South Carolina’s Healthy Connections Medicaid covers a wide range of medical care for eligible residents, including doctor visits, hospital stays, prescription drugs, behavioral health treatment, dental and vision care, durable medical equipment, family planning, non-emergency transportation, and long-term care at home or in a nursing facility.1SCDHHS. Getting Started The specific services available to you, and the limits that apply, depend on your age and the eligibility category you qualify under.
Most members receive care through a managed care organization that assigns a primary care provider and coordinates referrals. The underlying benefits are set by federal and state law, so every plan must cover them. Where plans sometimes differ is in extras like wellness reward programs.
Doctor Visits and Preventive Care
Every member has access to a primary care provider for checkups, management of chronic conditions like diabetes or high blood pressure, and referrals to specialists. Adult preventive care includes age-appropriate screenings such as mammograms and colonoscopies, immunizations, and office visits focused on lifestyle counseling.
Children’s preventive coverage is considerably broader because of a federal requirement called Early and Periodic Screening, Diagnostic, and Treatment, or EPSDT. It applies to everyone under 21 and guarantees comprehensive health assessments, vision and hearing tests, dental screenings starting by age three, and lab work at scheduled intervals.2eCFR. 42 CFR Part 441 Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21 Blood lead testing is required at 12 and 24 months, and any child between 24 and 72 months who missed those tests must be screened.3Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment The core principle of EPSDT is that if a screening identifies a problem, Medicaid must cover the treatment, even if the service is not otherwise part of the state’s standard benefit package.
Hospital Care
Both inpatient stays and outpatient procedures are covered. Inpatient coverage pays for a semi-private room, nursing care, and meals. A private room is covered only when a physician certifies it as medically necessary or when the hospital has no semi-private rooms available.4SCDHHS. Hospital Services Provider Manual Outpatient coverage includes same-day surgeries, emergency room visits, diagnostic imaging like X-rays and CT scans, and lab tests.
Watch for observation status. A hospital can keep you overnight for monitoring without formally admitting you as an inpatient, which means you are considered an outpatient the entire time. That changes how the stay is billed and what follow-up services are covered. If you are not sure of your status during a hospital stay, ask the nurse or the hospital’s patient advocate before discharge.
Prescription Drugs
The pharmacy benefit runs through a Preferred Drug List that identifies which medications are available without extra steps. Generic drugs are prioritized, and brand-name versions are covered when no generic exists or when a doctor documents a medical reason the brand is necessary. Some high-cost or specialized medications require prior authorization before the pharmacy can fill them, and quantity limits apply to certain drug classes.
If you arrive at the pharmacy with a prescription that requires prior authorization and your doctor has not yet obtained it, federal law requires that you receive at least a 72-hour emergency supply so your treatment is not interrupted.5Office of the Law Revision Counsel. 42 U.S. Code 1396d – Definitions The copayment is $3.40 per prescription for members age 19 and older. Medications for diabetes, behavioral health conditions, and smoking cessation carry no copayment.6South Carolina Medicaid. Appendix 3 Copayment Schedule
Dental and Vision
Coverage splits sharply by age. For members under 21, EPSDT requires comprehensive dental care including cleanings every six months, fillings, surgical extractions, and medically necessary orthodontic treatment with prior authorization.7InsureKidsNow.gov. Summary of Benefits Report for South Carolina, Medicaid Federal law prohibits states from limiting children’s dental benefits to emergency-only care.8Medicaid.gov. Dental Care Vision benefits for children include annual eye exams and eyeglasses.
Adults over 21 have a $1,000 annual dental benefit covering extractions, fillings, and one annual cleaning per benefit year (July 1 through June 30).9DentaQuest. South Carolina Healthy Connections Dental Plan That cap goes faster than you might expect once fillings are involved, so spacing non-urgent work across benefit years helps. Adult vision coverage focuses on medical eye exams for conditions like glaucoma or cataracts rather than routine refraction exams or eyeglasses.
Behavioral Health and Substance Use Treatment
Mental health services include individual and group therapy, psychiatric evaluations, and ongoing medication management for conditions like depression and anxiety. Crisis intervention is available for psychiatric emergencies, and rehabilitative services help with daily functioning. All providers must be licensed and enrolled in the Medicaid network.
Substance use treatment includes medically supervised detoxification and intensive outpatient programs, along with clinical assessments, counseling, and the medication-assisted treatments used for opioid and alcohol dependence. Frequency limits apply to therapy sessions, but your provider can request additional visits when clinically warranted.
Medical Equipment and Supplies
Durable medical equipment covers items used in your home that serve a medical purpose and withstand repeated use, including wheelchairs, hospital beds, walkers, canes, crutches, oxygen equipment, ventilators, and prosthetic and orthotic devices.10SCDHHS. Durable Medical Equipment Services Provider Manual Continuous glucose monitors and devices for obstructive sleep apnea are also covered. Most items require prior authorization, with your prescribing doctor submitting the medical justification.
One notable gap: hearing aids are covered only for members under 21 or adults enrolled in the Intellectual Disability and Related Disabilities waiver program. Adults outside that waiver are not covered.
Family Planning
Contraceptives, counseling, and related reproductive health services are included in full Healthy Connections coverage. South Carolina also runs a separate limited-benefit Family Planning program for people who do not qualify for full Medicaid under any other category.11SCDHHS. Family Planning Federal law classifies family planning as a mandatory Medicaid service.5Office of the Law Revision Counsel. 42 U.S. Code 1396d – Definitions
Long-Term Care at Home
For people who need long-term help with daily activities but want to stay out of a nursing home, SCDHHS operates the Community Long Term Care program. CLTC runs several Medicaid waiver programs, including Community Choices, an HIV/AIDS waiver, a Mechanical Ventilator Dependent waiver, and a Head and Spinal Cord Injury waiver.12SCDHHS. Waiver Management/Field Management To qualify, you must meet a nursing-facility level of care, meaning your needs are serious enough that you would otherwise require institutional placement.
Waiver services go well beyond standard Medicaid. Personal care aides help with bathing, dressing, toileting, meal preparation, and light housekeeping. Adult day health programs provide structured daytime supervision. Respite care gives family caregivers temporary relief. Additional supports can include help with shopping, managing finances, and monitoring your medical condition at home.13SC State Library. Community Long Term Care Provider Manual
Nursing Home Coverage
When home-based care is not enough, Healthy Connections covers nursing facility services for members who qualify medically and financially. Financial eligibility is stricter than for standard Medicaid: South Carolina uses an income cap tied to 300 percent of the federal Supplemental Security Income benefit level, and countable assets must fall below the program’s threshold.
If you have a spouse who will keep living at home, federal rules protect part of your combined assets and income for that spouse. For 2026, the protected asset amount ranges from a minimum of $32,532 to a maximum of $162,660, depending on total countable resources.14CMS. 2026 SSI and Spousal Impoverishment Standards
The five-year lookback is where most families run into trouble. When you apply for nursing home Medicaid, the state reviews every asset transfer you made during the 60 months before your application. If you gave away money, transferred property, or moved assets into certain trusts for less than fair market value, the state imposes a penalty period during which Medicaid will not pay for your nursing home care.15Office of the Law Revision Counsel. 42 U.S. Code 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets The penalty length depends on the amount transferred divided by the average monthly cost of nursing home care in South Carolina. A $150,000 gift, for example, could result in roughly two years of ineligibility. Planning around this rule needs to start well before a nursing home admission is on the horizon.
Once you are in a facility, most of your income goes toward the cost of care, but you keep a small monthly personal needs allowance for toiletries, clothing, and other incidentals. South Carolina sets this at no less than $100 per month, adjusted annually by the same cost-of-living increase applied to Social Security benefits.
Transportation to Appointments
Federal rules require every state Medicaid program to make sure beneficiaries can get to and from medical appointments.16eCFR. 42 CFR 431.53 – Assurance of Transportation This non-emergency medical transportation benefit covers rides to doctor visits, pharmacy pickups, behavioral health appointments, and other covered services. Your managed care plan typically arranges the rides, and you generally need to call the plan’s transportation line a few days before the appointment to schedule a pickup. EPSDT specifically reinforces this requirement for children.17Medicaid.gov. Assurance of Transportation
What You Pay Out of Pocket
Costs are kept low. Children, pregnant women, and other federally protected groups generally owe no copayments. Adults may owe small amounts for certain services. The published pharmacy copayment is $3.40 per prescription for members 19 and older, with $0 for diabetes medications, behavioral health drugs, and smoking cessation products.6South Carolina Medicaid. Appendix 3 Copayment Schedule Providers cannot refuse to see you or deny services because you are unable to pay a copayment at the time of service. The copayment remains your responsibility, but inability to pay cannot be used as grounds to turn you away.
If a Service Is Denied
If SCDHHS or your managed care plan denies a service, reduces your benefits, or terminates coverage, you have the right to a fair hearing. Federal rules give you up to 90 days from the date of the denial notice to request one.18eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries You can file electronically at scdhhs.gov/appeals, or by mail, fax, email, phone, or in person at the SCDHHS Office of Appeals and Hearings in Columbia.
Timing matters. If you request a hearing before the date a reduction or termination takes effect, your existing benefits must continue unchanged while the appeal is pending.19eCFR. 42 CFR Part 431 – State Organization and General Administration If you miss that window, you can still request reinstatement within 10 days after the action date. The tradeoff: if the original decision is upheld after the hearing, you could be asked to repay the cost of services received while the appeal was pending.
Estate Recovery After Death
Federal law requires South Carolina to seek repayment of Medicaid costs from the estates of members who were 55 or older when they received benefits. The state can recover the cost of nursing facility services, home and community-based services, and related hospital and prescription costs, and at the state’s option can extend recovery to any Medicaid-covered service.15Office of the Law Revision Counsel. 42 U.S. Code 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets
Recovery does not begin until after the death of a surviving spouse, and it is deferred entirely if there is a surviving child who is under 21, blind, or permanently disabled. The state must also offer a hardship waiver for heirs who would face genuine financial hardship from the recovery claim, such as when the home or asset in question is the family’s sole source of income. Request the waiver in writing with documentation of the hardship before assuming the claim is final.