Managed Care

Managed Care

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.

EPSDT Pediatric Screening Tools

The South Carolina Department of Health and Human Services (SCDHHS) is clarifying the use of developmental and behavioral health pediatric screening tools and providing guidance on the utilization of these tools.  Best practice indicates that standardized screenings of this type are recommended to be done during the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) visits or as dictated by clinical need.  This  is in alignment with the American Academy of Pediatrics (AAP) recommendations regarding screening and age appropriate development and mental health of children and adolescen

Coverage of Hydroxyprogesterone Injection

On December 20, 2013, the South Carolina Department of Health and Human Services (SCDHHS) issued Medicaid Bulletin 13-047 regarding hydroxyprogesterone caproate.  On July 3, 2014, the Food and Drug Administration issued updated guidance in regards to hydroxyprogesterone caproate.  In the new guidance, the FDA provided that its March 2011 statement related to hydroxyprogesterone caproate was superseded by its June 2012 statements in which the FDA “recommended using an FDA-approved drug product, such as Makena, instead of a compounded drug except when there is a specific medical need (e.g.

Deemed Baby Process and Assumptive Eligibility for Pregnant Women

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

2015 Medicare Deductible, Coinsurance and Medicaid Blood Deductible Rates for Dual-Eligible (Medicaid and Medicare) Members

The South Carolina Department of Health and Human Services (SCDHHS) has updated its reimbursement calculations for Medicare Deductible, Coinsurance and Blood Deductibles to reflect the new 2015 Medicare Rates for Dual-Eligible (Medicaid and Medicare) members.

Deemed Baby Process

The South Carolina Department of Health and Human Services (SCDHHS) implemented a new eligibility system in November. Throughout the launch, SCDHHS worked diligently to ensure the Agency provided timely and accurate eligibility determinations.  

During the system changeover, there was a delay in the completion of final determinations. SCDHHS continues to process applications and aims to be completely in the new system, resuming standard eligibility determination turnaround times, in the next few weeks. 

South Carolina Medicaid Preferred Drug List

The following revisions to the Preferred Drug List (PDL) are effective with dates of service on or after August 1, 2014. 

ANTIHISTAMINES, MINIMALLY SEDATING

Pulse Oximetry Policy

Effective on or after July 1, 2014, the South Carolina Department of Health and Human Services (SCDHHS) will update its policy to recognize the South Carolina Department of Health and Environmental Control (DHEC) Pulse Oximetry Screening test on newborns to detect congenital heart defects.  Pulse oximetry is a noninvasive test that estimates the percentage of hemoglobin in blood that is saturated with oxygen.   

Inpatient Psychiatric Coverage for beneficiaries 65 or older

Effective for services provided on or after July 1, 2014, the South Carolina Department of Health and Human Services (SCDHHS) will allow for coverage of inpatient psychiatric care for beneficiaries of Medicare and Medicaid who are 65 or older.

Psychiatric and Psychotherapy Services section of the Physicians, Laboratories, and Other Medical Professionals Manual

Effective July 1, 2014, the South Carolina Department of Health and Human Services (SCDHHS) has reinstated the Psychiatric and Psychotherapy Services section of the Physicians, Laboratories, and Other Medical Professionals Manual.  This section applies to all physicians, psychiatrists, and psychiatric nurse practitioners providing psychiatric services, as well as allied professionals who may provide psychotherapy services under the supervision of these professionals.

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