- 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.
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.|
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
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
Medicaid managed care contracts in South Carolina require plans to participate in care coordination activities, including:
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.
||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.|