Within certain limits, Medicaid will pay for services that are medically necessary. In
addition, some services are limited to a certain number during the state fiscal
year. (The state fiscal year runs from July 1 through June 30 of the
following year.)
Medicaid can pay for the following medical services:
- Inpatient Hospital Services - Medicaid will pay for inpatient hospital
care. Medicaid will pay for semi-private room only, unless it is
medically necessary to have a private room.
- Outpatient Hospital Services - Medicaid will pay for outpatient
hospital visits and emergency room visits.
- *Physicians' Services - Medicaid will pay for physicians' services.
Medicaid can also pay the services of a certified nurse midwife who
is employed by a physician or hospital. Physician services are not
limited for individuals who are under age 21 or who have Part B
Medicare benefits.
- Inpatient Physician Visits - Medicaid will also pay for a physician to
visit patients in the hospital. If the patient has to be seen by more
than one physician while in the hospital, Medicaid also pays for those
visits.
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Program - This program provides free medical check-ups for all
Medicaid eligible children (under the age of 21) and treatment for
medical problems. It is designed to be a preventive program.
-
Vision Care - The vision care program will pay for one vision test during any 12-month period of time. This program will also pay for eyeglasses for children under age 21 (only one (1) pair of glasses. Repairs and replacements during the year are not authorized. Medicaid will only pay for glasses for people age 21 and over who have had certain types of eye surgery. The Medicaid Program must approve Medicaid payment for all lenses, frames, and repairs in advance.
- Dental Services - For people under the age 21, Medicaid can pay for
dental check-ups and other dental services through the EPSDT
program. For people age 21 and over, Medicaid will pay for
emergency dental services only.
- *Rural Health Clinic Services - Health care services
furnished by Rural Health Clinics are cost based reimbursed through encounter codes using an all inclusive rate that reflects the cost of the services(up to the year's Medicaid CAP).
- Federally Qualified Health Center (FQHC) - Services are cost based reimbursed. Core services are reimbursed using encounter codes.
- Family Planning Services - This program pays for counseling,
diagnosis, treatment, and birth control drugs and supplies prescribed
or furnished by a physician.
- Laboratory and X-ray - Medicaid can pay for medically necessary
laboratory tests and X-ray services ordered by a physician.
- Durable Medical Equipment and Supplies - Durable medical equipment is equipment that provides therapeutic benefits or enables a recipient to perform certain tasks that he or she would be unable to undertake otherwise due to certain medical conditions and/or illnesses. Durable medical equipment is equipment that can withstand repeated use and is primarily and customarily used for medical reasons and is appropriate and suitable for use in the home. These may include medical supply products, surgical supplies, equipment such as wheelchairs, traction equipment, walkers, canes, crutches, ventilators, prosthetic and orthotic devices, oxygen, enternal and parenteral nutrients and other medically needed items when ordered by a physician as medically necessary in the treatment of a specific medical condition. The attending physician, physician assistant and/or nurse practitioner with prescriptive authority has the responsibility of determining the type or model of equipment needed and length of time the equipment is needed through a written necessity statement. Approval for Medicaid coverage of products requiring prior authorization is patient-specific and is determined according to certain established criteria. Luxury and deluxe models are restricted if standard models would be appropriate. Repairs to medical equipment are covered if reasonable.
- Pharmacy Services - Pharmacy Services provides needed pharmaceuticals for the purpose of saving lives in emergency situations or during short-term illness, to sustain life in chronic or long term illness, or to limit the need for hospitalization. Covered pharmacy services include the provision of most prescription drugs (brand name and generic) as well as over-the-counter drugs. Only rebated pharmaceuticals that are Food and Drug Administration (FDA) approved may be considered for reimbursement. For each medication dispensed (including OTCs), a valid prescription authorized by a licensed practitioner must be on file. Eligible beneficiaries from birth to their 21st birthday are allowed unlimited prescriptions per month. For beneficiaries over the age of 21, the traditional fee-for-service Medicaid program reimburses for a maximun of four prescriptions per month. For adult beneficiaries needing more than four prescriptions per month, a prescription limit override process is available if the prescription meets certain specified criteria. Some medications (and/or quantities) require prior authorization (PA), meaning that coverage is determined through a clincal PA process. Approval for Medicaid coverage of products requiring prior authorization is patient-specific and is determined according to established criteria. Medicaid reimburses for a maximum one-month supply of medication per prescription or refill. SCDHHS defines a one-month supply as a maximum 34-day supply per prescription for non-controlled substances. Controlled Substance Acts may further limit the maximum to a 31-day supply.
- Ambulance Transportation - Medicaid can pay for ambulance
transportation only if a patient cannot be moved any other way.
- Medical Transportation - Medicaid can pay for a van or a volunteer
driver to take patients to medical appointments if the medical
services to be received are covered by Medicaid. Medicaid will only
pay for this type of transportation when it is approved and arranged
in advance by the County Department of Social Services.
- *Podiatrists' Services - Medicaid will pay for diagnosis and treatment
of foot conditions not associated with routine foot care.
- Skilled Nursing Facility Services - The need for skilled nursing care in
a Community Long Term Care must approve nursing home.
- Intermediate Care Facility Services - The need for intermediate care in
a nursing home must be approved by Community Long Term Care.
- Home Health Services - These services are provided at the patient's
home, on doctor's orders, to people who are unable to leave their
homes due to illness or disability. These services include skilled
nursing, home health aides, and physical therapy. Medicaid will only
pay for 75 home health visits per year. Individuals who have Part A
Medicare benefits are not limited to 75 visits per year.
- Therapy - Therapy can be provided in the following situations as
ordered by a physician:
- In a nursing home (payment is included in the Medicaid payment
to the nursing home, inpatient only);
- As a Home Health Service;
- As an inpatient in a hospital, which has a certified therapy
department, and therapy may be continued at the hospital as an
outpatient if ordered by the doctor;
- *By an independent therapist for individuals under age 21;
- When prior approved by a sponsoring agency such as the Department of Education, Department of Health and
Environmental Control, etc.
- Inpatient Hospital Services for Individuals Under Age 21 - The need
for this care must be medically documented and, in some cases, the
need for care must be prior approved.
- Services for Individuals Age 65 or Older in Institutions for Mental
Diseases - Medicaid coverage is limited to long-term care (nursing
facility services) provided to individuals age 65 and older in
institutions for mental diseases.
- Mental Health Clinic Services - Many outpatient mental health clinic
services are covered, including counseling to people who are
emotionally or mentally disturbed, drug or alcohol abusers and some
mentally retarded people.
- Case Management - This service is available to non-institutionalized
mentally retarded individuals, emotionally disturbed children, certain
pregnant women and other targeted groups. Case Management
services are defined as those services necessary to coordinate an
optimum life style for the targeted population. The services include:
- Monitoring the patient's needs, and
- referral process to provider's for medical, educational, legal and
- rehabilitative services, with documented follow-up.
Case Management will assist in self-sufficiency of patient and act as
a deterrent to institutional care by facilitating service delivery. No
counseling services will be delivered by the case manager.
- Family Support Services - This service is only available to Medicaid
recipients who have serious medical conditions and/or social factors
that make an adverse impact on their health. Family Support
services include brief or in-depth assessments, service planning,
patient monitoring and education. These services are generally time
limited.
- Home and Community-Based Services - In addition to the services
already listed, individuals who are enrolled in home and community-
based waivers may receive special "waivered" services. These
special services are made available to these individuals in an effort to
help them remain in the community.
- Hospice Services - This service is available to recipients who choose
to elect the benefit and who have been certified to be terminally ill
with a life expectancy of six months or less by their attending
physician and/ or the Medical Director of the hospice. Hospice
services are provided to the recipient according to a plan of care
developed by the hospice.
- Rehabilitative Therapy Services for Individuals with Special Needs -
These services are available to recipients under the age of 21 with
special needs (e.g. sensory impairments, mental retardation, physical
disabilities, developmental disabilities and delays, etc.) and to
recipients of any age enrolled in the Mental Retardation/Related
Disabilities Waiver and the Head and Spinal Cord Injury Waiver. For
services to be covered, the recipient must have an Individualized
Family Service Plan (IFSP), an Individualized Education Plan (IEP) or a
valid treatment plan; and, be referred by one of the following state
agencies: the South Carolina Department of Disabilities and Special
Needs, the Department of Health and Environmental Control, the
South Carolina School for the Deaf and the Blind, or a local Education
Agency (School District). Certain services are subject to frequency
limits.
*limited to a combined total of twelve (12) visits per year.
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