reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 11 - Introduction to Income - FCC Programs › Rule 23-104-11.1 - Income Rules

Current through June 25, 2024
A. The Affordable
				Care Act (ACA) requires that state Medicaid programs use modified adjusted
				gross income or MAGI-based methodology for determining the income of an
				individual and the individual's household. MAGI methodology and rules are
				required in determining eligibility for Medicaid or CHIP or an 1115
				demonstration that involve FCC covered populations of children, pregnant women
				and parents and needy caretaker relatives. The ABD population is exempt from
				MAGI rules.
B. The MAGI methodology
				is aligned with the process used to determine eligibility for the premium tax
				credits and cost sharing reductions available to certain individuals purchasing
				coverage through the federal health insurance marketplace. The requirement that
				both Medicaid and the marketplace use MAGI-based income methodologies is
				designed to promote coordination and avoid gaps in coverage, to the extent
				possible, for individuals that transfer between different types of insurance
				affordability programs.
C. The use
				of liberalized income rules under 1902(r)(2) of the Social Security Act is
				prohibited under MAGI based methodology. This provision is only available to
				certain ABD covered categories of eligibility.
42 CFR§435.603
				  (Rev. 2012)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 11 - Introduction to Income - FCC Programs › Rule 23-104-11.2 - MAGI Defined

Current through June 25, 2024
A. MAGI and
				household income are defined in section 36B(d)(2)(A) and (B) of the Internal
				Revenue Code (IRC). The treatment of income is based on IRS tax rules, except
				for specified exceptions.
B.
				Modified adjust gross income, as amended by the ACA, has the literal meaning of
				income that is:
1. Decreased by allowable tax
				deductions that include trade and business deductions, losses from the sale or
				exchange of property, deductions attributable to rents or royalties, and
				deductions for alimony paid. Generally, the same adjustments to income
				allowable under IRS rules are allowable deductions from countable income for
				Medicaid and CHIP purposes.
2.
				Increased by the amount of interest received or accrued that is exempt from tax
				and foreign earned income that is excludable as taxable income.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 11 - Introduction to Income - FCC Programs › Rule 23-104-11.3 - Household Income

Current through June 25, 2024
A. MAGI based
				income rules require that financial eligibility is based on household income
				for FCC related programs.
B.
				Household income is the sum of the MAGI-based income of every individual
				included in the individual's household minus as amount equivalent to five (5)
				percentage points of the federal poverty level for the applicable family size,
				with the following exceptions.
1. The
				MAGI-based income of an individual who is included in the household of his or
				her natural, adopted or step parent and is not required to file a tax return is
				not included in the household income whether or not the individual files a tax
				return.
2. The MAGI-based income of
				a tax dependent other than a spouse or child and is not required to file a tax
				return is not included in the household income whether or not the individual
				files a tax return.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 11 - Introduction to Income - FCC Programs › Rule 23-104-11.4 - Exceptions to IRS Income Rules for MAGI Based Income

Current through June 25, 2024
A. The
				following are exceptions to using IRS rules for determining MAGI-based income
				for a household.
1. Income received in a lump
				sum, whether recurring or non-recurring, is counted in the month received.
				Recurring lump sum payments are not averaged.
2. Scholarships, awards or fellowship grants
				used for education purposes and not for living expenses are excluded from
				income. Amounts used for room and board are not excluded and count as
				income.
3. Certain income derived
				from American Indian and Alaska Native sources are excluded from income. Income
				that is excluded includes:
a. Distributions
				from Alaska Native Corporations and Settlement Trusts;
b. Distributions from any property held in
				trust, subject to federal restrictions, located within the most recent
				boundaries of a prior federal reservation, or otherwise under the supervision
				of the Secretary of the Interior;
c. Distributions and payments from rents,
				leases, rights of way, royalties, usage rights or natural resource extraction
				and harvest from rights of ownership or possession in any lands described in
				above or federally protected rights regarding off-reservation hunting, fishing,
				gathering or usage of natural resources;
d. Distributions resulting from real property
				ownership interests related to natural resources and improvements located on or
				near a reservation or within the most recent boundaries of a prior federal
				reservation or resulting from the exercise of federally-protected rights
				relating to such real property ownership interests;
e. Payments resulting from ownership
				interests in or usage rights to items that have unique religious, spiritual,
				traditional or cultural significance or rights that support subsistence or a
				traditional lifestyle according to applicable tribal law or custom.
f. Student financial assistance provided
				under the Bureau of Indian Affairs education programs.
4. Social Security benefits that are not
				taxable income under IRS rules are countable as income for MAGI purposes for
				all insurance affordability programs, including Medicaid and CHIP.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 11 - Introduction to Income - FCC Programs › Rule 23-104-11.5 - When Income Counts

Current through June 25, 2024
A. Current monthly
				income counts in determining eligibility for Medicaid and CHIP for new
				applicants and for recipients at the time of an annual review.
42 CFR §435.603
				  (Rev. 2012)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 12 - Income That Does Not Count Under IRS Rules - FCC Programs › Rule 23-104-12.1 - Income That Does Not Count

Current through June 25, 2024
A. The following is
				not an exhaustive list of income that does not count but represents the types
				more commonly encountered. If not addressed herein, IRS tax rules provide the
				governing policy.
1. Alimony is deducted from
				the income of the payer and is therefore a type of non-countable income;
				however, alimony payments received by an individual count as income.
2. Black Lung benefits are not taxable income
				and are not counted as income.
3.
				Child Support benefits are not counted as income to the payee or the child(ren)
				for whom it is paid; however, Child Support is not a deduction allowable from
				the income of the payer.
4. VA
				Benefits are not counted as income. Benefits paid by the Department of Veterans
				Affairs are not taxable income.
5.
				Workers' Compensation Benefits are not taxable income and are not counted as
				income.
6. Life Insurance Proceeds
				paid due to the death of the insured person are not taxable income and are not
				counted as income, unless the policy was sold or reassigned for a
				price.
7. Accelerated Death
				Benefits paid under a life insurance contract prior to the insured's death are
				excluded from income if the insured is terminally ill.
8. Public Assistance Benefits, such as SSI,
				TANF, and the value of assistance from programs such as SNAP and WIC are
				excluded from income. IV-E Foster Care and Adoption Assistance payments are
				also excluded from income.
9.
				Disaster relief income or grants from a qualified disaster relief payment,
				meaning the payment is to reimburse certain necessary living expenses following
				a federally declared disaster, are excluded from income.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 12 - Income That Does Not Count Under IRS Rules - FCC Programs › Rule 23-104-12.2 - Excluded Income from Specific Programs Providing Assistance

Current through June 25, 2024
A. The following are payments excluded from
				income that originate from a specific program that provides assistance
				payments.
1. Home Affordable Modification
				Program (HAMP). Pay-for-Performance Success Payments under the HAMP are not
				taxable income and are not countable.
2. Hardest Hit Fund and Emergency Homeowners'
				Loan Program payments. Payments from a State Housing Finance agency that can be
				used to pay mortgage interest or payments from Housing and Urban Development
				for an Emergency Homeowners' Loan Program (EHLP) are not countable as
				income.
3. Mortgage assistance
				payments under section 235 of the National Housing Act for mortgage assistance
				are not included in the homeowner's income.
4. Replacement housing payments made under
				the Uniform Relocation Assistance and Real Property Acquisition Policies Act
				for Federal and Federally Assisted Programs are not counted as
				income.
5. Relocation payments and
				home rehabilitation grants under section 105(a)(11) of the Housing and
				Community Development Act made by a local jurisdiction to a displaced
				individual moving from a flood-damaged residence to another residence is not
				counted as income. Home rehabilitation grants received by low-income homeowners
				in a defined area under the same act are also not countable as
				income.
6. Payments to reduce the
				cost of winter energy made by a state to qualified individuals to reduce their
				cost of winter energy are not countable as income.
7. Holocaust Victims Restitution. Payments
				received by a Holocaust victim or the heir of a Holocaust victim and interest
				earned on the payments are not taxable and are therefore not countable as
				income.
8. Historic preservation
				grants. Payments received under the National Historic Preservation Act to
				preserve a historically significant property are excluded from
				income.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 12 - Income That Does Not Count Under IRS Rules - FCC Programs › Rule 23-104-12.3 - Income that is Partially Excluded

Current through June 25, 2024
A. The following
				income is partially countable and partially excluded under the conditions
				specified for each type of payment.
1. Foster
				Care Provider payments received from a state, political subdivision, or
				qualified foster care placement agency for providing care to qualified foster
				individuals in an individual's home are not countable as income except in the
				following situations. A qualified foster individual is someone living in a
				foster family home who was placed there by an agency of the state or a
				qualified foster care placement agency.
a)
				Foster care payments are income to the foster care provider if the individual
				received payment for more than 5 individuals age 19 or older. Count as income
				the payment received for foster individuals in excess of the limit.
b) Difficulty-of-care payments are additional
				payments that are designated by the payer as compensation for providing
				additional care that is required for the physically, mentally or emotionally
				handicapped qualified foster individual. These payments count as income if
				received for more than 10 foster individuals under age 19 or 5 foster
				individuals age 19 or older. Count as income the payment received for foster
				individuals in excess of the limit.
c) If payment is made to maintain space in
				the home for emergency foster care, the payment is countable as
				income.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 14 - Verification of Income - FCC Programs › Rule 23-104-14.1 - Verification Requirements

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 104 - Income › Chapter 14 - Verification of Income - FCC Programs › Rule 23-104-14.2 - Reasonable Compatibility Rules

Current through June 25, 2024
A. Income verified
				from electronic data sources that is reasonably compatible with self-attested
				income allows a Medicaid or 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 federal data services
				hub 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 the federal hub 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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 105 - Budgeting › Chapter 1 - Introduction to Budgeting - FCC Programs › Rule 23-105-1.2 - Tax Filer Rules

Current through June 25, 2024
A. 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.
1. Spouses whose tax filing status is married
				filing jointly are considered one household whether living together or
				separately.
2. Spouses whose tax
				filing status is married filing separately are considered one household if
				living together. If living apart, they are treated as two (2) separate
				households.
3. A tax filer
				household in any other tax filing status includes the tax filer and all
				dependents that the tax filer claims.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 105 - Budgeting › Chapter 1 - Introduction to Budgeting - FCC Programs › Rule 23-105-1.3 - Exceptions to Tax Filer Rules

Current through June 25, 2024
A. A tax dependent
				who is not the tax filer's spouse or child is treated as a non-filer, described
				in Rule 1.4.
B. A tax dependent
				under age 19 who lives with two parents who do not expect to file a joint tax
				return is treated as a non-filer, described in Rule 1.4.
C. A tax dependent claimed as a tax dependent
				by a non-custodial parent is treated as a non-filer, described in Rule 1.4. 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.
42 CFR§435.603
				  (Rev. 2012)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 105 - Budgeting › Chapter 1 - Introduction to Budgeting - FCC Programs › Rule 23-105-1.4 - Non-Filer Rules

Current through June 25, 2024
A. 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
				19 living in the same household.
B.
				A non-filer adult's household includes the non-filer, the non-filer's spouse
				and his/her children living together. Income includes all countable 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. The
				exception to the rule of counting a child's income based on his/her tax filing
				requirement is this: 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.
C. A non-filer child's household includes the
				non-filer child and the child's parent(s) and siblings living
				together.
42 CFR§435.603
				  (Rev. 2012)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 105 - Budgeting › Chapter 2 - Extended Medicaid for Parent(s) and Caretaker Relatives › Rule 23-105-2.1 - Budgeting Rules for Extended Medicaid Due to Increased Earnings

Current through June 25, 2024
A. Parent(s) or Caretaker Relatives that lose
				Medicaid due to increased hours or income from employment are eligible for
				extended Medicaid for up to twelve (12) consecutive months from the month of
				ineligibility provided the adult(s) received Medicaid as a parent or caretaker
				relative for at least three (3) of the six (6) months immediately preceding the
				month in which the individual becomes ineligible. Extended Medicaid due to
				increased earnings is also referred to as Transitional Medicaid Assistance or
				TMA.
B. If the change in income is
				not reported timely, eligibility for extended Medicaid is determined using a
				look-back process where actual income information is gathered after the fact
				and the determination of the appropriate twelve (12) month period is calculated
				to begin the month after the month the family became ineligible for
				Medicaid.
C. The child(ren)
				associated with the parent(s) or caretaker relative case are also eligible for
				the same twelve (12) month period of extended Medicaid eligibility. Since
				children are guaranteed twelve (12) continuous months of eligibility once
				eligibility is established and at each review establishing continuing
				eligibility, the period of extended Medicaid under this provision cannot
				shorten a child's twelve (12) month period of continuous eligibility. When
				there is an overlap, the protected periods of eligibility run
				concurrently.
§ 1902 (e)(1)(B)
				  and §1925 of the Social Security Act
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 105 - Budgeting › Chapter 2 - Extended Medicaid for Parent(s) and Caretaker Relatives › Rule 23-105-2.2 - Budgeting Rules for Extended Medicaid - Increased Spousal Support

Current through June 25, 2024
A. Parent(s), meaning a single parent or
				parent and step-parent family, that lose Medicaid in the parent/caretaker
				relative category of coverage due to new or increased spousal support under
				title IV-D of the Social Security Act must continue to receive Medicaid for
				four (4) consecutive months following the month of ineligibility. The parent(s)
				must have received Medicaid for at least three (3) of the six (6) months
				immediately preceding the month in which the individual becomes
				ineligible.
B. If the change in
				income is not reported timely, eligibility for extended Medicaid is determined
				using a look-back process where actual income information is gathered after the
				fact and the determination of the appropriate four (4) month period is
				calculated to begin the month after the month the family became ineligible for
				Medicaid.
C. The child(ren)
				associated with the parent(s) losing Medicaid are also eligible for the same
				four (4) month period of extended Medicaid eligibility. The provision to grant
				four (4) months of extended coverage cannot shorten a child's twelve (12) month
				period of continuous eligibility. When there is an overlap, the protected
				periods of eligibility run concurrently.
42 CFR §435.115
				  (Rev. 1994)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.1 - Disclosure of Confidential Information

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.2 - Access to Public Information

Current through June 25, 2024
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,
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.3 - Maintenance of Records

Current through June 25, 2024
A. All
				professional, institutional, and contractual providers participating 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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.4 - Fundraising

Current through June 25, 2024
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,
5. Non-covered medical
				equipment, or
6. Non-covered
				medical services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.5 - Limited English Proficiency Plan (LEP)

Current through June 25, 2024
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.
Miss. Code Ann. §
										43-13-121;
				  Title VI Civil Rights Act 1964 USC Section
				  2000(d)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.6 - Timely Filing

Current through June 25, 2024
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. 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.
D. If a provider
				fails to meet the timely filing requirements, the beneficiary cannot be billed
				for those services.
42 C.F.R. §
											447.45; Miss. Code Ann. §§
										43-13-113,
				  43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.7 - Timely Processing of Claims

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.8 - Administrative Reviews for Claims

Current through June 25, 2024
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,
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.9 - Authorized Provider Representative

Current through June 25, 2024
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.
Miss. Code Ann.
				  §§ 43-13-117, 43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.10 - Electronic Signatures

Current through June 25, 2024
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,
c) Authenticates a person
				as the signer,
d) Includes the date
				and time of the application of the electronic signature, and
e) Indicates intent of approval of
				information contained in the electronically signed document or
				communication.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.11 - Provider Claim Submission Signatures

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 1 - General Administrative Rules for Providers › Rule 23-200-1.12 - National Correct Coding Initiative (NCCI) Edits

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 2 - Benefits › Rule 23-200-2.1 - Medicaid Services

Current through June 25, 2024
A. Federally
				Mandated Services - The following services are mandated for Mississippi
				Medicaid:
1. Early and Periodic Screening,
				Diagnostic and Treatment (EPSDT) (Mississippi Cool Kids 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).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 2 - Benefits › Rule 23-200-2.2 - Non-Covered Services

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 2 - Benefits › Rule 23-200-2.3 - Medicaid Cost Sharing for Medicare/Medicaid Dually Eligibles

Current through June 25, 2024
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 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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.2 - Newborn Child Eligibility

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.3 - Beneficiary Retroactive Eligibility

Current through June 25, 2024
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 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.
Miss. Code Ann. §
										43-13-117.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.4 - Eligibility for Medicare and Medicaid

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.5 - Verification of Eligibility

Current through June 25, 2024
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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.6 - Freedom of Choice of Providers

Current through June 25, 2024
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 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.
Miss. Code Ann. §
										43-13-121;
				  Social Security 1902(a)(23)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.7 - Beneficiary Cost Sharing

Current through June 25, 2024
A. The Division of
				Medicaid does not impose premiums on beneficiaries.
B. The Division of Medicaid does not impose
				cost sharing on beneficiaries.
U.S.C §
				  1396a; 42 C.F.R. §
											447.50 et seq.; Miss. Code Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.8 - Charges Not Beneficiary's Responsibility

Current through June 25, 2024
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 Medicaid program.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 3 - Beneficiary Information › Rule 23-200-3.9 - Charges Beneficiary's Responsibility

Current through June 25, 2024
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 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.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 200 - General Provider Information › Chapter 4 - Provider Enrollment › Rule 23-200-4.3 - Change of Ownership

Current through June 25, 2024
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.