8) hours or more between the hours of 12:01 a.m. and 11:59 p.m. on any given day.

a) Therapeutic Leave is not allowed during the fourteen (14) day assessment period following admission.

b) The attending physician or PMHNP must approve all therapeutic leave days.

3. Documentation at the time a resident leaves the facility must include:

a) The date/time of check-out,

b) The required time of return,

c) The name(s) of the person(s) with whom the leave will be spent,

d) The resident’s physical/emotional condition at the time of departure including vital signs,

e) The types and amounts of medication being provided and instructions in lay terms for taking them,

f) Therapeutic goals for the leave, as related to the goals established in the treatment plan,

g) The name and signature of the person with whom the resident is leaving, and

h) The signature of the staff person checking the resident out.

4. Documentation at the time of the resident’s return must include:

a) The date and time of check-in,

b) The resident’s physical/emotional condition at the time of return including vital signs and notation of any physical injury or complaint,

c) Whether or not any contraband was found,

d) The types and amounts of medication being returned, if any, and explanation of any missed doses,

e) An explanation of any early or late return from leave,

f) A brief report on the outcome of the leave by the parent or guardian,

g) The name and signature of the person returning the resident’s to the facility,

h) The signature of the staff person checking resident in, and

i) An assessment of the outcome of the leave must be conducted by the resident’s therapist within seventy-two (72) hours of the resident’s return from leave.

H. Creative arts therapies is defined as those therapies, including art, movement/dance, music and poetry, which a qualified professional uses the creative process and the resident’s response to the created product to help the resident resolve emotional conflicts, increase self- awareness, develop social skills, manage behavior, solve problems, reduce anxiety, improve reality orientation, and/or increase self-esteem.

I. Occupational therapy is defined as the use of purposeful activity, designed and guided by a qualified professional, to help the resident achieve functional outcomes that promote the highest possible level of independence.

J. Recreation therapy is defined as a process that utilizes recreation services for purposive intervention in physical, emotional and/or social behavior to bring about a desired change in

that behavior and to promote the growth and development of the resident.

K. Speech-Language Pathology is defined as remedial assistance with speech and/or language problems provided by a licensed speech-language pathologist.

L. When other therapies such as art therapy, recreational therapy, occupational therapy, dance/movement therapy, music therapy, speech/language therapy, are employed, their use must be documented in the clinical record in much the same manner as psychotherapy including date, length, type of session, together with a summary of the session's content, process, outcome and the therapist's name/signature.

Rule 4.11: Medical Treatment and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Requirements

A. The Division of Medicaid covers medically necessary Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for EPSDT-eligible beneficiaries in accordance with Miss. Admin. Code Part 223, without regard to service limitations and with prior authorization.

B. A psychiatric residential treatment facility (PRTF) must ensure that every individual receives medically necessary EPSDT services regardless of whether such services are identified in the individual’s plan of care.

C. Each PRTF must have written policies and procedures and a designated area for responding to an individual’s physical and/or medical needs in the PRTF.

D. EPSDT services in a PRTF must be provided by:

1. The PRTF,

2. Under arrangement between the PRTF and a qualified Mississippi Medicaid enrolled non-facility provider, and/or

3. By a qualified Mississippi Medicaid enrolled provider in the community not affiliated with or under arrangement with the PRTF.

E. The Division of Medicaid reimburses for medically necessary EPSDT services:

1. On the PRTF’s cost report if services are provided directly by the PRTF or under arrangement with the PRTF, or

2. Directly to the provider directly if EPSDT services are provided by a qualified Mississippi Medicaid enrolled provider in the community not affiliated with or under arrangement with the PRTF.

F. The Division of Medicaid does not reimburse a provider for any duplicative psychiatric service that the PRTF is responsible for providing.

G. PRTF providers must document all EPSDT services provided in the medical record.

History: Revised eff. 04/01/2019.

Rule 4.12: Special Procedures

A. The Division of Medicaid defines special procedures as seclusion and restraint and must be used as an immediate response only in emergency safety situations when needed to help a resident regain control of his/her behavior. At all times, the least restrictive effective intervention must be used. The potential therapeutic effects of prevention of self and other injury and reinforcement of behavioral boundaries must be weighed against the counter- therapeutic effects.

1. Seclusion is defined as the involuntary confinement of a resident in an area from which she/he is physically prevented from leaving. It is used to ensure the physical safety of the resident or others and to prevent the destruction of property or serious disruption of the milieu.

2. Restraint is defined as the restriction of a resident’s freedom of movement or normal access to his/her body through physical, mechanical or pharmacological means, in order from the least to the most restrictive method. It is used to ensure the resident’s physical safety.

a) Personal restraint is defined as the restraint of a resident through human physical action using a standard technique or method designed and approved for such use. It is used to prevent a resident from causing harm to self or others or to prevent destruction of property.

b) Mechanical restraint is defined as the restraint of a resident through the use of any mechanical device, material or equipment attached or adjacent to the resident’s body that s/he cannot easily remove.

c) Pharmacological restraint is defined as the use of a medication, which is not a standard part of the resident’s treatment regimen, to control or alter the resident’s mood or behavior or to restrict freedom of movement. Pharmacological restraint is used to insure the safety of the resident or others through a period of extreme agitation when less restrictive measures have not been effective. Standing PRN orders for pharmacological restraints are prohibited.

B. Seclusion or restraint must only be used in situations where less restrictive interventions have been determined to be ineffective. Any use of seclusion or restraint must be:

1. In accordance with appropriate techniques,

2. Applied by staff trained and approved to use such techniques,

3. Implemented in the least restrictive manner possible,

4. In a room that is safe and sanitary, with adequate lighting, ventilation and temperature control, and

5. Evaluated on a continual basis and ended at the earliest possible time based on the assessment and evaluation of the resident’s condition.

C. Seclusion or restraint cannot be used as a method of coercion, discipline or retaliation as compensation for lack of staff presence or competency, for the convenience of staff in controlling a resident’s behavior, or as a substitute for individualized treatment.

1. Restraint and seclusion must not be used simultaneously.

2. Any personal or mechanical restraint of a resident in a face-down position is prohibited.

3. Any personal or mechanical restraint of a resident in a spread-eagle position with legs and arms apart is prohibited.

4. Standing, or “as needed” (PRN), orders for seclusion or restraint are prohibited.

D. The following actions are required for any form of special procedure with the exceptions as noted below:

1. Only a physician or a PMHNP may order the seclusion or personal/mechanical restraint of a resident.

2. If seclusion or personal/mechanical restraint is initiated without orders from a physician or PMHNP, a verbal or telephone order must be obtained from the physician or PMHNP by an RN or LPN no later than one (1) hour after the start of the procedure. If the physician’s or PMHNP’s order cannot be obtained within the one (1) hour, the procedure must be discontinued.

3. Pharmacological restraint may be initiated only by medical staff acting on a physician’s or PMHNP’s orders. At the time of the order, the physician or PMHNP must identify a specific time when the procedure is expected to end and/or the expected duration of the medication’s effects, at which time the resident’s condition must be assessed and the incident must be processed with the resident.

4. The physician’s or PMHNP’s order for seclusion or personal/mechanical restraint must be for a time period not to exceed one (1) hour for residents younger than nine (9) years of age, or two (2) hours for residents nine (9) to twenty one (21) years of age.

a) The original order may be renewed, if clinically justified, in accordance with these limits for up to a total of twenty four (24) hours.

b) After the renewal limits of the original order are reached, a physician or PMHNP must see and assess the resident before issuing a new order.

5. The staff person responsible for terminating seclusion must be physically present in or immediately outside the seclusion room throughout the duration of the procedure.

6. The staff person responsible for terminating a mechanical restraint must be physically present throughout the duration of the procedure.

7. Within one (1) hour of the initiation of the emergency safety intervention, a physician, PMHNP or RN must conduct a face-to-face assessment of the physical and psychological well-being of the resident.

8. Even if the emergency safety intervention is terminated in less than one (1) hour, the face-to-face assessment must be conducted within an hour of its initiation.

9. The health and comfort of the resident must be assessed every fifteen (15) minutes by direct observation, and staff must record their findings at the time of observation.

10. Vital signs must be taken every hour unless contraindicated and documented in the resident’s record.

11. There must be clear criteria for ending the special procedure and the resident must be made aware of them when the procedure is initiated and at follow-up intervals as appropriate.

12. A physician, PMHNP, or RN must evaluate the resident’s well-being immediately after the seclusion or restraint is terminated.

13. At an appropriate time, but no later than twenty-four (24) hours following the conclusion of the special procedure, the resident must be given the opportunity to discuss with all staff involved in the procedure the antecedents, emotional triggers, and consequences of his/her behavior and any learning that occurred as a result of the intervention.

E. All staff who have direct resident contact must have ongoing education, training, and demonstration of knowledge of the proper and safe use of seclusion/ restraint and alternative techniques/methods for handling the behavior, symptoms, and situations that traditionally have been treated through seclusion and restraint. Training in the application of physical restraint must be a professionally recognized method, which does not involve restraining a

resident in a face-down or spread-eagle position with legs and arms apart.

F. If a facility provides for the use of seclusion/restraint, it must inform the prospective resident and the parent/guardian at the time of admission of the circumstances under which these special procedures are employed. The facility must provide the parent/guardian with a copy of its policy regarding seclusion/restraint and obtain a signed acknowledgment from the parent/guardian documenting that the policy was explained and a copy given to them. This acknowledgment must be filed in the resident’s record. In the event that a resident requires either seclusion or restraint, the PRTF must notify the parent/guardian as soon as possible, but no later than twenty-four (24) hours after the initiation of the procedure.

G. Documentation of each incident of seclusion or restraint must be part of the resident’s permanent record.

1. Documentation of each incident of seclusion or restraint, including personal, mechanical and pharmacological restraint, must include, but not be limited to, the following information:

a) The date and time the procedure started and ended,

b) The name of the physician or PMHNP who authorized it, the name(s) of staff who initiated the procedure, were involved in applying or monitoring it, and/or were responsible for terminating it,

c) Whether or not the resident returned from therapeutic leave within the preceding twenty-four (24) hours,

d) The reason the procedure was used,

e) Which less restrictive options were attempted, and how they failed,

f) Criteria for ending the procedure,

g) The results of the face-to-face assessment conducted by a physician, PMHNP or RN within one (1) hour after initiation of the procedure including:

(1) The resident’s physical and psychological status,

(2) The resident’s behavior,

(3) The appropriateness of the intervention measures, and

(4) Any complications resulting from the intervention.

h) The resident’s condition at the time of each fifteen (15) minute reassessment and at the end of the procedure,

i) The signature of the person documenting the incident,

j) A record of both staff/resident and staff only debriefing sessions, which must take place within twenty-four (24) hours of the use of seclusion/restraint, and must include the names of staff present for or excused from the debriefing and any changes to the resident’s treatment plan that resulted from the debriefings, and

k) Notification of the resident’s parents/guardians within twenty-four (24) hours of the initiation of each incident, including the date and time of notification and the name of the staff person providing the notification.

2. A separate log documenting all episodes of seclusion/restraint in the PRTF must be maintained. A multi-disciplinary team, including at least nursing personnel, physician or PMHNP, therapist, and quality management personnel, must review incidents of seclusion/restraint monthly. These meetings must be documented.

3. Information regarding the number of times seclusion or restraint have been employed by a facility must be included each month as part of the facility’s census report to the UM/QIO.

483.366(a); 483.356(a)(3)(ii); 483.358(d)(e)(f); 483.364(a); 483.362(a)(c); 483.370(a)(b).

Rule 4.13: Medication

A. Documents pertaining to medication must be accurate and readily located. When medication is a prescribed intervention for a problem identified in the resident’s treatment plan, it must be noted as such in the treatment plan. Medication changes must be made during treatment planning meetings whenever possible. When circumstances preclude this, the changes must be reviewed for all team members’ update at the next available staffing opportunity.

B. When medications are prescribed or changed, a member of the professional staff must review, with each resident’s parent/guardian, the following:

1. The name/class of medication,

2. The method of administration,

3. The symptoms targeted,

4. Possible side effects of the medication,

5. Possible long-term effects of the medication,

6. Treatment alternatives, and

7. Likely outcomes of using/not using the medication.

C. When a face-to-face encounter cannot be held with a parent/guardian prior to starting a medication regimen, the "informed consent" conference must be held by telephone, with the parent’s/guardian's responses noted and dated.

1. Two (2) PRTF staff must witness the form after talking with the parent/guardian.

2. The informed consent must be signed by the parent/guardian within thirty (30) days after the telephone consent.

D. Documentation must substantiate that medications have been accurately administered in accordance with the physician’s or PMHNP’s orders. Any variances must be justified in the record by medical staff.

E. An instrument for monitoring medication side effects must be identified and routinely administered to each resident who is prescribed psychoactive medication upon admission, at least every sixty (60) days during his/her stay and again at discharge.

F. Medication adjustment is defined as the use of a resident’s routine medication in a non- routine way to help the resident through a period of heightened stress or agitation. Medication adjustment is not considered to be a special procedure. Medication adjustments must not be sedating, must be administered orally, and must be taken voluntarily by the resident. Standing PRN orders for medication adjustments are acceptable.

Rule 4.14: Discharge Aftercare

A. No later than seven (7) days prior to the resident’s projected discharge date, the treatment team must develop a provisional aftercare plan for the resident. The plan's content must include, but not be limited to:

1. The planned discharge date,

2. The date of the resident’s admission and discharge,

3. The name of the person/agency expected to assume care and custody of the resident,

4. The physical location/address where the resident is expected to reside,

5. A list of the resident’s psychiatric diagnoses,

6. Behavior management recommendations for parents and any other suggestions which might contribute towards the resident’s successful participation in family life,

7. Educational summary and practical recommendations/suggestions for teachers which might contribute towards the resident’s success at school, and

8. Treatment recommendations or observations/comments for follow-up mental health clinicians which may increase the likelihood of success in therapeutic aftercare.

B. At the time of the resident’s discharge the facility must:

1. Amend the provisional aftercare plan to include:

a) The dates of the resident's admission and discharge,

b) The name of the person/agency expected to assume care and custody of the resident,

c) The physical location/address where the resident is expected to reside,

d) A list of the resident's psychiatric diagnoses,

e) Detailed information about the resident's medications the names, strengths and dosage instruction in lay terms for all medications prescribed for the resident, as well as any special instructions such as lab work requirements,

f) Behavior management and other pertinent recommendations for parents/caregivers,

g) Names, addresses and telephone numbers of the agencies/persons who will provide follow -up mental health services, the date and time of initial aftercare appointments, and treatment recommendations for the providers of those services,

h) Place where the resident will be attending school, a summary of the resident’s educational progress while at the PRTF, his/her current educational standing, and recommendations for the resident’s teachers,

i) Other recommended resources, if applicable, including recreational, rehabilitative, or other special programs believed to offer benefit to the resident,

j) The parent/guardian's signed acknowledgment that she/he was provided:

1. A copy of the resident's aftercare plan,

2. A minimum of a seven (7) day supply of the resident’s medications, and

3. Prescriptions for a thirty (30) day supply of the resident’s medications.

2. Provide the parent/guardian with:

a) A written copy of the final aftercare plan.

b) A supply of all current medications prescribed for the resident, equal to the amount already stocked for that resident by the PRTF but not less than a seven (7) day supply or more than a thirty (30) day supply.

c) Prescriptions for a thirty (30) day supply of all medications prescribed for the resident.

3. Seek the parent’s/guardian’s consent to release copies of the resident’s educational summary and recommendations to the resident’s school. If this consent is obtained, the educational information must be mailed to the resident’s school within one working day following the resident’s discharge. The school must not be sent the resident’s complete aftercare plan, but only the part pertaining to education.

4. Seek the parent’s/guardian’s consent to release copies of the resident’s aftercare plan and discharge summary to the providers of follow-up mental health services. If this consent is obtained, the aftercare plan and discharge summary must be mailed to mental health aftercare within two (2) weeks following the resident’s discharge.

Rule 4.15: Reporting Requirement

A. The PRTF must keep the Division of Medicaid informed of serious occurrences involving residents of the PRTF.

1. The death of any resident or a serious incident involving any resident, regardless of whether or not those involved were Medicaid beneficiaries, must be reported to the Division of Medicaid.

a) The death of any resident must be reported to the Division of Medicaid as soon as possible, but no later than close of business the same day.

b) Serious incidents must be reported by fax to the Division of Medicaid by close of the next business day.

2. The Division of Medicaid defines serious incidents as:

a) Serious injury of a resident, defined as any significant impairment of the physical condition of the resident as determined by qualified medical personnel.

1. This includes, but is not limited to, burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else.

2. All serious injuries that require medical intervention are to be reported.

b) Suicide attempt by a resident.

c) Elopement of a resident.

d) Allegations of sexual contact between residents.

e) Allegations of maltreatment, like abuse and/or neglect of a resident.

f) Any injury of a resident sustained in the course of a seclusion or restraint.

3. Each report must include:

a) The name of the resident, if she/he is a Medicaid beneficiary,

b) A description of the occurrence, and

c) The name, street address, and telephone number of the facility.

B. Serious incidents must also be reported to the appropriate agencies or entities according to applicable state and federal regulations. These include, but are not limited to:

1. Department of Human Services (DHS).

2. Mississippi State Department of Health, Bureau of Health Facilities Licensure and Certification (MSDH).

3. Disability Rights Mississippi (DRM) formerly known as the State Protection and Advocacy office.

4. Regional Office of the Center for Medicare and Medicaid Services (CMS)

5. Medicaid Fraud Control Unit, Attorney General (MFCU)

6. Utilization Management and Quality Improvement Organization (UM/QIO) for the Division of Medicaid.

Rule 4.16: Maintenance of Records

Refer to Maintenance of Records Part 200, Ch.1, Rule 1.3.

History

• Source: Miss. Code Ann. § 43-13-121
• Source: Miss. Code Ann. §§ 43-13-117, 43-13-121, 42 CFR § 447 Subparts B & C, Miss. Code Ann. § 43-13-117, 42 CFR § 447.15.
• Source: Miss. Code Ann. § 43-13-121; 142 CFR 441.154
• Source: Miss. Code Ann. § 43-13-121; 42 CFR 441.155(b)(1), 441.156(b)(2)
• Source: Miss. Code Ann. § 43-13-121; 42 CFR 441.154(a)(b); 441.155(b)(2); 441.155(c)(1)(2);
• Source: Miss. Code Ann. § 43-13-121; 42 CFR § 441.155(b)(1)(4)(5)
• Source: U.S.C. § 1396d; 42 C.F.R. §§ 431.107; 455.1; Miss. Code Ann. §§ 43-13-117, 43-13- 121.
• Source: Miss. Code Ann. § 43-13-121; 42 CFR 483.364(b)(1)(2); 483.356(a)(1)(2)(3)(4);
• Source: Miss. Code Ann. § 43-13-121.
• Source: Miss. Code Ann. § 43-13-121; 42 CFR 441, Subpart D
• Source: Miss. Code Ann. § 43-13-121; 43-21-353; 42 CFR 483.374
• Source: Miss. Code Ann. § 43-13-121; 43-21-353

Part 208 Home and Community Based Services (HCBS) Long Term Care

Chapter 4 Home and Community-Based Services (HCBS) Traumatic Brain Injury/Spinal Cord Injury Waiver

23 Miss. Admin. Code Pt. 208, R. 4.15 Grievances and Complaints

A. The Division of Medicaid and the Mississippi Department of Rehabilitation Services (MDRS) are responsible for investigating and documenting all grievances/complaints regarding all programs operated and/or certified by the Division of Medicaid. Grievances

may be made via phone, written letter format, or email. The Division of Medicaid has the final authority over any complaint or grievance.

B. Personnel issues are not considered as grievances or complaints within the scope or purview of the Division of Medicaid.

C. The Division of Medicaid’s toll-free Helpline is available at (800) 421-2408. MDRS case managers are required to provide the toll-free number at initial assessment and annually at recertification.

D. The Department of Rehabilitation Services must cooperate with the Division of Medicaid to resolve grievances/complaints in accordance with the requirements in the CMS-approved TBI/SCI Waiver, which is available on the Division of Medicaid’s website, www.medicaid.ms.gov.

History: New Rule to correspond with the TBI/SCI Waiver renewal (eff. 07/01/2023) eff. 08/01/2026.

History

• Source: 42 CFR § 441.301; Miss. Code Ann. § 43-13-121.

Part 209 Durable Medical Equipment, Medical Appliances and Medical Supplies

Chapter 1 Durable Medical Equipment and Medical Appliances

23 Miss. Admin. Code Pt. 209, R. 1.10 Apnea Monitors

A. Medicaid defines an apnea monitor as a device used to monitor respiratory movements. This may be accomplished by use of an apnea alarm mattress or by use of alarm sensitive devices to measure thoracic and abdominal movement and heart rate.

B. Medicaid covers apnea monitors for all beneficiaries:

1. When prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity.

2. For an initial three (3) month rental trial period, then recertification is required. The three (3) month rental trial period applies toward the maximum reimbursement for purchase.

3. [Reserved]

4. When the beneficiary is/had at least one (1) of the following:

a) An infant who has a diagnosis of apnea of prematurity.

b) A preterm infant with continued symptomatic apnea past thirty-six (36) weeks gestational age.

c) Been observed having or has a recorded episode of prolonged apnea within the last three (3) months that is documented by medical personnel and associated with bradycardia, reflux, cyanosis, or pallor. Medicaid defines prolonged apnea as cessation of breathing greater than twenty (20) seconds or bradycardia episodes less than sixty (60) beats per minute (bpm) for greater than five (5) seconds.

d) An infant who is a sibling of a child with sudden infant death syndrome (SIDS), or has two (2) siblings with a diagnosis of apnea.

e) Had an event or events requiring vigorous stimulation or resuscitation within the past three (3) months.

f) A tracheotomy.

g) An infant with bronchopulmonary dysplasia who requires oxygen and displays medical instability.

h) An adult or child has demonstrated symptomatic apnea due to neurological impairment, craniofacial malformation, central hyperventilation syndrome, or is secondary to gastrointestinal reflux

C. Medicaid will cover diagnoses not included above on an individual basis with appropriate documentation.

D. Medicaid does not cover apnea monitors for terminally ill beneficiaries or for those who have "do not resuscitate" orders.

E. Medicaid covers apnea monitors for an initial three (3) month certification. After the three (3) month initial certification, apnea monitors may be recertified up to seven (7) additional months with a new prescription or letter of medical necessity.

1. Medicaid will not reimburse for a three (3) month trial period then pay full purchase price.

2. Medicaid does not cover supplies, such as a battery pack, safety lead wires, electrodes, electrode belts, event recording downloads, or remote alarms separately.

3. Medicaid requires that apnea monitors must be returned to the DME provider after it is no longer required if the rental period is less than ten (10) months.

History: Revised eff. 09/01/2018.

Rule 1.11: Augmentative Communication Device (ACD)

A. The Division of Medicaid defines an augmentative, or alternative, communication device (ACD) as any type of system that allows beneficiaries with severe, expressive communication disorders, or speech-language impairments, to overcome the disabling effects of communication impairment by representation of vocabulary or ideas and expression of messages.

B. The Division of Medicaid covers ACD’s for all beneficiaries, when prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or a designated entity for rental up to the purchase amount, or purchase as indicated when the following criteria is met:

1. When ordered by a pediatrician, neurologist, or a physiatrist, a physician specializing in physical rehabilitation, and who has documented training in assessment for and prescription of ACD’s.

2. Documentation that the beneficiary’s ability to communicate using speech and/or writing is insufficient for communication purposes.

3. Documentation clearly supports that the beneficiary is mentally, emotionally, and physically capable of operating/using an ACD.

4. When the prescription includes specification for the ACD, component accessories, and all necessary therapies and/or training.

C. The Division of Medicaid requires an evaluation and recommendation be performed by a speech-language pathologist (SLP) in conjunction with other health professionals as appropriate.

1. A written copy of the evaluation and recommendation must be submitted with the request for prior authorization. This evaluation must include at a minimum:

a) Communication status and limitations, abilities to meet communication needs through other means such as sign language, manual communication, and the like,

b) Current speech and language skills,

c) Prognosis for speech and/or written communication,

d) Cognitive readiness, interactional/behavioral and social abilities,

e) Capabilities and needs including intellectual, including educational, postural, physical, sensory, including visual and auditory, motor, and cognitive,

f) Motivation to communicate,

g) Environmental, including residential, vocational and educational, assessment,

h) Current seating or positioning equipment and any modification that would be required secondary to the ACD,

i) Integration of communication with other behavior,

j) Alternative ACD(s) considered with comparison of capabilities,

k) Other communication methods/devices tried,

l) Ability of recommended ACD to be implemented/integrated into environments,

m) Ability to meet projected communication needs, like growth potential, projected length of time the beneficiary will be able to use the proposed system,

n) Anticipated changes, modifications, or upgrades with projected short and long-term time frames,

o) Anticipated prognosis with the specific device requested, and

p) Training plan including dates, names, addresses, and capabilities of available caregivers.

D. The Division of Medicaid allows for a trial period of at least thirty (30) days, not to exceed ninety (90) days, to ensure that the beneficiary’s needs are met by the proposed ACD and in the most cost-effective manner.

E. The Division of Medicaid does not cover carrying cases separately.

History: Revised eff. 08/01/2018.

Rule 1.12: Bath Bench or Shower Chair

A. The Division of Medicaid defines a bath bench or shower chair as durable medical equipment (DME) enabling a beneficiary to bathe or shower safely.

B. The Division of Medicaid covers a bath bench or shower chair when:

1. [Reserved],

2. Prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity,

3. The ordering physician or allowed NPP documents the beneficiary has a medical condition that will not allow him/her to safely shower or bathe without use of the bath bench or shower chair,

4. A physician or allowed NPP documents that the ordered bath bench or shower chair will allow the beneficiary to safely bathe or shower.

History: Revised eff. 09/01/2018. Revised-01/01/2013.

Rule 1.13: Battery and Battery Charger

A. The Division of Medicaid defines the following:

1. Battery is a device for generating electric current by chemical action.

2. Battery charger is a device that adds electrical energy to a battery.

B. The Division of Medicaid covers a sealed battery and single mode battery charger for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement

Organization (UM/QIO), the Division of Medicaid or designated entity, for purchase only, when all of the following criteria is met:

1. Batteries and battery chargers are associated with the purchase of equipment and are included in the maximum reimbursement for that equipment except for power wheelchair batteries [Refer to Miss. Admin. Code Part 209 Rule 1.47 and 1.48], and

2. Replacement batteries, if coverage criteria is met.

History: Revised eff. 10/01/2020; Revised eff. 09/01/2018. Revised – 01/01/2013.

Rule 1.14: Bi-level Positive Airway Pressure Device (BIPAP) With or Without an In-Line Heated Humidifier

A. Medicaid defines a bi-level positive airway pressure (BiPAP) device as a non-continuous, bi- level airway management device that cycles between the inspiratory and expiratory pressure levels in response to the patient's respiratory effort. The rise in pressure, during inspiration, supports the patient's breathing by splinting the airway to overcome the additional collapsing forces from inspiratory efforts. When inspiration has ended, the pressure drops at the point of exhalation removing the sensation of expiratory effort while still maintaining a therapeutic level of pressure in the circuit necessary to overcome collapsing forces in the airway.

B. Medicaid covers a BiPAP for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental for an initial three (3) months trial period if one (1) or more of the following is met:

1. The beneficiary was unable to tolerate the necessary CPAP pressures,

2. The beneficiary has frequent central apneas that do not resolve with administration of CPAP, or

3. The beneficiary’s baseline hypoxemia in cases involving chronic lung disease or hypoventilation syndromes is not corrected with administration of CPAP.

C. All related supplies are considered an integral part of the rental or purchase allowance of the BiPAP unit and separate charges for supplies or respiratory services are not covered.

D. Medicaid covers appropriate supplies for BiPAP units if owned by the beneficiary at maximum amounts expected to be medically necessary. Medicaid covers for amounts exceeding the maximum amount if there is documented justification and on individual bases.

E. After an initial three (3) month trial period, the BiPAP may be recertified up to seven (7) additional months with a BiPAP Compliance Medicaid Certificate of Medical Necessity completed by the ordering physician.

1. If the equipment was not effective or if the beneficiary was non-compliant, the equipment may be returned to the vendor.

2. The rental fees paid for the three (3) month trial period must apply toward the maximum reimbursement for purchase.

History: Revised eff. 09/01/2018.

Rule 1.15: Breast Pumps

A. The Division of Medicaid defines a breast pump as a device used to extract breast milk from a lactating mother.

B. The Division of Medicaid covers the following types of breast pumps for nursing mother beneficiaries when medically necessary, prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity.

1. The Division of Medicaid defines a manual breast pump as a single-user device manually operated to express breast milk from a lactating mother and is covered for purchase when:

a) Used to promote lactation when natural breastfeeding has been insufficient in maintaining adequate nutritional needs of the infant, or

b) Used to provide lactation support when natural breastfeeding is not possible.

2. The Division of Medicaid defines an electric breast pump as an electronic device used to express breast milk from a lactating mother and is covered for rental up to purchase amount, or for purchase when one (1) of the following is met:

a) The infant:

1. Is preterm or term and requires hospitalization longer than the mother,

2. Has a cleft palate or cleft lip,

3. Has cranial-facial abnormalities,

4. Is unable to suck adequately,

5. Has Failure to Thrive,

6. Has a low birth weight, or

7. Has other medical conditions that interfere with breastfeeding.

b) The mother:

1. Has a breast abscess,

2. Has mastitis,

3. Is hospitalized due to illness or surgery on short term basis,

4. Is unable to effectively use a manual pump to promote or maintain lactation due to a medical condition or physical limitation,

5. Is undergoing treatment with short-term medications which requires the pumping and discarding of breast milk, or

6. Has other medical conditions that interfere with breastfeeding.

C. All prior authorization requests must:

1. Be in the mother beneficiary’s name,

2. Include the mother beneficiary’s Medicaid ID number, and

3. Include an estimate of how many weeks or months the mother will require the electric breast pump.

History: Revised eff. 09/01/2018. Revised eff. 05/01/2014.

Rule 1.16: Cane

A. Medicaid defines a cane as an assistive device held in the hand and used for support during ambulation. This includes canes of all materials, single, quad or three pronged, adjustable or fixed.

B. Medicaid covers canes for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or

designated entity for rental up to purchase amount or purchase when indicated and all the following criteria met:

1. [Reserved]; and

2. When condition or injury causing impaired ambulation and when there is a potential for ambulation.

C. Tips, handgrips, adjustment features or other accessory items are inclusive in the rental or purchase of the cane.

D. Straight, single post canes may be either fixed or height adjustable. Medicaid covers straight canes for the following indications:

1. To relieve stress on a joint in post-surgery beneficiaries.

2. To aid beneficiaries with decreased balance due to vestibular, neurological, or orthopedic conditions.

E. Three prong or quad canes may be either fixed or height adjustable. Medicaid covers these canes for the following indications:

1. For beneficiaries who require an added base of support (BOS) provided with the cane for stance and ambulation.

2. For beneficiaries who have achieved increased ambulation skills and no longer require a walker but still need an assistive device with a wider BOS than a straight cane will offer.

F. All canes issued to children should be height adjustable to provide for growth.

G. Some beneficiaries may require two (2) canes for greater stability.

History: Revised eff. 09/01/2018.

Rule 1.17: Combination Positive Expiratory Pressure, Airway Oscillation, and Intermittent Flow Acceleration Device

A. The Division of Medicaid defines a combination positive expiratory pressure, airway oscillation, and intermittent flow acceleration device as a unit for mobilizing respiratory tract secretions in a beneficiary with chronic lung conditions such as, but not limited to:

1. Chronic obstructive lung disease,

2. Chronic bronchitis,

3. Cystic fibrosis, or

4. Emphysema.

B. The Division of Medicaid covers this device for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for purchase when the beneficiary has one (1) of the following diagnosis:

1. A chronic lung condition where mobilization of respiratory secretions is hindered,

2. Cystic fibrosis,

3. Bronchiectasis,

4. Chronic bronchitis/COPD, and

5. Atelectasis, or

6. Any other disease process in which secretion mobilization is needed.

C. Beneficiary teaching must be documented along with the beneficiary’s ability to properly use and clean the device.

D. The item may not be appropriate for children less than six (6) years of age.

1. For the item to be considered for children under age six (6), the ordering physician or allowed NPP conducting the face-to-face encounter must document that the child is able to use the device correctly.

2. Individual consideration will be given for children under age six (6).

History: Revised eff. 09/01/2018.

Rule 1.18: Commode Chairs and Other Toileting Aids

A. The Division of Medicaid defines commode chairs as toileting aids used to assist beneficiaries who are not able to use regular toilet facilities due to their physical condition.

B. The Division of Medicaid covers commode chairs and raised toilet seats for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated and all the following criteria met:

1. [Reserved]

2. When the beneficiary's physical condition is such that the beneficiary is unable to use regular toilet facilities.

3. A commode chair with detachable arms, if used to facilitate transferring the beneficiary or if the beneficiary has a body configuration that requires extra commode width.

4. A heavy duty or extra wide commode chair, with or without detachable arms, if the beneficiary’s body measurements are greater than the measurements specified by the manufacturer for the DME or the beneficiary’s weight is three hundred (300) pounds or greater. Documentation must be maintained for weight and measurements.

5. A raised toilet seat if the beneficiary has a medical condition such as being convalescent from hip surgery which prevents the beneficiary from using a regular commode without a raised seat.

6. A raised toilet seat if the beneficiary does not have a bedside commode capable of fitting over the toilet.

History: Revised eff. 09/01/2018.

Rule 1.19: Compressors

A. Medicaid defines compressors as machines that compress air into storage tanks for use by air driven equipment.

B. Medicaid covers for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for rental up to the purchase amount or purchase.

C. Medicaid covers compressors for separate reimbursement when used in conjunction with a ventilator, nebulizer, or other types of humidification equipment that is not self-contained or cylinder driven.

History: Revised eff. 09/01/2018.

Rule 1.20: Continuous Positive Airway Pressure (CPAP) With or Without an In-Line Heated Humidifier

A. The Division of Medicaid defines continuous positive airway pressure (CPAP) with or without an in-line heated humidifier as a non-invasive provision of air pressure through nasal administration and a flow generator system to prevent collapse of the oropharyngeal walls during sleep. For the Division of Medicaid’s purposes, apneas and hypopneas physiologically represent the same compromise, will be considered as equivalents, and will be referred to as "respiratory events."

B. The Division of Medicaid covers the rental of a CPAP during the three (3) month trial period for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, when the following criteria is met:

1. [Reserved],

2. When one (1) of the following is met:

a) The beneficiary experiences fifteen (15) or more respiratory events per hour, or between five (5) and fourteen (14) respiratory events per hour with documentation of the following symptoms:

1. Excessive daytime sleepiness,

2. Impaired cognition,

3. Mood disorders or insomnia, or

4. Documented hypertension, ischemic heart disease, or history of stroke.

b) The beneficiary is a prepubescent child and the polysomnogram demonstrates an average of one (1) or more respiratory events per hour.

c) The beneficiary is a child who has documented measurements of increased end-tidal carbon dioxide (CO

) values that confirm the presence of obstructive sleep apnea.

d) The beneficiary has a diagnosis of upper airway resistance syndrome with the presence of at least ten (10) respiratory related electroencephalogram (EEG) arousals per hour of sleep accompanied by a history of clinically significant daytime sleepiness or documented excessive daytime sleepiness as determined by a Multiple Sleep Latency Test, with a significant reduction in EEG arousals following administration of CPAP.

C. The Division of Medicaid will review, for determination of coverage for a CPAP, with appropriate documentation, the following medical conditions:

1. Persistent hypoxemia of oxygen saturation (SaO

) less than ninety percent (90%) during sleep even in the absence of obstructive sleep apnea,

2. Central sleep apnea,

3. Chronic alveolar hypoventilation syndrome,

4. Intrinsic lung disease,

5. Neuromuscular disease.

D. After the initial three (3) month trial period, the CPAP may be recertified up to seven (7) additional months with a CPAP Compliance Certificate of Medical Necessity completed by the ordering physician.

1. If the equipment was not effective or, if the beneficiary was non-compliant, the equipment must be returned to the vendor.

2. The rental fees paid for the three (3) month trial period will apply toward the maximum reimbursement for purchase.

3. After ten (10) consecutive months of rental, including the trial period, the CPAP is owned by the beneficiary.

E. The Division of Medicaid reimburses the DME supplier for the supplies listed below:

1. Full face mask used with a positive airway pressure device,

2. Face mask interface, replacement for full face mask,

3. Replacement pillows for nasal application device,

4. Replacement cushion for nasal mask interface,

5. Nasal interface, either a mask or cannula type, used with positive airway pressure device with or without head strip,

6. Headgear used with positive airway pressure device,

7. Chin strap used with positive airway pressure device,

8. Tubing used with positive airway pressure device,

9. Disposable Filter, used with positive airway pressure device,

10. Non-Disposable Filter, used with positive airway pressure device,

11. Oral interface used with positive airway pressure device,

12. Combination oral/nasal CPAP mask,

13. Replacement oral cushion for oral/nasal mask,

14. Replacement nasal pillows for oral/nasal mask, and

15. Humidifier water chamber.

F. Division of Medicaid does not cover for more than the usual maximum replacement amount unless documentation is submitted that justifies a larger quantity in the individual case.

History: Revised eff. 07/01/2021; Revised eff. 09/01/2018. Rule 1.21: Crutches

A. Medicaid defines crutches as assistive devices used for support during ambulation.

1. Crutches may provide underarm or forearm support.

2. Crutches may be made of wood or metal, fixed or adjustable in height and must be supplied with tips.

B. Medicaid covers crutches for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity.

1. Medicaid covers underarm crutches when the following criteria are met:

a) Post-op or post injury to reduce or alleviate weight bearing through the lower extremities.

b) Progression to ambulation without an assistive device.

2. Medicaid defines forearm crutches as crutches that decrease energy consumption during ambulation and provide increased support through the upper extremities.

a) Forearm crutches can be made of various materials, adjustable or fixed, and must be dispensed as a pair complete with handgrips.

b) Medicaid covers forearm crutches when the following criteria is met:

1. For those who will be long-term crutch users;

2. For use with beneficiaries whose balance does not require the base of support (BOS) provided by a walker; and

3. For beneficiaries who need the assistance provided by the crutch to increase their independence in the community. Beneficiaries may use a reciprocating, swing through, or swing to type of gait.

C. Medicaid covers customized crutches with prior authorization by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity.

D. Attachments to crutches are indicated when one (1) or both upper extremities are compromised due to surgical intervention, decreased range of motion, or contracture. The beneficiary may also need the attachment to provide a greater area of support.

E. Platform attachments are indicated when one (1) or both upper extremities have decreased range of motion at the elbow, shoulder, or wrist and allow the beneficiary to grasp and hold onto the crutch.

F. Tips, hand grips, adjustment features, and other accessory items not specifically listed as covered are inclusive in the rental or purchase of the crutches and Medicaid does not reimburse these as separate items.

History: Revised eff. 09/01/2018.

Rule 1.22: Diapers and Underpads

Refer to Part 209, Chapter 2: Medical Supplies, Rule 2.2.AA.

History: Revised eff. 05/01/2021; Revised eff. 01/01/2013.

Rule 1.23: Electromyography (EMG) Biofeedback Device

A. Medicaid defines an electromyography (EMG) biofeedback device as a device that uses recording equipment to detect, amplify and display a physiological response.

1. EMG uses surface electrodes that are attached to the skin over a specific muscle or group of muscles.

2. The EMG has an amplifier that is used to record the small electrical signals that are produced by contraction of the muscle fibers. These signals are amplified and converted into auditory and/or visual signals for display.

3. Biofeedback instruction can teach a patient to learn to modify or reinforce voluntary control of specific responses.

B. Medicaid covers for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for rental up to three (3) months, then requires recertification when one (1) or more of the following treatments are prescribed:

1. The beneficiary is in a prescribed therapeutic exercise program,

2. The beneficiary has musculoskeletal pain,

3. The beneficiary has musculoskeletal stress related injuries, or

4. The beneficiary is on a pre-chronic pain and headache program.

C. After the three (3) month rental period, the device may be recertified when documentation demonstrates desired outcomes are being achieved. The DME provider must thoroughly document that the beneficiary is capable of using and understanding the mechanism of biofeedback.

History: Revised eff. 09/01/2018.

Rule 1.24: Cochlear Implants and Implantable and Non-Implantable Auditory Osseointegrated Devices, Batteries and Battery Chargers

A. The Division of Medicaid covers repairs and external replacement parts for cochlear implant devices when medically necessary, prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designee , and ordered by an audiologist, otologist, otolaryngologist or other physician specialty who has documented training in assessment for and prescription of cochlear implant devices.

B. The Division of Medicaid covers repairs and external replacement parts of an implantable auditory osseointegrated device (AOD) when medically necessary, prior authorized by a UM/QIO, the Division of Medicaid, or designee and ordered by an audiologist, otologist, otolaryngologist or other physician specialty who has documented training in assessment for and the prescription of AODs.

C. The Division of Medicaid covers repairs and replacement parts of non-implantable AODs when medically necessary, prior authorized by a UM/QIO, the Division of Medicaid, or designee and ordered by an audiologist, otologist, otolaryngologist or other physician specialty who has documented training in assessment for and the prescription of AODs.

D. The Division of Medicaid covers batteries and battery chargers for cochlear implants and implantable and non-implantable AODs when medically necessary, prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designee, and ordered by an audiologist, otologist, otolaryngologist or other physician specialty who has documented training in assessment for and the prescription of AODs.

E. The manufacturer must provide a minimum one (1) year warranty for all items. [Refer to Part 209, Rule 1.4.]

History: Revised eff. 12/01/2015.

Rule 1.25: Gait Trainer

A. The Division of Medicaid defines a gait trainer as a device similar to a walker and consists of a wide based steel frame with four (4) casters/wheels and may include a seat or support accessories. The user has difficulty with balance and control of the trunk, has an unsteady gait and is uncoordinated in ambulation.

B. The Division of Medicaid covers for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to three (3) months, then requires recertification when ordered by a physician who specializes in physical medicine, orthopedics, or neurology and the following criteria is met:

1. The beneficiary has a condition which causes unsteady gait and difficulty with ambulation,

2. The beneficiary has been evaluated by a physical therapist (PT) or occupational therapist (OT) not employed by the DME supplier,

3. The PT/OT evaluation report must be submitted with the request for prior approval and must document medical necessity and indicates the approximate length of time the beneficiary will need the gait trainer,

4. The beneficiary's functional level is such that he/she is trainable in use of a gait trainer,

5. The beneficiary has the potential to be ambulatory and is involved in therapy to regain or strengthen ambulatory function,

6. There is enough space in the beneficiary's home for the beneficiary to utilize gait trainer, and

7. There are no medical contraindications to use of the gait trainer.

History: Revised eff. 09/01/2018.

Rule 1.26: Glucose Monitoring Devices

A. The Division of Medicaid defines glucose monitoring devices as durable medical equipment (DME) for home use to measure glucose levels which includes a:

1. Blood glucose monitor (BGM) defined as a portable battery-operated meter used to determine the beneficiary’s blood glucose level by exposing a reagent strip to a small blood sample resulting in the strip’s colorimetric reaction to glucose concentrations, and

2. Continuous glucose monitoring (CGM) defined as DME used to detect trends and patterns in the beneficiary’s glucose levels in the interstitial or intracellular fluid. There are two types of CGMs:

a) An adjunctive CGM requires the user verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions. The glucose levels are recorded by an external recorder that stores the data until it is downloaded for review or sent via a transmitter to an external monitor for beneficiary interaction.

b) A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results. These readings are intended to take the place of the information obtained from beneficiary self-monitoring of blood glucose via a BGM.

B. The Division of Medicaid covers a BGM for rental up to amount of purchase, or purchase when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity and ordered by a physician when all the following are criteria are met [Refer to Miss. Admin. Code Part 209, Chapter 2: Medical Supplies, Rule 2.2.C.1 for Blood Glucose Monitor (BGM) and Rule 2.2.C.2 for Continuous Glucose Monitor (CGM)]:

1. The beneficiary has one (1) of the following diagnoses:

a) Type I diabetes mellitus,

b) Type II diabetes mellitus, or

1. With a documented history of blood glucose fluctuating outside the normal range as specified by the physician,

2. Requiring oral diabetes medication, and

3. Requiring a prescribed specialized diet.

c) Gestational diabetes mellitus requiring treatment.

2. The medical record contains documentation that the beneficiary or caregiver is able to demonstrate the ability to accurately perform the blood glucose testing and accurately report the results.

3. The blood glucose monitor is specifically designed for home use rather than clinical use.

C. The Division of Medicaid covers a minimally invasive CGM for rental up to amount of purchase, or purchase when indicated, when approved by the Federal Drug Administration (FDA) as a medical device for home use, medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, ordered by the physician who is actively managing the beneficiary’s diabetes and the beneficiary meets all of the criteria outlined in Miss. Admin. Code, Part 225, Rule 4.3.

D. The CGM device must be a Food and Drug Administration (FDA) approved medical device and be capable of accurately measuring and transmitting beneficiary blood data. Refer to Miss. Admin. Code Part 225, Chapter 4: Continuous Glucose Monitoring Services.

History: Revised eff. 10/01/2023; Revised eff. 07/01/2021; Revised eff. 09/01/2018. Revised eff. 07/01/2015; Revised eff. 01/01/2013.

Rule 1.27: Hip Abductor Pillow/Wedge

A. Medicaid defines a hip abductor pillow wedge as a foam triangular shaped device placed between the beneficiary’s thighs and secured with straps. The device maintains constant abduction.

B. Medicaid covers hip abductor pillow wedges for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for purchase only, when ordered by a physician and one (1) of the following apply:

1. A diagnosis which has resulted in a condition that requires maintaining the beneficiary’s hips and thighs in abduction,

2. Subluxing or dislocating hip(s),

3. A diagnosis of an unstable hip,

4. Following the reduction of a dislocated hip,

5. Following hip replacement (hemi or total),

6. Following hip arthroplasty or hip fracture surgery,

7. Following adductor tenotomy or abductor advancement surgery, or

8. Wheelchair patients who must maintain a degree of hip abduction.

History: Revised eff. 09/01/2018.

Rule 1.28: Hospital Beds

A. The Division of Medicaid defines a hospital bed as a medical device with:

1. An articulating frame allowing adjustment of the head and foot of the bed,

2. A headboard,

3. A footboard,

4. A mattress, and

5. Side rails.

B. The Division of Medicaid covers hospital beds when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity and ordered by a physician for purchase or rental up to the purchase amount.

1. The Division of Medicaid defines a manual fixed-height hospital bed as one with manual head and leg elevation adjustments but no height adjustment and is covered when a beneficiary meets one (1) of the following:

a) Requires positioning of the body in ways not feasible with a non-hospital bed in order to alleviate pain,

b) Requires the head of the bed to be elevated thirty (30) degrees or more due to a medical condition including, but not limited to, congestive heart failure, chronic pulmonary disease, or risk of aspiration,

c) Has failed to achieve the desired clinical outcome, with pillows or wedges,

d) Requires equipment that can only be attached to a hospital bed,

e) Has a disease, injury, or condition causing paralysis, immobility, or severe malaise and weakness requiring the performance of bathing, bodily functions, and other treatment or care while in bed, or

f) Is semi-comatose or comatose.

2. The Division of Medicaid defines a manual variable-height hospital bed as one with manual height, head and leg elevation adjustments and is covered when a beneficiary:

a) Meets one (1) of the criteria listed in Miss. Admin. Code Part 209, Rule 1.28.B.1., and

b) Requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

3. The Division of Medicaid defines a semi-electric hospital bed as one with manual height adjustment and with electric head and leg elevation adjustments and is covered when a beneficiary:

a) Meets one (1) of the criteria in Miss. Admin. Code Part 209, Rule 1.28.B.1.a) through e) and B.2.b),

b) Is able to operate the hospital bed controls, and

c) Lives alone or with assistance of a caregiver, but without continuous twenty-four (24) hours per day caregiver support.

4. The Division of Medicaid defines bariatric hospital beds as heavy duty extra-wide and extra-heavy duty extra wide hospital beds used for beneficiaries whose weight and/or body measurements exceed the manufacturer’s limit for size or weight of a standard hospital bed and is covered when:

a) The beneficiary meets one (1) of the criteria listed in Miss. Admin. Code Part 209, Rule 1.28.B.1., and

b) Documentation includes current weight and body measurements that exceed the manufacturer’s limit for size and weight of a standard hospital bed which is obtained within thirty (30) days of request.

C. The Division of Medicaid covers total electric hospital beds when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity and when the following criteria are met:

1. An orthopedist, neurologist, physiatrist, or a physician with expertise in treating beneficiaries with disabilities and/or special needs orders the hospital bed and documents

the following:

a) Medical necessity detailing the clinical rationale for the hospital bed,

b) The number of hours and times of the day the beneficiary is expected to be in the hospital bed, and

c) The reason a lower cost hospital bed does not meet the needs of the beneficiary.

2. A Mississippi licensed occupational or physical therapist conducts an on-site evaluation of the location where the hospital bed is to be used includes certification of the following:

a) The hospital bed is for the exclusive use of the beneficiary,

b) The hospital bed can be installed without structural or electrical modifications to the environment, and

c) The beneficiary and/or caregiver are trained in the use, cleaning and care of the hospital bed.

3. The hospital bed has a full two (2) year warranty.

4. The beneficiary has not received a total electric hospital bed within the last five (5) years.

History: Revised eff. 07/01/2019. Revised eff. 09/01/2018. Revised eff. 05/01/2014.

Rule 1.29: Hydraulic Lift with Seat or Sling

A. The Division of Medicaid defines a patient hydraulic lift as a device used to transfer a beneficiary between a bed, a chair, wheelchair or portable commode chair but not solely for use in the bathroom.

B. The Division of Medicaid covers hydraulic lifts for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when ordered by a physician and all the following criteria is met:

1. Documentation that the beneficiary's condition is such that periodic position adjustment is necessary to effect improvement or to arrest or retard deterioration in his/her condition,

2. The beneficiary is bed or chair confined, and

3. There is an available caregiver in the home trained in the safe operation of the hydraulic lift.

C. The Division of Medicaid covers the seat or sling in the initial purchase price or the monthly rental price.

D. The Division of Medicaid covers an electric lift mechanism when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity and when the following criteria are met:

1. An orthopedist, neurologist, physiatrist, or a physician with expertise in treating beneficiaries with disabilities and/or special needs orders the lift and documents the following:

a) Medical necessity detailing the clinical rationale for the DME, and

b) The reason a manual lift does not meet the needs of the beneficiary.

2. A Mississippi licensed occupational or physical therapist conducts an on-site evaluation of the location where the bed is to be used includes certification of the following:

a) The lift is for the exclusive use of the beneficiary,

b) The lift can be installed without structural or electrical modifications to the environment, and

c) The beneficiary and/or caregiver are trained in the use, cleaning and upkeep of the lift.

3. The lift has a full two (2)-year warranty.

4. The beneficiary has not received an electric lift mechanism within the last five (5) years.

History: Revised eff. 07/01/2019. Revised eff. 09/01/2018.

Rule 1.30: Infusion Pump, Enteral/Parenteral/External

A. Medicaid defines an enteral pump as a device used to deliver nutritional requirements to the stomach or small bowel via a tube, including nasogastric, gastrostomy, jejunostomy and PEG tubes.

B. Medicaid covers enteral pumps for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or for purchase when ordered by a physician and if the following criteria is met:

1. The beneficiary is tube fed, and

2. The enteral feedings are the sole source of nutrition.

C. Medicaid defines a parenteral pump as a device used to deliver nutritional requirements intravenously. Intravenous nutrition is also referred to as Total Parenteral Nutrition (TPN) or hyperalimentation therapy.

D. Medicaid covers parenteral pumps if prior authorized, for rental up to purchase amount, or for purchase if indicted for all beneficiaries when ordered by a physician for beneficiaries who cannot absorb nutrients by the gastrointestinal tract.

E. Medicaid defines an ambulatory infusion pump as a small portable electrical device that is used to deliver parenteral medication. It is designed to be carried by or worn by the beneficiary.

F. Medicaid defines a stationary infusion pump as an electrical device which serves the same purpose as an ambulatory pump, but is larger and typically mounted on a pole.

G. Medicaid covers ambulatory and stationary pumps when prior authorized, for rental up to purchase amount, or purchase if indicated when ordered by a physician for home use when the following criteria is met:

1. Parenteral administration of the medication in the home is reasonable and medically necessary; and

2. An infusion pump is necessary to safely administer the medication.

History: Revised eff. 09/01/2018.

Rule 1.31: Insulin Pumps

A. Medicaid defines an insulin pump as a small battery-driven pump that delivers insulin subcutaneously. The pump can be programmed to deliver varying doses of insulin in accordance with changes in need for insulin during different conditions such as eating, exercise, sleep, or at a specific time of day.

B. Medicaid covers insulin pumps for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when ordered by an endocrinologist or other physician experienced in the treatment of diabetes and in the management of the insulin pump therapy and when one (1) or more of the following criteria is met:

1. The beneficiary has insulin dependent diabetes where control has been difficult to achieve, or

2. The beneficiary has fluctuating blood sugars and is on three (3) or more injections per twenty four (24) hours, or

3. The beneficiary is receiving treatment of secondary diabetic complications that require closer blood glucose control.

C. Medicaid requires the prescribing provider, with experience in the use of the pump and in a position to monitor the clinical course of the beneficiary, to document that the beneficiary and/or caregiver demonstrates:

1. Motivation to control the diabetes and to comply with the pump regiment,

2. The ability to learn how to use the pump effectively and the ability to comply with the regimen of the pump care, and

3. A commitment to comply with diet, exercise, medications, and frequent self-monitoring of blood glucose.

D. The prescribing provider and supplier of the pump must also ensure that the beneficiary and/or caregiver are fully educated about the beneficiary’s diabetic condition and use of the insulin pump.

History: Revised eff. 09/01/2018.

Rule 1.32: IV Poles

A. Medicaid defines an IV pole as a device to suspend fluid to be administered by gravity or pump.

B. Medicaid covers IV poles for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when ordered by physician when the beneficiary is receiving enteral or parenteral fluids or IV medications and the beneficiary is not using an ambulatory infusion pump.

History: Revised eff. 09/01/2018.

Rule 1.33: Nebulizer

A. Medicaid defines a nebulizer as an apparatus for producing a fine spray or mist primarily for use in administering drugs by inhalation.

1. This may be accomplished by rapidly passing air through a liquid or by vibrating a liquid at a high frequency so that the particles produced are extremely small.

2. Medicaid expects that the practitioner will have considered the use of a metered dose inhaler with and without a reservoir or spacer device, if age appropriate, and has determined that, for medical reasons, it was not sufficient for the administration of needed inhalation drugs.

B. Medicaid covers nebulizers for all beneficiaries for rental up to purchase amount, or purchase when indicated and ordered by a physician as follows:

1. A nebulizer is covered for rental only when a beneficiary has an acute condition, such as pneumonia or acute bronchitis, which is expected to resolve in a short time.

2. A nebulizer is covered for purchase when a beneficiary has a chronic condition that is not expected to resolve in a short time or is expected to recur frequently. Medical conditions that may be chronic or long term, but are not limited to:

a) Asthma,

b) Bronchopulmonary dysplasia,

c) Chronic bronchitis,

d) Chronic obstructive pulmonary disease,

e) Congenital heart anomaly,

f) Cystic fibrosis,

g) Diaphragmatic hernia, and

h) Respiratory distress syndrome.

History: Revised eff. 06/01/2021, Revised eff. 09/01/2018.

Rule 1.34: Neuromuscular Electrical Stimulator (NMES)

A. Medicaid defines a neuromuscular electrical stimulator (NMES) as a device that transmits an electrical impulse to the skin over selected muscle groups by way of electrodes to treat disuse atrophy where the nerve supply to the muscle is intact.

B. Medicaid covers for all beneficiaries when prior authorized, for rental only, when ordered by an orthopedist, neurologist or physiatrist, a physician specialized in physical rehabilitation, and when there is a documented diagnosis of disuse atrophy and the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and one (1)of the following apply:

1. The beneficiary has or has had casting or splinting of a limb.

2. The beneficiary has a contracture(s) due to scarring of soft tissue as in burn lesions.

3. The beneficiary has had hip replacement surgery, until orthotic training begins.

4. The beneficiary requires one (1) of the following:

a) Relaxation of muscle spasms,

b) Prevention or retardation of disuse atrophy,

c) Re-education of muscle,

d) Increasing of local blood circulation, or

e) Maintenance or increasing of range of motion.

C. The beneficiary and/or caregiver must be able to demonstrate proper use and care of equipment.

Rule 1.35: Oxygen and Oxygen Related Equipment

A. The Division of Medicaid covers oxygen and oxygen related equipment that allows for the safe delivery of oxygen as durable medical equipment (DME) and includes:

1. Stationary gaseous oxygen systems which include container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask and tubing,

2. Stationary liquid oxygen systems, which include container, contents, regulator, flow meter, humidifier, nebulizer, cannula or mask and tubing,

3. Portable gaseous or liquid oxygen systems, which include portable container, regulator, flow meter, humidifier, cannula or mask and tubing,

4. Oxygen concentrators, both stationary and portable, which include a humidifier, cannula or mask and tubing, or

5. Oxygen contents, liquid or gaseous.

6. Portable gaseous oxygen systems, which include home compressor used to fill portable oxygen cylinders, portable containers, regulator, flow meter, humidifier, cannula or mask and tubing.

B. The Division of Medicaid covers oxygen and oxygen related equipment for all beneficiaries when prior authorized by the Division of Medicaid or designee, for rental only when the following criteria are met:

1. The attending physician or consulting practitioner has examined the beneficiary and determined that he or she has one (1) of the following conditions that might be expected to improve with oxygen therapy:

a) A severe lung disease including, but not limited to:

1. Chronic obstructive pulmonary disease (COPD),

2. Diffuse interstitial lung disease,

3. Cystic fibrosis,

4. Bronchiectasis, or

5. Widespread pulmonary neoplasm.

b) Hypoxia-related symptoms or findings including, but not limited to:

1. Pulmonary hypertension,

2. Recurring congestive heart failure (CHF) due to cor pulmonale, or

3. Erythrocytosis.

2. When ordered by the attending physician and prior authorized by the Division of Medicaid or designee:

a) Prior to the initiation of oxygen therapy, and

b) Annually thereafter.

3. The order specifies the diagnosis necessitating oxygen therapy, oxygen flow rate, frequency, and duration of use, and estimates the period of need for oxygen and type of oxygen delivery system to be used.

4. The attending physician or consulting practitioner tried or considered alternative treatments and they were deemed clinically ineffective.

5. The qualifying blood gas study value was obtained under these conditions:

a) During an inpatient stay closest to, but no earlier than, two (2) days prior to the hospital discharge date, with oxygen therapy beginning immediately following the discharge,

b) During an outpatient encounter, within thirty (30) days of the date of the initial certification while the beneficiary is in a chronic stable state, which is when the beneficiary is not in a period of acute illness or an exacerbation of his or her underlying disease, or

c) If there is documentation in the medical record that it is detrimental to the life of the beneficiary to obtain oxygen levels on room air then Miss. Admin. Code Title 23, Part 209, Rule 1.35. B.6. is not required.

6. The beneficiary’s blood gas study, either by an oximetry test or arterial blood gas (ABG), values meet either the following Group I or Group II criteria.

a) Group I criteria:

1. The beneficiary when tested on room air while at rest and awake had an:

(a) Arterial oxygen (O

) saturation at or below eighty-eight percent (88%), or

(b) Arterial partial oxygen pressure (PO

) at or below fifty-five (55) millimeters (mm) of mercury (Hg).

2. The beneficiary when tested during exercise and, if during the day while at rest, arterial PO

is at or above fifty-six (56) mm Hg or an arterial oxygen saturation is at or above eighty-nine percent (89%):

(a) Arterial PO

is at or below fifty-five (55) mm Hg or an arterial oxygen saturation is at or below eighty-eight (88%), and

(b) There is documented improvement of hypoxemia during exercise with oxygen.

3. The beneficiary when tested during sleep, if the arterial PO

is at or above fifty- six (56) mm Hg or an arterial oxygen saturation is at or above eighty-nine (89%) while awake, additional testing must show:

(a) Arterial PO

is at or below fifty-five (55) mm Hg or an arterial oxygen saturation is at or below eighty-eight percent (88%) for at least five (5) minutes, which do not have to be continuous, or

(b) A decrease in arterial PO

of more than ten (10) mm Hg or a decrease in arterial oxygen saturation greater than five percent (5%) and for at least five (5) minutes, which do not have to be continuous, and has signs and symptoms reasonably attributable to hypoxemia including, but not limited to:

(1) Cor pulmonale,

(2) “P” pulmonale on electrocardiogram (ECG),

(3) Documented pulmonary hypertension, or

(4) Erythrocytosis reasonably attributable to hypoxemia.

b) Group II criteria:

1. The beneficiary when tested on room air at rest while awake had an:

(a) Arterial oxygen saturation of eighty-nine percent (89%) at rest and awake, or

(b) Arterial PO

of fifty-six (56) to fifty-nine (59) mm Hg, and

(1) There is dependent edema caused by congestive heart failure, or

(2) There is documentation supportive of pulmonary hypertension or cor pulmonale determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on ECG, with P wave greater than three (3) mm in standard leads II, III, or AVF, or

(3) There is erythrocytosis with a hematocrit greater than fifty-six percent (56%).

2. The beneficiary when tested during exercise had an:

(a) Arterial oxygen saturation of eighty-nine percent (89%), or

(b) Arterial PO

of fifty-six (56) to fifty-nine (59) mm Hg, and

(1) Dependent edema suggesting congestive heart failure,

(2) Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P”

pulmonale on ECG, P wave greater than three (3) mm in standard leads II, III, or AVF, or

(3) Erythrocythemia with a hematocrit greater than fifty-six percent (56%).

3. The beneficiary when tested during sleep for at least five (5) minutes, which do not have to be continuous, had an:

(a) Arterial oxygen saturation of eighty-nine percent (89%), or

(b) Arterial PO

of fifty-six (56) to fifty-nine (59) mm Hg, and

(1) Dependent edema suggesting congestive heart failure,

(2) Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on EKG, P wave greater than 3 mm in standard leads II, III, or AVF, or

(3) Erythrocythemia with a hematocrit greater than fifty-six percent (56%).

C. The Division of Medicaid does not cover oxygen and oxygen related equipment:

1. For the following conditions including, but not limited to:

a) Angina pectoris in the absence of hypoxemia.

b) Dyspnea without cor pulmonale or evidence of hypoxia.

c) Severe peripheral vascular disease resulting in clinically evident desaturation in one (1) or more extremities. There is no evidence that increased PO

will improve the oxygenation of tissues with impaired circulation.

d) Terminal illnesses that do not affect the respiratory system.

2. When the order is for when necessary (PRN) use only.

D. The Division of Medicaid reimburses for the rental of oxygen and oxygen related equipment, supplies and related services as follows:

1. For stationary oxygen systems, the DME provider:

a) Is allowed to bill a monthly rental fee which includes, but is not limited to, the following:

1. Regulators and flow meters,

2. Tubing,

3. Cannulas or mask,

4. Humidifier,

5. Nebulizer,

6. Oxygen contents,

7. Backup oxygen equipment,

8. Maintenance,

9. Repairs, and

10. Delivery.

b) Is allowed to bill for stationary oxygen contents when the provider includes:

1. The appropriate Healthcare Common Procedure Coding System (HCPCS) code indicating the prescribed flow rate is one (1) to (4) liters per minute (LPM), or

2. The appropriate HCPCS code and modifier indicating if the prescribed flow rate is:

(a) Less than one (1) liter per minute (LPM), or

(b) Greater than four (4) LPM.

c) Is not allowed to bill:

1. For medical supplies separately for the delivery of oxygen, or

2. For backup oxygen equipment.

d) Is not allowed to bill for a monthly rental if the beneficiary requires less than one (1) month of rental of oxygen, but must bill the daily rate for only those days the beneficiary required oxygen.

2. For portable oxygen systems, the rental is continuous and the DME provider:

a) Is allowed to bill:

1. Monthly for the portable oxygen system which includes, but is not limited to the following:

(a) Regulators and flow meters,

(b) Tubing,

(c) Cannulas or masks,

(d) Humidifiers,

(e) Portable container, and/or

(f) Supply reservoir.

2. For portable oxygen contents as medically necessary when the provider includes:

(a) The appropriate HCPCS code indicating the prescribed flow rate is less than (4) liters per minute (LPM), or

(b) The appropriate HCPCS code and modifier indicating if the prescribed flow rate is greater than four (4) LPM.

b) Is not allowed to bill portable oxygen contents exceeding one (1) unit per month.

1. A unit is defined as the quantity of oxygen the beneficiary uses per month.

2. The Division of Medicaid’s reimbursement is the same regardless of the quantity of oxygen dispensed.

3. The Division of Medicaid does not reimburse for:

a) The rental of a portable home compressor and the rental of portable oxygen equipment, including contents, at the same time, or

b) Portable oxygen contents based on the modifier indicating the oxygen flow rate.

E. The DME provider must document the following information in the beneficiary’s record after each visit:

1. Date of service,

2. Documentation of maintenance and/or repair, operation and safety of the oxygen equipment,

3. Determination of oxygen output,

4. Changing of filters, and

5. Proper functioning of the backup system.

History: Revised eff. 12/01/2018. Revised eff. 09/01/2018.

Rule 1.36: Pacemaker Monitor

A. Medicaid defines a pacemaker monitor as a self-contained device used in the evaluation of a pacemaker by trans-telephonic monitoring of the transmission of the generator's pulse rate.

1. By means of special equipment, the sound tone of the patient's pacemaker is transmitted over the telephone to a receiving system at a pacemaker clinic.

2. The sounds are converted into an electronic signal and permanently recorded on an ECG strip.

B. Medicaid covers pacemaker monitors for all beneficiaries with prior authorization by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated when ordered by a physician and all the following criteria is met:

1. The beneficiary has a pacemaker implanted for a cardiac arrhythmia.

2. The beneficiary/caregiver is capable of performing the pacemaker monitoring function.

3. The beneficiary has access to a telephone for transmission.

History: Revised eff. 09/01/2018.

Rule 1.37: Pulse Oximeter

A. Medicaid defines pulse oximeter as a photoelectric apparatus for determining the amount of oxygen in the blood. This is usually done by measuring the amount of light transmitted through a translucent part of the skin.

B. Medicaid covers pulse oximeters for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase if indicated when ordered by a physician and one (1) of the following criteria is met for a non-recording pulse oximeter:

1. The beneficiary has a documented serious respiratory diagnosis and requires short-term oximetry to rule out hypoxemia and/or determine the need for supplemental oxygen.

2. The beneficiary is dependent on a ventilator with supplemental oxygen.

3. The beneficiary has a tracheostomy and requires monitoring of O

saturation as determined by the practitioner.

4. The beneficiary requires supplemental oxygen and has unstable saturations.

5. The beneficiary is on supplemental oxygen and weaning is in process.

C. Medicaid covers a recording pulse oximeter when all the following criteria is met:

1. The beneficiary's condition meets one (1) of the criteria for a non-recording oximeter, and

2. The recording oximeter is being ordered by the practitioner to monitor the beneficiary during a specific event such as a weaning attempt from oxygen or ventilator, feeding times for an infant, or other times for which the physician needs documentation of the patient's blood oxygen saturation.

History: Revised eff. 09/01/2018.

Rule 1.38: Spacer/Aerosol-Holding Chamber

A. Medicaid defines a spacer/aerosol-holding chamber as a cylinder shaped device usually four (4) to eight (8) inches long with a one (1) way valve.

1. The device is attached to a metered dose inhaler (MDI).

2. Use of the spacer/aerosol-holding chamber slows the delivery of medication from the pressurized MDI and decreases the amount of medication deposited in the mouth and throat.

B. Medicaid covers spacer/aerosol-holding chambers for all beneficiaries for purchase when ordered by a physician and all the following criteria is met:

1. The beneficiary is unable to coordinate spraying the metered dose inhaler and inhaling.

2. The beneficiary has a medical diagnosis of asthma, chronic bronchitis or emphysema.

3. The beneficiary must have a metered dose inhaler.

History: Revised eff. 06/01/2021, Revised eff. 09/01/2018.

Rule 1.39: Suction Pump, Respiratory/Gastric

A. Medicaid defines a mobile or stationary home model suction pump as a lightweight, compact, electric aspirator designed for upper respiratory oral, pharyngeal and tracheal suction for use in the home. A suction device must be appropriate for home use without technical or professional supervision.

B. Medicaid covers stationary home model suction pump for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated when ordered by a physician and if the beneficiary is unable to clear the airway of secretions by coughing secondary to, but not limited to, one (1) of the following:

1. Cancer or surgery of the throat,

2. Paralysis of the swallowing muscles,

3. Tracheostomy, or

4. Comatose or semicomatose condition.

C. A mobile suction machine includes a vacuum regulator and is battery operated. The device includes a rechargeable battery and charger device, vehicle adapter cable, canister or bottle, connector and carrying case. Medicaid covers a mobile unit if all of the following apply:

1. Prescribed because the beneficiary is subject to secretions that require suctioning during travel.

2. The beneficiary is not being transported by an ambulance.

3. There is sufficient documentation to justify the medical necessity for both stationary and portable units.

D. Medicaid requires those using the suction apparatus must be sufficiently trained to adequately, appropriately and safely use the device.

History: Revised eff. 09/01/2018.

Rule 1.40: Traction Equipment

A. Medicaid defines traction equipment as encompassing a variety of equipment used to apply a pulling force to a part of the body. It may be used to minimize muscle spasms, to reduce, align, and immobilize fractures, to lessen deformity or to increase space between opposing surfaces within a joint.

B. Medicaid covers traction equipment for all beneficiaries when prior authorized, for rental up to three (3) months, then requires recertification when all the following criteria is met:

1. When ordered by an orthopedic physician, neurosurgeon, neurologist or a physiatrist, a physician who specializes in physical rehabilitation.

2. The beneficiary has a cervical or pelvic orthopedic impairment verified by radiographic documentation or has a documented history of chronic pain from an orthopedic impairment that has been unrelieved by other treatment modalities.

C. Medicaid requires all traction equipment must be of a type appropriate for use in the beneficiary's home.

Rule 1.41: Transcutaneous Electrical Nerve Stimulator (TENS)

A. Medicaid defines a transcutaneous electrical nerve stimulator (TENS) as a device that utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patient's perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins.

B. Medicaid covers TENS for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated when ordered by a physician and one (1) of the following criteria is met:

1. The TENS unit is being used for acute post-operative pain, the beneficiary is within thirty (30) days post-op, other treatment modalities have failed and the patient is being treated at home rather than an inpatient hospital. Approval is limited to thirty (30) days rental.

2. The beneficiary has intractable chronic pain of at least three (3) months duration from date of onset and a history of failed response to other treatment modalities. A thirty (30) to sixty (60) day trial period is required.

C. Medicaid covers for a conductive garment to be used with a TENS unit when ordered by the practitioner only if one (1) of the following apply:

1. The beneficiary cannot manage without the conductive garment because there is such a large area or so many sites to be stimulated and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires.

2. The beneficiary cannot manage without the conductive garment for the treatment of chronic intractable pain because the areas or sites to be stimulated are inaccessible with the use of conventional electrodes, adhesive tapes, and lead wires.

3. The beneficiary has a documented medical condition, such as a skin condition, that precludes the application of conventional electrodes, adhesive tapes, and lead wires.

4. The beneficiary requires electrical stimulation beneath a cast to treat chronic intractable pain.

D. Medicaid requires for purchase to be considered, the practitioner must provide a copy of the re-evaluation performed at the end of the trial period and documentation that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.

E. If a four (4) lead TENS unit is ordered, the practitioner must document why two (2) leads are insufficient to meet the patient's needs.

History: Revised eff. 09/01/2018.

Rule 1.42: Transfer Board

A. Medicaid defines a transfer board as a wooden or plastic device used to transfer individuals from one (1) surface to another. It may be used by caregivers to assist with bed mobility of a dependent patient.

B. Medicaid covers transfer boards for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated when ordered by a physician and one (1) of the following criteria is met:

1. The patient has decreased to absent lower extremity function and the board can be used by the patient or caregivers for successful transfer.

2. The patient is obese and unable to transfer without lifting.

3. It is required by the caregiver to assist with the bed mobility of the patient.

4. The caregiver is unable to lift the patient for transfer.

History: Revised eff. 09/01/2018.

Rule 1.43: Trapeze Bar/Equipment

Medicaid covers trapeze bars/equipment for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated and when ordered by a physician and one of the following criteria is met:

A. A trapeze bar or freestanding trapeze equipment when a beneficiary has truncal or lower extremity weakness and needs this device in order to rise to sit, change body position, or get in and/or out of bed.

B. An attached trapeze bar when it is either an integral part of or used on a hospital bed, and it has been determined that both the hospital bed and the trapeze bar are medically necessary.

C. A freestanding trapeze only when used with a non-hospital bed. The beneficiary must not be renting or own a hospital bed.

History: Revised eff. 09/01/2018.

Rule 1.44: Ventilator

A. Medicaid defines a ventilator as a mechanical device used for artificial ventilation of the lungs.

B. Medicaid covers ventilators for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental only, and ordered by a physician and one (1) of the following criteria is met:

1. The beneficiary is unable to maintain spontaneous respiration.

2. The beneficiary is unable to maintain safe levels of arterial carbon dioxide or oxygen with spontaneous breathing.

3. The beneficiary has a medical condition that requires mechanically assisted ventilation that is appropriate for home use, without continuous technical or professional supervision.

C. Medicaid covers the rental allowance which includes:

1. The equipment,

2. Delivery,

3. Freight and postage,

4. Set-up,

5. All supplies necessary for operation of the equipment,

6. Education of the patient and caregiver,

7. All maintenance and repairs or replacement,

8. Labor including respiratory therapy visits, and

9. Servicing charges.

History: Revised eff. 09/01/2018.

Rule 1.45: Walker

A. Medicaid defines a walker as an assistive device used to provide a wide base of support (BOS) for ambulation and stance.

1. It may be rigid or folding, rolling or a pickup type, and/or fixed or height adjustable.

2. The walker may have accessories to provide increased support.

B. Medicaid covers walkers for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental up to purchase amount, or purchase when indicated and must be ordered by a physician.

1. For a rigid or folding walker the following criteria must also be satisfied:

a) The beneficiary has a medical condition which causes impaired ambulation, but there is potential for the beneficiary to ambulate, and

b) There is a need for greater stability and security than can be provided by canes or crutches.

2. For a rigid pickup walker the same criteria apply, but the following specific criteria must also be met:

a) The beneficiary must be able to maintain balance while picking up the walker and moving it forward.

b) The beneficiary or caregiver must have means to transport a rigid walker.

c) Rigid walkers must provide a stable base of support:

d) For beneficiaries with impaired lower extremity weight-bearing ability such as spinal cord injury, cerebral palsy, congestive heart failure, stroke, post-operative conditions.

e) For beneficiaries with impaired balance during ambulation.

f) For ambulation training in newly braced children, adults in rehabilitation, and other diagnoses as medically necessary.

3. For wheeled walkers the same criteria applies but must meet also the following specific criteria:

a) The beneficiary must be able to maintain balance during ambulation with the rolling motion. It may be two (2) or four (4) wheeled.

b) Wheeled walkers are appropriate for beneficiaries who have difficulty using a rigid walker.

4. For folding walkers that are fixed, with or without wheels or seat, the same criteria from Rule 1.45 B. 1-3 above applies. Medicaid covers folding walkers that are push or pull types with two (2) or four (4) wheels.

5. For heavy duty walkers, multiple braking system, variable wheel resistance walkers the same criteria applies from Rule 1.45 B. 1-3 above, but must also meet the following criteria:

a) For larger or obese beneficiaries, or beneficiaries, who are unable to use a standard walker due to severe neurological disorders or restricted use of one (1) hand,

b) Beneficiaries whose gait patterns apply excessive force on the walker, and

c) Beneficiaries at risk of falling.

6. For attachments to walkers the same criteria applies from Rule 1.45 B. 1-3 above but must also meet the following:

a) When one (1) or both upper extremities are compromised due to surgical intervention, decreased range of motion, or contracture,

b) Provide a greater area of support,

c) When the beneficiary has decreased mobility and requires rest periods,

d) Seating attachments when beneficiaries who need rest periods during ambulation to conserve energy and maintain their endurance, and

e) Platform attachments for beneficiaries when one (1) or both upper extremities have decreased range of motion at the elbow, shoulder, or wrist that allows the beneficiary to grasp and hold onto the walker.

C. Medicaid covers for hand brakes when medically necessary.

History: Revised eff. 09/01/2018.

Rule 1.46: Wedge Seat Insert, Custom

A. Medicaid defines a custom wedge seat insert as an item that is made of various materials and is inserted into a seating system. It is used either for positioning or pressure reduction and has been uniquely constructed or substantially modified for a specific beneficiary.

B. Medicaid covers custom wedge seat inserts for all beneficiaries with prior authorization for purchase only, when ordered by pediatrician, orthopedist, neurosurgeon, neurologist, or a physiatrist, a physician specializing in physical rehabilitation, and has a stable seating device or a mobility device such as a buggy/stroller, stable seating device, or wheelchair to allow use of the item and is needed to:

1. Decrease posterior pelvic tilt, or

2. Assist with proper positioning for stable seating.

C. Medicaid requires that the assessment or evaluation must be performed by a physical therapist or occupational therapist not employed by the DME supplier or manufacturer.

D. If the beneficiary has an existing wheelchair custom seating system or a custom wheelchair seat that provides similar benefits, Medicaid does not cover this.

Rule 1.47: Wheelchairs

A. The Division of Medicaid defines a wheelchair as a seating system that is designed to increase the mobility of beneficiaries who would otherwise be restricted by inability to ambulate or transfer from one place to another.

B. The Division of Medicaid covers wheelchairs for all beneficiaries when ordered by the appropriate medical professional, is medically necessary and prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for rental up to purchase amount or for purchase as follows:

1. The provider must fully assess the beneficiary's needs and must ensure that the prescribed wheelchair is adequate to meet those needs, including measuring to ascertain proper height, width and weight and providing an automatic or special locking mechanism for those who are unable to apply manual brakes to prevent falls.

2. The beneficiary, family or caregiver and supplying vendor must be present for the wheelchair assessment. It is also recommended that each of these people be present at the delivery of the wheelchair.

3. At a minimum, all wheelchairs must include a seat, back, armrests (may be desk or full length, fixed or removable), leg rest (may be fixed, swing away detachable, or elevating), footplates, safety belts, anti-tipping device, wheels, and an appropriate type of wheel- locking mechanism, manual or automatic.

4. A standard wheelchair is covered when the beneficiary's condition is such that without the use of a wheelchair, he/she would be otherwise bed or chair confined.

5. An amputee wheelchair is covered if the beneficiary has had an amputation of one (1) or both lower extremities.

6. Hemi-wheelchairs are covered with appropriate documentation and medical necessity justification.

7. A tilt-in-space wheelchair is one that maintains the congruency of the seat to back angle while tilting the patient in space.

C. Standard manual wheelchairs with added accessories do not qualify as custom wheelchairs. Standard manual wheelchairs must be ordered by a physician.

1. A heavy duty standard manual wheelchair:

a) Is covered if the beneficiary meets the criteria for a standard manual wheelchair and meets one of the following criteria:

1. Weighs more than two hundred fifty (250) pounds, or

2. Body measurements do not conform to a standard manual wheelchair, or

3. Has severe spasticity.

b) Documentation must include:

1. Specific weight or measurements that cause the beneficiary to require this type chair, or

2. The specific condition causing the beneficiary to be unable to function with a standard manual wheelchair.

2. An extra heavy duty standard manual wheelchair:

a) Is covered if the beneficiary meets the criteria for a standard manual wheelchair and meets one of the following criteria:

1. Weighs more than three hundred (300) pounds, or

2. Body measurements do not conform to a standard or heavy duty wheelchair.

b) Documentation must include:

1. Specific weight and measurements causing the beneficiary to be unable to function with a standard manual or heavy duty wheelchair, and

2. Specific measurements causing the beneficiary to be unable to function with a standard manual or heavy duty wheelchair.

3. A high strength lightweight manual wheelchair is covered with appropriate documentation and medical necessity justification.

4. A lightweight manual wheelchair:

a) Is covered if a beneficiary meets all of the following criteria:

1. Meets the criteria for a standard manual wheelchair,

2. Cannot self-propel in a standard manual wheelchair using arms and/or legs, and

3. Is able to and does self-propel in a lightweight manual wheelchair.

b) Documentation must reflect the specific cause or condition that hinders the beneficiary from being able to function with a standard manual wheelchair.

5. An ultra-light manual wheelchair is covered with the appropriate documentation of medical necessity.

6. The Division of Medicaid defines a custom manual wheelchair as one uniquely constructed or substantially modified for a specific beneficiary. Custom manual wheelchairs must be ordered by a physician experienced in evaluating specialized needs for the purpose of prescribing custom manual wheelchairs after a face-to-face examination of the beneficiary.

D. Standard motorized/power wheelchairs with added accessories do not qualify as an individualized beneficiary specific custom motorized/power wheelchair. The Division of Medicaid covers standard motorized/power wheelchairs when all the following criteria are met:

1. Ordered by a physician experienced in evaluating specialized needs for the purpose of prescribing motorized/power wheelchairs after a face-to-face examination of the beneficiary.

2. Medically necessary with comprehensive documentation including, but not limited to:

a) That a manual wheelchair cannot meet the beneficiary’s needs,

b) The beneficiary requires the motorized/power wheelchair for six (6) months or longer.

c) The beneficiary must:

1. Be bed/chair confined and have documented severe abnormal upper extremity dysfunction or weakness.

2. Expect to have physical improvements or the reduction of the possibility of further physical deterioration, from the use of a motorized/power wheelchair or be for the necessary treatment of a medical condition.

3. Have a poor prognosis for being able to self-propel a functional distance in the future.

4. Not exceed the weight capacity of the motorized/power wheelchair being requested.

5. Have sufficient eye/hand perceptual capabilities to operate the prescribed motorized/power wheelchair safely.

6. Have sufficient cognitive skills to understand directions, such as left, right, front, and back, and be able to maneuver the motorized/power wheelchair in these directions independently.

7. Be independently able to move away from potentially dangerous or harmful situations when seated in the motorized/power wheelchair.

8. Demonstrate the ability to start, stop, and guide the prescribed motorized/power wheelchair within a reasonably confined area.

9. Be in an environment conducive to the use of the prescribed motorized/power wheelchair.

(a) The environment should have sufficient floor surfaces and sufficient door, hallway, and room dimensions for the prescribed motorized/power wheelchair unit to turn and enter/exit, as well as necessary ramps to enter/exit the residence.

(b) The environmental evaluation must be documented and signed by the beneficiary/caregiver and supplier for the prescribed motorized/power wheelchair.

(c) If the residential environment cannot accommodate the prescribed motorized/power wheelchair, the wheelchair is not covered.

10. Or the caregiver must be capable of maintaining the motorized/power wheelchair or be capable of having the motorized/power wheelchair repaired and maintained.

11. Have appropriate covered transportation for the prescribed motorized/power wheelchair.

3. The ordering practitioner must document:

a) The face-to-face examination in a detailed narrative note in the beneficiary’s chart and must clearly indicate that the reason for the visit was a mobility examination.

b) Whether or not the beneficiary currently possesses a motorized/power wheelchair not previously purchased by the Medicaid program.

c) And provide a certificate of medical necessity with comprehensive documentation that describes the medical reason(s) why a motorized/power wheelchair is medically necessary such that no other type of wheelchair can be utilized including, but not limited to:

1. The diagnosis/co-morbidities and conditions relating to the need for a motorized/power wheelchair.

2. Description and history of limitation/functional deficits.

3. Description of physical and cognitive abilities to utilize DME.

4. History of previous interventions/past use of mobility devices.

5. Description of existing DME, age and specifically why it is not meeting the beneficiary’s needs.

6. Explanation as to why a less costly mobility device is unable to meet the beneficiary’s needs.

7. Description of the beneficiary’s ability to safely tolerate/utilize the prescribed motorized/power wheelchair.

8. The type of chair and each individual attachment required by the beneficiary.

4. An initial evaluation documented by a physical therapist (PT) or occupational therapist (OT), not employed by the DME supplier or the manufacturer, within three (3) months of the written prescription date to determine individualized needs of the beneficiary which includes whether the beneficiary currently possesses a motorized/power wheelchair not previously purchased by the Medicaid program.

5. An agreement documented by both the prescribing physician and the PT or OT performing the initial evaluation that the motorized/power wheelchair being ordered is appropriate to meet the needs of the beneficiary.

6. A subsequent evaluation documented after the delivery of the motorized/power wheelchair by a PT or OT, not employed by the DME provider or the manufacturer, to determine if the motorized/power wheelchair is appropriate for the resident’s needs. The DME provider cannot bill the Division of Medicaid until the PT/OT documentation verifies on the subsequent evaluation that the motorized/power wheelchair is appropriate for the resident’s needs.

7. Documentation during the PT/OT initial and subsequent evaluations must include appropriate seating accommodation for beneficiary’s height and weight, specifically addressing anticipated growth and weight gain or loss.

8. The DME provider must fully assess the beneficiary’s needs and ensure that the motorized/power wheelchair is adequate to meet those needs.

E. The Division of Medicaid defines an individualized, beneficiary specific custom motorized/power wheelchair as one that has been uniquely constructed or substantially modified for a specific beneficiary. Individualized, beneficiary specific custom motorized/power wheelchairs must meet the following criteria:

1. Be ordered by a pediatrician, orthopedist, neurosurgeon, neurologist, or a physiatrist.

2. Meet all the requirements in Miss. Admin. Code Part 209, Rule 1.47.D.2– 8.

3. Coverage for a customized electronic interphase device, specialty and/or alternative controls require documentation of an extensive evaluation of each customized feature required for physical status and specification of medical benefit of each customized feature to establish that the beneficiary is unable to manage a motorized/power wheelchair without the assistance of said device.

a) For a joystick, hand or foot operated, device the beneficiary must demonstrate safe operation of the motorized/power wheelchair with extremity using a joystick. The beneficiary can manipulate the joystick with fingers, hand, arm, or foot.

b) For a chin control device, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the chin control device. The beneficiary must have a medical condition which prevents the use of their hands/arms but is able to move their chin and safely operate the chair in all circumstances.

c) For a head control device, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the head control device. The beneficiary must have a medical condition which prevents the use of their hands/arms but is able to move their head freely with control of their head and can safely operate the chair in all circumstances.

4. For an extremity control device, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the extremity control device. The beneficiary must have a medical condition which prevents or limits fine motor skills during the use of their extremities but is able to move their hands/arms/legs to safely operate the chair in all circumstances.

5. For a sip and puff feature, the beneficiary must demonstrate safe operation of the motorized/power wheelchair with manipulation of the sip and puff control. The beneficiary cannot move their body at all and cannot operate any other driver except this one.

F. Standard and custom motorized/power wheelchairs are limited to one (1) per beneficiary every five (5) years based on medical necessity. Reimbursement:

1. Is made only for one (1) wheelchair at a time.

2. Includes all labor charges involved in the assembly of the wheelchair,

3. Includes all covered additions, accessories and modifications which providers must bill:

a) An appropriate procedure or service HCPCS code when available in unbundled HCPCS codes, and/or

b) A bundled HCPCS code for unlisted, custom or miscellaneous DME where there is no

listed code or combination of HCPCS codes that adequately describes the item provided.

4. Includes support services such as emergency services, delivery, setup, education and ongoing assistance with use of the wheelchair.

5. Is made only after the PT or OT subsequent evaluation is completed.

G. Standard and custom motorized/power wheelchairs are not covered if the use of the standard and custom motorized/power wheelchair primarily benefits the beneficiary in their pursuit of leisure or recreational activities. Motorized/power wheelchairs are not covered for the convenience of the caregiver, ambulatory beneficiaries and non-compliant beneficiaries.

H. The Division of Medicaid does not cover home, environment, and vehicle adaptations, equipment and modifications for motorized/power wheelchair accessibility.

I. The DME provider providing standard and/or custom motorized/power wheelchairs to beneficiaries must have at least one (1) employee with Assistive Technology Professional (ATP) certification from Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) who specializes in wheelchairs and who must be registered with the National Registry of Rehab Technology Suppliers (NRRTS).

1. The NRRTS and RESNA certified personnel must have direct, in-person, face-to-face interaction and involvement in the motorized/power wheelchair selection for the beneficiary.

2. RESNA certifications must be updated every two (2) years.

3. NRRTS certifications must be updated annually.

4. If the certifications are found not to be current, the prior authorization request for the motorized/power wheelchair will be denied.

J. DME providers must provide a two (2) year warranty of the major components for custom motorized/power wheelchairs. [Refer to Part 209, Chapter 1, Rule 1.4.]

1. If the DME provider supplies a custom motorized/power wheelchair that is not covered under a warranty, the DME provider is responsible for any repairs, replacement or maintenance that may be required within two (2) years.

2. The warranty begins the date of delivery to the beneficiary.

3. A powered mobility base must have a lifetime warranty on the frame against defects in material and workmanship for the lifetime of the beneficiary.

4. The main electronic controller, motors, gear boxes, and remote joystick must have a two (2) year warranty from the date of delivery.

5. Cushions and seating systems must have a two (2) year warranty or full replacement for manufacturer defects or if the surface does not remain intact due to normal wear.

K. DME suppliers providing custom manual and/or motorized/power wheelchairs, customized electronic interphase devices, specialty and/or alternative controls for wheelchairs, extensive modifications and seating and positioning systems must have a designated repair and service department, with a technician available during normal business hours, between eight (8:00) a.m. and five (5:00) p.m. Monday through Friday. Each technician must keep on file records of attending continuing education courses or seminars to establish, maintain and upgrade their knowledge base.

L. The Division of Medicaid covers repairs, including labor and delivery, of DME that is owned by the beneficiary not to exceed fifty percent (50%) of the maximum allowable reimbursement for the cost of replacement.

1. Major repairs and/or replacement of parts require prior authorization from the UM/QIO and must include an estimated cost of the necessary repairs, including labor, and a documentation from the practitioner there is a continued need for the custom manual and/or motorized/power wheelchair.

2. An explanation of time involved for repairs and/or replacement of parts must be submitted to the UM/QIO.

3. Manufacturer time guides must be followed for repairs and/or replacement of parts.

4. The Division of Medicaid defines repair time as point of service and does not include travel time to point of service.

5. No payment is made for repairs or replacement if it is determined that intentional abuse, or misuse, of the wheelchair or components has occurred, which includes damage incurred due to inappropriate covered transportation for the prescribed motorized/power wheelchair.

6. Reimbursement will be made for up to one (1) month for a rental of a wheelchair while the beneficiary’s wheelchair is being repaired.

M. The Division of Medicaid covers a travel wheelchair when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity and when the following criteria are met:

1. The travel wheelchair is not intended for extended daily use, or as a substitute or long- term replacement for other types of wheelchairs,

2. The beneficiary does not exceed the weight capacity of the travel wheelchair, and

3. The travel wheelchair is for the exclusive use of the beneficiary.

History: Revised eff. 07/01/2021; Revised eff. 10/01/2020. Revised eff. 09/01/2018. Revised eff. 01/02/2015. Revised eff. 01/01/2013.

Rule 1.48: Wheelchair Accessories

A. Medicaid covers manual and motorized/power wheelchair accessories and options for all beneficiaries when ordered by a physician is medically necessary and prior authorized and for purchase only as follows:

1. Medical necessity is met and adequate documentation of the beneficiary's condition and needs are provided.

2. The beneficiary must already have a wheelchair that meets coverage criteria and the beneficiary's condition must be such that, without the use of a wheelchair, he/she would otherwise be bed or chair confined.

3. The amputee adapter, pair, is covered for a beneficiary with an amputation of one (1) or both lower extremities. This device mounted on the wheelchair to bring the center of gravity forward on the chair to prevent tipping over.

4. A detachable armrest is covered to allow the beneficiary to perform side transfers independently or with assistance.

5. A swing away armrest is covered to allow the beneficiary to perform side transfers independently or with assistance.

6. A mobile arm support is covered for a beneficiary to assist with ADL's or to provide support to position and/or increase function to a weak or diseased upper extremity.

7. An arm trough is covered to support beneficiaries with spasticity or decreased strength or tone in an upper extremity.

8. The anti-roll back device is covered when the beneficiary has little or no assistance and meets the criteria for a manual chair.

9. A fully reclining back is covered when one (1) of the following applies:

a) The beneficiary is quadriplegic.

b) The beneficiary has a fixed hip angle that prevents sitting at a ninety-degree angle.

c) The beneficiary has trunk or lower extremity casting/bracing that requires the reclining back for positioning.

d) The beneficiary needs to rest in a recumbent position two (2) or more times during the day and transfer between bed and chair is difficult.

10. Reinforced back and seat upholstery is covered when one (1) of the following applies:

a) The beneficiary is morbidly obese and requires a more stable base.

b) The beneficiary requires the extra reinforcement due to excessive movement disorders.

11. A solid back insert, planar back, single density foam, attached with straps is covered when one (1) of the following applies:

a) The beneficiary is using a sling seating system when the back is slung and requires increased support.

b) The beneficiary requires allowance for growth in a sling system up to one and one half inches (1½”) in growing room to the thigh area. The removable back is used until the beneficiary grows and then it is removed to allow for additional growth. This allows the therapist to order a standard wheelchair with growth potential for the beneficiary.

12. A calf pad is covered if the criteria for elevating leg rests are met.

13. A cylinder tank carrier is covered for beneficiaries with constant or intermittent oxygen needs.

14. High mount, flip up footrests are covered when the beneficiary has a lower leg, knee to foot, measurement that prevents them from using the manufactured mounting.

15. A footrest, lower extension tubes, each is covered when one (1) of the following applies:

a) The beneficiary is growing and will need the adjustability of lowering the footrests for growth.

b) The beneficiary has a leg length difference and needs the footrest to be mounted at different heights.

16. Footplate, adjustable angle, is covered when one (1) of the following applies:

a) The beneficiary has a fixed dorsiflexion or plantar flexion contracture.

b) The beneficiary has the tendency to develop pressure problems on the plantar surface of the foot.

17. Heel loops, are covered when one (1) of the following applies:

a) The beneficiary is seated in a tilt-in-space wheelchair.

b) The beneficiary has poor lower extremity muscular function and needs the support of the heel loop to keep the foot in place on the footrest.

c) The beneficiary needs the added support of a heel loop to assist in positioning of the lower extremities. This would be used for mild positioning only.

d) The heel loop with ankle strap is covered when one (1) of the following applies:

1. The beneficiary cannot control the movement of his/her lower extremities to position the foot and ankle.

2. The beneficiary is seated in a tilt-in-space wheelchair.

3. The beneficiary cannot maintain adequate positioning of the foot and ankle without an ankle strap.

4. The beneficiary has large feet or moves his/her feet excessively.

18. A hook on headrest extension, used to provide support for the head and neck, is covered if one (1) of the following applies:

a) The beneficiary has decreased to poor head/neck control and is seated in a sling seating system.

b) The beneficiary requires the use of a headrest for safety during transportation.

c) The beneficiary has frequent seizures and the headrest is used for support during or after the seizure.

d) The beneficiary has a reclining back wheelchair and requires support for the head and neck.

19. An IV hanger is covered for those beneficiaries who require continuous/intermittent IV's or tube feedings.

20. A leg strap is covered when one (1) of the following applies:

a) The beneficiary is seated in a tilt-in-space wheelchair and the strap is needed to prevent the lower extremity(ies) from falling backwards into the wheelchair.

b) The beneficiary has increased or excessive extensor tone in the lower extremities and the strap is needed in front of the lower extremities to prevent them from extending forward.

c) The beneficiary has muscle spasms of the lower extremities and requires the strap to help keep the feet positioned on the footplates.

21. The leg strap, H style, is covered if one (1) of the following applies:

a) The beneficiary requires the added reinforcement not supplied by the single leg strap.

b) The beneficiary has movement disorders and requires the added reinforcement of the H strap configuration.

22. Low pressure and positioning equalization pads, including one inch (1") to four inch (4") cushions for wheelchairs, are covered when one (1) or more of the following applies:

a) The beneficiary has a history of pressure sores or decubitus ulcers.

b) The beneficiary has a pelvic obliquity.

c) The beneficiary is very thin and is subject to pressure problems secondary to decreased adipose tissue at the bony prominences.

d) The beneficiary cannot move his/her trunk and/or lower extremities due to a spinal cord injury whether from birth or through an accident.

e) The beneficiary has decreased or no sensation in the trunk and/or lower extremities.

23. A one (1) arm drive attachment is covered when both of the following apply:

a) The beneficiary has functional use of only one (1) upper extremity.

b) There is sufficient cognition, dexterity and endurance to use this item.

24. Shoe holders are covered when the beneficiary requires the added support of a hard surface to position the foot.

25. The safety belt/pelvic strap that is in addition to the standard safety belt is covered when medically necessary to help maintain a neutral position of the pelvis when seated in the wheelchair or for those beneficiaries with an increased extensor tone.

26. The toe loop is covered when the beneficiary requires the cover of the forefoot to keep the foot positioned on the footplate.

27. A wheelchair tray is covered when medically necessary to assist with positioning of the trunk and upper extremities.

28. The wheel lock extension pair is covered when one (1) of the following applies:

a) The beneficiary does not have functional use of one (1) upper extremity. This allows the beneficiary to reach and lock both wheels independently without falling from the wheelchair.

b) The beneficiary has decreased strength and needs the extra height of the locks to achieve a greater lever arm for independent use of the wheel locks.

B. Non-covered accessories:

1. The following items are included in the base rate of the wheelchair for all beneficiaries and are not reimbursed separately:

a) Arms of the wheelchair,

b) Footrests, also known as footplates,

c) Large size footplates on a heavy duty wheelchair for beneficiaries who meet the criteria for that type chair,

d) Leg rests,

e) Elevating leg rests,

f) Standard safety belts,

g) The manual wheel lock assembly,

h) The automatic wheel lock assembly, a device fitted to the wheelchair which automatically locks the wheels when fifty percent (50%) or more of the beneficiary's body weight shifts forward. When one (1) of the following criteria exists, these locks are considered an essential part of the wheelchair and are included in the base rate of the wheelchair.

1. The beneficiary has significant upper extremity disability or weakness and he/she cannot operate manual locks.

2. The beneficiary does not have the cognitive awareness to consistently use manual locks.

2. Crutch and cane holders mounted to the back post of the wheelchair used to transport the cane or crutch of the beneficiary while in the wheelchair are considered not medically necessary and are not covered.

C. Any other accessory medically necessary is considered for coverage on an individual basis with appropriate documentation.

History: Revised eff. 10/01/2020; Revised eff. 09/01/2018; Revised – 01/01/2013.

Rule 1.49: Wheelchairs, Drivers and Seating, Custom

Refer to Part 209, Chapter 1, Rule 1.47 Wheelchairs

History: Revised – 01/01/2013

Rule 1.50: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Rule 1.51: Humidifier/Vaporizer

A. Medicaid defines a humidifier, heated or non-heated, as a device used to increase the moisture content of the air.

B. Medicaid covers humidifiers for all beneficiaries when ordered by a physician, medically necessary and prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for rental up to the purchase amount or for purchase.

C. Room Humidifiers and Vaporizers

1. Medicaid defines a room humidifier as a mechanical device used to increase the moisture content of the air in a room with a cool mist. Medicaid defines a steam vaporizer as a mechanical device that creates moisture in the air by heating the water into a hot mist. Medicaid defines a warm mist humidifier as a type of steam vaporizer that cools the moist steam before it is released into the room.

2. Room humidifiers and vaporizers are covered for beneficiaries who have a chronic diagnosis(es) indicating a respiratory condition in which ease of breathing could be facilitated by increasing the moisture content of the air. The diagnosis may include, but are not limited to:

a) Chronic bronchitis,

b) Asthmatic bronchitis,

c) Chronic Asthma,

d) Bronchopulmonary dysplasia, or

e) Chronic airway obstruction.

3. Documentation must be provided that the patient or caregiver is able to use and care for the equipment.

4. Humidifiers are not covered for acute upper respiratory infections, a chronic cough or colds unrelated to another diagnosis.

D. Medicaid defines a heat and moisture exchanger (HME), or an artificial nose, as a passive acting humidifier that collects expired heat and moisture and returns it during the following inspiration. The HME is covered when the beneficiary has:

1. An existing tracheostomy, and

2. Documentation that supplemental, direct humidification is required for the beneficiary’s tracheostomy.

E. High-Flow or Water Reservoir Humidifiers

1. High-Flow, water reservoir, heated or non-heated humidifiers include, but are not limited to pass-over, wick, and bubble types. High-flow and water reservoir humidifiers are used to provide supplemental heat and humidity and are covered as follows:

a) The use of high-flow, water reservoir humidifiers to increase moisture to the airway of a beneficiary with a tracheostomy is covered when the beneficiary has an existing tracheostomy and documentation is present that the beneficiary requires supplemental, direct humidification to the tracheostomy.

b) A high-flow, water reservoir humidifier is covered for C-PAP and Bi-PAP devices if criteria for coverage of the C-PAP or BI-PAP device are satisfied and documentation is present that the beneficiary requires supplemental humidification.

c) A high-flow, water reservoir humidifier is covered in conjunction with ventilators if criteria for coverage of the ventilator are satisfied and documentation is present that the beneficiary requires supplemental humidification.

2. Humidifiers are included in the rental or purchase price of that equipment when used in

conjunction with oxygen or IPPB treatments.

History: Revised eff. 09/01/2018. 01/01/2013.

Rule 1.52: Pressure Reducing Support Surface

A. Medicaid defines pressure reducing support surfaces as surfaces designed for beneficiaries with limited or no mobility who are bed confined most or all of the day and prone to developing pressure ulcers.

B. Medicaid covers pressure reducing support surfaces for all eligible beneficiaries when ordered by a physician, medically necessary and prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity for rental up to purchase amount or purchase.

C. Beneficiaries requiring pressure reducing support surfaces must have a care plan, established by the beneficiary's physician or home care nurse, documented in the beneficiary's medical record, which includes all of the following:

1. Education of the beneficiary and caregiver on the prevention and/or management of pressure ulcers.

2. Regular assessment by a nurse, physician, or other licensed health care practitioner.

3. Appropriate turning and positioning.

4. Appropriate wound care for a stage II, III or IV ulcer.

5. Appropriate management of moisture/incontinence.

6. Nutritional assessment and intervention consistent with the overall plan of care.

D. Medicaid defines a pressure pad for a mattress as a non-powered pressure reducing mattress overlay designed to be placed on top of a standard hospital or home mattress which includes a gel mattress overlay, an air mattress overlay, a water mattress overlay and a foam mattress overlay with a waterproof cover.

1. Medicaid covers a pressure pad when one (1) or more of the following apply:

a) The beneficiary is completely immobile and cannot make changes in body position without assistance.

b) The beneficiary has limited mobility and cannot independently make changes in body position significant enough to alleviate pressure.

c) The beneficiary has any stage of a pressure ulcer on the trunk or pelvis.

d) The beneficiary is essentially bedbound with an impaired nutritional status, fecal or urinary incontinence, altered sensory perception, or compromised circulatory status.

2. A replacement pad for use with a medically necessary power alternating pressure device owned by the beneficiary is covered if the beneficiary meets one (1) or more of the criteria in Rule 1.52, D.1.a-d.

3. A foam overlay or mattress, such as an egg crate without a waterproof cover, is not considered durable and is not covered under the DME program.

E. Powered Pressure Reducing Overlays and Mattresses

1. Medicaid defines a powered pressure reducing overlay as a low air loss, powered flotation device without low air loss, or alternating pressure with an air pump or blower providing either sequential inflation or deflation of the air cells or a low interface pressure throughout the overlay designed to reduce friction and shear and are to be placed on top of a standard hospital or home mattress.

2. Medicaid defines a powered pressure reducing mattress as a mattress with alternating pressure, low air loss, or powered flotation without low air loss. An air pump or blower provides both sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress. The surface is designed to reduce friction and shear and can be placed directly on a hospital bed frame.

3. Powered pressure reducing overlays and mattresses are covered when one (1) or more of the following applies:

a) The beneficiary has multiple stage II pressure ulcers, defined as partial thickness skin loss involving epidermis and/or dermis, on the truck or pelvis.

b) The beneficiary has been on a comprehensive ulcer treatment program and the ulcers have worsened or remained the same for one (1) month.

c) Large or multiple stage III pressure ulcers, defined as full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, or stage IV pressure ulcers, defined as full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, on the trunk or pelvis.

d) Myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the previous sixty (60) days.

History: Revised eff. 09/01/2018. 01/01/2013.

History

• Source: 42 U.S.C § 1395m; Miss. Code Ann. §§ 43-13-121; 43-13-117(7).
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-121; 43-13-117(17).
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. §§ 1395m, 1396d; 42 CFR §§ 440.60, 440.166, 440.210, 440.220; PHSA § 2713; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-117(7) and (17), 43-13-121.
• Source: 42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: Miss. Code Ann. § 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 USC §§ 1395m, 1395x; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. §§1395m, 1395x(n); Miss. Code Ann. §§ 43-13-117, 43-13-121, 83-9-353.
• Source: U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. § 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17); 43-13-121.
• Source: Miss. Code Ann. § 43-13-121; 43-13-117(17); Social Security Act § 1834
• Source: 42 U.S.C. § 1395m; 42 C.F.R. § 440.70; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: Miss. Code Ann. § 43-13-121; 43-13-117(17); Social Security Act § 1834
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.
• Source: Miss. Code Ann. § 43-13-121; 43-13-117(17); Social Security Act § 1834
• Source: 42 U.S.C. § 1395(m); Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 U.S.C. § 1395m; Miss. Code Ann. § 43-13-117(17), 43-13-121.
• Source: Miss. Code Ann. § 43-13-121
• Source: Miss. Code Ann. § 43-13-121.
• Source: Miss. Code Ann. § 43-13-121.

Part 210 Ambulatory Surgical Centers

23 Miss. Admin. Code Pt. 210 Ambulatory Surgical Centers

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 210 Ambulatory Surgical Centers

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 210: Ambulatory Surgical Centers ...................................................................................... 1 Part 210 Chapter 1: General ................................................................................................... 1 Rule 1.1: General............................................................................................................. 1 Rule 1.2: Definitions ....................................................................................................... 1 Rule 1.3: Provider Enrollment Requirements ................ Error! Bookmark not defined. Rule 1.4: Covered Services ............................................................................................. 2 Rule 1.5: Non-Covered Procedures ................................................................................. 3 Rule 1.6: Reimbursement ................................................................................................ 3 Rule 1.7: Documentation Requirements ........................ Error! Bookmark not defined. Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ................ 4

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Title 23: Division of Medicaid

Part 210: Ambulatory Surgical Centers

Part 210 Chapter 1: General

Rule 1.1: General

A. Medicaid considers an Ambulatory Surgical Center (ASC) a publicly, or privately, owned institution not considered a part of a hospital, in accordance with its function.

B. Ambulatory surgical centers must be operated by its own organized medical and administrative staff primarily for the purpose of providing elective surgical treatment for “outpatients” whose recovery under normal and routine circumstances will not require “inpatient” care.

C. The facility cannot include the offices of private physicians or dentists, whether practicing individually or in groups, but does include facilities engaged in such outpatient surgery, whether using the name “ambulatory surgical” facility or a similar or different name.

D. A facility considered to be operated by a hospital or hospital holding, leasing, or management company, whether for-profit or non-profit, must be a separate, identifiable entity which is physically, administratively and financially independent and distinct from other operations of any hospital.

E. Once licensed and certified as such, the “facility” will not be allowed to revert to the position as a component part of any hospital without securing a Certificate of Need to do so.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 416

Rule 1.2: Definitions

A. Add-on codes are defined as procedures performed in addition to the primary service/procedure and are never reported as a stand-alone code. Add-on codes describe additional intra-service work associated with the primary procedure.

B. Ambulatory surgery is defined as surgical procedure(s) that are more complex than office procedures, under local anesthesia, but less complex than procedures requiring prolonged postoperative monitoring and hospital care to ensure safe recovery and desirable results.

C. Bilateral procedures are defined as exact procedures identified by the same procedure codes which are performed on anatomically bilateral sides of the body during the same operative session.

D. Endoscopic procedure is defined as the performance of a procedure on interior organs and cavities of the body through an endoscope. An endoscope is a flexible fiber optic instrument used to visual the interior of a body cavity or organ.

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E. Incidental procedure is a procedure carried out at the same time as a primary procedure, but is clinically integral to the performance of the primary procedure or requires little additional physician resources.

F. Multiple surgeries are defined as separate procedures performed by the same physician on the same patient at the same operative setting.

G. Mutually exclusive procedures are defined as separate billing for two (2) or more procedures that are usually not performed for the same patient on the same date of service.

H. Unbundled procedures are defined as the use of two (2) or more procedure codes to describe a procedure or event when a single procedure code exists that comprehensively describes the surgery performed.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 416

Rule 1.3: Provider Enrollment Requirements

Ambulatory surgical centers must meet all of the applicable requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4.

Source: Miss. Code Ann. § 43-13-121; 43-13-117; 43-13-118; 43-13-129; 42 CFR § 416

History: Revised eff. 08/01/2026.

Rule 1.4: Covered Services

A. The Ambulatory Surgical Center (ASC) must have procedures for obtaining routine and emergency laboratory and radiology services from Medicare-approved facilities. The ASC, when contracting for those lab, x-ray and hospital services which directly relate to the surgical procedure, must be billed by the provider performing these services.

B. ASC services must be Medicare-approved items and services furnished by an ASC in connection with a covered surgical procedure furnished to a Medicaid beneficiary.

C. ASC services do not include items and services for which payment may be made under other provisions including, but not limited to, physician services, lab, x-ray or diagnostic procedures, other than those directly related to performance of the surgical procedure.

D. The ASC payment rate includes all the costs incurred by the ASC in providing services in connection with performing a specific procedure including, but not limited to, surgical supplies, equipment, and nursing services.

E. The Division of Medicaid covers the cost of corneal tissue used in corneal transplant cases. The reimbursement will be one hundred percent (100%) of the cost reflected on the invoice

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from the donor supplier excluding transportation fees. Transportation fees are not covered under the Medicaid program. This rule is applicable only to an ASC.

F. The Division of Medicaid covers medically necessary dental treatment in the ASC setting when all the following are met:

1. Quality, safe, and effective treatment cannot be provided in an office setting,

2. Inpatient hospitalization is not medically necessary [Refer to Miss. Admin. Code Part 204, Rule 1.11.B.], and

3. Certain dental procedures have been prior authorized by the Division of Medicaid or designee.

Source: 42 C.F.R. Part 416; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 10/01/2019.

Rule 1.5: Non-Covered Procedures

Non-covered services and procedures as outlined in Part 200, Chapter 2, Rule 2.2 performed in an Ambulatory Surgical Center are subject to Medicaid rules for reimbursement.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 416

Rule 1.6: Reimbursement

A. Mississippi Medicaid Ambulatory Surgical Care (ASC) rates are updated October 1 of each year based on eighty percent (80%) of the Medicare ASC Payment System rate in effect July 1 of that year set by the Center for Medicare and Medicaid Services (CMS).

B. Reimbursement is in accordance with the Medicaid ASC Procedure Schedule or the provider’s usual and customary charges, whichever is less.

C. The Division of Medicaid reimburses for multiple procedures as outlined in Miss. Admin. Code Part 203, Chapter 4.

D. Surgical or other procedures canceled due to scheduling conflicts of the operating suite or physician, beneficiary request, or other reason not related to medical necessity, cannot be billed and no payment will be made for the procedure. Services provided prior to the procedure may be billed and are subject to coverage rules for those services.

E. For surgical or other procedures canceled or terminated before completion due to changes in the beneficiary’s medical condition that threaten his/her well-being, only the services that were actually performed may be billed are subject to coverage rules for those services. Clear

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documentation regarding the medical necessity for cancellation or termination of the procedure must be provided.

F. ASC providers must bill the procedure code that accurately reflects the dental services rendered as follows:

1. Dental procedures performed by a Mississippi licensed dentist must be billed with a Code on Dental Procedures and Nomenclature (CDT).

2. Dental procedures performed by a Mississippi licensed dentist who is also a Mississippi licensed physician can bill either a CDT code or a Current Procedural Terminology (CPT) code.

Source: 42 C.F.R. Part 416; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with MS SPA 22-0026 (eff. 10/01/2022) effective 01/01/2023; Revised eff. 07/01/2021; Revised eff. 10/01/2019.

Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Source: Miss. Code Ann. § 43-13-121

Part 211 Federally Qualified Health Centers

23 Miss. Admin. Code Pt. 211 Federally Qualified Health Centers

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Administrative Code

Title 23: Medicaid Part 211 Federally Qualified Health Centers (FQHC)

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Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 211: Federally Qualified Health Centers ............................................................................. 1 Part 211 Chapter 1: General ................................................................................................... 1 Rule 1.1: Provider Enrollment/Requirements .................................................................. 1 Rule 1.2: Service Limits ................................................................................................... 2 Rule 1.3: Covered Services .............................................................................................. 2 Rule 1.4: Pregnancy-Related Eligibles............................................................................. 3 Rule 1.5: Reimbursement Methodology .......................................................................... 4 Rule 1.6: Documentation Requirements .......................................................................... 8 Rule 1.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ................ 9

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Title 23: Division of Medicaid

Part 211: Federally Qualified Health Centers

Part 211 Chapter 1: General

Rule 1.1: Definitions

The Division of Medicaid defines:

A. A Federally Qualified Health Center (FQHC) encounter as a face-to-face visit for the provision of services provided by physicians, physician assistants, nurse practitioners, nurse midwives, dentists, optometrists, clinical psychologists, Licensed Clinical Social Workers (LCSWs), Licensed Professional Counselors (LPCs), Licensed Marriage and Family Therapists (LMFTs), and Board Certified Behavioral Analysts (BCBAs).

B. An encounter rate as a prospective payment system (PPS) rate per encounter.

C. Clinician Administered Drugs and Implantable Drug System Devices (CADD) as certain physician-administered drugs, with limited distribution or limited access for beneficiaries and administered in an appropriate clinical setting, which may be reimbursed under the pharmacy benefit to the extent the CADDs were not included in the calculation of the FQHC’s PPS rate, as determined by the Division of Medicaid.

D. Change in the scope of service as a change in the type, intensity, duration and/or amount of services.

1. A change in the scope of services occurs if:

a) The FQHC has added or has dropped any services that meet the definition of an FQHC service as provided in federal regulations.

b) The service is included as a covered Medicaid service under the Mississippi Medicaid State Plan.

c) A change in the intensity is a change in the amount of health care services provided by the FQHC during an average encounter.

2. A change in the scope of service does not mean:

a) The addition or reduction of staff members to or from an existing service.

b) An increase or decrease in the number of encounters.

c) A change in the cost of a service is not considered in and of itself a change in the scope of service.

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E. Allowable costs as costs that:

1. Result from providing covered services,

2. Are reasonable in amount and are necessary for the efficient delivery of those services,

3. Include the direct cost center component (i.e., salaries and supplies) of providing the covered services, and

4. Are an allocated portion of overhead (i.e., administration and facility).

F. Co-mingling as the simultaneous operation of an FQHC and another physician practice where the two (2) practices share:

1. Hours of operation,

2. Use of the space,

3. Professional staff,

4. Equipment,

5. Supplies, and

6. Other resources.

Source: 42 C.F.R. § 440.230; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 18-0013, SPA 2013-033.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0012 (eff. 07/01/2018) eff. 06/01/2019. Revised eff. 06/01/2015. Revised eff. 07/01/2014.

Rule 1.2: Provider Requirements

A. To participate as a Federally Qualified Health Center (FQHC) in the Medicaid program, an organization must be approved by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) as an FQHC.

B. FQHC providers must comply with the requirements set forth in Miss. Admin. Code Part 200, Rule 4.8 for all providers in addition to the specific provider type requirements outlined below:

1. National Provider Identifier (NPI), verification from the National Plan and Provider Enumeration System (NPPES),

2. A copy of the interim rate notice or current rate letter from CMS,

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3. Copy of the nurse practitioner’s protocol and license to practice. If the nurse practitioner is not enrolled with the Division of Medicaid as a provider, the nurse practitioner must complete a provider application and obtain an individual provider number, and

4. Clinical Laboratory Improvement Amendments (CLIA) Information form and current CLIA certificate, if applicable.

C. The Division of Medicaid does not allow co-mingling.

D. Physicians and non-physician practitioners cannot operate a private Medicare or Medicaid practice during FQHC hours of operation using the FQHC’s resources.

E. The effective date of the Medicaid provider agreement will be the applicable date described in Miss Admin Code Title 23, Part 200, Rule 4.4.

F. The Division of Medicaid does not enroll out-of-state providers to provide FQHC services, except as described in Miss. Admin. Code Part 200, Rule 4.2 B.

G. FQHC mobile units must be surveyed by the Mississippi Department of Health (MSDH) and receive an approval letter from the Centers for Medicare and Medicaid Services (CMS) prior to providing services.

1. All federal and state requirements for FQHC mobile units must be met.

2. The mobile unit must have a fixed set of locations where the unit is scheduled to be providing services at specified dates and times.

a) Locations for FQHC mobile unit services must meet the rural and shortage area requirements at the time of survey.

b) The schedule of times and locations must be posted on the mobile unit and publicized by other means so that beneficiaries will know the mobile unit's schedule in advance.

3. NPs must remain within a seventy-five (75) mile distance from the primary physician.

Source: 42 C.F.R. Part 491; 42 C.F.R. § 440.230; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 2018-0012, SPA 2013-032.

History: Revised eff. 10/01/2025. Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0012 (eff. 07/01/2018) eff. 06/01/2019. Revised to correspond with SPA 2013-032 (eff. 11/01/2013) eff. 06/01/2015.

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Rule 1.3: Covered Services

A. The Division of Medicaid limits reimbursement to a Federally Qualified Health Center (FQHC) to no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different type of visit, as the Division of Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the following visit:

1. Medical,

2. Mental health,

3. Dental, or

4. Vision.

B. Visits with more than one (1) health professional and multiple visits with the same health professional that take place on the same day at a single location constitute a single encounter, except when the beneficiary:

1. Suffers an illness or injury subsequent to the first visit that requires additional diagnosis or treatment on the same day, or

2. Has multiple visit types on the same day.

C. An FQHC’s PPS rate covers the beneficiary’s visit to the FQHC, which is inclusive of all services and supplies and drugs and biologicals which are not usually self-administered by the beneficiary, furnished as an incident to a professional service.

1. The FQHC cannot refer the beneficiary to another provider that will bill the Division of Medicaid for the covered service, supply, drug or biological which is included in the FQHC’s encounter.

2. Drugs are included in the PPS rate, if purchased at a discounted price through a discount agreement except for Clinician Administered Drugs and Implantable Drug System Devices (CADD).

D. The Division of Medicaid covers CADD drugs separately from an FQHC encounter.

1. CADD drugs are listed on the Division of Medicaid’s website.

2. CADD drugs do not count toward monthly prescription drug limits applicable to covered outpatient drugs.

E. The Division of Medicaid covers ambulatory services performed by an FQHC employee or contractual worker for an FQHC beneficiary at the following sites:

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1. The FQHC, or

2. Beneficiary’s residence.

F. The Division of Medicaid covers an outside laboratory for lab services separate from the encounter rate.

G. The Division of Medicaid covers the delivery of FQHC services in a school-based clinic operated by an FQHC and staffed with a physician, nurse practitioner and/or physician assistant.

H. FQHC mobile units are covered services when the requirements of Miss. Admin. Code Title 23, Part 212, Rule 1.2 are met.

I. Diabetes Self-Management Training (DSMT) is a covered service that is included in the PPS rate for a core service for an FQHC but an encounter is not covered solely for DSMT.

J. Vaccine administration is a covered service that is included in the PPS rate for a core service for an FQHC but is not considered a core service.

Source: 42 C.F.R. Part 491; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 2018-0012.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0012 (eff.07/01/2018) eff. 06/01/2019. Revised eff. 06/01/2015.

Rule 1.4: Non-Covered Services

A. The Division of Medicaid does not reimburse an FQHC for services when performed in an inpatient or outpatient hospital setting. If a physician is employed by an FQHC and provides services in a hospital setting, the FQHC is prohibited from billing for these services. The physician must bill under the physician’s individual Medicaid provider number or group physician Medicaid provider number.

B. The Division of Medicaid does not consider the following as an encounter:

1. Vaccine administration, and/or

2. Diabetes Self-Management Training (DSMT).

Source: 42 C.F.R. Part 491; 42 C.F.R. § 435.116; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 2013-0019. History: Revised eff. 07/01/2021; Revised to correspond with SPA 13-0019 (eff. 01/01/2014) eff. 06/01/2015.

Rule 1.5: Reimbursement

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The Division of Medicaid reimburses Federally Qualified Health Center (FQHC) providers at a prospective payment system (PPS) rate per encounter and/or an alternative payment methodology (APM).

A. The Division of Medicaid uses the PPS methodology for reimbursement to FQHC providers per encounter as described below:

1. For services provided on and after January 1, 2001, during calendar year 2001, payment for services shall be calculated, on a per visit basis, in an amount equal to one hundred percent (100%) of the average of the FQHC’s reasonable costs of providing Medicaid covered services during fiscal years 1999 and 2000. The average rate will be computed from the FQHC Medicaid cost reports by applying a forty percent (40%) weight to fiscal year 1999 and a sixty percent (60%) weight to fiscal year 2000 and adding those rates together. If an FQHC first qualifies during fiscal year 2000, the rate will only be computed from the fiscal year 2000 Medicaid cost report. The PPS baseline calculation shall include the cost of all Medicaid covered services including other ambulatory services that were previously paid under a fee-for-service basis. This rate will be adjusted to take into account any increase or decrease in the scope of services furnished by the FQHC during fiscal year

3. Payment rates may be adjusted by the Division of Medicaid pursuant to changes in federal and/or state laws or regulations.

4. Beginning in calendar year 2002, and for each calendar year thereafter, the FQHC is entitled to the payment amount, on a per visit basis, to which the FQHC was entitled to in the previous year, increased by the percentage increase in the Medicare Economic Index (MEI) for primary care services for that calendar year, and adjusted to take into account any increase or decrease in the scope of services furnished by the FQHC during that calendar year. The rate will be retroactively adjusted to reflect the MEI.

5. New centers that qualify for the FQHC program after January 1, 2001, will be reimbursed the initial PPS rate which will be based on the rates established for other FQHCs located in the same or adjacent area with a similar caseload. In the absence of a comparable FQHC, the rate for the new provider will be based on projected costs. After the FQHC’s initial year, a Medicaid cost report must be filed in accordance with the State Plan. The cost report will be desk reviewed and a rate will be calculated in an amount equal to one hundred percent (100%) of the FQHC’s reasonable costs of providing Medicaid covered services. The FQHC may be subject to a retroactive adjustment based on the difference between projected and actual allowable costs. Claims payments will be adjusted retroactive to the effective date of the original rate. For each subsequent calendar year, the payment rate will be equal to the rate established in the preceding calendar year, increased by the percentage increase in the MEI for primary care services that is published in the Federal Register in the fourth (4 th ) quarter of the preceding calendar year.

B. The Division of Medicaid reimburses no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different provider type, as the Division of

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Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the provider types listed in Miss. Admin. Code, Title 23, Part 211, Rule 1.2.A. except if the beneficiary experiences an illness or injury requiring additional diagnosis or treatment subsequent to the first encounter. Services provided by a nurse practitioner (NP) or physician assistant (PA) are reimbursed the full PPS rate.

C. The Division of Medicaid reimburses for telehealth services which meet the requirements of Miss. Admin. Code Part 225 as follows:

1. An encounter for face-to-face telehealth services provided by the FQHC acting as a distant site provider.

2. A fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The FQHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021.

3. Reimburses a FQHC for both the distant and originating provider site when such services are appropriately provided by the FQHC.

D. An alternative payment methodology (APM) is an additional fee for certain services provided by the FQHC.

1. The Division of Medicaid reimburses an FQHC a fee in addition to the PPS rate when certain services are provided outside the Division of Medicaid’s regularly scheduled office hours.

a) The Division of Medicaid defines regularly scheduled office hours as the hours between 8:00 a.m. and 5:00 p.m., Monday through Friday, excluding Saturday, Sunday and federal and state holidays, referred to in Miss. Admin. Code, Part 211, Rule 1.5.B.1. as “office hours”.

b) To set regularly scheduled office hours outside of the Division of Medicaid’s definition of office hours, referred to in Miss. Admin. Code, Part 211, Rule 1.5.B.1. as “FQHC established office hours”.

c) The FQHC must maintain records indicating FQHC established office hours and any changes including:

1. The date of the change,

2. The FQHC established office hours prior to the change, and

3. The new FQHC established office hours.

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d) The Division of Medicaid reimburses a fee in addition to the PPS rate when the encounter occurs:

1. During the FQHC’s established office hours which are set outside of the Division of Medicaid’s definition of office hours, or

2. Outside of the Division of Medicaid’s office hours or the FQHC’s established office hours only for a condition which is not life-threatening but warrants immediate attention and cannot wait to be treated until the next scheduled appointment during office hours or the FQHC established office hours.

e) The Division of Medicaid reimburses only the appropriate PPS rate for an encounter scheduled during office hours or FQHC’s established office hours but not occurring until after office hours or FQHC established office hours.

E. The Division of Medicaid reimburses an FQHC the PPS rate for the administration, insertion, and/or removal of certain categories of physician administered drugs (PADs), referred to as Clinician Administered Drug and Implantable Drug System Devices (CADDs), reimbursed under the pharmacy benefit to the extent the CADDs were not included in the calculation of the FQHC’s PPS rate.

1. CADDs are located on the Division of Medicaid’s website.

2. CADDs not included on the Division of Medicaid’s list of CADD-classified drugs will be denied if billed through the pharmacy point-of-sale (POS).

F. If a physician employed by an FQHC provides physician services at an inpatient, outpatient, or emergency room hospital setting, the services must be billed under the individual physician’s Medicaid provider number and payment will be made directly to the physician. The financial arrangement between the physician and the FQHC must be handled through an agreement.

G. Change in the Scope of Service

1. An FQHC must notify the Division of Medicaid in writing of any change in the scope of services by the end of the calendar year in which the change occurred, including decreases in scope of service. The Division of Medicaid will adjust an FQHC PPS rate if the following criteria are met:

a) The FQHC can demonstrate there is a valid and documented change in the scope of services, and

b) The change in scope of services results in at least a five percent (5%) increase or decrease in the FQHC PPS rate for the calendar year in which the change in scope of service took place.

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2. An FQHC must submit a request for an adjustment to its PPS rate no later than one hundred eighty (180) days after the settlement date of FQHC Medicare final settlement cost report for the FQHC’s first full fiscal year of operation with the change in scope of services. The request must include the first final settlement cost report that includes twelve (12) months of costs for the new service. The adjustment will be granted only if the cost related to the change in scope of services results in at least a five percent (5%) increase or decrease in the FQHC PPS rate for the calendar year in which the change in scope of services took place. The cost related to a change in scope of services will be subject to reasonable cost criteria identified in accordance with federal regulations.

3. It is the responsibility of the FQHC to notify the Division of Medicaid of any change in the scope of service and provide the required proper and valid documentation to support the rate change. Such required documentation must include, at minimum, a detailed working trial balance demonstrating the increase or decrease in the FQHC’s PPS rate as a result of the change in scope of service. The Division of Medicaid will require the FQHC to provide such documentation in a format acceptable to the Division of Medicaid, including providing such documentation upon the Division of Medicaid’s pre-approved forms. The Division of Medicaid will also request additional information as it sees fit in order to sufficiently determine whether any change in scope of service(s) has occurred. The instructions and forms for submitting a request due to a change in scope of services located on the Division of Medicaid’s website.

4. Adjustments to the PPS rate for the increase or decrease in scope of services are reflected in the PPS rate for services provided in the calendar year following the calendar year in which the change in scope of services took place. The revised PPS rate generally cannot exceed the cost per visit from the most recent audited cost report.

5. The FQHC PPS rate will not be adjusted solely for a change in ownership status between freestanding and provider-based.

H. Cost Reports

1. All FQHCs must submit to the Division of Medicaid a copy of their Medicare cost report for information purposes using the appropriate Medicare forms postmarked on or before the last day of the fifth (5 th ) month following the close of its Medicare cost reporting year. All filing requirements must be the same as for Title XVIII. When the due date of the cost report falls on a weekend or State of Mississippi or federal holiday, the cost report is due on the following business day. Extensions of time for filing cost reports will not be granted by the Division of Medicaid except for those supported by written notification of the extension granted by Title XVIII. Cost reports must be prepared in accordance with the policy for reimbursement of FQHCs. The FQHC’s cost report must include information on all satellite FQHCs.

2. If the Medicare cost report is not received within thirty (30) days of the due date, payment of claims will be suspended until receipt of the required report. This penalty can only be waived by the Executive Director of the Division of Medicaid.

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3. An FQHC that does not file a Medicare cost report within six (6) calendar months after the close of its Medicare cost reporting year may be subject to cancellation of its provider agreement at the Division of Medicaid’s discretion.

I. Medicaid payments are not made to any organization prior to the date of approval and execution of a valid Medicaid provider agreement.

J. The Division of Medicaid reimburses an outside laboratory for laboratory services not listed in Miss. Admin. Code Part 211, Rule 1.2.C. separate from the PPS rate.

Source: 42 U.S. Code § 1396d; 42 C.F.R. Part 491; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 2018-0012, SPA 2016-0013, SPA 15-003, SPA 2013-032.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0012 (eff. 07/01/18) eff. 06/01/2019. Added Miss. Admin. Code Part 212, Rule 1.5.A.3. to correspond with SPA 15-003 (eff. 01/01/2015) eff. 12/01/2015; Revised to correspond with SPA 2013-032 (eff. 11/01/2013) eff. 06/01/2015.

Rule 1.6: Documentation Requirements

The Division of Medicaid requires Federally Qualified Health Centers (FQHCs) to maintain auditable records that substantiate the services provided in accordance with Miss. Admin. Code Title 23, Part 200, Rule 1.3. At a minimum, the records must contain the following on each beneficiary:

A. Date of service,

B. Beneficiary’s presenting complaint,

C. Provider’s findings,

D. Treatment rendered, and

E. Provider’s signature.

Source: 42 C.F.R. Part 491; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised eff. 06/01/2019; Revised eff. 06/01/2015.

Rule 1.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

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Source: 42 C.F.R. Part 491; 42 C.F.R. § 440.345; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 06/01/2019.

Part 212 Rural Health Clinics

23 Miss. Admin. Code Pt. 212 Rural Health Clinics

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 212 Rural Health Clinics

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 212: Rural Health Clinics .................................................................................................... 1 Part 212 Chapter 1: General ................................................................................................... 1 Rule 1.1: Provider Enrollment Requirements ........................................................................... 1 Rule 1.2: Service Limits ........................................................................................................... 2 Rule 1.3: Covered Services ....................................................................................................... 2 Rule 1.4: Reimbursement Methodology ................................................................................... 4 Rule 1.5: Documentation Requirements ................................................................................... 9 Rule 1.6: Co-Mingling .............................................................................................................. 9 Rule 1.7: Pregnancy Related Eligibles.................................................................................... 10 Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ....................... 10

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Title 23: Division of Medicaid

Part 212: Rural Health Clinics

Part 212 Chapter 1: General

Rule 1.1: Definitions

The Division of Medicaid defines:

A. Rural Health Clinic as a provider that has been designated a Rural Health Clinic by the Centers for Medicare and Medicaid Services (CMS) and for purposes of this policy includes both provider-based rural health clinics and freestanding rural health clinics.

1. Free Standing Rural Health Clinic as an independent clinic owned by a provider or a provider entity that does not qualify for, or have not sought, provider-based status, as designated by CMS.

2. Provider-Based Rural Health Clinic as a rural health clinic that is owned and operated as an essential part of a hospital, nursing home, or home health agency, as designated by CMS.

B. Rural Health Clinic (RHC) encounter as a face-to-face visit for the provision of services provided by physicians, physician assistants, nurse practitioners, nurse midwives, dentists, optometrists, clinical psychologists, Licensed Clinical Social Workers (LCSWs), Licensed Professional Counselors (LPCs), Licensed Marriage and Family Therapists (LMFTs), and Board Certified Behavioral Analysts (BCBAs).

C. An encounter rate as a prospective payment system (PPS) rate per encounter.

D. Clinician Administered Drugs and Implantable Drug System Devices (CADD) as certain physician-administered drugs, with limited distribution or limited access for beneficiaries and administered in an appropriate clinical setting, which were not included in the calculation of the RHC’s PPS rate, as determined by the Division of Medicaid.

E. Change in the scope of service as a change in the type, intensity, duration and/or amount of services.

1. A change in the scope of services occurs if:

a) The RHC has added or has dropped any services that meet the definition of an RHC service as provided in federal regulations.

b) The service is included as a covered Medicaid service under the Mississippi Medicaid State Plan.

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c) A change in the intensity is a change in the amount of health care services provided by the RHC during an average encounter.

2. A change in the scope of service does not mean:

a) The addition or reduction of staff members to or from an existing service.

b) An increase or decrease in the number of encounters.

c) A change in the cost of a service is not considered in and of itself a change in the scope of service.

F. Allowable costs as costs that:

1. Result from providing covered services,

2. Are reasonable in amount and are necessary for the efficient delivery of those services,

3. Include the direct cost center component (i.e., salaries and supplies) of providing the covered services, and

4. Are an allocated portion of overhead (i.e., administration and facility).

G. Co-mingling as the simultaneous operation of an RHC and another physician practice where the two (2) practices share:

1. Hours of operation,

2. Use of the space,

3. Professional staff,

4. Equipment,

5. Supplies, and

6. Other resources.

I. Medical facility as an RHC.

1. The medical facility is limited to an RHC and must have:

a) A permanent location, and

b) A published telephone number.

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2. The RHC must have regularly scheduled hours of operation which are posted in the facility.

Source: 42 C.F.R. § 440.230; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 18-0013, SPA 2013-033.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 18-0013 (eff. 07/01/2018) eff. 06/01/2019. Revised eff. 07/01/2014. Updated Miss. Admin. Code Part 212, Rule 1.1A. 05/01/13 to include 04/01/2012 compilation omission.

Rule 1.2: Provider Requirements

A. To participate as a Rural Health Clinic (RHC) in the Medicaid program, an organization must be approved by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) as an RHC.

B. RHC providers must comply with the requirements set forth in Miss. Admin. Code Part 200, Rule 4.8 for all providers in addition to the specific provider type requirements outlined below:

1. National Provider Identifier (NPI), verification from the National Plan and Provider Enumeration System (NPPES),

2. A copy of the interim rate notice or current rate letter from CMS,

3. Copy of the nurse practitioner’s protocol and license to practice. If the nurse practitioner is not enrolled with the Division of Medicaid as a provider, the nurse practitioner must complete a provider application and obtain an individual provider number, and

4. Clinical Laboratory Improvement Amendments (CLIA) Information form and current CLIA certificate, if applicable.

a) If the RHC performs only the six (6) tests listed in Miss. Admin. Code Part 212, Rule 1.3.D., a waiver certificate from the regional Clinical Laboratory Improvement Amendments (CLIA) office must be obtained.

b) If the RHC provides other laboratory tests on site, the RHC must comply with all CLIA requirements for the laboratory services actually provided.

C. An RHC must provide the following six (6) laboratory services on site which are included in the PPS rate:

1. Chemical examinations of urine by stick or tablet method or both, including urine ketones,

2. Hemoglobin or hematocrit,

3. Blood glucose,

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4. Examination of stool specimens for occult blood,

5. Pregnancy tests, and

6. Primary culturing for transmittal to a certified laboratory.

D. The Division of Medicaid does not allow co-mingling.

E. Physicians and non-physician practitioners cannot operate a private Medicare or Medicaid practice during RHC hours of operation using the RHC’s resources.

F. The effective date of the Medicaid provider agreement will be the applicable date described in Miss. Admin. Code Title 23, Part 200, Rule 4.4.

G. The Division of Medicaid does not enroll out-of-state providers to provide RHC services, except as described in Miss. Admin. Code Part 200, Rule 4.2 B.

H. RHC mobile units must be surveyed by the Mississippi Department of Health (MSDH) and receive an approval letter from the Centers for Medicare and Medicaid Services (CMS) prior to providing services.

1. All federal and state requirements for RHC mobile units must be met.

2. The mobile unit must have a fixed set of locations where the unit is scheduled to be providing services at specified dates and times.

a) Locations for RHC mobile unit services must meet the rural and shortage area requirements at the time of survey.

b) Provided only within the county or within forty (40) miles of the county where the RHC is located.

c) The schedule of times and locations must be posted on the mobile unit and publicized by other means so that beneficiaries will know the mobile unit's schedule in advance.

3. NPs must remain within a seventy-five (75) mile distance from the primary physician.

Source: 42 C.F.R. § 440.230; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 18-0013, SPA 2013-033.

History: Revised eff. 10/01/2025. Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0013 (eff. 07/01/2018) eff. 06/01/2019. Revised to correspond with SPA 2013-033 (eff. 11/01/2013) eff. 06/01/2015.

Rule 1.3: Covered Services

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A. The Division of Medicaid limits reimbursement to a Rural Health Clinic (RHC) to no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different type of visit, as the Division of Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the following visit:

1. Medical,

2. Mental health,

3. Dental, or

4. Vision.

B. Visits with more than one (1) health professional and multiple visits with the same health professional that take place on the same day at a single location constitute a single encounter, except when the beneficiary:

1. Suffers an illness or injury subsequent to the first visit that requires additional diagnosis or treatment on the same day, or

2. Has multiple visit types on the same day.

C. An RHC’s PPS rate covers the beneficiary’s visit to the RHC, which is inclusive of all services and supplies and drugs and biologicals which are not usually self-administered by the beneficiary, furnished as an incident to a professional service.

1. The RHC cannot refer the beneficiary to another provider that will bill the Division of Medicaid for the covered service, supply, drug or biological which is included in the RHC’s encounter.

2. Drugs are included in the PPS rate, if purchased at a discounted price through a discount agreement except for Clinician Administered Drugs and Implantable Drug System Devices (CADD).

D. The Division of Medicaid covers CADD drugs separately from an RHC encounter.

1. CADD drugs are listed on the Division of Medicaid’s website.

2. CADD drugs do not count toward monthly prescription drug limits applicable to covered outpatient drugs.

E. The Division of Medicaid covers ambulatory services performed by an RHC employee or contractual worker for an RHC beneficiary at the following sites:

1. The RHC, or

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2. Beneficiary’s residence.

F. The Division of Medicaid covers the services of an outside laboratory for laboratory services not listed in Miss. Admin. Code Part 212, Rule 1.2.C. separate from the encounter rate.

G. The Division of Medicaid covers an RHC as an originating and/or distant site telehealth provider. H. The Division of Medicaid covers the delivery of RHC services in a school-based clinic operated by an RHC and staffed with a physician, nurse practitioner and/or physician assistant.

I. RHC mobile units are covered services when the requirements of Miss. Admin. Code Title 23, Part 212, Rule 1.2 are met.

J. Diabetes Self-Management Training (DSMT) is a covered service that is included in the PPS rate for a core service for an RHC but is not considered a core service.

K. Vaccine administration is a covered service that is included in the PPS rate for a core service for an RHC but is not considered a core service.

Source: 42 C.F.R. § 440.20; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 18-0013, SPA 2013-033.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0013 (eff. 07/01/2018) eff. 06/01/2019. Revised eff. 06/01/2015.

Rule 1.4: Non-Covered Services

A. The Division of Medicaid does not reimburse an RHC for services when performed in an inpatient or outpatient hospital setting. If a physician is employed by an RHC and provides services in a hospital setting, the RHC is prohibited from billing for these services. The physician must bill under the physician’s individual Medicaid provider number or group physician Medicaid provider number.

B. The Division of Medicaid does not consider the following as an encounter:

1. Vaccine administration, and/or

2. Diabetes Self-Management Training (DSMT).

Source: 42 C.F.R. § 440.20; Miss. Code Ann. §§ 43-13-117, 43-13-121.

Rule 1.5: Reimbursement

The Division of Medicaid reimburses Rural Health Clinic (RHC) providers at a prospective payment system (PPS) rate per encounter and/or alternative payment methodology (APM).

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A. The Division of Medicaid uses the PPS methodology for reimbursement to RHC providers per encounter as described below:

1. For services provided on and after January 1, 2001, during calendar year 2001, payment for services shall be calculated, on a per visit basis, in an amount equal to one hundred percent (100%) of the average of the RHC’s reasonable costs of providing the Division of Medicaid covered services during fiscal years 1999 and 2000. If a RHC first enrolls during fiscal year 2000, the rate will only be computed from the fiscal year 2000 Medicaid cost report. The PPS baseline calculation shall include the cost of all Medicaid covered services including other ambulatory services that were previously paid under a fee-for-service basis. This rate will be adjusted to take into account any increase or decrease in the scope of services furnished by the RHC during fiscal year 2001.

2. Payment rates may be adjusted by the Division of Medicaid pursuant to changes in federal and/or state laws or regulations.

3. Beginning in calendar year 2002, and for each calendar year thereafter, the RHC is entitled to the payment amount, on a per visit basis, to which the RHC was entitled to in the previous year, increased by the percentage increase in the Medicare Economic Index (MEI) for primary care services for that calendar year, and adjusted to take into account any increase or decrease in the scope of services furnished by the RHC during that calendar year. The rate will be retroactively adjusted to reflect the MEI.

4. New clinics that qualify for the RHC program after January 1, 2001, will be reimbursed the initial PPS rate which will be based on the rates established for other RHCs located in the same or adjacent area with a similar caseload. In the absence of comparable RHCs, the rate for the new provider will be based on projected costs. The RHC’s Medicare final or amended final settlement cost report for the initial cost report period year will be used to calculate a PPS base rate that is equal to one hundred percent (100%) of the RHC’s reasonable costs of providing Medicaid covered services. If the initial cost report period represents a full year of RHC services, this final settlement rate will be considered the base rate. If the initial RHC cost report period does not represent a full year, then the rate from the first full year cost report will be used as the clinic’s base rate. For each subsequent calendar year, the payment rate will be equal to the rate established in the preceding calendar year, increased by the percentage increase in the MEI for primary care services that is published in the Federal Register in the fourth (4 th ) quarter of the preceding calendar year.

B. The Division of Medicaid reimburses no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different provider type, as the Division of Medicaid only reimburses for one (1) medically necessary encounter per beneficiary per day for each of the provider types listed in Miss. Admin. Code, Title 23, Part 212, Rule 1.2.A. except if the beneficiary experiences an illness or injury requiring additional diagnosis or treatment subsequent to the first encounter. Services provided by a nurse practitioner (NP) or physician assistant (PA) are reimbursed the full PPS rate.

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C. The Division of Medicaid reimburses for telehealth services which meet the requirements in Miss. Admin. Code Part 225 as follows:

1. An encounter for face-to-face telehealth services provided by the RHC acting as a distant site provider.

2. A fee per completed transmission for telehealth services provided by the RHC acting as an originating site provider. The RHC may not bill for an encounter visit unless a separately identifiable service is performed. The originating site facility fee will be paid at the existing fee-for-service rate in effect as of January 1, 2021.

3. Reimburses a RHC for both the distant and originating provider site when such services are appropriately provided by the RHC.

D. An alternative payment methodology is an additional fee for certain services provided by the RHC.

1. The Division of Medicaid reimburses a RHC a fee in addition to the PPS rate when certain services are provided outside the Division of Medicaid’s regularly scheduled office hours.

a) The Division of Medicaid defines regularly scheduled office hours as the hours between 8:00 a.m. and 5:00 p.m., Monday through Friday, excluding Saturday, Sunday and federal and state holidays, referred to in Miss. Admin. Code, Part 212, Rule 1.4.B.1. as “office hours”.

b) The Division of Medicaid permits RHCs to set regularly scheduled office hours outside of the Division of Medicaid’s definition of office hours, referred to in Miss. Admin. Code, Part 212, Rule 1.4.C.1. as “RHC established office hours”.

c) The RHC must maintain records indicating RHC established office hours and any changes including:

1. The date of the change,

2. The RHC established office hours prior to the change, and

3. The new RHC established office hours.

d) The Division of Medicaid reimburses a fee in addition to the PPS rate when the encounter occurs:

1. During the RHC’s established office hours which are set outside of the Division of Medicaid’s office hours, or

2. Outside of the Division of Medicaid’s office hours or the RHC’s established office hours only for a condition which is not life-threatening but warrants immediate

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attention and cannot wait to be treated until the next scheduled appointment during office hours or the RHC established office hours.

e) The Division of Medicaid reimburses only the appropriate PPS rate for an encounter scheduled during office hours or RHC’s established office hours but not occurring until after office hours or RHC established office hours.

E. The Division of Medicaid reimburses an RHC the PPS rate for the administration, insertion, and/or removal of certain categories of physician administered drugs (PADs), referred to as Clinician Administered Drug and Implantable Drug System Devices (CADDs), reimbursed under the pharmacy benefit to the extent the CADDs were not included in the calculation of the RHC’s PPS rate.

1. CADDs are located on the Division of Medicaid’s website.

2. CADDs not included on the Division of Medicaid’s list of CADD-classified drugs will be denied if billed through the pharmacy point-of-sale (POS).

F. If a physician employed by an RHC provides physician services at an inpatient, outpatient, or emergency room hospital setting, the services must be billed under the individual physician’s Medicaid provider number and payment will be made directly to the physician. The financial arrangement between the physician and the RHC must be handled through an agreement.

G. Change in the Scope of Services

1. An RHC must notify the Division of Medicaid in writing of any change in the scope of services by the end of the calendar year in which the change occurred, including decreases in scope of services. The Division of Medicaid will adjust an RHC PPS rate if the following criteria are met:

a) The RHC can demonstrate there is a valid and documented change in the scope of services, and

b) The change in scope of services results in at least a five percent (5%) increase or decrease in the RHC PPS rate for the calendar year in which the change in scope of service took place.

2. An RHC must submit a request for an adjustment to its PPS rate no later than one hundred eighty (180) days after the settlement date of the RHC Medicare final settlement cost report for the RHC’s first full fiscal year of operation with the change in scope of services. The request must include the first final settlement cost report that includes twelve (12) months of costs for the new service. The adjustment will be granted only if the cost related to the change in scope of services results in at least a five percent (5%) increase or decrease in the RHC PPS rate for the calendar year in which the change in scope of services took place. The cost related to a change in scope of services will be subject to reasonable cost criteria identified in accordance with federal regulations.

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3. It is the responsibility of the RHC to notify the Division of Medicaid of any change in the scope of service(s) and provide the required proper and valid documentation to support the rate change. Such required documentation must include, at minimum, a detailed working trial balance demonstrating the increase or decrease in the RHC’s PPS rate as a result of the change in scope of service(s). The Division of Medicaid will require the RHC to provide such documentation in a format acceptable to the Division of Medicaid, including providing such documentation upon the Division of Medicaid’s pre-approved forms. The Division of Medicaid will also request additional information as it sees fit in order to sufficiently determine whether any change in scope of service(s) has occurred. The instructions and forms for submitting a request due to a change in scope of services can be found on the Division of Medicaid’s website.

4. Adjustments to the PPS rate for the increase or decrease in scope of services are reflected in the PPS rate for services provided in the calendar year following the calendar year in which the change in scope of services took place. The revised PPS rate generally cannot exceed the cost per visit from the most recent audited cost report.

5. The RHC PPS rate will not be adjusted solely for a change in ownership status between freestanding and provider-based.

H. Cost Reports

1. All RHCs must submit to the Division of Medicaid a copy of their Medicare cost report for information purposes using the appropriate Medicare forms postmarked on or before the last day of the fifth (5 th ) month following the close of its Medicare cost-reporting year. All filing requirements shall be the same as for Title XVIII. When the due date of the cost report falls on a weekend or State of Mississippi or federal holiday, the cost report is due on the following business day. Extensions of time for filing cost reports will not be granted by the Division of Medicaid except for those supported by written notification of the extension granted by Title XVIII. Cost reports must be prepared in accordance with the State Plan for reimbursement of RHCs. The RHC’s cost report should include information on all satellite RHCs.

2. If the Medicare cost report is not received within thirty (30) days of the due date, payment of claims will be suspended until receipt of the required report. This penalty can only be waived by the Executive Director of the Division of Medicaid.

3. An RHC that does not file a Medicare cost report within six (6) calendar months after the close of its Medicare cost reporting year may be subject to cancellation of its provider agreement at the Division of Medicaid’s discretion.

I. Medicaid payments are not be made to any organization prior to the date of approval and execution of a valid Medicaid provider agreement.

J. The Division of Medicaid reimburses an outside laboratory for laboratory services not listed

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in Miss. Admin. Code Part 212, Rule 1.2.C. separate from the PPS rate.

Source: 42 U.S.C. 1396d; 42 C.F.R. §§ 440.20, 447.371; 45 C.F.R. Part 75; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 18-0013, SPA 2016-0014, SPA 2015-003, SPA 2013-033.

History: Revised eff. 07/01/2021; Revised to correspond with SPA 2018-0013 (eff. 07/01/18), 2016-0014 (eff. 05/01/16) eff. 06/01/2019. Added Miss. Admin. Code Part 212, Rule 1.4.A.3. to correspond with SPA 2015-003 (eff. 01/01/2015) eff. 12/01/2015; Revised to correspond with SPA 2013-033 (eff. 11/01/13) eff. 06/01/2015.

Rule 1.6: Documentation Requirements

The Division of Medicaid requires Rural Health Clinics (RHCs) to maintain auditable records that will substantiate the services provided in accordance with Miss. Admin. Code Title 23, Part 200, Rule 1.3. At a minimum, the records must contain the following on each patient:

A. Date of service,

B. Beneficiary’s presenting complaint,

C. Provider’s findings,

D. Treatment rendered, and

E. Provider’s signature.

Source: 42 C.F.R. § 440.20; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; Revised eff. 06/01/19.

Rule 1.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Renamed rule eff. 07/01/2021.

Part 213 Therapy Services

Chapter 2 Occupational Therapy

23 Miss. Admin. Code Pt. 213, R. 2.3 Covered Occupational Therapy Services

A. The Division of Medicaid covers occupational therapy services in the outpatient setting when medically necessary, ordered by a physician, physician assistant or nurse practitioner, and prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or a designated entity to treat a beneficiary’s illness, condition, or injury and the following requirements are met:

1. The services require the knowledge, skill and judgment of a state-licensed occupational therapist.

2. The Certificate of Medical Necessity (CMN) for initial referral/order is completed by the prescribing provider prior to the occupational therapy evaluation.

3. The plan of care (POC) is developed by a state-licensed occupational therapist.

4. The prescribing provider approves the initial/revised POC with a signature and date:

a) Before the initiation of treatment or change in treatment, or

b) Within thirty (30) calendar days of the verbal order for the initial treatment plan or change in treatment.

5. The services are rendered as individualized therapy, consistent with the

symptomatology/diagnosis and do not exceed the beneficiary’s needs.

6. The services do not duplicate another provider’s services including those services provided in a school-based setting.

B. The Division of Medicaid reimburses for covered occupational therapy services provided by:

1. A state-licensed occupational therapist.

2. A state-licensed occupational therapist assisted by a state-licensed occupational therapist assistant under direct, on-site supervision by a state-licensed occupational therapist.

a) The Division of Medicaid defines direct, onsite supervision as face-to-face oversight by a state-licensed occupational therapist at regular intervals, as prescribed by the standards of the Accreditation Council of Occupational Therapy Education (ACOTE) and does not include:

1. Contacts by telephone,

2. Contacts by pager,

3. Video conferencing, and/or

4. Any method not approved by the Division of Medicaid.

b) The initial evaluation, POC, and discharge summary must be completed by a state-licensed occupational therapist.

3. A state-licensed occupational therapist assisted by an occupational therapy student who is enrolled in an accredited occupational therapy program while completing the clinical requirements necessary for graduation under direct, on-site supervision of a state-licensed occupational therapist, referred to as student assisted occupational therapy services.

a) The Division of Medicaid defines direct, on-site supervision of an occupational therapy student as the face-to-face oversight by a state-licensed occupational therapist.

b) The state-licensed occupational therapist must be physically present and engaged in student oversight during the entirety of a therapy session such that the state-licensed occupational therapist is considered to be providing the occupational therapy service.

C. The state-licensed occupational therapist cannot supervise at the same time during the work day more than:

1. One (1) occupational therapy student,

2. A total of four (4) state-licensed occupational therapist assistants, or

3. One (1) occupational therapy student and three (3) state-licensed occupational therapist assistants.

History: Revised eff. 01/01/2016.

Rule 2.4: Non-Covered Occupational Therapy Services

The Division of Medicaid does not cover or reimburse for occupational therapy services in the outpatient setting when:

A. Services are not certified/ordered by a physician, physician assistant, or nurse practitioner,

B. The plan of care (POC) has not been approved, signed, and dated by the physician, physician assistant, or nurse practitioner within established timeframes [Refer to Miss. Admin. Code Part 213, Rule 2.3.A.4],

C. Services do not meet medical necessity criteria,

D. Services do not require the knowledge, skills, and judgment of a state-licensed occupational therapist,

E. Documentation supports that the beneficiary has attained the occupational therapy goals or has reached the point where no further significant improvement can be expected,

F. Documentation supports that the beneficiary has not reached occupational therapy goals and is unable to participate and/or benefit from skilled intervention, refuses to participate, or is otherwise noncompliant with the occupational therapy regimen,

G. The beneficiary can perform services independently or with the assistance of unskilled personnel or family members,

H. Services duplicate other concurrent therapy,

I. Services are for maintenance and/or palliative therapy which maintains function and generally does not involve complex procedures or the professional skill, judgment, or supervision of a state-licensed occupational therapist,

J. Conditions could be reasonably expected to improve spontaneously without therapy,

K. Services are ordered daily or multiple times per day from the initiation of therapy through discharge,

L. Services are normally considered part of nursing care,

M. Services are provided through a Comprehensive Outpatient Rehabilitation Facility (CORF),

N. Services are billed as separate fees for self-care/home-management training,

O. Services are related solely to employment opportunities or the purpose is vocationally based,

P. Services are for general wellness, exercise, and/or recreational programs,

Q. Services are provided by occupational therapy aides,

R. Services are delivered in a group therapy or co-therapy session,

S. Services are investigational or experimental,

T. Services consist of acupuncture or biofeedback,

U. Services are outside the scope/and or authority of the state-licensed occupational therapist’s specialty and/or area of practice,

V. The provider has not met the prior authorization/pre-certification requirements,

W. Services are provided in the home setting, or

X. Services are not specifically listed as covered by the Division of Medicaid.

History: Revised eff. 01/01/2016.

Rule 2.5: Prior Authorization/ Precertification

A. The UM/QIO will determine medical necessity, the types of therapy services, and the number of units reasonably necessary to treat the beneficiary’s condition. The frequency of visits provided by the therapist must match the Plan of Care signed by the prescribing provider.

B. Prior Authorization/Pre-certification for outpatient therapy services is only required for certain procedure codes when the services fall into one (1) of the following categories:

1. Therapy services provided to beneficiaries, adult and/or children in individual therapist offices or in therapy clinics,

2. Therapy services provided to beneficiaries, adult and/or children, in the outpatient department of hospitals,

3. Therapy services provided to beneficiaries, adult and/or children, in physician offices/clinics,

4. Therapy services provided to beneficiaries in nursing facilities,

5. Therapy services covered under regular State Plan benefits and provided to beneficiaries also enrolled in a Home and Community-Based Services (HCBS) waiver program, and

6. Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have been exhausted.

C. Exclusions to Prior Authorization/Precertification

1. Prior Authorization/Precertification is not required, regardless of procedure codes used, when the services fall into one (1) of the following categories:

a) Therapy services provided to beneficiaries in an ICF/MR,

b) Therapy services provided to beneficiaries in a Private Nursing Facility for the Severely Disabled (PNFSD),

c) Therapy services provided to beneficiaries enrolled in a hospice program, or

d) Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have not been exhausted.

D. Prior Authorization/Pre-certification Request - Processes related to certification and recertification of therapy services must be handled in accordance with the procedures set forth by the UM/QIO.

History: Revised eff. 11/01/2021.

Rule 2.6: Prescribing Provider Orders/Responsibilities

A. Medicaid provides benefits for therapy services that are medically necessary, as certified by the prescribing provider.

B. The prescribing provider must complete a Certificate of Medical Necessity for Initial Referral/Orders form and submit it to the therapist prior to therapy evaluation.

C. Therapy services must be furnished according to a written plan of care (POC). The plan of care must be approved by the prescribing provider before treatment is begun. Medicaid defines approval as the prescribing provider has reviewed and agreed with the therapy plan. The review can be done in person, by telephone, or facsimile. An approved plan does not

mean that the prescribing provider has signed the plan prior to implementation, only that he/she has agreed to it. The plan of care must be developed by a therapist in the discipline. A separate plan of care is required for each type of therapy ordered by the prescribing provider. The plan must, at a minimum, include the following:

1. Beneficiary demographic information,

2. Name of the prescribing provider,

3. Dates of service,

4. Diagnosis/symptomatology/conditions and related diagnosis codes,

5. Reason for referral,

6. Specific diagnostic and treatment procedures/modalities and related procedure codes,

7. Frequency of therapeutic encounters,

8. Duration of therapy,

9. Precautions, if applicable,

10. Short and long term goals that are specific, measurable, and age appropriate,

11. Plan for the home program,

12. Discharge plan, and

13. Therapist’s signature, name and title, and date.

14. Medicaid requires the POC to cover a period of treatment up to six (6) months. The projected period of treatment must be indicated on the initial POC and must be updated with each subsequent revised POC. Medicaid does not cover a POC for a projected period of treatment beyond six (6) months.

15. Medicaid requires a revised POC in the following situations:

16. The projected period of treatment is complete and additional services are required,

17. A significant change in the beneficiary’s condition and the proposed treatment plan requires that a therapy provider propose a revised POC to the prescribing provider, or the prescribing provider requests a revision to the POC. In either case, the therapy provider must submit a revised POC to the UM/QIO for certification prior to rendering services, and

18. Information/documentation submitted to the UM/QIO indicates the POC needs further review/revision by the therapist/prescribing provider at intervals different from the proposed treatment dates. The therapy provider must submit a revised POC to the UM/QIO for authorization/certification prior to rendering services,

19. All therapy plans of care, initial and revised, must be authenticated, with signature and date, by the prescribing provider. The prescribing provider must sign the POC before initiation of treatment or within thirty (30) calendar days of the verbal order approving the treatment plan. This applies to both initial and revised plans of care.

20. Medicaid accepts the signature on the revised plan of care as a new order.

21. The prescribing provider may make changes to the plan established by the therapist, but the therapist cannot unilaterally alter the plan of care established by the prescribing provider.

22. The servicing provider, the licensed therapist, is responsible for providing a copy of the initial plan of care and all revisions to the prescribing provider.

23. Medicaid does not cover therapy services when documentation supports that the beneficiary has not reached therapy goals and is unable to participate and/or benefit from skilled intervention, refuses to participate, or is otherwise noncompliant with the therapy regimen. Noncompliance is defined as failure to follow therapeutic recommendations which may include any or all of the following:

24. Failure to attend scheduled therapy sessions,

25. Failure to perform home exercise program as instructed by the therapist,

26. Failure to fully participate in therapy sessions,

27. Failure of the parent/caregiver to attend therapy sessions with beneficiary who is incapable of carrying out the home program without assistance, and

28. Failure to properly use special equipment or adaptive devices. Failure of parent/caregiver/beneficiary to otherwise comply with therapy regimen as documented in the medical record.

29. Medicaid requires a mandatory face-to-face visit with the beneficiary by the prescribing provider at least every six (6) months and, requires the encounter is documented.

History: Revised eff. 04/01/2021.

Rule 2.7: Evaluation/Re-Evaluation

8. A Certificate of Medical Necessity for Initial Referral/Orders must be completed by the prescribing provider, and it must be received by the therapist prior to performing the initial evaluation. The evaluation does not require prior authorization.

9. Before therapy is initiated, a comprehensive evaluation of the beneficiary’s medical condition, disability, and level of functioning must be performed to determine the need for treatment and, when treatment is indicated, to develop the treatment plan. The initial evaluation must be completed by a state-licensed therapist. The evaluation must be written and must demonstrate the beneficiary’s need for skilled therapy based on functional diagnosis, prognosis, and positive prognostic indicators. The evaluation must form the basis for therapy treatment goals, and the therapist must have an expectation that the patient can achieve the established goals.

10. Initial evaluations should, at a minimum, contain the following information:

11. Beneficiary demographic information,

12. Name of the prescribing provider,

13. Date of the evaluation,

14. Diagnosis/functional condition or limitation being treated and onset date,

15. Applicable medical history: mechanism of injury, diagnostic imaging/testing, recent hospitalizations including dates, medications, co-morbidities, with complicating or precautionary information,

16. Prior therapy history for same diagnosis/condition and response to therapy,

17. Level of function, prior and current,

18. Clinical status including cognitive function, sensation/proprioception, edema, vision/hearing, posture, active and passive range of motion, strength, pain, coordination, bed mobility, balance, while sitting and standing, transfer ability, ambulation at level and elevated surfaces, gait analysis, assistive/adaptive devices either currently in use or required, activity tolerance, presence of wounds including description and incision status, assessment of the beneficiary’s ability to perform activities of daily living and potential for rehabilitation, age appropriate information on all children by chronological age/corrected age, motivation for treatment, other significant physical or mental disabilities/deficiencies that may affect therapy,

19. Special/standardized tests including the name, scores/results, and dates administered,

20. Social history including effects of the disability on the beneficiary and the family, architectural/safety considerations present in the living environment, identification of the primary caregiver, caregiver’s ability/inability to assist with therapy,

21. Discharge plan including requirements to return to home, school, and/or job,

22. Impression/interpretation of findings, and

23. Occupational therapist’s signature, with name and title and date.

24. Medicaid covers re-evaluations based on medical necessity. Re-evaluations do not require prior authorization through the UM/QIO. Documentation must reflect significant change in the beneficiary’s condition or functional status. Significant change is defined as a measurable and substantial increase or decrease in the beneficiary’s present functional level compared to the level documented at the beginning of treatment.

25. The components of the re-evaluation and the documentation requirements are the same as the initial evaluation, but are focused on assessing significant changes from the initial evaluation or progress toward treatment goals and making a professional judgment about continued care, modifying goals and/or treatment, or termination of therapy services. Documentation should include improvements and setbacks, as well as, interventions required to treat any medical complications. When expected progress has not been realized and continued therapy is planned, the re-evaluation needs to include valid indications to support the expectation that significant improvement will occur in a reasonable and predictable time frame.

D. In all cases, other than termination of therapy services, re-evaluation findings must be reflected in revisions to the therapy plan of care.

2. The servicing provider, or licensed therapist, is responsible for providing a copy of the initial evaluation and all re-evaluations to the prescribing provider.

History: Revised eff. 04/01/2021.

Rule 2.8: Maintenance Therapy

A. Maintenance programs do not require the professional skills of a licensed therapy provider, are not considered medically necessary, and are not covered by Medicaid.

B. Maintenance programs must be planned and taught before the end of active therapy treatment so that the beneficiary, family members, or other unskilled caregivers can carry out the program. If the maintenance program is not established until after the rehabilitative program has been completed, the skills of a therapist for development of a maintenance program are not considered medically necessary and are covered.

Rule 2.9: Documentation

A. Occupational therapy providers must document and maintain records in accordance with the requirements set forth in Part 200, Chapter 1, Rule 1.3.

B. Required documentation by an occupational therapy servicing provider includes, but is not limited to, the following:

1. Beneficiary demographic information,

2. A copy of the Certificate of Medical Necessity for Initial Referral/Orders completed by the prescribing provider,

3. Signed consent for treatment,

4. Original copies of all Outpatient Therapy Evaluation/Re-Evaluation forms specific to the therapy ordered,

5. Original copies of all Outpatient Therapy Plan of Care forms specific to the therapy ordered,

6. Original copies of all tests performed or a list of all tests performed, test results, and the written evaluation reports,

7. Treatment log if treatment times are not documented in the progress notes including all requirements of timed codes as follows:

a) The Division of Medicaid defines timed codes as procedure codes that reference a time per unit.

b) The Division of Medicaid covers units of timed codes based upon the total time actually spent in the delivery of the service.

c) The Division of Medicaid considers the following activities as not part of the total treatment time:

1. Pre and post-delivery of services,

2. Time the beneficiary spends not being treated, and

3. Time waiting for equipment or for treatment to begin.

d) The Division of Medicaid defines untimed codes as procedure codes that are not

defined by a specific time frame.

e) The Division of Medicaid does not require documentation of the treatment time for untimed codes.

f) The Division of Medicaid only covers one (1) unit for untimed codes regardless of the amount of time taken to complete the service.

8. Progress notes:

a) Must be documented at least weekly.

b) Must include:

1. Date/time of service,

2. Specific treatment modalities/procedures performed,

3. Beneficiary’s response to treatment, functional progress,

4. Problems interfering with progress,

5. Education/teaching activities and results,

6. Conferences,

7. Progress toward discharge goals/home program activities, and

8. The signature and title of the therapist providing the service(s).

c.) If treatment times are documented in the progress notes in lieu of a treatment log, all requirements for timed codes must be met, Refer to timed and untimed codes in this Part.

9. Discharge Summary, if applicable, and

10. A copy of the completed prior approval form with prior approval authorization, if applicable.

C. Required documentation by a prescribing occupational therapy provider includes, but is not limited to, the following:

1. Date(s) of service,

2. Beneficiary demographic information,

3. Signed consent for treatment,

4. Medical history/chief complaint,

5. Diagnosis,

6. Specific name/type of all diagnostic studies and results/findings of the studies,

7. Treatment rendered and response to treatment,

8. Medications prescribed including name, strength, dosage, and route,

9. Orders that are signed and dated for all medications, treatments, and procedures rendered,

10. Discharge planning and beneficiary instructions,

11. Copy of the Certificate of Medical Necessity for Initial Referral/Orders, and

12. Evidence that the beneficiary was seen, face-to-face, and evaluated/re-evaluated every six (6) months, at a minimum.

D. The prescribing occupational therapy provider must retain copies of the rendering provider’s/ therapist’s documentation as follows:

1. Initial therapy evaluation and all re-evaluations,

2. Initial plan of care and all revisions,

3. Written evaluation reports for all tests, and

4. Discharge summary, if applicable.

History: Revised eff. 01/01/20.

Rule 2.10: Dual Eligibles

A. Medicaid covers therapy services not covered by Medicare if the reason for the Medicare denial is other than for medical necessity. The therapy services must be prior authorized/ precertified through the UM/QIO.

B. Beneficiaries may not receive services under both programs simultaneously.

Rule 2.11: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

History

• Source: 42 CFR § 410. 59, 410.61; Miss. Code Ann. § 43-13-121.
• Source: 42 CFR § 410.59; Miss. Code Ann. § 43-13-121.
• Source: Miss. Code Ann. § 43-13-121
• Source: 42 C.F.R. §§ 410.59, 410.61; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: 42 C.F.R. §§ 410.59, 410.61; Miss. Code Ann. §§ 43-13-117, 43-13-121.
• Source: Miss. Code Ann. § 43-13-121
• Source: 42 C.F.R. §§ 422.504, 485.715; Miss. Code Ann. §§ 43-13-117, 43-13-121,.
• Source: Miss. Code Ann. § 43-13-121
• Source: Miss. Code Ann. § 43-13-121

Part 214 Pharmacy Services

23 Miss. Admin. Code Pt. 214 Pharmacy Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 214 Pharmacy Services

Table of Content

Table of Contents Title 23: Medicaid .......................................................................................................................1 Part 214: Pharmacy Services ....................................................................................................1 Part 214 Chapter 1: General Pharmacy ...................................................................................1 Rule 1.1: Provider Enrollment and Pharmacy Participation ...........................................1 Rule 1.2: Pharmacy Services .........................................................................................2 Rule 1.3: Drugs Subject to Exclusion or Otherwise Restricted..............................2 Rule 1.4: Prior Authorization.....................................................................4 Rule 1.5: Reimbursement.........................................................................5 Rule 1.6: Prescription Requirements............................................................ 5 Rule 1.7: Refills/Renewals of Prescription Drugs ..........................................................8 Rule 1.8: Generic Mandates for Prescription Drugs .......................................................9 Rule 1.9: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).................9 Rule 1.10: Preferred Drug List ................................................................................... 10 Rule 1.11: Smoking Cessation ..................................................................11 Rule 1.12: Beneficiary Signature ............................................................11 Rule 1.13: Retrospective Drug Utilization Review (DUR).................................12

Rule 1.14: Participating Federally Qualified Health Center (FQHC) Providers........12

Rule 1.15: 340B Program......................................................................13

Rule 1.16: Clinician Administered Drugs and Implantable Drug System Devices (CADDs).........................................................................................13

Part 214 Chapter 2: Pharmacy Disease Management...................................................13

Rule 2.1: Provider Enrollment and Pharmacy Participation...............................13

Rule 2.2: Program Services....................................................................14

Rule 2.3: Components of Pharmacy Disease Management...............................15

Rule 2.4: Eligibility.............................................................................15

Rule 2.5: Reimbursement......................................................................16

Rule 2.6: Pharmacy Disease Management Documentation Requirement..............16

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Title 23: Division of Medicaid

Part 214: Pharmacy Services

Part 214 Chapter 1: General Pharmacy

Rule 1.1: Provider Enrollment and Pharmacy Participation

A. Pharmacists must comply with the requirements set forth in Part 200, Chapter 4, Rule 4.8 for all providers in addition to the provider type specific requirements that follow:

1. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration System (NPPES),

2. Written confirmation from the IRS confirming the tax identification number and legal business name, and

3. Copy of current pharmacy permit issued by the Mississippi Board of Pharmacy.

B. Pharmacies participating in the Mississippi Medicaid program must:

1. Have a MS Board of Pharmacy permit for one of the following specified types of pharmacies:

a) Retail pharmacy must hold a community pharmacy permit,

b) Closed-door pharmacy must hold a specialty community pharmacy permit, and

c) Institutional pharmacy must hold an Institutional I or Institutional II pharmacy permit.

2. Be physically located within the state of Mississippi or within a thirty (30) mile radius of the state borders except if the servicing pharmacy provider is:

a) Providing drugs to a Mississippi Medicaid beneficiary who is a resident of a nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF/IID) or psychiatric residential treatment facility (PRTF) or receiving specialized care that is located outside of the thirty (30) mile radius, or

b) The source of a drug not obtainable from any pharmacy provider within the state of Mississippi within the thirty (30) mile radius.

C. The Division of Medicaid reimburses pharmacy providers only for prescriptions that are received:

1. Via hand delivery by a beneficiary or his/her representative,

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2. Directly via phone, fax, mail or other electronic means such as e-mail or electronic prescribing from a prescribing provider licensed under State law or an agent with medical training under the health professional’s direct supervision. [Refer to Miss. Admin. Code, Part 214, Chapter 1, Rule 1.6.]

D. For Change of Ownership Liability refer to Miss. Admin. Code Part 200, Chapter 4, Rule 4.3.

Source: Miss. Code Ann. §§ 43-13-121, 73-21-105, 73-21-106.

Rule 1.2: Covered Services

A. The Division of Medicaid covers the following pharmacy services including, but not limited to:

1. Prescription drug coverage which includes all legend prescription drugs manufactured by a company that has signed a drug rebate agreement with certain specific Centers for Medicare and Medicaid Services (CMS) exceptions.

2. Over-the-counter (OTC) drug coverage which is limited to OTC drugs listed on the OTC Formulary.

3. Immunization coverage which includes certain vaccines. [Refer to Miss. Admin. Code Part 224, Rule 1.7].

B. The Division of Medicaid is not required to cover prescription drugs from manufacturers that do not participate in the federal drug rebate program.

C. The Division of Medicaid covers prescribed drugs that are not covered outpatient drugs, including drugs authorized for import by the Food and Drug Administration, when medically necessary during drug shortages identified by the Food and Drug Administration.

Source: 42 USC §§ 1396b, 1396r-8; Deficit Reduction Act (DRA); Miss. Code Ann. § 43-13- 121.

History: Revised to correspond with MS SPA 24-0015 (eff. 10/01/24) eff. 06/01/2025; Revised eff. 01/01/2016.

Rule 1.3: Drugs Subject to Exclusion or Otherwise Restricted

A. The Division of Medicaid does not cover pharmacy benefits for full benefit, dual eligible individuals who are entitled to receive Medicare benefits under Part A, B, or C, except for drugs in the Medicare excluded categories.

B. Medicaid excluded or otherwise restricted drugs include, but are not limited to:

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1. Drugs when used for anorexia, weight loss, or weight gain, except selected drugs used to treat obesity.

2. Drugs when used to promote fertility,

3. Drugs when used for cosmetic purposes or hair growth,

4. Over-the-counter (OTC) items except those listed on the Division of Medicaid’s OTC formulary w h i c h are assigned an appropriate National Drug Code (NDC) on their label and are manufactured by a company that has signed a rebate agreement,

5. Drugs when used for the symptomatic relief of cough and colds except for cough and/or cold drugs listed on the OTC formulary and benzonatate,

6. Prescription vitamins and mineral products except for:

a) Prenatal vitamins,

b) Folic acid, and

c) Cyanocobalamin (vitamin B 12 ) injections.

7. Covered outpatient drugs which the manufacturer requires, as condition of sale, that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee,

8. Those drugs designated less than effective by the Federal Drug Administration (FDA) as a result of the Drug Efficacy Study Implementation (DESI) program unless provided through expanded EPSDT services in Miss. Admin. Code Part 223.

9. [Deleted eff. 01/01/2014],

10. [Deleted eff. 01/01/2014],

11. Drugs when used for the treatment of sexual or erectile dysfunction, unless such drugs are used to treat a condition, other than sexual or erectile dysfunction, for which the drugs have been approved by the FDA.

12. Drugs that are investigational or approved drugs used for investigational purposes,

13. Drugs used for off-label indications which are not found in official compendia or generally accepted in peer reviewed literature,

14. Drugs dispensed after the expiration date,

15. Drugs classified as herbal and/or homeopathic products,

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16. Moved to Miss. Admin. Code Part 214, Chapter 1, Rule 1.3.C,

17. Drugs produced by manufacturers that do not have signed rebate agreements with the federal government as required by the Omnibus Budget Reconciliation Act (OBRA) of 1990, unless provided through expanded EPSDT services in Miss. Admin. Code Part 223, and

18. Compounded prescriptions except for hyperalimentation. The Division of Medicaid defines compounded prescriptions as mixtures of two or more ingredients.

C. The Division of Medicaid does not reimburse for the cost of shipping or delivering drugs.

Source: Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2502, 124 Stat. 119 (2010), as amended by Pub. L. 111-152, 124 Stat. 1029 (2010); Social Security Act §§ 1927(d)(2)(7); 1935(d)(1)(2); 42 CFR §§ 423.100, 423.772, 423.906(c); 42 U.S.C. §§ 1396r- 8(a), 1396r-8(d); SPA 14-011; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with MS SPA 23-0013 (eff. 07/01/2023) eff. 12/01/2023. Deleted Miss. Admin. Code Part 214, Rule 1.3 B 9 and 10 to correspond with SPA 14-011 (eff. 01/01/2014), moved Miss. Admin. Code, Part 214, Chapter 1, Rule 1.3.B.16 to Miss. Admin. Code, Part 214, Chapter 1, Rule 1.3.C, eff. 07/01/2014; Revised Miss. Admin. Code Part 214, Rule 1.3.B. eff. 01/01/2013.

Rule 1.4: Prior Authorization

A. The Division of Medicaid requires prior authorization of certain covered drugs to ensure use as approved by the Food and Drug Administration (FDA) for specific medical conditions.

1. Prior authorization of drugs must be obtained from the Division of Medicaid’s Pharmacy Prior Authorization Unit or its designee before the drug may be dispensed.

2. All prior authorization requests must be submitted electronically via web-portal or by facsimile.

3. Only the Mississippi Medicaid enrolled prescribing provider or a member of the provider’s staff may request prior authorization.

4. Prior authorization requests submitted by agents of drug manufacturers will be denied.

B. The Division of Medicaid reimburses for a seventy-two (72) hour emergency supply of a prescribed drug when a medication is needed without delay and prior authorization is not available and applies to all drugs requiring a prior authorization either because they are:

1. Non-preferred drugs listed in the Preferred Drug List (PDL), or

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2. A drug affected by clinical or prior authorization edits which would need prescriber prior approval.

Source: 42 USC § 1396r-8(d)(5); Miss. Code Ann. §§ 43-13-117(A)(9), 43-13-121, 73-21-129.

History: Revised Miss. Admin. Code Part 214, Rule 1.4.A.1-B.2 eff. 07/01/2013.

Rule 1.5: Reimbursement

The Division of Medicaid reimburses for certain legend and non-legend drugs:

A. As authorized under the State Plan,

B. Prescribed by a Mississippi Medicaid enrolled prescribing provider licensed to prescribe drugs, and

C. Dispensed by a Mississippi Medicaid enrolled pharmacy in accordance with Federal and State laws.

Source: 42 U.S.C. § 1396a(a)(30)(A); 42 C.F.R. § 447.332; Miss. Code Ann. §§ 43-13-121, 73- 21-155.

History: Revised to correspond with SPA 17-0002 (eff. 04/01/2017) eff. 11/01/2018.

Rule 1.6: Prescription Requirements

A. Pharmacists in the legal employ of the pharmacy provider or under the personal direction of a pharmacist employed by the pharmacy provider must submit claims for services rendered. Prescriptions must be dispensed at the provider’s actual physical location of the pharmacy.

B. For purposes of this rule, the Division of Medicaid defines a prescribing provider as an enrolled Mississippi Medicaid provider duly licensed and acting within the scope of practice of his/her profession according to State law.

C. All non-electronic prescriptions must be written on tamper-resistant pads/paper in order to be eligible for reimbursement by the Division of Medicaid.

1. The tamper-resistant prescription pads/paper requirement applies to all Medicaid prescribing providers including physicians, dentists, optometrists, nurse practitioners and other providers who prescribe outpatient drugs including over-the-counter drugs.

2. Exemptions to this mandate include:

a) Prescriptions presented by other modes of transmission including facsimile, electronic or e-prescribed, and telephone,

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b) Written orders prepared in an institutional setting, including intermediate care facilities and nursing facilities, provided that the beneficiary never has the opportunity to handle the written order and the order is given by licensed staff directly to the dispensing pharmacy, or

c) Transfer of a prescription between two (2) pharmacies, provided that the receiving pharmacy is able to confirm by facsimile or telephone call the authenticity of the tamper-resistant prescription with the original pharmacy.

3. Pharmacy providers must return all funds to the Division of Medicaid for any dispensed prescription which is written hard copy on a non-tamper-resistant pad/paper.

D. The pharmacy provider must ensure the integrity of telephone, electronic and/or faxed prescriptions.

E. The Division of Medicaid’s monthly drug service limits are as follows:

1. Six (6) prescription drugs dispensed per month, with no more than two (2) brand name (single source or innovator multiple source drug if less expensive than the generic equivalent) drugs per month. Beneficiaries may exceed the prescription limits when prior authorized as medically necessary.

a) Preferred brand drugs listed on the Universal Preferred Drug List (PDL) do not count toward the two (2) brand limit, and

b) Over-the-counter (OTC) drugs prescribed by a physician listed on the Division of Medicaid’s OTC drugs PDL do not count toward the two (2) brand limit.

2. Prescription drugs dispensed to institutionalized long-term care beneficiaries are exempt from the monthly service limit.

3. Early and Periodic Screening, Diagnosis and Treatment (EPSDT)-eligible beneficiaries may receive more than the six (6) prescription drugs or two (2) brands, if deemed medically necessary, through expanded EPSDT services. [Refer to Miss. Admin. Code, Part 214, Chapter 1, Rule 1.9 for medically necessary services for EPSDT eligible beneficiaries.]

F. The Division of Medicaid requires that all drugs be prescribed in a full month’s supply which may not exceed a thirty one (31) day supply. The following exceptions are allowed:

1. Drugs in therapeutic classes commonly prescribed for less than a month’s supply including, but not limited to, antibiotics and analgesics,

2. Drugs that, in the prescribing provider’s professional judgment, are not clinically appropriate for the beneficiary to be dispensed in a month’s supply,

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3. Drug products where the only available package size of the product is one that exceeds the thirty one (31) day supply limit,

4. Certain drugs issued by the Mississippi Department of Health (MSDH) and approved by the Division of Medicaid, including, but not limited to:

a) Contraceptives which may be dispensed in a one (1) year supply, and

b) Tuberculosis (TB) medications which may be dispensed in a three (3) month supply.

5. Six (6) vials, sixty (60) ml each, of insulin may be dispensed at one time,

6. Oral contraceptives may be dispensed in three (3) month supplies,

7. Prenatal vitamins may be dispensed in three (3) month supplies,

8. Those products with cumulative maximum daily and/or monthly units as recommended by the Food and Drug Administration (FDA) and the manufacturer, and/or as recommended by the Drug Utilization Board and approved by the Division of Medicaid,

9. Those products limited by authority of the Division of Medicaid with the potential for misuse, abuse, or diversion for the public safety, well-being and/or health, or

10. A limited listing of maintenance medications, approved by the Division of Medicaid, which may be dispensed in no more than a ninety (90) day supply.

G. In emergency situations, the Division of Medicaid will reimburse for a seventy two (72) hour supply of drugs that require prior authorization. [Refer to Miss. Admin. Code, Part 214, Chapter 1, Rule 1.4.B.]

H. Pharmacy claims must be billed using the National Drug Code (NDC) number of the product dispensed. Pharmacy providers must bill the eleven (11) digit NDC for the drug and package size actually dispensed. This requirement is for all products, regardless of legend or over-the- counter (OTC) status.

I. Pharmacy prescription claims must be billed with the National Provider Identification (NPI) number for the individual prescriber.

1. The NPI number on a pharmacy prescription claim must be for the prescribing provider and not for an entity.

2. The pharmacy is responsible for maintaining current and accurate prescriber identification on file.

3. Access to provider identification information must be available to all pharmacy

8

employees.

4. Non-compliance with Miss. Admin. Code, Part 214, Chapter 1, Rule 1.6.I. may result in termination of point-of-sale (POS) privileges and/or recovery of false claims.

Source: 42 U.S.C. § 1396b, 42 C.F.R. § 440.120; Miss. Code Ann. §§ 43-13-117, 43-13-121, 73-21-115.

History: Revised to correspond with MS SPA 24-0015 (eff. 10/01/24) eff. 06/01/2025; Revised to correspond with SPA 19-0004 (eff. 07/01/2019) eff. 10/01/2019; Revised Miss. Admin. Code, Part 214, Chapter 1, Rule 1.6, C.3, G. and I. 07/01/2013; Revised Miss. Admin. Code, Part 214, Chapter 1, Rule 1.6, E. 01/01/2013.

Rule 1.7: Refills/Renewals of Prescription Drugs

A. A written, faxed, e-prescribed, or telephoned prescription may be refilled, in compliance with the prescriber’s order, up to a limit of eleven (11) times per year, if compliant with state and/or federal regulations and guidelines. Additionally, the following are applicable:

1. The absence of an indication to refill by the prescribing provider renders the prescription non-refillable.

2. Refills are reimbursable only if specifically authorized by the prescribing provider.

3. The Division of Medicaid does not reimburse prescription refills:

a) Exceeding the specific number authorized by the prescribing provider.

b) Dispensed after one (1) year from the date of the original prescription.

c) With greater frequency than the approximate interval of time that the dosage regimen of the prescription would indicate, unless extenuating circumstances are documented which would justify the shorter interval of time before the refilling of the prescription.

d) With quantities in excess of the prescribing provider’s authorization.

e) Without an explicit request from a beneficiary or the beneficiary’s responsible party, such as a caregiver, for each filling event. The possession, by a provider, of a prescription with remaining refills authorized does not in itself constitute a request to refill the prescription.

f) Until seventy-five percent (75%) of the day’s supply of the drug has elapsed as indicated on the prescription.

g) For any controlled substance (Schedule III, IV, and V) until eighty- five percent (85%) of the day’s supply of the drug has elapsed as indicated on the prescription.

9

Any attempt to refill a prescription through the Point-of-Sale system before the twenty-sixth (26th) day will be automatically denied.

h) For any Schedule II narcotics.

B. Beneficiaries or providers cannot waive the explicit refill request and enroll beneficiaries in an electronic automatic refill in pharmacies.

C. The Division of Medicaid may permit an early refill of an original claim as long as the monthly service limits have not been exhausted under one (1) of the following circumstances:

1. The beneficiary’s life is at risk,

2. When an acute clinical condition is occurring, which would require extra medication to stop or mitigate further morbidity, or

3. The prescribing provider either increases the dosing frequency or the amount per dose.

a) The prescribing provider must document the change in dosage or frequency by writing or phoning in a new prescription.

b) The prescriber(s) who wrote the original prescription must initiate any request for additional medication.

4. If a beneficiary requires an early refill, the prescribing provider must request an exception override of this requirement by seeking approval from Division of Medicaid’s Pharmacy Prior Authorization (PA) Unit.

D. The Division of Medicaid does not reimburse for replacement of prescription medications unless the beneficiary can show good cause, which must include documentation such as a police report or insurance claim, that the prescription medications were lost, stolen or otherwise destroyed beyond the beneficiary’s control. A replacement may be approved only if the monthly service limit, if applicable, has not been reached.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 11/01/2014.

Rule 1.8: Generic Mandates for Prescription Drugs

Mississippi law requires that the Division of Medicaid does not reimburse for a brand name drug if an equally effective generic equivalent is available and the generic equivalent is the least expensive.

A. Generic drugs classified as non-preferred by the Division of Medicaid require prior

10

authorization.

B. In the absence of a specific request for the brand name drug from the prescribing provider to the pharmacist, the pharmacist must follow standard practice guidelines for the State of Mississippi and fill the prescription with the generic equivalent unless the branded agent is preferred and the generic agent is non-preferred.

C. Prior authorization (PA) is required for any brand name multiple source drug that has a generic equivalent except Narrow Therapeutic Index (NTI) drugs as defined by the Division of Medicaid.

Source: Miss. Code Ann. §§ 43-13-117, 73-21-115, 73-21-117, 73-21-123, 73-21-127, 73-21- 129.

Rule 1.9: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Miss. Admin. Code, Part 223, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.10: Preferred Drug List

A. The Division of Medicaid recommends that prescribers use the drugs on the Preferred Drug List (PDL).

1. The PDL is defined as a list of drugs reviewed and proposed by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians, pharmacists, nurse practitioners, and/or other health care professionals. Final approval of the PDL is the responsibility of the Executive Director of the Division of Medicaid.

2. The PDL contains a wide range of generic and preferred brand name products approved by the FDA.

3. A medication becomes a preferred drug based first on safety and efficacy, then on cost- effectiveness.

B. Prior authorizations for non-preferred drugs may be approved for medically accepted indications when criteria have been met.

C. Drugs must be prescribed and dispensed in accordance with medically accepted indications for uses and dosages. No payment will be made under the Medicaid program for services, procedures, supplies or drugs still in clinical trials and/or investigative or experimental in nature.

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D. Prior authorizations are reviewed and a determination notice provided within twenty-four (24) hours from receipt of request. If a PA is not available, a seventy-two (72) hour emergency supply must be dispensed. Pharmacists should use his/her professional judgment regarding whether or not there is an immediate need every time the seventy-two (72) hour option is used. The seventy-two (72) hour emergency procedure must not be used for routine and continuous overrides.

E. The PDL is subject to change. [Refer to the Division of Medicaid’s website for a current listing of prescription drugs on the PDL.]

Source: Social Security Act § 1927; Miss. Code Ann. § 43-13-121.

History: Effective – 07/01/2012.

Rule 1.11: Smoking Cessation Agents

The Division of Medicaid covers all FDA approved smoking cessation OTC and prescription drugs and nicotine replacement products when used to promote smoking cessation, except dual eligible as Part D will cover.

Source: Miss. Code Ann § 43-13-121.

History: Effective - 01/01/2013.

Rule 1.12: Beneficiary Signature

A. The pharmacy must obtain the signature of beneficiary or his/her representative signature and their relationship to the beneficiary for each prescription received with the exception of beneficiaries living in long-term care facilities, i.e. nursing facilities, intermediate care facilities for the intellectually disabled (ICF/IID), psychiatric residential treatment facilities (PRTF) and/or nursing facilities for the severely disabled (NFSD).

1. Electronic signatures are acceptable.

2. One signature per prescription is required.

3. The pharmacist may sign for a prescription if the beneficiary or his/her representative is not capable of signing. When signing the pharmacist must:

a. Document the circumstances preventing the beneficiary or his/her representative from signing for the prescription, and

b. Sign the prescription signature record with his/her own name and the beneficiary’s name.

4. For shipped or delivered prescriptions, the pharmacy must obtain the signature of the

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beneficiary or his/her representative and their relationship to the beneficiary unless the beneficiary waives the signature requirement, or the pharmacy has a signature on file.

a. The pharmacy must maintain signatures on-site and in an auditable manner.

b. The Division of Medicaid will not reimburse for medications lost in transit and/or not received by the beneficiary.

c. During a national or statewide emergency, a signature is not required.

1. The provider must document the emergency.

2. The provider must document confirmation of delivery by an alternate means including, but not limited to:

(a) Telephone,

(b) Text message, or

(c) Other electronic communication.

d. If a beneficiary has waived the signature requirement, the pharmacy must maintain documentation of the waiver.

B. Prescription signature records for received prescriptions must include the prescription serial number, date medication is received and the beneficiary or his/her representative’s signature and their relationship to the beneficiary.

1. Prescription signature records must be retained for a period of five (5) years for audit purposes.

2. Prescription signature records for shipped prescriptions must be retained for a period of five (5) years and must include the delivery confirmation for audit purposes.

3. Prescription signature records must be maintained on-site and in an auditable manner.

C. The pharmacy must comply with all applicable Federal and/or State laws and regulations regarding signature requirements.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 06/01/2025. Revised eff. 08/01/2020, Rule 1.12 A.-E. added 07/01/13 to include 04/01/12 compilation omission.

Rule 1.13: Retrospective Drug Utilization Review (DUR)

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A. The Division of Medicaid utilizes a quality assurance program, Drug Utilization Review (DUR), to:

1. Promote patient safety by an increased review and awareness of outpatient prescribed drugs including drug appropriateness,

2. Enhance and improve the quality of pharmaceutical care and patient outcomes by encouraging optimal drug use, and

3. Educate physicians and pharmacists on appropriate, safe and effective drug therapy.

B. The Division of Medicaid’s DUR Board is composed of twelve (12) participating physicians and pharmacists who are active MS Medicaid providers and in good standing with their licensing boards who meet quarterly.

Source: The Omnibus Budget Reconciliation Act (OBRA 90); Miss. Code Ann. § 43-13-107.

History: New Rule eff. 11/01/2014.

Rule 1.14: Participating Federally Qualified Health Center (FQHC) Providers

All drugs, as defined by the Veterans Health Care Act of 1992 Title VI, purchased by an in- house pharmacy of a Federally Qualified Health Center (FQHC) at a discounted price must be reported on the cost report and are reimbursed through the core services encounter rate and not billed through the Pharmacy Program.

Source: The Veterans Health Care Act of 1992 Title VI.

History: New Rule eff. 11/01/2014.

Rule 1.15: 340B Program

Providers participating in the 340B program must adhere to all the provisions in Miss. Admin. Code Part 200, Chapter 4, Rule 4.10.

Source: Sec. 340B of the Public Health Service Act (Pub. L. 102-585), as amended by the Patient Protection and Affordable Care Act (Pub. L. 111-148), Health Care and Education Reconciliation Act (Pub. L. 111-152) and Medicare and Medicaid Extenders Act of 2010 (Pub. L. 111-309); Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: New Rule eff. 11/01/2014.

Rule 1.16: Clinician Administered Drugs and Implantable Drug System Devices (CADDs)

A. The Division of Medicaid defines Clinician Administered Drugs and Implantable Drug System Devices (CADDs) as certain physician-administered drugs, with limited distribution

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or limited access for beneficiaries and administered in an appropriate clinical setting, which may be billed as either a medical claim or pharmacy point-of-sale (POS) claim, as determined by the Division of Medicaid.

B. The Division of Medicaid covers certain CADD drugs which are listed on the Division of Medicaid’s website.

C. CADD drugs which are dispensed by a pharmacy provider directly to a prescriber for administration do not count toward a beneficiary’s monthly prescription drug limits.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121; MS SPA 2018-0011.

History: Revised to correspond with SPA 23-0011 (eff. 5/01/2023) eff. 09/01/2023. New Rule to correspond with SPA 2018-0011 (eff. 7/1/18) eff. 06/01/2019.

Part 214 Chapter 2: Pharmacy Disease Management

Rule 2.1: Provider Enrollment and Pharmacy Participation

A. Pharmacists participating in the Medicaid program and providing disease management services must comply with the requirements outlined in Part 214, Chapter 1, Rule 1.1 in addition to the following requirements:

1. National Provider Identifier (NPI) verification from National Plan and Provider Enumeration System (NPPES),

2. Copy of current pharmacist’s license or permit,

3. Verification of social security number using a social security card, driver’s license if it notes the social security number, military ID or a notarized statement signed by the provider noting the social security number. The name noted on verification must match the name on the W-9, and

4. Credentials from a nationally recognized credentialing agency applicable to the specific disease for which care is provided.

B. Pharmacy disease management provider agreements will not be initiated or maintained with any pharmacist whose place of business is physically located more than thirty (30) miles from the borders of Mississippi.

C. Only individual pharmacists can enroll as a pharmacy disease management provider. Pharmacies with multiple individual pharmacy disease management providers may apply for group management services under one (1) group provider number; but each individual pharmacist in the group must maintain his/her own individual provider number. Businesses such as partnerships and corporations are not allowed to operate as pharmacy disease management providers.

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Source: 42 CFR 455, Subpart E; Miss. Code Ann. § 43-13-121.

History: Revised eff. 11/01/2020.

Rule 2.2: Program Services

A. Pharmacy Disease Management (PDM) services are those provided for Medicaid beneficiaries with specific chronic disease states of diabetes, asthma, hyperlipidemia, anti- coagulation therapy, or other disease states as defined by the Division of Medicaid. It is a patient-centered concept integrating the pharmacist into the health care team with shared responsibility for disease management and therapeutic outcomes.

B. A referral for PDM services is required and services must be provided by a specially credentialed pharmacist. Pharmacy care records including a written referral and all laboratory test results must be transferred from the referring physician to the pharmacist. PDM services performed by the pharmacist must not duplicate services provided by the physician.

C. The pharmacist must be knowledgeable about pharmaceutical products and the design of therapeutic approaches that are safe, effective, and cost-efficient for patient outcomes. He or she is to function in an educational capacity to ensure the patient understands and complies with the proper usage of all drugs prescribed by the physician. It is the responsibility of the pharmacist to:

1. Evaluate the patient,

2. Consult with the physician concerning the suggested/prescribed drug therapy,

3. Counsel the patient regarding compliance, and

4. Provide the patient with educational and informational materials specific to the disease and/or drug.

D. Communication is required between the referring physician and the pharmacist. Pharmacy disease management services follow a protocol developed between the pharmacist and patient’s physician.

E. The pharmacist provider must personally render all pharmacy disease management services billed to Medicaid. A relief pharmacist employed for pharmacy disease management services must bill Mississippi Medicaid using his/her own individual Medicaid provider number.

Source: Miss. Code Ann. § 43-13-121

Rule 2.3: Components of Pharmacy Disease Management

A. The primary components of this service are as follows:

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1. Patient evaluation,

2. Compliance assessment,

3. Drug therapy review,

4. Disease state management, according to clinical practice guidelines, and

5. Patient/caregiver education.

B. The pharmacist must provide a separate, distinct area conducive to privacy for a seated, face- to-face consultation with the beneficiary, such as a partitioned booth or a private room. This consultation is used to privately educate the beneficiary.

C. A copy of the pharmacy care records, including the documentation for services, must be shared with the patient’s physician and remain on file in the pharmacist’s facility and available for audit by the Division of Medicaid.

Source: Miss. Code Ann. § 43-13-121

Rule 2.4: Eligibility

A. Pharmacy disease management services are not covered for beneficiaries in long term care facilities or for beneficiaries receiving home health services.

B. Neither OBRA-mandated counseling nor JCAHO-mandated institutional discharge counseling qualify as a pharmacy disease management service.

C. Pharmacy disease management services are available to the parent or other responsible guardian when the beneficiary is a minor and/or mentally challenged and living at home.

Source: Miss. Code Ann. § 43-13-121

Rule 2.5: Reimbursement

A. Pharmacy disease management services are reimbursed on a per encounter basis. When billing for an encounter, pharmacy disease management providers must use the appropriate procedure code. An encounter must be at least fifteen (15) minutes and average thirty (30) minutes.

B. The number of encounters is limited to twelve (12) per beneficiary per fiscal year.

Source: Miss. Code Ann. § 43-12-121

Rule 2.6: Pharmacy Disease Management Documentation Requirements

In addition to the documentation requirements applicable to all pharmacy providers, pharmacy

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disease management providers must maintain additional documentation. The disease management pharmacist must maintain at his/her place of business proof of current certification for the specific disease state for which reimbursement is sought. A pharmaceutical care record, or patient record, must be maintained on each individual beneficiary for whom services are billed. These records must be retained and maintained in a manner conducive to audit, in alphabetical order and for a minimum of five (5) years. At a minimum, the following documents must be maintained, in date order, within each individual beneficiary’s pharmaceutical care record:

A. A referral from the beneficiary’s physician/nurse practitioner,

B. A copy of the protocol in accordance with the National Clinical Practice Guidelines authorizing pharmacy disease management of the beneficiary,

C. Documentation of all oral and written communication with the beneficiary’s physician/nurse,

D. Copies of all laboratory data provided, and

E. All pharmacist notes, including progress reports, pertaining to the care of the beneficiary.

Source: Miss. Code Ann. § 43-13-117, 43-13-118, 43-13-121, 43-13-129

Part 215 Home Health Services

23 Miss. Admin. Code Pt. 215 Home Health Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 215 Home Health Services

ntents Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 215: Home Health Services ................................................................................................. 1 Part 215 Chapter 1: Home Health Services ............................................................................. 1 Rule 1.1: Definitions ........................................................................................................ 1 Rule 1.2: Provider Enrollment Requirements .................................................................. 2 Rule 1.3: Covered Services .............................................................................................. 2 Rule 1.4: Non-Covered Services ...................................................................................... 5 Rule 1.5: Reimbursement ................................................................................................. 6 Rule 1.6: Documentation.................................................................................................. 7 Rule 1.7: Early, Periodic Screening, Diagnosis and Treatment (EPSDT) ....................... 8

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Title 23: Division of Medicaid

Part 215: Home Health Services

Part 215 Chapter 1: Home Health Services

Rule 1.1: Definitions

The Division of Medicaid defines:

A. Home health services as skilled nursing visits, home health aide visits, and durable medical equipment, supplies and appliances provided to a beneficiary:

1. At the beneficiary's place of residence,

2. Ordered by the beneficiary's physician or non-physician practitioner (NPP) as part of a written plan of care reviewed by the physician or NPP every sixty (60) days.

B. Residence as any setting in which normal life activities take place, other than a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

C. Durable medical equipment, supplies and appliances in Miss. Admin Code Title 23, Part 209.

D. Out-patient setting as any setting where a beneficiary receives services and is not admitted as a resident or inpatient.

E. Order as the certification of need for home health services.

F. Recertification as the certification of continued need for home health services.

G. A face-to-face encounter, for home health services, as an in person visit, including telehealth, which occurs between a physician or allowed non-physician practitioner and a beneficiary for the primary reason the beneficiary requires home health services and must occur no more than ninety (90) days before or thirty (30) days after the start of home health services.

H. Allowed non-physician practitioner (NPP) as a:

1. Nurse practitioner or clinical nurse specialist working in collaboration with the beneficiary's physician, or

2. Physician assistant under the supervision of the beneficiary's physician.

Source: 42 C.F.R. § 440.70; Miss. Code Ann. §§ 43-13-117, 43-13-121.

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History: Revised eff. 07/01/2021; Revised and renamed rule eff. 09/01/2018.

Rule 1.2: Provider Enrollment Requirements

Home health providers, including out-of-state providers, must meet all of the applicable requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4.

Source: 42 C.F.R. § 440.70, 42 C.F.R. Part 455, Subpart E; 42 C.F.R. Part 484; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. Revised eff. 09/01/2018.

Rule 1.3: Covered Services

A. The Division of Medicaid covers the following home health services:

1. Skilled nursing visits.

a) Intermittent or part-time skilled nursing services must be provided during the visit by a registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a RN employed by a home health agency in accordance with Mississippi State Department of Health, Division of Health Facilities Licensure and Certification (MSDH-DHFLC) standards or an RN when no home health agency exists in the area.

b) The RN must be a graduate of an approved school of professional nursing, who is licensed as an RN by the State in which they practice.

2. Home health aide visits for home health aide services.

a) Home health aide services must be provided directly by an aide employed by a home health agency and in accordance with MSDH-DHFLC standards.

b) The home health aide must be an individual who has successfully completed a state- established or other home health aide training program approved by the MSDH- DHFLC.

c) A supervisory visit must be made every sixty (60) days by an RN.

d) Home health aide services may be provided without the requirement of receiving skilled nursing services.

3. Durable medical equipment, medical supplies and appliances as described in Miss. Admin. Code Title 23, Part 209.

B. The Division of Medicaid covers up to thirty-six (36) home health visits per state fiscal year.

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C. Home health services must be medically necessary and reasonable for the treatment of the beneficiary’s disability, illness, or injury.

D. To receive home health services a beneficiary must:

1. Be unable to travel to an outpatient setting for the needed services, or

2. Have a condition that is so fragile or unstable that the beneficiary cannot receive the services in an outpatient setting, and

3. Be seen by a physician or allowed non-physician practitioner (NPP) at least every sixty (60) days for the purpose of recertification of home health services.

E. Home health services must be provided to a beneficiary at the beneficiary’s place of residence defined as any setting in which normal life activities take place, other than:

1. A hospital,

2. Nursing facility,

3. Intermediate care facility for individuals with intellectual disabilities except when the facility is not required to provide the home health service, or

4. Any setting in which payment is or could be made under Medicaid for inpatient services that include room and board.

F. The beneficiary’s physician or allowed NPP, must document that a face-to-face encounter occurred no more than ninety (90) days before or thirty (30) days after the start of home health services. The face-to-face encounter must be related to the primary reason the beneficiary requires the home health service.

G. Home health services must be provided in accordance with an order written by a physician, nurse practitioner, or physician assistant working in accordance with State law as part of a written plan of care, which must be reviewed every sixty (60) days.

H. Recertification must occur at the time the plan of care is reviewed, and must be signed and dated by the physician or allowed NPP who reviews the plan of care.

I. The home health agency providing home health services must be certified to participate as a home health agency under Medicare, and comply with all applicable state and federal laws and requirements.

J. Home health services are covered for beneficiaries eligible for both Medicare and Medicaid if:

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1. The beneficiary is not receiving and does not qualify for home health services covered under Medicare,

2. The beneficiary is eligible for home health services provided by Medicaid,

3. The home health services are medically necessary, and

4. All requirements of Miss. Admin. Code Title 23, Part 215 are met.

K. The Division of Medicaid covers home health services furnished to a beneficiary in another state to the same extent that home health services are covered in-state if:

1. Home health services are needed because of a medical emergency,

2. It would cause the beneficiary's condition to decline if they were required to return to Mississippi in order to receive necessary home health services,

3. The Division of Medicaid determines, on the basis of medical advice, the medically necessary home health services or necessary supplementary resources are more readily available in the other state,

4. It is general practice for beneficiaries in a particular locality to use resources in another state, or

5. The beneficiary has not been a resident for more than thirty (30) days in the state where the home health agency operates.

L. The Division of Medicaid requires the following guidelines for an out of state home health agency:

1. If the beneficiary has been a resident for more than thirty (30) days in the state where the home health agency operates, the beneficiary would be considered a resident of that state and the Mississippi Division of Medicaid would not reimburse for services provided, or

2. If the beneficiary has not been a resident for more than thirty (30) days in the state where the home health agency operates, the Mississippi Division of Medicaid would reimburse for services.

M. Out-of-state providers are required to request a provider number and meet all home health agency requirements.

Source: 42 C.F.R. § 440.70; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with MS SPA 24-0006 (eff. 07/01/2024) eff. 11/01/2024; Revised eff. 07/01/2021; Revised eff. 07/01/2019.

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Rule 1.4: Non-Covered Services

The Division of Medicaid does not cover:

A. Home health services provided to a beneficiary who can receive the services in an outpatient setting including, but not limited to:

1. Outpatient hospital,

2. Free-standing clinic, or

3. Nursing facility.

B. Services that are not medically necessary.

C. Services that are not part of a written plan of care reviewed and recertified every sixty (60) days by a physician.

D. Services provided by a home health agency that has not met the requirements for participation in Medicare.

E. Services that have not been ordered by a physician.

F. Services provided in another state where the beneficiary has been a resident for more than thirty (30) days.

G. The following services under the home health benefit:

1. Physical therapy,

2. Occupational therapy, and/or

3. Speech-language pathology and audiology services.

Source: 42 C.F.R. § 440.70; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 09/01/2018.

Rule 1.5: Reimbursement

A. In order to receive reimbursement from the Division of Medicaid for the face-to-face encounter, the encounter must be conducted by an enrolled Medicaid provider.

B. The Division of Medicaid reimburses for home health services based on reasonable cost determined in accordance with the State Plan and Medicare principles of reimbursement, except when Medicare guidelines are contradictive to directives of the State Plan or the

6

Division of Medicaid. In such a situation, the State Plan or the Division of Medicaid will prevail.

1. Medicaid cost reporting schedules must be included with the Medicare cost report to compute Medicaid reimbursement.

2. A schedule must be completed to reflect the lower of reasonable costs or customary charge provisions as they apply to Medicaid.

3. In addition to the lower of costs or charge limitations, reimbursement for home health services is limited to and cannot exceed the prevailing costs of providing nursing facility services.

C. The Division of Medicaid reimburses for the initial assessment visit for skilled nursing services and aide services as listed below:

1. If a beneficiary is assessed for services without a skilled nursing service performed during the initial assessment visit and is not admitted to the home health program, the initial assessment visit cannot be billed and must be claimed as an administrative cost.

2. If a beneficiary is assessed for services and a skilled nursing service is performed during the initial assessment visit and is admitted to the home health program for continuation of skilled nursing and/or aide visits, the initial assessment visit can be billed and is not considered an administrative cost.

3. If a beneficiary is assessed for services with a skilled nursing service performed during

   the initial assessment visit only and is not admitted to the home health program, the home

   health agency must elect either to:

   1. Claim the initial assessment visit as an administrative cost, or
   2. Admit and discharge the beneficiary on the same day from the home health program

   and bill for the one (1) initial assessment visit and is not considered an administrative

   cost.

4. If a beneficiary is assessed for only home health aide services and a skilled nursing service is not performed during the initial assessment visit and the beneficiary is not admitted to the home health program, the initial assessment visit cannot be billed and is considered as an administrative cost.

5. If a beneficiary is assessed for only home health aide services and a skilled nursing

   service is performed during the initial assessment visit and the beneficiary is admitted to

   the home health program, the home health agency must elect either to:

   1. Claim the initial assessment visit as an administrative cost, or
   2. Bill the initial assessment visit as a skilled nursing service.

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D. Supervisory visits are administrative costs and are not directly reimbursable.

E. The Division of Medicaid reimburses a medical supply add-on calculated as described in the State Plan.

Source: 42 C.F.R. § 440.70; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with SPA 23-0003 (eff. 02/01/2023) eff. 05/01/2023; Revised eff. 07/01/2021; Revised eff. 09/01/2018.

Rule 1.6: Documentation

A. The Division of Medicaid requires the home health agency to maintain auditable records that substantiate the services provided and include, at a minimum, the following in each beneficiary’s record verifying services provided by the home health agency are medically necessary [Refer to Maintenance of Records Part 200, Rule 1.3.]:

1. Physician or non-physician practitioner (NPP) referral,

2. Appropriate information identifying the beneficiary,

3. Name of the physician or NPP,

4. Documentation of the face-to-face encounter with the ordering physician or allowed non- physician practitioner (NPP) including:

a) Documentation that the required face-to-face encounter related to the primary reason the beneficiary needs the services occurred ninety (90) days before or thirty (30) days after the start of home health services,

b) Identification of the physician or allowed NPP who conducted the encounter, and

c) The date of the face-to-face encounter,

5. If the face-to-face encounter was performed by an allowed NPP, the clinical findings of the face-to-face encounter must be incorporated into a written or electronic document in the beneficiary's medical record.

6. Documentation that the services cannot be provided in any other setting other than the beneficiary’s residence.

7. The initial order and all recertifications signed by the physician or NPP which must include:

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a) Justification home health services are medically necessary and reasonable for treatment of the beneficiary’s illness, injury, or condition,

b) The type of services required, and

c) The estimated duration home health services will be needed,

8. The beneficiary's plan of care,

9. Documentation that the beneficiary's plan of care is reviewed and recertified by a physician or NPP every sixty (60) days,

10. Signed copy of orders, new orders or changes in orders for medications, medical supplies, treatments, dietary, and activities,

11. Case conference report(s) covering all disciplines,

12. Lab results and other diagnostic test results,

13. Discharge summary to include transfers and hospital stays,

14. Documentation of all verbal communications between the home health agency and the physician and/or allowed NPP, and

15. Documentation that a supervisory visit was made by a registered nurse (RN) at least every sixty (60) days for home health aide services.

B. Home health agencies must provide and the physician must maintain copies of the documentation in Miss. Admin. Code Part 215, Rule 1.6.A. in each beneficiary's record verifying services provided by the home health agency are medically necessary. [Refer to Maintenance of Records Part 200, Rule 1.3.]

Source: 42 C.F.R. §§ 440.70, 484.48; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121, 43-13-129.

History: Revised eff. 07/01/2021; Revised eff. 09/01/2018.

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Part 216 Dialysis Services

23 Miss. Admin. Code Pt. 216 Dialysis Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 216 Dialysis Services

Table o

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 216: Dialysis Services ......................................................................................................... 1 Part 216 Chapter 1: Dialysis Services .................................................................................... 1 Rule 1.1: Provider Enrollment Requirements .................................................................. 1 Rule 1.2: Covered Services .............................................................................................. 1 Rule 1.3: Bundled ESRD PPS Rate ................................................................................. 2 Rule 1.4: Professional Services ........................................................................................ 2 Rule 1.5: Documentation Requirements .......................................................................... 3 Rule 1.6: Immunizations .................................................................................................. 3 Rule 1.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ....... Error! Bookmark not defined.

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Title 23: Division of Medicaid

Part 216: Dialysis Services

Part 216 Chapter 1: Dialysis Services

Rule 1.1: Provider Enrollment Requirements

Freestanding or hospital-based kidney dialysis centers must meet all of the applicable requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4.

Source: 42 CFR 455, Subpart E; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026.

Rule 1.2: Covered Services

A. The Division of Medicaid covers:

1. Hemodialysis,

2. Peritoneal dialysis,

3. Continuous Ambulatory Peritoneal Dialysis (CAPD), and

4. Continuous Cyclic Peritoneal Dialysis (CCPD).

B. Prior authorization is not required for dialysis services.

C. The Division of Medicaid covers:

1. All resources used in providing outpatient dialysis services, including supplies and equipment used to administer dialysis in the ESRD (end stage renal disease) facility or at a beneficiary’s home, drugs, biologicals, laboratory tests, and support services under the bundled ESRD PPS (prospective payment system) rate,

2. Professional services,

3. Antibiotics, when used at home by a beneficiary, to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis, and

4. Specified lab tests and injectable drugs not included in the bundled ESRD PPS rate, when medically necessary.

Source: 42 CFR Part 494; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with SPA 14-003 (eff. 01/01/2014) eff. 05/01/2014.

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Rule 1.3: Bundled ESRD PPS Rate

A. The Division of Medicaid reimburses ESRD facilities the bundled ESRD PPS rate effective as of January 1, of each year.

B. The ESRD PPS rate provides a single payment for all resources used in providing dialysis services including supplies, equipment, drugs, biologicals, laboratory services and support services.

1. The facility must furnish all necessary services, equipment, and supplies.

2. The appropriate revenue codes must be billed for the ESRD PPS rate.

3. Dialysis services are not reimbursed if there are no corresponding treatment notes.

Source: 42 CFR 494; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with SPA 24-0001 (eff. 01/01/2024) eff. 06/01/2025; Revised eff. 07/01/2021; Revised to correspond with SPA 14-003 (eff. 01/01/2014) eff. 05/01/2014Title 23: Medicaid Rule 1.4: Professional Services

A. The Division of Medicaid covers related physician services for ESRD billed with the appropriate procedure codes which are excluded from the ESRD PPS rate.

1. The physician or qualified health care professional must provide one (1) face-to-face visit with the beneficiary monthly.

2. The medical record must contain the physician or qualified health care professional’s documentation substantiating the medical necessity for additional face-to-face visits.

3. Documentation must be legibly written, signed and dated during the face-to-face visit.

4. Documentation by the interdisciplinary team cannot substantiate the medical necessity of the physician or qualified health care professional’s face-to-face visit.

B. Physician services are not covered under the facility’s provider number.

C. Face-to-face physician visits are not included in the physician services visit limit.

D. Evaluation and management services provided to the beneficiary which are unrelated to dialysis services cannot be performed during the dialysis session and must be reported separately.

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Source: 42 CFR § 414.310; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with SPA 14-003 (eff. 01/01/2014) eff. 05/01/2014.

Rule 1.5: Documentation Requirements

A. Dialysis providers must maintain auditable records that substantiate the dialysis services provided.

B. The physician or qualified healthcare professional’s documentation in the medical record must include, but is not limited to, the following:

1. Dates of service,

2. Monthly face-to-face evaluation of the beneficiary’s current health status, medical condition, provider findings and appropriateness of the treatment plan,

3. Mode of dialysis and treatment plan,

4. All treatments, medications, biologicals, lab tests and other studies both included and excluded in the ESRD PPS rate, and

5. A legible signature of the physician or qualified healthcare professional with documented credentials to support the service rendered and date of entry.

C. If more than one (1) face-to-face physician or qualified healthcare professional visit is required within a month the:

1. Physician or qualified healthcare professional’s documentation must support the medical necessity for the visit.

2. Interdisciplinary team documentation cannot be used to substantiate billing a physician or qualified healthcare professional’s face-to-face visit.

D. The dialysis facility’s record must include, but is not limited to, the following:

1. Dates of service,
2. Current annual evaluation including age and gender-appropriate history and physical examination documented by a physician including all pertinent lab and diagnostic procedures,
3. Individualized treatment notes which must include documentation verifying each face-to- face physician visit,
4. Beneficiary assessment in accordance with 42 CFR § 494.80,

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5. Mode of dialysis and treatment plan,
6. All treatments, medications, biologicals, lab tests and other studies both included and excluded in the ESRD PPS rate,
7. A written plan of care prepared and reviewed monthly by an interdisciplinary team that includes the beneficiary’s physician and other healthcare professionals, as appropriate, familiar with the beneficiary’s condition, and
8. A legible signature of the physician or healthcare professional with documented credentials to support the service rendered and date of entry. Source: Miss. Code Ann. § 43-13-121.

History: Revised to correspond with SPA 14-003 (eff. 01/01/2014) eff. 05/01/2014.

Rule 1.6: [Reserved]

Part 217 Vision Services

23 Miss. Admin. Code Pt. 217 Vision Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 217 Vision Services

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 217: Vision Services ........................................................................................................... 1 Part 217 Chapter 1: General ....................................................................................................... 1 Rule 1.1: Vision Services ................................................................................................. 1 Rule 1.2: Provider Enrollment ........................................ Error! Bookmark not defined. Rule 1.3: Reimbursement ................................................................................................. 1 Rule 1.4: Non-Covered Services ...................................................................................... 2 Rule 1.5: Eye Examinations/Refractions ......................................................................... 3 Rule 1.6: Lacrimal Punctum Plugs ................................................................................... 3 Rule 1.7: Documentation.................................................................................................. 5 Rule 1.8: Dual Eligibles ................................................................................................... 5 Rule 1.9: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ................ 5 Part 217 Chapter 2: Contact Lenses .......................................................................................... 6 Rule 2.1: Coverage Criteria .............................................................................................. 6 Rule 2.2: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ................ 7 Part 217 Chapter 3: Eyeglasses ................................................................................................. 7 Rule 3.1: Coverage Criteria .............................................................................................. 7 Rule 3.2: Lens Coating ..................................................................................................... 8 Rule 3.3: Cataract/Ocular Surgery ................................................................................. 10 Rule 3.4: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 10

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Title 23: Division of Medicaid

Part 217: Vision Services

Part 217 Chapter 1: General

Rule 1.1: Vision Services

Vision service is an optional benefit under the state’s Medicaid program and financial assistance is provided as follows:

A. Eyeglasses for all Medicaid beneficiaries who have had surgery on the eyeball or ocular muscle that results in a vision change for which eyeglasses are medically indicated within six (6) months of the surgery and is in accordance with rules established by Medicaid, or

B. One (1) pair of eyeglasses every five (5) years and in accordance with rules established by Medicaid. In either instance, the eyeglasses must be prescribed by a physician skilled in diseases of the eye or an optometrist, whichever the beneficiary selects.

C. Eye exams for all eligible beneficiaries are covered.

Source: Miss. Code Ann. § 43-13-121; 43-113-117(11); 42 CFR 441.30

Rule 1.2: Provider Enrollment

Providers of vision services, and those who dispense optical items such as eyeglasses and contacts must meet all of the applicable requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4.

Source: Miss. Code Ann. § 43-13-121; 42 CFR 455, Subpart E

History: Revised eff. 08/01/2026.

Rule 1.3: Reimbursement

A. Medicaid covers vision services under a statewide uniform fixed fee schedule for the professional services of the optometrist or ophthalmologist plus actual acquisition cost for eyeglass frames and lenses. The provider of eyeglasses must bill the actual acquisition cost (AAC) for the frames and lenses. Medicaid will cover the frames and lenses based on the lower of AAC or the maximum fee as determined by Medicaid. Effective as of July 1, 2021 all rates and/or fees for items and services will remain the same as those in effect for State Fiscal Year (SFY) 2021.

B. Medicaid does not permit providers of optometric services to charge a beneficiary an additional amount for services or supplies, like frames, above the fee established. The provider cannot dispense a more expensive frame than is covered under the Medicaid

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program and collect the difference from the beneficiary.

C. A beneficiary may purchase non-covered services, like scratch resistant lens coating. Providers cannot bill Medicaid and hold the eyeglasses or contacts until Medicaid pays the provider. Providers may not bill Medicaid for replacement costs associated with provider error or poor workmanship.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021.

Rule 1.4: Non-Covered Services

A. The Division of Medicaid does not cover vision services including, but not limited to, eye exams, eyeglasses, frames, lenses, and/or contact lenses, for beneficiaries enrolled in the Family Planning Waiver (FPW).

B. The Division of Medicaid does not cover the following including, but not limited to:

1. Eyeglasses solely for protective, fashion, cosmetic, sports, occupational or vocational purposes,

2. More than one (1) pair of eyeglasses every five (5) years,

3. Single vision eyeglasses in addition to multifocal eyeglasses,

4. Progressive bifocals,

5. Sunglasses,

6. Upgraded frames,

7. Eyeglass cases,

8. Engraving,

9. Contact lens supplies and/or solutions,

10. Eyeglass or contact lens insurance,

11. Lens coating, unless specified by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity,

12. Orthoptics,

13. Dispensing fees,

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14. Contact lenses, unless specified by a UM/QIO, the Division of Medicaid, or designated entity,

15. Refractive surgery including, but not limited to, Lasik surgery, radial keratotomy, photorefractive keratectomy, and/or astigmatic keratotomy,

16. Services and items requiring prior authorization for which authorization has been either denied or not requested, or

17. Replacement of lenses or frames due to:

a) Provider error in prescribing, frame selection, or measurement, or

b) Poor workmanship and/or materials.

Source: 42 CFR §§ 435.116, 441.30; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 13-0019; Healthier Mississippi Waiver.

History: Revised to correspond with SPA 13-0019 (eff. 01/01/14) and Healthier Mississippi Waiver (HMW) Renewal (eff. 07/24/2015) eff. 04/01/2016.

Rule 1.5: Eye Examinations/Refractions

A. Medicaid requires eye examinations/refractions to be performed by an optometrist or an ophthalmologist. Medicaid covers for one (1) refraction every five (5) years. No prior authorization is required. The appropriate procedure code must be billed.

B. Medicaid covers medically necessary diagnostic services that aid in the evaluation, diagnosis, and or treatment of ocular disease or injury for all beneficiaries regardless of age. Coverage is limited to the eye examination. The exam counts toward the sixteen (16) physician office visits. Providers must bill using the appropriate procedure codes for new and established patients.

Source: 42 CFR § 441.30; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021.

Rule 1.6: Lacrimal Punctum Plugs

A. Medicaid covers medically necessary insertion of collagen and silicone punctum plugs when there is a documented diagnosis consistent with moderately severe to severe dry eye syndrome. A signed treatment/surgical consent form, specific to plug insertion, is required.

B. Medicaid does not cover the following:

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1. Insertion of silicone plugs less than ten (10) days following collagen plug insertion,

2. Insertion of plugs for the treatment of any condition other than dry eye syndrome, contact lens intolerance, refractive correction, glaucoma, or sinus maladies,

3. Repetitive use of temporary or dissolvable collagen plugs when semi-permanent or permanent treatment is indicated,

4. Repetitive use of semi-permanent or non-dissolvable silicone plugs when there is an absence of documentation to support the need, such as plug fell out, and/or when permanent treatment is indicated, or

5. Separate reimbursement for the plug itself or when the cost of the plug is included in payment for the insertion.

C. Medicaid covers up to two (2) collagen or silicone plugs per office visit. In most cases, placement of one (1) plug in each lower punctum is sufficient to alleviate symptoms. Up to two (2) additional plugs may be performed for a total of four (4), but documentation must reflect that the additional plugs were medically necessary. There must be a period of no less than ten (10) days between the insertion of collagen plugs and the insertion of silicone plugs.

D. Providers must use the appropriate procedure code in conjunction with the appropriate and applicable modifier for each plug is placed into a punctum.

E. There may be both a diagnostic occlusion with a temporary dissolvable collagen plug and a therapeutic occlusion with a semi-permanent, non-dissolvable silicone, plug performed on the same beneficiary within a short amount of time. Medicaid does not cover if the length of time between insertion of collagen and silicone plugs is less than ten (10) days.

F. Medicaid requires documentation of the following for insertion of lacrimal punctum plugs:

1. Symptoms, including dryness, scratchiness, itching, redness, burning, foreign body sensation,

2. Comorbidities that might be related to ophthalmic disease,

3. Diagnostic tests and results, including visual acuity exam, slit lamp exam, tear film break- up time (BUT), Schirmer’s tear test, and/or staining procedures,

4. Signed treatment/surgical consent form(s) specific to insertion of the plug,

5. Specific treatments rendered, including conservative treatments, and the results, and

6. Operative report(s).

G. Documentation must be sufficient to support the type, either temporary or semi-permanent,

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and the number of plugs inserted. Documentation must reflect a minimum of ten (10) days between insertion of temporary plugs and the insertion of semi-permanent plugs.

Source: Miss. Code Ann. § 43-13-121

Rule 1.7: Documentation

Records must be documented and maintained in accordance with Part 200, Chapter 1, Rule 1.3. The vision medical record documentation must contain the following on each beneficiary:

A. Date(s) of service,

B. Demographic information,

C. Current medical history,

D. Examination and/or treatment rendered,

E. Specific name/type of all diagnostic studies, and the result/finding of the studies,

F. Specific order for all lenses, lens coating, and ocular prosthetics, and

G. Provider’s signature.

Source: Miss. Code Ann. § 43-13-121; 43-13-117; 43-13-118; 43-13-129

Rule 1.8: Dual Eligibles

A. Medicare covers vision services provided to dual eligible beneficiaries, in accordance with the rules outlined in this Part, for services not covered by Medicare when the reason for the Medicare denial is other than medical necessity.

B. Dual eligible beneficiaries cannot be billed the balance between standard and deluxe frames as the Medicare and Medicaid payment is considered payment in full.

C. Providers must adhere to the rules for Third Party billing outlined in Part 306.

Source: Miss. Code Ann. § 43-13-121

Rule 1.9: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

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Part 217 Chapter 2: Contact Lenses

Rule 2.1: Coverage Criteria

A. Medicaid does not cover contact lenses when prescribed for routine correction of refractive errors.

B. Medicaid covers contact lenses prescribed by an ophthalmologist or an optometrist when there is documentation that supports the following criteria:

1. Conventional eyeglasses will not result in acceptable visual correction, and

2. Contact lenses are medically necessary for the treatment of the following diseases or injury to the eye:

a) Keratoconus,

b) Keratoglobus,

c) Irregular cornea astigmatism,

d) Nystagmus,

e) Progressive myopia over 6 diopters, where contact lens will improve visual acuity or retard the progressive myopia and lessen the frequency of prescription changes,

f) Hyperopia over 3.5 diopters, where contact lenses will improve visual acuity,

g) Anisometropia greater than 3 diopters or greater than 2.5, if there is documented intolerance to glasses as a result of anisometropia,

h) Disease or deformity of the nose, skin, or ears that precludes the wearing of eyeglasses,

i) Post-operative cataract surgery, or

j) Treatment as a result of eye surgery, other than cataracts, which must be provided within six (6) months of the surgery to be covered.

C. Corneal bandages when used as lenses are not covered as a separate reimbursement. The cost of the lenses is included in the payment for the physician and/or facility’s service. Providers should bill using the appropriate procedure code. Prior authorization is required.

D. Prescriptions must include lens specifications such as power, size, curvature, flexibility, and gas-permeability for contact lenses.

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E. Medicaid does not cover for replacement of lost or stolen contact lenses.

F. Prior authorization is required for all contact lenses. The request must properly document that one (1) of the diagnoses listed under coverage criteria is involved, and it must reflect that conventional eyeglasses is not an acceptable method of correction.

Source: Miss. Code Ann. § 43-13-121

Rule 2.2: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Part 217 Chapter 3: Eyeglasses

Rule 3.1: Coverage Criteria

A. Medicaid covers eyeglasses prescribed by an ophthalmologist or optometrist when documentation supports the following:

1. Eyeglasses are medically necessary,

2. Eyeglasses are prescribed to significantly improve vision or correct a medical condition, and

3. Eyeglasses meet eyeglass program specifications for frames and lenses.

B. Coverage benefits/limitations include:

1. Beneficiaries are allowed one (1) complete pair of eyeglasses every five (5) years. Prior authorization is not required unless manually priced codes are used. This includes eyeglass lenses and frames.

2. Repairs and replacements are not covered.

C. Prescriptions for eyeglass lenses must include lens specifications such as lens type, power, axis, prism, absorptive power, and impact resistance.

D. Prescriptions for lens coating must include the appropriate diagnosis codes and/or narrative diagnosis.

E. Lenses may be glass or plastic. All lenses must meet FDA impact resistant regulations.

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F. Only standard frames with the appropriate code are covered. Deluxe frames are not covered. Eyeglass frames should be durable and constructed to be normally resistant to damage or breakage to minimize the need for replacement.

G. Fitting is a separate service and is covered. Fitting includes measurement of anatomical facial characteristics, the writing of laboratory specifications, and the final adjustment of spectacles to the visual axes and anatomical topography.

Source: Miss. Code Ann. § 43-13-121; 43-13-117(1)

Rule 3.2: Lens Coating

A. For purposes of this rule the following definitions will apply:

1. Antireflective is a coating applied to a lens to reduce the amount of reflected light and glare that reaches the eye.

2. Mirror coating is applied to a lens that allows the lens to take on the properties of a two- way mirror.

3. Scratch resistant coating is applied to a lens that helps retard crazing of the lens, thus extending the product life.

4. Tint is an opaque or transparent color coating applied to a lens. The parts of the light spectrum that are absorbed by the lens are determined by the color of the tint.

5. Photochromatic coating is applied to a lens that allows the lens to adjust to the amount of available light.

6. Polarized coating is applied to a lens that filters out reflected light and glare.

7. UV coating is applied to a lens to filter out ultraviolet light.

B. Medicaid covers tinted lenses, photochromatic lenses, or UV protected lens when medically necessary for the following medical diagnoses:

1. Other disturbances of aromatic amino-acid metabolism,

2. Degeneration of macula and posterior pole,

3. Pigmentary retinal dystrophy,

4. Cataracts,

5. Keratitis,

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6. Corneal opacity and other disorders of cornea,

7. Disorders of conjunctiva,

8. Aphakia,

9. Congenital Aphakia,

10. Aniridia, and

11. Pseudophakos.

C. Non-covered services include:

1. Scratch resistant coating,

2. Antireflective coating,

3. Mirror coating,

4. Polarized coating, and

5. Diagnoses other than those listed under coverage criteria.

D. Prescriptions for lens coating must include the appropriate diagnosis code and/or a narrative diagnosis.

E. A beneficiary may purchase non-covered lens coating services. Charges for non-covered services must not be billed to Medicaid.

F. Documentation must comply with the requirements for maintenance of records set forth in Part 200, Chapter 1, Rule 1.3 in addition to following documentation specific to lenses and lens coating:

1. Orders and prescriptions for eyeglass lenses must include lens specifications such as lens type, power, axis, prism, absorptive factor, and impact resistance.

2. Orders and prescriptions for contact lenses must include lens specifications such as power, size, curvature, flexibility, and gas permeability.

3. Orders and prescriptions for lens coating must include appropriate diagnosis and/or narrative diagnosis.

Source: Miss. Code Ann. § 43-13-121; 43-13-117; 43-13-118; 43-13-129

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Rule 3.3: Cataract/Ocular Surgery

A. Medicaid covers eyeglasses, including the frames and lenses for beneficiaries who have had surgery on the eyeball or ocular muscle. The surgical benefit will be applied, regardless of whether the beneficiary has received eyeglasses during the benefit period, when all of the following criteria are met:

1. Surgery results in a vision change,

2. Eyeglasses are medically indicated within six (6) months of the surgery, and

3. Eyeglasses are prescribed by an optometrist or ophthalmologist.

B. Beneficiaries who undergo multiple surgeries will be eligible for the benefit following each surgery if all criteria is met.

C. Beneficiaries who experience refractive changes after the six (6) month post-surgical period are subject to the eyeglass benefit limitations.

D. Medicaid does not cover refractive surgery including, but not limited to:

1. Lasik surgery,

2. Radial keratotomy,

3. Photorefractive keratectomy, or

4. Astigmatic keratotomy.

E. Beneficiaries who undergo the procedures listed in Rule 3.3 D above cannot receive the surgical benefit. Beneficiaries who need eyeglasses following any of these surgeries are subject to the eyeglass benefit limitations.

Source: Miss. Code Ann. § 43-13-121; 43-13-117(11)

Rule 3.4: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Source: Miss. Code Ann. § 43-13-121

Part 218 Hearing Services

23 Miss. Admin. Code Pt. 218 Hearing Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 218 Hearing Services

Table of Contents

Table of Contents Title 23: Division of Medicaid ........................................................................................................ 1 Part 218: Hearing Services .......................................................................................................... 1 Part 218 Chapter 1: General .................................................................................................... 1 Rule 1.1: Provider Enrollment Requirements ................ Error! Bookmark not defined. Rule 1.2: Cochlear Implants ............................................................................................ 1 Rule 1.3: Implantable and Non-Implantable Auditory Osseointegreated Device (AOD) .......................................................................................................................................... 3 Rule 1.4: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).............6

1

Title 23: Division of Medicaid

Part 218: Hearing Services

Part 218 Chapter 1: General

Rule 1.1: Provider Enrollment Requirements

A. State-licensed audiologists and physicians must render services within their scope of practice.

B. All providers of Medicaid services must meet all of the applicable requirements for enrollment as outlined in Miss. Admin. Code Title 23, Part 200, Chapter 4.

Source: Miss. Code Ann. § 43-13-121; 42 CFR 440.110; 42 CFR 455, Subpart E

History: Revised eff. 08/01/2026.

Rule 1.2: Cochlear Implants

A. Medicaid covers for unilateral cochlear implantation when there is documentation that demonstrates the procedure is medically necessary and would be beneficial in reducing limitations of hearing impairment.

B. The following must be documented by the surgeon and/or audiologist:

1. Severe to profound sensorineural hearing loss in both ears as defined by FDA criteria with a lack of benefit from a well-fitting aid,

2. Cognitive ability to use auditory clues, patient motivation and a willingness to undergo an extended program of rehabilitation,

3. Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system,

4. No contraindications to surgery, and

5. The device must be used in accordance with the FDA approved labeling.

C. Documentation for children twelve (12) months of age to seventeen (17) years of age must include:

1. The onset of hearing impairment must have occurred during the pre-or post-linguistic period, and

2. Bilateral severe to profound sensorineural deafness must be demonstrated by the inability

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to improve on age-appropriate closed set word identification tasks with amplification, or lack of progress in auditory training.

D. Documentation for adults eighteen (18) years of age and older must include:

1. The onset of hearing impairment must have occurred during the pre-linguistic, peri- linguistic, or post-linguistic period, and

2. Post-linguistic deafened adults must demonstrate current FDA guidelines on test scores on sentence recognition scores from tape-recorded tests in the beneficiary’s best listening condition.

E. Medicaid covers bilateral cochlear implantation when there is documentation that demonstrates the procedure is medically necessary and would be beneficial in reducing limitations of hearing impairment. Bilateral cochlear implantation must meet all of the criteria for unilateral cochlear implantation, above, in addition to the following criteria and circumstances.

F. Medicaid covers bilateral cochlear implants under two (2) different circumstances:

1. Simultaneous bilateral cochlear implants, and

2. Subsequent contralateral cochlear implantation in patients who have already received a previous unilateral cochlear implant.

G. Simultaneous bilateral cochlear implants are covered for beneficiaries who:

1. Have significant deafness, caused by meningitis with subsequent risk for early cochlear ossification, and, in the opinion of the treating physician, are appropriate candidates for bilateral cochlear implantation for the syndrome of post-meningitis deafness prior to cochlear ossification, or

2. Pre-lingually deaf children with profound hearing loss, and who, in the opinion of the treating specialist physician, would benefit from the additional neuronal stimulation afforded by simultaneous bilateral cochlear implantation at an early age. Some patients in this category may, in the opinion of the treating specialist physician, benefit from a staged or subsequent contralateral cochlear implantation as opposed to a simultaneous implantation.

H. Subsequent contralateral cochlear implantation are covered for beneficiaries who:

1. Have bilateral profound deafness that have fallen short of communication goals despite prior placement of a unilateral cochlear implant, and in the opinion of the treating specialist physician, would substantially benefit from a subsequent contralateral cochlear implant,

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2. Are prelingually deaf children with bilateral profound hearing loss who have had prior unilateral cochlear implantation and who, in the opinion of the treating specialist physician, would substantially benefit from a subsequent contralateral cochlear implant, or

3. Have bilateral auditory neuropathy to the extent such that their cochlear function is structurally normal but who have abnormal findings on auditory brainstem response testing, and, in the opinion of the treating specialist physician, would substantially benefit from a subsequent contralateral cochlear implant.

I. Medicaid does not cover for bilateral cochlear implantation, either as a simultaneous procedure or a subsequent contralateral implantation if, in the opinion of the treating physician, audiologist, or therapist, the beneficiary has sufficient limited hearing in the lesser affected ear either could either be:

1. Sufficiently augmented by a hearing aid to augment the opposite cochlear implant, or

2. Could later benefit from a future surgical or other medical intervention to improve the hearing in the non-implanted ear.

J. Medicaid covers a subsequent contra-lateral cochlear implant procedure, the testing, services and procedures, to properly evaluate a beneficiary and address the proper post-operative care and therapy for a second cochlear implant, when the beneficiary already has a unilateral cochlear implant.

K. Medicaid does not cover the cost of the cochlear implant device through the Durable Medical Equipment program. The cost of the device is covered by the usual reimbursement methodology for either inpatient or outpatient hospital services and must be billed by the hospital. Medicaid does not cover additional benefits for the device if the surgical procedure is performed in any other outpatient settings.

L. Medicaid covers the repair and/or replacement of the cochlear implant external speech processor and other minor supplies including batteries, cords, battery charger, and headsets through the Durable Medical Equipment (DME) program. Medicaid covers these items for all beneficiaries by DME providers only. Medicaid requires prior approval for repairs or replacements of external implant parts.

M. Medicaid requires documentation by the provider of rehabilitative services supporting medical necessity and must be retained in the beneficiary’s medical record.

Source: Miss. Code Ann. § 43-13-121

Rule 1.3: Implantable and Non-Implantable Auditory Osseointegrated Device (AOD)

A. The Division of Medicaid defines an implantable auditory osseointegrated device (AOD) as a surgically implantable hearing system which transmits sound vibrations through a sound

4

processor to the inner ear by direct bone conduction through the skull.

1. The Division of Medicaid covers implantable AODs in accordance with the Food and Drug Administration (FDA) approved labeling in an Ambulatory Surgical Center (ASC) and the outpatient hospital setting for beneficiaries five (5) years of age and older with conductive, mixed, or single-sided sensorineural hearing loss who can benefit from sound amplification, meets FDA approved audiologic criteria for the prescribed implantable AOD, and meets at least one (1) of the following conditions:

a) Congenital, surgical, or acquired malformation(s) of the external ear canal or middle ear,

b) Severe chronic otitis externa or otitis media with persistent otorrhea and documented failure with air conducted hearing aids,

c) Tumors of the external ear canal and/or tympanic cavity,

d) Dermatitis of the external canal, or

e) Other anatomic or medical conditions in which an air conduction hearing aid is contraindicated.

2. The Division of Medicaid does not cover implantable AODs for beneficiaries:

a) Under five (5) years of age,

b) With bilateral sensorineural hearing loss, or

c) With insufficient bone volume or bone quality to support implant placement.

B. The Division of Medicaid defines a non-implantable AOD as a sound processor attached to the skull using a hard or soft headband in which sound vibrations are transmitted transcutaneously through the bones of the skull to the inner ear.

1. The Division of Medicaid covers non-implantable AODs in accordance with the FDA approved labeling when prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designee for beneficiaries with conductive, mixed, or single-sided sensorineural hearing loss who can benefit from sound amplification, meets FDA approved audiologic criteria for the prescribed non-implantable AOD and meets at least one (1) of the conditions listed in Miss. Admin. Code Part 218, Rule 1.3.A.1.a)-e).

2. The Division of Medicaid does not cover the following:

a) Non-implantable AODs for bilateral sensorineural hearing loss,

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b) Replacement of lost or stolen processors, or

c) Non‐medically necessary accessories.

C. The Division of Medicaid covers batteries, repairs, and external replacement parts for implantable and non-implantable AODs as outlined in Miss. Admin. Code Part 209, Rule 1.24.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 12/01/2015.

Rule 1.4: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Source: Miss. Code Ann. § 43-13-121

Part 219 Laboratory

23 Miss. Admin. Code Pt. 219 Laboratory

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 219 Laboratory

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 219: Laboratory Services ..................................................................................................... 1 Part 219 Chapter 1: General .................................................................................................... 1 Rule 1.1: Provider Enrollment Requirements ................ Error! Bookmark not defined. Rule 1.2: Independent Laboratory Services .................................................................... 1 Rule 1.3: Routine Venipuncture ...................................................................................... 1 Rule 1.4: Independent Diagnostic Testing Facilities and Other Independent Mobile Diagnostic Units .............................................................................................................. 2 Rule 1.5: Trofile Assay .................................................................................................... 3 Rule 1.6: Paternity Testing ............................................................................................... 3 Rule 1.7: Qualitative Drug Screening .............................................................................. 3 Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ................ 5 Rule 1.9: Genetic Testing...........................................................................5 Rule 1.10: Tuberculosis (TB) Testing............................................................6

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Title 23: Division of Medicaid

Part 219: Laboratory Services

Part 219 Chapter 1: General

Rule 1.1: Provider Enrollment Requirements

Independent laboratory providers must meet all of the applicable requirements set forth in Miss. Code Title 23, Part 200, Chapter 4.

Source: Miss. Code Ann. § 43-13-121; 42 CFR 455, Subpart E; Social Security Act § 1902(a)(9)(c).

History: Revised eff. 08/01/2026.

Rule 1.2: Independent Laboratory Services

The Division of Medicaid does not reimburse independent laboratories for lab procedures performed for beneficiaries during an inpatient hospital stay. The All Patient Refined Diagnosis-Related Group (APR-DRG) payment that the hospital receives is considered to cover all services provided during the inpatient hospital stay. The hospital is responsible for reimbursement to independent laboratories.

Source: SPA 2012-008; Miss. Code Ann. §§ 43-13 117, 121.

History: Revised Miss. Admin. Code Part 219, Rule 1.2 to correspond with SPA 2012-008 (eff. 10/01/2012) eff. 05/01/2014.

Rule 1.3: Routine Venipuncture

Medicaid covers routine venipuncture performed for the purpose of obtaining a blood sample for laboratory testing as follows:

A. Routine venipuncture must be billed with appropriate procedure code.

B. Physicians, nurse practitioners, physician assistants, hospitals, and independent laboratories are covered one (l) for routine venipuncture only if the blood sample is drawn and all of it is referred to a separate, non-affiliated laboratory. If all or part of the sample is retained for a test to be performed in the facility where the venipuncture was performed, the physicians, nurse practitioners, physician assistants, hospitals, and independent laboratories are not covered for the venipuncture.

C. EPSDT screening providers are covered for routine venipuncture when performed for lead screening and/or RPR screening only if the blood sample is drawn and all of it is referred to a separate, non-affiliated laboratory. If all or part of the sample is retained for a test to be

2

performed in the facility where the venipuncture was performed, the provider is not covered for the venipuncture.

D. The Mississippi State Department of Health (MSDH), Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) providers who are reimbursed an encounter rate are not covered separately for performance of routine venipuncture during the same encounter.

E. Finger/heel/ear sticks that are performed for the purpose of collecting blood specimens or obtaining blood specimens via a partially or completely implantable venous access device are not covered.

F. Dialysis facilities will not be reimbursed outside the composite rate.

Source: Miss. Code Ann. § 43-13-121

Rule 1.4: Independent Diagnostic Testing Facilities and Other Independent Mobile Diagnostic Units

A. Medicaid only covers Independent Diagnostic Testing Facilities (IDTF), or other independent mobile diagnostic units, including portable x-ray providers, for services provided to dual-eligible beneficiaries. Outpatient testing and diagnostic services are covered when ordered by the beneficiary’s physician and billed by an approved Medicaid provider, limited to physicians, physician clinics, Federally Qualified Health Centers, Rural Health Clinics, and county health department clinics.

B. An IDTF is defined by the Centers for Medicare and Medicaid Services (CMS) as “a fixed location, a mobile entity, or an individual non-physician practitioner. It is independent of a physician’s office or hospital.” These providers perform diagnostic tests such as ultrasounds, echocardiograms, pulmonary function tests, neurological and neuromuscular tests, x-rays, cardiac monitoring, and nuclear medicine.

C. Medicaid covers for a physician to contract with an IDTF or other independent mobile diagnostic unit to provide technical services and, assuming that there are no Stark II or other anti-kickback statute violations, allows for a claim to be filed for either the technical component or the complete procedure if the physician also interprets the procedure.

D. The physician contracting with an IDTF or other independent mobile diagnostic unit may not be employed by or own any part of the IDTF or other independent mobile diagnostic unit.

E. IDTFs and other independent mobile diagnostic units may not pay an additional fee to any physician when they perform the technical component of the procedure.

Source: Miss. Code Ann. § 43-13-121; 42 CFR 410.33

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Rule 1.5: Trofile Assay

A. The “Trofile Assay” is covered for beneficiaries who are HIV-positive and diagnosed with Acquired Immune Deficiency Syndrome (AIDS) who have evidence of viral replication and HIV-1 strain resistance to multiple anti-retroviral agents.

B. Medicaid covers “Trofile Assay” for beneficiaries age sixteen (16) and over with the following restrictions/guidelines:

1. The assay is to be obtained only in anticipation of treatment of HIV/AIDS patients with CCR5 antagonist agents who:

a) Are “treatment experienced” defined as having been previously treated with anti- retroviral regimen(s),

b) Have never received Maraviroc/Selzentry or other CCR5-antagonist agents, and

c) Have been deemed to have “virologic failure,” or failed to obtain sufficiently low HIV viral loads despite prior appropriate anti-retroviral therapy.

2. Medicaid covers one (1) assay per beneficiary, per lifetime. Repeated testing or testing in follow-up of therapy with CCR5 agents is not covered.

3. The treating physician has expertise in Infectious Diseases and/or treating HIV patients with anti-retroviral agents; or the treating physician has consulted with an Infectious Disease physician prior to requesting the assay.

Source: Miss. Code Ann. § 43-13-121

Rule 1.6: Paternity Testing

A. Medicaid defines paternity testing as any laboratory test used to establish the genetic relationship between an alleged father and a child.

B. Medicaid does not cover Paternity testing.

Source: Miss. Code Ann. § 43-13-121

Rule 1.7: Qualitative Drug Screening

Medicaid will cover medically necessary qualitative drug screens for:

Suspected drug overdose, and one (1) or more of the following conditions are present:

a) Unexplained coma,

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b) Unexplained altered mental status,

c) Severe or unexplained cardiovascular instability, or cardiotoxicity,

d) Unexplained metabolic or respiratory acidosis,

e) Unexplained head trauma with neurological signs and symptoms, and/or

f) Seizures with an undetermined history.

Beneficiaries who present with clinical signs/symptoms of substance abuse.

High risk pregnancy, only when the documented patient history demonstrates that the procedure is medically necessary. Medicaid does not consider a qualitative drug screen as a routine component of assessment.

EPSDT services, only when the documented patient history demonstrates that the procedure is medically necessary. Medicaid does not consider a qualitative drug screen as a routine component of assessment.

Beneficiaries who are locked into a Beneficiary Health Management Program to assure compliance. 6. Beneficiaries prescribed certain medications as part of a treatment plan that requires testing according the Mississippi Board of Medical Licensure.

The appropriate procedure chemistry codes must be used for quantitation of drug screens and procedure therapeutic drug assays for therapeutic drug levels. All diagnosis codes must support medical necessity for the drug screen.

Non-covered Services:

1. Medicaid does not cover qualitative drug screens for the following:

a) To screen for the same drug with both a blood and a urine specimen simultaneously,

b) For legal purposes that are unrelated to medical treatment and not medically necessary such as, but not limited to screenings ordered by the court or law enforcement,

c) For employment purposes,

d) For the active treatment of substance abuse, including monitoring for compliance, or

e) As a component of medical examination for administrative purposes.

Documentation Requirements

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1. The ordering/referring provider must retain documentation supporting medical necessity in the medical record. All tests must be ordered in writing, and all drugs/drug classes to be screened must be indicated in the order. A copy of the lab results must be retained in the medical record.

2. If the provider rendering the service is other than the ordering/referring provider, the provider rendering the service must maintain hard copy documentation of the ordering/referring provider’s order for the test and the lab results. The order must include clinical indication/medical necessity in addition to all drugs/drug classes to be screened.

3. Records must be documented and maintained in accordance with Part 200, Chapter 1, Rule 1.3.

Source: Miss. Code Ann. §§ 43-13-121; 43-13-117; 43-13-118; 43-13-129; 73-43-11.

History: Revised eff. 11/01/2024.

Rule 1.8: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Source: Miss. Code Ann. § 43-13-121

Rule 1.9: Genetic Testing

A. The Division of Medicaid defines genetic testing as a type of genetic analysis to confirm or rule out suspected genetic disorders.

B. The Division of Medicaid covers genetic testing when medically necessary to establish a diagnosis when:

1. The beneficiary has significant clinical features suggestive of a genetic disorder,

2. The result of the test will directly impact clinical management and guide treatment being delivered to the beneficiary, and

3. After completion of conventional diagnostic studies, a definitive diagnosis remains uncertain.

C. The Division of Medicaid defines genetic screening as a type of genetic analysis to identify risk of genetic disorders.

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D. The Division of Medicaid covers genetic screening as a pregnancy related service to support the health of the pregnant woman and fetus when:

1. The screening has not been performed previously during the same pregnancy

2. The beneficiary received all of the necessary information to make an informed decision and did not decline the screening. E. The Division of Medicaid does not cover genetic testing or screening:

3. If considered to be experimental, investigational or unproven,

4. For the purpose of determining ancestry, or

5. Other purposes not specifically defined that are not diagnostic in nature.

F. Prior authorization is required for genetic testing and screening procedures as determined by the Division of Medicaid.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2026; New Rule eff. 10/01/2014.

Rule 1.10: Tuberculosis (TB) Testing

A. The Division of Medicaid covers the following tuberculosis (TB) tests when a beneficiary has an increased risk for TB infection, as determined by the Centers for Disease Control and Prevention (CDC) and state law, and is administered in compliance with CDC recommendations and guidelines:

1. Mantoux tuberculin skin test (TST), and

2. Interferon-gamma release assays (IGRA).

B. The Division of Medicaid providers must have a documented treatment plan for a beneficiary with a positive tuberculin skin test to include:

1. A medical evaluation, including chest x-ray and clinical assessment, and

2. An evaluation for a course of treatment for latent TB infection.

C. The Division of Medicaid does not cover TB testing for the routine screening of beneficiaries in the absence of specific risk factors for TB.

D. Staff who read TB skin tests must be certified by the Mississippi State Department of Health (MSDH) TB Certification Program.

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E. The provider must refer beneficiaries with a positive TB test to the MSDH Tuberculosis Program.

F. The Division of Medicaid providers must document the following:

1. The medical necessity for TB testing,

2. TST information which must include the following:

a) Manufacturer and lot number of the injected antigen,

b) Expiration date of solution,

c) Dose administered,

d) Injection site,

e) Signature or initials of the person who administered the TST,

f) Size of induration in millimeters (mm),

g) Date and time the test was read,

h) Reader’s signature and initials, and

i) Any adverse reactions.

3. Referral to the MSDH Tuberculosis Program for beneficiaries with positive TB tests.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 01/01/2016.

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Part 220 Radiology Services

23 Miss. Admin. Code Pt. 220 Radiology Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 220 Radiology Services

Table of Contents

Table of Contents Title 23: Division of Medicaid ........................................................................................................ 1 Part 220: Radiology ........................................................................................................................ 1 Part 220 Chapter 1: General ............................................................................................................ 1 Rule 1.1 Provider Enrollment Requirements ................................. Error! Bookmark not defined. Rule 1.2: Positron Emission Tomography (PET) Scans ................ Error! Bookmark not defined. Rule 1.3: Radiopharmaceuticals .................................................... Error! Bookmark not defined. Rule 1.4: Teleradiology ................................................................. Error! Bookmark not defined. Rule 1.5: Port Films ....................................................................... Error! Bookmark not defined. Rule 1.6: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) ... Error! Bookmark not defined. Rule 1.7: Computed Tomography (CT) Scans and Computed Tomography Angiography (CTA)......................................................................................................... .. 7 Rule 1.8: Magnetic Resonance Angiography (MRA) and Magnetic Resonance Imaging (MRI)......................................................................................................... .. 7 Rule 1.9: Positron Emission Tomography (PET) Scans............................................. .... 8 Rule 1.10: Nuclear Cardiac Imaging Studies......................................................... ... 10 Rule 1.11: Documentation............................................................................... .. 11

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Title 23: Division of Medicaid

Part 220: Radiology

Part 220 Chapter 1: General

Rule 1.1: Provider Enrollment Requirements

A. Radiology providers must meet all of the applicable requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4.

B. Independent Diagnostic Testing Facility (IDTF) providers can only be enrolled for submission of crossover claims.

1. IDTF providers cannot be enrolled for submission of straight Medicaid claims.

2. A copy of the Medicare certification from the Medicare Intermediary is required.

3. The Explanation of Medicare Benefits (EOMB) is not acceptable.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 455, Subpart E.

History: Revised eff. 08/01/2026.

Rule 1.2: Prior Authorization

A. Effective July 1, 2013, prior authorization is required by the radiology Utilization Management/Quality Improvement Organization (UM/QIO) for medical necessity and appropriateness of the service for the following advanced imaging procedures:

1. Computed Tomography (CT) Scans and Computed Tomography Angiography (CTA),

2. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA),

3. Positron Emission Tomography (PET) Scans, and

4. Nuclear Cardiac Imaging Studies.

B. Prior Authorization for the advanced imaging procedures listed in Rule 1.2.A. is required in all settings except in an:

1. Inpatient hospital,

2. Emergency room, or

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3. Outpatient hospital twenty-three (23) hour observation period.

C. The prior authorization request must be submitted by either the ordering or the rendering provider.

1. The provider must submit documentation indicating medical necessity and appropriateness of the service to the radiology UM/QIO, including, but not limited to, the:

a) Results of a recent clinical evaluation,

b) Diagnosis or clinical condition which the imaging evaluation is being ordered,

c) Treatment history related to the stated diagnosis or clinical condition,

d) Treatment plan related to the stated diagnosis or clinical condition, and

e) Previous imaging results related to the stated diagnosis or clinical condition.

2. Medical necessity and appropriateness of the service is based on nationally-accepted guidelines and radiology protocols based on peer reviewed literature for urgent, emergent and non-emergent services including, but not limited to, the:

a) Division of Medicaid’s radiology UM/QIO Clinical Decision Support Tool for Advanced Diagnostic Imaging,

b) American College of Radiology’s Appropriateness Criteria,

c) American Academy of Neurology,

d) American Academy of Orthopedic Surgeons,

e) American College of Cardiology,

f) American Heart Association, and/or

g) National Comprehensive Cancer Care Network.

D. Prior authorization must be received by the provider before the procedure is rendered except in medically urgent situations.

E. In the event of a medical emergent condition or situation a retrospective review may be requested.

1. The request must be received by the radiology UM/QIO within three (3) business days from the date of service.

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2. The Division of Medicaid defines a medical emergent condition or situation as one which:

a) The patient faces immediate risk of loss of life or limb,

b) Could seriously jeopardize the life or health of the beneficiary or their ability to regain maximum function based on a prudent layperson's judgment, or

c) In the opinion of a practitioner with knowledge of the beneficiary's medical condition, would subject the beneficiary to severe pain that cannot be adequately managed without the requested advanced imaging procedure.

Source: Miss. Code Ann. § 43-13-121, 42 CFR §§ 431.10(e), 440.230(d).

History: Added Rule 1.2.C. eff. 01/01/2014, Added to correspond with approved SPA 2013-007 (eff. 07/01/2013) eff. 07/01/2013.

Rule 1.3: Radiopharmaceuticals

A. The Division of Medicaid covers radiopharmaceuticals administered for diagnostic or therapeutic purposes separately from the diagnostic procedure or visit.

1. Only the units administered are covered.

2. Radiopharmaceuticals must be approved by the (FDA), used in accordance with FDA approved conditions, and be administered in dosages that meet FDA regulations.

3. Radiopharmaceuticals considered experimental, investigative, or in clinical trial are not covered.

A. The Division of Medicaid covers radiopharmaceuticals administered in a physician office, clinic or independent radiology facility.

C. Radiopharmaceuticals administered in an outpatient hospital setting is reimbursed in accordance with the Division of Medicaid’s outpatient hospital methodology.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.4: Teleradiology [Refer to Part 225, Chapter 3]

History: Moved with Revisions to Miss. Admin. Code Part 225, Chapter 3 eff. 07/01/2015.

Rule 1.5: Port Films

A. Medicaid does not cover the review and interpretation of port films, referred to as the

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professional component.

B. Medicaid covers the taking of the port film, one (1) unit for every five (5) treatments, referred to as the technical component.

C. Multiple treatments representing two (2) or more treatment sessions furnished on the same day are covered if the medical record contains documentation of a distinct break in therapy sessions and the treatments are of the character usually furnished on different days.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.6: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.7: Computed Tomography (CT) Scans and Computed Tomography Angiography (CTA)

A. Effective July 1, 2013, Computed Tomography (CT) scans and Computed Tomography Angiography (CTA), with or without contrast, must be prior authorized by the radiology UM/QIO as noted in Rule 1.2.

B. The Division of Medicaid does not cover:

1. A limited or follow-up CT scan for any given area of the body during the same encounter as a full diagnostic CT scan,

2. A two (2)-dimensional rendering after a three (3)-dimensional rendering of a CT scan,

3. A CT/SPECT (Single Photon Emission Computed Tomography) nuclear medicine imaging only for:

a) Localization, or

b) Attenuation correction purposes,

3. A whole body CT for screening of asymptomatic beneficiaries, or

4. The performance of CT screenings in healthy beneficiaries.

Source: Miss. Code Ann. § 43-13-121; 42 CFR §§ 431.10(e), 440.230(d).

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History: Added Rule 1.7.B. eff. 01/01/2014, Added to correspond with approved SPA 2013-007 (eff. 07/01/2013) eff. 07/01/2013.

Rule 1.8: Magnetic Resonance Angiography (MRA) and Magnetic Resonance Imaging (MRI)

A. Effective July 1, 2013, Magnetic Resonance Angiography (MRA) and Magnetic Resonance Imaging MRI), with or without contrast, must be prior authorized by the radiology UM/QIO as noted in Rule 1.2.

B. The Division of Medicaid covers a functional MRI when used as part of a preoperative evaluation for a planned craniotomy and is required for localization of eloquent areas of the brain, such as those responsible for speech, language, motor function, and senses, which might potentially be put at risk during the proposed surgery.

C. The Division of Medicaid does not cover an MRA or MRI for:

1. Screening of asymptomatic beneficiaries,

2. Screening of healthy beneficiaries, or

3. A two (2)-dimensional rendering after a three (3)-dimensional rendering has been performed.

Source: Miss. Code Ann. § 43-13-121; 42 CFR §§ 431.10(e), 440.230(d).

History: Added Rule 1.8.B. and C. eff. 01/01/2014, Added to correspond with approved SPA 2013-007 (eff. 07/01/2013) eff. 07/01/2013.

Rule 1.9: Positron Emission Tomography (PET) Scans

A. Effective July 1, 2013, Positron Emission Tomography (PET) scans must be prior authorized by the radiology UM/QIO as noted in Rule 1.2.

B. The Division of Medicaid covers one (1) fluorodeoxyglucose (FDG) PET scan for solid tumors, myeloma or lymphoma that are biopsy proven or strongly suspected based on other diagnostic testing for the following therapeutic purposes related to the initial treatment strategy to determine:

1. Whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure,

2. Optimal anatomic location for an invasive procedure, or

3. The anatomic extent of a tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

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C. The Division of Medicaid covers PET scans for initial anti-tumor treatment strategy, formerly “diagnosis” and “staging”, for the following oncologic conditions:

1. Thyroid cancer,

2. Non-small cell, lung cancer,

3. Colorectal cancer,

4. Melanoma,

5. Lymphoma,

6. Head and neck cancer, excluding thyroid and central nervous system,

7. Esophageal cancer,

8. Male and female breast cancer when used in staging distant metastasis,

9. Cervical cancer that is newly diagnosed following conventional imaging that is negative for extra-pelvic metastasis,

10. Ovarian cancer,

11. Testicular cancer,

12. Brain cancer,

13. Pancreatic cancer, or

14. Soft tissue carcinoma,

D. The Division of Medicaid does not cover PET scans for the initial anti-tumor treatment strategy, formerly “diagnosis” and “staging”, for the:

1. Initial diagnosing of breast cancer or the initial staging of axillary nodes,

2. Initial diagnosing of cervical cancer,

3. Evaluation of regional lymph nodes in melanoma, or

4. Diagnosis of adenocarcinoma of the prostate.

E. The Division of Medicaid covers PET scans for subsequent anti-tumor treatment strategy, formerly “restaging” and “monitoring response to treatment”, after the completion of the initial treatment course for the following oncologic conditions:

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1. Breast cancer,

2. Colorectal cancer,

3. Esophageal cancer,

4. Head and neck (non-CNS/thyroid), excluding thyroid and central nervous system,

5. Lymphoma,

6. Melanoma,

7. Non-small cell lung cancer,

8. Thyroid cancer,

9. Ovarian cancer,

10. Cervical cancer, or

11. Myeloma.

F. The Division of Medicaid covers FDG-PET scans for refractory seizures only for pre- surgical evaluation of localization of a focus of refractory seizure activity.

G. The Division of Medicaid does not cover PET scans for chronic osteomyelitis, infection of hip arthroplasty, and fever of unknown origin.

Source: Miss. Code Ann. § 43-13-121; 42 CFR §§ 431.10(e), 440.230(d).

History: Revised Rule 1.9. B. – E. and added G. eff. 01/01/02014, Added to correspond with approved SPA 2013-007 (eff. 07/01/2013) eff. 07/01/2013.

Rule 1.10: Nuclear Cardiac Imaging Studies

A. Effective July 1, 2013, nuclear cardiac imaging studies must be prior authorized by the radiology UM/QIO as noted in Rule 1.2.

B. The Division of Medicaid covers the following nuclear cardiac imaging:

1. Perfusion of the heart, either at rest or with pharmacological stress, for the diagnosis and management of beneficiaries with known or suspected coronary artery disease when one (1) of the following criteria are met:

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a) The PET scan, whether at rest alone or at rest with stress, is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT) scan, or

b) The PET scan, whether at rest alone or at rest with stress, is performed following an inconclusive SPECT scan.

1. The PET scan must be considered medically necessary to determine what medical or surgical intervention is required to treat the beneficiary.

2. The Division of Medicaid defines an inconclusive SPECT scan as a test(s) whose results are equivocal, technically uninterpretable, or discordant with a beneficiary’s other clinical data documentation in the beneficiary’s medical record.

2. For the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization or following an inconclusive SPECT.

a) A SPECT scan is not covered following an inconclusive PET scan.

b) Refer to Rule 1.10.B.1.b) 2).

C. The Division of Medicaid does not cover a SPECT/CT (Single Photon Emission Computed Tomography) which involves a SPECT multi-planar imaging (MPI) nuclear medicine scan only for:

1. Localization,

2. Accuracy, and

3. Attenuation correction purposes.

Source: Miss. Code Ann. § 43-13-121; 42 CFR §§ 431.10(e), 440.230(d).

History: Added Rule 1.10.C. eff. 01/01/2014.

Rule 1.11: Documentation

A. Documentation for advanced imaging procedures must:

1. Include the referring physician, nurse practitioner or physician’s assistant documentation of medical necessity and criteria met in Rule 1.2,

2. Not duplicate other covered diagnostic tests,

3. Be maintained in the referring provider’s file,

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4. Include documentation the procedure involved only FDA approved drugs and devices and did not involve investigational drugs, as determined by the FDA,

5. Support the referral to the rendering provider, and

6. Be maintained in accordance with Part 200, Chapter 3, Rule 1.3.

B. Providers and facilities are subject to on-site and documentation reviews of technical and professional imaging services and are reimbursed only for procedures, products, and services within the scope of the provider’s clinical practice.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 431.10(e).

History: Added Rule 1.11 eff. 01/01/2014.

Part 221 Family Planning Services

23 Miss. Admin. Code Pt. 221 Family Planning Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 221 Family Planning Services

Table of Contents

Table of Contents Title 23: Division of Medicaid..................................................................................................... Part 221: Family Planning Services .............................................................................. Page 1 Part 221 Chapter 1: General ......................................................................................... Page 1 Rule 1.1: Purpose ................................................................................................ Page 1 Rule 1.2: Freedom of Choice ............................................................................... Page 1 Rule 1.3: Beneficiary Cost Sharing ..................................................................... Page 1 Rule 1.4: Covered Services ................................................................................. Page 1 Rule 1.5: Non-Covered Services ......................................................................... Page 2 Rule 1.6: Documentation/ Record Maintenance ................................................... Page 3 Rule 1.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)......Page 5 Rule 1.8: Reimbursement..................................................................Page 5 Part 221 Chapter 2: 1115 Demonstration Waiver ......................................................... Page 5 Rule 2.1: Purpose ................................................................................................ Page 6 Rule 2.2: Eligibility ............................................................................................. Page 6 Rule 2.3: Freedom of Choice ............................................................................... Page 7 Rule 2.4: Covered Services ................................................................................. Page 8 Rule 2.5: Non-Covered Services ....................................................................... Page 10 Rule 2.6: Quality Assurance .............................................................................. Page 11 Rule 2.7: Beneficiary Cost Sharing ................................................................... Page 12 Rule 2.8: Primary Care Referrals ....................................................................... Page 12 Rule 2.9: Documentation/Record Maintenance .................................................. Page 12 Rule 2.10: Reimbursement.................................................................Page 14

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Title 23: Division of Medicaid

Part 221: Family Planning and Family Planning Related Services

Chapter 1: Family Planning and Family Planning Related State Plan Services

Rule 1.1: Purpose

The Division of Medicaid covers family planning and family planning related State Plan services and supplies, directly or under arrangements with others, to individuals capable of reproduction, including minors who can be considered to be sexually active, who are eligible under the State Plan and who desire such services and supplies.

Source: 42 USC §1396a; Miss. Code Ann. § 43-13-121.

Rule 1.2: Freedom of Choice

A. Medicaid beneficiaries have the right to freedom of choice of providers for Medicaid covered services in accordance with Miss. Admin. Code Part 200, Rule 3.6.

B. Beneficiaries have freedom of choice to:

1. Receive or reject family planning and family planning related services,

2. Choose family planning and family planning related services providers, and

3. Choose any method of birth control, including sterilization.

C. Beneficiaries must not be coerced to employ or not to employ any particular method of birth control including sterilization.

D. Providers must ensure that information is given in such a way as to encourage and support freedom of choice.

Source: 42 USC § 1396a; Miss. Code Ann. § 43-13-121.

History: Added Miss. Admin. Code Part 221, Rule 1.2.C, revised eff. 07/01/2015.

Rule 1.3: Beneficiary Cost Sharing

Family planning and family planning related services are exempt from cost sharing (co-pay) requirements in accordance with Miss. Admin. Code Part 200, Rule 3.7.

Source: 42 USC § 1396a; 42 CFR §§ 447.50-447.57; Miss. Code Ann. § 43-13-121.

Rule 1.4: Covered Services

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A. Family planning and family planning related services are available for eligible beneficiaries who voluntarily choose to:

1. Prevent pregnancy,

2. Plan the number of pregnancies, or

3. Plan the spacing between pregnancies.

B. Family planning and family planning related services include, but are not limited to:

1. Contraceptive injections purchased by the provider and administered in the provider’s office,

2. Prescription contraceptives dispensed through the pharmacy program,

3. Insertion, removal, and removal with reinsertion of a contraceptive intrauterine device,

4. Insertion, removal, and removal with reinsertion of a contraceptive implant,

5. Diaphragm or cervical cap fitting with instructions,

6. Vaginal rings,

7. Voluntary vasectomy and tubal ligation procedures, including tubal sterilization by hysteroscopy if the criteria in Miss. Admin. Code Part 202, Rule 5.3. is met, and

8. Laboratory procedures, including, but not limited to:

a) Papanicolaou (Pap) smears, and

b) Screenings for sexually transmitted infections (STIs)/sexually transmitted diseases (STDs).

C. Counseling and education are considered part of the family planning visit and cannot be billed separately.

Source: 42 USC § 1396a; 42 CFR Part 441, Subpart F; Miss. Code Ann. §§ 43-13-117, 43-13- 121.

History: Revised eff. 07/01/2015; Revised Rule 1.4.B.4. 10/01/2013.

Rule 1.5: Non-Covered Services and Items

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Services and items not considered family planning and family planning related services include, but are not limited to:

A. Facilitating services, including, but not limited to, parking and child care while family planning and family planning related services are being obtained,

B. Indirect services including, but not limited to, telephone contacts/consultations,

C. Drugs used to promote fertility,

D. Emergency contraceptives and related services,

E. Over-the-counter drugs and supplies including, but not limited to, pregnancy tests and spermicides,

F. Infertility studies and procedures to enhance fertility including, but not limited to, reversal of sterilization, artificial or intrauterine insemination or in-vitro fertilization,

G. Abortions and related services,

H. Hysterectomy and related services for sterilization purposes,

Menopausal or post-menopausal treatment and related services,

J. Removal of an implanted device for a non-Medicaid eligible individual,

K. Natural family planning services,

L. Ultrasound and radiology services,

M. Cancer screening services, except for Pap smears,

N. Services to a beneficiary whose age or physical condition precludes reproduction,

O. Services to a beneficiary known to be pregnant,

P. Reversal of voluntary sterilization, or

Q. Services outside the scope and/or authority of the provider’s specialty and/or area of practice.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 07/01/2015.

Rule 1.6: Documentation/Record Maintenance

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A. Providers of family planning and family planning related services must comply with the requirements for maintenance of records outlined in Miss. Admin. Code Part 200, Rule 1.3.

B. Documentation of family planning and family planning related services must include, but are not limited to:

1. Signed and dated consent for treatment, if applicable,

2. Signed and dated consent for sterilization, if applicable, as outlined in Miss. Admin. Code Part 202, Rule 5.3.,

3. Date of service and reason for visit,

4. Demographic information, including name, address, Medicaid number, date of birth, sex, and marital status,

5. Comprehensive health history, updated at least annually, including, but not limited to:

a) Health risk factors,

b) Personal medical, sexual and contraceptive history,

c) Plans for having children, and

d) Obstetrical and gynecological history.

6. Complete family history, updated at least annually,

7. Allergies, including type, reaction, and treatment,

8. Specific name/type of all diagnostic studies, including, but not limited to, laboratory and the result/finding of the studies,

9. Treatments/procedures rendered,

10. Physical findings including vital signs and weight,

11. Documentation of all medications including contraceptives whether administered by the provider, prescribed, or issued via physician/prescriber samples, and must include, but not limited to:

a) The name,

b) Strength,

c) Dose,

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d) Route of administration,

e) Site for all injectables, and

f) Manner in which prescription was issued including, but not limited to, in writing, by telephone, electronically or via facsimile.

12. Contraceptive supplies whether administered by the provider, prescribed, or issued via provider/prescriber samples,

13. Contraceptive devices,

14. Contraception counseling,

15. Date, time, and signature for all entries in the beneficiary’s record, and

16. Provider’s order, which must include the time, date, and signature, for all medications, treatments, and procedures rendered.

Source: 42 CFR Part 441, Subpart F; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121, 43- 13-129.

History: Revised eff. 07/01/2015.

Rule 1.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Miss. Admin. Code Part 223 without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121.

Rule 1.8: Reimbursement

A. The Division of Medicaid reimburses for only the provider’s whole acquisition cost (WAC) for physician administered drugs or implantable drug system devices.

B. The Division of Medicaid does not reimburse for provider/prescriber drug samples.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2022; Revised eff. 07/01/2021; New Rule eff. 07/01/2015.

2.10

Chapter 2: 1115(a) Family Planning and Family Planning Related Waiver Services

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Rule 2.1: Purpose

A. The Division of Medicaid covers family planning and family planning related waiver services and supplies, referred to as FPW in Miss. Admin. Code Part 221, Chapter 2, for all women and men, ages thirteen (13) through forty-four (44), who are capable of reproduction, who would not otherwise qualify for Medicaid, and with incomes at or below one hundred eighty-five percent (185%) of the federal poverty level, converted to a Modified Adjusted Gross Income (MAGI) equivalent standard through the 1115(a) Family Planning Waiver (FPW) Demonstration.

B. Providers are responsible for verification of covered FPW services and participant eligibility under the 1115(a) FPW Demonstration.

Source: Miss. Code Ann. § 43-13-121.

History: Revised Miss. Admin. Code Part 221, Rule 2.1.A. eff. 10/01/2015. Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2015) eff. 07/01/2015.

Rule 2.2: Eligibility

A. The Family Planning Waiver (FPW) limits eligibility to individuals age thirteen (13) through forty-four (44) who are capable of reproducing and meet the following criteria:

1. Individual has a family income at or below one hundred eighty-five percent (185%) of the federal poverty level, converted to a Modified Adjusted Gross Income (MAGI) equivalent.

2. Female individual is not pregnant and has not had a medical procedure that would prevent pregnancy including, but not limited to, tubal ligation procedures, including tubal sterilization by hysteroscopy,

3. Male individual has not had a medical procedure that would prevent reproduction, including, but not limited to, a vasectomy,

4. Individual is uninsured and is not enrolled in Medicare, Medicaid, Children’s Health Insurance Program (CHIP) or possesses other health insurance coverage that provides family planning and family planning related services,

5. Individual is a U.S. citizen or documented immigrant, and

6. Individual is a Mississippi resident.

B. Individuals eligible for the FPW remain eligible for twelve (12) consecutive months, or for the duration of the program if less than one (1) year and must recertify at the end of each year of eligibility.

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C. The participant will lose eligibility when one (1) of the following occurs:

1. Moves from the state of Mississippi,

2. Becomes eligible for another Medicaid program, Medicare, or obtains health insurance with family planning and family planning related benefits,

3. Requests closure or termination of FPW services,

4. Has a procedure that prevents reproduction,

5. Becomes pregnant,

6. Turns forty-five (45) years of age, or

7. Is deceased.

D. FPW applicants are considered only for eligibility in the FPW; however, an application for full Medicaid benefits may be filed at any time.

Source: 42 U.S.C. §§ 1315, 1396; Miss. Code Ann. §§ 43-13-115, 43-13-117, 43-13-121.

History: Revised to correspond with MS SPA 23-0015 (eff. 04/01/2023) eff. 04/01/2024. Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018. Revised Miss. Admin. Code Part 221, Rule 2.2.A.1. eff. 10/01/2015. Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2015) eff. 07/01/2015.

Rule 2.3: Freedom of Choice

A. Participants have the right to freedom of choice of providers for Family Planning Waiver (FPW) services in accordance with Miss. Admin. Code Part 200, Rule 3.6.

B. Participants have freedom of choice to:

1. Receive or reject FPW services,

2. Choose FPW providers, and

3. Choose any method of birth control, including sterilization.

C. Participants must not be coerced to employ or not to employ any particular method of birth control, including sterilization.

D. Providers must ensure that information is given in such a way as to encourage and support

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freedom of choice.

Source: 42 U.S.C. § 1396a; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018.

Rule 2.4: Covered Services

A. Family Planning Waiver (FPW) services are available for eligible participants who voluntarily choose to:

1. Prevent pregnancy,

2. Plan the number of pregnancies, or

3. Plan the spacing between pregnancies.

B. FPW services are limited to four (4) visits annually between January 1 through December 31 and include:

1. A one (1) time initial visit defined as the first time a participant receives family planning services from a provider and must be billed using the appropriate preventive medicine code and include:

a) The establishment of a medical record,

b) An in-depth evaluation including a complete medical history,

c) A complete physical examination, including a clinical breast exam and cervical cancer screening, according to nationally recommended guidelines,

d) Establishment of baseline laboratory data,

e) FPW counseling and education which includes contraceptive and sexually transmitted disease (STD) prevention information, and

f) Issuance of supplies or prescriptions covered under the FPW.

2. An annual visit defined as the re-evaluation of an established participant the next year following the one (1) time initial evaluation and must be billed using the appropriate preventive medicine code and include:

a) An update to the medical record,

b) Interim history,

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c) Complete physical examination, including a clinical breast exam and cervical cancer screening,

d) Appropriate diagnostic lab tests or procedures,

e) FPW services management, education and counseling, and

f) Renewal or change of contraceptive prescriptions or supplies.

3. A follow-up visit is defined as an evaluation of an established participant with a new or existing family planning or family planning related issue, and must be billed using the appropriate evaluation and management code and include:

a) An evaluation of the participant’s contraceptive program,

b) Renewal or change of the contraceptive prescription or supplies, and

c) Additional opportunities for counseling and education regarding reproductive health and family planning and family planning related issues.

C. FPW only covers the following drugs and supplies:

1. Prescription oral contraceptive agents,

2. Contraceptive patches,

3. Self-inserted contraceptive products,

4. Injectable contraceptives dispensed in the pharmacy venue and administered in the provider’s office,

5. Contraceptive injections purchased by the provider and administered in the provider’s office,

6. Medications for the treatment of a sexually transmitted infection (STI)/ STD identified or diagnosed during a routine or periodic FPW visit except for human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) and hepatitis,

7. Medications and/or treatments for vaginal infections or disorders, other lower genital tract and genital skin infections or disorders, and urinary tract infections when these conditions are identified or diagnosed during a routine or periodic FPW visit, and

8. Condoms provided and billed by the provider separately on the medical claim.

D. Covered contraceptive devices include:

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1. Insertion, removal, and removal with reinsertion of a contraceptive intrauterine device,

2. Insertion, removal, and removal with reinsertion of a contraceptive implant,

3. Diaphragm or cervical cap fitting with instructions, and

4. Vaginal rings.

E. Voluntary vasectomy and tubal ligation procedures, including tubal sterilization by hysteroscopy, and all necessary follow-up procedures if the criteria in Miss. Admin. Code Part 202, Rule 5.3 is met.

F. Laboratory procedures that must be conducted during initial and annual visits include the following:

1. Blood count,

2. Pap smear according to nationally recommended guidelines for cervical cancer screening,

3. Screenings for STI/STD and HIV/AIDS, and

4. Pregnancy test, as indicated.

Source: 42 U.S.C. §§ 1315, 1396; 42 C.F.R. Part 441, Subpart F; Miss. Code Ann. §§ 43-13- 117, 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018. Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2015) eff. 07/01/2015.

Rule 2.5: Non-Covered Services and Items

Services and items not considered Family Planning Waiver (FPW) services and not reimbursable under the waiver program include, but are not limited to, the following:

A. Facilitating services including, but not limited to, transportation, parking, and child care while FPW services are being obtained,

B. Indirect services, including, but not limited to, telephone contacts/consultations,

C. Drugs used to promote fertility,

D. Over-the-counter emergency contraceptives and related services,

E. Over-the-counter drugs and supplies including, but not limited to, pregnancy tests,

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spermicides, and condoms.

F. Infertility studies and procedures to enhance fertility including, but not limited to, reversal of sterilization, artificial or intrauterine insemination or in-vitro fertilization,

G. Abortions and related services,

H. Hysterectomy and related services for sterilization purposes,

I. Menopausal or post-menopausal treatment and related services,

J. Removal of an implanted device for a non-FPW eligible individual,

K. Natural family planning services,

L. Cancer screening services, except for Pap smears,

M. Mammograms,

N. Services to a participant whose age or physical condition precludes reproduction,

O. Services to a participant known to be pregnant,

P. Reversal of voluntary sterilization,

Q. Services outside the scope and/or authority of the provider’s specialty and/or area of practice,

R. Inpatient hospital visit,

S. All services provided for the treatment of a medical condition not considered family planning or family planning related,

T. Services for participants who have received a sterilization procedure and have completed all necessary follow-up procedures, and

U. Prescriptions other than contraceptives and medications to treat STI/STD, vaginal infections or disorders, other lower genital tract and genital skin infections or disorders, and urinary tract infections.

Source: 42 U.S.C. §§ 1315, 1396; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018. Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2015) eff. 07/01/2015.

Rule 2.6: Quality Assurance

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A. The Quality Assurance Plan:

1. Ensures the provision of comprehensive, accessible, quality and appropriate Family Planning Waiver (FPW) services,

2. Provides a system for accountability and measuring performance, and

3. Improves care outcomes and quality of life.

B. The Division of Medicaid in conjunction with the Mississippi State Department of Health (MSDH) monitors quality and improvement activities for MSDH clinics to:

1. Ensure standards of care for FPW services utilize evidence-based best practices, and

2. Conduct periodic in-house desk or on-site review of medical records.

C. The Division of Medicaid conducts periodic in-house desk or on-site reviews of medical records to determine that participants have received appropriate medical care and are appropriately referred for needed primary care.

Source: Miss. Code Ann. § 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018.

Rule 2.7: Participant Cost Sharing

Family Planning Waiver (FPW) services are exempt from cost sharing (co-pay) requirements in accordance with Miss. Admin. Code Part 200, Rule 3.7.

Source: 42 U.S.C. § 1396a; 42 C.F.R. §§ 447.50-447.57; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018.

Rule 2.8: Primary Care Referrals

A. Health concerns identified during a Family Planning Waiver (FPW) visit but not covered by the FPW must be followed up by a primary care provider with an appropriate clinical referral.

B. Providers should refer participants to other social service and healthcare providers as medically indicated including, but not limited to, a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).

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C. As a component of the medical record audit, the primary care referral must be documented in the participant’s medical record.

Source: Miss. Code Ann. § 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018.

Rule 2.9: Documentation/Record Maintenance

A. Providers of Family Planning Waiver (FPW) services must comply with the requirements for maintenance of records outlined in Miss. Admin. Code Part 200, Rule 1.3.

B. FPW services documentation must include, but is not limited to:

1. Date of service,

2. Reason for visit,

3. Physical findings including vital signs, and weight,

4. Documentation of a physical exam, clinical breast exam and cervical cancer screenings conducted at the initial and annual visits,

5. Treatments/procedures rendered,

6. Demographic information, including name, address, Medicaid number, date of birth, sex, and marital status,

7. Allergies including type, reaction and treatment,

8. Comprehensive health history, updated at least annually including, but not limited to:

a) Health risk factors,

b) Personal medical, sexual and contraceptive history,

c) Plans for having children, and

d) Obstetrical and gynecological history.

9. Complete family history, updated at least annually,

10. Specific name/type of all diagnostic studies including, but not limited to, laboratory and the result/finding of the studies,

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11. Documentation of all medications including contraceptives, whether administered by the provider, prescribed, or issued via samples and must include the:

a) Name,

b) Strength,

c) Dose,

d) Route of administration,

e) Site for all injectables, and

f) Manner in which prescription was issued including, but not limited to, in writing, by telephone, electronically or via facsimile.

12. Contraceptive supplies whether administered by the provider, prescribed, or issued via samples,

13. Contraceptive devices,

14. Documentation of education and counseling on contraception management, sexually transmitted infections (STI)/sexually transmitted disease (STD), human immunodeficiency virus infection (HIV) and acquired immune deficiency syndrome (AIDS),

15. Date, time, and signature for all entries in the participant’s record,

16. Provider’s order, which must include the time, date, and signature for all medications, treatments and procedures rendered,

17. Signed and dated consent for treatment, as applicable,

18. Primary care referrals, if applicable,

19. OB/GYN referral if beneficiary is determined to be pregnant, and

20. Signed and dated consent for sterilization, if applicable, as outlined in Miss. Admin. Code Part 202, Rule 5.3.

Source: 42 C.F.R. Part 441, Subpart F; Miss. Code Ann. §§ 43-13-117, 43-13-118, 43-13-121.

History: Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2018) eff. 11/01/2018. Revised to correspond with the Family Planning Waiver renewal (eff. 01/01/2015) eff. 07/01/2015.

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Rule 2.10: Reimbursement

A. The Division of Medicaid reimburses for only the provider’s whole acquisition cost (WAC) for physician administered drugs or implantable drug system devices.

B. The Division of Medicaid does not reimburse for provider/prescriber drug samples.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2022; Revised eff. 07/01/2021; New Rule eff. 07/01/2015.

Part 222 Maternity Services

23 Miss. Admin. Code Pt. 222 Maternity Services

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 222 Maternity Services

of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 222: Maternity Services ....................................................................................................... 1 Part 222 Chapter 1: General ..................................................................................................... 1 Rule 1.1: Maternity Services ............................................................................................ 1 Rule 1.2: Multiple Birth Deliveries ................................................................................. 1 Rule 1.3: Maternal Fetal Ultrasound ............................................................................... 4 Rule 1.4: Maternity Epidurals .......................................................................................... 6 Rule 1.5: (Reserved) ......................................................................................................... 5 Rule 1.6: Reimbursement for Delivery and Tubal Ligation............................................. 7 Rule 1.7: Sterilization ....................................................................................................... 7 Rule 1.8: Terbutaline Therapy ......................................................................................... 7 Rule 1.9: 17 Alpha-Hydroxyprogesterone ...................... Error! Bookmark not defined. Rule 1.10: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 7 Rule 1.11:Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services..6 Rule 1.12: Tobacco Cessation Counseling Services...........................................6 Part 222 Chapter 2: Perinatal High Risk Management and Infant Services ............................ 9 Rule 2.1: Provider Participation ....................................................................................... 9 Rule 2.2: Freedom of Choice ........................................................................................ 10 Rule 2.3: High Risk Pregnant Women ........................................................................... 10 Rule 2.4: High Risk Infants ............................................ Error! Bookmark not defined. Rule 2.5: Plan of Care ..................................................... Error! Bookmark not defined. Rule 2.6: Medical Record Documentation Requirements ............. Error! Bookmark not defined. Rule 2.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) .............. 17

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Title 23: Division of Medicaid

Part 222: Maternity Services

Part 222 Chapter 1: General

Rule 1.1: Maternity Services

A. The Division of Medicaid covers maternity services which include:

1. Antepartum services defined by the Division of Medicaid as the care of a pregnant woman during the time in the maternity cycle that begins with conception and ends with labor.

2. Delivery services defined by the Division of Medicaid as the care involved in labor and delivery.

3. Postpartum services defined by the Division of Medicaid as the care of the mother inclusive of both hospital and office visits following delivery for twelve (12) months including any remaining days in the month in which the twelfth (12 th ) month occurs.

B. The Division of Medicaid covers inductions of labor or cesarean sections prior to one (1) week before the treating physician’s expected date of delivery when medically necessary due to one (1) of the following medical and/or obstetric conditions including, but not limited to:

1. Non-reassuring fetal status or fetal compromise,

2. Fetal demise in prior pregnancy,

3. Fetal malformation,

4. Intrauterine Growth Restriction (IUGR),

5. Preeclampsia,

6. Eclampsia,

7. Isoimmunization,

8. Placenta previa, accreta, or abruption,

9. Thrombophilia or an occurrence of maternal coagulation defects,

10. Complicated chronic or gestational hypertension,

11. Chorioamnionitis,

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12. Premature rupture of membranes,

13. Oligohydramnios,

14. Polyhydramnios,

15. Multiple gestations,

16. Poorly controlled diabetes mellitus (pregestational or gestational),

17. HIV infection,

18. Pulmonary disease,

19. Renal disease,

20. Liver disease,

21. Malignancy,

22. Cardiovascular diseases,

23. Classical or vertical uterine incision from prior cesarean delivery, or

24. Prior myomectomy.

C. The Division of Medicaid does not cover non-medically necessary early elective deliveries, prior to the expected due date including, but not limited to, the following:

1. Maternal request,

2. Convenience of the beneficiary or family,

3. Maternal exhaustion or discomforts,

4. Availability of effective pain management,

5. Provider convenience,

6. Facility scheduling,

7. Suspected macrosomia with documented pulmonary maturity with no other medical indication,

8. Well-controlled diabetes,

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9. History of rapid deliveries,

10. Long distance between beneficiary and treating facility, or

11. Adoption.

D. Medical records will be subject to retrospective review. Reimbursement for hospital and professional services related to the delivery will be recouped if determined not to have met criteria for coverage.

E. Antepartum and postpartum office visits do not apply to the physician services limit.

F. A period of presumptive eligibility is provided to pregnant women according to the following:

1. Presumptive Eligibility for Pregnant Women (PEPW) covers ambulatory prenatal care for pregnant women that are determined presumptively eligible by a qualified provider on the basis of preliminary information.

2. Ambulatory prenatal care includes medically necessary pregnancy-related services rendered in a clinic or outpatient setting, outpatient labs and exams, and pregnancy related prescription drugs prescribed by a licensed Medicaid provider.

a) Birthing expenses and hospital services are not covered during a period of presumptive eligibility.

b) All State Plan limits apply to services provided during a period of presumptive eligibility.

3. In order to enroll as a qualified provider for PEPW determinations, providers must:

a) Satisfy the requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4,

b) Submit the Application for PEPW Qualified Provider and an executed Memorandum of Understanding (MOU), and

c) Be enrolled with the Mississippi Division of Medicaid as one of the following provider types:

1. Federally Qualified Health Center (FQHC),

2. Mississippi Department of Health (MSDH) County Health Department,

3. Rural Health Clinic (RHC),

4. Obstetrician, or

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5. Primary Practice Clinic.

d) Providers may be disqualified from making PEPW determinations for failure to meet the following timeliness and accuracy performance standards:

1. Ninety-five percent (95%) of beneficiaries determined presumptively eligible by the provider must submit Medicaid applications prior to the end of the presumptive eligibility period.

2. Ninety-five percent (95%) of beneficiaries that submit a timely Medicaid application must be determined eligible for Medicaid.

4. The presumptive eligibility period begins on the date the determination is made and ends at the earlier of the:

a) The date of approval or denial of the filed Medicaid application, if an application for Medicaid has been filed by the last day on the month following the month in which the presumptive eligibility determination is made, or

b) The last day of the month following the month in which the determination of presumptive eligibility was made, if an application for Medicaid was not filed.

5. The qualified provider must notify the Division of Medicaid within five (5) business days of the date the determination is made.

6. There may be no more than one (1) presumptive eligibility period per pregnancy.

Source: Miss. Code Ann. §§ 43-13-115(8), 43-13-117, 43-13-121. History: Revised to correspond with MS SPA 24-0010 (eff. 07/01/2024) eff. 01/01/2026. Revised to correspond with MS SPA 23-0015 (eff. 04/01/2023) eff. 04/01/2024. Revised eff. 01/02/2015. Rule 1.2: [Reserved] History: Removed eff. 01/02/2015. Rule 1.3: Maternal Fetal Ultrasound

A. For a fetal biophysical profile, the physician may bill one (1) unit for each fetus being evaluated in cases of multiple gestations.

B. For an ultrasound during hospitalization, Medicaid reimburses the physician submitting a claim for a visit and a review of an ultrasound on the same date of service for the visit only. A physician’s interpretation of the results of an ultrasound will be reimbursed as a separate service when prepared with a separate distinctly identifiable signed written report using the

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appropriate procedure code with the appropriate modifier which indicates professional component only.

C. Medicaid does not cover routine sonography during pregnancy.

D. Medicaid covers medically necessary ultrasounds when all of the following criteria are met:

1. The ultrasound is consistent with the beneficiary’s signs, symptoms, and/or condition,

2. Diagnosis cannot be made through clinical evaluation of the beneficiary’s signs and symptoms, and

3. The results of the ultrasound can reasonably be expected to influence the beneficiary’s treatment plan.

E. For Medicaid reimbursement for any type of obstetrical ultrasound, documentation in the beneficiary’s record must justify the medical necessity. This documentation includes, but is not limited to, at least one (1) of the following:

1. Fetal measurements, as applicable to gestational age, such as crown-rump length, biparietal diameter (BPD), occipitofrontal diameter/head circumference (OFD or HC), abdominal circumference (AC), or femur length (FL),

2. Fetal position,

3. Placental location,

4. Amniotic fluid assessment or measurement,

5. Suspected or known fetal anomalies or conditions,

6. Fetal measurements relative to determination of suspected or known intrauterine growth retardation (IUGR), or

7. Presence of multiple gestations.

F. Documentation must reflect the type of obstetrical ultrasound actually performed, limited or complete.

G. The biophysical profile combines ultrasound with a non-stress test to check fetal well-being. The five (5) fetal parameters checked are as follows:

1. Reactive non-stress test,

2. Fetal breathing movement,

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3. Fetal body movement,

4. Fetal muscle tone, and

5. Amniotic fluid volume.

H. Documentation must include a report on each of the five (5) parameters listed in Part 222, Chapter 1 Rule 1.3.G.

I. Providers must maintain proper and complete documentation to verify services provided.

1. The provider has full responsibility for maintaining documentation to justify the services provided.

2. Records must be documented and maintained in accordance with requirements set forth in Part 200, Chapter 1, Rule 1.3.

Source: Miss. Code Ann. § 43-13-121

Rule 1.4: Maternity Epidurals

A. Medicaid covers a maternity epidural for all pregnant Medicaid beneficiaries. Medicaid considers maternity epidurals as a medically necessary service for treatment of labor pain and does not consider it an elective procedure.

B. A physician who is participating in the Medicaid program must take all reasonable measures to ensure that maternity patients are instructed and offered an epidural as an available and covered service under Medicaid as part of the patient’s prenatal counseling. The patient’s options for pain relief medication during childbirth must be explained to her.

C. Anesthesiologists/CRNAs cannot refuse to provide a maternity epidural to a Medicaid beneficiary except when medically contraindicated.

1. An anesthesiologist/CRNA who is participating in the Medicaid program must make available and offer maternity epidural services to pregnant Medicaid beneficiaries and cannot require a pregnant Medicaid beneficiary to pay for an epidural.

2. He/she must accept the Medicaid payment as payment in full and cannot require a co- payment for his/her services. Under federal Medicaid law, deductions, cost sharing, or similar charges are not permitted for Medicaid services furnished to pregnant women. Thus, a participating provider’s demand for these additional payments would be in violation of the law.

3. The decision to have an epidural is to be decided between the beneficiary and her anesthesiologist/CRNA in consultation with the obstetrician. No means of coercion, dissuasion, or refusal by an anesthesiologist/CRNA to provide an epidural to a

7

beneficiary in labor shall be utilized in determining this decision.

D. A hospital that accepts a pregnant Medicaid beneficiary for treatment accepts the responsibility for making sure that the beneficiary has access to an epidural.

1. If an anesthesiologist does not accept a Medicaid patient for treatment, the hospital has the responsibility of assuring the delivery of this service.

2. A pregnant beneficiary is entitled to receive the service from a provider who has accepted her as a patient without the imposition of deductibles, cost sharing, or similar charges.

Source: Miss. Code Ann. § 43-13-121

Rule 1.5: [Reserved]

History: Removed eff. 01/02/2015.

Rule 1.6: Reimbursement for Delivery and Tubal Ligation

A delivery, cesarean section or vaginal, and a tubal ligation performed at the same setting will be reimbursed at one hundred percent (100%) of the fee schedule for each procedure.

Source: Miss. Code Ann. § 43-13-121

Rule 1.7: Sterilization

Medicaid reimburses covered sterilization procedures when the criteria for covered sterilization are satisfied in accordance with Part 202, Chapter 1, Rule 1.8.

Source: Miss. Code Ann. § 43-13-121; 42 CFR 441, Subpart F

Rule 1.8: Terbutaline Therapy

Terbutaline pump therapy with uterine activity monitoring for beneficiaries who are at risk for preterm labor is not covered by Medicaid.

Source: Miss. Code Ann. § 43-13-121

Rule 1.9: [Reserved]

Rule 1.10: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

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The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization.

Source: Miss. Code Ann. § 43-13-121

Rule 1.11: Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services

A. The Division of Medicaid defines Screening, Brief Intervention, and Referral to Treatment (SBIRT) as an early intervention approach that targets pregnant women with nondependent substance use to provide effective strategies for intervention prior to the need for more extensive or specialized treatment.

B. SBIRT services must include:

1. Screening of a pregnant woman for risky substance use behaviors using evidence based standardized assessments or validated screening tools,

2. Brief intervention of a pregnant woman showing risky substance use behaviors in a short conversation, providing feedback and advice, and

3. Referral to treatment for brief therapy or additional treatment to a pregnant woman whose assessments or screenings indicate a need for additional services.

C. The Division of Medicaid covers one (1) SBIRT service per pregnancy when performed by one (1) of the following licensed practioners:

1. Physician,

2. Nurse Practioner,

3. Certified Nurse Midwife,

4. Physician Assistant,

5. Licensed Clinical Social Worker,

6. Licensed Professional Counselor, or

7. Clinical Psychologist.

D. SBIRT services provided through a Community Mental Health Center or Private Mental Health Center must be performed by one (1) of the licensed practitioners listed in Miss. Admin. Code Part 222, Rule 1.11.

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E. The Division of Medicaid reimburses for SBIRT services according to Healthcare Common Procedure Coding System (HCPCS) guidelines and in accordance with applicable provider reimbursement methodologies.

1. SBIRT services provided by Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and the Mississippi State Department of Health (MSDH) providers, are covered in the encounter rate for core services. An encounter cannot be paid solely for SBIRT services.

2. SBIRT services are not covered in an inpatient hospital setting.

F. The Division of Medicaid covers all medically necessary services for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) eligible beneficiaries in accordance with Miss. Admin. Code Part 223 without regard to service limitations and with prior authorization.

G. Providers of SBIRT services must document and maintain auditable records that meet the requirements set in Part 200, Chapter 1. Rule 1.3 including the following:

1. A copy of the evidence based standardized assessment screening tool with scoring,

2. Brief description of the intervention, and

3. Referral information.

Source: 42 C.F.R. §§ 440.210, 440.250; Miss. Code Ann. §§ 43-13-117, 43-13-121. History: New rule to correspond to SPA 17-0003 (eff. 07/01/2017), eff. 11/01/2017. Rule 1.12: Tobacco Cessation Counseling Services

A. The Division of Medicaid covers one (1) face-to-face counseling session per quit attempt with mandatory referral to the Mississippi (MS) Tobacco Quit Line for pregnant women who use tobacco.

B. Face-to-Face sessions must be provided by:

1. Or under supervision of a physician,

2. Any other health professional who is legally authorized to furnish such services under State Law and who is authorized to provide Medicaid coverable services other than tobacco cessation services, or

3. Any other health professional legally authorized to provide tobacco cessation services under State Law and who is specifically designated by the Secretary in regulations.

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C. The Division of Medicaid covers tobacco cessation counseling services in the encounter rate for a core service for Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), and the Mississippi State Department of Health (MSDH) providers.

D. The Division of Medicaid does not reimburse for an encounter if the only service provided is tobacco cessation counseling services.

E. The Division of Medicaid reimburses for services made from a statewide uniform fee schedule and paid at the lesser of the usual and customary charge on the physician’s fee schedule.

Source: 42 U.S.C. § 1396d; Miss. Code Ann. § 43-13-121; SPA 2013-002.

History: New Rule to correspond with SPA 2013-002 (effective 03/01/14), eff. 03/01/2019.

Part 222 Chapter 2: Perinatal High Risk Management and Infant Services

Rule 2.1: Provider Participation

A. The provider, agency, or entity of Targeted Case Management (TCM) services for high-risk women who are pregnant and up to sixty (60) days postpartum or high-risk infants through one (1) year of age must comply with the requirements to enroll as a Mississippi Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Provider and meet the following requirements:

1. Have a minimum of two (2) years’ experience providing comprehensive case management services to the target population,

2. Have an established system to coordinate services for Medicaid beneficiaries,

3. Have established referral systems, linkages, and referral ability with essential social and health services agencies, and

4. Employ Registered Nurses with the following qualifications as case managers:

a) Be licensed by the Mississippi Board of Nursing and in good standing,

b) Have one (1) year documented experience working with the target population,

c) Have experience, skills, and/or training in crisis intervention,

d) Have effective communication skills,

e) Have access to multi-disciplinary staff, when needed, and

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f) Possess knowledge of resources for the service community.

Source: Miss. Code Ann. §§ 43-13-121, 43-13-117(19)(a)

History: Revised eff. 07/01/2024.

Rule 2.2: Covered Services

A. A medical risk screen must be conducted to determine the need to refer an individual for Targeted Case Management (TCM) services. Referrals for TCM services must be initiated during the pregnancy for the woman, or birth through one (1) year of age for the infant. The medical risk screen must:

1. Be completed by a physician, physician assistant, a nurse practitioner, or certified nurse- midwife,

2. Only be conducted once per pregnancy unless the beneficiary changes providers and the new provider is unable to obtain the beneficiary’s medical records, and

3. Be completed up to two (2) times for infants, if risk factors are present.

B. Targeted Case Management is a collaborative process of assessment, care planning, care coordination, and evaluation of services to meet the identified needs of eligible women who are pregnant and up to sixty (60) days postpartum or infants from birth through (1) year of age. TCM activities include:

1. An initial comprehensive assessment that is beyond risk screening must be conducted to determine the specific needs of the participant and identify which, if any, referrals for extended or other services are needed. The initial comprehensive assessment must, at a minimum:

a) Be performed by the RN case manager,

b) Be completed within fifteen (15) calendar days after the referral is received for TCM, and

c) Be maintained in the participant’s case record.

2. A Plan of Care (POC) must be developed and periodically updated which, at a minimum:

a) Reflects the specific needs identified through applicable assessments,

b) Establishes specific goals (long and short-term),

c) Includes interventions to address the participant’s goals and meet the identified needs,

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d) Must be action oriented with identifiable outcomes that are measurable and achievable within a manageable time frame,

e) Must be updated timely to reflect changes in the participant’s needs or status,

f) Identifies each interdisciplinary team member’s responsibilities in addressing identified needs, and

g) Provides a personalized discharge plan that, at a minimum, identifies all goals or needs that extend beyond case closure. Processes must be in place to coordinate appropriate linkages and services prior to case closure. Discharge planning must be documented in the case file.

3. Care Coordination includes regular communication, information-sharing, and collaboration between case management and others serving the participant, within a single agency or among several community-based agencies. All care coordination activities must be recorded in the case file and must, at a minimum include:

a) Regular communication with the participant, participant’s family or authorized representative, provider(s), and the interdisciplinary team,

b) Coordinating access to services and benefits, reducing barriers, and establishing linkages with other services providers,

c) Referrals and related activities including, but not limited to, scheduling appointments to help the participant obtain needed services and linking the participant with medical, social, educational, or other program(s) or resource(s) that are capable of providing needed services to address identified needs and achieve goals specified in the POC,

d) Revising the POC to reflect the changes in the needs or status of the participant,

e) Processes for participant transfer to a new TCM provider, if chosen, and

f) Making appropriate referrals as needed and upon case closure to ensure continuation of care.

4. Monitoring and follow-up activities include activities and contacts that are necessary to ensure the POC is implemented and adequately addresses the participant’s needs. Activities may be with the participant, the participant’s personal or authorized representative, or the participant’s service provider and must be conducted at least monthly and more often as necessary. Monitoring and follow-up activities include, but are not limited to:

a) Monthly face-to-face contact with the participant,

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b) Monthly case conference with the interdisciplinary team,

c) Initial contact with the participant’s primary care provider(s) upon enrollment into the program and continued communication with the primary care provider(s) if the participant’s condition or status changes,

d) Routine review and follow-up of case notes from all service providers, and

e) Review and revision of the POC routinely and as needed.

C. Extended services for eligible participants who are pregnant and up to sixty (60) days postpartum or infants from birth through one (1) year of age are based upon the specific needs identified on the initial comprehensive assessment.

1. Appropriate referral(s) for extended services must be initiated by the case manager.

2. Any extended service(s) being provided must be included in the POC and evaluated by the case manager at least monthly. Extended services include:

a) Initial nursing assessment and evaluation performed by a registered nurse (RN) within ten (10) business days from referral,

b) Nursing services performed by an RN which must include health education,

c) Home visit for postpartum assessment and follow-up performed by an RN,

d) Nutritional assessment and counseling performed by a registered dietician or licensed nutritionist within ten (10) business days from referral,

e) Nutritional counseling and dietician visit performed by a registered dietician or licensed nutritionist,

f) Mental health assessment performed by a non-physician practitioner within ten (10) business days from referral, and

g) Behavioral health prevention education services performed by a mental health professional.

Source: Miss. Code Ann. §§ 43-13-121, 43-13-117(19)(a); 42 CFR § 440.169.

History: Revised eff. 07/01/2024.

Rule 2.3: Documentation Requirements

A. To qualify for reimbursement, a case file with adequate documentation must be maintained for each participant receiving Targeted Case Management (TCM) through the Perinatal

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High-Risk Management/Infant Services System (PHRM/ISS) program. Each TCM case file must, at a minimum, contain:

1. The name of the individual, as well as other personal information including, but not limited to:

a) Date of birth and Medicaid ID number,

b) Expected date of delivery,

c) Date when prenatal care began,

d) Name of primary provider,

e) Delivery date,

f) Delivery method,

g) Birth control plan chosen by participant,

h) Date(s) of postpartum visit(s) with medical provider,

i) Date of postpartum home visit with Extended Service RN,

j) Birth weight, and

k) Dates of EPSDT well-child visits

l) Release of information consent;

2. The dates and other information regarding case management services including:

a) Medical risk screening form including, but not limited to:

1. Date screening was performed,

2. Name of person/provider completing medical risk screen, and

3. Specific risk factors identified

b) Referral date and referral source,

b) Enrollment date,

c) Assessment dates;

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3. The name of the provider agency (if relevant) and the person providing the case management service.

a) Participant transfer to new TCM provider including, but not limited to:

1. Reason for transfer to new TCM provider,

2. Transfer consent form signed and dated by participant, and

3. Transfer notes;

4. The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved.

a) Screening/assessment results,

b) Long and short-term goals with time frame for completion,

c) Planned interventions,

d) Outcome of interventions,

e) Dates and reasons for review and/or revision, and

f) Discharge plans and case closure documentation including, but not limited to:

(1) Reason for closure,

(2) Services provided and outcomes, including any unmet goals and/or ongoing needs,

(3) Referrals to providers and other resources to address unmet goals and ongoing needs, and

(4) Notification to participant and primary care provider(s) regarding case closure and any post case closure referrals that have been made;

5. Whether the individual has declined services in the care plan and the individual’s signature declining the service.

6. The need for, and occurrences of, coordination with other case managers, including:

a) Documentation of referrals:

(1) Date of referral,

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(2) Name of provider/entity to whom the referral was made,

(3) Reason for referral, and

(4) Outcome of referral(s);

b) Case Conference including, but not limited to:

(1) Date of case conference,

(2) Case conference attendees, and

(3) Case conference notes including interdisciplinary team recommendations/plans and any revisions to the POC;

7. A timeline for obtaining needed services.

8. A timeline for reevaluation of the plan.

Source: Miss. Code Ann. §§ 43-13-121, 43-13-117, 43-13-118, 43-13-129; 42 CFR § 441.18.

History: Revised eff. 07/01/2024.

Rule 2.4: Freedom of Choice

Medicaid beneficiaries have the right to freedom of choice of providers for Medicaid covered services. Refer to Part 200, Chapter 3, Rule 3.6.

Perinatal High-Risk Management/Infant Services System (PHRM/ISS) Targeted Case Management (TCM) services will not restrict an individual’s free choice of providers. An eligible beneficiary may choose to receive extended or enhanced services through any PHRM/ISS provider.

Source: Miss. Code Ann. § 43-13-121; 42 CFR § 441.18; Social Security Act 1902(a)(23)

History: Revised eff. 07/01/2024.

Rule 2.5: Reimbursement A. The provider must bill the appropriate HCPCs code and modifier HD for maternity and infant services to be reimbursed under the PHRM/ISS program.

B. Payments under the plan must not duplicate payments made to public agencies or private entities under other program authorities for the same purpose.

C. Only medically necessary services are covered under the Medicaid program.

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Source: Miss. Code Ann. §§ 43-13-121, 43-13-117; 42 CFR § 441.18.

History: Revised eff. 07/01/2024.

Rule 2.6: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 07/01/2024.

Rule 2.7: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Source: Miss. Code Ann. § 43-13-121

Part 223 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Chapter 1 General

23 Miss. Admin. Code Pt. 223, R. 1.7 Diagnostic and Treatment Program Services

A. EPSDT diagnostic and treatment services consists of all medically necessary services needed to correct or ameliorate physical or mental illnesses and conditions discovered by a screening, whether or not such services are covered under the State Plan; and for a Medicaid eligible child or youth under age twenty-one (21) years, if the service is determined by the Division of Medicaid or its representative to be medically necessary.

B. A medically necessary service is defined as any service that is reasonably necessary to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap or cause physical deformity or malfunction. There must also be no other equally effective, more conservative, or substantially less costly course of treatment available or suitable for the client requesting the service.

C. To receive payment for any service that is not specifically included as a covered service under any Medicaid Administrative Rule or under the federally approved State Plan, the requestor must submit a request for prior authorization.

Rule 1.8: Reimbursement

A. The Division of Medicaid reimburses a separate fee in addition to the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) periodic screenings and medically necessary interperiodic visits for each of the following when documented in accordance with Miss. Admin. Code Title 23, Part 223, Rule 1.6.A.

1. Developmental screenings according to the American Academy of Pediatrics (AAP) guidelines,

2. Vision screenings,

3. Hearing screenings,

4. Autism screenings,

5. Depression screenings,

6. Maternal depression screening, and

7. Other medically necessary services prior authorized by the Division of Medicaid or designee, if required:

a) Lab tests, excluding hemoglobin or hematocrit,

b) Diagnostic tests, and

c) Other procedures.

B. The Division of Medicaid reimburses EPSDT screening fees using Current Procedural Terminology (CPT) Codes based on the American Medical Association (AMA) methodology for determining medical services at the same rate that was in effect for State Fiscal Year (SFY) 2021.

C. The Division of Medicaid only reimburses Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) and Mississippi Department of Health (MSDH) Clinics an encounter rate that is all inclusive of all items listed in Miss. Admin. Code Title 23, Part 223, Rule 1.8.A.

History: Revised to correspond with SPA 21-0028 (eff. 07/01/2021) eff. 08/01/2021; Revised to correspond with SPA 18-0014 (eff. 10/01/2018) effective 12/01/2018. New Rule to correspond with SPA 15-017 (eff. 11/01/2016) eff. 10/01/2016.

History

• Source: Miss. Code Ann. § 43-13-121; Section 1905 (r) (5) of the Social Security Act
• Source: 42 U.S.C. § 1396d; 42 C.F.R Part 441, Subpart B; Miss. Code Ann. §§ 43-13-117, 43- 13-121.

Part 224 Immunizations

23 Miss. Admin. Code Pt. 224 Immunizations

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 224 Immunizations

Table of Contents

Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 224: Immunizations ............................................................................................................. 1 Rule 1.1: Reserved .......................................................................................................... 1 Rule 1.2: Provider Requirements .................................................................................... 1 Rule 1.3: Vaccines for Children (VFC) Program ............................................................. 1 Rule 1.4: Vaccines for Beneficiaries Nineteen (19) Years of Age or Older ................... 2 Rule 1.5: Refer to Part 224, Rules 1.3 & 1.4 .................................................................. 4 Rule 1.6: Vaccines for Pregnant and Postpartum Beneficiaries................................4 Rule 1.7: Vaccines Available Through the Pharmacy Venue................................5

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Title 23: Division of Medicaid

Part 224: Immunizations

Part 224 Chapter 1: General

Rule 1.1: Definitions

The Division of Medicaid defines:

A. Centers for Disease Control and Prevention (CDC) as the nation’s public health protection agency with the authority to implement regulations related to protecting America from health and safety threats, both foreign and within the United States, and increasing public health security.

B. The Advisory Committee for Immunization Practices (ACIP) as a committee of medical and public health experts who develop recommendations on the use of vaccines in the civilian population of the United States whose recommendations stand as public health guidance for safe use of vaccines and related biological products.

C. The Vaccines for Children (VFC) Program as a federally funded program that provides vaccines at no cost to Mississippi Medicaid providers enrolled as VFC providers. The Mississippi State Department of Health (MSDH) is the lead agency in administering the VFC Program and distributing the vaccines to VFC enrolled providers allowing for eligible children eighteen (18) years of age and younger to receive free vaccines.

Source: 42 U.S.C. §§ 1396s, 300aa-26; Miss. Code Ann. §§ 41-23-37, 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021.1/01/2016.

Rule 1.2: Provider Requirements

A. Providers who administer vaccines must:

1. Be enrolled as a Mississippi Medicaid provider in accordance with Miss. Admin. Code Title 23, Part 200, Chapter 4, and

2. Operate within their scope of practice.

B. Pharmacists who administer vaccines must be employed by a Mississippi Medicaid enrolled pharmacy provider.

C. Providers administering vaccines to beneficiaries eighteen (18) years of age or younger:

1. Must participate in the Vaccines for Children (VFC) program administered by the Mississippi State Department of Health (MSDH).

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2. Comply with all federal and state laws and MSDH guidelines and requirements of the VFC program.

3. Exceptions to this rule are for:

a) Obstetricians administering the tetanus, diphtheria and pertussis (Tdap) vaccine to pregnant or postpartum beneficiaries.

b) Vaccines not available through the VFC program.

D. The Division of Medicaid defers to Mississippi’s professional medical, pharmacy and nursing licensure boards for ancillary staff requirements for vaccine administration unless Federal law allows for less restrictive requirements.

Source: 42 U.S.C. § 1396s; 42 C.F.R. Part 455, Subpart E; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021.

Rule 1.3: Covered Services

The Division of Medicaid covers vaccines according to the indications and guidelines of the Centers for Disease Control and Prevention (CDC) administered to beneficiaries:

A. Eighteen (18) years of age and younger when administered by physician and non- physician practitioner providers enrolled as a Vaccine for Children (VFC) provider through the medical benefit.

B. Eighteen (18) years of age and younger who are pregnant or postpartum receiving the Tdap vaccine when administered by an obstetrician regardless of VFC enrollment through the medical benefit.

C. Ten (10) to eighteen (18) years of age when administered by a pharmacist employed by a pharmacy provider enrolled as a VFC provider through the point-of-sale pharmacy billing venue.

D. Nineteen (19) years of age and older when administered by a physician or non-physician practitioner or a pharmacist who is employed by a pharmacy provider through the medical and point-of-sale pharmacy billing venue.

E. Of any age, for vaccines not listed on the CDC recommended Immunization Schedules required for travel outside of the United States, with prior authorization.

Source: 42 USC §§ 1396s, 300aa-26; Miss. Code Ann. §§ 41-23-37, 43-13-121.

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History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021, Revised eff. 01/01/2016.

Rule 1.4: Non-Covered Services

The Division of Medicaid does not cover the administration of additional components in a combination vaccine separately if ACIP recommends a combination vaccine available through the VFC program.

Source: 42 USC § 300aa-26; Miss. Code Ann. 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021, Revised eff. 01/01/2016.

Rule 1.5: Reimbursement

A. The Division of Medicaid reimburses the lessor of the provider’s usual and customary charge or a fee from the Mississippi Medicaid fee schedule.

1. Physicians, nurse practitioners, and physician assistants:

a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age and younger by VFC enrolled providers:

(1) The administration fee for each single or combination vaccine administered.

(2) No additional reimbursement for the cost of the vaccine.

(3) An administration fee in addition to an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) visit or physician office visit only when a separately identifiable service is provided at the time of the vaccine administration.

b) For the tetanus, diphtheria, and pertussis (Tdap) vaccine administered by an obstetrician to pregnant or postpartum beneficiaries eighteen (18) years or younger per ACIP’s recommendations regardless of VFC enrollment:

(1) An administration fee for the Tdap combination vaccine.

(2) A fee for the cost of the vaccine(s) as listed on the vaccine Medicaid fee schedule.

c) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee for each single or combination vaccine if recommended by ACIP.

(2) A fee for the cost of the vaccine(s) as listed on the medical vaccine Medicaid fee

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schedule.

2. Pharmacy providers:

a) For vaccines available through the VFC program administered to beneficiaries ten (10) to eighteen (18) years of age by VFC enrolled pharmacy providers:

(1) The administration fee for each single or combination vaccine if recommended by ACIP.

(2) No additional reimbursement for the cost of the vaccine(s).

(3) No professional dispensing fee is paid for vaccine administration.

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee, the same fee as for a primary care physician (PCP) attested non-physician practitioner, for each single or combination vaccine if recommended by ACIP.

(2) A fee for the cost of the vaccine(s) as listed on the pharmacy vaccine Medicaid fee schedule. The allowable ingredient cost is based on the Wholesale Acquisition Cost (WAC) + 0%.

(3) No professional dispensing fee is paid for vaccine administration.

c) Because vaccines are not classified as outpatient drugs:

(1) Vaccines will not be included in the pharmacy prescription limit.

(2) Copays will not be charged to beneficiaries.

3. A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or MSDH clinic the cost of a vaccine and vaccine administration as part of an encounter.

4. A long-term care facility for Medicaid beneficiaries when facility staff administers a vaccine:

a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age or younger, the administration is reimbursed as part of the facility’s per diem rate as routine nursing services on the cost report. There is no additional reimbursement for the cost of the vaccine.

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) The administration is reimbursed as part of the facility’s per diem rate as routine

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nursing services on the cost report.

(2) The cost of the vaccine in the per diem rate as reported as an allowable cost on the cost report.

c) The long-term care facility cannot claim vaccine costs on the cost report if an outside provider administers a vaccine.

5. An outside provider for Medicaid only beneficiaries in a long-term care facility when an outside provider administers a vaccine:

a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age or younger, the administration fee. There is no additional reimbursement for the cost of the vaccine.

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee for each single or combination vaccine if recommended by ACIP.

(2) A fee for the cost of the vaccine(s) as listed on:

(a) The medical vaccine Medicaid fee schedule if billed on a medical claim, or

(b) The pharmacy vaccine Medicaid fee schedule if billed on a pharmacy claim.

c) The long-term care facility cannot claim these costs on the facility’s Medicaid cost report.

6. Outpatient hospitals:

a) For vaccines available through the VFC program administered to beneficiaries ten (10) to eighteen (18) years of age by VFC outpatient hospital providers:

(1) The administration fee for each single or combination vaccine if recommended by ACIP.

(2) No additional reimbursement for the cost of the vaccine(s).

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee for each single or combination vaccine if recommended by ACIP.

(2) A fee for the vaccine(s) as listed on the outpatient prospective payment system (OPPS) fee schedule.

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B. The Division of Medicaid does not reimburse for:

a) The cost of a vaccine available through the VFC program administered to beneficiaries eighteen (18) years of age or younger except for the Tdap vaccine when purchased by an obstetrician who is not a VFC enrolled provider and administered to pregnant or postpartum beneficiaries.

b) An administration fee or for vaccines available through the VFC program when administered by non-VFC enrolled outpatient hospital providers to beneficiaries eighteen years of age or younger.

c) The administration of additional components of a combination vaccine available through the VFC program if recommended by ACIP.

d) A FQHC, RHC or MSDH clinic encounter solely for the administration of vaccines.

e) A vaccine administration fee to long-term care facilities, FQHCs, RHCs, and MSDH clinics.

f) A long-term care facility for costs on the cost report associated with the cost of vaccines if an outside provider administers the vaccine(s).

g) Vaccine(s) administered to dual-eligible beneficiaries if covered by Medicare.

Source: 42 U.S.C. §§ 1396s, 300aa-26; Miss. Code Ann. §§ 41-23-37, 43-13-121.

History: Revised eff. 07/01/2022; Revised eff. 07/01/2021; Revised to correspond with SPA 20- 0013 (eff. 09/01/2020) eff. 04/01/2021, Revised eff. 01/01/2016.

Rule 1.6: Documentation

Providers administering vaccines must document the following in addition to other documentation required by other federal and state regulatory agencies:

A. The date the beneficiary, or parent or legal representative if the beneficiary is a minor, received a current copy of the relevant federal Vaccine Information Statement (VIS) for each vaccine prior to the administration and confirmation that the beneficiary was given an opportunity to discuss concerns,

B. The date of publication of the VIS,

C. The date the vaccination was given,

D. The vaccine manufacturer and lot number of the vaccine administered,

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E. The signature and title of the individual who administered the vaccine, and

F. Any adverse events that occurred after vaccination.

Source: 42 USC §§ 1396s, 300aa-26; Miss. Code Ann. §§ 43-13-117, 43-13-121. History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021; New Rule eff. 04/01/2015.

History: Revised eff. 01/01/2016.

Part 225 Telemedicine

23 Miss. Admin. Code Pt. 225 Telemedicine

Title 23: Division of Medicaid

Part 225: Telemedicine

Chapter 1: Telehealth Services

Rule 1.1: Definitions

The Division of Medicaid defines telemedicine as a method which uses electronic information and communication equipment to supply and support health care when remoteness disconnects patients and links primary care physicians, specialists, providers, and beneficiaries which includes, but is not limited to, telehealth services, remote patient monitoring services, teleradiology services, store-and-forward and continuous glucose monitoring services.

A. The Division of Medicaid defines telehealth services as the delivery of health care by an enrolled Mississippi Medicaid provider, through a real-time communication method, to a beneficiary who is located at a different site. The interaction must be:

1. Live,

2. Interactive, and

3. Audiovisual.

B. The Division of Medicaid defines the originating site, also referred to as the spoke site, as the physical location of the beneficiary at the time the telehealth service is provided.

C. The Division of Medicaid defines the distant site, also referred to as the hub site, as the physical location of the provider delivering the telehealth service at the time the telehealth service is provided.

D. The Division of Medicaid defines the telepresenter as medical personnel who:

1. Is a Mississippi Medicaid provider, or employed by a Mississippi Medicaid provider and directly supervised by the provider or an appropriate employee of the provider if the medical personnel’s license or certification requires supervision,

2. Is trained to use the appropriate technology at the originating site,

3. Is able to facilitate comprehensive exams under the direction of a distant site practitioner who is, or is employed by, a Mississippi Medicaid provider.

4. Must remain in the exam room for the entirety of the exam unless otherwise directed by the distant site provider for the appropriate treatment of the beneficiary, and

5. Must act within the scope of their practice, license, or certification.

E. The Division of Medicaid defines direct supervision as the provider’s, or an appropriate employee of the provider, presence in the office suite and immediately available to furnish assistance and direction throughout the performance of the telehealth service but does not require the provider to be physically present in the room when the telehealth service is delivered.

Source: 42 C.F.R. § 410.78; Miss. Code Ann. § 43-13-121; SPA 15-003.

History: Revised eff. 08/01/2020; New to correspond with SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.

Rule 1.2: Provider Requirements

A. Providers of telehealth services must be an enrolled Mississippi Medicaid provider in accordance with Miss. Code Title 23, Part 200, Chapter 4, acting within their scope-of- practice, license, medical certification or Mississippi Department of Health (MDSH) certification and must comply with state and federal guidelines, including but not limited to, authorization of prescription medications at both the originating and distant site.

B. The Division of Medicaid requires that providers utilize telehealth technology sufficient to provide real-time interactive communications that provide the same information as if the telehealth visit was performed in-person. Equipment must be compliant with all applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA).

C. The use and delivery of telemedicine services does not alter a provider’s privacy obligations under federal and/or state law and a provider or entity operating telehealth services that involve protected health information (PHI) must meet the same Health Insurance Portability and Accountability Act (HIPAA) requirements the provider or entity would for a service provided in person.

Source: 42 C.F.R. § 410.78; The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (as amended by the Genetic Information Nondiscrimination Act (GINA) of 2008 and the Health Information Technology for Economic and Clinical Health Act (HITECH Act), Title XIII of Division A, and Title IV of Division B of the American Recovery and Reinvestment Act (ARRA) 0f 2009) and its implementing regulations, including 45 C.F.R. Parts 160 and 164, Subparts A and E (Privacy Rule), and Subparts A and C (Security Rule); Miss. Code Ann. § 43-13-121; SPA 20-0010; SPA 15-003.

History: Revised eff. 08/01/2026. Revised eff. 08/01/2020; Revised eff. 07/01/2018; Added Miss. Admin. Code Part 225, Rule 1.2.C.6. eff. 05/01/2016; New to correspond with SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.

Rule 1.3: Covered Services

A. The Division of Medicaid covers medically necessary telehealth services as a substitution for

an in-person visit for consultations, office visits, and/or outpatient visits when all the required medically appropriate criteria is met which aligns with the description of the Current Procedural Terminology (CPT) evaluation and management (E&M) and Healthcare Common Procedure Coding System (HCPCS) guidelines.

B. The Division of Medicaid covers telehealth services at the following locations:

1. At the following originating sites:

a) Office of a physician or practitioner,

b) Outpatient Hospital (including a Critical Access Hospital (CAH)),

c) Rural Health Clinic (RHC),

d) Federally Qualified Health Center (FQHC),

e) Community Mental Health/Private Mental Health Centers,

f) Therapeutic Group Homes,

g) Indian Health Service Clinic,

h) School-based clinic,

i) School which employs a school nurse,

j) Inpatient hospital setting, or

k) Beneficiary’s home.

2. At the distant site the following provider types are allowed to render telehealth services:

a) Physicians,

b) Physician Assistants,

c) Nurse Practitioners,

d) Psychologists,

e) Licensed Clinical Social Workers (LCSWs),

f) Licensed Professional Counselors (LPCs),

g) Licensed Marriage and Family Therapists (LMFTs),

h) Board Certified Behavior Analysts (BCBAs) or Board Certified Behavior Analyst- Doctorals (BCBA-Ds),

i) Community Mental Health Centers (CMHCs),

j) Private Mental Health Centers,

k) Federally Qualified Health Centers (FQHCs),

l) Rural Health Centers (RHCs),

m) Physical, occupational or speech therapy, or

n) Mississippi State Department of Health (MSDH) clinics.

C. The Division of Medicaid requires a telepresenter who meets the requirements of Miss. Admin Code Part 225, Rule 1.1.D. at the originating site unless the originating site is the beneficiary’s home or as determined by the Division.

Source: 42 C.F.R. § 410.78; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 15-003.

History: Revised eff. 02/01/2024. Revised eff. 07/01/2021; Revised eff. 08/01/2020; New to correspond with SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.

Rule 1.4: Non-Covered Services

The Division of Medicaid does not:

A. Cover a telehealth service if that same service is not covered in an in-person setting.

B. Cover a separate reimbursement for the installation or maintenance of telehealth hardware, software and/or equipment, videotapes, and transmissions.

C. Cover early and periodic screening, diagnosis, and treatment (EPSDT) well child visits through telehealth.

D. Cover physician or other practitioner visits through telehealth for non-established beneficiaries.

E. Consider the following as telehealth services:

1. Telephone conversations,

2. Chart reviews;

3. Electronic mail messages;

4. Facsimile transmission;

5. Internet services for online medical evaluations, or

6. Communication through social media, or

7. Any other communication made in the course of usual business practices including, but not limited to,

a) Calling in a prescription refill, or

b) Performing a quick virtual triage.

F. Cover the installation or maintenance of any telecommunication devices or systems.

Source: 42 C.F.R. § 410.78; Miss. Code Ann. § 43-13-121; SPA 15-003.

History: Revised eff. 06/01/2024; Revised eff. 02/01/2024. Revised eff. 07/01/2021; Revised eff. 08/01/2020; New to correspond with SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.

Rule 1.5: Reimbursement

A. The Division of Medicaid reimburses the provider at the originating site the Mississippi Medicaid telehealth originating site facility fee for telehealth services per completed transmission, in addition to a separately identifiable covered service if performed.

1. The following providers are eligible to receive the originating site facility fee for telehealth services per transmission:

a) The office of a physician or practitioner,

b) An outpatient hospital, including a Critical Access Hospital (CAH),

c) A Rural Health Clinic (RHC),

d) A Federally Qualified Health Center (FQHC),

e) A Community Mental Health/Private Mental Health Center,

f) A Therapeutic Group Home,

g) An Indian Health Service Clinic,

h) A School-Based Clinic, or

i) School which employs a nurse.

2. The originating site provider can only bill for an encounter or Evaluation and Management (E&M) visit if a separately identifiable covered service is performed.

3. An inpatient hospital’s originating site fee is included in the All Patient Refined/Diagnosis Related Group (APR-DRG) payment.

B. The Division of Medicaid reimburses all providers delivering a medically necessary telehealth service at the distant site at the current applicable Mississippi Medicaid fee-for- service rate or encounter for the service provided. The provider must include the appropriate modifier on the claim indicating the service was provided through telehealth.

C. Providers delivering simultaneous distant and originating site services to a beneficiary are reimbursed:

1. The current applicable Mississippi Medicaid fee-for-service rate for the medical service(s) provided, and

2. Either the originating or distant site facility fees, not both, except for RHC, FQHC and CMHC when such services are appropriately provided by the same organization.

Source: 42 C.F.R. § 410.78; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 15-003.

History: Revised eff. 07/01/2021; Revised eff. 08/01/2020; Revised eff. 07/01/2018; Added Miss. Admin. Code Part 225, Rule 1.5.B.2.f) eff. 05/01/2016; New to correspond with SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.

Rule 1.6: Documentation

The provider must document the same information as for a comparable in-person service and be maintained at both the originating and distant site of the telehealth services provided including, but not limited to:

A. Signed consent for treatment using telehealth,

B. Medically appropriate reason telehealth was utilized to provide services,

C. Beneficiary’s presenting diagnosis and symptoms,

D. Specific name/type of all diagnostic studies and results/findings of the studies, and

E. Plan of Care.

Source: Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2020; New to correspond with SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.

Rule 1.7: Procedures during States of Emergency

The Mississippi Division of Medicaid will allow additional coverage of telehealth services during a state of emergency as declared by either the Governor of Mississippi or the President of the United States. Details of enhanced services include the following that will terminate at the discretion of the Mississippi Division of Medicaid:

A. A beneficiary may seek treatment utilizing telehealth services from an originating site not listed in the Mississippi Medicaid State Plan regarding Telehealth (SPA 3.1-A Introductory Pages 1 and 2). These emergency exceptions include the following:

1. A beneficiary’s residence may be an originating site without prior approval by the Division of Medicaid.

2. Health care facilities not listed in the State Plan wishing to act as an originating site must first be granted approval by the Division of Medicaid before rendering originating site telehealth services.

B. A beneficiary may seek treatment utilizing telehealth services from a distant site provider not listed under Miss. Admin. Code Part 223, Rule 1.3. as determined by the Division of Medicaid.

C. Telehealth services are expanded to include use of telephonic audio that does not include video when authorized by the State of Mississippi.

D. A beneficiary may use the beneficiary’s personal telephonic land line in addition to a cellular device, computer, tablet, or other web camera-enabled device to seek and receive medical care in a synchronous format with a distant-site provider.

E. When the beneficiary receives services in the home, the requirement for a telepresenter to be present may be waived.

F. The Division of Medicaid requires that providers utilize telehealth technology compliant with all applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA) or otherwise compliant with guidance or notifications regarding the HIPAA Privacy and Security Rules issued by the Office of Civil Rights of the U.S. Department of Health and Human Services that is specific to the State of Emergency.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121; MS SPA 20-0015.

History: Revised eff. 08/01/2020; New Rule to correspond with SPA 20-0015 (eff. 03/01/2020) eff. 03/20/2020.

Part 225 Chapter 2: Remote Patient Monitoring Services

Rule 2.1: Definitions

A. The Division of Medicaid defines telemedicine as a method which uses electronic information and communication equipment to supply and support health care when remoteness disconnects patients and links primary care physicians, specialists, providers, and beneficiaries which includes, but is not limited to, telehealth services, remote patient monitoring services, teleradiology services, store-and-forward and continuous glucose monitoring services.

B. The Division of Medicaid defines remote patient monitoring as using digital technologies to collect medical and other forms of health data from individuals in one location and electronically transmit that information securely to healthcare providers in a different location for interpretation and recommendation.

Source: Miss. Code Ann. § 43-13-121.

History: New eff. 07/01/2015.

Rule 2.2: General Provider Information

A. Providers of remote patient monitoring services must meet all of the applicable requirements set forth in Miss. Admin. Code Title 23, Part 200, Chapter 4.

B. Remote patient monitoring services must be delivered by an enrolled Medicaid provider acting within their scope-of-practice and license and in accordance with state and federal guidelines.

C. The use and delivery of remote patient monitoring services does not alter a covered provider’s privacy obligations under federal/and or state law and a provider or entity operating telehealth services that involve protected health information (“PHI”) must meet the same Health Insurance Portability and Accountability Act (HIPAA) requirements the provider or entity would for a service provided in person.

D. Providers of remote patient monitoring services must have protocols in place to address all of the following:

1. A mechanism for monitoring, tracking and responding to changes in a beneficiary’s clinical condition, and

2. A process for notifying the prescribing physician of significant changes in the beneficiary’s clinical signs and symptoms.

Source: The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 (as amended by the Genetic Information Nondiscrimination Act (“GINA”) of 2008 and the

Health Information Technology for Economic and Clinical Health Act (“HITECH Act”), Title XIII of Division A, and Title IV of Division B of the American Recovery and Reinvestment Act (“ARRA”) 0f 2009) and its implementing regulations, including 45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and Subparts A and C (“Security Rule”); Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. New eff. 07/01/2015.

Rule 2.3: Covered Services

A. The Division of Medicaid covers remote patient monitoring of devices when medically necessary, ordered by a physician, physician assistant or nurse practitioner which includes, but not limited to:

1. Implantable pacemakers,

2. Defibrillators,

3. Cardiac monitors,

4. Loop recorders,

5. External mobile cardiovascular telemetry, and

6. Continuous glucose monitors.

B. The Division of Medicaid covers remote patient monitoring, for disease management when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), Division of Medicaid or designee, ordered by a physician, physician assistant, or nurse practitioner for a beneficiary who meets the following criteria:

1. Has been diagnosed with one (1) or more of the chronic conditions as defined by the Centers of Medicare and Medicaid Services (CMS) which include, but are not limited to:

a) Diabetes,

b) Congestive Heart Failure (CHF),

c) Chronic Obstructive Pulmonary Disease (COPD),

d) Heart disease,

e) Mental health, and

f) Sickle cell.

2. Is capable of using the remote patient monitoring equipment and transmitting the necessary data or has a willing and able person to assist in completing electronic transmission of data.

C. Prior Authorization must include the following:

1. An order for remote patient monitoring services, signed and dated by the prescribing physician,

2. A plan of care, signed and dated by the prescribing physician, that includes transmission frequency and duration of monitoring requested,

3. Beneficiary’s diagnosis and risk factors that qualify the beneficiary for remote patient monitoring,

4. Attestation that the beneficiary is cognitively intact and able to operate the equipment or has a willing and able person to assist in completing transmission of data, and

5. Attestation that the beneficiary is not receiving duplicative services via disease management.

D. Remote patient monitoring services must be provided in the beneficiary’s private residence.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121, 83-9-353.

History: Revised eff. 07/01/2021, Revised eff. 01/01/2021; New eff. 07/01/2015.

Rule 2.4: Non-Covered Services

The Division of Medicaid does not cover remote patient monitoring for disease management as outlined in Miss. Admin. Code Part 225, Rule 2.3.B. for a beneficiary who is a resident of an institution that meets the basic definition of a hospital or long-term care facility.

Source: Miss. Code Ann. § 43-13-121.

History: New eff. 07/01/2015.

Rule 2.5: Reimbursement

A. The Division of Medicaid reimburses for remote patient monitoring:

1. Of devices when billed with the appropriate code, and

2. For disease management:

a) A daily monitoring rate for days the beneficiary’s information is reviewed.

b) Only one (1) unit per day is allowed, not to exceed thirty-one (31) days per month.

c) An initial visit to install the equipment and train the beneficiary may be billed as a set-up visit.

d) Only one set-up is allowed per episode even if monitoring parameters are added after the initial set-up and installation.

e) Only one (1) daily rate will be reimbursed regardless of the number of diseases/chronic conditions being monitored.

B. The Division of Medicaid does not reimburse for the duplicate transmission or interpretation of remote patient monitoring data.

Source: Miss. Code Ann. § 43-13-121.

History: New eff. 07/01/2015.

2.6: Documentation

The provider must document the remote patient monitoring service the same as for a comparable in person service which includes, but is not limited to:

A. The monitoring equipment meets all of the following requirements:

1. Capable of monitoring any data parameters included in the plan of care,

2. Food and Drug Administration (FDA) Class II hospital-grade medical device, and

3. Capable of accurately measuring and transmitting beneficiary glucose and/or blood pressure data.

B. Qualified staff installed the remote patient monitoring equipment necessary to monitor and transmit the data according to the beneficiary’s care plan.

C. Clinical data was provided to the beneficiary’s primary care physician or his/her designee.

D. Monitoring of the beneficiary’s clinical data was not duplicated by any other provider.

E. Beneficiary’s home environment has the necessary space and connections for installation and transmission of data.

Source: Miss. Code Ann. § 43-13-121.

History: New eff. 07/01/2015.

Part 225 Chapter 3: Teleradiology Services

Rule 3.1: Definitions

The Division of Medicaid defines telemedicine as a method which uses electronic information and communication equipment to supply and support health care when remoteness disconnects patients and links primary care physicians, specialists, providers, and beneficiaries which includes, but is not limited to, telehealth services remote patient monitoring services, teleradiology services, store-and-forward and continuous glucose monitoring services.

A. The Division of Medicaid defines store-and-forward as telecommunication technology for the transfer of medical data from one (1) site to another through the use of a camera or similar device that records or stores an image which is transmitted or forwarded via telecommunication to another site for teleconsultation and includes, but is not limited to, teleradiology services.

B. The Division of Medicaid defines a:

1. Teleradiology service as the electronic transmission of radiological images, known as store-and-forward images, from one (1) location to another for the purposes of interpretation.

2. Consulting provider as a licensed physician who interprets the radiological image, at the distant site and who must be licensed in the state within the United States in which he/she practices.

3. Distant site, also referred to as a hub site, as the location of the teleradiology consulting provider.

4. Referring provider as a licensed physician, physician assistant, or nurse practitioner who orders the radiological service and who must be licensed in the state within the United States in which he/she practices.

5. Originating site, also referred to as the spoke site, as the location where the beneficiary is receiving the teleradiology service.

A. Store-and-forward as telecommunication technology for the transfer of medical data from one (1) site to another through the use of a camera or similar device that records or stores an image which is transmitted or forwarded via telecommunication to another site for teleconsultation and includes, but is not limited to, teleradiology.

7. The transmission cost as the cost of the line charge incurred during the time of the transmission of a telehealth service.

Source: Miss. Code Ann. § 43-13-121.

History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.

Rule 3.2: General Provider Information

A. Teleradiology services must be delivered by an enrolled Medicaid provider, in accordance with Miss. Admin. Code Title 23, Part 200, Chapter 4 acting within their scope-of-practice and license and in accordance with state and federal guidelines.

B. The use and delivery of teleradiology services does not alter a covered provider’s privacy obligations under federal/and or state law and a provider or entity operating telehealth services that involve protected health information (“PHI”) must meet the same Health Insurance Portability and Accountability Act (HIPAA) requirements the provider or entity would for a service provided in person.

C. The teleradiology service provider must ensure:

1. Images are provided without clinically significant loss of data from image acquisition through transmission to final image display to enable the consulting provider to accurately interpret the image,

2. Equipment used provides image quality appropriate to the clinical need.

3. The radiologic examination at the originating site be performed at the originating site by qualified personnel:

a) Trained in the performance of the specified radiological service,

b) Operating within the licensure requirements of the state in which the service is being performed, and

c) Under the supervision of a qualified licensed physician.

4. Teleradiology systems provide network and software security protocols to protect the confidentiality of a beneficiary’s identification and imaging data with measures implemented to safeguard the data and to ensure data integrity against intentional or unintentional corruption of the data.

Source: The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 (as amended by the Genetic Information Nondiscrimination Act (“GINA”) of 2008 and the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”), Title XIII of Division A, and Title IV of Division B of the American Recovery and Reinvestment Act (“ARRA”) 0f 2009) and its implementing regulations, including 45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and Subparts A and C (“Security Rule”); Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. Moved with Revisions from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.

Rule 3.3: Covered Services

The Division of Medicaid covers:

A. One (1) technical and one (1) professional component for each teleradiology procedure only for providers enrolled as a Mississippi Medicaid provider and when there are no geographically local radiologist providers to interpret the images.

B. The technical component of the radiological service is covered at the originating site.

C. The professional component of the radiological service is covered at the distant site.

Source: Miss. Code Ann. § 43-13-121.

History: Moved with Revisions from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.

Rule 3.4: Non-Covered Services

The Division of Medicaid does not cover:

A. The transmission cost or any other associated cost of teleradiology,

B. Both the technical and professional component of teleradiology services for one (1) provider, or

C. One (1) provider billing for services performed by another provider.

Source: Miss. Code Ann. § 43-13-121.

History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.

Rule 3.5: Reimbursement

A. The Division of Medicaid reimburses for:

1. The technical component of the radiological service at the originating site for only providers enrolled as a Mississippi Medicaid provider.

2. The professional component of the radiological service at the distant site only for providers enrolled as a Mississippi Medicaid provider.

B. If a hospital chooses to bill for purchased or contractual teleradiology services, the service must be billed under a physician group provider number only.

Source: Miss. Code Ann. § 43-13-121.

History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.

Rule 3.6: Documentation

A. Teleradiology documentation must include, but not limited to:

1. At the originating site: a) The reason teleradiology was utilized to deliver the service including there was no local radiologists to interpret the images,

b) Date(s) of service,

c) Beneficiary demographic information,

d) Signed consent for treatment, if applicable,

e) Medical history,

f) Beneficiary’s presenting complaint,

g) Diagnosis, and

h) Specific name/type of all diagnostic studies and results/findings of the studies.

2. At the distant site: a) Date(s) of service,

b) Beneficiary demographic information,

c) Medical history,

d) Beneficiary’s presenting complaint,

e) Diagnosis,

f) Specific name/type of all diagnostic studies and results/findings of the studies, and

g) Radiological images.

Source: Miss. Code Ann. § 43-13-121.

History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.

Part 225 Chapter 4: Continuous Glucose Monitoring Services

Rule 4.1: Definitions

A. The Division of Medicaid defines telemedicine as a method which uses electronic information and communication equipment to supply and support health care when remoteness disconnects patients and links primary care physicians, specialists, providers, and beneficiaries which includes, but is not limited to, telehealth services remote patient monitoring services, teleradiology services, store-and-forward, and continuous glucose monitoring services.

B. The Division of Medicaid defines a continuous glucose monitoring service as:

1. The download, retrospective review and interpretation of blood glucose values by a physician, physician’s assistant or nurse practitioner when captured for more than seventy-two (72) hours on a continuous glucose monitor system, and

2. Adjunct monitoring, not an alternative, to traditional self-monitoring of blood glucose levels, supplying additional information on glucose trends that are not available from self-monitoring.

Source: Miss. Code Ann. § 43-13-121.

History: New eff. 07/01/2015.

Rule 4.2: General Provider Information

A. Continuous glucose monitoring services must be delivered by an enrolled Medicaid provider in accordance with Part 200, Chapter 4 acting within their scope-of-practice and license and in accordance with state and federal guidelines.

B. The use and delivery of continuous glucose monitoring services does not alter a covered provider’s privacy obligations under federal/and or state law and a provider or entity operating telehealth services that involve protected health information (“PHI”) must meet the same Health Insurance Portability and Accountability Act (HIPAA) requirements the provider or entity would for a service provided in person.

Source: The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 (as amended by the Genetic Information Nondiscrimination Act (“GINA”) of 2008 and the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”), Title XIII of Division A, and Title IV of Division B of the American Recovery and Reinvestment Act (“ARRA”) 0f 2009) and its implementing regulations, including 45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and Subparts A and C (“Security Rule”); Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026. New eff. 07/01/2015.

Rule 4.3: Covered Services

A. The Division of Medicaid covers:

1. A continuous glucose monitoring (CGM) service when medically necessary, prior authorized by the UM/QIO, Division of Medicaid or designee, ordered by the physician who is actively managing the beneficiary’s diabetes and the beneficiary meets all of the following criteria:

a) Has an established diagnosis of type I or type II diabetes mellitus that is poorly controlled as defined below:

1. Unexplained hypoglycemic episodes,

2. Nocturnal hypoglycemic episode(s),

3. Hypoglycemic unawareness and/or frequent hypoglycemic episodes leading to impairments in activities of daily living,

4. Suspected postprandial hyperglycemia,

5. Recurrent diabetic ketoacidosis, or

6. Unable to achieve optimum glycemic control as defined by the most current version of the American Diabetes Association (ADA).

b) Be able, or have a caregiver who is able, to hear and view CGM alerts and respond appropriately.

c) Has documented self-monitoring of blood glucose at least four (4) times per day.

d) Requires insulin injections three (3) or more times per day or requires the use of an insulin pump for maintenance of blood glucose control.

e) Requires frequent adjustment to insulin treatment regimen based on blood glucose testing results,

f) Had an in-person visit with the ordering physician within six (6) months prior to ordering to evaluate their diabetes control and determined that criteria (1-4) above are met,

g) Has an in-person visit every six (6) months following the prescription of the CGM to assess adherence to the CGM regimen and diabetes treatment plan.

2. CGM service only when the blood glucose data is obtained from a Federal Drug Administration (FDA) approved durable medical equipment (DME) medical device for home use.

B. The Division of Medicaid does not require the provider to have a face-to-face office visit with the beneficiary to download, review and interpret the blood glucose data.

Source: 42 U.S.C. § 1395x(n); Miss. Code Ann. § 43-13-121.

History: Revised eff. 10/01/2023; Revised eff. 07/01/2021; New eff. 07/01/2015.

Rule 4.4: Non-Covered Services

A. The Division of Medicaid does not cover non-medically necessary non-durable medical equipment (DME) CGM devices that are not approved by the Food and Drug Administration (FDA) and do not comply with the FDA and American Diabetes Association (ADA) recommendations.

B. The Division of Medicaid does not cover non-DME devices including, but not limited to, smartphones, tablets, or personal computers.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 07/01/2021; New eff. 07/01/2015.

Rule 4.5: Reimbursement

A. The Division of Medicaid reimburses for:

1. One (1) retrospective review and interpretation of blood glucose values per month, and

2. A one (1) time device hook-up which includes beneficiary education.

B. The Division of Medicaid does not reimburse for a separate Evaluation and Management (E&M) visit unless a separately identifiable service is performed.

Source: Miss. Code Ann. § 43-13-121.

History: New eff. 07/01/2015.

Rule 4.6: Documentation

Continuous glucose monitoring (CGM) service documentation must include, but is not limited to:

A. The beneficiary and/or care giver is capable of operating the continuous glucose monitoring

system,

B. The beneficiary:

1. Has an established diagnosis of type I or type II diabetes mellitus that is poorly controlled as defined in Miss. Admin. Code Part 225, Rule 4.3.A.1.a),

2. Requires three (3) insulin injections per day, or use of an insulin pump, for maintenance of blood glucose control,

3. Requires regular self-monitoring of at least four (4) times a day,

4. Requires frequent adjustment to insulin treatment regimen based on blood glucose testing results,

5. Had an in-person visit with the ordering physician within six (6) months prior to ordering to evaluate their diabetes control and determined that criteria (1-4) above are met,

6. Has an in-person visit every six (6) months following the prescription of the CGM to assess adherence to the CGM regimen and diabetes treatment plan.

C. The CGM is a Food and Drug Administration (FDA) approved medical device and is capable of accurately measuring and transmitting beneficiary blood data.

Source: 42 U.S.C. § 1395x(n); Miss. Code Ann. §§ 43-13-117, 43-13-121, 83-9-353.

History: Revised eff. 10/01/2023; Revised eff. 07/01/2021; New eff. 07/01/2015.

Part 300 Appeals

Chapter 4 Claim Denials

23 Miss. Admin. Code Pt. 300, R. 4.2 Errors Made within the Timely Processing Period

A. The Provider may not seek relief from the Division for a claim denied due to an error within the timely processing period until the provider exhausts the applicable process for the type of error as detailed below.

1. Fiscal Agent Error

a) When a claim is denied due to Fiscal Agent Error(s) within the timely processing period, the provider must notify the fiscal agent to correct the error.

b) If the Fiscal Agent does not correct the error within the timely processing period, the provider may contact Division of Medicaid Office of Provider Solutions within ninety (90) days of the end of the timely processing period for an Administrative Review for the Denied Claim.

2. Provider Billing Errors

a) Claims submitted within the timely filing period that deny due to a Provider Billing Error(s) may be resubmitted to the Fiscal Agent within the timely processing period.

b) Claims submitted outside of the timely filing period will only be reviewed if the requirements listed in Part 200, Rule 1.6 are met. The Division has discretion to grant or refuse an Administrative Review for a Denied Claim.

c) Denial of a request for an Administrative Review for a Denied Claim is the Division’s Final Administrative Decision.

d) If the Division does grant a request for Administrative Review of a Denied Claim, the Division of Medicaid’s Office of Provider Solutions will render the Division’s Final Administrative Decision.

3. Providers may not appeal the technical denial of a claim for failure to timely obtain a prior authorization.

B. Claims Denied for Untimeliness

1. Providers may request an Administrative Review for a claim denied for untimeliness within ninety (90) calendar days of the denial of a claim when:

a) The provider is unable to meet the timely filing requirement due to retroactive beneficiary eligibility and has:

1. Received prior authorization, if required, from the Utilization Management/Quality Improvement Organization (UM/QIO) within ninety (90) days of the system add date of the eligibility determination, and

2. Filed the claim within ninety (90) days of the system add date of the eligibility determination,

b) The Division of Medicaid adjusts claims after timely filing and timely processing deadlines have expired,

c) A Medicare crossover claim has been filed within one hundred eighty (180) calendar days from the Medicare paid date and the provider is dissatisfied with the disposition of the Medicaid claim, or

d) The Fiscal Agent’s untimeliness decision was incorrect.

2. Requests for an Administrative Review for a Denied Claim must include:

a) Documentation of timely filing or documentation that the provider was unable to file the claim timely due to the beneficiary's retroactive eligibility;

b) Documentation that explains the facts that support the provider’s position as to how the denied claim meets one (1) or more of the requirements in Miss. Admin. Code, Title 23, Part 300, Rule 4.1.B. and the reasons the provider believes the Provider complied with Medicaid regulations;

c) A new claim submission for the claim in question; and

d) Any other documentation as required or requested by the Division of Medicaid.

3. Requests for an Administrative Review for a claim adjusted after the expiration of timely filing must include:

a) A copy of the Remittance Advice that includes the claim adjustment;

b) Documentation supporting the Provider’s position that the claim meets one (1) or more of the requirements of Rule 4.1.C. of this Chapter;

c) A new claim submission for the subject claim; and

d) Any other documentation as required and/or requested by the Division.

C. Medical necessity

1. Providers may request a reconsideration when a claim is denied due to failure to meet medical necessity requirements by submitting the required documentation to the fiscal agent within ninety (90) days of the denial.

2. If the provider is not satisfied with the fiscal agent’s medical necessity determination, the provider may request, in writing, an administrative hearing with the Division of Medicaid within ninety (90) days of the receipt of the fiscal agent’s medical necessity determination through the appeal process as described in Rule 3.1 of this Part.

History

• Source: Miss. Code Ann. §§ 43-13-113, 43-13-117, 43-13-121.

Part 301 School Based Administrative Claiming

23 Miss. Admin. Code Pt. 301 School Based Administrative Claiming

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 301 School Based Administrative Claiming

Table of Contents Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 301: School Based Administrative Claiming .......................................................................... 1 Part 301 Chapter 1: School Based Administrative Claiming ..................................................... 1 Rule 1.1: Purpose ................................................................................................................ 1 Rule 1.2: Provider Qualifications ....................................................................................... 1 Rule 1.3: Quality Assurance & Monitoring Plan ................................................................ 2 Rule 1.4: Reimbursement.................................................................................................... 5

1

Title 23: Division of Medicaid

Part 301: School Based Administrative Claiming

Part 301 Chapter 1: School Based Administrative Claiming

Rule 1.1: Purpose

A. The Division of Medicaid, the Mississippi Department of Education (MDE) and individual schools share in the responsibility for promoting access to healthcare for students in the public school system, preventing costly or long term healthcare problems for at-risk students, and coordinating student’s healthcare needs with other providers.

B. The Medicaid School-Based Administrative Claiming program (SBAC) allows school districts to be reimbursed for some of their costs associated with school-based health and outreach activities which are not claimable under the Medicaid School Health-Related Services “fee for service” program or under other Medicaid “fee for service” programs. In general, the types of school-based health and outreach activities funded under SBAC are the referral of students/families for Medicaid eligibility determinations, the provision of health care information and referral, coordination and monitoring of health services and interagency coordination. These activities include:

1. Medicaid Outreach,

2. Facilitating application for Medicaid and eligibility determination,

3. Transportation-related activities in support of Medicaid covered services,

4. Medicaid related Translation services,

5. Program planning, policy development and interagency coordination related to medical services,

6. Medicaid specific training, and

7. Referral, coordination and monitoring of Medicaid services.

Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; 42 CFR 430.1 and 42 CFR 431.15; OMB Circular A-87

Rule 1.2: Provider Qualifications

State school districts that participate in the School Based Administrative Claiming (SBAC) program must meet the following requirements:

A. Have a signed agreement with the Mississippi Department of Education (MDE),

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B. Attend staff training conducted by MDE,

C. Keep time studies of work activities via computer generated electronic documentation,

D. Determine statistically valid time sample results,

E. Prepare cost determinations and allocations,

F. Prepare and submit to MDE a quarterly invoice, and

G. Follow the yearly calendar published by MDE.

Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; 42 CFR 430.1 and 42 CFR 431.15; OMB Circular A-87

Rule 1.3: Quality Assurance & Monitoring Plan

A. The Division of Medicaid will establish and maintain a quality assurance process which ensures the quality management of the program. It is necessary to monitor the SBAC program in order to assure that Medicaid dollars are utilized to make Administrative Claiming available to eligible Mississippi Public School Districts enrolled in the SBAC program.

B. Mississippi Department of Education (MDE) Oversight and Monitoring

1. MDE will implement and provide oversight and monitoring actions to ensure that school districts are in compliance with SBAC requirements. At a minimum, these actions are to ensure that:

a) The time study is performed correctly,

b) The time study results are valid,

c) The financial data submitted is true and correct,

d) Training requirements are met, and

e) Appropriate documentation is maintained to support the time study and invoices.

C. Division of Medicaid Oversight and Monitoring

1. Validation of the program will include the Division of Medicaid performing the following actions quarterly:

a) Randomly select ten (10) percent of the sampled responses,

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b) Review the sampled responses and independently code the activities of the ten (10) percent selected, and

c) Validate the accuracy of the original coder.

2. Documentation must be readily accessible and available to the Division of Medicaid or CMS. The MDE agrees to share data as a apart of the quality assurance program timely upon request by the Division of Medicaid. The MDE will make available to the Division of Medicaid the documentation/records/reports maintained for the SBAC program.

3. The Division of Medicaid areas of review include:

a) The time study – sampling methodology, the sample, and time study results,

b) Compliance with training requirements,

c) Financial reviews, and

d) Documentation compliance.

4. The school districts will make available to the Division of Medicaid the documentation/records/reports maintained from the SBAC program.

5. These documentation/records/reports include, but are not limited to:

a) Random Moment Sampling (RMS) documents,

b) Methodology that supports the construction of the Administrative Claiming billing process,

c) Revenue projection reports, and

d) School district quarterly reports.

6. The school districts must submit copies of the time logs for each participating school in the area to MDE.

7. The Division of Medicaid will verify a small percentage of time logs quarterly to ensure accuracy. Verification will be through direct face-to-face contact with the sampled participants.

8. Each quarter the Division of Medicaid will audit the following:

a) A percentage of the time logs of the sampled school staff to ascertain if the sampled participants understood the instructions on sampling time forms, and

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b) Verify that the time study form turned in was completed by the individual who signed the form and that he/she accurately reported his/her activity at the time he/she was sampled, to the best of his/her knowledge.

D. Monitoring Objectives: Monitors from various organizations review the Administrative Claiming program documents and provide performance standards to validate whether or not the providers and/or Administrative Claiming program have:

1. Complied with federal and state laws, regulations and policies,

2. Complied with the terms of the Administrative Claiming Guide agreement,

3. Billed the Division of Medicaid for those services that were authorized and actually delivered in compliance with the Administrative Claiming Guide, and

4. Provided a service which produced an effective and cost effective outcome for beneficiaries and the Medicaid program.

E. Desk Reviews: Periodically the Division of Medicaid staff may conduct desk reviews of Administrative Claiming services. These desk reviews include, but are not limited to, the analysis of required documentation and various reports.

F. On-Site Visits: The on-site visits will be scheduled periodically to be conducted by Medicaid Administrative Claiming staff. During on-site visits, required records and documents will be reviewed for consistency with claims submitted and with applicable program requirements.

G. Cooperation Required of the Provider During Monitoring Activities

1. The school districts must cooperate fully with monitoring activities, evaluations or other reporting requirements authorized by the Division of Medicaid. Records and supporting information must be made available as required for any authorized monitoring activities.

2. The school districts’ Administrative Claiming Coordinator or authorized representatives must cooperate fully with monitoring activities, evaluations or other reporting requirements authorized by the Division of Medicaid. Records and supporting information must be made available as required for any authorized monitoring activities. He/she must also be available to answer questions during the monitoring review and to receive the results of the review.

H. Findings from Monitoring Reviews

1. The Division of Medicaid staff that conducts the monitoring review will prepare a report of monitoring activity. A copy of the report will be forwarded to the school district with a request, when appropriate, for a response to be submitted to the Division of Medicaid within thirty (30) days after the receipt of the report. The response should include a plan

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of correction, as necessary, which addresses any deficiencies noted in the monitoring report.

2. The staff of the Division of Medicaid will review the response and contact the reviewer within thirty (30) days of the receipt of the response regarding the acceptance of the response and approval of the plan of correction.

3. The school district will be notified in writing by the Division of Medicaid of any administrative noncompliance with provider agreement terms or applicable regulations.

4. If items of noncompliance are not corrected, the Division of Medicaid may take appropriate actions to ensure correction by the school district of noted problem(s), or the Division of Medicaid may terminate the provider’s participation in the Medicaid Administrative Claiming program.

5. Erroneous overpayments to providers are subject to restitution. The provider is entitled to notification by the Division of Medicaid of the erroneous payment(s). If the provider has been overpaid, he/she will be contacted regarding the repayment schedule.

I. Technical Assistance Provided by Medicaid

1. Medicaid staff is available to provide technical assistance to the Administrative Claiming provider and SBAC districts in resolving any contractual or performance problems. However, technical assistance visits by the Division of Medicaid staff are not comprehensive reviews of the services under the terms of contracts or provider agreements for services. If deficiencies are not identified during the provision of technical assistance, the provider is still responsible for audit exceptions and correcting any other contractual or performance problems noted during monitoring activities.

2. The Division of Medicaid is not liable for acts or omissions of the Administrative Claiming provider, contracted providers, school districts or their employees. The provider should seek their own legal counsel regarding questions of liability.

J. All records pertaining to the Administrative Claiming program must be maintained for a period of five (5) years after each quarterly claim is filed with the Division of Medicaid, unless an ongoing audit or resolution of an audit exception is in process which requires that the records be maintained until the audit is resolved.

Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; 42 CFR 430.1 and 42 CFR 431.15; OMB Circular A-87

Rule 1.4: Reimbursement

Reimbursement under the SBAC program is paid from those invoices filed during the quarter directly following the quarter of billing, for reported allowable reimbursable activities, in accordance with the Mississippi School Based Administrative Claiming Guide (as approved by

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CMS), following applicable federal and state rules and regulations. However, it is imperative that claims for all allowable reimbursable activities be documented. The school district will be responsible for any refund due to an audit exception or denial considered appropriate by CMS or the Division of Medicaid. In the event of determination by federal authorities of non-compliance with federal regulations and standards, the school district will be liable to the Division of Medicaid in full for all penalties, sanctions and disallowances assessed against the Division of Medicaid.

Source: Miss. Code Ann. § 43-13-121; Section 1903 (a)(7) of the Act; 42 CFR 430.1 and 42 CFR 431.15; OMB Circular A-87

Part 302 RESERVED

23 Miss. Admin. Code Pt. 302 RESERVED

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 302 Reserved

Table of Contents Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 302 Chapter 1: RESERVED .............................................. Error! Bookmark not defined.

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Title 23: Division of Medicaid

Part 302: Reserved

Part 303 Reserved

23 Miss. Admin. Code Pt. 303 Reserved

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 303 Reserved

Table of Contents Table of Contents Title 23: Division of Medicaid ....................................................................................................... 1 Part 303: Reserved

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Title 23: Division of Medicaid

Part 303: Reserved

Part 304 Audit

23 Miss. Admin. Code Pt. 304 Audit

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 304 Audit

Table of Contents Table of Contents

Title 23: Division of Medicaid ....................................................................................................... 1 Part 304: Audit ................................................................................................................................ 1 Part 304 Chapter 1: Audit .......................................................................................................... 1 Rule 1.1: Audit Rule ............................................................................................................ 1 Rule 1.2: False Claims Act .................................................................................................. 3

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Title 23: Division of Medicaid

Part 304: Audit

Part 304 Chapter 1: Audit

Rule 1.1: Audit Rule

A. General: It is the mission of the Division of Medicaid to ensure compliance, efficiency, and accountability within the Mississippi Medicaid program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupment, and identifying avenues for cost avoidance. The Division of Medicaid shall conduct auditing and monitoring reviews of Medicaid providers accordingly.

B. Audit and Monitoring Reviews

1. The Division of Medicaid utilized bureau staff, contracted audit entities or combination of both, selects Medicaid providers for review.

2. An audit or monitoring review has the following objectives:

a) To determine if services billed and paid under the State’s Medicaid program were:

1. Provided to an eligible beneficiary,

2. Medically necessary,

3. Provided at the appropriate level of care,

4. Appropriately documented, specifically including the assignment of diagnosis and procedure codes submitted by providers and that may be used by the Division of Medicaid to calculate payment.

5. In accordance with the Mississippi Medicaid Provider Manual, Mississippi State Plan, and official notices through other means such as, but not limited to, the Mississippi Medicaid Provider Bulletin, Remittance Advice header messages, and official communications from the Agency, and

6. For service for which the reimbursement rate is based on a cost report, that the cost report contains only allowable costs and were completed in accordance with the Mississippi Medicaid Provider Manual, the Cost Report Instructions as posted on the Mississippi Medicaid website and Mississippi State Plan.

b) To provide a systematic and uniform method of determining compliance with state and federal program rules and regulations,

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c) To provide a mechanism for data gathering this can be used to modify the State’s Medicaid program and State Medicaid Rules and procedures,

d) To determine if the services provided meet the community standard of care, and

e) To determine if the provider is maintaining clinical and fiscal records which substantiate claims submitted for payment during the review period.

C. Audit Methods and Locations: The Division of Medicaid selects the appropriate method of conducting the review including, but not limited to, the following:

1. On-site reviews, conducted on the provider’s premises,

2. Desk audits, conducted at the Division of Medicaid’s or contracted auditor’s offices, or

3. A combination of an on-site and a desk audit.

D. Audit/Monitoring Review Overview

1. Audits/Monitoring reviews will involve the examination of the provider’s medical and/or financial records. Providers must maintain appropriate documentation in the client’s medical or health care service records to verify the level, type, and extent of services provided. Providers must:

a) Keep legible, accurate, and complete charts and records to justify the services provided to each client,

b) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains, and

c) Make charts and records available to Medicaid staff, other State and Federal agencies, and its contractors thereof, upon request. Records shall be maintained in accordance with Part 200, Chapter 1, Rule 1.3.

2. A provider’s bill for services, appointment books, accounting records, or other similar documents alone do not qualify as appropriate documentation for services rendered.

3. If a provider fails to participate or comply with the Division of Medicaid’s audit process or unduly delays the audit process, the Division of Medicaid considers the provider’s actions or lack thereof, as abandonment of the audit.

4. If the Division of Medicaid suspects a provider of fraud, abusive practice, audit abandonment, or present a risk of imminent danger to clients, the Division of Medicaid shall take one or more of the actions listed below.

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a) Immediately issue a final report,

b) Terminate the provider’s agreement with Medicaid,

c) Issue a subpoena for the provider’s records, or

d) Refer the provider to the appropriate prosecuting authority.

E. Audit/Monitoring Review Process: In general, the audit/monitoring review process will consist of the following:

1. Provider Notification,

2. Field Entrance Conference,

3. Procedures for Submitting Documentation Electronically,

4. Examination of Documentation,

5. Field Exit Conference,

6. Draft Report,

7. Exit Conference,

8. Final Report, and

9. Administrative Hearings as required.

Source: Miss. Code Ann. § 43-13-121; § 43-13-117 (A)(1)(d)

History: Revised - 10/01/2012

Rule 1.2: False Claims Act

A. General

1. Section 6032 of the federal Deficit Reduction Act (DRA) of 2005 (Public Law 109-171) set forth administrative requirements which impacts entities receiving annual Medicaid payments of at least $5,000,000. The DRA requires certain governmental, for-profit and non-profit providers and other entities that receive Medicaid funding to provide employee education regarding the False Claims Act and take actions that will address fraud, waste and abuse in health care programs that receive federal funds. Any entity that receives $5,000,000 or more annually must establish the following policies as a condition of participation in the Medicaid program:

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a) The entity must establish written policies for all employees of the entity including management and of any contractor or agency of the entity that provides detailed information about the False Claims Act established under Sections 3729 through 3733 of Title 31, United States Code.

b) The entity must include as part of such written policies, detailed provisions regarding the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse.

c) The entity must include in any employee handbook for the entity, a specific discussion of the laws described above, the rights of employees to be protected as whistleblowers, and the entity’s policies and procedures for detecting and preventing fraud, waste, and abuse.

2. Annually, the Division of Medicaid will identify and mail notices to providers and contractors that provide Medicaid health care items or services that were paid $5,000,000 or more during the prior federal fiscal year. The $5,000,000 threshold will be measured based upon the aggregate payments received by an entity during the federal fiscal year October 1 through September 30, even if that entity has multiple provider and/or tax id numbers. For example, a health system that includes a hospital, skilled nursing facility and home health program and collectively receives more than $5,000,000 in aggregate reimbursement annually will be subject to this requirement. Once notified, the entity will have thirty (30) calendar days to submit the documentation requested in the letter to confirm compliance.

3. It is the responsibility of each entity meeting the annual threshold to establish and disseminate written policies. In addition, the entity must provide those policies to the Division of Medicaid including any revisions. The Division of Medicaid will perform annual monitoring activities to ensure that entities are in compliance with this section. Providers will be selected on a random basis or as needed.

4. If an employee or contractor or agent of an entity reports suspected fraud, waste, or abuse in the Medicaid program, the entity must report that information to the Bureau of Program Integrity at the Division of Medicaid by the next business day. Entities must investigate all allegations within a reasonable time period and report the results of the investigation to the Division.

B. Reporting Requirements - False Claims information must be reported to the appropriate federal and/or state entity including Medicaid and the Federal Office of Inspector General in the U.S. Department of Health and Human Services.

C. Sanctions - If an entity is found not to be in compliance with any part of the requirements noted above, the provider will be given a thirty (30) day notice by the Division of Medicaid that suspension of the entity’s provider number(s) and payment may be held at the sole discretion of the Division of Medicaid. The entity must submit appropriate documentation to

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the satisfaction of the Division of Medicaid in order for the non-compliance status to be lifted. The Division of Medicaid will work in conjunction with the Attorney General’s office and the Office of the Inspector General (OIG) on cases of non-compliance.

D. Definitions- For purposes of this rule Medicaid defines the terms used as follows:

1. Entity - An “entity” includes a governmental agency, organization, unit, corporation, partnership, or other business arrangement including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists, whether for-profit or not-for-profit, which receives or makes payment, under a State Plan approved under title XIX or under any waiver of such plan. In addition, persons are considered entities. A “person” includes any natural person, corporation, firm, association, organization, partnership, limited liability company, business or trust. If an entity furnishes items or services at more than a single location or under more than once contractual or other payment arrangement, the provisions of this section will apply if the aggregate payments to that entity meet the $5,000,000 annual threshold. This applies whether the entity submits claims for payments using one or more provider identification or tax identification numbers.

2. Employee - An “employee” includes any officer or employee of the entity.

3. Contractor or Agent - A “contractor” or “agent” includes any contractor, subcontractor, agent, or other person which or who, on behalf of the entity, furnishes or otherwise authorizes the furnishing of Medicaid health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by the entity.

4. Knowingly - “Knowing” and “Knowingly” is defined to mean that a person:

a) Has actual knowledge of falsity of information in the claim,

b) Acts in deliberate ignorance of the truth or falsity of the information in a claim, or

c) Acts in reckless disregard of the truth or falsity of the information in the claim. The federal False Claims Act does not require proof of a specific intent to defraud the United States government. Instead, entities can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to Medicaid. Examples include knowingly making false statements, falsifying records, double-billing for items or services, or submitting bills for services or items never furnished.

5. Whistleblower - An individual who has direct and independent knowledge of the information on which the allegations are based and has voluntarily provided the information to the Government before filing an action under Sections 31 USC 3729 through 3733 which is based on the information.

6. Claim - A “claim” includes any request or demand for money that is submitted to the Division or its fiscal agent.

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E. Appeals - Refer to Part 300, Chapter 1, Rule 1.1 for the rule regarding Administrative Hearings for Providers.

Source: Miss. Code Ann. § 43-13-121

Part 305 Program Integrity

23 Miss. Admin. Code Pt. 305 Program Integrity

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 305 Program Integrity

Table of Contents

Title 23: Division of Medicaid

Part 305: Program Integrity

Part 305 Chapter 1: Program Integrity..................................................................2 Rule 1.1: Definitions ......................................................................................2 Rule 1.2: Fraud, Waste, and Abuse.....................................................................4 Rule 1.3: Overpayments.................................................................................6 Rule 1.4: Provider Peer Review Protocol ............................................................8 Rule 1.5: Improper Payments Due to Inaccurate Eligibility Information........................13 Rule 1.6: Medicaid Eligibility Quality Control......................................................13

Part 305 Chapter 2: Beneficiary Health Management............................................... 14 Rule 2.1: Authority and Purpose........................................................................14 Rule 2.2: Program Oversight............................................................................15 Rule 2.3: Provider Participation........................................................................15 Rule 2.4: Beneficiary Notification.....................................................................15 Rule 2.5: Provider Selection............................................................................16 Rule 2.6: Beneficiary Health Management (BHM) Services .....................................17 Rule 2.7: Exclusions.....................................................................................18 Rule 2.8: Reimbursement...............................................................................18

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Title 23: Division of Medicaid

Part 305: Program Integrity

Part 305 Chapter 1: Program Integrity

Rule 1.1: Definitions

A. Abuse is defined as beneficiary practices that result in unnecessary cost to the Medicaid program and/or provider practices that are inconsistent with sound fiscal, business, or medical practices that result in:

1. An unnecessary cost to the Mississippi Medicaid Program,

2. Reimbursement for services that are not medically necessary, or

3. Reimbursement for services that fail to meet professionally recognized standards for health care.

B. Administrative Appeal is defined in Miss. Admin. Code Title 23, Part 300.

C. Beneficiary error is defined as the beneficiary’s incomplete, incorrect or misleading information because the beneficiary misunderstood, was unable to comprehend the relationship of the facts about the situation to eligibility requirements or there was other inadvertent failure on the beneficiary’s part to supply the pertinent or complete facts affecting Medicaid or Children's Health Insurance Program (CHIP) eligibility.

D. Corrective Action Plan (CAP) is defined as a documented plan that includes a well-defined identification of the problem, a specific time frame for the remedy to be implemented, specific actions taken to remedy the defined problem, plan on how to prevent the problem from recurring and the consequences if the problem is not resolved. At a minimum, the CAP must include:

a) The specific obligations violated,

b) The specific actions taken that address correction of the behavior that led to the violation(s),

c) The duration of the CAP which must be greater than ninety (90) calendar days, and

d) The means by which compliance with the CAP will be monitored and assessed.

E. Credible allegation of fraud is defined as an allegation from any source that has indicia of reliability in which the Division of Medicaid has verified through facts and evidence including, but not limited to, alleged fraud from:

1. Fraud hotline complaints,

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2. Claims data mining, and/or

3. Patterns identified through provider audits, civil false claims cases, and law enforcement investigations.

F. Demand Letter is defined as a notification that a provider is required to refund improper payments.

G. Fraud is defined as an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person, or an act that constitutes fraud as defined by federal or state law.

H. Incorrect payment is defined as an error in reimbursement which results in an overpayment or underpayment which may be due to a billing error, systems error and/or human error.

I. Overpayment is defined as any payment which results in a provider receiving any amount of reimbursement to which the provider is not legally entitled to receive.

J. Peer Review (PR) is defined as a retrospective review of medical records by the Division of Medicaid’s Utilization Review/Quality Improvement Organization (UM/QIO) to assess if:

a) Services and items were reasonable and medically necessary;

b) The quality of services met professionally recognized standards of health care;

c) The beneficiary received the appropriate health care in a safe, appropriate and cost- effective setting based on the beneficiary’s diagnosis and severity of the symptoms;

d) Services were provided economically and only when and to the extent they were medically necessary; and

e) The utilization billing and coding practices and/or overall utilization patterns of a provider for beneficiaries being reviewed are appropriate.

K. Peer Review Consultant (PRC) is defined as the medical reviewer in a comparable specialty as the provider or a certified professional coder (CPC) when appropriate.

L. Peer Review Panel (PRP) is defined as at least three (3) providers, at least one (1) of whom practices in the same class group as the subject provider; Selection of the PRP members shall ensure that their objectivity and judgment will not be affected by personal bias for or against the subject provider or by direct economic competition or cooperation with the subject provider.

M. Reconsideration Review is defined as an impartial review of the case by a Peer Review

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Consultant not involved in the initial Peer Consultant Review determination, at the request of the Division of Medicaid, a provider, or as part of a UM/QIO follow-up.

N. Waste is defined as the overutilization, underutilization, or misuse of resources.

Source: 42 C.F.R. Part 455; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026.Revised eff. 03/01/2023; Revised and moved language to Rules 1.2-1.4, and 1.6 eff. 11/01/2016; Revised Miss. Admin. Code Part 305, Rule 1.1.D. eff. 10/01/2014; Miss. Admin. Code Part 305, Rule 1.1.B.3. and D.1. revised effective 08/15/2013 to comply with the Medical Assistance Participation Agreement Section C.

Rule 1.2: Fraud, Waste, and Abuse

A. The Division of Medicaid investigates suspected cases of fraud, waste, and abuse.

B. The Division of Medicaid makes a formal, written fraud referral to the Medicaid Fraud Control Unit (MFCU) as required under federal and/or state law or regulations.

C. The Division of Medicaid suspends all payments to a provider when the Division of Medicaid determines there is a credible allegation of fraud as required under federal and/or state law or regulations.

D. The Division of Medicaid notifies providers of suspension of payments within five (5) days of the suspension unless requested in writing by a law enforcement agency to temporarily withhold such notice.

E. The Division of Medicaid will:

1. Make a referral to the appropriate law enforcement agency if there is reason to believe that a beneficiary has defrauded the Medicaid program.

2. Conduct a full investigation if there is reason to believe that a beneficiary has abused the Medicaid program or if an applicant made a false statement or failed to disclose a material fact in his/her Medicaid application.

Source: 42 §§ C.F.R. 455.21, 455.23; Miss. Code Ann. §§ 43-13-121, 43-13-129.

History: Revised eff. 08/01/2026.New rule, language moved from Miss. Admin. Code Part 305 Rule 1.1 eff. 11/01/2016.

Rule 1.3: Overpayments

A. Providers must notify the Division of Medicaid's Office of Program Integrity in writing within thirty (30) calendar days of the discovery of any overpayments.

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1. Any self-disclosure of overpayments submitted to the Division of Medicaid must include the following information:a) Name and address of the affected provider,

b) A provider which is entity owned, controlled, or otherwise part of a system or network must include:

1. A description or diagram of any pertinent business/legal relationships,

2. The names and addresses of any related and/or affected entities, corporate divisions, departments, or branches, and

3. The name and address of the disclosing entity’s designated representative,

c) Medicaid provider number(s) associated with claims,

d) Tax identification number(s),

e) Payee identification number(s),

f) Affected claims submitted in Excel or Access which must include the following information:

1. Beneficiary name,

2. Claim transmittal control number (TCN),

3. Procedure code,

4. Dates of service,

5. Billed amount,

6. Paid amount,

7. Paid date, and

8. Refund amount,

g) A report that includes a full description of the information being disclosed, the person who identified the overpayment and the manner in which the individual discovered it,

h) A detailed account of the provider’s investigation of the overpayment,

i) A statement disclosing whether the provider is under investigation by any

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government agency or contractor,

j) A statement detailing the provider’s explanation of the cause of the overpayment,

k) A certification that the information submitted to the Division of Medicaid is based upon a good faith effort to disclose a billing inaccuracy and is true and correct, and

l) The methodology used in determining the amount of the overpayment.

2. The provider must submit additional information to the Office of Program Integrity as requested in order to verify the information submitted including the financial impact.

3. Any issues discovered during the verification process which are outside the scope of the self-disclosure may be treated as new matters subject to further investigation.

4. Refunds to the Division of Medicaid for overpayments must be conducted through the claims payment adjustment process or in the form of a refund check within thirty (30) calendar days of the overpayment discovery.

5. Self-disclosure does not release the provider from any other cause of action, civil or criminal, by another state agency or department of the United States under applicable law and regulations regarding these payments.

B. The Division of Medicaid, or designee, will send a demand letter via certified mail return receipt requesting the refund of overpayments discovered through audit or investigation:

1. On or before thirty (30) calendar days following the receipt of the demand letter, sent via certified mail, or thirty (30) calendar days from the date of the letter if the provider does not sign the certified mail notice, the provider must:

a) Request an administrative hearing [Refer to Miss. Admin. Code Part 300], or

b) Refund the overpayment by:

1. A lump sum payment,

2. Offsetting against current payments through the claims payment adjustment process until overpayment is recovered,

3. A repayment agreement executed between the provider and the Division of Medicaid, or

4. Any other method of recovery available to and deemed appropriate by

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the Division of Medicaid.

2. Providers that fail to refund overpayments as described in Miss. Admin. Code Part 305, Rule 1.3.B.1.b) within the thirty (30) calendar day timeframe, may:

a) Be placed under investigation for waste and/or abuse of the Medicaid program, and

b) Be subject to charges for any allowable interest under state law which will begin accruing thirty-one (31) calendar days after receipt of the demand letter sent via certified mail, or thirty (30) calendar days from the date of the letter if the provider does not sign the certified mail notice.

C. The Division of Medicaid will accept reimbursement for overpayments without penalty in the event that:

1. Overpayments are disclosed voluntarily and in good faith, and

2. The acts that led to the overpayments were not the result of fraudulent or abusive conduct.

D. The Division of Medicaid will refund any payment recovered in error.

Source: 42 C.F.R. Part 455; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2026.New rule, language moved from Miss. Admin. Code Part 305 Rule 1.1 eff. 11/01/2016.

Rule 1.4: Provider Peer Review Protocol

A. Mississippi Medicaid providers must ensure that the services or items provided to beneficiaries are:

1. Provided economically, to the extent medically necessary,

2. Of a quality that meets professionally recognized standards of health care,

3. Supported by the appropriate documentation of medical necessity and quality,

4. Provided when no other effective and more conservative or substantially less costly treatment, service and/or setting are available,

5. Not solely for the convenience of the beneficiary, the beneficiary’s family, or the provider, and/or

6. Not primarily custodial care, unless custodial care is a covered service.

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B. Providers with a possible violation of one (1) or more of the obligations listed in Rule 1.4.A. are generally referred to the fee-for-service (FFS) Utilization Management/Quality Improvement Organization (UM/QIO) to perform a Peer Review (PR).

1. A Peer Review Consultant (PRC) is selected by the Medical Director of the UM/QIO, or designee, when a referral is received from the Division of Medicaid, which has already made an initial audit/investigation.

a) The selection process of the PRC ensures that they practice in a comparable specialty as the provider being reviewed and that the PRC’s objectivity and judgment will not be affected by personal bias for or against the subject provider, or by direct economic competition or cooperation with the provider.

b) The Division of Medicaid will provide records relevant to the possible violation to the PRC.

c) If the PRC determines that there is no further action needed, then the case is closed. If the PRC identifies violations or confirms violations, then the PRC refers the case for a Peer Review Panel (PRP).

2. After reviewing the case, the PRP may close a case if they determine that there was no violation.

a) If they determine or confirm one or more violations exist, then the PRP will notify The Division of Medicaid with additional proposed actions. Actions by the UM/QIO PRP may include:

1. If the PRP determines that there has been no violation of obligations, it will notify the Division of Medicaid, in writing, of that finding and recommend that the case be closed with no further action taken. Along with the written notification of the PRP recommendations, the PRP will also transmit the records it relied on to make the recommendation, as well as the transcript of the minutes of the PRP meeting.

2. The Division of Medicaid shall make a final decision, within ten (10) business days of its receipt of the recommendation, and so inform the UM/QIO. The Division of Medicaid may accept the recommendation, take other action on the case, or return the case to the UM/QIO for further action, as specified by the Division of Medicaid.

b) If the PRP finds a potential violation of one or more of the requirements listed in Miss. Admin. Code Title 23, Part 305, Rule 1,4 A., the UM/QIO shall notify the Division of Medicaid in writing of the preliminary recommended findings within ten (10) business days of the PRP decision. The letter must contain all related requirements in Part 305, including, but not limited to, giving notice of potential

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violation(s), the specifics of the potential violation(s), and the PRP’s recommended date to have the provider attend a Peer Review Panel conference, which will be set no later than thirty (30) calendar days after the notice to the Division of Medicaid.

1. The Division of Medicaid shall make a final decision, within ten (10) business days of its receipt of the recommendation, and so inform the UM/QIO. The Division of Medicaid may accept the recommendation, take other action on the case, or return the case to the UM/QIO for further action, as specified by the Division of Medicaid. If the Division of Medicaid accepts the PRP recommendation, at the same time it notifies the UM/QIO, Director of Program Integrity, or his designee, will transmit a letter by certified mail, restricted delivery, return receipt requested to the provider with all of the relevant information listed above.

2. The provider shall be instructed in the letter to provide the PRP with any additional information in support of the provider’s position within a specified time. The provider also must submit a written statement to the Division of Medicaid within ten (10) business days of receipt of the findings notification indicating whether the provider agrees or disagrees with the findings. At the UM/QIO’s discretion, the provider may choose alternate dates to convene the PRP conference meeting. If the provider agrees with the findings, the Division of Medicaid may send a Corrective Action Plan (CAP) letter to the provider.

c) If the PRP determines that the provider has violated one or more of the requirements listed in Miss. Admin Code Title 23 Part 305 Rule 1.4 A., it will formulate recommendations that will include a corrective action plan (CAP), provider education requirements, and/or recoupment. The UM/QIO PRP shall submit all findings and recommendations in writing to the Division of Medicaid within ten (10) business days of the PRP decision. The letter must contain all related requirements in Part 305, including, but not limited to the violation(s), the specifics of the violation(s), and the PRP’s recommended actions and recommended date to have the provider attend a Peer Review Panel conference, which will be set no later than thirty (30) calendar days after the notice to the Division of Medicaid.

1. The Division of Medicaid shall make a final decision, within ten (10) business days of its receipt of the recommendations, and so inform the UM/QIO. The Division of Medicaid may accept the recommendation, take other action on the case, or return the case to the UM/QIO for further action, as specified by the Division of Medicaid, and as defined in Part 305. If the Division of Medicaid accepts the PRP recommendation, at the same time it notifies the UM/QIO, the Division of Medicaid will transmit a letter by certified mail, restricted delivery, return receipt requested to the provider with all of the relevant information listed above.

2. The provider shall be instructed in the letter to provide the PRP with any additional information in support of the provider’s position within ten (10)

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business days prior to the conference to allow time for its proper study. At the UM/QIO’s discretion, the provider may choose alternate dates to convene the conference meeting. Regardless of a provider’s acceptance of findings, for any confirmed violations of Part 305, which resulted in or identified any improper payments, the Division of Medicaid will send a certified demand letter to that provider. If the provider agrees with the findings, the Division of Medicaid may send a CAP letter to the provider.

C. The Division of Medicaid will send all provider correspondence regarding findings, decisions, or other documents from a PRC or PRP by certified mail, restricted delivery, return receipt requested.

D. The provider must sign and return the CAP within ten (10) business days after receipt of the Demand Letter and CAP. If the provider fails to submit the signed CAP to the Division of Medicaid within (10) business days, a sanction may be imposed on the provider. The UM/QIO Medical Director, or designee, and the Peer Review Consultant will monitor the signed CAP.

E. Within thirty (30) calendar days of the receipt of a completed CAP, the PRC will determine if the provider complied with the CAP, and whether or not the CAP was effective. If the CAP was effective and the provider has met all requirements, the Division of Medicaid will notify the provider that the review is closed. If the CAP was not effective and the provider is deemed to be continuing to violate requirements, the provider will be subject to a sanction.

1. If the provider disagrees with the findings of the PRC, the provider may request a Reconsideration Review using the following steps:

a) The provider may submit a request for a Reconsideration Review to the Division of Medicaid within ten (10) business days of receipt of the final findings notification.

b) The Reconsideration Review request must include the reason for the request, pertinent medical documentation, or other information to justify the need for reconsideration.

c) The UM/QIO will select a different PRC, who practices in a comparable specialty, to obtain a second opinion.

d) The Reconsideration Review will include the findings of the initial PRC.

e) The Division of Medicaid is notified in writing by the UM/QIO Contract Administrator of the findings, action recommended, the records relied upon to make the recommendation, and the Peer Review Consultant’s notes.

f) The Division of Medicaid will notify the provider of the results of the Reconsideration Review which will be one (1) of the following:

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1. No violation of requirements and the review is closed, or

2. Violation of requirements affirmed and a Demand Letter and CAP are sent to the provider.

2. If the provider disagrees with the findings of the Reconsideration Review, the provider may request an Administrative Hearing. [Refer to Miss. Admin. Code Part 300]

3. If the provider does not request an Administrative Hearing, the Division of Medicaid will proceed with the appropriate administrative action outlined in the Demand Letter.

F. The process for sanctions include the following steps and information:

1. The Executive Director of the Division of Medicaid, or designee, upon review of the record, proceedings, and recommendation of the Division of Medicaid Administrative Hearing Officer and/or Peer Review Consultant, will render a final written decision whether or not to impose sanctions, which may include disqualification, suspension, or termination from the Medicaid program for a limited period or permanently.

2. A violation of requirements such that the life and welfare of the provider’s beneficiaries are in jeopardy, the provider is subject to immediate suspension.

3. The Executive Director of the Division of Medicaid, or designee will notify the provider of the intent to impose a sanction by sending a notice containing the following:

a) The authority and responsibility afforded the Division of Medicaid under Miss. Code Ann. Section 43-13-121;

b) The requirement(s) violated;

c) The situation, circumstance, or activity that resulted in the violation;

d) A summary of the information used in arriving at the determination to initiate sanction; and

e) Notice that the Division of Medicaid will impose the sanction(s) within thirty (30) calendar days of the date of provider’s receipt of the notice unless the provider requests an Administrative Hearing within thirty (30) calendar days of the receipt of the notice.

4. The Executive Director of the Division of Medicaid, or designee may assess all or any part of the cost of implementing the sanction protocol to the provider.

5. The decision made by the Executive Director, or their designee is the final administrative decision.

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Source: 42 C.F.R. Part 455; Miss. Code Ann. § 43-13-121.

History: Revised eff. 08/01/2025. Revised and moved from Miss. Admin. Code, Part 300, eff. 03/01/2023; New rule, language moved from Miss. Admin. Code Part 305 Rule 1.1 eff. 11/01/2016.

Rule 1.5: Improper Payments Due to Inaccurate Eligibility Information

A. The Division of Medicaid will identify the cause of any improper payments due to an error in the beneficiary’s eligibility information including, but not limited to, incorrect income or deductions, and take corrective action.

B. All underpayments are corrected upon discovery:

1. Underpayments resulting from agency error may be corrected retroactively.

2. Underpayments resulting from beneficiary errors are corrected, but they are not corrected retroactively.

C. The Division of Medicaid will attempt to recover the amount of any overpayment from the beneficiary directly or from the beneficiary’s state tax refund when the beneficiary provides incorrect eligibility data resulting in an overpayment.

Source: Miss. Code Ann. § 43-13-121.

History: New Rule, language moved from Miss. Admin. Code Part 100, Chapter 6 eff. 11/01/2016.

Rule 1.6: Medicaid Eligibility Quality Control

A. A beneficiary must cooperate with Medicaid Eligibility Quality Control (MEQC) reviews.

B. If a beneficiary fails to cooperate with MEQC reviews and an investigator is unable to obtain information needed to complete a review, the case will be referred back to the regional office for a redetermination.

1. As part of the redetermination process, the information needed by the MEQC will be requested.

2. If the information is not provided to the regional office, coverage will be terminated because the Division of Medicaid will be unable to determine eligibility.

Source: 42 C.F.R. § 431.810, et seq.

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History: New Rule, language moved from Miss. Admin. Code Part 100, Chapter 7 eff. 11/01/2016.

Part 305 Chapter 2: Beneficiary Health Management

Rule 2.1: Authority and Purpose

A. The Division of Medicaid defines Beneficiary Health Management (BHM) as the program implemented by the Division of Medicaid to:

1. Closely monitor program usage and to identify beneficiaries who may be potentially over utilizing or misusing their Medicaid services and benefits.

2. Restrict beneficiaries whose utilization of medical and/or pharmacy services is documented at a frequency or amount that is not medically necessary.

3. Prevent beneficiaries from obtaining non-medically necessary quantities of prescribed drugs through multiple visits to physicians and pharmacies.

B. The Division of Medicaid will lock-in beneficiaries for twelve (12) consecutive months whose utilization of medical and/or pharmacy services is documented as being excessive, as determined in accordance with utilization guidelines established by the Division of Medicaid, to specific providers in order to monitor services received and reduce unnecessary or inappropriate utilization.

C. The Division of Medicaid requires a beneficiary to designate a physician and/or a pharmacy of choice when the beneficiary’s medical record indicates utilization is excessive or inappropriate with reference to medical need, and in accordance with the BHM program, to:

1. Promote quality health care,

2. Promote coordination of care and ensure appropriate access for beneficiaries at high risk of overdose,

3. Provide continuity of medical care,

4. Prevent harmful practices such as duplication of medical services, drug interaction, and possible drug abuse,

5. Prevent misuse or excessive utilization of beneficiary’s Medicaid benefits,

6. Provide education and monitoring to deter misuse and/or excess utilization, and

7. Assure beneficiaries are receiving only health care services which are medically necessary as defined in Miss. Admin. Code Part 200, Rule 5.1.

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Source: 42 C.F.R. § 431.54; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019. Rule 2.2: Program Oversight

A. The Division of Medicaid’s Office of Program Integrity:

1. Manages the Beneficiary Health Management (BHM) program,

2. Screens beneficiaries against criteria designed to identify drug seeking behavior and inappropriate use of prescription drugs, and

3. Reviews claims and pharmacy point-of-sale data to identify patterns of inappropriate, excessive or duplicative use of pharmacy services.

B. The Division of Medicaid may request the Mississippi Coordinated Access Network (MSCAN) contractor to lock-in beneficiaries who have had prior lock-ins with the Medicaid fee-for-service program or other Medicaid-participating Coordinated Care Organizations (CCOs).

Source: 42 C.F.R. § 431.54; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised eff. 05/01/2025. Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019.

Rule 2.3: Provider Participation

The Beneficiary Health Management (BHM) program may include physician only, pharmacy only, or physician and pharmacy providers.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019.

Rule 2.4: Beneficiary Notification

A. The Division of Medicaid will notify the beneficiary in writing prior to the imposing of the restrictions of:

1. Its intent to enroll them in the Beneficiary Health Management (BHM) program, and

2. Their opportunity for a hearing as outlined in Miss. Admin. Code Part 300.

B. The Division of Medicaid will ensure that the beneficiary has reasonable access to Medicaid services of adequate quality taking into account geographic location and reasonable travel time.

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C. The BHM program restrictions do not apply to emergency services provided to the beneficiary.

Source: 42 C.F.R. § 431.54; Miss. Code Ann §§ 43-13-117, 43-13-121.

History: Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019.

Rule 2.5: Provider Selection

A. The beneficiary has ten (10) days to choose his/her Beneficiary Health Management (BHM) designated physician and/or pharmacy provider(s) from the date of receipt of the notification letter.

B. The Division of Medicaid will designate a BHM physician and/or pharmacy provider for the beneficiary if the beneficiary does not specify a provider within the ten (10) day time-frame.

C. Beneficiaries are required to specify one (1) physician and/or one (1) pharmacy and up to three (3) physician specialists, if requested, for his/her medical and/or pharmacy services while in the Beneficiary Health Management (BHM) program.

D. The beneficiary may request a change in his/her BHM physician and/or pharmacy provider if any of the following occur:

1. Change in physical address of the beneficiary or a provider,

2. Death, retirement, or closing of the specified physician, pharmacy and/or specialist,

3. Change in primary diagnosis which requires a different specialist, or

4. The BHM physician and/or pharmacy provider disenrolls or loses eligibility to participate in the Mississippi Medicaid Program.

E. The BHM physician or specialist may refer the beneficiary to another provider for consultation by submitting the BHM Referral Form to the Division of Medicaid, Office of Program Integrity, or designee.

1. Prior approval from the Division of Medicaid or designee is required before the beneficiary can be seen by the referring physician.

2. Emergency situations are excluded from this requirement.

3. The referral may cover one (1) or multiple visits as long as those visits are part of the consulting physician’s plan of care and are medically necessary.

4. A referral is limited to one (1) year from the date of approval.

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F. The Division of Medicaid will lock-in beneficiaries to only one (1) pharmacy when one (1) of the following criteria is met:

1. The beneficiary has one (1) or more of the following:

a) Received services from four (4) or more prescribers and/or four (4) or more pharmacies relative to controlled substances in the past six (6) months, including emergency department visits,

b) A history of substance use disorder within the past twelve (12) months,

c) A diagnosis of drug abuse or narcotic poisoning within the past twelve (12) months, or

d) Utilizes cash payments to purchase controlled substances.

2. When any written prescription is stolen, forged or altered,

3. When the Division of Medicaid has received a proven report of fraud, waste and/or abuse from one (1) or more of the following:

a) Prescriber,

b) Pharmacy,

c) Any medical provider, and/or

d) Law enforcement entity.

Source: 42 C.F.R. § 431.54; Miss. Code Ann §§ 43-13-117, 43-13-121.

History: New Rule eff. 02/01/2019.

Rule 2.6: Beneficiary Health Management (BHM) Services

The Division of Medicaid locks-in a beneficiary in the Beneficiary Health Management (BHM) program for a period of twelve (12) months with ongoing reviews to monitor patterns of care.

A. Beneficiaries in the BHM program are allowed two (2) counseling sessions in addition to State Plan service limits per month during the twelve (12) month lock-in.

B. Beneficiaries locked-in the BHM program will continue to have access to the following services with applicable State Plan service limits:

1. Emergency department,

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2. Inpatient hospital,

3. Outpatient hospital,

4. Dental,

5. Vision,

6. Mental Health,

7. Home Health and Durable Medical Equipment (DME), medical appliances and medical supplies,

8. Hospice, and

9. Medicaid Waivers.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019.

Rule 2.7: Exclusions

The Division of Medicaid may exclude a beneficiary from the Beneficiary Health Management (BHM) program if the beneficiary:

A. Has one (1) of the following diagnoses including, but not limited to:

1. Cancer,

2. Sickle cell anemia, or

3. Burns.

B. Is enrolled in hospice care.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019.

Rule 2.8: Reimbursement

A. The Division of Medicaid reimburses for:

1. Office visits only with the Beneficiary Health Management (BHM) designated physician,

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2. Drugs prescribed only by the BHM designated physician, by the consultant physician, or by an emergency department physician, and

3. Drugs dispensed only by the BHM designated pharmacy provider.

B. The Division of Medicaid requires post utilization review by the Division of Medicaid or designee for reimbursement to physician and/or pharmacy provider(s) other than the BHM designated physician and/or pharmacy provider(s) when :

1. Emergency care is required and the BHM designated physician and/or pharmacy provider is not available, or

2. The BHM designated physician and/or pharmacy provider requires consultation with another physician and/or pharmacy provider.

C. BHM designated physician and/or pharmacy providers are required to bill the specified procedure codes if counseling sessions are provided.

1. The counseling procedure codes can be billed in conjunction with any other service the BHM designated physician provides to the beneficiary.

2. Documentation must support billing of the specified procedure codes by the BHM designated physician and/or pharmacy.

D. The Division of Medicaid reimburses for inpatient hospitalization for treatment of alcohol and/or drug abuse when the diagnosis is a substance use disorder diagnosis in accordance with the most current Diagnostic and Statistical Manual (DSM) of Mental Disorders and the inpatient hospital stay is prior authorized by the Division of Medicaid or designee.

Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised and moved from Miss. Admin. Code Part 302 eff. 02/01/2019.

Part 306 Third Party Recovery

23 Miss. Admin. Code Pt. 306 Third Party Recovery

Title 23: Medicaid

Administrative Code

Title 23: Medicaid Part 306 Third Party Recovery

Table of Contents

Title 23: Division of Medicaid ....................................................................................................... 1 Part 306: Third Party Recovery ...................................................................................................... 1 Part 306 Chapter 1: Third Party Recovery ................................................................................. 1 Rule 1.1: General.................................................................................... 1 Rule 1.2: Medicaid Cost Avoidance .................................................................................... 2 Rule 1.3: Billing ................................................................................................................... 3 Rule 1.4: Casualty Cases...................................................................................................... 6 Rule 1.5: Requests for Medical Information ........................................................................ 7 Rule 1.6: Third Party Sources .............................................................................................. 8 Rule 1.7: Coordination of Benefits ...................................................................................... 9 Rule 1.8: Estate Recovery Requirements.........................................................10

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Title 23: Division of Medicaid

Part 306: Third Party Recovery

Part 306 Chapter 1: Third Party Recovery

Rule 1.1: Definitions

The Division of Medicaid defines:

A. Third party as any individual, entity or program that is, or maybe, liable to pay all, or part of the expenditures for medical assistance furnished under the State Plan.

B. Cost Avoidance as a method of avoiding payment of Medicaid claims when other insurance resources are available to the Medicaid beneficiary.

C. Pay and Chase method as reimbursing the provider for a specific covered service and pursuing recovery of the payment from a third party source.

D. Casualty Cases as claims that involve the treatment of injuries arising out of vehicular collision, industrial accident, product liability, malpractice cases, etc. in which collection from the third party may be contingent upon legal action.

E. Preferred provider organization (PPO) as a medical care arrangement in which medical professionals and facilities provide services to subscribed beneficiaries at reduced rates. PPO medical and healthcare providers are called preferred providers.

Source: 42 CFR §§ 433.136, 433.137, 433.145; Miss. Code Ann. §§ 43-13-121, 43-13-125, 43- 13-305, 43-13-311, 43-13-313.

History: Revised eff. 04/01/2021; Revised Miss. Admin. Code Part 306, Rule 1.1.A. eff. 06/01/2015.

Rule 1.2: Provider Requirements

A. Medicaid providers must:

1. Identify and report any third party source to the Division of Medicaid.

2. Cooperate with the Division of Medicaid in the recovery of payments from the third party source. Providers will be held liable, to the extent of the Division of Medicaid’s payment, for failure to cooperate with the Division of Medicaid’s staff when they have knowledge of third party coverage.

3. Accept either the third party payment or the Division of Medicaid's payment for services provided as payment in full.

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B. Providers cannot refuse to furnish Medicaid covered services to a beneficiary because of a third party's potential liability for the services.

C. The Division of Medicaid may reduce any payment amount otherwise due the provider by up to three (3) times the amount incorrectly received from the beneficiary if the provider is found in violation of Miss. Admin. Code Part 306, Rule 1.3.C.

D. The provider must obtain a signed statement from the beneficiary if beneficiary indicates they no longer have third party insurance. The statement must include the name of the insurance company, the policy number, and the beginning and ending date of coverage and must be submitted to the Division of Medicaid.

E. Requests for Medical Information

1. The Division of Medicaid requires that any medical information concerning a Medicaid beneficiary released by a provider must contain the following information:

a) The person is or was a Medicaid beneficiary at the time the services were rendered,

b) His/her Medicaid identification number, and

c) The claim has been submitted to the Division of Medicaid or has been paid by the Division of Medicaid.

2. If a provider receives a request for medical claims or other medical information from a Medicaid beneficiary or someone acting on the beneficiary's behalf, such as an attorney, insurance company, etc., release of said information will be restricted as follows:

a) Copies of claims or medical records requested by a beneficiary or the beneficiary’s parent, guardian or legal representative must be furnished if the provider receives a written authorization for release of the information.

b) Information requested by an insurance carrier with whom a claim has been filed must be furnished directly to the carrier.

c) The provider must comply promptly to a request for medical information from a Medicaid beneficiary's attorney once a signed authorization from the beneficiary has been received.

d) Medical records or billing information requested by the Disability Determination Service (DDS) or a school system, for educational evaluation, must be sent directly to the requester. Notification to the Division of Medicaid is not necessary.

Source: 42 CFR §§ 433.136, 433.137, 433.145; Miss. Code Ann. §§ 43-13-121, 43-13-125, 43- 13-305, 43-13-311, 43-13-313.

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History: Revised to correspond with SPA 23-0011 (eff. 5/01/2023) eff. 09/01/2023. Revised eff. 04/01/2021.

Rule 1.3: Billing

A. Providers must file a claim with the third party prior to billing Medicaid. Documentation of payment or denial must be submitted to the Division of Medicaid with the claim including but not limited to:

1. The explanation of benefits (EOB),

2. Any amount paid by the third party, and

3. If the claim is denied by the third party, the reason for the denial.

B. In the event there is no response from the third party source in sixty (60) days from the date of submittal, the provider may submit the claim to Medicaid as directed in Miss. Admin. Code Part 306, Rule 1.3.J.

C. When a Medicaid beneficiary is covered by a private insurance policy whose administrator has a preferred provider organization (PPO) in which the Medicaid provider:

1. Does not participate, the provider must submit the claim to the Division of Medicaid with a statement indicating the provider is not a member of a particular PPO, the insurance company name and address, and specific third party filing data and follow the Division of Medicaid’s instruction regarding the claim.

2. Does participate, the Division of Medicaid does not reimburse for the difference between a third party payment and the provider’s charges as the provider has agreed to accept the PPO’s payment as payment in full.

D. The provider must obtain or make reasonable efforts to obtain an assignment of benefits from the beneficiary prior to billing third party insurance.

E. If a provider is unable to obtain an assignment of benefits, the provider must submit the claim to the Division of Medicaid and include the third party information.

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F. The provider must file and obtain Medicare payment for the service or obtain a Medicare denial before the Division of Medicaid can pay the claim.

G. If the beneficiary has Medicare A, B, and/or C and private insurance, the provider must bill Medicare and the private insurer prior to submitting the claim to Medicaid.

H. If Medicare coverage is found after Medicaid has paid the claim, the Division of Medicaid will recoup the payments from the provider and the provider must bill Medicare.

I. The provider must attach the EOB from the third party to the claim submitted to the Division of Medicaid.

J. The provider must make every effort to acquire payment from the third party source before filing the claim with Medicaid. When a provider bills a third party insurer and does not receive a response, the provider must:

1. Submit a written inquiry to the third party if no response has been received within thirty (30) days from the date of original claim submission,

2. File the claim with the Division of Medicaid, attaching a completed copy of the “TPL Edit Override Attachment: No Response Form” if no response has been received in sixty (60) days from the date of original claim submission. This form must be signed and dated by the provider or an authorized provider representative. The claim is adjudicated according to the Medicaid payment policies.

K. If a provider receives payment from a third party and the Division of Medicaid for the same service, the provider must refund the full Medicaid payment and may refile the claim with Medicaid if the third party payment is less than Medicaid fee.

L. For hospitals having a PPO contract with an insurance company with payments subject to retroactive adjustments, the amount to be reported as third party liability on the claim must be as follows:

1. If the third party insurer pays a final amount, which is not subject to change, then the third party payment should be reported as the third party liability amount.

2. If the third party insurer makes an interim payment, which may be adjusted or settled later based on contractual agreements with the provider, the maximum third party reimbursement should be reported as the third party liability amount.

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a) If future settlements with other third party insurers result in the provider refunding amounts to the third party insurer, the Division of Medicaid makes no additional payment.

b) If future settlements with third party insurers result in the third party insurer making an additional payment to the provider, the following should be adhered to:

1. If third party liability amounts have been reported as benefits as required in item Miss. Admin. Code Part 306, Rule 1.3.O.2, no amounts are due the Division of Medicaid.

2. If third party liability amounts have been reported at less than the maximum amount payable by the third party insurer, the provider will be liable for the overpayment by the Division of Medicaid, plus interest and penalty when applicable.

Source: 42 CFR §§ 433.139, 433.145-433.148; Miss. Code Ann. § 43-13-121.

History: Revised eff. 06/01/2022; Revised eff. 04/01/2021.

Rule 1.4: Casualty Cases

A. In the event a provider has knowledge that an individual is a Medicaid beneficiary and is receiving or has received health care services which may be covered by Medicaid as a result of the accident or incident, the provider is prohibited from:

1. Demanding any payment from the Medicaid beneficiary or his representative, or

2. Pursuing collection of any type against the Medicaid beneficiary or his representative.

B. A provider who has filed and accepted Medicaid payment and who fails to notify the Division of Medicaid that the provider has also received payment from a third party will be referred to the Medicaid Fraud Control Unit for investigation/prosecution for any possible violation of federal or state laws.

C. A provider may be excluded from participation in the Medicaid Program if the provider:

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1. Accepts payment from a third party and fails to comply with the provisions of this policy, or

2. Fails to refund to Medicaid a duplicate payment within thirty (30) days of receipt of the duplicate payment.

Source: Miss. Code Ann. §§ 43-13-121, 43-13-313.

History: Revised eff. 04/01/2021.

Rule 1.5: Reimbursement

A. The Division of Medicaid must be billed as the payor of last resort.

B. Providers are required to file a claim with the third party prior to filing with the Division of Medicaid except in the following circumstances:

1. Preventive pediatric service, including EPSDT services, claims must be paid in accordance with the usual payment schedule.

2. Covered services furnished to an individual on whose behalf child support enforcement is being carried out by the state Title IV-D program must be paid in accordance with the usual payment schedule.

C. Medicaid will not pay for services denied by Medicare due to lack of medical necessity but may pay claims denied for other reasons as long as the services are covered under the Medicaid program.

Source: 42 U.S.C. § 1396(a)(25); Miss. Code Ann. § 43-13-121.

History: Revised eff. 04/01/2021.