Archives > 1976 South Carolina Code of Laws - Previous Versions > 2005 Session > Title 43

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Title 43 - Social Services

CHAPTER 7.

MEDICAL AND HOSPITAL CARE

ARTICLE 1.

MEDICAL AND HOSPITAL CARE OF PERSONS QUALIFIED FOR PUBLIC ASSISTANCE

SECTION 43-7-10. Repealed by 1989 Act No. 189, Part II, Section 35K, eff June 8, 1989.

SECTION 43-7-20. State Department shall secure Federal funds.

The State Department shall secure Federal funds, when available, to assist in the program for medical and hospital care hereby authorized.

SECTION 43-7-30. Repealed by 1986 Act No. 516, Section 6, eff June 11, 1986.

SECTION 43-7-40. Repealed by 1990 Act No. 539, Section 2, eff June 6, 1990.

SECTION 43-7-50. Payments for professional services under State Medicaid Program shall be uniform within State.

For the purpose of computing the amount of reimbursement for professional services under the State Medicaid Program, all localities in the State of South Carolina shall be deemed "similar" by virtue of being within the State's boundaries and the amount of reimbursement for similar services rendered by professionals within the same specialty of medical or dental practice shall be equal regardless of place of residence or place of practice, so long as the place of practice is within the boundaries of the State of South Carolina. No agency of the State shall reimburse professionals, or cause professionals to be reimbursed, at rates of payment which vary as a result of geographic locations.

SECTION 43-7-60. False claim, statement, or representation by medical provider prohibited; violation is a misdemeanor; penalties.

(A) For purposes of this section:

(1) "provider" includes a person who provides goods, services, or assistance and who is entitled or claims to be entitled to receive reimbursement, payment, or benefits under the state's Medicaid program. "Provider" also includes a person acting as an employee, representative, or agent of the provider.

(2) "false claim, statement, or representation" means a claim, statement, or representation made or presented in any form including, but not limited to, a claim, statement, or representation which is computer generated or transmitted or made, produced, or transmitted by an electronic means or device.

(B) It is unlawful for a provider of medical assistance, goods, or services to knowingly and wilfully make or cause to be made a false claim, statement, or representation of a material fact:

(1) in an application or request, including an electronic or computer generated claim, for a benefit, payment, or reimbursement from a state or federal agency which administers or assists in the administration of the state's medical assistance or Medicaid program; or

(2) on a report, certificate, or similar document, including an electronic or computer generated claim, submitted to a state or federal agency which administers or assists in the administration of the state's Medicaid program in order for a provider or facility to qualify or remain qualified under the state's Medicaid program to provide assistance, goods, or services, or receive reimbursement, payment, or benefit for this assistance, goods, or services.

For purposes of this subsection, each false claim, representation, or statement constitutes a separate offense.

(C) It is unlawful for a provider of medical assistance, goods, or services knowingly and wilfully to conceal or fail to disclose any material fact, event, or transaction which affects the:

(1) provider's initial or continued entitlement to payment, reimbursement, or benefits under the state's Medicaid plan; or

(2) amount of payment, reimbursement, or benefit to which the provider may be entitled for services, goods, or assistance rendered.

For purposes of this subsection, each fact, event, or transaction concealed or not disclosed constitutes a separate offense.

(D) A person who violates the provisions of this section is guilty of medical assistance provider fraud, a Class A misdemeanor and, upon conviction, must be imprisoned not more than three years and fined not more than one thousand dollars for each offense.

(E) In addition to all other remedies provided by law, the Attorney General may bring an action to recover damages equal to three times the amount of an overstatement or overpayment and the court may impose a civil penalty of two thousand dollars for each false claim, representation, or overstatement made to a state or federal agency which administers funds under the state's Medicaid program. Upon a finding that the provider has violated a provision of this section, the state agency which administers the Medicaid program may impose other administrative sanctions against the provider authorized by law. A civil or criminal action brought under this section may be filed or brought in either the county where the false claim, statement, or representation originated or in the county in which the false claim, statement, or representation was received by the Health and Human Services Finance Commission or other agency of the State responsible for administering the state's Medicaid Program.

SECTION 43-7-70. False statement or representation on application for assistance prohibited; violation is a misdemeanor; penalties.

(A)(1) It is unlawful for a person to knowingly and wilfully to make or cause to be made a false statement or representation of material fact on an application for assistance, goods, or services under the state's Medicaid program when the false statement or representation is made for the purpose of determining the person's entitlement to assistance, goods, or services.

(2) It is unlawful for any applicant, recipient, or other person acting on behalf of the applicant or recipient knowingly and wilfully to conceal or fail to disclose any material fact affecting the applicant's or recipient's initial or continued entitlement to receive assistance, goods, or services under the state's Medicaid program.

(3) It is unlawful for a person eligible to receive benefits, services, or goods under the Medicaid program to sell, lease, lend, or otherwise exchange rights, privileges, or benefits to another person.

(B) A person who violates the provisions of this section is guilty of medical assistance recipient fraud, a Class A misdemeanor and, upon conviction, must be imprisoned not more than three years or fined not more than one thousand dollars, or both.

SECTION 43-7-80. Provider required to keep separate accounts and records; violation is a misdemeanor; penalties.

(A) A provider of medical assistance, goods, or services under the state's Medicaid program who is required by state or federal law, regulation, or written policy to maintain separate accounts for patient funds and accurate records of those funds must maintain separate accounts and records of the accounts. It is unlawful for a provider, or a person acting as the provider's agent or employee, to transfer, remove, or encumber or cause to be removed, transferred, or encumbered patient funds for a purpose other than as authorized. Repayment or retransfer of patient funds or satisfaction of an encumbrance on them is not a defense under this section and repayment, retransfer, or satisfaction is admissible as relevant evidence only at sentencing, if the provider is found guilty of a violation of this section.

(B) A person who violates the provisions of this section is guilty of a Class A misdemeanor and, upon conviction, must be imprisoned not more than three years and fined not more than one thousand dollars.

(C) In addition to all other remedies under this section, the Attorney General may bring an action to recover damages equal to five thousand dollars for each violation of this section. Upon a finding that a provider has violated a provision of this section, the state agency which administers the Medicaid program also may take other administrative action authorized under relevant state or federal laws.

SECTION 43-7-90. Enforcement of Sections 43-7-60 to 43-7-80.

The Attorney General has the authority and responsibility to investigate and initiate appropriate action for alleged or suspected violations of Sections 43-7-60 through 43-7-80.

ARTICLE 3.

ATTACHMENT TO COLLECT FOR COUNTY PAID MEDICAL CARE

SECTION 43-7-210. Right to attach wages, fees and commissions of medical care recipients and persons liable for expenses.

Wages, fees and commissions due or to become due any person who has received medical care for himself or for a person whose medical expenses, he is obligated by law or has contracted to pay, exclusive of doctor's fees, which has been paid for by a county, may be attached as hereinafter set forth.

SECTION 43-7-220. Petition for attachment; effective date of order.

The director of the county social services department or the chief administrator of any county operated hospital hereinafter referred to as petitioner, upon alleging in a verified petition, (a) that there was expended for the previous fiscal year in the county where the medical care was rendered, twenty-four percent of the total operating budget for such county, public funds for the hospitalization, medical care and treatment of persons in a sum in excess of twenty-four percent of the total operating budget for such county, (b) that the person or someone for whom he is legally responsible has received medical care, excluding doctor's fees, in a stated amount, (c) that the cost of this care has been paid by the county, (d) that the person is gainfully employed, (e) that the person is indebted to the county for the cost of medical care received, (f) that the name of the person's employer and the approximate amount of the person's average weekly gross wage, and (g) that the county has not been paid for the cost of the medical care rendered, may apply to the court of common pleas or any other court having concurrent jurisdiction in the county where the person is employed, for an order requiring the employer of such person, to withhold from his wages, fees or commissions due or to become due, a sum not to exceed fifteen percent of the average gross weekly wage earned by such person each week, and to pay whatever amount so collected over to the petitioner once a month until the amount found to be due has been paid in full. The order shall not become effective until twenty days after the order has been served on all respondents as hereinafter designated.

SECTION 43-7-230. Service of summons, petition and order on employee and employer; answers.

A duplicate copy of the summons, petition, and order shall be served on the person who is employed and his employer, who shall both be designated respondents. Each shall have twenty days in which to answer or otherwise plead.

SECTION 43-7-240. Time for showing cause for dismissal; grounds for dismissal without prejudice.

Any or all respondents shall have twenty days from the service of the order to show cause why the order should not become effective or the action dismissed. The following shall constitute good and sufficient grounds for dismissing the action, but without prejudice to the petitioner:

(a) That in the discretion of the court, the imposition of the order would result in extreme hardship on the person due to some situation beyond his control.

(b) That any one of the allegations set forth in the petition as required by Section 43-7-220 above is false.

SECTION 43-7-250. Production of payroll records and other information.

If doubt exists as to the amount the person earns, then on motion of petitioner the court shall require the employer to produce the payroll records of such person and to furnish any other information pertinent to the question.

SECTION 43-7-260. Appeals.

Should any person be aggrieved by the order, he may appeal as in other cases brought in the court of common pleas, but such appeal shall not stay the order issued.

SECTION 43-7-270. Return of money wrongfully withheld with interest and attorney's fee.

Should it be determined that the person receiving medical care is not indebted as alleged in the petition, any money withheld from him shall be returned together with six per cent interest and a reasonable attorney's fee as set by the court, provided an attorney has been employed by such person.

SECTION 43-7-280. Deduction from payments for employer's services.

Every employer shall be allowed to deduct and retain from the amount of the payment, one dollar from each monthly payment made to petitioner to reimburse him for services rendered in the action.

ARTICLE 5.

ASSIGNMENT AND SUBROGATION OF CLAIMS FOR REIMBURSEMENT FOR MEDICAID SERVICES

SECTION 43-7-410. Definitions.

(A) "Applicant" means an individual whose written application for Medicaid has been submitted to the agency determining medicaid eligibility, but has not received final action. This includes an individual (living or deceased) whose application is submitted by a representative or a person acting responsibly for the individual.

(B) "Commission" means the State Health and Human Services Finance Commission.

(C) "Medicaid" means the medical assistance program authorized by Title XIX of the Social Security Act and administered by the State Health and Human Services Finance Commission.

(D) "Person" means any natural person, company, association, partnership, corporation, or any other legal entity.

(E) "Practitioner" means a physician or other health care professional licensed under state law to practice his profession.

(F) "Private Insurer" means:

(1) a commercial insurance company offering health or casualty insurance to individuals or groups, including experienced-rated contracts and indemnity contracts;

(2) a profit or nonprofit prepaid plan offering either medical services or full or partial payment for the diagnosis or treatment of an injury, disease, or disability;

(3) an organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these plans or services, including self-insured and self-funded plans; or

(4) a group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, a service benefit plan, or a health maintenance organization.

(G) "Provider" means an individual, firm, corporation, association, institution, or other legal entity which is providing, or has been approved to provide, medical assistance to a recipient pursuant to the State Medical Assistance Plan and in accord with Title XIX of the Social Security Act-Medical Assistance (Medicaid).

(H) "Recipient" means an individual who has been determined to be eligible for health services as described in the State Medical Assistance Plan in accord with Title XIX of the Social Security Act-Medical Assistance (Medicaid).

(I) "Third Party" means any individual, entity, or program that is or may be liable to pay all or part of the medical cost of injury, disease, or disability of an applicant or recipient.

SECTION 43-7-420. Assignment to State Health and Human Services Finance Commission of right to recover amount paid by Medicaid from third party or private insurer.

(A) Every applicant or recipient, only to the extent of the amount of the medical assistance paid by Medicaid, shall be deemed to have assigned his rights to recover such amounts so paid by Medicaid from any third party or private insurer to the State Health and Human Services Finance Commission. This assignment shall not include rights to Medicare benefits. The applicant or recipient shall cooperate fully with the State Health and Human Services Finance Commission in its efforts to enforce its assignment rights.

(B) An applicant's and recipient's determination of, and continued eligibility for, medical assistance under Medicaid is contingent upon his cooperation with the Commission in its efforts to enforce its assignment rights. Cooperation includes, but is not limited to, reimbursing the Commission from proceeds or payments received by the applicant or recipient from any third party or private insurer.

(C) Every applicant or recipient is considered to have authorized all persons, including insurance companies and providers of medical care, to release to the Commission all information needed to enforce the assignment rights of the Commission.

SECTION 43-7-430. Subrogation to State Health and Human Services Finance Commission of right to recover amount paid by Medicaid from third party or private insurer.

(A) The State Health and Human Services Finance Commission shall be automatically subrogated, only to the extent of the amount of medical assistance paid by Medicaid, to the rights an applicant or recipient may have to recover such amounts so paid by Medicaid from any third party or private insurer. The applicant or recipient shall cooperate fully with the State Health and Human Services Finance Commission and shall do nothing after medical assistance is provided to prejudice the subrogation rights of the State Health and Human Services Finance Commission.

(B) An applicant's and recipient's determination of, and continued eligibility for, medical assistance under Medicaid is contingent upon his cooperation with the Commission in its efforts to enforce its subrogation rights. Cooperation includes, but is not limited to, reimbursing the Commission from proceeds or payments received by the recipient from any third party or private insurer.

(C) Every applicant or recipient is considered to have authorized all persons, including insurance companies and providers of medical care, to release to the Commission all information needed to enforce the subrogation rights of the Commission.

SECTION 43-7-440. Enforcement of, and superiority of, rights of Commission; identification of third parties liable for medical costs; ineffectiveness of certain insurance provisions; liability for improper settlement, compromise, or disbursement of funds.

(A) The Commission, to enforce its assignment or subrogation rights, may take any one, or any combination of, the following actions:

(1) intervene or join in an action or proceeding brought by the applicant or recipient against any third party, or private insurer, in state or federal court.

(2) commence and prosecute legal proceedings against any third party or private insurer who may be liable to any applicant or recipient in state or federal court, either alone or in conjunction with the applicant or recipient, his guardian, personal representative of his estate, dependents, or survivors;

(3) commence and prosecute legal proceedings against any third party or private insurer who may be liable to an applicant or recipient, or his guardian, personal representative of his estate, dependents, or survivors;

(4) commence and prosecute legal proceedings against any applicant or recipient;

(5) settle and compromise any amount due to the State Health and Human Services Finance Commission under its assignment and subrogation rights. Provided, further, any representative or attorney retained by an applicant or recipient shall not be considered liable to State Health and Human Services Finance Commission for improper settlement, compromise or disbursement of funds unless he has written notice of State Health and Human Services Finance Commission's assignment and subrogation rights prior to disbursement of funds;

(6) reduce any amount due to the State Health and Human Services Finance Commission by twenty-five percent if the applicant or recipient has retained an attorney to pursue the applicant's or recipient's claim against a third party or private insurer, that amount to represent the State Health and Human Services Finance Commission's share of attorney's fees paid by the applicant or recipient. Additionally, the State Health and Human Services Finance Commission may, in its discretion, share in other costs of litigation by reducing the amount due it by a percentage of those costs, the percentage calculated by dividing the amount due the State Health and Human Services Finance Commission by the total settlement received from the third party or private insurer. Provided, further, any representative or attorney retained by an applicant or recipient shall not be considered liable to State Health and Human Services Finance Commission for improper settlement, compromise, or disbursement of funds unless he has written notice by certified mail of State Health and Human Services Finance Commission's assignment and subrogation rights prior to disbursement of funds.

(B) Providers and practitioners who participate in the Medicaid program shall cooperate with the Commission in the identification of third parties whom they have reason to believe may be liable to pay all or part of the medical costs of the injury, disease, or disability of an applicant or recipient.

(C) Any provision in the contract of a private insurer issued or renewed after June 11, 1986, which denies or reduces benefits because of the eligibility of the insured to receive assistance under Medicaid, is null and void.

In enrolling a person or in making payments for benefits to a person or on behalf of a person, no private insurer may take into account that the person is eligible for or is provided medical assistance under a State Plan for Medical Assistance pursuant to Title XIX of the Social Security Act.

(D) The assignment and subrogation rights of the Commission are superior to any right of reimbursement, subrogation, or indemnity of any third party or recipient. Provided, further, any representative or attorney retained by an applicant or recipient shall not be considered liable to State Health and Human Services Finance Commission for improper settlement, compromise, or disbursement of funds unless he has written notice of State Health and Human Services Finance Commission's assignment and subrogation rights prior to disbursement of funds.

In a case where a third party has a legal liability to make payments for medical assistance to or on behalf of a person, to the extent that payment has been made under a State Plan for Medical Assistance pursuant to Title XIX of the Social Security Act for health care items or services furnished to the person, the State is considered to have acquired the rights of the person to payment by any other party for the health care items or services.

SECTION 43-7-450. Claims or actions pending or brought before June 11, 1986.

Any claim or action pending or brought before June 11, 1986 may be completed and enforced as provided by law prior to June 11, 1986.

SECTION 43-7-460. Recovery of medical assistance paid from estates of certain individuals.

(A) The State Department of Health and Human Services shall seek recovery of medical assistance paid under the Title XIX State Plan for Medical Assistance from the estate of an individual who:

(1) at the time of death was an inpatient in a nursing facility, intermediate care facility for the mentally retarded, or other medical institution if the individual is required, as a condition of receiving services in the facility under the state plan, to spend for costs of medical care all but a minimal amount of the person's income required for personal needs; or

(2) was fifty-five years of age or older when the individual received medical assistance, but only for medical assistance consisting of nursing facility services, home and community-based services, and hospital and prescription drug services provided to individuals in nursing facilities or receiving home and community-based services.

(B) Recovery under this section may be made only after the death of the decedent's surviving spouse, if any, and only at a time when the decedent has no surviving child under age twenty-one or no child who is blind or permanently and totally disabled as defined in Title XVI of the Social Security Act.

(C) Recovery under this section must be waived by the department upon proof of undue hardship, asserted by an heir or devisee of the property claimed pursuant to 42 U.S.C. 1396p(b)(3). Until conflicting hardship standards and criteria are issued by the Secretary of the United States Department of Health and Human Services, the following are considered instances of undue hardship in which recovery must be waived:

(1) with respect to the decedent's home property, if the decedent could have transferred the home property on or after the date of his or her Medicaid application without incurring a penalty under 42 U.S.C. Section 1396p(c), if the property could have been transferred without penalty to a:

(a) spouse who has survived the decedent;

(b) surviving child of the decedent who was under age twenty-one or blind or totally disabled;

(c) surviving sibling of the decedent who possessed an equity interest in the property and who lived in the home for a period of at least one year immediately prior to the date the decedent was institutionalized; or

(d) surviving child of the deceased who lived in the home for a period of at least two years immediately before the decedent became institutionalized and who provided care which allowed the decedent to delay institutionalization.

However, hardship under this item only applies if the individual to whom the property could have been transferred without penalty is actually residing in the home at the time the hardship is claimed and this hardship status only protects up to one hundred thousand dollars of appraised value of the home property and to the extent the appraised value of the home property exceeds one hundred thousand dollars, that portion of the value that exceeds one hundred thousand dollars, is subject to recovery by the department as otherwise authorized under this section.

(2) with respect to the decedent's home and one acre of land surrounding the house, if an immediate family member:

(a) has resided in the home for at least two years immediately prior to the recipient's death;

(b) is actually residing in the home at the time the hardship is claimed;

(c) owns no other real property or agrees to sell all other interest in real property and give the proceeds to the department; and

(d) has annual gross family income that does not exceed one hundred eighty-five percent of the federal poverty guidelines.

(3) with respect to an income producing asset:

(a) the spouse's or immediate family member's annual gross family income would fall below the federal poverty guidelines without the income produced by the asset; and

(b) at the time of death, the asset is not producing annual income in excess of one hundred eighty-five percent of the federal poverty guidelines or the spouse or immediate family member agrees to pay all income in excess of one hundred eighty-five percent of the federal poverty guidelines to the department until the department recovers all medical assistance due under this section.

(D) Recovery of medical assistance payments under this section applies to medical assistance paid after June 30, 1994.

(E) Claims against an estate under this section have priority as established in Section 62-3-805(a)(2)(ii).

(F) For purposes of this section:

(1) "estate" means all real and personal property and other assets included within the individual's estate as defined in Section 62-1-201(11);

(2) the "state plan" means Title XIX State Plan for Medical Assistance in effect at the decedent's death;

(3) "immediate family member" means a child, parent, brother, or sister of the deceased.

(G) Notwithstanding subsection (A)(2) upon the enactment of any amendments to federal law which grants states the option to exempt home and community-based services or other noninstitutional Medicaid services from the estate recovery provisions mandated by Section 13612 of the federal Omnibus Budget Reconciliation Act of 1993, the State Health and Human Services Finance Commission shall seek recovery of medical assistance paid under the Title XIX State Plan for Medical Assistance from the estate of an individual who:

(1) at the time of death was an inpatient in a nursing facility, intermediate care facility for the mentally retarded, or other medical institution if the individual is required, as a condition of receiving services in the facility under the state plan, to spend for costs of medical care all but a minimal amount of the person's income required for personal needs; or

(2) was fifty-five years of age or older when the individual received medical assistance but only for medical assistance consisting of nursing facility services.