South Carolina

In South Carolina:
  • As of July 1, 2011, there were 862,145 beneficiaries enrolled in the state’s Medicaid program. 428,765 beneficiaries are enrolled in four Medicaid-only managed care organizations (MCOs), while 142,296 beneficiaries are enrolled in a primary care case management program (PCCM) known as the Medical Homes Network. All Medicaid beneficiaries are also enrolled in a transportation-only Prepaid Ambulatory Health Plan.
  • Physical health services are provided to children primarily through managed care organizations, though disabled or foster care children may be enrolled in the state’s PCCM program. Limited behavioral health services are available through MCOs, and most behavioral are paid for a fee-for-service basis. Oral health benefits are administered by DentaQuest.
As of 2013, 695,485 individuals were eligible for South Carolina’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 80% and a participant ratio of 61%. 333,902 children received dental services of any kind, with 319,129 receiving preventive dental services.
Last updated September 2014
Medical Necessity
Medicaid policy manuals in South Carolina define medical necessity as:
“Medical Necessity (the provision of which may be limited by specific manual provisions, bulletins, and other directives) is directed toward the maintenance, improvement, or protection of health or toward the diagnosis and treatment of illness or disability.”
Initiatives to Improve Access
Reporting & Data Collection South Carolina’s Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant) is supporting work to collect CHIPRA quality indicator data from 18 pediatric practice.
Behavioral Health
South Carolina Medicaid allows providers to bill for developmental screenings at select well-child visits (9 months, 18 months, 24 months, and 48 months). Providers must use a standardized screening tool; the state suggests: the
  • Ages and Stages Questionnaire (ASQ) or Ages and Stages Questionnaire/Social Emotional (ASQ-SE)
  • Denver DST/Denver II
  • Battelle Developmental Screener
  • Bayley Infant Neurodevelomental Screener(BINS)
  • Early Language Accomplishment Profile (ELAP)
  • Brigance Screens II
  • Modified Checklist for Autism in Toddlers (M-CHAT)
  • Vanderbilt Rating Scales
  • Behavior Assessment Scale for Children-Second Edition (BASC- II)
The state allows Child Service Professionals—required to have training in children’s behavioral health but not specific certification is required—to provide rehabilitative behavioral health services to children. Medicaid covers Behavioral Modification for children in the community, as well as Skills Training and Development Services for Children.
Support to Providers and Families
Support to Providers
The state offers provider bulletins to keep providers abreast of policy changes in a number of areas including EPSDT. The Medicaid manual for physicians contains detailed information about the EPSDT benefit and its requirements.
Providers from the 18 pediatric primary care practices participating in the Quality Through Technology and Innovation in Pediatrics (QTIP) initiative participate in learning collaboratives that share information on quality improvement, health information technology, quality reporting, and enhanced primary care.
Support to Families
Member education about the EPSDT benefit is primarily the responsibility of Medicaid managed care plans. Materials for families on the state’s website are focused on helping families determine eligibility and enroll in Medicaid.
Care Coordination
Medicaid managed care contracts in South Carolina require plans to participate in care coordination activities, including:
  • Developing referral systems to connect enrollees with specialists,
  • Monitoring and follow-up activities for in-networks providers and creation of linkages to providers outside of the plan’s network
  • Targeted case management services, including for children in foster care or the juvenile justice system or children with serious emotional disturbance, and
  • Transferring medical and developmental data to school settings to coordinate care with school-based services.

Beneficiaries enrolled in the state’s Medical Home Network primary care case management program. The state provides a list of patient-centered medical home practices in the state.


Through the Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant), South Carolina Medicaid is helping 18 pediatric primary care practices transform to become patient-centered medical homes. The project provides a Patient Centered Medical Home Toolkit to help guide practices through the medical home certification process.

Oral Health
South Carolina Medicaid covers application of topical fluoride varnish by primary care providers during well-child visits for children up to age 3. Physician applying fluoride varnish must also offer relevant oral health anticipatory guidance. The state also offers a Medicaid dental provider manual that includes information on dental benefits for children.