DRSC Medicaid Guide

It is important to understand your rights so that you can advocate for yourself if you have a problem. We call this self-advocacy.

3.2 Basic Medicaid Rights

Freedom of Choice

People have the right to receive Medicaid services from the provider of their choice. For example, if a person chooses a case management agency to provide services,but would like to switch to a different provider for any reason, the individual has the right to do so.

Reasonable Promptness

People have the right to receive Medicaid services within a reasonable period of time. However, the law does not define exactly how long is too long.

3.3 Medicaid Appeals

Federal law allows people receiving Medicaid to appeal or challenge decisions that deny, terminate, or reduce their services. This appeal process is called a Fair Hearing. Medicaid must send a letter, called a “notice,” about the decision. The agency must mail this notice at least 10 days before the decision takes effect.

The notice should include:

Details about the decision
The effective date of the decision
The reason for the decision
The law or policy that supports the decision
Information about your right to appeal
How to keep receiving services during the appeal process

If your services are going to change but you did not receive a written notice, immediately ask your case manager for a letter explaining the changes.

To start the appeal process, you or your representative (an attorney, friend, family member, or other spokesperson) must send a written request to the address below within 30 daysof receiving the written notice.(See Appendix) Please attach a copy of the written notification you received with your appeal request. In your request for a fair hearing, you must clearly state what issues you wish to appeal.

Division of Appeals and Hearings

Department of Health and Human Services

P.O. Box 8206

Columbia, SC 29202-8206

The decision will be final if you do not request an appeal within 30 days of receiving the written notification. A request for a fair hearing is considered filed if postmarked within 30 days of receiving notice. The Division of Appeals and Hearings will inform you in writing about the status of your request within 10 days.

You may be eligible to keep receiving Medicaid benefits while waiting for the hearing decision. If you want continued benefits, you must request this in writing when you file your appeal. You should also contact your case manager within 10 calendar days of the notice date. If the hearing decision is not in your favor, you may have to repay Medicaid benefits you received during the appeals process.

For more information, read the DRSC Factsheet on Medicaid Fair Hearings. You can also contact Disability Rights South Carolina to see if we can assist you with your appeal.

Department of Health and Human Services Waiver Appeals

If you are found ineligible for waiver services under a waiver run by DHHS the process is the same as the Medicaid appeal above.

Office of Intellectual and Developmental Disabilities Waiver Appeals

If you receive a decision from OIDD that reduces your level of care or services, the written notice must explain why services are being denied or reduced. The notice should also explain your right to appeal or challenge the decision through the Medicaid appeal process.

If you disagree with the decision, send an appeal letter to the Office Director of the Office of Intellectual and Developmental Disabilities within 30 days, explaining why you feel the decision was incorrect, previous efforts you have taken to resolve the complaint, and what outcome you are seeking. You may request that current services continue while your appeal is being reviewed, but you should make that request within 10 days. You may be responsible for repayment of these services if you lose your appeal. Ask your case manager to explain this process if you have concerns about repayment. If you do not receive a written decision on your appeal within 30 days, contact your case manager to check the status.

If you receive an unfavorable decision from the Office Director, you may appeal the decision in writing to the SC Department of Health and Human Services within 30 days and contact us at DRSC for possible representation.

3.4 Medicaid Advocacy

To State Agencies

People can share their experiences and make their voices heard in several ways. You can provide your feedback to the state agencies that run Medicaid. DHHS and the Office of Intellectual and Developmental Disabilities (OIDD) are required to request “public comment” before making major changes to the Medicaid program. For example:

DHHS must request public comment before changing state plan services or waiver services. DHHS must also request public comment on its waiver programs every five years during the process of renewing them with CMS. DHHS posts items requiring public comment on their website.
The office of Intellectual and Developmental Disabilities must request public comment before making changes to its internal policies called Directives. OIDD posts items requiring public comment on their website.

To State Legislators

Medicaid members can also advocate by contacting their state lawmakers and providing information about their experiences with the Medicaid program.

3.5 Your Rights to Home and Community-Based Services

You have the right to receive services at home or in the community rather than in an institution. In 1990, Congress passed the Americans with Disabilities Act (ADA). The ADA includes the Integration Mandate, which requires states to administer programs in “the most integrated setting appropriate to the needs of qualified individuals with disabilities.” In 1999, the United States Supreme Court interpreted this mandate in a case known as Olmstead v. LC. It held that the unjustified institutionalization of people with disabilities by the state government is discrimination. The Court held that States must ensure access to community-based services for people with disabilities when

The treatment team decides the services are appropriate
The person does not oppose community-based services
The State can reasonably provide the community-based services, taking into account its available resources and the needs of other individuals receiving disability services.

The Medicaid program provides an important way for people with disabilities to receive services needed to help them live in the community safely. States administering the Medicaid program must comply with the Olmstead decision.

3.6 Who Can Help You If You Have a Problem

Disability Rights South Carolina

We offer many services to help you protect your rights, including information and referral, self-advocacy assistance, legal and advocacy support, and training. Our services are free of charge to all residents of South Carolina with a disability. We can also provide information and technical assistance to family members and professionals advocating for people with disabilities in South Carolina.

Help Line: 1-866-275-7273

Email: [email protected]

If you live in another state, visit the National Disability Rights Network’s website at www.ndrn.org to find your state’s Protection & Advocacy office.

Federal Department of Health and Human Services’ Office for Civil Rights (OCR)

Investigates alleged violations of a person’s right to live in the community under the Olmstead decision.

Website: https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html

South Carolina Legal Services

South Carolina Legal Services (SCLS) provides free legal assistance in a wide variety of civil (non-criminal) legal matters to eligible low-income residents of South Carolina.

Phone: 1-(888) 346-5592

Website: https://sclegal.org/

South Carolina Appleseed Legal Justice Center

South Carolina Appleseed Legal Justice Center advocates for low-income South Carolinians on issues such as health care, immigration, reentry issues, housing, education, hunger, public benefits, domestic violence, and consumer issues.

Phone: 803-779-1113

Website: https://www.scjustice.org/

South Carolina Bar Association

South Carolinians can find an attorney online via the SC Bar’s Lawyer Referral Service or attend a free legal clinic in their local community.

Phone: (803) 799-6653

Website: https://www.scbar.org/

Centers for Independent Living

There are three Centers for Independent Living (CILs) in South Carolina. They provide independent living services for people with disabilities. These programs provide tools, resources, and supports for integrating people with disabilities fully into their communities.