South Carolina Medicaid Fee Schedule 2026: Rates, Limits & Provider Guide

Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against SCDHHS official publications and Medicaid.gov | Last Updated: April 2026

CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility and billing rates, contact SCDHHS directly or visit Medicaid.gov.

Quick Summary

• Program name: Healthy Connections Medicaid, run by SCDHHS
• Two delivery systems: Fee-for-Service (FFS) and Managed Care (MCO)
• 2026 FMAP: Federal government pays 69.57% of costs; South Carolina pays 30.43%
• Managed care composite PMPM rate (amended): $364.42 (base, excluding add-ons)
• Income limits updated: March 1, 2026, based on 2026 FPL and 2.8% SSI COLA
• Check if you qualify: Use our Medicaid eligibility calculator 2026 to see if you meet income rules in South Carolina

What Is the South Carolina Medicaid Fee Schedule?

The South Carolina Medicaid fee schedule is the official list of payment rates the state uses to pay doctors, hospitals, pharmacies, and other providers. It tells providers exactly how much Medicaid will pay for each service.

South Carolina’s Medicaid program is called Healthy Connections Medicaid. It is run by the South Carolina Department of Health and Human Services (SCDHHS). The program pays for health care through two main tracks: Fee-for-Service (FFS) and Managed Care Organizations (MCOs).

Understanding these rates matters if you are a provider billing Medicaid — or a patient who wants to know how your care is covered. This guide covers every major rate category for 2026, based entirely on official SCDHHS and CMS sources.

How South Carolina Medicaid Pays for Care in 2026

South Carolina uses two payment systems. Most beneficiaries get care through MCOs, which receive a fixed monthly payment per member. Long-term care and some waiver programs still use FFS, where providers bill for each service.

The state fiscal year (SFY) runs July 1 through June 30. The federal fiscal year (FFY) runs October 1 through September 30. This matters because different rate updates follow different cycles.

Fee-for-Service (FFS)

FFS is used mainly for nursing home care, waiver programs, and some specialty services. SCDHHS publishes individual FFS fee schedules on its provider portal. Providers bill for each service and receive payment according to the published rate.

Managed Care Organizations (MCOs)

Most Healthy Connections Medicaid members are enrolled in managed care. The state pays MCOs a per-member-per-month (PMPM) capitation rate. MCOs then pay providers directly. Milliman, Inc. certifies that these rates are actuarially sound each year.

2026 Managed Care Capitation Rates

This is one of the most important sections for providers and policymakers. SCDHHS contracted Milliman, Inc. to develop and certify actuarially sound capitation rates for SFY 2026 (July 1, 2025–June 30, 2026).

The original SFY 2026 rate certification was issued June 18, 2025. An amendment was certified on December 15, 2025.

What Changed in the December 2025 Amendment

Three changes were made in the amended rates:

1. The Physician Directed Payment Program was removed (not implemented in SFY 2026)
2. Administrative expenses were reduced by 0.1% per rate cell
3. The Supplemental Teaching Physician (STP) directed payment was updated to reflect final CMS approval of $160,028,404

The amended composite PMPM (base, excluding add-ons) is $364.42 — a 0.1% decrease from the original $364.82.

Amended SFY 2026 Base Capitation Rates (Excluding Add-Ons)

These rates cover July 1, 2025 through June 30, 2026:

Total Rates Including State-Directed Payment Add-Ons

When state-directed payment programs are added, total PMPMs are higher. Selected examples:

Total projected managed care expenditures under amended SFY 2026 rates: $6,319.2 million ($4,395.9M federal / $1,923.2M state).

State-Directed Payment Add-On Programs (SFY 2026)

These are paid outside the base capitation rate as separate payment terms:

Note: The Physician Directed Payment Program was removed for SFY 2026 and will not be implemented this period.

Fee-for-Service Physician & Professional Rates

For services outside managed care, SCDHHS publishes FFS fee schedules at scdhhs.gov/providers/fee-schedules. These cover physician, nursing, therapy, behavioral health, and many other service categories.

The most recent confirmed FFS physician rate update was effective July 1, 2024, when SCDHHS based reimbursement on the 2024 Medicare Physician Fee Schedule.

⚠️ Data Gap: As of April 2026, SCDHHS has not published a bulletin announcing a new 2026 FFS physician rate update. The last confirmed formal update was July 1, 2024. Providers should monitor scdhhs.gov/communications for any new announcements.

Rate Methodology by Provider Type (Most Recent Confirmed)

Selected E&M Visit Rates (Base, Established Patients)

These Evaluation & Management rates were confirmed as of the July 2023 update and remain the current FFS baseline:

For all current CPT-level rates, use the live SCDHHS fee schedule files at scdhhs.gov.

Behavioral Health & Psychiatric Facility Rates

Behavioral health is a covered benefit under both managed care and FFS. SCDHHS has made several important rate changes in this area since 2024.

Inpatient Psychiatric Hospitals

Effective for dates of service on or after July 1, 2024, SCDHHS moved from a DRG methodology to a per diem approach:

• Stand-alone inpatient psychiatric hospitals: $800 per member, per day
• SC Department of Mental Health hospitals: $800 per member, per day

Psychiatric Residential Treatment Facilities (PRTFs) — Non-State-Owned

Effective for dates of service on or after July 1, 2024:

• Standard PRTF per diem: $525 per member, per day
• Autism Specialty PRTF per diem: $788 per member, per day (for facilities meeting SCDHHS autism criteria)

State-Owned PRTF — New Rate Effective January 1, 2026

This is a new development in 2026. Effective January 1, 2026, SCDHHS amended the South Carolina Title XIX State Plan to establish a separate reimbursement rate for state-owned governmental PRTF providers. No such rate existed before this date.

Estimated annual budget impact: approximately $1.17 million total. This change was made to improve access to behavioral health services and expand the provider network.

⚠️ Data Gap: The specific per diem dollar amount for the new state-owned PRTF rate was not published in the public notice. The full dollar rate requires review of the State Plan Amendment text at CMS.

Hospital Reimbursement

Hospital payments under South Carolina Medicaid include both inpatient FFS rates and supplemental payments. Two key updates affect SFY 2026.

Disproportionate Share Hospital (DSH) Payments — FFY 2026

For FFY 2026 (October 1, 2025–September 30, 2026):

• Base year cost reporting uses hospital fiscal year ending 2024
• Inflation trending is updated through end of calendar year 2024
• National DSH allotments face aggregate reductions of $8 billion for FFY 2026–2028 under the ACA DSH reduction framework
• SCDHHS does not expect to expend 100% of its FFY 2026 DSH allotment

Inpatient Swing Bed and Administrative Day Rates

Effective October 1, 2025, SCDHHS updated swing bed and administrative day rates. The projected annual cost increase is less than $10,000 (deemed immaterial). The 2025 calendar year swing bed nursing facility rate was confirmed at $253.95; an updated 2026 figure has not yet been published in official SC sources.

Ventilator-Dependent Nursing Facility Wing

Effective for services on or after November 21, 2024 (CMS SPA approved):

• Per diem rate: $708.00 per Medicaid patient day
• Qualifying wing must have a minimum of 20 beds dedicated solely to ventilator-dependent services

Nursing Facility Rates (Long-Term Care / FFS)

Long-term nursing home care is paid on a Fee-for-Service basis. It is carved out of managed care capitation (except short-term stays). SCDHHS conducts annual rate redeterminations effective October 1 each year.

For the period beginning October 1, 2025 (which covers most of SFY 2026):

• Minimum occupancy factor used in rate calculation: 90%
• Percent skilled is based on SFY 2025 Medicaid paid days

⚠️ Data Gap: Specific per-diem nursing facility rates by individual facility are determined through SCDHHS’s cost-report methodology and are not publicly aggregated. Contact SCDHHS directly for facility-specific rates.

Private-Pay Nursing Home Costs in South Carolina (2026 Context)

For comparison, private-pay nursing home costs in South Carolina in 2026:

South Carolina nursing home costs are 17–20% below the national average. Medicaid reimbursement rates are set separately through SCDHHS’s cost-based methodology and are typically lower than private-pay rates.

Pharmacy Reimbursement

Pharmacy payments in South Carolina Medicaid operate through both managed care and FFS channels. A state-directed payment for independent pharmacies was established for SFY 2026.

Independent Community Pharmacy Directed Payment (SFY 2026)

• Base MCO payment to pharmacies: approximately 80% of Medicare
• State-directed add-on: $7 per script (uniform, for all SC Medicaid-enrolled independent pharmacies)
• Combined estimated payment level: approximately 104.4% of State Plan approved rates
• Total SFY 2026 payment pool: $9,500,000 (~$0.98 PMPM composite)

Pending PBM Legislation (S. 342)

A bill pending in the South Carolina Legislature as of early 2026 would set a pharmacy reimbursement floor at 104% of NADAC (National Average Drug Acquisition Cost) and provide a dispensing fee equal to the current Medicaid professional dispensing fee. As of March 2026, the bill had passed out of committee but was not yet enacted.

⚠️ Data Gap: The specific current Medicaid pharmacy professional dispensing fee (FFS) for SFY 2026 was not confirmed in reviewed official sources. The SCDHHS Pharmacy Services Manual (updated October 1, 2025) is the authoritative source.

South Carolina Medicaid Income Limits 2026

SCDHHS updated income limits across all Healthy Connections programs effective March 1, 2026, based on 2026 FPL figures and the January 1, 2026 SSI Federal Benefit Rate (FBR) after a 2.8% COLA adjustment.

For a full breakdown of how these income limits compare to other states, see our guide to Medicaid income limits by state 2026.

Income Limits for Long-Term Care and Waiver Programs

Income Limits by Eligibility Category (Effective March 1, 2026)

Resource limits (effective January 1, 2026): $9,950 for individuals and $14,910 for couples (applies to ABD, QMB, SLMB, and QI programs).

Important: South Carolina has not adopted ACA Medicaid expansion. Adults without a qualifying category (age, disability, pregnancy, or dependent children) generally do not qualify for Healthy Connections Medicaid, regardless of income.

Federal Matching Rate (FMAP) for South Carolina 2026

The FMAP determines how much of South Carolina’s Medicaid costs are paid by the federal government:

South Carolina’s state share is approximately 30.43% for regular Medicaid. The high FMAP reflects the state’s lower per-capita income relative to the national average.

What Does Healthy Connections Medicaid Cover?

South Carolina Medicaid covers a broad range of services under its SFY 2026 managed care contracts. Coverage includes both physical and behavioral health services.

Core covered services include:

• Physician services and outpatient care
• Inpatient hospital services
• Maternity services and newborn care (including the KICK birth episode payment)
• Prescription drugs
• Mental health and substance use disorder services
• Rehabilitative behavioral health services
• Durable Medical Equipment (DME)
• EPSDT / Well Child services (Early & Periodic Screening, Diagnosis and Treatment)
• Autism Spectrum Disorder (ASD) services
• Home health services
• Ambulance transportation
• Vision care, podiatry, audiology, and hearing aids
• Family planning
• Transplant services (carved into managed care February 1, 2024)
• Developmental Evaluation Center (DEC) services (carved in February 1, 2024)
• Tobacco cessation coverage

Short-term nursing home stays are covered under managed care. Long-term nursing home care is covered under FFS and is carved out of MCO capitation.

How to Apply for Medicaid in South Carolina

Applying for Healthy Connections Medicaid in South Carolina is straightforward. Here are the steps:

1. Check your eligibility. Review the income limits in this guide or use the Medicaid fee schedule 2026 resource to understand what services may be covered.
2. Gather your documents. You will need proof of identity, residency, income, and citizenship or immigration status.
3. Apply online. Visit apply.scdhhs.gov to submit your application electronically.
4. Apply by phone. Call SCDHHS at 1-888-549-0820 to apply by phone or get help.
5. Apply in person. Visit your local SCDHHS county office. Find your nearest office at scdhhs.gov/offices.
6. Apply by mail. Download the paper application from scdhhs.gov and mail it to your local county office.

For most programs, eligibility is determined based on Modified Adjusted Gross Income (MAGI) and household size. Long-term care programs also consider resources (assets).

What Happens After You Apply?

After you submit your application, here is what to expect:

Most applications are processed within 45 days. Disability-related applications may take up to 90 days. You will receive a written notice from SCDHHS with a decision.

If approved, your coverage start date may be backdated to the first day of the month you applied. If denied, you have the right to appeal. Your notice will include instructions for requesting a fair hearing.

Once enrolled, you will be assigned to a managed care plan (MCO) if you are in a managed care population. You will receive a Medicaid card and member handbook from your MCO.

Renewal happens annually. SCDHHS will send renewal paperwork before your coverage ends. Respond promptly to avoid a gap in coverage.

Frequently Asked Questions (FAQ)

2026 Data Gaps: What Is Not Yet Confirmed

Some specific dollar figures for 2026 have not been published in official sources as of April 2026:

Sources & Disclaimer

Sources:

• Medicaid.gov — Official Medicaid information
• Healthcare.gov — Medicaid & CHIP overview
• SCDHHS — South Carolina Department of Health and Human Services
• Milliman, Inc. — SFY 2026 Actuarial Certification (original June 18, 2025; amended December 15, 2025), commissioned by SCDHHS
• CMS-approved South Carolina State Plan Amendments (Medicaid.gov)
• SCDHHS provider bulletins and public notices (scdhhs.gov/communications)

Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only and does not constitute legal or medical advice. Income limits, rates, and payment figures are drawn from official sources and are subject to change. Providers should verify current rates directly with SCDHHS before billing. For official eligibility determinations, contact SCDHHS or visit Medicaid.gov.

Last Updated: April 2026