Current through September 24, 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.
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 its designee.
5. Services,
procedures, supplies or drugs still in clinical trials deemed as
investigational or experimental in nature.
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
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 hospice
services for beneficiaries enrolled in a Home and Community-Based (HCB) waiver
program or enrollment in more than one (1) HCB waiver program including, but
not limited to:
1. Elderly and Disabled
(E&D) Waiver,
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 (TD/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.
42 USC § 1396n,
49 USC § 1185b; 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).
