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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:
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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
[4212] 27
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;
[4212] 28
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,
[4212] 29
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;
[4212] 30
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----
[4212] 34
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