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



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204.05.08 Family Planning Annual Review


(Eff. 08/01/14)

An annual review is required.

If a Family Planning Beneficiary is found ineligible at an annual review, the Eligibility Worker should determine if that individual would be eligible in any other payment category. If so, appropriate action must be taken to follow the ex parte process. Refer to MPPM 101.11.


Procedure for Conducting a Family Planning Annual Review


MEDS Procedure:
MEDS generates a review form based on the Next Review Date shown on the ELD01 screen in MEDS. It is the responsibility of the Eligibility Worker to acknowledge receipt of the review form in MEDS.
Select Worker Menu, select Regular Review, and put “R” for Review Status. The system will pull up all cases associated with the Eligibility Worker’s User ID scheduled for review.
Select the beneficiary’s name and place the date in the “Form Received Column,” then MOD screen. This procedure will acknowledge that you have received the review form from the beneficiary and will not allow the case that you have selected to be closed until you have actually completed the review.
Note: Once you have acknowledged receipt of the review form in MEDS, an eligibility decision must be made within 60 days from receipt of the review form so that the beneficiary’s case can be processed in a timely manner during the review period.


Procedure:


  • Make sure the beneficiary’s review form is complete.

  • Note any alleged changes or discrepancies.

  • Complete a budget sheet to determine continued eligibility.





If continued eligible:


  • Update MEDS information by going to ELD01 and updating the necessary fields and the Date of Next Review (which is equal to 12 months from the Decision Date).

  • MOD screen, press pf15 “Make Decision,” and then press pf24 “Act on Decision.”

Case should now be in Maintenance Status.


If ineligible:


  • Begin closure procedures in MEDS.

  • Go to ELD01 and enter updated information in the necessary fields. Put in the correct closure code, so that a notice will be sent to the beneficiary explaining the reason for case closure.

  • Go to ELD02 to make sure the appropriate month the case is to close is properly displayed. Press pf24 “Act on Decision.” Do not “Make Decision.”



204.06 Regular Foster Care


(Eff. 01/01/14)

This section addresses Medicaid eligibility requirements for children in special living arrangements such as the following:




  • Residing in Foster Care (children in the custody of the Department of Social Services (DSS));

  • Receiving adoption assistance because the child has special needs;

  • Living in other out-of-home placements. (Refer to MPPM 207.01.01.)


A child who is placed into DSS care and control through emergency protective custody, ex parte order, consent and waiver, or a voluntary placement agreement is considered to be in DSS custody. Foster Care children are not restricted to the Foster Care coverage group. Foster Care children may be eligible under any Medicaid coverage group as long as they meet the requirements for that group, regardless of placement.
Foster Care children under age 21, who are in DSS custody, and children under age 21, living in other out-of-home placements (group homes and residential treatment facilities), may be eligible in Foster Care Payment Category 60 if they meet certain requirements. To be eligible in this category, the individual must reside in a licensed foster home, or other approved facility, and must have income below 62% the FPL. (Refer to MPPM 103.04.)
Eligibility for this coverage group must be re-determined annually for Foster Care children under the age of 18. Children between the ages of 18 and 21 must meet additional requirements for eligibility to continue under this payment category.
The Department of Social Services (DSS) has custody of Foster Care children, and is responsible for their welfare. Children placed in an out-of-state living arrangement and remaining in the custody of DSS are considered residents of South Carolina. Therefore, the review form should be sent directly to the County DSS Office to ensure that the review is being done in a timely manner.


Procedure for Determining Regular Foster Care Eligibility


MEDS Procedure:
Enter the County DSS Office address on the Primary Individual Screen (HMS04). This procedure sends the review form directly to the County DSS Office and allows the DSS human services worker to complete and return the form in a timely manner to the DHHS Medicaid Eligibility Worker for processing.




204.06.01 Types of Placements


(Eff. 01/01/14)

An out-of-home placement is defined as one in which a child is in a setting other than with his/her parents. The following are examples of out-of-home placements:





Note: For a listing of RTFs, refer to the Appendix at the end of this chapter.

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