Managed Care

Managed Care

Patient Centered Medical Home (PCMH) Incentive Update

The South Carolina Department of Health and Human Services (SCDHHS) is informing all practices currently recognized by the National Committee for Quality Assurance (NCQA) as a patient-centered medical home (PCMH) or who have applied or are considering applying for PCMH certification that the following modifications are being made to its PCMH incentive program, effective July 1, 2017.

Monthly Prescription Limit

Effective with dates of service on or after July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will no longer limit the number of prescriptions available to Medicaid beneficiaries.

If you have any questions regarding this policy, please contact the Provider Service Center at (888) 289-0709.

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

Changes to the Psychiatric Hospital Services Provider Manual Regarding Psychiatric Residential Treatment Facilities (PRTFs)

Effective with dates of service on or after July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will include psychiatric residential treatment facility (PRTF) services and providers in the coordinated care benefit provided by SCDHHS-contracted managed care organizations (MCOs). MCO members will access PRTF services through the MCO they have chosen or to which they have been assigned. Individuals not choosing or not mandatorily assigned to an MCO will continue to access PRTF services through the SCDHHS Medicaid fee-for-service (FFS) benefit.

Modification to Codes that require Filing to TPL

Effective for dates of service on or after July 1, 2017, and as required by 1902(a) (25) of the Social Security Act, the South Carolina Department of Health and Human Services (SCDHHS) will implement cost avoidance rules for the procedure codes reflected below. Service providers will be required to file claims to any liable third-party insurer before submitting a claim to SCDHHS for payment.

Tobacco Cessation Coverage

Effective with dates of service on or after July 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) is enhancing tobacco cessation coverage for full-benefit Medicaid beneficiaries to align with recommendations from the Centers for Disease Control and Prevention (CDC) and the American Lung Association (ALA). This update applies to both the fee-for-service and managed care Medicaid benefits.

The following medications will be available without prior authorization or co-payment when prescribed by a Medicaid provider:

Pediatric Screening (CPT) 96127

Effective Nov. 1, 2016, the South Carolina Department of Health and Human Services (SCDHHS) will limit payment for Current Procedural Terminology (CPT) code 96127 to a maximum of two units per date of service. This is consistent with the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) limit for this service. This bulletin supersedes previous SCDHHS guidance, provided March 31, 2015, indicating that a maximum of four units are payable per date of service for CPT code 96127.

Rescind Physical Medicine and Therapy Policy Update; Medicaid Bulletin #14-001 Released Feb. 6, 2014

Effective immediately the South Carolina Department of Health and Human Services (SCDHHS) is rescinding the policy, bulletin 14-001 released Feb. 6, 2014, that allowed services delivered to recipients 21 years and over in place of service (62) Outpatient Rehabilitation Facility. Beneficiaries will continue to receive outpatient physical, occupational and speech therapies (PT/OT/SP) services in an outpatient hospital, clinic or office setting.

Physician Assistant Enrollment

All licensed Physician Assistants (PAs) providing services to Healthy Connections beneficiaries must be enrolled as providers with the South Carolina Department of Health and Human Services (SCDHHS). PAs providing services to Medicaid Managed Care enrolled members must also be enrolled and credentialed with the member's Managed Care Organization (MCO).

Pursuant to 42 CFR Part 455, Subpart E, all providers who refer or order items or services covered by the Medicaid program must be enrolled as described above.

Pharmacy Co-Payments Waiver

In an effort to improve beneficiary adherence to prescribed courses of medication, the South Carolina Department of Health and Human Services (SCDHHS) will waive the copayment for specified classes of medications effective July 1, 2015. Initially, this copayment waiver will apply to medications for the treatment of diabetes and behavioral health disorders. However, SCDHHS may modify the medications subject to the copayment waiver without further notice. Information regarding which medications are exempt from copayments will be made available on the SCDHHS Preferred Drug List (PDL).

Hepatitis C Virus (HCV) Pharmacy Benefit Carve Out

Effective with dates of service on or after July 1, 2015, the South Carolina Department of Health and Human Services (SCDHHS) will carve out coverage for medications used to treat Hepatitis C Virus (HCV) from the Managed Care Organization (MCO) benefit. Pharmacy claims for these medications for Medicaid members enrolled in a Medicaid Managed Care Organization (MCO) will be covered through the Fee-For-Service (FFS) pharmacy program. All FFS coverage rules, prior authorization requirements and preferred drug classifications will apply.

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