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TO ENACT THE "MEDICAID ACCOUNTABILITY AND IMPROVEMENT ACT" BY AMENDING SECTION 44-6-80, CODE OF LAWS OF SOUTH CAROLINA, 1976, RELATING TO THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ANNUAL REPORT, SO AS TO FURTHER SPECIFY THE CONTENTS OF THIS REPORT, ESPECIALLY WITH REGARD TO THE MEDICAID PROGRAM, AND TO REQUIRE THIS REPORT TO BE SUBMITTED TO CERTAIN COMMITTEES OF THE GENERAL ASSEMBLY; TO ADD SECTION 44-6-110 SO AS TO SPECIFY MEDICAID ELIGIBILITY DETERMINATION CRITERIA THAT THE DEPARTMENT MUST DEVELOP AND TO FURTHER PROVIDE CERTAIN PROCEDURES FOR ADMINISTRATION OF THE MEDICAID PROGRAM; TO ADD SECTION 38-71-270 SO AS TO REQUIRE HEALTH INSURERS TO PROVIDE IDENTIFYING INFORMATION ON ITS INSUREDS SO THAT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES CAN DETERMINE IF MEDICAID RECIPIENTS HAVE OTHER HEALTH COVERAGE; TO ADD ARTICLES 8 AND 9, CHAPTER 6, TITLE 44 SO AS TO PROVIDE PROCEDURES FOR MEDICAID UTILIZATION CONTROL AND CARE MANAGEMENT, INCLUDING THE ESTABLISHMENT OF THE PHARMACY AND THERAPEUTICS COMMITTEE TO MAKE RECOMMENDATIONS, AMONG OTHER THINGS, TO THE DEPARTMENT CONCERNING MEDICATIONS TO BE ON A PREFERRED DRUG LIST AND TO PROVIDE FOR MEDICAID FRAUD AND ABUSE CONTROLS, INCLUDING CONTRACTING WITH THE ATTORNEY GENERAL'S OFFICE FOR ASSISTANCE WITH INVESTIGATIONS, MONITORING BENEFIT USE, AND CONDUCTING AUDITS AND INVESTIGATIONS OF MEDICAID PROVIDERS; TO AMEND SECTION 43-3-65, RELATING TO COUNTIES PROVIDING OFFICE SPACE AND CERTAIN SERVICES FOR COUNTY DEPARTMENTS OF SOCIAL SERVICES, SO AS TO ALSO REQUIRE COUNTIES TO PROVIDE SUCH ASSISTANCE TO THE DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND TO REPEAL JOINT RESOLUTION 370 OF 2002, RELATING TO ANNUAL NURSING HOME FRANCHISE FEES.
Be it enacted by the General Assembly of the State of South Carolina:
SECTION 1. This act may be cited as the "Medicaid Accountability and Improvement Act".
SECTION 2. Section 44-6-80 of the 1976 Code is amended to read:
"Section 44-6-80. The department must submit to the Governor, the State Budget and Control Board, and the General Assembly an annual report concerning the work of the department including details on improvements in the cost effectiveness achieved since the enactment of this chapter and must recommend changes for further improvements.
Interim reports must be submitted as needed to advise the Governor and the General Assembly of substantive issues. (A) By the end of the following calendar year of each year, the department shall publish a South Carolina Medicaid annual report containing actions from the preceding state fiscal year including, but not limited to:
(1) amendments to the state's Medicaid plan approved by the federal government;
(2) amendments to any state Medicaid waiver program approved by the federal government;
(3) waiver renewals granted by the federal government;
(4) new waivers granted by the federal government;
(5) eligibility policy or provider rate changes that required publication of a public notice;
(6) Medicaid enrollment and recipients as of the end of the fiscal year and corresponding numbers for the preceding state fiscal year;
(7) Medicaid managed care enrollment as of the end of the fiscal year and corresponding information for the preceding state fiscal year;
(8) total Medicaid expenditures as of the end the fiscal year and corresponding information for the preceding state fiscal year;
(9) expenditures by category of service as of the end of the fiscal year and corresponding information for the preceding state fiscal year;
(10) a comparison of Medicaid provider reimbursement rates with those of the State Health Plan and Medicare;
(11) a list of all federally-approved Medicaid recipient cost-sharing requirements;
(12) a report on the department's efforts to recover Medicaid overpayments in the previous fiscal year and to control Medicaid waste, fraud, and abuse;
(13) independently for each state agency that used general fund or other state appropriations for state Medicaid matching funds in the state fiscal year:
(a) recipients as of the end of the fiscal year and corresponding numbers for the preceding state fiscal year;
(b) total Medicaid expenditures as of the end of the fiscal year and corresponding information from the preceding state fiscal year;
(c) Medicaid expenditures by category of service as of the end of the fiscal year and corresponding information from the preceding state fiscal year; and
(d) a comparison of the state agency's reimbursement rates with those of other state agencies providing the same or similar service and those of private providers, if any, providing the same or similar service. The state agencies shall cooperate with the department and provide information necessary to complete this comparison. Failure to cooperate shall result in withholding of FFP by the department.
(B) The department shall provide this report to the House Ways and Means Committee, Senate Finance Committee, House Medical, Military, Public and Municipal Affairs Committee, and Senate Medical Affairs Committee."
SECTION 3. Article 1, Chapter 6, Title 44 of the 1976 Code is amended by adding :
"Section 44-6-110. (A) The department shall develop eligibility determination criteria and procedures for full benefit Medicaid applicants that:
(1) provide for face-to-face initial and continued eligibility determinations when administratively feasible and cost-effective;
(2) prevent the routine initiation of coverage until verification of all required eligibility information is complete unless the applicant is a pregnant woman;
(3) require verification of all unearned income including, but not limited to, child support or alimony;
(4) require proof of citizenship or legal alien status when the department may have reasonable grounds to believe that the applicant is not a citizen or legal alien;
(5) require proof of South Carolina residency when the department may have reasonable grounds to believe that the applicant is not a state resident;
(6) require the applicant, the applicant's legal guardian or other responsible party, or the applicant's power of attorney to sign the application attesting to the accuracy of the information provided; and
(7) require at least annual continuing eligibility redeterminations using the same standards as applied to the initial eligibility determination process.
(B) The department shall require that all files pertaining to Medicaid eligibility of any agency employee, a member of an agency employee's family including, but not limited to, a spouse, parent, step-parent, grandparent, step-grandparent, child, step-child, sibling, or step-sibling or any individual residing with an agency employee be transferred to a central location for processing.
(C) The department shall conduct regular audits of eligibility files for completeness and accuracy. The files reviewed must be selected by an approved statistical method that ensures a reasonable competency level.
(D) The department shall maintain an electronic interface with the South Carolina Employment Security Commission to provide employment and earning information on Medicaid applicants.
(E) The department shall structure the eligibility determination function in a manner that is administratively efficient.
(F) Notwithstanding any other provision of law and except as provided below, any promissory note received after July 1, 2004, by a Medicaid applicant or recipient or the spouse of a Medicaid applicant or recipient in exchange for assets that if retained by the applicant or recipient or his spouse would cause the applicant or recipient to be ineligible for Medicaid benefits must, for Medicaid eligibility purposes, be deemed to be fully negotiable under the laws of this State unless it contains language plainly stating that it is not transferable under any circumstances. To be considered valid for Medicaid eligibility determination purposes, a promissory note must be actuarially sound, require monthly installments that fully amortize over the life of the loan, and be free of any conditional or self-canceling clauses."
SECTION 4. Article 1, Chapter 71, Title 38 of the 1976 Code is amended by adding:
"Section 38-71-270. An insurer, including a managed care organization, providing health insurance to residents of this State shall submit the names and other identifying information of its insureds to the Department of Insurance in the manner and time prescribed by the department. The department shall submit this information to the Department of Health and Human Services to be used to identify Medicaid recipients who have other health coverage."
SECTION 5. Chapter 6, Title 44, of the 1976 Code is amended by adding:
Section 44-6-1000. (A) The department shall identify Medicaid recipients in the highest tier of health care expenditures and with multiple chronic conditions and initiate utilization control and care management programs designed to ensure appropriate use of health care services by this population.
(B) The department shall expeditiously apply for any waivers or other federal approvals necessary to implement this section.
(C) The department shall evaluate the effectiveness of these programs in improving health outcomes and decreasing health care expenditures among this population.
Section 44-6-1010. (A) The department shall review Medicaid services provided by state agencies and other providers and shall promote the most cost-effective use of the state's overall Medicaid resources. The purpose of the review is to:
(1) eliminate duplication;
(2) pay comparable rates for comparable services;
(3) establish a market-based concept for service;
(4) evaluate the effectiveness of service.
(B) The department may designate a primary case manager for each Medicaid recipient and may limit case management services to ensure that the provisions of this section are met.
Section 44-6-1020. For purposes of this article:
(1) 'Chairman' means the Chairman of the Pharmacy and Therapeutics Committee.
(2) 'Committee' means the Pharmacy and Therapeutics Committee.
(3) 'Department' means the Department of Health and Human Services.
(4) 'Director' means the Director of the Department of Health and Human Services.
Section 44-6-1030. (A) There is established within the department, the Pharmacy and Therapeutics Committee. The committee must consist of fifteen members appointed by the director and serving at the pleasure of the director. The members must include eleven physicians and four pharmacists licensed to practice in this State and actively engaged in providing services to the Medicaid population in this State. Though not a prerequisite to serving, the physician members of the committee may have experience in treating diabetes, cancer, HIV/AIDS, mental illness, and hemophilia and may practice in internal medicine, primary care, and pediatrics.
(B) The committee must adopt by-laws that include, at a minimum, the length of the term for members. A chairman and vice-chairman must be elected on an annual basis from the committee membership. Members may not be compensated for service on the committee; however, members may be reimbursed for actual and necessary expenses incurred pursuant to discharging committee duties in an amount not to exceed the mileage and subsistence amounts allowed by law for members of boards, commissions, and committees.
(C) The committee shall meet at least quarterly and may meet at other times at the discretion of the chairman or the director. Committee meetings are subject to the provisions of the Freedom of Information Act, and the department shall publish notice of regular business meetings of the committee at least thirty days prior to the meeting. However, the director or chairman may call special meetings of the committee and provide such public notice as may be practical.
(D) The committee shall provide for public comment, including comment on clinical and patient care data from Medicaid providers, representatives of the pharmaceutical industry, and patient advocacy groups. Trade secrets as defined in Section 34-4-40(a)(1) and relevant federal law must not be publicly disclosed.
(E) The committee shall recommend to the department therapeutic classes of drugs that should be included on a preferred drug list. For those recommended classes, the committee shall recommend the drug or drugs preferred within that class based on safety and efficacy. In determining safety and efficacy, the committee may consider all submitted public comment or clinical information including, but not limited to, scientific evidence, standards of practice, peer-reviewed medical literature, randomized clinical trials, pharmacoeconomic studies, and outcomes research data. The committee also shall recommend prior authorization criteria for non-preferred drugs in the recommended therapeutic classes.
Section 44-6-1040. Any preferred drug list program implemented by the department must include procedures to:
(1) ensure that a request for prior authorization that has no material defect or impropriety can be processed within twenty-four hours of receipt;
(2) allow the prescribing physician to request and receive notification of any delay or negative decision in regard to a prior authorization request;
(3) allow the prescribing physician to request and receive a second review of any denial of a prior authorization request; and
(4) allow a pharmacist to dispense an emergency, seventy-two hour supply of a drug requiring prior authorization without the prior authorization if the pharmacist:
(a) has made a reasonable attempt to contact the prescribing physician to request that the prescribing physician secure prior authorization; and
(b) reasonably believes that refusing to dispense a seventy-two hour supply would unduly burden the Medicaid recipient and produce undesirable health consequences.
Section 44-6-1050. A grant of prior authorization for a drug is specific to the drug, rather than the actual prescription, and extends to all refills allowed pursuant to the original prescription and to subsequent prescriptions for the same drug at the same dosage if the time allowed by the prior authorization has not expired.
Section 44-6-1060. A Medicaid recipient who has been denied prior authorization for a prescribed drug is entitled to appeal this decision through the department's appeals process.
Section 44-6-1070. For prescriptions reimbursed by the department, a Medicaid recipient is deemed to have consented to substitution of a less costly generic equivalent satisfying the individual consent requirements of Section 40-43-86(H)(6).
Section 44-6-1200. (A) In accordance with federal law, the department shall conduct audits, reviews, investigations, and inspections of providers, including other state agencies and recipients, in order to prevent and detect fraud, abuse, and waste in the Medicaid program.
(B) The department may only reimburse for medically necessary covered services provided to Medicaid recipients. For purposes of this section:
(1) 'Medically necessary services' means those services that are of an amount, duration, and scope that is:
(a) provided in accordance with all applicable state and federal Medicaid laws, regulations, manual provisions, bulletins, and other directives;
(b) directed toward the maintenance, restoration, or protection of health or toward the diagnosis and treatment of illness or disability.
(2) 'Covered services' means services that are clearly and specifically included as covered in the Medicaid provider manual, including published bulletins or other directives.
(C) The department may sanction providers found to be in violation of this section. Sanctions may include, but are not limited to, any or all of the following :
(1) denial of payment, in whole or in part, or recovery of overpayments, in whole or in part;
(2) rejection of a prospective provider's application for participation in the Medicaid program;
(3) suspension or termination of a Medicaid provider agreement;
(4) assessment of a fine; and
(5) assessment of an interest charge from the date of claim payment to the date of repayment on amounts paid to the provider in excess of amounts that are appropriately due under Medicaid program policies and procedures.
(D) The department shall monitor recipients' use of Medicaid benefits and develop interventions or sanctions for recipients identified misusing Medicaid benefits.
Section 44-6-1210. (A) The department may expand its fraud and abuse efforts by using internal and external resources including, but not limited to, the ability to contract with other entities for the purpose of maximizing the department's ability to prevent and detect Medicaid fraud, abuse, and waste.
(B) The department may contract with the Attorney General's Office to conduct investigations of recipients suspected of Medicaid fraud and abuse including, but not limited to:
(1) submitting false applications or providing false or misleading information in order to obtain Medicaid benefits;
(2) sharing or selling the Medicaid card;
(3) diverting or reselling prescription drugs and other goods or supplies provided by Medicaid; and
(4) otherwise fraudulently obtaining Medicaid benefits to which they were not entitled.
(C) The department shall meet at least quarterly with the staff of the Attorney General's Office involved in Medicaid provider and recipient fraud, abuse, and waste investigation and prosecution to determine the status of cases referred to the Attorney General's Office and to ensure that both entities are expeditiously pursuing their responsibilities in this regard.
Section 44-6-1220. The department may offset the administrative costs associated with preventing and detecting fraud, abuse, and waste from the collections received from its fraud, abuse, and waste efforts."
SECTION 6. Section 43-3-65 of the 1976 Code, as added by Section 59A, Part II, Act 155 of 1997, is amended to read:
"Section 43-3-65. The governing authorities of each county must provide office space and facility service, including janitorial, utility, and telephone services, and related supplies, for Department of Health and Human Services eligibility processing and the county Department of Social Services."
SECTION 7. Joint Resolution 370 of 2002 is repealed.
SECTION 8. If any section, subsection, paragraph, subparagraph, sentence, clause, phrase, or word of this act is for any reason held to be unconstitutional or invalid, such holding shall not affect the constitutionality or validity of the remaining portions of this act, the General Assembly hereby declaring that it would have passed this act, and each and every section, subsection, paragraph, subparagraph, sentence, clause, phrase, and word thereof, irrespective of the fact that any one or more other sections, subsections, paragraphs, subparagraphs, sentences, clauses, phrases, or words hereof may be declared to be unconstitutional, invalid, or otherwise ineffective.
SECTION 9. Unless otherwise provided, this act takes effect upon approval by the Governor.
This web page was last updated on Tuesday, June 23, 2009 at 2:22 P.M.