New Medicaid Regulations on NPs Prescribing DME

View an update from this article by the MS Division of Medicaid by clicking here.

Nurse practitioners throughout Mississippi recently received letters from the Mississippi Division of Medicaid stating that they are no longer able to prescribe durable medical equipment (DME) due to a change in the CMS regulations for DME under hospice regulations.  This was a shock to many, and it prompted many meetings throughout the state to figure out the “whats” and “why” behind this.

As we have investigated and been part of the discussions around this, we have learned much.  Here is a brief summary.

The origin of this language appears to stem back to the passage of the Affordable Care Act in 2008.  Language from the ACA changed CMS guidelines to require that only physicians are eligible to order DME – a change from what was previously allowed.  At that time, Mississippi had just recently submitted and received approval for our new Medicaid technical language.

This language had stayed in effect until this year, 2018, where Mississippi Medicaid filed its new State Plan Amendment (SPA) 17-0001 in response to the passage of the 2018 Medicaid technical bill.  This new language this year was approved by CMS with one caveat, that the DME portion of home health is changed to meet their standing guidelines as stated by the ACA in accordance with 42 CFR 440.70.

Representatives from the Mississippi Division of Medicaid had lengthy conversations with CMS to determine the cause of this change, and to fight for the state’s providers.  It turns out that CMS actually asked Mississippi Medicaid to not only enforce the new policy effective immediately, but to actually back-bill providers for a period of time for improperly ordering DME, despite the fact that it was done according to Mississippi-approved policies.  Mississippi Medicaid fought hard for Mississippi providers, and it prompted CMS to compromise on not requiring the retroactive refunded payments, but rather kicked out the effective date to September 1, 2018.  At and after this date, only physicians will be eligible to order DME.

As I mentioned, there have been numerous conversations around this and many considerations of how to fix it.  We are likely looking at a short-term fix and a long-term fix, but more investigate is underway with other states that have already dealt with the issue and found resolution.  In order to not disrupt the work that is being done, I will hold back from detailing the solutions that are being discussed at this time.  I can say that the goal, though, is to find a way that is legal and medically compliant to allow NPs to continue to order DME.

We are monitoring the situation closely and have a “seat at the table” with discussions.

Hopefully there will be headway soon before this takes full effect on September 1, 2018 so that we do not hamper the good work that is being done to treat patients in Mississippi that have a need for basic DME.

Please contact Ryan Kelly at 601.898.3001 for questions or additional information.


Lowering Drug Costs

By Ryan Kelly –

I think we can all agree that prescription drug prices are often too high.  Of course, there are several key reasons why this is the case: 1) research, 2) litigation defense and payout, 3) shareholder profits, among several others.

So, how will we work to lower these drug prices?

First, it involves leadership.  Recently President Trump delivered a speech in which is called for a lowering of drug prices, whether voluntary or forced.  Being the free-market person that President Trump is, it’s likely that the “behind the scenes work” would involve incentives to companies for lowering the cost.  For patients, though, this could be very positive.

A second effort underway currently is with prescription discount cards.  One that the MRHA uses as a partner is Mississippi Drug Card.  This card is loaded with pre-negotiated pricing that helps patients to lower their burden.  These prices are often competitive to those offered with insurance on many prescription types.  Another unique card is offered by individual pharmaceutical companies.  These cards, or vouchers, will entitle beneficiaries to receive steep discounts on drugs at the counter.  One such from Astra Zeneca, for instance, can be used with 340(b) pricing on diabetes medications like Farxiga, Xigduo XR, and Qtern to allow a patient to receive medication at no cost.  But, these cards cannot be used alongside government-funded insurance plans (Medicare, Medicaid, and Tricare).

We look forward to seeing more efforts on how to reduce the cost burden of prescription drugs for our members.  At the moment, it looks like the tide is starting to turn.


CR Bills Passes – Provides Vital Funding for Healthcare Services

By Ryan Kelly –

Delegates from the Mississippi Rural Health Association traveled to Washington last week (week of February 5th) to attend the NRHA Policy Institute as well as visit with elected officials in the House and Senate.  Delegates included Michael Nester, H.C. Watkins; Zach Allen, Children’s International; Joanie Perkins, North Sunflower; and Paul Gardner, MS Hospital Association.

We are pleased to say that our needs were many but our ask was simple – support the Continuing Resolution bill, which provided needed funding and regulatory relief asked in our 2018 Legislative Packet.

And, we are more pleased to say that the CR bill passed the House and the Senate.  Our concerns were heard through our visits with Sens. Cochran and Wicker and Reps. Harper, Palazzo, Kelly and Thompson.

Sen. Wicker may have said it best when he paused in our conversation, reflected, and said “it’s a lot of money, but there’s a lot of need, and if we’re going to continue to be a first world country, then we need to fund what is needed to do just that.”  We appreciate the candor of all of our legislators and the hard decision that it is to balance a budget, provide tax relief and regulatory relief, and fund the programs that we all need.  It’s not an easy job.

The C.R. Bill accomplished the following

2 year extension of federal qualified health centers (community health centers)

Averts FY18 and FY19 Medicaid Disproportionate Share Hospital reductions

Provides a 2 year extension of public health programs:

  • National Health Service Corps
  • Teaching health Center Graduate Medical Education
  • Family-to-Family Health Information Centers
  • Sexual risk avoidance education programs
  • Personal responsibility education program
  • Special Diabetes Program for Type 1 Diabetes and the Special Diabetes Program for Indians

Provides Permanent Medicare Changes

  • Repeal Medicare payment cap for therapy services
  • Removal of the rental cap for durable medical equipment under Medicare with respect to speech generating devices

2 year extension of Medicare policies

  • Funding for quality measure endorsement, input, and selection
  • Medicare-Dependent hospital and Low-Volume hospital programs
  • Geographic Practice Cost Indices (GPCI) floor for physician payments

5 year extension of Medicare policies with reforms

  • Home health rural add-on payment
  • Ground ambulance add-ons

Telehealth provisions including:

  • Expanding access to home dialysis therapy
  • Increasing convenience for Medicare Advantage enrollees through telehealth
  • Providing accountable care organizations (ACOs) the ability to expand the use of telehealth
  • Expanding the use of telehealth for individuals with stroke


MBML Updates Prescribing Rules

By Ryan Kelly –

You may have noticed previous posts from the MRHA regarding the Mississippi Board of Medical Licensure’s prescribing updates.  The Board met on Thursday, February 1st to finalize recommendation and provide extra clarity for comments made during the open comment period.

View Proposed Rules (updated 2.15.2018)

The overall goal of these rules is to curb the epidemic of opioid prescriptions in Mississippi.  It is estimated that more than 200,000 Mississippians are addicted to some form of opioid medication.  That is roughly 6.7% of our state’s population!

The regulations took meaningful but radical changes to prescribing regulations, primarily focused on opioid and benzodiazepine medications.  The number of changes are too numerous to include in this post, but you can find a white paper published by the MRHA on the rules by clicking here.

The board clarified many of the comments that we sent during the open comment period during their meeting on February 1st.  Those include the following:

  • ADHD medication prescriptions do not require the use of the Mississippi Prescription Monitoring Program (MPMP)
  • In Rule 1.7H, providers may issue a 10 day supply of opioid medication with an optional 10 day refill before a new script is made.  The new script may also include a 10 day supply with a 10 day refill, in perpetuity.  This does require strong documentation, however, and use of the MPMP.
  • Point of Service drug testing for opioid and benzodiazepine prescription requirements are changed to CDC recommendations, which requires that they are performed no less than 3 times per calendar year.
  • In Rule 1.11, telemedicine services and co-providers can both satisfy requirements for refilling and writing scripts for fellow providers.  Additional clarity on this is needed and may be reflected once the final text is posted.
  • Addition of language from Rule 5.5 within Rule 1 to restate the availability of telehealth to satisfy the “physical exam” requirements set forth in Rule 1

Other Considerations

At this same meeting, the Mississippi Board of Medical Licensure addressed telehealth and scope of practice items, including:

  • Mississippi officially being confirmed in the telehealth compact…we are now officially a state of primary licensure for telehealth
  • Consideration of expanding tele-emergency offerings to both Level 1 and Level 2 trauma centers
  • Refined definition of primary care to include family practice, general medicine, and pediatrics
  • Expansion of physician / nurse practitioner collaboration to be with unlimited geographical distance within Mississippi for the definition of primary care collaboration mentioned above

Overall, the Board’s effort to refine the definition and intent of the rules and provide needed clarity is appreciated.  With this clarity, providers should have additional confidence in moving forward with prescribing medication to their patients in Mississippi.

Hopefully, our next step as a state will be to determine the best course of action for rehabilitation and detoxification of patients suffering from opioid addiction.


What the proposed tax cut bills may mean for Mississippi’s healthcare

By Ryan Kelly –

Tax reform has long since been a goal of Republicans since the election of President Trump, and it appears that the House and Senate have found common language with enough votes to pass (down party lines).

The legislation, which will provide substantial tax breaks to individuals in all tax brackets (except for those not currently paying taxes), may increase the federal deficit by $1.5 trillion, according to the Congressional Budget Office.  House and Senate Republicans are anticipating increased tax receipts to make up the shortfall.

It is this deficit, along with provisions to effectively eliminate the individual mandate for health insurance,  that is causing some in the healthcare community heartburn.

In my investigation into what is likely going to make it into a reconciled House/Senate bill, I became nauseous at the lies, mistruths and propaganda put out about the bill.  It’s times like these that I wonder if there are any national news sources that are unbiased any longer.

So, instead of citing any source out there, I’m simply going to tell you the good and the bad of what I think will happen.  Please keep in mind, regarding “the good” and “the bad,” this is in my point of view.  And, this relates only to how it will affect healthcare both directly and indirectly.

The Good

The tax cut will benefit all Americans of all economic tax brackets, with the exception of the lowest tier, who do not pay taxes.  This will ideally free up extra dollars that can be saved and used toward healthcare as needed.

The tax cut will allow medical professionals (who normally fall in the middle class) to receive substantial tax breaks and eliminate the inheritance tax, which is essentially a double tax on already taxed dollars.

The tax cut will likely eliminate the tax penalty on the individual mandate for health insurance, which will allow individuals to self-pay or find more affordable coverages as they come online soon.  I see this a positive due to the very high premiums that many must pay with no ability to meet the high deductibles.  But…

The Bad

The tax cut, by eliminating the penalty for not having a health insurance plan, will likely destabilize the health insurance marketplace to some degree, causing premiums to continue to increase from unreasonably high levels to absurd levels.

The tax cut will likely prompt Congress to find additional cuts to entitlement programs, which will likely focus on Medicare and Medicaid.  It will almost certainly create a necessary cut to both, with Medicare possibly receiving a phased-in age of benefit increase for future generations (which was probably coming sooner or later anyway).

Perhaps the worst provision that I see is actually not with any of the above, but it’s with the rollback of tax-exempt municipal bond financing for capital projects undertaken by not-for-profit hospitals and other qualifying not-for-profit organizations. It would prohibit advance re-funding of prior tax-exempt bond issues.  This may prevent rural hospitals from having access to the bond market and force them to rely more heavily on conventional loans, which often carry higher interest and are more difficult to come by (thanks in large part to Dodd Frank).


I think it’s safe to say that it will have at least a moderate level of impact to the insurance marketplace, to consumer choice, and to hospital financing.  Whether this ends up being a catalyst for positive or negative change remains in the details and the rollout of the new provisions.

My suggestion for providers – stay flexible and prepare to change as needed.  My suggestion to consumers – find a health insurance plan that works best for you, and either create an official Health Savings Account (HSA) or start your own savings account to be used just for healthcare needs in case of emergencies.  These are all things we should be doing anyway, but it may be even more important moving forward.

State Representative Stacey Wilkes is Recipient of the One Rural Award

State Representative Stacey Wilkes, District 108, was recently recognized by the Mississippi Rural Health Association as the recipient of its One Rural Award before an audience of more than 180 healthcare professionals at its 22nd Annual Conference in Jackson. Wilkes earned this award due to her consistent support of healthcare legislation, particularly due to her support of policy that would support hospitals like Poplarville’s Pearl River County Hospital.

Ryan Kelly, executive director of the Mississippi Rural Health Association states, “Rep. Wilkes has worked both personally and professionally to support healthcare in Mississippi. Coming from a rural community, she fully understands the challenges that we face with delivering quality healthcare to a unique population under less than favorable economic conditions. Her dedication to making positive improvements while bringing all stakeholders to the table make her the ideal candidate for this prestigious award.”

State Senator Angela Hill, District 40, introduced Wilkes for her award with remarks including her personal and professional relationship with Wilkes as well as the need for those elected office that share the heart and values that we all have for our communities.

Rep. Wilkes won a special election in 2017 to fill the recently vacant House seat previously held by Mark Formby, who was appointed by Governor Phil Bryant to a state position. Wilkes, a native of Pearl River County, is married to Rodney Wilkes and resides in Picayune.


Sen. Roger Wicker Recognized as MRHA National Legislator of the Year

U.S. Senator Roger Wicker was recently recognized by the Mississippi Rural Health Association as its National Legislator of the Year before an audience of more than 180 health care professionals at its 22nd Annual Conference in Jackson. Sen. Wicker has supported multiple pieces of healthcare legislation in the past year, including those that supported the stabilization of rural hospital and rural health clinic payment methodologies, the 340(b) prescription drug program, telehealth, opioid abuse, colorectal cancer screenings, rural broadband access and new strategies for delivering rural healthcare.

Ryan Kelly, executive director of the Mississippi Rural Health Association states, “Sen. Wicker and his staff have done a superb job at supporting rural health in Mississippi. He is eager to support positive legislation that benefits Mississippi’s health infrastructure and policies in order to allow providers and facilities to take greater leadership roles at improving our citizens’ health Outcomes.”

Sen. Wicker has supported and co-sponsored multiple pieces of healthcare legislation over the past several years, most notably supporting telehealth. Other legislation has supported the creation of new models of healthcare, stabilizing rural hospital and rural health clinic payment methodologies, opioid abuse, colorectal cancer screenings, rural broadband access, Representing Mississippi in the US Senate since 2007, Sen. Wicker has held multiple leadership roles in the Senate and with the Republican Party. Prior to his service in the Senate, Wicker was elected seven times, beginning in 1994, to represent Mississippi’s First Congressional District in the House of Representatives. Before being elected to Congress, he served in the state Senate on behalf of Lee and Pontotoc counties.A native of Pontotoc, Mississippi, Sen. Wicker is married to the former Gayle Long of Tupelo, where they currently reside.