Learn About Coverage For Medicaid in South Carolina

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What services are covered by South Carolina Medicaid? What Medicaid types of insurance can enrollees apply for? How much is Medicaid in terms of cost? These are among the common questions that Medicaid applicants have.

South Carolina Medicaid coverage is also known as Health Connections. This is a publicly funded insurance program that pays for the health needs of eligible low-income individuals and families in South Carolina. The Medicaid program helps eligible applicants to afford quality healthcare from different providers around the state.

How Much Does Medicaid Cost in South Carolina?

SC Medicaid coverage enables members with eligibility to enjoy quality health care for free or at a low cost. Some services are offered for free while others come with a copayment. Copays may apply for specific services depending on a member’s category. Confirm the estimate Medicaid costs of the service you need with your primary care provider (PCP).

South Carolina Medicaid coverage requires enrollees to pay co-payments for services that exceed 4 prescriptions per month and 12 doctor visits per year. Generally, the following Medicaid services require a copay:

  • Inpatient and outpatient hospital services
  • Prescription medications
  • Clinic visits
  • Visits to the dentist, chiropractor, podiatrist, optometrist, nurse practitioner or physician
  • Home health
  • Medical equipment

Medicaid cost estimates in SC do not apply for some recipients. Members for whom costs do not apply include anyone receiving home and community based waiver services, individuals receiving emergency services, individuals in health institutions, pregnant women and those receiving family planning services and children aged 19 years or younger.

Download our informative guide to learn more about Medicaid coverage and costs.

A beneficiary must present his or her SC Medicaid services card when visiting a provider, as well as cards from other applicable insurance plans for which they are enrolled.

What Services are Covered by Medicaid in South Carolina?

South Carolina Medicaid coverage pays for various medical services, including:

  • Home and community based long-term care services
  • Family planning and support services, alcohol and drug abuse services
  • Mental health services and ICF (Intermediate Care Facility) for mental retardation
  • Inpatient psychiatric care, ambulance services, hospice care
  • Transportation to Medicaid appointments
  • Prescription and over-the-counter drugs (various restrictions apply)
  • Optometric, eye care and other visions services
  • EPSDT (Early Periodic Screening, Diagnostics and Treatment) for children
  • Doctor or specialists visits (chiropractor, podiatrist, midwife, nursing practitioner, physician)
  • Laboratory tests and X-ray services

For more information on covered services and costs, download our helpful benefits guide.

SC Medicaid coverage pays for EPSDT screening service, which includes hearing, dental and vision screenings, lab tests, routine shots, health education, nutrition and growth assessments, physical exams, health and growth history. Recipients should schedule their children for checkups at:

  • Birth.
  • 2 months.
  • 4 months.
  • 6 months.
  • 9 moths.
  • 1 year.
  • 15 months.
  • 18 months.

What does SC Medicaid not cover or partially covers? Some Medicaid services require prior authorization and/or come with various restrictions. For example, members that are below 21 years get full dental services, including crowns and fillings. However, dental care is not available to adults, except for emergency cases.

South Carolina Medicaid coverage also pays for comprehensive eye care for members that are below 21 years. Children have a free eye exam and are entitled to one pair of glasses per year. On the other hand, adults can have one eye checkup per year and can only be entitled to glasses after undergoing cataract surgery.

What Does Medicaid Not Cover in South Carolina?

South Carolina Medicaid coverage does not apply to all medical services. Sometimes, beneficiaries will have to pay for medical services out-of-pocket or by using third party coverage. Examples of services not covered by Medicaid in South Carolina include:

  • Various prescriptions drugs, especially brand name ones. For some drugs, prior authorization is required from the Medicaid coverage health plan.
  • Fertility services such as surgery to reverse sterilization, hysterectomy for sterilization reasons, etc.
  • Private rooms, unless they are medically necessary
  • Abortion services, unless required to save the life of the mother or to end a pregnancy resulting from incest or rape
  • Medical services, drugs or procedures that are considered experimental and not generally accepted as standard procedure by the wider medical fraternity
  • Elective cosmetic surgery
  • Services that have been determined not to be medically necessary
  • Services offered by a provider that is out-of-network or from out of South Carolina, unless with prior authorization

The Medicaid services covered or omitted are revised often. Confirm the Medicaid cost estimates of the service you need with your health provider.

Understanding Types of Medicaid Insurance in South Carolina

There are various types of Medicaid insurance in South Carolina. Recipients can have both SC Medicaid coverage and a third party insurance company’s services. If a Medicaid beneficiary is under another insurance plan, the provider must first bill it before Medicaid can step in to cover any payments.

If qualified for Medicaid services, recipients will have to choose a health plan. This is a managed care organization (MCO) that has been contracted by South Carolina to provide health care services. The types of Medicaid insurance available determine the network of providers, clinics and physicians where members can access health care services covered.

The major health plans in South Carolina are FirstChoice, Aetna, Healthgram (formerly Primary Physician Care), Cigna Behavioral Health, Molina Healthcare, Absolute Total Care, Blue Cross and Blue Shield of South Carolina and Blue Choice of South Carolina

Applicants can choose the type of SC Medicaid insurance they want after the application has been approved. If an applicant chooses a doctor or provider, he or she will be matched with health plans whose networks the doctor participates in.