Medicaid Program Information

TYPES OF MEDICAID


 

There are a number of programs within the South Carolina Department of Health and Human Services (SCDHHS) designed to meet the complex needs of the individuals. As a Healthy Connections Medicaid member, coverage may be administered in several ways depending on individual need. 

Types of coverage include:

  • Fee-for-Service (FFS)—SCDHHS pays providers for health care services. This typically includes services offered under a waiver program.
  • Managed Care Organizations (MCOs) & Medicare Medicaid Plans (MMPs)—Partnered health plans pay contracted providers for health care services. 
     
  • Medical Homes Network (MHN)—SCDHHS pays providers for health care services in a primary care physician network only.
     
  • Home and Community-Based waiver programs (HCBS)—Designed to meet the needs of those with disabilities or chronic conditions. Eligibility is based, in-part, by an individual’s medical necessity.

SERVICE DELIVERY


 

  

Managed Care

Waiver Services

Support Services

 
 
       Click the any of the images above to be directed to areas of interest.
 

PROGRAMS AND OPTIONS


Most members enrolled with Healthy Connections Medicaid will also enroll with an MCO. When a member is in an MCO, the MCO covers services. An MCO may offer extra benefits to members. Extra benefits may vary by plan.

Once a plan is chosen, a member will have 90 days to make a change to their chosen MCO. After the first 90 days, members will remain enrolled with the MCO for the remainder of the benefit year.

Healthy Connections Medicaid also has an optional MMP program members may join if they are already participating in Medicare and Healthy Connections Medicaid. The program is called Healthy Connections Prime. Enrollment in this program is voluntary, and members may change their plan monthly.

Click to learn more about Healthy Connections Prime.

Members who are interested in enrolling or who would like to learn more about MCOs and MMPs can visit https://www.scchoices.com. You can contact SC Choices by phone, fax, and/or TTY:

Phone: (877) 552-4642

Fax: (877) 552-4672

TTY Line (for hearing impaired): (877) 552-4670

An enrollment counselor can help you Monday – Friday, 8 a.m. – 6 p.m., excluding South Carolina state holidays.

MANAGED CARE 


Managed Care Organizations (MCOs)

  • Adults with low incomes
  • Older adults
  • People with disabilities
  • Pregnant people
  • Children

   Note: Additional criteria may apply.

 

Medicare-Medicaid Plans (MMPs)

  • Ages 65 or older
  • Full Medicare benefits
  • Full Healthy Connections Medicaid benefits
  • Not currently residing in a nursing facility

Note: Some exclusions may apply.

WAIVERS


Some members may be eligible for one of several waiver programs. A waiver is a type of program designed for people with disabilities and chronic health conditions. The waivers allow healthcare professionals to provide care in a person’s home or community instead of a long term care facility.

SCDHHS and the South Carolina Department of Disabilities and Special Needs (DDSN) operate HCBS waiver programs in South Carolina. A summary of who is eligible for these waiver programs, which services are provided and how the programs are operated can be found by clicking on the Waiver Summary Chart.

Note: Waiver eligibility may vary. 

Community Long Term Care

Community Long Term Care (CLTC) offers programs to help individuals who want to live at home, need assistance with their care, and are financially eligible for Medicaid.

Under CLTC, if eligible, a member may access additional services through one of several waiver programs:

Home and Community-Based Service (HCBS) waivers:

Community Choices
  • Frail elderly
  • Disabled
  • Ages 18 and older
  • Meets nursing facility level of care
HIV/AIDS
  • Diagnosed with AIDS or HIV-positive with episodes of specific related conditions
  • Hospital level of care
Mechanical Ventilator Dependent
  • Elderly
  • Disabled
  • Ages 21 and older
  • Requires the use of mechanical ventilation
  • Meets nursing facility level of care

For questions about eligibility and how to make a referral for CLTC waivers, call (888) 971-1637 or visit https://phoenix.scdhhs.gov/eref.

Youth Waivers

The Medically Complex Children (MCC) waiver serves children who meet the nursing facility level of care and have a chronic physical/health condition that is expected to last longer than 12 months and meet medical criteria defined by the state, including dependency upon comprehensive medical, nursing, and health supervision or intervention. 

Medically Complex
Children 
  • Ages 0 to 18 with chronic physical/health condition(s)
  • Expected to last at least 12 months
  • Hospital level of care
     

Palmetto Coordinated System of Care

This program serves children and youth with serious behavioral health challenges who are in or most at-risk of out-of-home placements. 

Palmetto Coordinated System of Care
  • Ages 0 to 21 with behavioral health challenges
  • Must meet targeted criteria to be assessed for High Fidelity Wraparound eligibility

Click to to learn more about the Palmetto Coordinated System of Care.

DDSN Waiver Services

In addition to the waivers and programs listed above, and in partnership with the Department of Disabilities and Special Needs (DDSN), three additional waivers are administered for members with other needs. 

Waivers Administered by DDSN:

Intellectual Disability/Related Disabilities (ID/RD) Waiver
  • Diagnosis of intellectual or related disability
  • All ages
  • Meets ICF-IID level of care
Community Supports Waiver
  • Diagnosis of intellectual or related disability
  • All ages
  • Meets ICF-IID level of care
Head and Spinal Cord Injury (HASCI) Waiver
  • Diagnosis of traumatic brain injury, spinal cord injury, or simliar disability
  • Ages 0 - 65
  • Meets ICF-IID level of care

Click to learn more about DDSN-administered waivers

 

SUPPORT PROGRAMS


Home Again

The Home Again program is designed to assist eligible individuals who live in a skilled nursing facility or a hospital to move back into their homes and communities. The South Carolina Department of Health and Human Services was awarded Money Follows the Person (MFP) grant from Centers for Medicare & Medicaid Services to develop the Home Again program and started to implement the program in 2013. 

  • Currently reside in a skilled nursing facility or hospital
  • Have been in the institution for at least 60 consecutive days
  • Be on Medicaid payment for at least one day before transitioning
  • Meet either Intermediate or Skilled Level of Care

Click to learn more about Home Again.

Children's Personal Care

Personal Care services are available to eligible children from birth through the 20th year.

Click to learn more about Children's Personal Care.

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