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.3 Do not assume you have 90 days; the deadline that governs you is the thirty-day one printed on your notice.

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. That shorter, separate window is covered in the next section.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 If the standard timeframe could jeopardize your life, health, or ability to attain, maintain, or regain maximum function, you may request an expedited appeal, which SCDHHS may grant.2

One more protection applies to renewals. If your coverage was terminated only because you did not return a renewal form or requested information on time, federal law at 42 CFR 435.916 requires the agency to reconsider your eligibility without a new application if you submit what was missing within 90 days after the termination date.5

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 If you request continuation in time, your services or benefits 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.4 The trigger is timing. Request the hearing before the action takes effect, and put your request to continue benefits in writing.

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.4

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.6

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.7 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.8 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.8 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 Whichever route applies, file before the thirty-day deadline on your notice, and 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.