Physicians Services Provider Manual and Reimbursement Rate Updates

The South Carolina Department of Health and Human Services (SCDHHS) is announcing updates to several policies outlined in its Physicians Services Provider Manual. The agency is also updating physician reimbursement rates. The policy and reimbursement updates discussed in this bulletin are all effective for dates of service on or after July 1, 2024. The Physicians Services Provider Manual is available on SCDHHS’ website and will be updated to reflect these changes by July 1, 2024.

Physician Rate Updates

The physician services reimbursement methodology will be based on the 2024 Medicare physician fee schedule. The Medicaid base rates will apply to the calculations for the advanced practice providers’ rates and the qualifying provider’s enhanced rates, as currently indicated in the Medicaid State Plan. The updated physician rates and advanced practice providers’ rates are published in the Base Physician, Enhanced Physician, Independent Laboratory and Radiology and the Advanced Practice Providers’ respective fee schedules that are available on SCDHHS’ website. These fee schedules will be updated to reflect these changes by July 1, 2024.

Breast Cancer Screening Recommendations Update

SCDHHS will update its breast cancer screening policy to align with the U.S. Preventive Services Task Force’s final recommendation statement on screening for breast cancer. Breast cancer screening will be covered for Healthy Connections Medicaid members once every two years, starting at age 40 and continuing through age 74.

Syphilis Screening During Pregnancy Recommendations Update

SCDHHS will adopt the American College of Obstetricians and Gynecologists’ most recent recommendations for screening serologically for syphilis during pregnancy rather than using a risk-based approach to testing. SCDHHS will cover up to three screenings during each pregnancy. Screenings will be covered with the following frequency:

• At the first prenatal care visit;
• Once during the third trimester; and
• At birth

Ambulatory Care Visits

SCDHHS has evaluated utilization data and state and national trends and will make the current suspension of ambulatory care visit limitations permanent. The previous suspension of the ambulatory care visit limitation was enacted in response to the COVID-19 public health emergency (PHE) via Medicaid bulletin MB# 20-003. A subsequent agency bulletin, MB# 24-010, issued March 21, 2024, announced the extension of the ambulatory care visit limit suspension for one year after the expiration of the federal PHE, in alignment with the Consolidated Appropriations Act of 2023.

Cost-sharing

Effective for dates of service on and after July 1, 2024, all services will be covered without cost-sharing. This policy change removes all requirements for co-payments and applies to all Healthy Connections Medicaid members.

Non-invasive Prenatal Screening (NIPS)

SCDHHS will no longer require prior authorization for NIPS. Updated criteria are detailed in the Physicians Services Provider Manual.

Continuous Glucose Monitoring (CGM)

SCDHHS is expanding its existing coverage for CGM for full-benefit Healthy Connections Medicaid members. This change was announced in MB# 24-036.

CGM will be covered with prior authorization that includes the following criteria:

1. CGM must be prescribed by one of the following qualified healthcare providers:
   1. Primary care provider (a physician, physician assistant or advanced practice registered nurse);
   2. Obstetrician; or
   3. Endocrinologist
2. The Medicaid member must have one of the following clinical criteria:
   1. Type 1 diabetes mellitus;
   2. Gestational diabetes; or,
   3. Type 2 diabetes with one of the following:
      1. Any type of insulin dependency, or,
      2. Non-insulin treated diabetes with recurrent moderate (level 2) or at least one severe (level 3) hypoglycemic event

Reminder of Implementation of a Single Preferred Drug List (PDL)

Providers are reminded that SCDHHS will implement a single, state-directed pharmacy benefit PDL for all providers enrolled in the Healthy Connections Medicaid program effective July 1, 2024. This change was announced in Medicaid bulletin MB# 24-016. The single PDL that will become effective July 1, 2024, will be based on SCDHHS’ current fee- for-service PDL, which is available in the pharmacy section of SCDHHS’ website. Provider resources related to the transition to the single PDL are also available in the pharmacy section of SCDHHS’ website. These resources include a list of frequently asked questions, a recorded training session and continuity of care resources.

South Carolina’s Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the authorizations, coverage and reimbursement related to the services described in this bulletin for Healthy Connections Medicaid members who are enrolled in an MCO.

Providers should direct any questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Callers should select option two when calling the PSC. Providers can also submit an online inquiry at https://www.scdhhs.gov/providers/contact-provider-representative.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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