South Carolina Code of Regulations
Chapter 126 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
Article 3 - MEDICAID
Subarticle 2 - ELIGIBILITY FOR THE MEDICAL ASSISTANCE (MEDICAID) PROGRAM
Section 126-375 - Medical Institution Vendor Payments

Universal Citation: SC Code Regs 126-375

Current through Register Vol. 48, No. 9, September 27, 2024

A. Vendor payments are made on behalf of eligible individuals to medical institutions in accordance with Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

B. An individual must meet all of the following requirements in order to be eligible for a medical institution vendor payment.

(1) Meet all eligibility criteria for any eligible group specified in 126-365 and 126-377.

(2) Reside in a Title XIX certified medical facility which has a current contract with the Department of Health and Human Services.

(3) Have written documentation from the Department of Health and Human Services or its designee that institutional care is medically necessary, and have an appropriate level of care certified by the Department of Health and Human Services or its designee.

(4) Apply all available income, less allowable exclusions, to the cost of care. The amount of income to be applied to the cost of care shall be confirmed with the individual and the medical institution.

C. All applicants for Medicaid-sponsored long term care must have medical necessity certified by the Department of Health and Human Services or its designee. This certification includes the designation of the level of care needed by the applicant based on the appropriate Level of Care Criteria (either the South Carolina Level of Care Criteria for Long Term Care or the South Carolina Level of Care Criteria for Intermediate Care Facility/Personswith Intellectual Disability), as developed by the Department of Health and Human Services. Medical necessity and level of care must be certified prior to admission to a long term care facility or if an individual applies for assistance while in a long term care facility, prior to the date Medicaid vendor payment can begin. The Level of Care Criteria, as well as further clarification of these mandatory preadmission requirements, can be found under cover of Medicaid Bulletins issued by the Department of Health and Human Services. These Medicaid Bulletins can be obtained from the office of the Department of Health and Human Services, from any Community Long Term Care area office, or from county Department of Social Services offices.

D. Determination of Recurring Income.

(1) The amount of income which the individual must apply to the cost of care is determined in accordance with Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

(2) In the month of entry into a medical facility from a non-institutional living arrangement, the individual's income shall not be counted as recurring income. In the month of discharge from a medical facility to a non-institutional living arrangement, a portion of the individual's income shall not be counted as recurring income.

(3) An SSI eligible individual entering a medical facility shall not be eligible automatically for a medical institution vendor payment. The SSI recipient's eligibility for Medicare, Special Age Seventy-two Social Security Benefits, Veterans Benefits, or other benefits shall be explored and utilized, if available. A level of care must be certified by the Department of Health and Human Services or its designee and the monthly recurring income computed. If an individual's SSI is terminated while he is in the institution because of too much income, he may reapply for MAO.

Disclaimer: These regulations may not be the most recent version. South Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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