23 Miss. Code. R. 200-5.3 - 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 the physician visit limit of twelve (12) per fiscal year.

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.

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 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 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).

Notes

23 Miss. Code. R. 200-5.3

Miss. Code Ann. §§ 43-13-117, 43-13-121.

Amended 4/1/2018 Amended 9/1/2023