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  South Carolina Healthy Connections (Medicaid) Program

 

OVERVIEW


WHAT IS HEALTHY CONNECTIONS (MEDICAID)?

Healthy Connections (Medicaid) is South Carolina's grant-in-aid program by which the federal and state governments share the cost of providing medical care for needy persons who have low income. Title XIX of the Social Security Act that was signed into law by the president on July 30, 1965 authorized the program. Congress has continually changed the Medicaid program since it was created and enacted by legislation. South Carolina began participation in the Medicaid program in July 1968.

Because state and federal governments share the cost of the Medicaid program, states are given some flexibility in providing coverage to its needy citizens. For this reason, the rules for Medicaid coverage vary from state to state. An individual who is eligible in South Carolina is not necessarily eligible if he or she moves to North Carolina, Georgia, etc.

ARE (HEALTHY CONNECTIONS) MEDICAID AND MEDICARE THE SAME?

No, Healthy Connections (Medicaid) is a program that pays for health care for needy people of the state. To receive Medicaid benefits, an individual must meet certain non-financial and financial guidelines and categorical requirements.

Medicare is a health insurance program for people age 65 and over or people who have received Social Security disability benefits for 24 months. There is no financial eligibility test for Medicare. Medicare is divided into several parts, including Parts A, B and D. Part A is called hospital insurance. It pays at least part of such care as hospital services, skilled nursing home care, hospice care, etc. Part B is called medical insurance. It pays at least part of such care as doctor's services, X-ray and other radiation therapy, durable medical equipment, outpatient surgery, certain physical and occupational therapy, ambulance services, dialysis, home health services, etc. Part D is called prescription drug coverage. Medicare prescription drug coverage is insurance. Private companies provide coverage through Medicare drug plans. Medicare drug plans will help pay for both brand name and generic drugs you need.

A person can have both Medicaid and Medicare. For a person who has both, Healthy Connections (Medicaid) will pay the monthly Medicare premium and certain services not covered by Medicare. Cost sharing will be paid only for Qualified Medicare Beneficiaries (QMB).



WHO IS ELIGIBLE FOR MEDICAID?

Individuals who meet certain non-financial and financial guidelines and categorical requirements may qualify for Healthy Connections (Medicaid) coverage. States are required to cover certain groups (mandatory groups) and states are given the option of covering other groups (optional groups).

Historically, Medicaid eligibility rules have been closely linked to those of the cash assistance programs such as Family Independence (FI), previously known as Aid to Families with Dependent Children, or the Supplemental Security Income (SSI) program. However, in recent years, Congress has given states more flexibility in establishing policies for the different coverage groups. At the same time, Congress has added more mandatory coverage groups and placed more requirements on some of the services provided.



HOW DOES AN INDIVIDUAL APPLY FOR MEDICAID?

The Department of Health and Human Services (DHHS) determines eligibility for Medicaid. An individual applying for Medicaid as an SSI recipient must apply at their local Social Security office. Generally, an individual who is approved for SSI will automatically receive Medicaid. Applications for all other coverage groups may be filed in person or by mail. Applications may be filed at out-stationed locations such as the county health departments, community health centers, most hospitals and the county Department of Social Service offices.

Persons who are approved for Medicaid receive permanent, plastic Healthy Connections (Medicaid) card. They are instructed to take the card with them when they receive a medical service.

SOUTH CAROLINA MEDICAID OPTIONS

The South Carolina Medicaid program offers different ways for its members to receive healthcare services. The choices are either managed care or fee-for-service.

To find out more about these Medicaid options, please call the DHHS Resource Center at 1-888-549-0320, Monday through Friday from 8:00 a.m. to 5:00 p.m.

CAN A MEDICAID MEMBER CHOOSE HIS PROVIDER?

Medicaid beneficiaries have the right to choose their own physician, hospital, pharmacy, or other medical provider. The provider must be enrolled as a Medicaid provider in order for a payment to be made. The provider must also be willing to accept the Medicaid payment as payment in full.

The South Carolina Medicaid program has a freedom of choice waiver to cover high-risk pregnant women. The women enrolled in the waiver must receive their care from certain physicians and delivery services at certain hospitals. The purpose of the waiver is an attempt to improve upon birth outcomes in our state.

WHAT IF THE MEDICAID MEMBER HAS HEALTH INSURANCE?

If a member has health insurance that covers a provided service, the insurance provider is the primary payer. Medicaid does not pay for services that the member's health insurance is legally obligated to pay.

MEDICAID COVERAGE GROUPS

A. Low Income Families (LIF)

    At least one child in the home is under age 18 (age 19 if in a secondary school) and lives in a family with low income. Countable resources must be at or below $30,000 per Budget Group.

  • Four Month Extended Medicaid-These are individuals who lost their LIF benefit due to increased child support. Their Medicaid continues for four months after they become ineligible for LIF.


  • Transitional Medicaid (TM)-Up to 24 months of Medicaid benefits are available after the loss of LIF eligibility if earnings or hours of employment of the parent or caretaker relative or loss of earned income disregard caused LIF ineligibility.

  • Title IV-E- These are children who were or would have been eligible for FI at the time they were placed for adoption or in foster care. These children are automatically entitled to Medicaid coverage.
  • Ribicoff Children - These are children whose family income is below 50% of the Federal Poverty Level. Countable resources must be at or below $30,000 per Budget Group. They can be eligible even if they live with both parents. South Carolina provides Medicaid benefits to these children up to age 18.
  • B. Supplemental Security Income (SSI) -


    A cash payment through the Social Security Administration and Medicaid benefits are available to aged, blind or disabled individuals who have a monthly income of $908 or less and resources at or below $2,000. For a couple, the SSI income limit is $956. (Income limits change in January each year.) DHHS determines eligibility for retroactive SSI.

    Some individuals who have lost their eligibility for SSI are still entitled to Medicaid coverage. They are:

    • 1977 Pass Alongs -
      These are individuals who would still be eligible for SSI "but for" Social Security cost of living increases they received since 1977.

    • Disabled Widows and Widowers -
      These are individuals who would still be eligible for SSI "but for" a 1983 change in the actuarial reduction formula and subsequent cost of living increases.

    • Disabled Adult Children -
      These are individuals who would still be eligible for SSI "but for" entitlement to or an increase in Social Security Disabled Adult Child benefits.

    • Early Widows/Widowers -
      These are individuals age 60 through 64 who would still be eligible for SSI "but for" early receipt of Social Security benefits.

    C. Qualified Medicare Beneficiaries (QMB) -


    These are individuals who have Medicare Part A hospital insurance and have a monthly income at or below 100% of the Federal Poverty Level ($908 for an individual and $1,226 for a couple). Their countable resources must be below $6,680 for an individual or $10,020 for a couple. A separate QMB determination is done for all Medicaid beneficiaries who have Medicare Part A, regardless of their coverage group.

    D. Specified Low Income Medicare Beneficiaries (SLMBs)-


    These are individuals who must have Medicare Part A hospital insurance and have a monthly income greater than 100% and less than 120% of the Federal Poverty Level for an individual ($1,089) or a couple ($1,471). Their countable resources must be below $6,680 for an individual or $10,020 for a couple. For these individuals, Medicaid does not pay Medicare co-insurance and deductibles and any Medicaid covered services other than the Part B Premium.

    E. Optional Coverage for (Pregnant) Women and Infants (OCWI)-


    Medicaid coverage is provided to pregnant women and infants who have a monthly income at or below 185% of the Federal Poverty Level (currently $3,446 for a family of four). Countable resources must be at or below $30,000 per Budget Group.

    F. Family Planning (FP) Wavier Services -


    Medicaid coverage is provided to individuals (men and women) of any age if their family income is at or below 185% of the Federal Poverty Level (currently $3,446 for for a family of four). Countable resources must be at or below $30,000 per Budget Group.

    G. Partners for Healthy Children (PHC) -


    This is coverage for children up to age 19 who live in families whose monthly income is at or below 200% of the Federal Poverty Level. Countable resources must be at or below $30,000 per Budget Group.

    H. Home and Community-Based (Waiver) Services (HCBW) -


    These are individuals who need nursing home care but choose to stay at home rather than in an institution and can receive special services through a waiver to help them remain in their home. This group also includes individuals whose eligibility is determined using a special income level (i.e., individuals who have countable resources at or below $2,000 and a gross monthly income at or below the Medicaid Cap of $2,022 (this limit changes each January).

    I. Optional State Supplementation -


    These are aged, blind or disabled individuals who have countable resources at or below $2,000 and who have a monthly countable income at or below $1,157 and who reside in Community Residential Care Facilities (CRCF). The optional supplement payment is made through the Department of Health and Human Services.

    J. Children For Whom a State Adoption Assistance Agreement is in Effect -


    These are special needs children for whom there is a State Adoption Assistance Agreement in place and for whom the State Adoption Assistance Agency has determined a placement could not be made without medical assistance. Countable resources must be at or below $30,000 per Budget Group.

    K. Children Under 21 With Special Living Arrangements-


    These are children under age 21 who reside in a foster home or a group home. Their board payment is fully or partially sponsored by public funds. If the child's income is below FI standards, he or she can qualify for Medicaid coverage. Countable resources must be at or below $30,000 per Budget Group.

    L. Aged, Blind and Disabled (ABD) Individuals-


    These are individuals with a countable monthly income at or below 100% of the Federal Poverty Level ($908 for an individual and $1,226 for a couple - limits change in March each year). Their countable resources must be below $6,680 for an individual or $10,020 for a couple.

    M. TEFRA (or Katie Beckett) Children -


    These are children age 18 or younger that live at home and meet the SSI definition of disability for a child and meet the level of care required for Medicaid sponsorship in either a nursing home, ICF/MR or an acute care hospital. The parent's income and resources are not considered in determining eligibility. Individuals eligible under this group must have gross monthly income at or below $2,022 (this limit changes in January each year) and resources below $2,000.

    N. Working Disabled Individuals -


    These are individuals who meet the Social Security definition of disabled and are working. Eligibility is determined using a two-step process. In the first step, the family's income, after allowable deductions, is at or less than 250% of the Federal Poverty Level (currently $3,861 for a family of three). If the family income meets this test, the individual's own unearned income must be at or below 100% of the Federal Poverty Level for an individual (currently $3,815 for a family of three) and resources at or below $6,680.

    O. Qualified Disabled and Working Individuals-


    These are individuals who have Medicare Part A and have income at or below 200% of the Federal Poverty Level ($1,815 for an individual). The individual's resources must be at or below $4,000. For these individuals, the Medicaid program is required to pay their Medicare Part A premiums only. These individuals must not be otherwise eligible for Medicaid.

    P. Breast and Cervical Cancer Program (BCCP)-


    The Breast and Cervical Cancer Prevention and Treatment Act of 2000 allows states to provide full Medicaid benefits to uninsured women who are found in need of treatment for breast and/or cervical cancer or pre-cancerous lesions (CIN 2/3 or atypical hyperplasia).


    South Carolina Medicaid covers two options: Best Chance Network patient and Non-Best Chance Network patient. The eligibility criteria for each option are as follows:

      Option 1: Best Chance Network (BCN) Patient


    • She must meet SC state residency and identity requirements (refer to the Medicaid Policy and Procedures Manual - 102.03 and 102.02).


    • She has been screened for breast or cervical cancer under the Best Chance Network program, diagnosed and found in need of treatment for either breast or cervical cancer or pre-cancerous lesions (CIN 2/3 or atypical hyperplasia).


    • She is age 47-64.


    • She does not have other insurance coverage that would cover breast and/or cervical cancer or pre-cancerous lesions (CIN 2/3 or atypical hyperplasia), including Medicare Part A or B.


    • Her family income is at or below 200% of the Federal Poverty Level.


    • She is not eligible for another Medicaid eligibility group.


    • Option 2: Non-Best Chance Network (Non-BCN) Patient


      Women diagnosed by a non-BCN provider and found in need of treatment for either breast or cervical cancer or pre-cancerous lesions (CIN 2/3 or atypical hyperplasia) can be eligible effective July 1, 2005, for Medicaid coverage if the following criteria are met:

    • She must meet SC state residency and identity requirements (refer to the Medicaid Policy and Procedures Manual - 102.03 and 102.02).


    • She is under age 65.


    • She does not have other insurance coverage that would cover breast and/or cervical cancer or pre-cancerous lesions (CIN 2/3 or atypical hyperplasia), including Medicare Part A or B.


    • Her family income is at or below 200% of the Federal Poverty Level.


    • She is not eligible for another Medicaid eligibility group.


    • For questions about the Best Chance Network program, please call the American Cancer Society (toll-free) at 1-800-ACS-2345.


    HEALTHY CONNECTIONS (MEDICAID) PROGRAM INCOME CHARTS

    General Hospital,
    Nursing Home, TEFRA/Katie Beckett and
    Home and Community Based (Waiver) Services

    (300% of the Federal Benefit Rate-FBR)
    January 1, 2012

    Family Size Monthly Income Limit
    Individual $2,094
    Spousal Allocation $2,841


    Optional State Supplementation (OSS)
    January 1, 2009
    Monthly Net Income Limit:
    $1,157


    Aged, Blind or Disabled
    100% Of Poverty Level

    March 1, 2011
    Family Size Monthly Income Annual Income
    1 $908 $10,890
    2 $1,226 $14,710


    Optional Coverage For Pregnant Women And Infants
    185% of Poverty Level

    March 1, 2009
    Family Size Monthly Income Annual Income
    1 $1,670 $20,036
    2 $2,247 $26,955
    3 $2,823 $33,874
    4 $3,400 $40,793
    5 $3,976 $47,712
    6 $4,553 $54,631
    7 $5,130 $61,550
    8 $5,706 $68,469
    Each Additional Member $577 $6,919
    For each additional family member, add $6,919 to the annual income.
    Divide by 12 and round up to the next whole dollar for the monthly income.

    Partners for Healthy Children
    COVERAGE FOR CHILDREN AGE 1 TO 19
    March 1, 2011
    200% of the Federal Poverty Level
    Family Size 200% FPL
    1 $1,815
    2 $2,452
    3 $3,089
    4 $3,725
    5 $4,362
    6 $4,999
    7 $5,635
    8 $6,272
    Each additional person $637
    For family sizes over 8, add the amount shown for each extra person to income limit for 8.


    Specified Low Income Medicare Beneficiaries (SLMB) & Qualifying Individual (QI)
    March 1, 2011
    120% of Poverty Level
    Family Size SLMB
    120%
    QI
    135%
    1 (Individual) $1,089 $1,226
    2 (Couple) $1,471 $1,655


    Working Disabled
    250% Of Poverty Level
    March 1, 2009
    Family Size Monthly Income Annual Income
    1 $2,257 $27,075
    2 $3,036 $36,425
    3 $3,815 $45,775
    4 $4,594 $55,125
    5 $5,373 $64,475
    6 $6,153 $73,825
    7 $6,932 $83,175
    8 $7,711 $92,525
    Each Additional Member $780 $9,350
    For each additional family member, add $9,350 to the annual income.
    Divide by 12 and round up to the next whole dollar for the monthly income.


    November 1, 2011
    Family Size Net Income Limit
    1 $454
    2 $613
    3 $773
    4 $932
    5 $1,091
    6 $1,250
    7 $1,409
    8 $1,568
    Note: For family sizes over 8, add $160.00 for each extra person to the net income limit for 8.
    To calculate the gross income limit, multiply the net income limit by 185%.



    REGULAR FOSTER CARE MEDICAID INCOME LIMITS
    November 1, 2011
    Family Size Monthly Income Limit
    1 $454



    Breast and Cervical Cancer Program (BCCP)
      (200% of the Federal Poverty Level)
    March 1, 2011
    Family Size Monthly Income Annual Income
    1 $1,815 $21,780
    2 2,452 29,424
    3 3,089 37,068
    4 3,725 44,700
    5 4,362 52,344
    6 4,999 59,988
    7 5,635 67,620
    8 6,272 75,264
    Each Additional Member 637 7,644
    For each additional family member, add $7,644 to the annual income.



    MEDICAL SERVICES

    Within limits, Medicaid will pay for services that are medically necessary.

    For Medicaid payment purposes, the following definitions apply:

      Children - birth through 20 years

      Adults - 21 years and older

    Co-payments - The Medicaid program requires a beneficiary to pay a small part of their medical bill for some services called a co-payment. The reason for this step is to enable them to assume some responsibility for their medical care. Co-payments are paid to the provider when services are rendered. The provider will tell the beneficiary when a co-payment is applicable.

    Medicaid can pay for the following health care services:

    • Hospital inpatient, outpatient, emergency room
    • Lab and X-ray
    • Doctor office visits (physician, nurse practitioner, midwife, podiatrist, chiropractor)
    • Well child care-EPSDT
    • Well adult care
    • Vision
    • Dental
    • Prescription drug (not all drugs are covered)
    • Family Panning
    • Medical equipment
    • Hospice
    • Ambulance
    • Transportation to medical appointments
    • Nursing facility
    • ICF for mentally retarded
    • Inpatient psychiatric care
    • Home Health
    • Physical therapy
    • Speech/language therapy
    • Mental health services
    • Alcohol and drug abuse services
    • Family support services
    • Targeted case management
    • Behavioral Health Services for emotionally disturbed children
    • Home and Community based long term care services

    Call 1-888-549-0820 if you have any questions about services.

    Monday through Friday from 8:00a.m. to 5:00p.m.




    WHERE TO APPLY


    By Mail for TEFRA & Breast and Cervical Cancer Program:

    South Carolina Department of Health & Human Services
    Division of Central Eligibility Processing
    Post Office Box 100101
    Columbia, South Carolina 29202-3101
    Telephone (803) 898-2997

    In Person or By Mail for all other Programs:

    Jump to County
    A-C D-G H-K L-P Q-T U-Z

    A-C

    Abbeville County DHHS Office
    Post Office Box 130
    903 West Greenwood Street
    Abbeville, South Carolina 29620
    (864) 366-5638

    Aiken County DHHS Office
    Post Office Box 2748
    1410 Park Avenue, SE
    Aiken, South Carolina 29801
    (803) 643-1938

    Allendale County DHHS Office
    611 Mulberry Street
    Allendale, South Carolina 29810
    (803) 584-8137

    Anderson County DHHS Office
    Post Office Box 160
    224 McGee Road
    Anderson, South Carolina 29625
    (864) 260-4541

    Bamberg County DHHS Office
    Post Office Box 544
    374 Log Branch Road
    Bamberg, South Carolina 29003-0544
    (803) 245-4361

    Barnwell County DHHS Office
    Post Office Box 648
    29 Allen Street
    Barnwell, South Carolina 29812
    (803) 541-3825

    Beaufort County DHHS Office
    Post Office Box 1255
    1905 Duke Street
    Beaufort, South Carolina 29902
    (843) 470-4625

    Berkeley County DHHS Office
    Post Office Box 1409
    2 Belt Drive
    Moncks Corner, South Carolina 29461
    (843) 719-1131

    Calhoun County DHHS Office
    Post Office Box 378
    2831 Old Belleville Road
    St. Matthews, South Carolina 29135
    (803) 874-3384

    Charleston County DHHS Office
    Post Office Box 13748
    326 Calhoun Street
    Charleston, South Carolina 29403
    (843) 740-5900

    Cherokee County DHHS Office
    Post Office Box 89
    1434 North Limestone
    Gaffney, South Carolina 29340
    (864) 487-2521

    Chester County DHHS Office
    Post Office Box 447
    115 Reedy Street
    Chester, South Carolina 29706
    (803) 377-8131

    Chesterfield County DHHS Office
    Post Office Box 855
    201 North Page Street
    Chesterfield, South Carolina 29709
    (843) 623-5226

    Clarendon County DHHS Office
    Post Office Box 788
    3 South Church Street
    Manning, South Carolina 29102
    (803) 435-4305

    Colleton County DHHS Office
    Post Office Box 110
    215 South Lemacks Street
    Walterboro, South Carolina 29488
    (843) 549-1894

    D-G

    Darlington County DHHS Office
    Post Office Drawer 2077
    300 Russell Street, Room 145
    Darlington, South Carolina 29532
    (843) 398-4427

    Dillon County DHHS Office
    Post Office Box 351
    1213 Highway 34 West
    Dillon, South Carolina 29536
    (843) 774-2713

    Dorchester County DHHS Office
    Post Office Box 56
    201 Johnston Street - Building 17
    St. George, South Carolina 29477
    (843) 563-9524

    Edgefield County DHHS Office
    Post Office Box 386
    500 W.A. Reel Drive
    Edgefield, South Carolina 29824
    (803) 637-4040

    Fairfield County DHHS Office
    Post Office Box 1139
    1136 Kincaid Bridge Rd
    Winnsboro, South Carolina 29180
    (803) 635-5502 ex. 425

    Florence County DHHS Office
    2685 South Irby Street, Box 1
    Florence, South Carolina 29505
    (843) 669-3354

    Georgetown County DHHS Office
    Post Office Box 371
    330 Dozier Street
    Georgetown, South Carolina 29440
    (843) 546-5134

    Greenville County DHHS Office
    Post Office Box 9399
    301 University Ridge, Suite 6700
    Greenville, South Carolina 29603
    (864) 467-7800
    (864) 467-7926

    Greenwood County DHHS Office
    Post Office Box 1016
    1118 Phoenix Street
    Greenwood, South Carolina 29646
    (864) 229-5258

    H-K

    Hampton County DHHS Office
    102 Gin Altman Avenue
    Hampton, South Carolina 29924
    (803) 914-0053

    Horry County DHHS Office
    Post Office Box 290
    1601 11th Ave., 2nd Floor
    Conway, South Carolina 29526
    (843) 381-8260

    Jasper County DHHS Office
    Post Office Box 1150
    204 North Jacob Smart Boulevard
    Ridgeland, South Carolina 29936
    (843) 726-7747

    Kershaw County DHHS Office
    Post Office Box 220
    110 East DeKalb Street
    Camden, South Carolina 29020
    (803) 432-7676 EXT. 106

    L-P

    Lancaster County DHHS Office
    Post Office Box 2169
    200 E. Dunlap Street
    Lancaster, South Carolina 29720
    (803) 286-8208
    FAX:
    (803) 286-8743

    Laurens County DHHS Office
    Post Office Box 388
    93 Human Resources Road
    Clinton, South Carolina 29325
    (864) 833-6109

    Lee County DHHS Office
    Post Office Box 406
    820 Brown Street
    Bishopville, South Carolina 29010
    (803) 484-5376

    Lexington County DHHS Office
    605 West Main Street
    Lexington, South Carolina 29072
    FI Medicaid
    (803) 785-2991
    SSI Medicaid
    (803) 785-2975

    Marion County DHHS Office
    Post Office Box 1837
    1311 North Main Street
    Marion, South Carolina 29571
    (843) 423-5417

    Marlboro County DHHS Office
    Post Office Drawer 1074
    1 Ag Street
    Bennettsville, South Carolina 29512
    (843) 479-4389

    McCormick County DHHS Office
    215 North Mine Street
    McCormick, South Carolina 29835
    (864) 465-2627

    Newberry County DHHS Office
    Post Office Box 1225
    2107 Wilson Road
    Newberry, South Carolina 29108
    (803) 321-2155

    Oconee County DHHS Office
    Post Office Box 979
    100 Brown Square
    Walhalla, South Carolina 29691
    (864) 638-4400

    Orangeburg County DHHS Office
    Post Office Box 1407
    2570 Old St. Matthews Road NE
    Orangeburg, South Carolina 29118
    (803) 531-3101

    Pickens County DHHS Office
    Post Office Box 160
    212 McDaniel Avenue
    Pickens, South Carolina 29671
    (864) 898-5815

    Q-T

    Richland County DHHS Office
    3220 Two Notch Road
    Columbia, South Carolina 29204
    (803) 714-7562 or (803) 714-7549

    Saluda County DHHS Office
    Post Office Box 245
    613 Newberry Hwy (Highway #121 North)
    Saluda, South Carolina 29138
    (864) 445-2139

    Spartanburg County DHHS Office
    Post Office Box 4847
    1000 N. Pine Street, Suite 23/Pinewood Shopping Ctr.
    Spartanburg, South Carolina 29303
    (864) 596-2714

    Sumter County DHHS Office
    Post Office Box 2547
    105 North Magnolia Street, 3rd Floor
    Sumter, South Carolina 29151
    (803) 773-5531

    U-Z

    Union County DHHS Office
    Post Office Box 1068
    200 South Mountain Street
    Union, South Carolina 29379
    (864) 429-1660

    Williamsburg County DHHS Office
    Post Office Drawer 767
    831 Eastland Avenue
    Kingstree, South Carolina 29556
    (843) 355-5411

    York County DHHS Office
    PO Box 710
    1890 Neelys Creek Road
    Rock Hill, SC 29730
    (803) 327-9061



    3/01/08