S.C. Code Regs. § § 126-510

Current through Register Vol. 48, No. 11, November 22, 2024

Section 126-510 - Application Process

When it is determined that an individual needs hospitalization and that he may qualify for assistance through the MIAP, the procedures stated below shall be followed.

A. For nonemergency admissions, the patient shall be referred to the designee in the county of residence for an eligibility determination. The designee shall notify the patient and the admitting hospital or physician of the outcome of the eligibility determination. Eligibility shall be determined prior to admission.

B. For emergency admissions, the hospital shall admit the patient and obtain a signed application from the applicant, his relative or other individual authorized to act on his behalf. The hospital shall collect information pertaining to the individual's eligibility. The hospital shall then forward the information to the designee in the individual's county of residence for processing. The county designee shall notify the patient and the hospital of the outcome of the eligibility determination in accordance with Section H of this subpart.

C. Eligibility shall be determined on an episodic basis. A new application is required for each period of hospitalization. Exception: If the patient is readmitted to the hospital within thirty (30) days of the date of discharge, he is not required to file another application; however, it must be determined that the patient's financial circumstances have not changed.

D. The application must be submitted by the patient or a responsible person acting on his behalf. If the applicant is not capable of submitting his own application and he has no one to act on his behalf, the hospital may submit the application.

E. A retroactive application may be filed only if an individual failed to apply at the time of hospitalization. The individual must be able to establish that he was eligible at the time of hospitalization. All retroactive applications must be filed within one (1) year after discharge from the hospital. Retroactive sponsorship by MIAP may be made only if the program had not sponsored $15 million in unreimbursed hospital care during the year in which the hospitalization occurred. These procedures also apply if an application is made on behalf of a deceased individual.

F. The applicant shall furnish required documentation to establish eligibility. The designee shall assist the applicant in obtaining needed documentation when the applicant is incapable of obtaining such documentation.

G. Disposition of applications for assistance through the MIAP shall be made within fifteen (15) working days unless an eligibility determination for other benefits such as Medicaid must be made prior to certification for payment or unless more time is needed to obtain adequate documentation. If disposition of an application is not made within fifteen (15) working days, the reason for delay must be documented. This time frame, is separate from the fifteen (15) working days that a county is allowed for the review of hospital claims, if it elects to do so.

For applicants who are potentially eligible for Medicaid, the MIAP application cannot be approved until the applicant has applied for and been denied Medicaid benefits for a reason other than those identified in the MIAP Manual. The fifteen (15) day time frame does not apply in this situation.

H. The designee shall provide written notification to applicants and providers of the decision on MIAP applications.

I. If an applicant disagrees with the decision made on his case, he may request a reconsideration at the county level. This reconsideration request must be made within thirty (30) days of the notification of the decision. The reconsideration decision shall be made by an individual(s), other than the person who made the eligibility determination, designated by the county's chief administrative officer. If the applicant disagrees with the reconsideration decision, he may request a fair hearing from the Appeals Unit of the Department. This request must be made in writing within thirty (30) days of the reconsideration decision. The fair hearing will be conducted in accordance with the Department Appeals and Hearing Regulations, R. 126-150 et seq.

S.C. Code Regs. § 126-510

Replaced and amended by State Register Volume 42, Issue No. 05, eff. 5/25/2018.