Communications

Public Notices

Public Notice of Final Action for Professional Service Fee Schedules

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action regarding reimbursement methodologies and rates for certain services provided under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/30/2020 - 4:01pm

Public Notice of Final Action for Medicaid Coverage of Contraceptives

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action to allow coverage for a 12-month supply of systemic contraceptives through Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/29/2020 - 11:50am

Public Notice of Final Action for Early Intervention/Family Training Services Program Rate Increase

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payments for the Early Intervention/Family Training Services Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/10/2020 - 10:44am

Public Notice of Proposed Action for Medicaid Coverage of Contraceptives

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed action to allow coverage for a 12-month supply of systemic contraceptives through Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/28/2020 - 10:27am

Final Action for the Introduction of Therapeutic Foster Care for Child Medicaid Beneficiaries

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action regarding the introduction of a therapeutic foster care (TFC) benefit for child Medicaid beneficiaries under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/28/2020 - 10:19am

Public Notice of Final Action for Covered Outpatient Drug Reimbursement Methodology Update

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following actions regarding reimbursement methodology for covered outpatient drugs (COD) purchased through the pharmacy program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/14/2020 - 1:26pm

Public Notice of Final Action for the Supplemental Teaching Physician (STP) Payment Program

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payments for the Supplemental Teaching Physician (STP) Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 03/30/2020 - 11:12am

Public Notice of Proposed Action for the Supplemental Teaching Physician (STP) Payment Program

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed action regarding its methods and standards for setting payments for the Supplemental Teaching Physician (STP) Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 02/28/2020 - 2:20pm

Amendment for the Community Choices Waiver and Waiver Specific Transition Plan

South Carolina Department of Health and Human Services (SCDHHS) intends to file an amendment with the Centers for Medicare and Medicaid Services (CMS) for the Community Choices (SC.0405) Home and Community-Based Services (HCBS) waiver operated through the Community Long Term Care (CLTC) program. The approved effective date of the existing waiver is July 1, 2016.
Post date: 02/21/2020 - 1:29pm

Palmetto Coordinated System of Care 1915(b)/(c) Waiver Applications

The South Carolina Department of Health and Human Services (SCDHHS) gives notice that an 1915(c) application for the Palmetto Coordinated System of Care (PCSC) waiver will be submitted to the Centers of Medicaid and Medicare (CMS).
Post date: 02/06/2020 - 3:37pm

State Community Engagement Implementation Task Force

The purpose of this task force is to coordinate the efforts of those agencies and entities necessary to implement the Healthy Connections Community Engagement Initiative, as outlined in Executive Order 2019-39, which was issued on Dec. 12, 2019.
Post date: 01/30/2020 - 8:54am

Final Action for FFY 2020 DSH Payments, Inpatient/Outpatient Hospital Rates, Swing Bed Hospital and Administrative Day Rates and South Carolina Department of Mental Health Long-Term Psychiatric Hospital Rates

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following actions regarding its methods and standards for establishing Medicaid Disproportionate Share Hospital (DSH) payments to qualifying DSH hospitals, for potentially increasing inpatient hospital per discharge rates and outpatient hospital multipliers, for updating the
Post date: 01/13/2020 - 11:29am

Final Action for the Essential Public Safety Net Nursing Facility Payment Program

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payments for the Essential Public Safety Net (EPSN) Nursing Facility Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 12/31/2019 - 12:42pm

Final Action for the Home-Based Private Duty Nursing Services Program

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payments for the Home-Based Private Duty Nursing Services Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 12/31/2019 - 12:30pm

Final Action for the Reintroduction of Podiatry Benefits for Adult Medicaid Beneficiaries

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following  action regarding the reintroduction of podiatry benefits for adult Medicaid beneficiaries under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 12/31/2019 - 12:10pm

Proposed Action for FFY 2020 DSH Payments, Inpatient/Outpatient Hospital Rates, Swing Bed Hospital and Administrative Day Rates and South Carolina Department of Mental Health Long-Term Psychiatric Hospital Rates

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed actions regarding its methods and standards for establishing Medicaid Disproportionate Share Hospital (DSH) payments to qualifying DSH hospitals, for potentially increasing inpatient hospital per discharge rates and outpatient hospital multipliers, for upd
Post date: 11/27/2019 - 4:02pm

Proposed Action for the Home-Based Private Duty Nursing Services Program

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed action regarding its methods and standards for setting payments for the Home-Based Private Duty Nursing Services Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).Effective for services provided o
Post date: 11/27/2019 - 12:15pm

Proposed Action for the Reintroduction of Podiatry Benefits for Adult Medicaid Beneficiaries

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed actions regarding the reintroduction of podiatry benefits for adult Medicaid beneficiaries under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 11/27/2019 - 11:58am

Proposed Action for the Essential Public Safety Net Nursing Facility Payment Program

The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed action regarding its methods and standards for setting payments for the Essential Public Safety Net (EPSN) Nursing Facility Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 11/27/2019 - 11:47am

Revised South Carolina Home and Community-Based Services Statewide Transition Plan

The South Carolina Department of Health and Human Services (SCDHHS) gives notice that the revised South Carolina Home and Community-Based Services (HCBS) Statewide Transition Plan, required per Centers for Medicare and Medicaid Services (CMS) HCBS Rule (42 CFR 441.301(c)(6)), was submitted to CMS for review. It will become effective upon CMS approval.
Post date: 10/14/2019 - 4:00pm

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Healthy Connections Medicaid Member Newsletters

Latest Press Releases RSS icon

Jul 7, 2020

The South Carolina Department of Health and Human Services (SCDHHS) announced it will immediately begin accepting applications for a new limited-benefit Medicaid coverage group to provide reimbursement for coronavirus disease 2019 (COVID-19) testing for those without healthcare coverage. SCDHHS’ COVID-19 Limited Benefit Program was authorized by the Families First Coronavirus Response Act (FFCRA) and will provide additional financial support to increase access to testing, a critical component of the state’s response to addressing the pandemic, for South Carolinians without other sources of healthcare coverage.

Mar 31, 2017

Governor Henry McMaster today announced Christian L. Soura’s resignation as Director of the South Carolina Department of Health and Human Services, effective April 7, 2017.

Jun 2, 2016

South Carolina Birth Outcomes Initiative Wins National Award for Innovative Strategies to Improve Health of Moms and Babies

Feb 23, 2016

Beginning April 1, the South Carolina Department of Health and Human Services (SCDHHS) will require that providers verify Medicaid members' controlled substance prescription history before issuing prescriptions for opioids

Reports / Statistics

The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and wasteful practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is critical because of the need to assure that public resources are properly managed.

Read Full Report

Posted: 04/09/2020 - 3:05pm

The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and wasteful practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is critical because of the need to assure that public resources are properly managed.

Download Full Presentation

Posted: 03/21/2019 - 4:13pm

The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General's Office for fraud and the recovery of funds lost due to fraud, waste and abuse.

 

Download Full Presentation

Posted: 04/01/2018 - 4:22pm

The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General's Office for fraud and the recovery of funds lost due to fraud, waste and abuse. 

Download Full Report

Posted: 04/01/2017 - 2:44pm

Submitted April 1, 2016

The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General’s Office for fraud and the recovery of funds lost due to fraud, waste and abuse.

The National Health Care Anti-Fraud Association estimates that financial losses due to health care fraud are in the tens of billions of dollars each year. Other estimates by government and law enforcement agencies such as the FBI place the loss due to health care fraud as high as 10 percent of annual health care expenditures. Federal regulations define fraud as “intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.” (42CFR 455.2) Medicaid fraud is a criminal matter. Waste, improper claims, billing errors, and abuse also cause losses of Medicaid funds but are not criminal actions.

SCDHHS receives fraud “tips” from its fraud hotline and also conducts extensive data mining to identify potential fraud cases. Federal regulations require SCDHHS to conduct a preliminary investigation upon suspicion of fraud and then refer the cases to the Medicaid Fraud Control Unit (MFCU) in the SC Attorney General’s Office. Cases are also referred to the MFCU from other sources, such as the FBI, the federal Office of Inspector General, other state agencies, and the MFCU’s own fraud hotline. SCDHHS’ Division of Program Integrity conducts these preliminary investigations and collaborates with the MFCU on all fraud cases. Fraud cases can take several years before final adjudication and the collection of any penalties or claim refunds by SCDHHS.

The MFCU also participates in national global cases that arise in connection with a U.S. Department of Justice investigation. Those cases oftentimes involve manipulation of wholesale drug prices by pharmaceutical companies to increase Medicaid payments. While considered fraud cases, they are prosecuted as civil cases as opposed to criminal cases. In calendar year 2015 thirteen (13) settlements resulted from cases originating out of the National Association of Medicaid Fraud Control Unit (NAMFCU) actions resulting in recoveries of $6,606,395.75.

The following table illustrates Medicaid provider fraud cases that were opened during calendar year 2015 and reflects the number of settlements and convictions that occurred during calendar year 2015.  The percent of fraud cases referred by SCDHHS was 27%. Total 2015 calendar year recoveries were $11,866,071.32. Federal laws and regulations require the return of the federal share of Medicaid funds recovered. Approximately 68% of the recovered amount must be returned to the federal government. SCDHHS can retain the state share (approximately 32%) of the recoveries and re-use the funds to again match federal monies for the on-going operation of the Medicaid program.

FRAUD CASES 2015
Provider Fraud Cases
New Provider Fraud Cases Opened * 94                   
Active * 54
Closed * 40
Number / % Referred by SCDHHS # 21 / 27%
Results
Recovered as a result of Provider Fraud Convictions/Referrals1 $467,695.24
Recoveries from all other PI cases1,2 $4,791,980.33
Convictions 12
National Association of Medicaid Fraud Control Units (NAMFCU)
# Of Cases Settled 13
Amounts Recovered1 $6,606,395.75

 

1.     All dollars shown are combined federal and state. Some of the recoveries in 2015 are from cases opened in prior year(s).

2.     Program Integrity recoveries due to cases for waste, overpayments, improper payments, and abuse that were not referred for potential fraud.

*      Includes Globals

#     Does Not Include Globals

 

Print Version

Posted: 04/01/2016 - 12:02pm

Submitted April 1, 2015

The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General's Office for fraud and the recovery of funds lost due to fraud, waste and abuse.

The National Health Care Anti-Fraud Association estimates that financial losses due to health care fraud are in the tens of billions of dollars each year. Other estimates by government and law enforcement agencies such as the FBI place the loss due to health care fraud as high as 10 percent of annual health care expenditures. Federal regulations define fraud as ¡§intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.¡¨ (42CFR 455.2) Medicaid fraud is a criminal matter. Waste, improper claims, billing errors, and abuse also cause losses of Medicaid funds but are not criminal actions.

SCDHHS receives fraud ¡§tips¡¨ from its fraud hotline and also conducts extensive data mining to identify potential fraud cases. Federal regulations require SCDHHS to conduct a preliminary investigation upon suspicion of fraud and then refer the cases to the Medicaid Fraud Control Unit (MFCU) in the SC Attorney General¡¦s Office. Cases are also referred to the MFCU from other sources, such as the FBI, the federal Office of Inspector General, other state agencies, and the MFCU¡¦s own fraud hotline. SCDHHS¡¦ Division of Program Integrity conducts these preliminary investigations and collaborates with the MFCU on all fraud cases. Fraud cases can take several years before final adjudication and the collection of any penalties or claim refunds by SCDHHS. In general, healthcare fraud involves filing a false claim for Medicaid payments, which can include services that were never provided, or were provided but were not medically necessary. The MFCU also participates in national cases against pharmaceutical companies that manipulate wholesale prices on drugs to get more money from Medicaid. While these are also considered fraud cases, they are prosecuted as civil cases as opposed to criminal cases.

The following table reports Medicaid provider fraud cases that were opened during calendar year 2014 updated for the most current data available through December 31, 2014; the amounts recovered by the Attorney General¡¦s Office and Program Integrity and the number of convictions for the same time frame; and the number of recoveries from civil settlements in the national pharmaceutical cases. The federal share of the Medicaid funds recovered (approximately 68%) must be returned; SCDHHS can retain the state share of these recoveries and use it to again match federal monies for the on-going operation of the Medicaid program.

The total number of on-going cases for Medicaid provider fraud at the Attorney General¡¦s totaled 136, to include pharmaceutical cases, as of December 31, 2014; 79 of these cases were referred by SCDHHS. This includes cases that were opened in previous years (and therefore not counted in the table below) but are still on-going as of the January 16, 2015, based on the Provider Case List provided by the Attorney General¡¦s Office.

FRAUD CASES 2014
Provider Fraud Cases
New Provider Fraud Cases Opened * 78
Active * 38
Closed * 40
  Number / % Referred by SCDHHS # 24 / 30.77 %
Results
Recovered as a result of Provider Fraud Convictions/Referrals (1) $246,512.64
Recoveries from all other PI cases (2) $4,382,490.82
Convictions 11
Pharmaceutical Manufacturer Cases
# Of Cases Settled 18
Amounts Recovered (3) $21,524,869.91

 

  1. All dollars shown are federal and state; the state share is approximately 32%. Some of the recoveries in 2014 are from cases opened in prior year(s).
  2. Program Integrity recoveries due to cases for waste, overpayments, improper payments, and abuse that were not referred for potential fraud.
  3. 58% of the recoveries from global pharmaceutical manufacturer cases are state funds.

 

* Includes Pharmaceuticals # Does Not Include Pharmaceuticals

 

Print Version

Posted: 04/01/2015 - 10:56am

SCDHHS Budget Presentation
February 3, 2015

Download Full Presentation

Posted: 02/04/2015 - 9:30am

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