Deemed Baby Process and Assumptive Eligibility for Pregnant Women

PROVIDER ALERT

As part of the South Carolina Department of Health and Human Services' (SCDHHS) ongoing transition to its new eligibility system, we want to provide you with a progress update regarding pregnant women applications and deemed babies. SCDHHS continues to make system improvements to expedite these processes while working through deemed baby and pregnant women eligibility determinations. SCDHHS appreciates your continued patience and asks that you please continue to provide services to these individuals.

Deemed Babies

As a reminder, if a child is born to a Medicaid-eligible mother and eligibility has been verified for the mother, then the child will be deemed eligible for Healthy Connections Medicaid as a result of the mother's eligibility. This includes mothers who are eligible for Emergency Services only. A deemed baby remains eligible for an entire year of Medicaid coverage.

If the mother is enrolled in a Healthy Connections Managed Care Organization (MCO) health plan at the time of the child's birth, in most cases, the newborn will be enrolled in the same MCO health plan. Even if the newborn is not enrolled in the same health plan as the mother, the infant remains Medicaid eligible for a full year as a deemed baby.

SCDHHS encourages all providers to continue providing medically-necessary services to newborns, prior to obtaining their Medicaid identification numbers in cases where the mother is currently Medicaid eligible. Billing for these procedures can be held until such time as the newborn's identification is obtained. Billing for well-child visits prior to obtaining the newborn's identification can be billed as follows:

  • For Fee for Service Claims: Claims may be billed under the mother's Healthy Connections Medicaid identification number
  • For MCO Claims: Claims must be billed under the newborn's Healthy Connections Medicaid identification number

 

Pregnant Women

South Carolina provides assumptive eligibility to pregnant women. The applicant is provided eligibility based on self-reported information regarding citizenship, residency, the pregnancy, and income. SCDHHS encourages all providers to provide medically-necessary services to assumptively-eligible pregnant women prior to obtaining their final Medicaid eligibility determination. If additional clarification regarding the eligibility criteria for pregnant women is required, please contact the Provider Service Center at (888) 289-0709.

SCDHHS will provide another update on our progress within 60 days. In the meantime, if you have any questions, please contact the Provider Service Center at (888) 289-0709.

Thank you for your patience and continued support as SCDHHS works to improve the Medicaid process for the Healthy Connections members and providers.

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