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Properly account for the refund. If the form is incomplete, the provider will be contacted for the additional information. Items 1, 2 or 3, 4, 5, 6, & 7 must be completed. Attach appropriate document(s) as listed in item 8. 1. Provider Name: 2. Medicaid Legacy Provider # (Six Characters) OR 3. NPI# & Taxonomy 4. Person to Contact: 5. Telephone Number: 6. Reason for Refund: check appropriate box Other Insurance Pai.

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Groups & Programs Low Income Families (LIF) Qualified Disabled & Working Individuals (QDWI) Specified Low Income Medicare Beneficiaries (SLMB) Medically Indigent Assistance Program (MIAP) Optional State Supplementation Program(OSS) Working Disabled Program(WD)

Adults: Only medically necessary exams are covered for adults. Retroactive services and routine eye exams are not covered. Children: One eye exam and glasses are covered for children. Copayments A copayment is a fixed amount you pay for a covered health care service, usually paid at the time you receive the service.

Eligibility levels for parents are presented as a percentage of the 2023 FPL for a family of three, which is $24,860. Eligibility limits for single adults without dependent children are presented as a percentage of the 2023 FPL for an individual, which is $14,580.

Requests can be made by calling the Healthy Connections Member Contact Center toll free at 1-888-549-0820 from 8 a.m.-6 p.m., Monday-Friday.

In order to become eligible to participate in the Medicaid program, providers are required to either complete a provider enrollment agreement form or sign a contract with DHHS depending on what type of services they provide.

Verifying Eligibility for Enrolled Members Providers can access information online to help determine if an individual is enrolled in Medicaid through the South Carolina Medicaid Web Portal, commonly known as the “web tool.” To access the web tool, please visit https://portal.scmedicaid.com/login .

In approximately half of the states, ABD Medicaid's income limit is $914 / month for a single applicant and $1,371 for a couple. In the remaining states, the income limit is generally $1,215 / month for a single applicant and $1,643 / month for a couple.

Parent/Caretaker Relatives (formally LIF) Family SizeMonthly Income (Eff. 03/01/2023)1753.3021,018.8631,284.4341,550.005 more rows

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232