South Carolina Administrative Code

126-308. End Stage Renal Disease Services. End stage renal disease services are available in or out of a hospital or clinic.

126-309. Family Planning Services. Family planning services are furnished for purposes of enabling such individuals to freely determine the number and spacing of their children. Services are available to minors who are considered to be sexually active.

126-310. Hospital Services. A. Inpatient hospital services provided by the Medicaid Program are for the care and treatment of illness, injuries or disabilities certified medically necessary by a physician and reviewed for appropriate- ness of admission, length of stay and ancilla…

126-311. Laboratory and X-ray Services/Tests. Laboratory and x-ray services/tests must be ordered by a professional practitioner within the scope of his/her practice with the expectation of making a reasonable medical determination.

126-312. Medical Transportation Services. Medically necessary transportation services by ambulance, contracted transportation providers and volunteer drivers are available to recipients receiving covered Medicaid service.

126-313. Mental Health Clinic Services. Mental health clinic services are those services that are provided on an outpatient basis within a community setting meeting the standards as set forth by the South Carolina Department of Mental Health

126-314. Nursing Facility Services. Medicaid sponsors skilled, intermediate, and intermediate/persons with intellectual disability nursing care services in accordance with the level of care determination established by the utilization review mechanism. These nursing facility serv…

126-315. Physicians’ Services. Physicians’ services must be medically necessary and furnished by or under the direct supervision of an individual licensed under state law to practice medicine or osteopathy and within the scope of practice of these disciplines.

126-316. Podiatry Services. Podiatry services are those services that are necessary for the diagnosis and treatment of foot conditions not associated with routine foot care.

126-317. Prescribed Drugs. Prescribed drugs are drugs prescribed by a licensed practitioner and dispensed by a licensed pharmacist or practitioner according to limitations set forth in the Title XIX State Plan and in provider manuals.

126-318. Psychiatric Facility Services. Inpatient psychiatric facility services are available for individuals younger than twenty-two years of age and sixty-five years of age and older.

126-319. Rehabilitative Services. Rehabilitative services are limited to outpatient mental health rehabilitative services meeting stan- dards as determined by the State Health and Human Services Finance Commission and the South Carolina Department of Mental Health.

126-320. Rural Health Clinic Services. Rural health clinic services are medically necessary services provided by a facility which participates in the Medicare Program and contracts with the Health and Human Services Finance Commission.

126-321. Speech Pathology. Speech evaluations are provided by authorized providers for Medicaid recipients through the month they turn twenty-one years of age.

126-322. Tubercular Facility Services. Tubercular facility services are limited to individuals age sixty-five or older in institutions for the treatment of tuberculosis and include only inpatient hospital services.

126-323. Vision Care. Vision care consists of vision examination and corrective eye-wear to include contact lenses when medically necessary. Only post surgical lenses are available for recipients age twenty-one years and over.

126-335. Hospital Reimbursement. A. Reimbursement for covered inpatient hospital services shall be by a prospective payment system. B. Providers may seek a correction to the statistical calculation which establishes the maximum allowable payment rate by requesting in writing a re…

126-350. Definitions. A. Medicaid is the common name for Title XIX of the Social Security Act. B. Medicare is the common name for Title XVIII of the Social Security Act. C. Supplemental Security Income (SSI) is the common name for Title XVI of the Social Security Act. It is admin…

126-355. Application Procedures. A. Any individual or family who is determined eligible for financial assistance under the Aid to Families with Dependent Children, Optional State Supplementation, Refugee Assistance, or Supple- mental Security Income programs is eligible for Medic…

126-360. General Requirements. A. Medical assistance is available to residents of this State who meet the eligibility requirements of this chapter and who are United States citizens or who are aliens lawfully admitted for permanent residence or otherwise permanently residing in t…

126-365. Categorically Needy Eligible Groups. A. Medicaid eligible persons through the Aid to Families With Dependent Children (AFDC) program are: (1) All persons in the AFDC budget group. (2) All children for whom the State makes an adoption assistance or foster care maintenance…

126-370. Redetermination of Categorically Needy Eligibility. Eligibility for continued benefits shall be redetermined at least every 12 months.

126-375. Medical Institution Vendor Payments A. Vendor payments are made on behalf of eligible individuals to medical institutions in accordance with Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith. B. An individual must meet a…

126-380. Denial, Termination, or Reduction of Benefits. A. When an individual’s Medicaid benefits are denied, discontinued or changed, the individual shall receive notice pursuant to Title XIX of the Social Security Act. The notice shall include an explanation of the individual’s…

126-399. Conflict Between State and Federal Regulations. When the requirements of the State and the Federal regulations are not in agreement, the requirements of the Federal regulations shall prevail. ARTICLE 4 PROGRAM EVALUATION SUBARTICLE 1 ADMINISTRATIVE SANCTIONS AGAINST MEDI…

126-400. Definitions. A. Provider - means an individual, firm, corporation, association or institution which is providing, or has been approved to provide, medical assistance to a beneficiary pursuant to the State Medical Assistance Plan and in accord with Title XIX of the Social…

126-401. Sanctions. A. The Administrator of the Title XIX Single State Agency may invoke one (1) or more of the following administrative sanctions against a Medicaid provider who has been determined to have abused the Medicaid Program: (1) Educational Intervention; (2) Postpaymen…

126-402. Factors for Sanction. The factors to be considered in determining sanctions shall include, but not be limited to, the following: A. Seriousness of the offense(s); B. Extent of violation(s); C. History of prior violation(s); D. Prior imposition of sanction(s); E. Provider…

126-403. Grounds for Sanction. The grounds for sanctioning providers shall include, but not be limited to, the following: A. Presenting or causing to be presented for payment any false or fraudulent claim for services or merchandise. B. Submitting or causing to be submitted false…

126-404. Fair Hearings. A. Any Medicaid provider who has been notified in writing by the Single State Agency of a proposed recoupment of overpayments, a proposed exclusion, suspension or termination due to an administrative determination of abuse, or a proposed exclusion, suspens…

126-405. Reinstatement. An individual or entity who has been excluded from Medicaid may be reinstated only by the Medicaid agency that imposed the exclusion. An individual or entity may submit to the State agency a request for reinstatement at any time after the date specified in…

126-425. Beneficiary Utilization. A. Definitions. (1) The Division of Program Integrity of the South Carolina Department of Health and Human Services (DHHS) is designed to safeguard against unnecessary, harmful, wasteful, and uncoordinated utilization of services by Medicaid elig…

126-500. Definitions. A. ‘‘Department’’ means the South Carolina Department of Health and Human Services. B. ‘‘County resident’’ means an individual who is a state resident and who lives in a particular county. For the purpose of determining eligibility for the MIAP, an individua…

126-505. Responsibilities for Eligibility Determination. A. The Department shall develop uniform criteria and materials for statewide use. A detailed description of the criteria, procedures, and materials which include an application form and letter of notification may be found i…

126-510. Application Process. When it is determined that an individual needs hospitalization and that he may qualify for assistance through the MIAP, the procedures stated below shall be followed. A. For nonemergency admissions, the patient shall be referred to the designee in th…

126-515. Non-Financial Eligibility Requirements. In order to be eligible for assistance from the MIAP, an individual must meet the following non- financial eligibility criteria. A. Residence. The individual shall be a resident of the State. A migrant or seasonal farm worker shall…

126-520. Financial Eligibility Requirements. The following elements are considered in determining eligibility for assistance through the MIAP. A. Family Composition. For details, refer to the definition of family at 126-500(D). If the applicant is a minor child, his stepparent is…

126-530. Services Covered by the Medically Indigent Assistance Program. A. Except as otherwise provided in this section, only inpatient hospital services which are covered by the South Carolina Medicaid Program as inpatient hospital services shall be covered by the MIAP. B. Psych…

126-535. Sponsorship From the Medically Indigent Assistance Program. A. Payments shall be made only to general hospitals. B. Individuals shall not be sponsored by the MIAP until all other means of reimbursement or service provision have been exhausted. This includes payments from…

126-540. Recovery by the Medically Indigent Assistance Program. A. The MIAP shall be reimbursed if an individual or the services delivered to that individual are later determined to be ineligible for coverage. B. The ineligible person or the person for whom ineligible services ar…

126-560. The Department shall use a prospective payment system which considers diagnostic related groupings and per diem costs to reimburse hospitals for inpatient services provided to Medically Indigent beneficiaries. A. The method for processing and payment of claims shall be a…

126-570. Grace Period. County Assessments shall be paid in accordance with the provisions of 44-6-146(C) of the 1976 Code, as amended. The grace period referred to in this section shall be ten (10) working days from the date the assessment was originally due. The assessment must …

126-800. Definitions. A. Administrator of the State Medicaid Agency means the Executive Director of South Carolina Department of Health and Human Services. B. Annual Standard Survey means an annual standard survey conducted on each nursing facility, without prior notice to the fa…

126-810. Imposition of Sanctions. The Administrator, or his designee, of the State Medicaid Agency may apply one or more of the following sanctions against a Medicaid nursing facility which has failed to correct deficiencies or make acceptable progress toward correction of defici…

126-820. Factors for Sanctions. The factors to be considered in determining sanctions shall include, but are not limited to, the following: A. Seriousness of the deficiencies involves a determination of whether the deficiencies have a direct or indirect relationship to resident h…

126-830. Assessment of Sanctions. The Administrator, or his designee, of the State Medicaid Agency may impose penalties in accordance with Section 126-840, Schedule of Sanctions of these regulations. Civil monetary penalties under each class shall be assessed based on an amount p…

126-840. Schedule of Sanctions. CLASS I DEFICIENCY: A. Violation of requirements which present an indirect relationship to resident health, safety or welfare, and which does not create a substantial and/or immediate risk to health and safety. B. Remedies/Sanctions: 1. Deny paymen…