All coverable, medically necessary, services must be provided even if the service is not available under Healthy Connections Medicaid to beneficiaries through the month of their 21st birthday. Additional health care services are available under the federal Medicaid program if they are medically necessary to treat, correct or ameliorate illnesses and conditions discovered regardless of whether the service is covered by the State Plan.
Healthy Connections Medicaid makes the final determination of medical necessity and it is determined on a case-by-case basis. Provider recommendations will be taken in to consideration, but are not the sole determining factor in coverage. Healthy Connections Medicaid determines which treatment it will cover among equally effective, available alternative treatments. All in-state resources should be exhausted before treatment outside of the state is considered.
EPSDT Medical Necessity Does NOT include:
- Experimental or investigational treatments
- Services or items not generally accepted as effective; and/or not within the normal course and duration of treatment
- Services for caregiver or provider convenience.
- Services for which South Carolina Healthy Connections Medicaid has a waiver are also not considered to be State Plan benefits, and therefore are not a benefit under EPSDT.
- Items such as respite, behavioral interventions, in-home support services and home modifications are examples of waiver services.