A. Administration of the Medicaid Program

• Library: A Practical Guide to Elder and Special Needs Law in South Carolina (SCBar) (2021 Ed.)

A. ADMINISTRATION OF THE MEDICAID PROGRAM

Medicaid, also known as the Medical Assistance Program,¹ is a program that pays for essential health care services for certain categories of persons who have limited assets and income. The purpose of Medicaid is "to furnish (1) medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services, and (2) rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care ...." 42 U.S.C. § 1396-1. The Medicaid program is a cooperative program between federal and state governments and jointly administered by both. See Pashby v. Delia, 709 F.3d 307, 313-14 (4th Cir. 2013); Doe v. Kidd, 501 F.3d 348, 351 (4th Cir. 2007). Federal law determines the basic rules, and then each state has some discretion to develop their own programs and guidelines, as long as they stay within the rules set by federal law. See Pashby, 709 F.3d at 314.

In South Carolina, the Medicaid program is administered by the South Carolina Department of Health and Human Services (SCDHHS). SCDHHS is the single state Medicaid agency in South Carolina, but it contracts with other agencies to run some of the Medicaid programs.

The federal government funds approximately 70% of South Carolina's Medicaid program. The amount funded is known as the federal medical assistance percentage (FMAP).² South Carolina pays the remaining costs of the Medicaid program, known as the "state match."³ The state also chooses which optional groups of persons it will cover, sets financial eligibility requirements, and determines the scope of optional benefits it will offer. SCDHHS is responsible for issuing policies governing Medicaid eligibility requirements and procedures, the scope of benefits, and provider billing and reimbursement procedures. SCDHHS maintains the SCDHHS Medicaid Policy and Procedures Manual (MPPM) which can be found at http://www1.scdhhs.gov/mppm/.

The Medicaid program is contained in Title XIX of the Social Security Act 42 U.S.C. §§ 1396-1396w-5. The Centers for Medicare and Medicaid Services (CMS) promulgates regulations interpreting the Medicaid statute at 42 C.F.R. Parts 430-456. CMS also publishes interpretive guidelines, program instructions, and policy transmittals that expand on the regulations. The State Medicaid Manual published by CMS is a valuable tool...