Ana səhifə

South carolina department of health and human services medicaid policy and procedures manual

Yüklə 0.73 Mb.
ölçüsü0.73 Mb.
1   2   3   4   5   6   7   8   9   ...   21

101.04.05 DHHS Employees Conflict of Interest (Rev. 10/01/10)

DHHS employees must never directly or indirectly request that another DHHS employee process an application for themselves, family members, or friends. An application for a DHHS employee, family members, or friends must be discussed with his or her immediate supervisor and/or Regional Administrator to avoid a conflict of interest. Applications for an employee or immediate family members must be handled according to the policy in MPPM 101.04.04. An application for the friend of an agency employee must be assigned by the supervisor or Regional Administrator. DHHS employees must not review, research or change information on MEDS related to a member of their household or immediate family. DHHS employees must not review, research, or change information on MEDS related to friends of an employee unless the case has been assigned to the employee by the supervisor or Regional Administrator.

101.04.06 Informing the Applicant (Rev. 07/01/10)

Should an application interview be needed, the interview (which may be conducted by telephone or in person) must include at a minimum the following explanations:

  • The eligibility requirements, the agency's standard of promptness, the right to a fair hearing, the procedure for requesting a hearing, rights under Title VI of the Civil Rights Act of 1964, and rights under Title V and Section 504 of the Rehabilitation Act of 1973

Note: The DHHS Brochure 24160, Rights and Responsibilities of SC Healthy Connections Medicaid Applicants and Beneficiaries, must be given to the applicant/authorized representative. This brochure replaces the individual Civil Rights Pamphlet and Fair Hearing and Appeals Brochure. MEDS can be updated to document that the brochures have been given to the applicant/authorized representative

  • The responsibility of the applicant to give complete and accurate information, to report any changes in circumstances and penalties for providing false information. (Refer to MPPM 101.14 for a complete discussion of these Rights and Responsibilities.)

  • An explanation of the methods of establishing eligibility, including the need for making collateral contacts and the use of documentary and other records for verifying pertinent information, including the use of computer matches (such as BENDEX, IEVS) to verify the presence of income of family members

  • The services covered by Medicaid, including instructions on the appropriate use of the Medicaid insurance card

  • The third-party liability process, including the responsibility to cooperate in obtaining medical support

  • The services available through the Women, Infants, and Children (WIC) program at the county health department. Where appropriate, the applicant must be referred to the WIC program.

  • The estate recovery program, when appropriate. (Refer to MPPM 304.27, Nursing Home, Waivered Services, General Hospital.)

  • The services available to children under age 21 through the Early, Periodic Screening, Diagnosis and Treatment program (EPSDT)

101.04.07 Request for Informal Medicaid Eligibility Opinion (Renum. 01/01/09; Eff. 01/01/07)

Individuals seeking assistance from other social service agencies may be required to obtain a statement from the SCDHHS indicating he/she is not eligible for Medicaid. If the individual indicates through questioning that none of the categorical eligibility requirements would be met, the Eligibility Worker may complete a DHHS Form 3300, Informal Medicaid Eligibility Opinion, to give to the individual. It must be explained that the decision is not an official denial, and it cannot be appealed. If a proper denial letter is required, an application must be filed, and a decision rendered after all eligibility factors have been examined according to Medicaid policy. The DHHS Form 3300 cannot be used to indicate a person’s ineligibility due to financial or other non-categorical eligibility criteria.

    1. Retroactive Applications (Rev. 10/01/13)

The agency may authorize Medicaid for any or all of the three (3) calendar months proceeding the month of application for medical assistance. An applicant may be eligible for retroactive coverage even though the application for current or continuing medical benefits is denied. A separate application is not required for retroactive benefits unless the application is made posthumously. Retroactive eligibility will only be considered after a full application has been submitted.

The following requirements must be met after retroactive Medicaid is explained to the applicant:

  • Retroactive coverage must be explored if the individual alleges that he/she has outstanding medical expenses and requests that eligibility be determined for Medicaid benefits.

  • It must be established that the individual met all financial and categorical criteria in each of the retroactive month(s) for which Medicaid eligibility is requested. Eligibility is also determined based on the individual’s actual financial circumstances for each of the retroactive months in question.

  • When the individual’s categorical eligibility is based on the factors of blindness or disability, blindness or disability must be established and/or verified for the retroactive period.

If the above requirements are met, the individual may be found eligible for Medicaid for any or all of the retroactive months. The eligibility decision must be made independently for each of the three (3) months and documented in the case file.

Procedure For Retroactive Decisions Made After The Initial Medicaid Determination

  1. MEDS does not generate a notice for a retroactive determination made after the initial Medicaid eligibility decision. The eligibility worker must notify the applicant/beneficiary using the DHHS Form 3229-D, Notice of Approval/Denial for Retroactive Medicaid Benefits.

  2. The eligibility worker must also provide DHHS Form 945, Verification of Medicaid, for retroactive decisions made after the initial Medicaid determination.

Note the Following

  1. DHHS Form 945 is also used for other requests to verify Medicaid eligibility.

  2. Specific instructions regarding retroactive coverage for OCWI-Pregnant Woman cases are found in MPPM 203.02.09.

  3. In some situations, the individual may be found eligible for Medicaid benefits, but not for a vendor payment because certain Medicaid requirements specific to long-term care were not met.

  4. If the individual was a resident in another state throughout one of the months in the retroactive period, he/she must apply for benefits in that state. (Refer to MPPM 102.03.09)

Procedure For Updating Retroactive Coverage In MEDS

(Do not change the Begin Date set by the system after performing Make Decision in MEDS)


Go to the top of the screen to change the date to the retroactive coverage month needed.


Complete the screen by entering the countable Budget Group members, countable income and other information pertinent to the payment category. Do not update the “Next Review Date”.


MEDS will display an ELD02 screen for each member included in the Budget Group. The eligibility Begin and End dates for that retroactive month will display.

Note: If the Medical Services in the Last 3 Months indicator on the HMS06, Household Member Detail screen in MEDS was set to N when the application was locked, the retroactive budget months will not be found. A GroupLink ticket must be submitted.

1   2   3   4   5   6   7   8   9   ...   21

Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur © 2016
rəhbərliyinə müraciət