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									BIL:     4212
TYP:     General Bill GB
INB:     House
IND:     19990602
PSP:     Pinckney
SPO:     Pinckney, Cobb-Hunter and Lloyd
DDN:     l:\council\bills\psd\7481ac99.doc
RBY:     House
COM:     Medical, Military, Public and Municipal Affairs Committee 27 H3M
SUB:     Children's Health Act, Medical, Minors, Insurance, Hospitals, Kidcare,
         Healthy Kids Corporation


HST:

Body     Date       Action Description                        Com     Leg Involved
______   ________   _______________________________________   _______ ____________
House    19990602   Introduced, read first time,              27 H3M
                    referred to Committee


Printed Versions of This Bill




TXT:
 1
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 8
 9                           A BILL
10
11   TO AMEND TITLE 44, CODE OF LAWS OF SOUTH
12   CAROLINA, 1976, RELATING TO HEALTH, BY ADDING
13   CHAPTER 82 SO AS TO ENACT THE “CHILDREN’S
14   HEALTH ACT” WHICH CREATES THE CHILDREN’S
15   MEDICAL SERVICES PROGRAM TO PROVIDE CHILDREN
16   WITH    SPECIAL    HEALTH     CARE  NEEDS   A
17   COMPREHENSIVE MANAGED SYSTEM OF CARE; TO
18   CREATE THE SOUTH CAROLINA KIDCARE PROGRAM TO
19   PROVIDE    HEALTH    BENEFITS   TO  UNINSURED,
20   LOW-INCOME CHILDREN THROUGH AFFORDABLE
21   HEALTH BENEFITS COVERAGE OPTIONS TO WHICH
22   FAMILIES MAY CONTRIBUTE FINANCIALLY TO THE
23   HEALTH CARE OF THEIR CHILDREN; TO CREATE THE
24   SOUTH CAROLINA HEALTHY KIDS CORPORATION
25   PROGRAM TO ORGANIZE SCHOOL CHILDREN GROUPS
26   TO FACILITATE THE PROVISION OF COMPREHENSIVE
27   HEALTH INSURANCE COVERAGE TO CHILDREN; TO
28   PROVIDE FOR THE POWERS AND DUTIES OF STATE
29   AGENCIES TO CARRY OUT THESE PROGRAMS, AND TO
30   PROVIDE ELIGIBILITY CRITERIA AND PROGRAM
31   COMPONENTS AND BENEFITS; AND TO REQUIRE THE
32   ESTABLISHMENT OF DEVELOPMENTAL EVALUATION
33   AND INTERVENTION SERVICES AT EACH HOSPITAL
34   THAT PROVIDES LEVEL II OR LEVEL III NEONATAL
35   INTENSIVE CARE SERVICES AND TO STATE WHAT
36   SERVICES MUST BE PROVIDED.
37
38   Be it enacted by the General Assembly of the State of South
39   Carolina:
40
41   SECTION 1. This act may be cited as the “Children’s Health
42   Act”.

     [4212]                       1
 1
 2   SECTION 2. Title 44 of the 1976 Code is amended by adding:
 3
 4                             “CHAPTER 82
 5
 6                            Children’s Health
 7
 8                                Article 1
 9
10                      Children’s Medical Services
11
12      Section 44-82-5. The General Assembly intends that the
13   Children’s Medical Services program:
14      (1) provide to children with special health care needs a
15   family-centered, comprehensive, and coordinated statewide
16   managed system of care that links community-based health care
17   with multidisciplinary, regional, and tertiary pediatric specialty
18   care. The program may provide for the coordination and
19   maintenance of consistency of the medical home for children in
20   families with a Children’s Medical Services program participant,
21   in order to achieve family-centered care;
22      (2) provide essential preventive, evaluative, and early
23   intervention services for children at risk for or having special
24   health care needs, in order to prevent or reduce long term
25   disabilities;
26      (3) serve as a principal provider for children with special health
27   care needs under Titles XIX and XXI of the Social Security Act;
28   and
29      (4) be complementary to children’s health training programs
30   essential for the maintenance of a skilled pediatric health care
31   workforce for all South Carolinians.
32
33      Section 44-82-10. When used in this article, unless the
34   context clearly indicates otherwise:
35      (1) ‘Children’s Medical Services network’ or ‘network’ means
36   a statewide managed care service system that includes health care
37   providers, as defined in this section.
38      (2) ‘Children with special health care needs’ means those
39   children under age twenty-one years whose serious or chronic
40   physical or developmental conditions require extensive preventive
41   and maintenance care beyond that required by typically healthy
42   children. Health care utilization by these children exceeds the
43   statistically expected usage of the normal child adjusted for

     [4212]                            2
 1   chronological age. These children often need complex care
 2   requiring multiple providers, rehabilitation services, and
 3   specialized equipment in a number of different settings.
 4      (3) ‘Department’ means the Department of Health and Human
 5   Services.
 6      (4) ‘Eligible individual’ means a child with a special health
 7   care need or a female with a high-risk pregnancy, who meets the
 8   financial and medical eligibility standards established in
 9   regulation.
10      (5) ‘Health care provider’ means a health care professional,
11   health care facility, or entity licensed or certified to provide health
12   services in this State that meets the criteria as established by the
13   department.
14      (6) ‘Health services’ includes the prevention, diagnosis, and
15   treatment of human disease, pain, injury, deformity, or disabling
16   conditions.
17      (7) ‘Participant’ means an eligible individual who is enrolled in
18   the Children’s Medical Services program.
19      (8) ‘Program’ means the Children’s Medical Services program
20   established in the department.
21      (9) ‘Program director’ means the director of the Children’s
22   Medical Services program appointed by the director of the
23   department pursuant to Section 44-82-25.
24
25      Section 44-82-15. (A) This article applies to health services
26   provided to eligible individuals who are:
27        (1) enrolled in the Medicaid program;
28        (2) enrolled in the South Carolina Kidcare program
29   established pursuant to Section 44-82-315; and
30        (3) uninsured or underinsured, provided that they meet the
31   financial eligibility requirements established in this article, and to
32   the extent that resources are appropriated for their care.
33      (B) The Children’s Medical Services program consists of the
34   following components:
35        (1) the infant metabolic screening program established in
36   Section 44-82-30;
37        (2) a federal or state program authorized by the General
38   Assembly;
39        (3) the developmental evaluation and intervention program
40   established pursuant to Article 7;
41        (4) the Children’s Medical Se1rvices network.
42      (C) The Children’s Medical Services program shall not be
43   deemed an insurer and is not subject to the licensing requirements

     [4212]                             3
 1   of the South Carolina Insurance Department or the regulations of
 2   the Department of Insurance, when providing services to children
 3   who receive Medicaid benefits, other Medicaid-eligible children
 4   with special health care needs, and children participating in the
 5   South Carolina Kidcare program. This exemption shall not extend
 6   to contractors.
 7
 8      Section 44-82-20. The department shall have the following
 9   powers, duties, and responsibilities to:
10      (1) provide or contract for the provision of health services to
11   eligible individuals;
12      (2) determine the medical and financial eligibility standards for
13   the program and to determine the medical and financial eligibility
14   of individuals seeking health services from the program;
15      (3) recommend priorities for the implementation of
16   comprehensive plans and budgets;
17      (4) coordinate a comprehensive delivery system for eligible
18   individuals to take maximum advantage of all available funds;
19      (5) promote, establish, and coordinate programs relating to
20   children’s medical services in cooperation with other public and
21   private agencies and to coordinate funding of health care programs
22   with federal, state, or local indigent health care funding
23   mechanisms;
24      (6) initiate, coordinate, and request review of applications to
25   federal and state agencies for funds, services, or commodities
26   relating to children’s medical programs;
27      (7) sponsor or promote grants for projects, programs,
28   education, or research in the field of medical needs of children,
29   with an emphasis on early diagnosis and treatment;
30      (8) oversee and operate the Children’s Medical Services
31   network;
32      (9) establish reimbursement mechanisms for the Children’s
33   Medical Services network;
34      (10) establish Children’s Medical Services network standards
35   and credentialing requirements for health care providers and health
36   care services;
37      (11) serve as a provider and principal case manager for children
38   with special health care needs under Titles XIX and XXI of the
39   Social Security Act;
40      (12) monitor the provision of health services in the program,
41   including the utilization and quality of health services;
42      (13) administer the Children with Special Health Care Needs
43   program in accordance with Title V of the Social Security Act;

     [4212]                           4
 1     (14) establish and operate a grievance resolution process for
 2   participants and health care providers;
 3     (15) maintain program integrity in the Children’s Medical
 4   Services program;
 5     (16) receive and manage health care premiums, capitation
 6   payments, and funds from federal, state, local, and private entities
 7   for the program;
 8     (17) appoint health care consultants for the purpose of providing
 9   peer review and making recommendations to enhance the delivery
10   and quality of services in the Children’s Medical Services
11   program;
12     (18) make rules to carry out the provisions of this act.
13
14      Section 44-82-25. (A) The Children’s Medical Services
15   program shall have a central office and area offices. The director
16   of the program must be a licensed physician appointed by the
17   director of the department who has specialized training and
18   experience in the provision of health care to children and who has
19   recognized skills in leadership and the promotion of children’s
20   health programs.
21      (B) The director of the department, in consultation with the
22   program director, shall designate Children’s Medical Services area
23   offices to perform operational activities including, but not limited
24   to:
25        (1) providing case management services for the network;
26        (2) providing local oversight of the program;
27        (3) determining an individual’s medical and financial
28   eligibility for the program;
29        (4) participating in the determination of a level of care and
30   medical complexity for long-term care services;
31        (5) authorizing services in the program and developing
32   spending plans;
33        (6) participating in the development of treatment plans;
34        (7) taking part in the resolution of complaints and grievances
35   from participants and health care providers.
36      (C) Each Children’s Medical Services area office shall be
37   directed by a licensed physician who has specialized training and
38   experience in the provision of health care to children. The director
39   of a Children’s Medical Services area office shall be appointed by
40   the director of the program.
41



     [4212]                           5
 1      Section 44-82-30. (A) The department shall establish the
 2   medical criteria to determine if an applicant for the Children’s
 3   Medical Services program is an eligible individual.
 4      (B) The following individuals are financially eligible for the
 5   program:
 6         (1) a high-risk pregnant female who is eligible for
 7   Medicaid;
 8         (2) a child with special health care needs from birth to age
 9   twenty-one years who is eligible for Medicaid;
10         (3) a child with special health care needs from birth to age
11   nineteen years who is eligible for a program under Title XXI of the
12   Social Security Act;
13         (4) a child with special health care needs from birth to age
14   twenty-one years whose projected annual cost of care adjusts the
15   family income to Medicaid financial criteria. In cases where the
16   family income is adjusted based on a projected annual cost of care,
17   the family shall participate financially in the cost of care based on
18   criteria established by the department;
19         (5) a child with special health care needs as defined in Title
20   V of the Social Security Act relating to children with special health
21   care needs.
22      (C) The department shall determine the financial and medical
23   eligibility of children for the program. The department shall also
24   determine the financial ability of the parents, or persons or other
25   agencies having legal custody over such individuals, to pay the
26   costs of health services under the program. The department may
27   pay reasonable travel expenses related to the determination of
28   eligibility for or the provision of health services.
29      (D) Any child who has been provided with surgical or medical
30   care or treatment under this article prior to being adopted shall
31   continue to be eligible to be provided with such care or treatment
32   after his or her adoption, regardless of the financial ability of the
33   persons adopting the child.
34
35      Section 44-82-35. Benefits provided under the program shall
36   the same benefits provided to children as specified in the
37   mandatory and optional Medicaid Services in the State Medicaid
38   Plan. The department may offer additional benefits for early
39   intervention services, respite services, genetic testing, genetic and
40   nutritional counseling, and parent support services, if such services
41   are determined to be medically necessary. No child or person
42   determined eligible for the program who is eligible under Title
43   XIX or Title XXI of the Social Security Act shall receive any

     [4212]                            6
 1   service other than an initial health care screening or treatment of an
 2   emergency medical condition until such child or person is enrolled
 3   in Medicaid or a Title XXI program.
 4
 5      Section 44-82-40. (A) The department shall establish the
 6   criteria to designate health care providers to participate in the
 7   Children’s Medical Services network. The department shall follow,
 8   whenever available, national guidelines for selecting health care
 9   providers to serve children with special health care needs.
10      (B) The department shall require that all health care providers
11   under contract with the program be duly licensed in the State, if
12   such licensure is available, and meet such criteria as may be
13   established by the department.
14      (C) The department may initiate agreements with other state or
15   local governmental programs or institutions for the coordination of
16   health care to eligible individuals receiving services from such
17   programs or institutions.
18
19      Section 44-82-45. (A) The department shall reimburse health
20   care providers for services rendered through the Children’s
21   Medical Services network using cost-effective methods, including,
22   but not limited to, capitation, discounted fee-for-service, unit costs,
23   and cost reimbursement. Medicaid reimbursement rates shall be
24   utilized to the maximum extent possible, where applicable.
25      (B) Reimbursement to the Children’s Medical Services
26   program for services provided to children with special health care
27   needs who participate in the South Carolina Kidcare program
28   pursuant to Article 3 and who are not Medicaid recipients shall be
29   on a capitated basis.
30
31     Section 44-82-50. (A) The program shall apply managed care
32   methods to ensure the efficient operation of the Children’s Medical
33   Services network. Such methods include, but are not limited to,
34   capitation payments, utilization management and review, prior
35   authorization, and case management.
36     (B) The components of the network are:
37        (1) qualified primary care physicians who shall serve as the
38   gatekeepers and who shall be responsible for the provision or
39   authorization of health services to an eligible individual who is
40   enrolled in the Children’s Medical Services network;
41        (2) comprehensive specialty care arrangements to provide
42   acute care, specialty care, long-term care, and chronic disease
43   management for eligible individuals;

     [4212]                             7
 1        (3) case management services.
 2     (C) The Children’s Medical Services network may contract
 3   with school districts for the provision of school-based services,
 4   where available, for Medicaid-eligible children who are enrolled in
 5   the Children’s Medical Services network.
 6
 7     Section 44-82-55. The department is authorized to establish
 8   health care provider agreements for participation in the Children’s
 9   Medical Services program.
10
11     Section 44-82-60. The Children’s Medical Services program
12   shall develop quality of care and service integration standards and
13   reporting requirements for health care providers that participate in
14   the Children’s Medical Services program. The program shall
15   ensure that these standards are not duplicative of other standards
16   and requirements for health care providers.
17
18      Section 44-82-65. The department shall adopt and implement a
19   system to provide assistance to eligible individuals and health care
20   providers to resolve complaints and grievances. To the greatest
21   extent possible, the department shall use existing grievance
22   reporting and resolution processes. The department shall ensure
23   that the system developed for the Children’s Medical Services
24   program does not duplicate existing grievance reporting and
25   resolution processes.
26
27      Section 44-82-70. The department shall operate a system to
28   oversee the activities of Children’s Medical Services program
29   participants, and health care providers and their representatives, to
30   prevent fraudulent and abusive behavior, overutilization and
31   duplicative utilization, and neglect of participants and to recover
32   overpayments as appropriate. The department shall refer incidents
33   of suspected fraud and abuse, and overutilization and duplicative
34   utilization, to the appropriate regulatory agency.
35
36      Section 44-82-75. (A) The department may initiate, fund, and
37   conduct research and evaluation projects to improve the delivery of
38   children’s medical services. The department may cooperate with
39   public and private agencies engaged in work of a similar nature.
40      (B) The Children’s Medical Services network shall be included
41   in any evaluation conducted in accordance with the provisions of
42   Title XXI of the Social Security Act.
43

     [4212]                            8
 1      Section 44-82-80. (A) The director of the department shall
 2   appoint a Statewide Children’s Medical Services Network
 3   Advisory Council for the purpose of acting as an advisory body to
 4   the department. The duties of the council include, but are not be
 5   limited to:
 6        (1) recommending standards and credentialing requirements
 7   for health care providers rendering health services to Children’s
 8   Medical Services network participants;
 9        (2) making recommendations to the Director of the
10   Children’s Medical Services program concerning the selection of
11   health care providers for the Children’s Medical Services network;
12        (3) reviewing and making recommendations concerning
13   network health care provider or participant disputes that are
14   brought to the attention of the advisory council;
15        (4) providing input to the Children’s Medical Services
16   program on the policies governing the Children’s Medical Services
17   network;
18        (5) reviewing the financial reports and financial status of the
19   network and making recommendations concerning the methods of
20   payment and cost controls or the network;
21        (6) reviewing and recommending the scope of benefits for
22   the network;
23        (7) reviewing network performance measures and outcomes
24   and making recommendations for improvements to the network
25   and its maintenance and collection of data and information.
26      (B) The council shall be composed of twelve members
27   representing the private health care provider sector, families with
28   children who have special health care needs, the Department of
29   Health and Human Services, the Department of Insurance, the
30   South Carolina Chapter of the American Academy of Pediatrics,
31   an academic health center pediatric program, and the health
32   insurance industry. Members shall be appointed for four-year,
33   staggered terms. In no case shall an employee of the Department of
34   Health serve as a member or as an ex officio member of the
35   advisory council. A vacancy shall be filled for the remainder of the
36   unexpired term in the same manner as the original appointment. A
37   member may not be appointed to more than two consecutive terms.
38   However, a member may be reappointed after being off the council
39   for at least two years.
40      (C) Members shall receive no compensation, but shall be
41   reimbursed for per diem, mileage and subsistence as provided by
42   law for members of State boards, committees, and commissions.
43

     [4212]                           9
 1      Section 44-82-85. The director of the department may establish
 2   technical advisory panels to assist in developing specific policies
 3   and procedures for the Children’s Medical Services program.
 4
 5
 6   SECTION 2. The 1976 Code is amended by adding:
 7
 8                                Article 3
 9
10                    South Carolina Kidcare Program
11
12     Section 44-82-305. This article may be cited as the ‘South
13   Carolina Kidcare Act’.
14
15      Section 44-82-310. As used in this article:
16      (1) ‘Actuarially equivalent’ means that:
17         (a) the aggregate value of the benefits included in health
18   benefits coverage is equal to the value of the benefits in the
19   benchmark benefit plan; and
20         (b) the benefits included in health benefits coverage are
21   substantially similar to the benefits included in the benchmark
22   benefit plan, except that preventive health services must be the
23   same as in the benchmark benefit plan.
24      (2) ‘Applicant’ means a parent who applies for determination
25   of eligibility for health benefits coverage.
26      (3) ‘Benchmark benefit plan’ means the form and level of
27   health benefits coverage established in Section 44-82-335 .
28      (4) ‘Child’ means any person under nineteen years of age.
29      (5) ‘Child with special health care needs’ means a child whose
30   serious or chronic physical or developmental condition requires
31   extensive preventive and maintenance care beyond that required by
32   typically healthy children. Health care utilization by such a child
33   exceeds the statistically expected usage of the normal child
34   adjusted for chronological age, and such a child often needs
35   complex care requiring multiple providers, rehabilitation services,
36   and specialized equipment in a number of different settings.
37      (6) ‘Children’s Medical Services network’ or ‘network’ means
38   a statewide managed care service system as defined in Section
39   44-82-15.
40      (7) ‘Community rate’ means a method used to develop
41   premiums for a health insurance plan that spreads financial risk
42   across a large population and allows adjustments only for age,
43   gender, family composition, and geographic area.

     [4212]                          10
 1      (8) ‘DHHS’ means the Department of Health and Human
 2   Services.
 3      (9) ‘Department’ means the Department of Health.
 4      (10) ‘Enrollee’ means a child who has been determined eligible
 5   for and is receiving coverage under this article.
 6      (11) ‘Enrollment ceiling’ means the maximum number of
 7   children receiving premium assistance payments, excluding
 8   children enrolled in Medicaid, that may be enrolled at any time in
 9   the South Carolina Kidcare program. The maximum number shall
10   be established annually in the general appropriations act or by
11   general law.
12      (12) ‘Family’ means the group or the individuals whose income
13   is considered in determining eligibility for the South Carolina
14   Kidcare program. The family includes a child with a custodial
15   parent or caretaker relative who resides in the same house or living
16   unit. The family may also include other individuals whose income
17   and resources are considered in whole or in part in determining
18   eligibility of the child.
19      (13) ‘Family income’ means cash received at periodic intervals
20   from any source, such as wages, benefits, contributions, or rental
21   property. Income also may include any money that is counted as
22   income under the Family Independence Program administered by
23   the Department of Social Services.
24      (14) ‘Guarantee issue’ means that health benefits coverage must
25   be offered to an individual regardless of the individual’s health
26   status, preexisting condition, or claims history.
27      (15) ‘Health benefits coverage’ means protection that provides
28   payment of benefits for covered health care services or that
29   otherwise provides, either directly or through arrangements with
30   other persons, covered health care services on a prepaid per capita
31   basis or on a prepaid aggregate fixed-sum basis.
32      (16) ‘Health insurance plan’ means health benefits coverage
33   under a health plan offered by any certified health maintenance
34   organization or authorized health insurer, except a plan that is
35   limited to the following: a limited benefit, specified disease, or
36   specified accident; hospital indemnity; accident only; limited
37   benefit convalescent care; Medicare supplement; credit disability;
38   dental; vision; long-term care; disability income; coverage issued
39   as a supplement to another health plan; workers’ compensation
40   liability or other insurance; or motor vehicle medical payment
41   only.



     [4212]                           11
 1      (17) ‘Medicaid’ means the medical assistance program
 2   authorized by Title XIX of the Social Security Act, and regulations
 3   thereunder, and administered in this State by the DHHS.
 4      (18) ‘Medically necessary’ means the use of any medical
 5   treatment, service, equipment, or supply necessary to palliate the
 6   effects of a terminal condition, or to prevent, diagnose, correct,
 7   cure, alleviate, or preclude deterioration of a condition that
 8   threatens life, causes pain or suffering, or results in illness or
 9   infirmity and which is:
10        (a) consistent with the symptom, diagnosis, and treatment of
11   the enrollee’s condition;
12        (b) provided in accordance with generally accepted
13   standards of medical practice;
14        (c) not primarily intended for the convenience of the
15   enrollee, the enrollee’s family, or the health care provider;
16        (d) the most appropriate level of supply or service for the
17   diagnosis and treatment of the enrollee’s condition; and
18        (e) approved by the appropriate medical body or health care
19   specialty involved as effective, appropriate, and essential for the
20   care and treatment of the enrollee’s condition.
21      (19) ‘Medikids’ means a component of the South Carolina
22   Kidcare program of medical assistance authorized by Title XXI of
23   the Social Security Act, and regulations thereunder, and as
24   administered by Department of Health and Human Services.
25      (20) ‘Preexisting condition exclusion’ means, with respect to
26   coverage, a limitation or exclusion of benefits relating to a
27   condition based on the fact that the condition was present before
28   the date of enrollment for such coverage, whether or not any
29   medical advice, diagnosis, care, or treatment was recommended or
30   received before the date.
31      (21) ‘Premium’ means the entire cost of a health insurance plan,
32   including the administration fee or the risk assumption charge.
33      (22) ‘Premium assistance payment’ means the monthly
34   consideration paid by the agency per enrollee in the South Carolina
35   Kidcare program towards health insurance premiums.
36      (23) ‘Program’ means the South Carolina Kidcare program, the
37   medical assistance program authorized by Title XXI of the Social
38   Security Act as part of the federal Balanced Budget Act of 1997.
39      (24) ‘Resident’ means a United States citizen, or qualified alien,
40   who is domiciled in this State.
41      (25) ‘Substantially similar’ means that, with respect to
42   additional services as defined in Section 2103(c)(2) of Title XXI of
43   the Social Security Act, these services must have an actuarial value

     [4212]                           12
 1   equal to at least seventy-five percent of the actuarial value of the
 2   coverage for that service in the benchmark benefit plan and, with
 3   respect to the basic services as defined in Section 2103(c)(1) of
 4   Title XXI of the Social Security Act, these services must be the
 5   same as the services in the benchmark benefit plan.
 6
 7     Section 44-82-315. The South Carolina Kidcare program is
 8   created to provide a defined set of health benefits to previously
 9   uninsured, low-income children through the establishment of a
10   variety of affordable health benefits coverage options from which
11   families may select coverage and through which families may
12   contribute financially to the health care of their children.
13
14     Section 44-82-320. The South Carolina Kidcare program
15   includes health benefits coverage provided to children through:
16     (1) Medicaid;
17     (2) Medikids as created in Section 44-82-325;
18     (3) The South Carolina Healthy Kids Corporation as created in
19   Section 44-82-520;
20     (4) Employer-sponsored group health insurance plans approved
21   under; and
22     (5) The Children’s Medical Services network established in
23   Article 1. Except for coverage under the Medicaid program,
24   coverage under the South Carolina Kidcare program is not an
25   entitlement. No cause of action shall arise against the State, the
26   department, the South Carolina Department of Social Services, or
27   the DHHS for failure to make health services available to any
28   person under this article.
29
30      Section 44-82-325. (A) The Medikids program component is
31   created in the Department of Health and Human Services to
32   provide health care services under the South Carolina Kidcare
33   program to eligible children using the administrative structure and
34   provider network of the Medicaid program.
35      (B) The director of the department shall appoint an
36   administrator of the Medikids program component. The
37   Department of Health and Human Services is designated as the
38   state agency authorized to make payments for medical assistance
39   and related services for the Medikids program component of the
40   South Carolina Kidcare program. Payments shall be made, subject
41   to any limitations or directions in the general appropriations act,
42   only for covered services provided to eligible children by qualified
43   health care providers under the South Carolina Kidcare program.

     [4212]                           13
 1      (C) The Medikids program component shall not be subject to
 2   the licensing requirements of the South Carolina Insurance
 3   Department or regulations of the department.
 4      (D) Benefits provided under the Medikids program component
 5   shall be the same benefits provided to children as specified in the
 6   State Medicaid plan for mandatory and optional Medicaid services.
 7      (E) A child who is under the age of five years is eligible to
 8   enroll in the Medikids program component of the South Carolina
 9   Kidcare program, if the child is a member of a family that has a
10   family income which exceeds the Medicaid applicable income
11   level but which is equal to or below two hundred percent of the
12   current federal poverty level. In determining the eligibility of the
13   child, an assets test is not required. A child who is eligible for
14   Medikids may elect to enroll in South Carolina Healthy Kids
15   coverage or employer-sponsored group coverage. However, a child
16   who is eligible for Medikids may participate in the South Carolina
17   Healthy Kids program only if the child has a sibling participating
18   in the South Carolina Healthy Kids program and the child’s county
19   of residence permits such enrollment.
20      (F) Enrollment in the Medikids program component may only
21   occur during periodic open enrollment periods as specified by
22   DHHS. During the first twelve months of the program, there must
23   be at least one, but no more than three, open enrollment periods.
24   The initial open enrollment period shall be for ninety days, and
25   subsequent open enrollment periods during the first year of
26   operation of the program shall be for thirty days. After the first
27   year of the program, DHHS shall determine the frequency and
28   duration of open enrollment periods. An applicant shall apply for
29   enrollment in the Medikids program component and proceed
30   through the eligibility determination process at any time
31   throughout the year. However, enrollment in Medikids may not
32   begin until the next open enrollment period; and a child may not
33   receive services under the Medikids program until the child is
34   enrolled in a managed care plan. In addition, once determined
35   eligible, an applicant may receive choice counseling and select a
36   managed care plan
37      (G) DHHS shall establish a special enrollment period of thirty
38   days duration for any newborn child who is eligible for Medikids,
39   or for any child who is enrolled in Medicaid if the child loses
40   Medicaid eligibility and becomes eligible for Medikids, or for any
41   child who is enrolled in Medikids if the child moves to another
42   county that is not within the coverage area of the child’s Medikids
43   managed care plan department.

     [4212]                           14
 1      (H) DHHS shall establish enrollment criteria that includes
 2   penalties or waiting periods of not fewer than thirty days for
 3   reinstatement of coverage upon voluntary cancellation for
 4   nonpayment of premiums.
 5
 6      Section 44-82-330. (A) A child whose family income is equal
 7   to or below two hundred percent of the federal poverty level is
 8   eligible for the South Carolina Kidcare program as provided in this
 9   section. In determining the eligibility of a child, an assets test is
10   not required.
11      (B) A child who is not eligible for Medicaid, but who is eligible
12   for the South Carolina Kidcare program, may obtain coverage
13   under any of the other types of health benefits coverage authorized
14   in this article if the coverage is approved and available in the
15   county in which the child resides. However, a child who is eligible
16   for Medikids may participate in the South Carolina Healthy Kids
17   program, as provided for in Article 5, only if the child has a sibling
18   participating in the South Carolina Healthy Kids program and the
19   child’s county of residence permits such enrollment.
20      (C) A child who is eligible for the South Carolina Kidcare
21   program who is a child with special health care needs, as
22   determined through a risk-screening instrument, is eligible for
23   health benefits coverage from and may be referred to the
24   Children’s Medical Services network.
25      (D) The following children are not eligible to receive premium
26   assistance for health benefits coverage under this article:
27        (1) a child who is eligible for coverage under a state health
28   benefit plan on the basis of a family member’s employment with a
29   public agency in the State;
30        (2) a child who is covered under a group health benefit plan
31   or under other health insurance coverage, excluding coverage
32   provided under the South Carolina Healthy Kids Corporation as
33   established under Article 5;
34        (3) a child who is seeking premium assistance for
35   employer-sponsored group coverage, if the child has been covered
36   by the same employer’s group coverage during the six months
37   prior to the family’s submitting an application for determination of
38   eligibility under the South Carolina Kidcare program;
39        (4) a child who is an alien, but who does not meet the
40   definition of qualified alien, in the United States; or
41        (5) a child who is an inmate of a public institution or a
42   patient in an institution for mental diseases.


     [4212]                            15
 1      (E) A child whose family income is above two hundred percent
 2   percent of the federal poverty level or a child who is excluded
 3   under the provisions of subsection (D) may participate in the South
 4   Carolina Kidcare program excluding the Medicaid program but is
 5   subject to the following provisions:
 6        (1) The family is not eligible for premium assistance
 7   payments and must pay the full cost of the premium including any
 8   administrative costs.
 9        (2) DHHS is authorized to place limits on enrollment in
10   Medikids by these children in order to avoid adverse selection.
11   The number of children participating in Medikids whose family
12   income exceeds two hundred percent of the federal poverty level
13   must not exceed ten percent of total enrollees in the Medikids
14   program.
15        (3) The board of directors of the South Carolina Healthy
16   Kids Corporation, established pursuant to Article 5 is authorized to
17   place limits on enrollment of these children in order to avoid
18   adverse selection. In addition, the board is authorized to offer a
19   reduced benefit package to these children in order to limit program
20   costs for such families. The number of children participating in the
21   South Carolina Healthy Kids program whose family income
22   exceeds two hundred percent of the federal poverty level must not
23   exceed ten percent of total enrollees in the South Carolina Healthy
24   Kids program.
25        (4) Children described in this subsection are not counted in
26   the annual enrollment ceiling for the South Carolina Kidcare
27   program.
28      (F) Once a child is determined eligible for the South Carolina
29   Kidcare program, the child is eligible for coverage under the
30   program for six months without a redetermination or reverification
31   of eligibility, if the family continues to pay the applicable
32   premium. A child who has not attained the age of five years and
33   who has been determined eligible for the Medicaid program is
34   eligible for coverage for twelve months without a redetermination
35   or reverification of eligibility.
36
37     Section 44-82-335. (A) For purposes of the South Carolina
38   Kidcare program, benefits available under Medicaid and Medikids
39   include those goods and services provided under the medical
40   assistance program authorized by Title XIX of the Social Security
41   Act, and regulations thereunder, as administered in this State by
42   DHHS. This includes those mandatory and optional Medicaid
43   services authorized under the State Medicaid Plan, rendered on

     [4212]                           16
 1   behalf of eligible individuals by qualified providers, in accordance
 2   with federal requirements for Title XIX, subject to any limitations
 3   or directions provided for in the general appropriations act or state
 4   law, and according to methodologies and limitations set forth in
 5   DHHS regulations and policy manuals and handbooks
 6   incorporated by reference thereto.
 7      (B) In order for health benefits coverage to qualify for premium
 8   assistance payments for an eligible child under the health benefits
 9   coverage, except for coverage under Medicaid and Medikids, must
10   include the following minimum benefits, as medically necessary:
11        (1) Preventive health services including:
12           (a) well-child care, including services recommended in
13   the Guidelines for Health Supervision of Children and Youth as
14   developed by the American Academy of Pediatrics;
15           (b) immunizations and injections;
16           (c) health education counseling and clinical services;
17           (d) vision screening; and
18           (e) hearing screening.
19        (2) All covered services provided for the medical care and
20   treatment of an enrollee who is admitted as an inpatient to a
21   hospital except:
22           (a) all admissions must be authorized by the enrollee’s
23   health benefits coverage provider;
24           (b) the length of the patient stay must be determined based
25   on the medical condition of the enrollee in relation to the necessary
26   and appropriate level of care;
27           (c) room and board may be limited to semiprivate
28   accommodations, unless a private room is considered medically
29   necessary or semiprivate accommodations are not available;
30           (d) admissions for rehabilitation and physical therapy are
31   limited to fifteen days for each contract year.
32        (3) Visits to an emergency room or other licensed facility if
33   needed immediately due to an injury or illness and delay means
34   risk of permanent damage to the enrollee’s health.
35        (4) Maternity and newborn care including prenatal and
36   postnatal care, with the following limitations:
37           (a) coverage may be limited to the fee for vaginal
38   deliveries; and
39           (b) initial inpatient care for newborn infants of enrolled
40   adolescents shall be covered, including normal newborn care,
41   nursery charges, and the initial pediatric or neonatal examination,
42   and the infant may be covered for up to 3 days following birth.


     [4212]                           17
 1         (5) Organ transplantation services including pretransplant,
 2   transplant, and postdischarge services and treatment of
 3   complications after transplantation for transplants deemed
 4   necessary and appropriate
 5         (6) Outpatient services including preventive, diagnostic,
 6   therapeutic, palliative care services, and other services provided to
 7   an enrollee in the outpatient portion of a health facility except that:
 8           (a) services must be authorized by the enrollee’s health
 9   benefits coverage provider; and
10           (b) treatment for temporomandibular joint disease (TMJ)
11   is specifically excluded.
12         (7) Behavioral health services:
13           (a) mental health benefits including:
14              (1) inpatient services, limited to not more than thirty
15   inpatient days for each contract year for psychiatric admissions, or
16   residential services in licensed facilities in lieu of inpatient
17   psychiatric admissions; however, a minimum of ten of the thirty
18   days must be available only for inpatient psychiatric services when
19   authorized by a physician; and
20              (2) outpatient services, including outpatient visits for
21   psychological or psychiatric evaluation, diagnosis, and treatment
22   by a licensed mental health professional, limited to a maximum of
23   forty outpatient visits each contract year.
24           (b) Substance abuse services include:
25              (1) inpatient services, limited to not more than seven
26   inpatient days per contract year for medical detoxification only and
27   thirty days of residential services; and
28              (2) outpatient services, including evaluation, diagnosis,
29   and treatment by a licensed practitioner, limited to a maximum of
30   forty outpatient visits for each contract year.
31         (8) Durable medical equipment including equipment and
32   devices that are medically indicated to assist in the treatment of a
33   medical condition and specifically prescribed as medically
34   necessary, with the following limitations:
35           (a) low-vision and telescopic aides are not included;
36           (b) corrective lenses and frames may be limited to one
37   pair every two years, unless the prescription or head size of the
38   enrollee changes;
39           (c) hearing aids shall be covered only when medically
40   indicated to assist in the treatment of a medical condition;
41           (d) Covered prosthetic devices include artificial eyes and
42   limbs, braces, and other artificial aids.


     [4212]                            18
 1         (9) Health practitioner services including services and
 2   procedures rendered to an enrollee when performed to diagnose
 3   and treat diseases, injuries, or other conditions, including care
 4   rendered by health practitioners acting within the scope of their
 5   practice, with the following exceptions:
 6            (a) chiropractic services shall be provided in the same
 7   manner as in the State Medicaid Plan;
 8            (b) podiatric services may be limited to one visit per day
 9   totaling two visits per month for specific foot disorders.
10         (10) Home health services including prescribed home visits
11   by both registered and licensed practical nurses to provide skilled
12   nursing services on a part-time intermittent basis, subject to the
13   following limitations:
14            (a) coverage may be limited to include skilled nursing
15   services only;
16            (b) meals, housekeeping, and personal comfort items may
17   be excluded; and
18            (c) private duty nursing is limited to circumstances where
19   such care is medically necessary.
20         (11) Hospice services include reasonable and necessary
21   services for palliation or management of an enrollee’s terminal
22   illness, with the following exceptions:
23         (a) Once a family elects to receive hospice care for an
24   enrollee, other services that treat the terminal condition will not be
25   covered; and
26         (b) Services required for conditions totally unrelated to the
27   terminal condition are covered to the extent that the services are
28   included in this section.
29         (12) Laboratory and x-ray services including diagnostic
30   testing, which includes clinical radiologic, laboratory, and other
31   diagnostic tests.
32         (13) Nursing facility services including regular nursing
33   services, rehabilitation services, drugs and biologicals, medical
34   supplies, and the use of appliances and equipment furnished by the
35   facility, with the following limitations:
36            (a) all admissions must be authorized by the health
37   benefits coverage provider;
38            (b) the length of the patient stay shall be determined based
39   on the medical condition of the enrollee in relation to the necessary
40   and appropriate level of care, but is limited to not more than one
41   hundred days for each contract year;



     [4212]                            19
 1            (c) room and board may be limited to semiprivate
 2   accommodations, unless a private room is considered medically
 3   necessary or semiprivate accommodations are not available;
 4            (d) specialized treatment centers and independent kidney
 5   disease treatment centers are excluded;
 6            (e) private duty nurses, television, and custodial care are
 7   excluded;
 8            (f) admissions for rehabilitation and physical therapy are
 9   limited to fifteen days for each contract year.
10         (14) Prescribed drugs within these conditions:
11            (a) coverage shall include drugs prescribed for the
12   treatment of illness or injury when prescribed by a licensed health
13   practitioner acting within the scope of his or her practice;
14            (b) prescribed drugs may be limited to generics if
15   available and brand name products if a generic substitution is not
16   available, unless the prescribing licensed health practitioner
17   indicates that a brand name is medically necessary;
18            (c) prescribed drugs covered under this section shall
19   include all prescribed drugs covered under the State Medicaid
20   Plan.
21         (15) Therapy services including rehabilitative services, which
22   include occupational, physical, respiratory, and speech therapies,
23   with the following limitations:
24            (a) services must be for short-term rehabilitation where
25   significant improvement in the enrollee’s condition will result; and
26            (b) services shall be limited to not more than twenty-four
27   treatment sessions within a sixty-day period for each episode or
28   injury, with the sixty-day period beginning with the first treatment.
29         (16) Transportation      services     including      emergency
30   transportation required in response to an emergency situation.
31         (17) Lifetime maximum of one million for each covered
32   child.
33         (18) Cost-sharing provisions must comply with Section
34   44-82-340.
35         (19) The following exclusions apply:
36            (a) experimental or investigational procedures that have
37   not been clinically proven by reliable evidence are excluded;
38            (b) services performed for cosmetic purposes only or for
39   the convenience of the enrollee are excluded; and
40            (c) abortion may be covered only if necessary to have the
41   life of the mother or if the pregnancy is the result of an act of rape
42   or incest.


     [4212]                            20
 1      (C) This section sets the minimum benefits that must be
 2   included in any health benefits coverage, other than Medicaid or
 3   Medikids coverage, offered under this article. Health benefits
 4   coverage may include additional benefits not included under this
 5   subsection, but may not include benefits excluded under this
 6   section. Health benefits coverage may extend any limitations
 7   beyond the minimum benefits described in this section. Except for
 8   the Children’s Medical Services network, the agency may not
 9   increase the premium assistance payment for either additional
10   benefits provided beyond the minimum benefits described in this
11   section or the imposition of less restrictive service limitations.
12      (D) Health insurers, health maintenance organizations, and their
13   agents are subject to the provisions of the South Carolina
14   Insurance Code, except for any provisions waived in this section.
15   Except as expressly provided in this section, a law requiring
16   coverage for a specific health care service or benefit, or a law
17   requiring reimbursement, utilization, or consideration of a specific
18   category of licensed health care practitioner, does not apply to a
19   health insurance plan policy or contract offered or delivered under
20   this article unless that law is made expressly applicable to such
21   policies or contracts. Notwithstanding any other provision of law,
22   a health maintenance organization may issue contracts providing
23   benefits equal to, exceeding, or actuarially equivalent to the benefit
24   plan authorized by this section.
25
26     Section 44-82-340. These limitations on premiums and
27   cost-sharing are established for the program:
28     (1) enrollees who receive coverage under the Medicaid
29   program may not be required to pay:
30        (a) Enrollment fees, premiums, or similar charges; or
31        (b) copayments, deductibles, coinsurance, or similar
32   charges;
33     (2) Enrollees in families with a family income equal to or
34   below one hundred fifty percent of the federal poverty level, who
35   are not receiving coverage under the Medicaid program, may not
36   be required to pay:
37        (a) enrollment fees, premiums, or similar charges that
38   exceed the maximum monthly charge permitted under Section
39   1916(b)(1) of the Social Security Act; or
40        (b) copayments, deductibles, coinsurance, or similar charges
41   that exceed a nominal amount, as determined consistent with
42   regulations referred to in Section 1916(a)(3) of the Social Security
43   Act. However, these charges may not be imposed for preventive

     [4212]                            21
 1   services, including well-baby and well-child care, age-appropriate
 2   immunizations, and routine hearing and vision screenings.
 3      (3) Enrollees in families with a family income above one
 4   hundred fifty percent of the federal poverty level, who are not
 5   receiving coverage under the Medicaid program or who are not
 6   eligible under Section 44-82-330(E), may be required to pay
 7   enrollment fees, premiums, copayments, deductibles, coinsurance,
 8   or similar charges on a sliding scale related to income, except that
 9   the total annual aggregate cost-sharing with respect to all children
10   in a family may not exceed five percent of the family’s income.
11   However, copayments, deductibles, coinsurance, or similar charges
12   may not be imposed for preventive services, including well-baby
13   and well-child care, age-appropriate immunizations, and routine
14   hearing and vision screenings.
15
16     Section 44-82-345. In order for health insurance coverage to
17   qualify for premium assistance payments for an eligible child
18   under this article, the health benefits coverage must:
19     (1) be certified by the Department of Insurance as meeting,
20   exceeding, or being actuarially equivalent to the benchmark benefit
21   plan;
22     (2) be guarantee issued;
23     (3) be community rated;
24     (4) not impose any preexisting condition exclusion for covered
25   benefits; however, group health insurance plans may permit the
26   imposition of a preexisting condition exclusion;
27     (5) comply with the applicable limitations on premiums and
28   cost-sharing in Section 44-82-340;
29     (6) comply with the quality assurance and access standards
30   developed under Section 44-82-370; and
31     (7) establish periodic open enrollment periods, which may not
32   occur more frequently than quarterly.
33
34      Section 44-82-350. The Department of Health and Human
35   Services, in consultation with the Department of Health and
36   Environmental Control, the Department of Social Services, and the
37   South Carolina Healthy Kids Corporation, shall by January 1 of
38   each year submit to the Governor and the General Assembly a
39   report of the South Carolina Kidcare program. In addition to the
40   items specified under Section 2108 of Title XXI of the Social
41   Security Act, the report shall include an assessment of access to
42   health care, as well as the following:


     [4212]                           22
 1      (1) an assessment of the operation of the program, including
 2   the progress made in reducing the number of uncovered
 3   low-income children;
 4      (2) an assessment of the effectiveness in increasing the number
 5   of children with creditable health coverage;
 6      (3) the characteristics of the children and families assisted
 7   under the program, including ages of the children, family income,
 8   and access to or coverage by other health insurance prior to the
 9   program and after disenrollment from the program;
10      (4) the quality of health coverage provided, including the types
11   of benefits provided;
12      (5) the amount and level, including payment of part or all of
13   any premium, of assistance provided;
14      (6) the average length of coverage of a child under the
15   program;
16      (7) the program’s choice of health benefits coverage and other
17   methods used for providing child health assistance;
18      (8) the sources of nonfederal funding used in the program;
19      (9) an assessment of the effectiveness of Medikids, Children’s
20   Medical Services network, and other public and private programs
21   in the State in increasing the availability of affordable quality
22   health insurance and health care for children;
23      (10) a review and assessment of state activities to coordinate the
24   program with other public and private programs;
25      (11) an analysis of changes and trends in the State that affect the
26   provision of health insurance and health care to children;
27      (12) a description of any plans the State has for improving the
28   availability of health insurance and health care for children;
29      (13) recommendations for improving the program;
30      (14) other studies as necessary.
31
32      Section 44-82-360. In order to implement this article, the
33   following agencies shall have the following duties:
34      (1) the Department of Social Services shall:
35        (a) develop a simplified eligibility application mail-in form
36   to be used for determining the eligibility of children for coverage
37   under the South Carolina Kidcare program, in consultation with
38   DHHS, the Department of Health, and the South Carolina Healthy
39   Kids Corporation. The simplified eligibility application form must
40   include an item that provides an opportunity for the applicant to
41   indicate whether coverage is being sought for a child with special
42   health care needs. Families applying for children’s Medicaid


     [4212]                            23
 1   coverage must also be able to use the simplified application form
 2   without having to pay a premium;
 3        (b) establish and maintain the eligibility determination
 4   process under the program except as specified in item (5). The
 5   department shall directly, or through the services of a contracted
 6   third-party administrator, establish and maintain a process for
 7   determining eligibility of children for coverage under the program.
 8   The eligibility determination process must be used solely for
 9   determining eligibility of applicants for health benefits coverage
10   under the program. The eligibility determination process must
11   include an initial determination of eligibility for any coverage
12   offered under the program, as well as a redetermination or
13   reverification of eligibility each subsequent six months. A child
14   who has not attained the age of five years and who has been
15   determined eligible for the Medicaid program is eligible for
16   coverage for twelve months without a redetermination or
17   reverification of eligibility. In conducting an eligibility
18   determination, the department shall determine if the child has
19   special health care needs;
20        (c) inform      program      applicants      about    eligibility
21   determinations and provide information about eligibility of
22   applicants to Medicaid, Medikids, the Children’s Medical Services
23   network, and the South Carolina Healthy Kids Corporation, and to
24   insurers and their agents, through a centralized coordinating office;
25        (d) promulgate regulations necessary for conducting
26   program eligibility functions.
27      (2) The Department of Health and Environmental Control
28   shall:
29        (a) design an eligibility intake process for the program, in
30   coordination with the Department of Social Services, DHHS, and
31   the South Carolina Healthy Kids Corporation. The eligibility
32   intake process may include local intake points that are determined
33   by the Department of Health and Environmental Control in
34   coordination with the Department of Social Services;
35        (b) design and implement program outreach activities;
36        (c) chair a state-level coordinating council to review and
37   make recommendations concerning the implementation and
38   operation of the program. The coordinating council shall include
39   representatives from the department, the Department of Social
40   Services, DHHS, the South Carolina Healthy Kids Corporation,
41   the Department of Insurance, local government, health insurers,
42   health maintenance organizations, health care providers, families


     [4212]                            24
 1   participating in the program, and organizations representing
 2   low-income families;
 3         (d) in consultation with the South Carolina Healthy Kids
 4   Corporation and the Department of Social Services, establish a
 5   toll-free telephone line to assist families with questions about the
 6   program;
 7         (e) promulgate regulations necessary to implement outreach
 8   activities.
 9      (3) The Department of Health and Human Services shall:
10         (a) calculate the premium assistance payment necessary to
11   comply with the premium and cost-sharing limitations specified in
12      Section 44-82-340. The premium assistance payment for each
13   enrollee in a health insurance plan participating in the South
14   Carolina Healthy Kids Corporation shall equal the premium
15   approved by the South Carolina Healthy Kids Corporation and the
16   Department of Insurance, less any enrollee’s share of the premium
17   established within the limitations specified in Section 44-82-340.
18   The premium assistance payment for each enrollee in an
19   employer-sponsored health insurance plan approved under this
20   article shall equal the premium for the plan adjusted for any
21   benchmark benefit plan actuarial equivalent benefit rider approved
22   by the Department of Insurance, less any enrollee’s share of the
23   premium established within the limitations specified in Section
24   44-82-340. In calculating the premium assistance payment levels
25   for children with family coverage, the department shall set the
26   premium assistance payment levels for each child proportionately
27   to the total cost of family coverage;
28         (b) Annually calculate the program enrollment ceiling based
29   on estimated per-child premium assistance payments and the
30   estimated appropriation available for the program;
31         (c) make premium assistance payments to health insurance
32   plans on a periodic basis. The department may use its Medicaid
33   fiscal agent or a contracted third-party administrator in making
34   these payments. The agency may require health insurance plans
35   that participate in the Medikids program or employer-sponsored
36   group health insurance to collect premium payments from an
37   enrollee’s family. Participating health insurance plans shall report
38   premium payments collected on behalf of enrollees in the program
39   to the department in accordance with a schedule established by the
40   department;
41         (d) monitor compliance with quality assurance and access
42   standards;


     [4212]                           25
 1         (e) establish a mechanism for investigating and resolving
 2   complaints and grievances from program applicants, enrollees, and
 3   health benefits coverage providers, and maintain a record of
 4   complaints and confirmed problems;
 5         (f) approve health benefits coverage for participation in the
 6   program, following certification by the Department of Insurance;
 7         (g) promulgate regulations necessary for calculating
 8   premium assistance payment levels, calculating the program
 9   enrollment ceiling, making premium assistance payments,
10   monitoring access and quality assurance standards, investigating
11   and resolving complaints and grievances, administering the
12   Medikids program, and approving health benefits coverage. The
13   Department of Health and Human Services is designated the lead
14   state agency for Title XXI of the Social Security Act for purposes
15   of receipt of federal funds, for reporting purposes, and for ensuring
16   compliance with federal and state regulations.
17      (4) The Department of Insurance shall certify that health
18   benefits coverage plans that seek to provide services under the
19   South Carolina Kidcare program, except those offered through the
20   South Carolina Healthy Kids Corporation or the Children’s
21   Medical Services network, meet, exceed, or are actuarially
22   equivalent to the benchmark benefit plan and that health insurance
23   plans will be offered at an approved rate. In determining actuarial
24   equivalence of benefits coverage, the Department of Insurance and
25   health insurance plans must comply with the requirements of
26   Section 2103 of Title XXI of the Social Security Act. The
27   department shall promulgate regulations necessary for certifying
28   health benefits coverage plans.
29      (5) The South Carolina Healthy Kids Corporation shall retain
30   its functions authorized by law, including eligibility determination
31   for participation in the Healthy Kids program.
32      (6) The Department of Health and Human Services, the
33   Department of Health and Environmental Control, the Department
34   of Social Services, the South Carolina Healthy Kids Corporation,
35   and the Department of Insurance, after consultation with and
36   approval of the Speaker of the House of Representatives and the
37   President of the Senate, are authorized to make program
38   modifications that are necessary to overcome any objections of the
39   United States Department of Health and Human Services to obtain
40   approval of the state’s child health insurance plan under Title XXI
41   of the Social Security Act.
42


     [4212]                           26
 1      Section 44-82-365. The department shall develop a program, in
 2   conjunction with the Department of Education, the Department of
 3   Social Services, the Department of Health and Human Services,
 4   the South Carolina Healthy Kids Corporation, local governments,
 5   employers, and other stakeholders to identify low-income,
 6   uninsured children and, to the extent possible and subject to
 7   appropriation, refer them to the Department of Social Services for
 8   eligibility determination and provide parents with information
 9   about choices of health benefits coverage under the South Carolina
10   Kidcare program. These activities shall include, but are not limited
11   to, training community providers in effective methods of outreach;
12   conducting public information campaigns designed to publicize the
13   South Carolina Kidcare program, the eligibility requirements of the
14   program, and the procedures for enrollment in the program; and
15   maintaining public awareness of the South Carolina Kidcare
16   program. Special emphasis shall be placed on the identification of
17   minority children for referral to and participation in the South
18   Carolina Kidcare program.
19
20     Section 44-82-370. Except for Medicaid, the department, in
21   consultation with DHHS and the South Carolina Healthy Kids
22   Corporation, shall develop a minimum set of quality assurance and
23   access standards for all program components. The standards must
24   include a process for granting exceptions to specific requirements
25   for quality assurance and access. Compliance with the standards
26   shall be a condition of program participation by health benefits
27   coverage providers. These standards shall comply with the
28   provisions Title XXI of the Social Security Act.
29
30                                Article 5
31
32               South Carolina Healthy Kids Corporation
33
34     Section 44-82-505. This article may be cited as the South
35   Carolina Healthy Kids Corporation Act.’
36
37      Section 44-82-510. (A) The General Assembly finds that
38   increased access to health care services could improve children’s
39   health and reduce the incidence and costs of childhood illness and
40   disabilities among children in this State. Many children do not
41   have comprehensive, affordable health care services available. It is
42   the intent of the General Assembly that the South Carolina Healthy
43   Kids Corporation provide comprehensive health insurance

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 1   coverage to such children. The corporation is encouraged to
 2   cooperate with any existing health service programs funded by the
 3   public or the private sector.
 4      (B) It is the intent of the General Assembly that the South
 5   Carolina Healthy Kids Corporation serve as one of several
 6   providers of services to children eligible for medical assistance
 7   under Title XXI of the Social Security Act. Although the
 8   corporation may serve other children, the General Assembly
 9   intends the primary recipients of services provided through the
10   corporation be school-age children with a family income below
11   two hundred percent of the federal poverty level, who do not
12   qualify for Medicaid. It is also the intent of the General Assembly
13   that state and local government South Carolina Healthy Kids
14   funds, to the extent permissible under federal law, be used to
15   obtain matching federal dollars.
16
17     Section 44-82-515. Nothing in this article shall be construed
18   as providing an individual with an entitlement to health care
19   services. No cause of action shall arise against the State, the South
20   Carolina Healthy Kids Corporation, or a unit of local government
21   for failure to make health services available under this section.
22
23      Section 44-82-520. (A) There is created the South Carolina
24   Healthy Kids Corporation, a not-for-profit corporation which
25   operates on sites designated by the corporation.
26      (B) The South Carolina Healthy Kids Corporation shall phase
27   in a program to:
28        (1) organize school children groups to facilitate the
29   provision of comprehensive health insurance coverage to children;
30        (2) arrange for the collection of any family, local
31   contributions, or employer payment or premium, in an amount to
32   be determined by the board of directors, to provide for payment of
33   premiums for comprehensive insurance coverage and for the actual
34   or estimated administrative expenses procedures for the operation
35   of the corporation;
36        (3) establish,      with    consultation   from     appropriate
37   professional organizations, standards for preventive health services
38   and providers and comprehensive insurance benefits appropriate to
39   children; provided that such standards for rural areas shall not limit
40   primary care providers to board-certified pediatricians;
41        (4) establish eligibility criteria which children must meet in
42   order to participate in the program;


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 1         (5) establish procedures under which applicants to and
 2   participants in the program may have grievances reviewed by an
 3   impartial body and reported to the board of directors of the
 4   corporation;
 5         (6) establish participation criteria and, if appropriate,
 6   contract with an authorized insurer, health maintenance
 7   organization, or insurance administrator to provide administrative
 8   services to the corporation;
 9         (7) establish enrollment criteria which shall include penalties
10   or waiting periods of not fewer than sixty days for reinstatement of
11   coverage upon voluntary cancellation for nonpayment of family
12   premiums;
13         (8) if a space is available, establish a special open
14   enrollment period of thirty days’ duration for any child who is
15   enrolled in Medicaid or Medikids if such child loses Medicaid or
16   Medikids eligibility and becomes eligible for the South Carolina
17   Healthy Kids program;
18         (9) contract with authorized insurers or any provider of
19   health care services, meeting standards established by the
20   corporation, for the provision of comprehensive insurance
21   coverage to participants. Such standards shall include criteria
22   under which the corporation may contract with more than one
23   provider of health care services in program sites. Health plans shall
24   be selected through a competitive bid process. The selection of
25   health plans shall be based primarily on quality criteria established
26   by the board. The health plan selection criteria and scoring system,
27   and the scoring results, shall be available upon request for
28   inspection after the bids have been awarded;
29         (10) develop and implement a plan to publicize the South
30   Carolina Healthy Kids Corporation, the eligibility requirements of
31   the program, and the procedures for enrollment in the program and
32   to maintain public awareness of the corporation and the program;
33         (11) secure staff necessary to properly administer the
34   corporation. Staff costs shall be funded from state and local
35   matching funds and such other private or public funds as become
36   available. The board of directors shall determine the number of
37   staff members necessary to administer the corporation;
38         (12) as appropriate, enter into contracts with local school
39   boards or other agencies to provide onsite information, enrollment,
40   and other services necessary to the operation of the corporation;
41         (13) provide a report annually to the Governor, The Director
42   of the Department of Insurance, the Superintendent of Education,


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 1   Senate President,        and the Speaker of the House of
 2   Representatives.
 3        (14) each fiscal year, establish a maximum number of
 4   participants by county, on a statewide basis, who may enroll in the
 5   program without the benefit of local matching funds. Thereafter,
 6   the corporation may establish local matching requirements for
 7   supplemental participation in the program. The corporation may
 8   vary local matching requirements and enrollment by county
 9   depending on factors which may influence the generation of local
10   match including, but not limited to, population density, per capita
11   income, existing local tax effort, and other factors. The corporation
12   also may accept in-kind match in lieu of cash for the local match
13   requirement to the extent allowed by Title XXI of the Social
14   Security Act; and
15        (15) establish eligibility criteria, premium and cost-sharing
16   requirements, and benefit packages which conform to the
17   provisions of the South Carolina Kidcare program established in
18   Article 3.
19      (C) Coverage under the corporation’s program is secondary to
20   any other available private coverage held by the participant child
21   or family member. The corporation may establish procedures for
22   coordinating benefits under this program with benefits under other
23   public and private coverage.
24
25     Section 44-82-525. The South Carolina Healthy Kids
26   Corporation shall be a private corporation not for profit, and shall
27   have all powers necessary to carry out the purposes of this article,
28   including, but not limited to, the power to receive and accept
29   grants, loans, or advances of funds from any public or private
30   agency and to receive and accept from any source contributions of
31   money, property, labor, or any other thing of value, to be held,
32   used, and applied for the purposes of this article.
33
34      Section 44-82-530. (A) The South Carolina Healthy Kids
35   Corporation shall operate subject to the supervision and approval
36   of a board of directors chaired by the Insurance Commissioner or
37   her or his designee, and composed of twelve other members
38   selected for three-year terms of office:
39        (1) one member appointed by the Superintendent of
40   Education from among three persons nominated by the South
41   Carolina Association of School Administrators;



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 1        (2) one member appointed by the Superintendent of
 2   Education from among three persons nominated by the South
 3   Carolina Association of School Boards;
 4        (3) one member appointed by the Superintendent of
 5   Education from the Office of School Health Programs of the South
 6   Carolina Department of Education;
 7        (4) one member appointed by the Governor from among
 8   three members nominated by the South Carolina Pediatric Society;
 9        (5) one member, appointed by the Governor, who represents
10   the Children’s Medical Services Program;
11        (6) one member appointed by the Director of the Department
12   of Insurance from among three members nominated by the South
13   Carolina Hospital Association;
14        (7) two      members,      appointed    by the        Insurance
15   Commissioner, who are representatives of authorized health care
16   insurers or health maintenance organizations;
17        (8) one member, appointed by the Governor, from among
18   three members nominated by the South Carolina Academy of
19   Family Physicians;
20        (9) one member, appointed by the Governor, who represents
21   the Department of Health and Human Services; and
22      (B) A member of the board of directors may be removed by the
23   official who appointed that member. The board shall appoint an
24   executive director, who is responsible for other staff authorized by
25   the board.
26      (C) Board members are entitled to receive, from funds of the
27   corporation, reimbursement for per diem and mileage as provided
28   by law for members of boards, committees, and commissions.
29      (D) There shall be no liability on the part of, and no cause of
30   action shall arise against, any member of the board of directors, or
31   its employees or agents, for any action they take in the
32   performance of their powers and duties under this article.
33
34      Section 44-82-535. (A) The corporation shall not be deemed
35   an insurer. The officers, directors, and employees of the
36   corporation shall not be deemed to be agents of an insurer. Neither
37   the corporation nor any officer, director, or employee of the
38   corporation is subject to the licensing requirements of the
39   insurance code or the rules of the Department of Insurance.
40   However, any marketing representative utilized and compensated
41   by the second corporation must be appointed as a representative of
42   the insurers or health services providers with which the corporation
43   contracts.

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 1      (B) The board has complete fiscal control over the corporation
 2   and is responsible for all corporate operations.
 3      (C) The Department of Insurance shall supervise any
 4   liquidation or dissolution of the corporation and shall have, with
 5   respect to such liquidation or dissolution, all power granted to it
 6   pursuant to the insurance code.
 7
 8      Section 44-82-540. (A) Notwithstanding any other provision
 9   of law to the contrary, the South Carolina Healthy Kids
10   Corporation shall have access to the medical records of a student
11   upon receipt of permission from a parent or guardian of the
12   student. Such medical records may be maintained by state and
13   local agencies. Any identifying information, including medical
14   records and family financial information, obtained by the
15   corporation pursuant to this subsection is confidential. Neither the
16   corporation nor the staff or agents of the corporation may release,
17   without the written consent of the participant or the parent or
18   guardian of the participant, to any state or federal agency, to any
19   private business or person, or to any other entity, any confidential
20   information received pursuant to this subsection.
21      (B) A person who violates subsection (A) is guilty of a
22   misdemeanor and, upon conviction, must be fined one thousand
23   dollars or imprisoned for sixty days.
24
25                                Article 7
26
27               Developmental Evaluation and Intervention
28
29      Section 44-82-705 . (A) The General Assembly finds that the
30   high-risk and disabled newborn infants in this State need
31   in-hospital and outpatient developmental evaluation and
32   intervention and that their families need training and support
33   services. The General Assembly further finds that there is an
34   identifiable and increasing number of infants who need
35   developmental evaluation and intervention and family support due
36   to the fact that increased numbers of low-birthweight and sick
37   full-term newborn infants are now surviving because of the
38   advances in neonatal intensive care medicine; increased numbers
39   of medically involved infants are remaining inappropriately in
40   hospitals because their parents lack the confidence or skills to care
41   for these infants without support; and increased numbers of infants
42   are at risk due to parent risk factors, such as substance abuse,
43   teenage pregnancy, and other high-risk conditions.

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 1      (B) It is the intent of the General Assembly to establish
 2   developmental evaluation and intervention services at all hospitals
 3   providing Level II or Level III neonatal intensive care services, in
 4   order that families with high-risk or disabled infants may gain the
 5   services and skills they need to support their infants.
 6      (C) It is the intent of the General Assembly to provide a
 7   statewide coordinated program to screen, diagnose, and manage
 8   high-risk infants identified as hearing-impaired. The program shall
 9   develop criteria to identify infants who are at risk of having
10   hearing impairments, and shall ensure that all parents or guardians
11   of newborn infants are provided with materials regarding hearing
12   impairments prior to discharge of the newborn infants from the
13   hospital.
14      (D) It is the intent of the General Assembly that a methodology
15   be developed to integrate information on infants with potentially
16   disabling conditions with other early intervention programs,
17   including Part C of Public Law No. 105-17.
18
19      Section 44-82-710. (A) Developmental         evaluation       and
20   intervention services shall be established at each hospital that
21   provides Level II or Level III neonatal intensive care services.
22   Program services shall be made available to an infant or toddler
23   identified as being at risk for developmental disabilities, or
24   identified as medically involved, who, along with his or her family,
25   would benefit from program services. Program services shall be
26   made available to infants or toddlers in a Level II or Level III
27   neonatal intensive care unit or in a pediatric intensive care unit,
28   infants who are identified as being at high risk for hearing
29   impairment or who are hearing-impaired, or infants who physician
30   assistant, psychologist, psychotherapist, educator, social worker,
31   nurse, physical or occupational therapist, speech pathologist,
32   developmental evaluation and intervention program director, case
33   manager, others who are involved with the in-hospital and
34   posthospital discharge care plan, and anyone the family wishes to
35   include as a member of the team. The family support plan is a
36   written plan that describes the infant or toddler, the therapies and
37   services the infant or toddler and his or her family need, and the
38   intended outcomes of the services.
39      (B) These developmental evaluation and intervention services
40   must be included:
41        (1) discharge planning by the multidisciplinary team,
42   including referral and follow-up to primary medical care and
43   modification of the family support plan;

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 1        (2) education and training for neonatal and pediatric
 2   intensive care services staff, volunteers, and others, as needed, in
 3   order to expand the services provided to high-risk,
 4   developmentally disabled, medically involved, or hearing-impaired
 5   infants and toddlers and their families;
 6        (3) follow-up intervention services after hospital discharge,
 7   to aid the family and the high-risk, developmentally disabled,
 8   medically involved, or hearing-impaired infant’s or toddler’s
 9   transition into the community. Support services shall be
10   coordinated at the request of the family and within the context of
11   the family support plan;
12        (4) referral to and coordination of services with community
13   providers;
14        (5) educational materials about infant care, infant growth
15   and development, community resources, medical conditions and
16   treatments, and family advocacy. Materials regarding hearing
17   impairments shall be provided to each parent or guardian of a
18   hearing-impaired infant or toddler;
19        (6) involvement of the parents and guardians of each
20   identified high-risk, developmentally disabled, medically involved,
21   or hearing-impaired infant or toddler.”
22
23   SECTION 3. This act takes effect upon approval by the Governor.
24                            ----XX----




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