Medicare Part D: The Medicare prescription drug benefit program. We call this program “Part D” for short. Medicare Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Medicare Part B or Medical Assistance. Our plan includes Medicare Part D.Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that covers services (such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.
Medical Assistance: This is the name of Minnesota’s Medicaid program. Medical Assistance is run by the state and is paid for by the state and the federal government. It helps people with limited incomes and resources pay for long-term services and supports and medical costs.
It covers extra services and some drugs not covered by Medicare. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Coverage Criteria

South Country utilizes CMS or DHS coverage criteria, evidence-based standards of care (i.e. InterQual Solution), and South Country Medical policy as medical necessity criteria when reviewing medical necessity for benefit coverage for authorization decisions.

Coverage criteria for Medicare plans:

South Country follows the below CMS coverage guidelines and rules:

  • National coverage determinations (NCDs) and/or local coverage determinations and/or articles (LCDs/LCAs)
  • Other CMS guidance including, the Medicare Benefit Policy Manuals, Medicare Claims Processing Manuals and MLN Matters publications.

When coverage criteria are not fully established in the above CMS guidelines or applicable Medicare statute, a decision for medical necessity would be based on standard of care for that service/item using South Country’s “general medical necessity” policy.

Coverage criteria for Medicaid plans:

South Country follows the below coverage guidelines:

  • Department of Human Services (MHCP) coverage manuals
  • InterQual, or other nationally recognized guidelines
  • South Country internal medical policies


South Country internal coverage policies: