South Carolina Code of Regulations Chapter 126 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
South Carolina Code of Regulations Chapter 126 is dedicated to the South Carolina Department of Health and Human Services (SCDHHS). This chapter contains the comprehensive administrative rules and regulations that govern the state's primary agency responsible for administering the Medicaid program and related health and human services.
Overall Purpose of South Carolina Code of Regulations Chapter 126:
The overarching purpose of Chapter 126 is to provide the detailed regulatory framework for SCDHHS to fulfill its mission: "To purchase the most health for our citizens in need at the least possible cost to the taxpayer." This involves:
Administering Medicaid (Healthy Connections): This is the core function. The regulations ensure the effective and efficient operation of South Carolina's Medicaid program, which provides health coverage for eligible low-income, disabled, and elderly individuals.
Ensuring Access to Healthcare: Setting rules for eligibility, covered services, and provider participation to ensure that eligible South Carolinians have access to medically necessary care.
Fiscal Accountability: Establishing rules for provider reimbursement, cost controls, and prevention of fraud and abuse within the Medicaid program.
Consumer Protection: Outlining appeal procedures and ensuring non-discrimination in program administration.
Implementing Federal and State Laws: Translating the broad mandates of Title XIX of the Social Security Act (Medicaid) and other state laws into specific, enforceable regulations.
Key Areas and Articles within Chapter 126:
Chapter 126 is organized into several key articles, each addressing a critical component of SCDHHS's operations:
Article 1 - Administration:
General Provisions: Includes broad statements on non-discrimination (based on race, color, national origin, handicap, or age) and the overall administration of programs in accordance with federal civil rights acts.
Appeal Procedures: Details the process for individuals or providers to appeal agency actions or decisions. This includes timelines for filing appeals, the role of a Hearing Officer, and procedures for formal hearings.
Protected Information: Defines what constitutes protected information (e.g., financial eligibility, medical data) and sets strict rules for its use and disclosure, primarily for purposes directly connected to program administration, research, and audits.
Provider Manuals and Bulletins: These regulations often refer to and incorporate provider manuals and Medicaid Bulletins, which provide more detailed instructions for healthcare providers on billing, claims, and program requirements.
Article 3 - Medicaid (Healthy Connections): This is the most extensive and crucial part of the chapter, providing detailed rules for the Medicaid program:
Scope of the Program: Defines who is eligible for Medicaid (e.g., children, pregnant women, parents/caretaker relatives, people over 65, people with disabilities, breast and cervical cancer patients) and general conditions for receiving services.
Covered Services: Lists the specific services covered by the Medicaid program. This can include:
Audiology Services
Certified Nurse Midwifery Services
Community Long Term Care Home and Community-Based Services
Dental Care
Durable Medical Equipment
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (for children)
End Stage Renal Disease Services
Family Planning Services
Hospital Services (inpatient and outpatient)
Laboratory and X-ray Services
Medical Transportation Services
Mental Health Clinic Services
Nursing Facility Services
Physicians' Services
Podiatry Services
Prescribed Drugs
Psychiatric Facility Services
Rehabilitative Services
Rural Health Clinic Services
Speech Pathology
Tubercular Facility Services
Vision Care
Reimbursement Rules: Specifies how various providers (e.g., hospitals, nursing facilities) are reimbursed for services provided to Medicaid recipients. This may include methodologies like prospective payment systems.
Article 4 - Program Evaluation / Administrative Sanctions for Medicaid Providers:
Definitions and Sanctions: Defines terms related to provider conduct and outlines various sanctions that can be imposed on Medicaid providers for violations (e.g., suspension, termination from the program, fines).
Grounds for Sanction: Specifies reasons for imposing sanctions, such as fraud, abuse, non-compliance with regulations, or providing substandard care.
Fair Hearings: Guarantees due process for providers facing sanctions, including the right to a fair hearing.
Article 5 - Medically Indigent Assistance Program (MIAP):
Eligibility and Covered Services: Rules for a state-funded program that provides limited medical assistance to individuals who are medically indigent but may not qualify for full Medicaid.
Payment Process: How hospitals and other providers are reimbursed for services provided under MIAP.
County Assessments: Rules related to funding contributions from counties for the MIAP.
Article 7 - Social Services Block Grants [Deleted]: This article previously covered rules for Social Services Block Grants but has since been deleted or replaced, indicating a change in administrative structure or program delivery.
Article 8 - Intermediate Sanctions for Medicaid Certified Nursing Facilities:
Specific regulations outlining the types of intermediate sanctions (less severe than termination from the program) that can be imposed on nursing facilities that are not in full compliance with Medicaid requirements, aimed at ensuring quality of care.
Article 9 - Optional State Supplementation Program:
Rules for a state-funded program that provides supplemental cash assistance to certain aged, blind, or disabled individuals in residential care facilities, beyond what federal Supplemental Security Income (SSI) provides.
In summary, South Carolina Code of Regulations Chapter 126 provides the vital, granular detail necessary for the South Carolina Department of Health and Human Services to manage the complex Medicaid program and associated health assistance programs, ensuring that healthcare services are delivered efficiently, accountably, and in a manner that protects the state's vulnerable populations.
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