Centers for Medicare and Medicaid Services (CMS) Cell and Gene Therapy (CGT) Access Model Overview
The Cell and Gene Therapy (CGT) Access Model is a multi-year model for states and manufacturers to test whether a CMS-led approach to developing and administering outcomes-based agreements for CGTs increases Medicaid members’ access to innovative treatments, improves their health outcomes, and reduces health care costs and burden to state Medicaid programs.
The initial focus of the model is on CGTs for sickle cell disease. The Mississippi Division of Medicaid is participating in the CGT Access Model beginning on January 1, 2026.
More information about the model can be found here: https://www.cms.gov/priorities/innovation/innovation-models/cgt.
Billing Instructions for Providers
Pursuant to State Plan Amendment MS 25-0006, the Mississippi Division of Medicaid will reimburse select drugs provided in an inpatient hospital setting separately from the APR-DRG payment. A separate claim must be submitted to receive reimbursement for select drugs during the time of inpatient services. The list of select high-cost drugs carved out of inpatient DRG rates can be found here: https://medicaid.ms.gov/providers/fee-schedules-and-rates/.
Per the requirements set by this model, provider billing instructions for cell and gene therapies for sickle cell disease are linked below.
Prior Authorization Criteria
Per the requirements set by this model, prior authorization criteria for each CGT for sickle cell disease are linked below. Please submit the prior authorization request to Telligen if the member is enrolled in fee-for-service or to the member’s respective coordinated care organization.
CGT Access Model Cooperative Agreement Funding
Overview
As the gene therapy journey is complex, states had the opportunity to apply for funding to implement services that improve members’ ability to access these promising therapies. Mississippi was one of eight applicants awarded Cooperative Agreement funding through this Model.
Funding will be used across calendar years 2026 to 2030:
- Create dedicated patient support roles to guide and support members throughout their gene therapy treatment journey
- Partner with a community-based organization to:
- o Expand, and not duplicate or replace, transportation and travel-related support, including lodging and meals, for members and their caregivers
- o Connect patients and caregivers in the Model to subsidized childcare from licensed providers
- o Develop and launch educational and awareness efforts for members, providers, and local communities about sickle cell disease, cell and gene therapies, and supportive services available
Program Coordinator
Funded through the Cooperative Agreement, the Program Coordinator is a position that will focus on supporting members who will receive CGT for sickle cell disease through the CMS Cell and Gene Therapy Access Model.
Responsibilities of this role include, but are not limited to:
- Act as the primary liaison for the CGT Access Model
- Guide Model members through the full treatment journey
- Connect members to supportive resources
The Mississippi Division of Medicaid is accepting applications for this position until March 13, 2026. Additional information can be found here: https://medicaid.ms.gov/resources/procurement/
The contact information for the Program Coordinator will be available after the position is filled.
Educational and Awareness Initiatives
Please stay tuned for educational and awareness resources and initiatives.
