South Carolina Medicaid Appeals and Fair Hearings

If your South Carolina Medicaid coverage was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is decided.1 In South Carolina, Healthy Connections Medicaid appeals are decided by the South Carolina Department of Health and Human Services (SCDHHS) Office of Appeals and Hearings, and your notice sets a filing deadline of thirty days, shorter than the federal ceiling of 90 days.2

In This Guide

• What you can appeal in South Carolina Medicaid
• South Carolina Medicaid appeal deadlines that decide your case
• How to keep your benefits during the appeal
• Managed care (MCO) appeals: exhaust your plan first
• How to request a South Carolina Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in South Carolina Medicaid

Federal law guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires South Carolina's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted upon with reasonable promptness, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.1

In South Carolina, an appeal is asking for a hearing because you disagree with a decision made by SCDHHS, a managed care plan, or another party acting for the agency.2 That covers the full range of adverse actions:

• An application denial (income, assets, or documentation)
• A termination or reduction of eligibility or of a covered service
• A cut to the number of authorized service hours, such as personal care
• A prior authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service

If you have not yet filed and want the application steps themselves, start with How to Apply for South Carolina Medicaid.

South Carolina Medicaid appeal deadlines that decide your case

Two deadlines matter most in a South Carolina Medicaid appeal, and they are different numbers.

The first is the request window: read it off your own notice. South Carolina notices give thirty days to appeal, measured from either the date of the notice or the day you receive it, depending on the notice.2 That is within, but shorter than, the federal rule at 42 CFR 431.221(d), which caps the deadline at a reasonable time not to exceed 90 days from the date the notice is mailed.2 The federal 90 days is not a fallback: it is the outer limit on the window a state may allow, not a minimum you are owed, so South Carolina's shorter deadline is the one that binds you and it is fully enforceable. If it has already passed, file in writing anyway, as soon as you can, say why the request is late, and ask the Office of Appeals and Hearings to accept it, but treat that as a long shot rather than a second deadline.2

The second is the continuation window: to keep your current benefits flowing during the appeal, request continuation within ten days of the date on the notice.2

A different clock governs how fast your case is decided rather than when you must file. Ordinarily, beneficiary appeals should be concluded within 90 days of filing.2

One more protection applies to renewals. If your coverage was terminated only because you did not return a renewal form on time, federal law at 42 CFR 435.916 requires the agency to reconsider your eligibility without a new application if you submit the renewal form within 90 days after the termination date. That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, South Carolina may offer the same window but is not required to, so ask SCDHHS.4

How to keep your benefits during the appeal

Keeping your benefits during the appeal is called aid paid pending, and it is never automatic. You have to ask for it, and you have to ask in time.

Under the South Carolina rule, new services cannot be started during an appeal, but a member may request that existing benefits or services continue during the appeal if the request is made within ten days of the date on the notice.2 Request continuation in time and your services or benefits generally stay at the prior level while the appeal is decided.

South Carolina's continuation rule tracks the federal continuation rule at 42 CFR 431.230(a): when the agency sent the required advance notice and you request the hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing, unless the sole issue in dispute is one of federal or state law or policy rather than the facts of your case.3 The trigger is timing. Request the hearing before the action takes effect, and put your request to continue benefits in writing.

If the action has already taken effect, continuation under 42 CFR 431.230 no longer applies, but a separate rule at 42 CFR 431.231 lets the agency reinstate services when you request a hearing not more than ten days after the date of action.3

Continuation carries one cost if you lose. Disputed benefits you received during the appeal may have to be repaid if the hearing officer upholds the decision.2 Federal law at 42 CFR 431.230(b) permits the agency to recoup the cost of services furnished solely because benefits were continued.3

Managed care (MCO) appeals: exhaust your plan first

Most South Carolina Medicaid members get their care through a Managed Care Organization (MCO), a private health plan that SCDHHS contracts with to manage benefits. When an MCO denies care, you appeal to the plan before you reach a state fair hearing. South Carolina partners with five MCOs: Absolute Total Care, BlueChoice (Healthy Blue), Humana Healthy Horizons, Molina, and Select Health (First Choice).2

Under 42 CFR 438.404, a South Carolina Medicaid managed care plan (MCO) must give you timely, written notice of an adverse benefit determination. That notice must tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue during the appeal.5

You have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal, which can be requested orally or in writing.6 An MCO has only one level of appeal, and in South Carolina you should work through it before filing an appeal with the Office of Appeals and Hearings; note that MCOs may have their own appeal times and procedures, so read your notice carefully.2

A South Carolina Medicaid managed care plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours of receiving it. Either timeframe can be extended by up to 14 calendar days if you request the extension or the plan shows the state that more information is needed and the delay is in your interest.7 Request the 72-hour expedited track whenever waiting on the standard timeline could seriously jeopardize your health.

Once the plan resolves the appeal against you, the state must give you no less than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing; the exact number within that band is set by the state.7 If instead you receive waiver services through the South Carolina Department of Disabilities and Special Needs (SCDDSN), complete its reconsideration process before filing with the Office of Appeals and Hearings.2

How to request a South Carolina Medicaid fair hearing

Appeals and fair hearings in South Carolina are decided by the SCDHHS Office of Appeals and Hearings, which oversees appeals filed by an applicant, member, or provider from an adverse agency decision.2 A fair hearing is an in-person proceeding conducted by a hearing officer; hearings are not held telephonically and are most often held at Jefferson Square, 1801 Main Street, Columbia, SC 29201.2

To appeal a Medicaid eligibility decision, state what you are appealing and why, and include a copy of the notice you received. You can file:2

• Online at scdhhs.gov/appeals, where an electronic confirmation is emailed to you
• By phone at 888-549-08202
• By fax to 803-255-8206 or 803-255-8251
• By mail to Attn: Eligibility Appeals, SCDHHS, PO Box 8206, Columbia, SC 29202
• By email to eligappeals@scdhhs.gov

Appeals that are not about eligibility go to the Office of Appeals and Hearings at PO Box 8206, Columbia, SC 29202, or appeals@scdhhs.gov. You can reach the Office of Appeals and Hearings at (803) 898-2600 or (800) 763-9087.2 For a decision made by SCDHHS, file before the thirty-day deadline on your notice.2 If you are instead coming out of a managed care plan's internal appeal, the longer window above applies: no less than 90 and no more than 120 calendar days, running from the date of the plan's notice of resolution rather than from an agency notice.7 Either way, if you want your current benefits to continue, ask for continuation within ten days of the date on the notice.2

Learn More

Find personalized help navigating a South Carolina Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.