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Healthy Connections Medicaid team members and managed care plans will never ask for money, gift cards or something else of monetary value via text, email or a phone call. If someone contacts you asking for something of monetary value to get or keep Medicaid coverage, please report it by contacting the Medicaid fraud hotline at (888) 364-3224 Monday through Friday from 8:30 a.m. to 5 p.m. or by sending an email to FraudRes@scdhhs.gov.

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Managed Care Carve-in FAQs

All Providers  

Q: What populations were carved-into managed care on Jan. 1, 2026?  

A: The below categories of Healthy Connections Medicaid members who are 18 years of age or older were carved-into managed care on Jan. 1, 2026.   

  • Those who are dually enrolled in Medicare and Medicaid, regardless of age;   
  • Medicaid members enrolled in the HIV/AIDS Waiver;   
  • Medicaid members enrolled in the Mechanical Ventilator Dependent (Vent) Waiver;   
  • Medicaid members enrolled in the Community Choices Waiver; and  
  • Medicaid members who reside in a nursing facility   
  • These members are now enrolled in a Medicaid managed care organization (MCO) for coverage of Medicaid State Plan services.  
 

Q: Do I need a new authorization to continue providing care, medical supplies or durable medical equipment (DME)?  

A: No, not for existing authorizations. The transition from a FFS to managed care delivery model includes a 90-day continuity of care period for Healthy Connections Medicaid members. During this continuity of care period, MCOs are required to honor all previous prior authorizations and ensure there is no break in access to service or covered medical supplies for members. Additionally, there have been no changes made to the authorization and payment of waiver services.   

Q: Do I need to be in-network with an MCO to be paid for claims?  

A: During the continuity of care period, MCOs are required to ensure access to service or covered medical supplies and DME for members. During this period, MCOs are responsible for paying claims for authorized services for Healthy Connections Medicaid members covered by their plan regardless of the providers’ MCO network status.  

Once the continuity of care period is over, providers must be enrolled with the MCO in which the Healthy Connections Medicaid member is enrolled.  

Q: Where can I find information about how to submit claims or enroll with an MCO?  

A: Providers can find contact and enrollment/credentialing information for each South Carolina MCO on SCDHHS’ website.  

Nursing Facilities  

Q: Will the MCOs be required to give retroactive authorization for any authorizations that may have been missed?  

A: Nursing facility services are not carved into Medicaid managed care; therefore authorizations and payments will remain a Medicaid FFS responsibility. Furthermore, as of Jan. 1, 2026, nursing facilities will no longer need to bill Medicaid managed care plans for the first 90 days of Medicaid skilled nursing facility services.  

Q: Will there be a disenrollment process for nursing home patients who are enrolled in an MCO?  

A: All Medicaid members over the age of 18 and enrolled in both Medicare and Medicaid as well as individuals enrolled in Community Choices, HIV or Vent HCBS waivers and individuals residing in a nursing facility were enrolled in a Medicaid managed care plan effective Jan. 1, 2026. The Prime/Dual program sunset on Dec. 31, 2025, per federal Centers for Medicare and Medicaid Services (CMS) instructions and those individuals were transitioned to a new Dual Special Needs (D-SNP) Medicare Advantage Plan. As part of this transition, we unwound nursing facility services from that managed care environment and returned it to FFS Medicaid. Individuals residing in a nursing home that are now enrolled in a managed care plan will have access to case management services, additional benefits and only medical services (e.g. hospital services) will be reimbursed by the MCO.  

Q: How will patients who were already enrolled in hospice be handled?  

A: SCDHHS’ system now allows individuals enrolled in hospice to continue to receive hospice services via Medicaid FFS but continue to allow the individual to remain in the home and community-based waiver program and/or the MCO.  

Q: Will the plans be held to the same standards as traditional Medicaid FFS in regard to authorizations, bed hold and, complex care guidelines?  

A: Nursing facility services are not carved into Medicaid managed care; therefore, authorizations and payments will remain a Medicaid FFS responsibility. Furthermore, as of Jan. 1, 2026, nursing homes will no longer need to bill Medicaid managed care plans for the first 90 days of Medicaid skilled nursing facility services.  

Q: Will patients revert back to FFS or stay managed by an MCO and review authorizations every three months? Will they follow SCDHHS guidelines for complex care?  

A: Nursing facility services (including complex care or nursing home vent) are not carved into Medicaid managed care; therefore, authorizations and payments will remain a Medicaid FFS responsibility. Furthermore, as of Jan. 1, 2026, nursing homes will no longer need to bill Medicaid managed care plans for the first 90 days of Medicaid skilled nursing facility services.  

Q: Our organization does not have contracts with the various Medicaid MCOs. What impact will this have?  

A: No impact. Nursing facility services (including complex care or nursing home vent) are not carved into Medicaid managed care; therefore, authorizations and payments will remain a Medicaid FFS responsibility. Furthermore, as of Jan. 1, 2026, nursing homes will no longer need to bill Medicaid managed care plans for the first 90 days of Medicaid skilled nursing facility services.  

Q: What impact will this change have on delivery of Part B therapy services for residents in a Medicaid stay?  

A: No impact. Nursing facility services (including complex care or nursing home vent) are not carved into Medicaid managed care; therefore, authorizations and payments will remain a Medicaid FFS responsibility. Furthermore, as of Jan. 1, 2026, nursing homes will no longer need to bill Medicaid managed care plans for the first 90 days of Medicaid skilled nursing facility services. SCDHHS also does not authorize nor reimburse Medicare services and nursing facilities should continue normal billing practices with Medicare FFS.  

Q: Will there be changes to the turn around document (TAD), or will Medicaid billing continue as normal?   

A: No, there are no changes to the TAD. Medicaid billing will continue as normal.  

Q: Will the MCO's ever transition into Prime plans? If so, that will affect the members Medicare. Are Prime plans going away?  

A: Prime sunset on Dec. 31, 2025. Nursing homes previously billing Prime plans for Medicaid nursing facility days should start billing Medicaid FFS for service dates beginning on Jan. 1, 2026.  

Q: The residents who are currently enrolled in Prime plans, if the Prime plans go away, will they just transition back to traditional Medicare?  

A: The Prime/Dual program sunset on Dec. 31, 2025, per federal CMS instructions. Those individuals were transitioned to a new D-SNP Medicare Advantage Plan effective Jan. 1, 2026. As part of this transition, SCDHHS unwound nursing facility services from that managed care environment and returned it to Medicaid FFS.  

Q: If someone misses enrollment due to a hospital stay and they are auto enrolled in a plan, are they able to switch plans? What is the timeframe to switch? Is there an immediate change option for when a resident is auto enrolled in a plan and not accepted by a provider?   

A: Medicaid members have 90 days to switch plans once they are enrolled into a Medicaid managed care plan.  

Q: When someone is approved for Medicaid, what does the enrollment into a Medicaid managed care plan look like? Is there a timeline?  

A: It typically takes up to 45 days from a Medicaid application approval to enroll into the Medicaid managed care plan due to notice/member letter timelines.  

Q: ls there "open enrollment" for Medicaid managed care plans moving forward every year? 

A: Yes, annually.

HCBS Waiver Providers

Q: How will HCBS waiver services be authorized for Healthy Connections Medicaid members that have been carved into an MCO?

A: Waiver services for members enrolled in the HIV/AIDS, Vent and Community Choices waivers will continue to be authorized through the FFS delivery model.

A comparison grid of waiver covered services, broken down by each HCBS waiver is available for reference on SCDHHS’ website.

Q: Where should claims be submitted for Medicaid State Plan services for members in the HIV/AIDS, Vent and Community choices waivers? 

A: For dates of service on and after Jan. 1, 2026, claims for medical services for members who are enrolled in the HIV/AIDS, Vent and Community Choices waivers should be submitted to the MCO in which the member is now enrolled. 

Waiver services that are only covered through the HIV/AIDS, Vent and Community Choices waivers should still be submitted and will be paid as they have been through the FFS Medicaid program. 

Providers can find contact information for each South Carolina MCO on SCDHHS’ website.

A comparison grid of waiver covered services, broken down by each HCBS waiver is available for reference on SCDHHS’ website.