South Carolina Administrative Code

126-125. General. The State Health and Human Services Finance Commission shall administer its programs in accordance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, as amended, to the end that n…

126-150. Definitions. A. Agency—The Department of Health and Human Services and its employees. B. Appeal—The formal process of review and adjudication of Agency determinations, which shall be afforded to any person possessing a right to appeal pursuant to statutory, regulatory an…

126-152. Appeal Procedure. A. An appeal shall be initiated by the filing of a notice of appeal within thirty (30) days of written notice of the Agency action or decision which forms the basis of the appeal. The failure to file the requisite notice of appeal within the thirty (30)…

126-154. Hearing Officer. A Hearing Officer has the authority, among other things to: direct all procedures; issue interlocu- tory orders; schedule hearings and conferences; preside at formal proceedings; rule on procedural and evidentiary issues; require the submission of briefs…

126-156. Prehearing Conferences. The Hearing Officer, within his discretion, may direct the parties in any appeal to meet prior to a formal hearing for the purpose of narrowing the issues and exploring the possibilities of settlement of matters in contest.

126-158. Hearing Procedures. A. All parties to an appeal shall have the right to be represented by counsel, call witnesses, submit documentary evidence, cross-examine the witnesses of an adverse party, and make opening and closing statements. B. Representation in Proceedings. A b…

126-170. General. A. Disclosure of Commission held client information is limited to purposes directly connected to the administration of the Commission’s programs and grants. B. This Subarticle applies to Commission held client information from all programs and grants administere…

126-171. Protected Information. Protected information is of two (2) general types which include but are not limited to the following: A. Information regarding the financial eligibility determination and authorization of payment or benefits: 1. Names and addresses; 2. Social and e…

126-172. Purposes Directly Connected to the Administration of the Programs and Grants. Purposes directly connected to the administration of programs and grants include, but are not limited to: A. Establishing eligibility; B. Determining the amount of payments or other benefits; C…

126-173. Release of Information. A. Access to eligibility information is restricted to persons, agencies, and entities which by their own rules or by contract are subject to confidentiality standards which are comparable to those set forth in this Subarticle. In addition, the inf…

126-174. Distribution of Materials to Recipients and Providers. A. The agency may not distribute any materials to recipients or providers unless the material has no political implications, provides no commercial advantage to any entity, and is directly related to the administrati…

126-175. Penalties. A. The Commission may impose sanctions for violations of the provisions of this Subarticle through its progressive disciplinary procedures for Commission personnel. B. The intent is that violations of this Subarticle may also be subject to penalty provisions i…

126-300. General. A. Clients eligible for Medicaid may obtain medically necessary services from providers enrolled in the program. B. Medicaid recipients who are residents of South Carolina and referred for medical services outside ‘‘South Carolina Medicaid Services Area’’ must r…

126-301. Services Covered by the Medicaid Program. A. Categorically eligible: (1) Audiology services (2) Certified nurse midwifery services (3) Community long term care services (4) Dental Services (5) Durable medical equipment (6) Early and Periodic Screening, Diagnosis and Trea…

126-302. Audiology Services. Audiology services are hearing evaluations and hearing aids for recipients through the month they turn twenty-one years of age.

126-303. Certified Nurse Midwifery Services. Midwifery services are covered when furnished by a certified nurse midwife (CNM) in a clinical practice meeting the education and training requirements set forth in the laws governing nursing in South Carolina pertaining to CNM’s.

126-304. Community Long Term Care Home and Community Based Services. A. Home and community based services may be provided to Medicaid eligible persons eighteen years of age or older, who have been determined by community long term care to require a skilled or intermediate level o…

126-305. Dental Care. Dental Care consists of any covered preventive, surgical, therapeutic and emergency dental service provided by a licensed dentist. Only emergency dental services are available for recipients age twenty- one years and over.

126-306. Durable Medical Equipment. Durable medical equipment consists of orthotic and prosthetic devices, supplies and durable medical equipment when medically necessary.

126-307. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services are available to eligible Medicaid recipients from birth through the month they turn twenty-one years of age. This program cover…

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…