Email: Chapter 9, Article 4C
§9-4C-1. Definitions.
The following words when used in this article have the meanings ascribed to them in this section, except in those instances where the context clearly indicates a different meaning:
(a) "Ambulance service provider" means a person rendering ambulance services within this state and receiving reimbursement, directly as an individual provider or indirectly as an employee or agent of a medical clinic, partnership or other business entity.
(b) "General health care provider" means an audiologist, a behavioral health center, a chiropractor, a community care center, an independent laboratory, an independent X ray service, an occupational therapist, an optician, an optometrist, a physical therapist, a podiatrist, a private duty nurse, a psychologist, a rehabilitative specialist, a respiratory therapist and a speech therapist rendering services within this state and receiving reimbursement, directly as an individual provider or indirectly as an employee or agent of a medical clinic, partnership or other business entity.
(c) "Inpatient hospital services provider" means a provider of inpatient hospital services for purposes of Section 1903(w) of the Social Security Act.
(d) "Intermediate care facility for individuals with an intellectual disability services provider" means a provider of intermediate care facility services for individuals with an intellectual disability for purposes of Section 1903(w) of the Social Security Act.
(e) "Nursing facility services provider" means a provider of nursing facility services for purposes of Section 1903(w) of the Social Security Act.
(f) "Outpatient hospital service provider" means a hospital providing preventative, diagnostic, therapeutic, rehabilitative or palliative services that are furnished to outpatients.
(g) "Secretary" means the Secretary of the Department of Human Services.
(h) "Single state agency" means the single state agency for Medicaid in this state.
§9-4C-2. General Medicaid enhancement board.
(a) The general Medicaid enhancement board created by this section is hereby continued in all respects, except as otherwise provided in this section. Current members of the board who represent groups not represented on the board on and after the effective date of this article shall not serve on the board after such date. The Governor shall appoint new members to the board to represent groups not previously represented on the board within thirty days after the effective date of this article.
(b) This board shall consist of members appointed by the Governor, including one representative from each of the following sixteen groups: Audiologists, behavioral health centers, chiropractors, community care centers, independent laboratory services, independent x-ray services, occupational therapists, opticians, optometrists, physical therapists, podiatrists, private duty nurses, psychologists, rehabilitative specialists, respiratory therapists and speech therapists. In addition to the members appointed by the Governor, the secretary, or his or her designee, shall serve as an ex officio, nonvoting member of the board.
(c) After the initial appointment of the board, any appointment to fill a vacancy shall be for the unexpired term only and shall be made in the same manner as the initial appointment. The terms of the lay persons who are members of the board as of March 17, 1994, shall expire on July 1, 1994.
(d) The terms of all members expire on July 1, 1996.
§9-4C-3. Dentist provider Medicaid enhancement board.
There is hereby continued the dentist provider Medicaid enhancement board to consist of five members. In order to carry out the purposes of this article, the dentist provider Medicaid enhancement board shall represent dentist providers. The board shall consist of three dentists, one lay person and the secretary, or his or her designee, who shall serve as an ex officio, nonvoting member. The Governor shall select the dentist members from six recommendations submitted to the Governor by the state dental association and the lay board member at his or her discretion. The state dental association shall submit all recommendations to the Governor within five days of the effective date of this article. The Governor shall make all appointments within fifteen days of receipt of all recommendations. After the initial appointment of the board, any appointment to fill a vacancy shall be for the unexpired term only, shall be made in the same manner as the initial appointment, and the terms of all members shall expire on July 1, 1996.
§9-4C-4. Ambulance service provider Medicaid enhancement board.
There is hereby continued the ambulance service provider Medicaid enhancement board to consist of seven members. In order to carry out the purpose of this article, this board shall represent ambulance service providers. The board shall consist of five ambulance service providers, one lay person and the secretary, or his or her designee, as an ex officio, nonvoting member. The Governor shall make all appointments within twenty days of the effective date of this article. After the initial appointment of the board, any appointment to fill a vacancy shall be for the unexpired term only, and the terms of all members shall expire on July 1, 1996.
§9-4C-5. Facility providers' Medicaid enhancement board.
(a) The outpatient hospital Medicaid enhancement board created by this section shall cease to exist on the effective date of this article.
(b) There is hereby continued the facility providers' Medicaid enhancement board to consist of seven members. In order to carry out the purpose of this article, the board shall represent ambulatory surgical centers, inpatient hospital service providers, outpatient hospital service providers, nursing facility service providers and intermediate care facility for individuals with an intellectual disability service providers.
(c) The board shall consist of one representative from each of the aforementioned classes of health care providers, one lay person and the secretary, or his or her designee, who shall serve as an ex officio, nonvoting member. The Governor shall make all appointments within thirty days after the effective date of this article.
(d) After initial appointment of the board, any appointment to fill a vacancy shall be for the unexpired term only, shall be made in the same manner as the initial appointment, and the terms of all members shall expire on July 1, 1996.
§9-4C-6. Expenses for citizen members.
Each appointed board member for each board created pursuant to this article shall serve without compensation but shall be reimbursed for the cost of reasonable and necessary expenses actually incurred in the performance of his or her duties.
§9-4C-7. Powers and duties.
(a) Each board created pursuant to this article shall:
(1) Develop, recommend, and review reimbursement methodology where applicable, and develop and recommend a reasonable provider fee schedule, in relation to its respective provider groups, so that the schedule conforms with federal Medicaid laws and remains within the limits of annual funding available to the single state agency for the Medicaid program. In developing the fee schedule the board may refer to a nationally published regional specific fee schedule, if available, as selected by the secretary in accordance with §9-4C-8 of this code. The board may consider identified health care priorities in developing its fee schedule to the extent permitted by applicable federal Medicaid laws, and may recommend higher reimbursement rates for basic primary and preventative health care services than for other services. In identifying basic primary and preventative health care services, the board may consider factors, including, but not limited to, services defined and prioritized by the basic services task force of the health care planning commission in its report issued in December of the year 1992; and minimum benefits and coverages for policies of insurance as set forth in and minimum benefits and coverages for policies of insurance as set forth in chapter thirty-three of this code and rules of the Insurance Commissioner promulgated thereunder. If the single state agency approves the adjustments to the fee schedule, it shall implement the provider fee schedule;
(2) Review its respective provider fee schedule on a quarterly basis and recommend to the single state agency any adjustments it considers necessary. If the single state agency approves any of the board’s recommendations, it shall immediately implement those adjustments;
(3) Assist and enhance communications between participating providers and the Department of Human Services;
(4) Meet and confer with representatives from each specialty area within its respective provider group so that equity in reimbursement increases or decreases may be achieved to the greatest extent possible and when appropriate to meet and confer with other provider boards; and
(5) Appoint a chairperson to preside over all official transactions of the board.
(b) Each board may carry out any other powers and duties as prescribed to it by the secretary.
(c) Nothing in this section gives any board the authority to interfere with the discretion and judgment given to the single state agency that administers the state’s Medicaid program. If the single state agency disapproves the recommendations or adjustments to the fee schedule, it is expressly authorized to make any modifications to fee schedules as are necessary to ensure that total financial requirements of the agency for the current fiscal year with respect to the state’s Medicaid plan are met and shall report such modifications to the Joint Committee on Government and Finance on a quarterly basis. The purpose of each board is to assist and enhance the role of the single state agency in carrying out its mandate by acting as a means of communication between the health care provider community and the agency.
(d) In addition to the duties specified in subsection (a) of this section, the ambulance service provider Medicaid board shall develop a method for regulating rates charged by ambulance services.
§9-4C-8. Duties of Secretary of Department of Human Services.
(a) The secretary, or his or her designee, shall serve on each board created pursuant to this article as an ex officio, nonvoting member and shall keep and maintain records for each board.
(b) In relation to outpatient hospital services, the secretary shall furnish information needed for reporting purposes. This information includes, but is not limited to, the following:
(1) For each hospital, the amount of payments and related billed charges for hospital outpatient services each month;
(2) The percentage of the state’s share of Medicaid program financial obligation from time to time as necessary; and
(3) Any other financial and statistical information necessary to determine the net effect of any cost shift.
(c) The secretary shall determine an appropriate resolution for conflicts arising between the various boards.
(d) The secretary shall purchase nationally published fee schedules to be used, if available, as a reference by the Medicaid enhancement boards in developing fee schedules.
§9-4C-9.
Repealed.
Acts, 1993 1st Ex. Sess., Ch. 7.
§9-4C-10.
Repealed.
Acts, 1993 1st Ex. Sess., Ch. 7.
§9-4C-11. Effective date.
The provider fee schedules as adopted by the single state agency through recommendations by each board become effective on January 1, 1992: Provided, That those fee schedules based upon fees that require prior approval of the health care financing administration are effective on the effective date approved by the health care financing administration: Provided, however, That for those fees subject to an established Medicare upper limit, the effective date is the first day of the month immediately succeeding the date the fees can be raised sufficiently to comply with section ten of this article.
§9-4C-12.
Repealed.
Acts, 1993 1st Ex. Sess., Ch. 7.