Department of Insurance

In accordance with CMS guidance, the Mississippi Department of Insurance ("Department") has created a form entitled "Renewal Form for Individual Products" ("Form"), which is found in Rule 16.06 of this Regulation. Issuers may begin using this form immediately, without the necessi…

If any provision of this regulation, or the application thereof to any person or circumstance, is held invalid, such determination shall not affect other provisions or applications of this regulation which can be given effect without the invalid provision or application, and to t…

This Regulation shall be effective thirty (30) days after final adoption with the Office of the Secretary of State. Notes 19 Miss. Code. R. 3-16.05 Miss. Code Ann. §§ 25-43-3.108; 25-43-3.112; 83-5-1 (Rev. 2011). Adopted 4/22/2015

RENEWAL FORM FOR INDIVIDUAL PRODUCTS OFFERED OUTSIDE OF THE MARKETPLACE Important: We are continuing to Offer Your Health Coverage. Dear (First Name of Subscriber): Your health insurance coverage is coming up for renewal. On (Date of Renewal), you will be automatically re-enrolle…

This regulation is adopted and promulgated pursuant to the authority granted by Miss. Code Ann. § 83-5-1, §§ 83-9-1 et seq., §§ 83-41-401 et seq. and in accordance with the provisions of the Administrative Procedures Act found at Miss Code Ann. § 25-43-1 et seq. Notes 19 Miss. Co…

A. Purpose. The purpose of this regulation is to establish requirements for companies who offer fully insured, comprehensive, major medical health insurance products on the remittance of certain claims data to large employer groups as defined by Mississippi Insurance Department B…

A. Upon request by a large employer group ("group") or the group's agent or broker, the group's health carrier shall make available the currently available summary health information, aggregate paid claim, and premium data accumulated for the current and the immediately preceding…

If any section or portion of a section of this regulation or the application thereof to any person or circumstance is held by a court to be invalid, such invalidity shall not affect any other provision of that section or application of this regulation which can be given effect wi…

This regulation shall become effective thirty (30) days after filing for final adoption with the Office of the Secretary of State. Notes 19 Miss. Code. R. 3-17.05 Miss Code Ann.§ 25-43-3.112; § 25-43-3.113 (Rev. 2018). Adopted 1/1/2021

This Regulation shall be known and may be cited as the Managed Care Plan Certification Regulation and is promulgated by the Commissioner of Insurance pursuant to the authority granted to him by Title 83, the Mississippi Insurance Code; the requirements of Miss. Code Ann. § 25-43-…

The purpose of this Regulation is to establish a process for certifying managed care plans pursuant to the provisions of Miss. Code Ann. § 83-41-401 et seq., also known as the Mississippi Patient Protection Act of 1995. Additionally, it furthers the goals of the Managed Care Plan…

For purposes of this Regulation, the term "managed care entities" as used herein, shall include a "health carrier" as that term is defined in Rule 14.03 of Title 19, Part 3, Chapter 14. Any term defined in Rule 14.03 of Title 19, Part 3, Chapter 14 will have the same meaning in t…

This Regulation shall apply to all managed care plans, managed care entities and managed care contractors; provided, however, the Regulation shall not apply to the Mississippi State Employee Health Plan or to any managed care plan regulated by the Mississippi Division of Medicaid…

A. Beginning June 1, 2025, managed care entities shall file with the Commissioner sample contract forms proposed for use with its participating providers and intermediaries. B. By June 1 of each calendar year, managed care entities shall submit to the Commissioner, in an electron…

A. Based on the information managed care entities must submit pursuant to this Regulation and the Managed Care Network Adequacy Regulation, the Commissioner shall review such information and if found sufficient, the Commissioner shall issue an annual certification of each managed…

The Commissioner, at any time, may review a managed care entity's compliance with this Regulation or the Managed Care Plan Network Adequacy Regulation, request information from the managed care entity necessary to investigate the managed care entity's compliance, and order the co…

A managed care entity or managed care contractor may designate material submitted to the Commissioner pursuant to this regulation as confidential and exempt from disclosure to the public under the Mississippi Public Records Act if the health carrier deems the material to meet the…

A violation of this Regulation shall be subject to the penalty provisions set forth in Miss. Code Ann. § 83-5-17, as well as other penalty provisions under applicable law. Notes 19 Miss. Code. R. 3-18.09 Miss. Code Ann. § 83-5-17; § 83-41-405; § 83-41-413 (Rev. 2022) Adopted 8/12…

If any provision of this Regulation, or the application of the provision to any person or circumstance shall be held invalid, the remainder of the Regulation, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not …

This Regulation shall be effective thirty (30) days after final adoption with the Office of the Secretary of State. All provider and intermediary contracts in effect on the effective date of this Regulation, or which are issued or put inforce on or after the effective date of thi…

This Regulation shall be known and may be cited as the Utilization Review Regulation and is promulgated by the Commissioner of Insurance pursuant to the authority granted to him by Title 83, the Mississippi Insurance Code; the requirements of Miss. Code Ann. §§ 25-43-1.101 et seq…

The purpose of these rules and regulations is to promote the delivery of quality health care in a cost effective manner; foster greater coordination between payors and providers conducting utilization review activities; protect patients, business and providers by ensuring that pr…

Unless otherwise defined herein, any term defined in Miss. Code Ann. §§ 83-5-901 through 83-5-937 shall have the same meaning in this Regulation. Notes 19 Miss. Code. R. 3-19.03 Miss. Code Ann. §§ 83-5-901 through 83-5-937. Adopted 1/1/2025

This Regulation shall apply to every health insurance issuer and all health benefit plans, as both terms are defined in Miss. Code Ann. § 83-9-6.3, and all private review agents and utilization review plans, as both terms are defined in Miss. Code Ann. § 41-83-1, with the excepti…

(1) Adverse determination: A determination by a health insurance issuer that, based on the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance…

(1) A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case by case basis, may not conduct utilizatio…

(1) A certificate expires on the second anniversary of its effective date unless certification has been renewed for a two (2) year term. (2) Before the certification expires, the certified private review agent may renew its certification for an additional two (2) year term, if th…

(1) The Commissioner shall deny a certificate to an applicant if the Department finds that the applicant does not: a. Have available the services of a sufficient number of registered nurses, that are supervised by appropriate physicians to efficiently carry out its utilization re…

(1) Responsibility for Obtaining Certificationa. In the absence of any contractual agreement to the contrary, the enrollee is responsible for notifying the private review agent in a timely manner and obtaining certification for health care services, if required by the health bene…

(1) Each private review agent shall have in place procedures for appeals of determinations not to certify an admission, procedure, service or extension of stay. The right to appeal shall be available to the patient or enrollee, and to the attending physician on behalf of the pati…

(1) Utilization review of prior authorizations in nonurgent circumstances. If a health insurance issuer requires prior authorization of a health care service, the health insurance issuer must make an approval or adverse determination and notify the enrollee, the enrollee's health…

To facilitate an Urgent Prior Authorization request in a timely manner as required by statute and this Rule, a health insurance issuer must establish a policy to ensure Health Care Professionals, defined as a physician, registered professional nurse or other individual appropriat…

When a provider or facility makes a request for prior authorization, should a health insurance issuer make an adverse determination, the health insurance issuer shall include in writing the following in the notification to the enrollee, the enrollee's health care professional, an…

1) A health insurance issuer must ensure that all appeals are reviewed by a physician when the request is by a physician or a representative of a physician. The physician must:a. Possess a current and valid nonrestricted license to practice medicine in any United States jurisdict…

Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care for emergency services, such shall…

(1) A prior authorization approval shall be valid for the lesser of six (6) months after the date the health care professional or provider receives the prior authorization approval or the length of treatment as determined by the patient's health care professional or the renewal o…

(1) If a health insurance issuer requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition, including, but not limited to, chemotherapy for the treatment of cancer, the approval shall remain …

(1) On receipt of information documenting a prior authorization approval from the enrollee or from the enrollee's health care professional or health care provider, a health insurance issuer shall honor a prior authorization granted to an enrollee from a previous health insurance …

(1) A health insurance issuer may not revoke or further limit, condition or restrict a previously issued prior authorization approval while it remains valid under this act. (2) Notwithstanding any other provision of law, if a claim is properly coded and submitted timely to a heal…

(1) By January 1, 2025, all health insurance issuer or designee utilization review organization shall make available a standardized electronic prior authorization request transaction process using an internet webpage, internet webpage portal, or similar electronic, internet, and …

(1) By June 1, 2025, and each June 1 after that date, a health insurance issuer shall report to the department, on a form issued by the department, the following aggregated trend data, de-identified of protected health information, related to the insurer's practices and experienc…

Pursuant to Miss. Code Ann. § 83-5-909(7), health insurance issuers using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. Following each calendar year, the statistics must be …

The Department may issue a cease-and-desist order or require a private review agent or health insurance issuer to submit a plan of correction for violation of Miss. Code Ann. §§ 83-5-901 through 83-5-937. The Department may impose upon a private review agent, health benefit plan …

(1) A failure by a health insurance issuer to comply with the deadlines and other requirements specified in this act shall result in any health care services subject to review to be automatically deemed authorized by the health insurance issuer or its contracted private review ag…

If any provision of this Regulation, or the application of the provision to any person or circumstance shall be held invalid, the remainder of the Regulation, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not …

This Regulation shall be effective on and after January 1, 2025. Notes 19 Miss. Code. R. 3-19.26 Miss. Code Ann. § 25-43-3.108 (Rev. 2022); Miss. Code Ann. §§ 83-5-901 through 83-5-937. Adopted 1/1/2025

MEMORANDUM TO ALL COMPANIES WRITING HEALTH AND ACCIDENT INSURANCE: The Department is being deluged with letters from insureds requesting assistance in the payment of claims. A great number of the letters from the insureds state that an "agent" told them to write the Department an…