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June 14, 2023

Questions About Medicaid Redetermination in SC? We Have Answers

The South Carolina Department of Health and Human Services (SCDHHS) resumed its standard Medicaid eligibility annual reviews process April 1, 2023. This federally required process is in place to ensure those enrolled in Medicaid programs continue to meet established eligibility criteria. The restart of this process was required by the Consolidated Appropriations Act, 2023, which was passed by Congress and signed into law by President Joe Biden Dec. 23, 2022. A dashboard has been created by the South Carolina Department of Heath and Human Services tracking the process and is available here.

Why is it important for Medicaid beneficiaries to know the status of their coverage? 

Prior to the COVID pandemic and the public health emergency (PHE), Medicaid enrollees were reviewed annually to verify their eligibility for Medicaid benefits. As part of the PHE, this process was suspended, which means that since March 2020 effectively no one lost their Medicaid coverage – even those no longer eligible. On April 1, the suspension of the review process ended, initiating the redetermination process over the next 12 months. This means the state’s Medicaid agency must verify eligibility for its entire population over the next year – about 1.3M members. Some of these members will no longer be eligible and some that are eligible will lose their Medicaid benefits simply because they do not complete the process that’s required to maintain their coverage.  

What should hospitals know about the state’s outreach efforts? 

SCDHHS is mailing, emailing and texting Medicaid members about the restart of the annual review process, but many beneficiaries won’t know they have a coverage issue until they visit the doctor or hospital to access services. So, hospitals and other providers are uniquely positioned to assist patients in completing the process necessary to regain their Medicaid coverage and making patients aware of resources available to them. 

Which patients are most likely impacted? 

All Medicaid beneficiaries will be reviewed; however, the agency is able to use data matching to verify eligibility information for some beneficiaries, and they won’t need to return a review form. Their benefits will continue. Children will likely be the least impacted group. Non-disabled adults, especially those who have turned 19 since 2020 are most likely to be affected. Patients should also know that their children may still be eligible for Medicaid even if the patient is not because these two populations have different income eligibility criteria.  

If a person shows up at the hospital and has lost their Medicaid coverage, does that mean the hospital won’t get paid by Medicaid for the service? 

There are a few possible scenarios: 

  • If the patient is no longer eligible for Medicaid, the hospital will not be paid. 
  • If it’s still in the window of time for a person to submit their review form and they do so and are deemed eligible, the hospital can get paid. Medicaid beneficiaries have a 90-day grace period after their coverage has expired where services can still be paid by Medicaid if they return their review form, and the beneficiary meets eligibility requirements. 
  • If the person fills out an application because they missed the review window, the hospital can still be paid for services that occur up to 3 months prior to an application date, but the patient must check the box that says they had services prior to application date and must be deemed eligible. 

What resources are available to patients who are no longer eligible for full-benefit Medicaid coverage?  

There is a Medicaid program named Transitional Medical Assistance (TMA) which is available to assist beneficiaries whose income increases above the FPL% for full Medicaid coverage. During the annual review process, families are automatically assessed for eligibility in all categories, including TMA. There’s also a limited benefit Medicaid program called Family Planning which will provide coverage for certain screenings and services. The income limit is higher for this program and patients may contact the Medicaid agency to learn more. Some of the patients could also be eligible for subsidized coverage on the Federal Marketplace.  

How can hospitals and healthcare providers increase awareness about this issue? 

Maximize the use of social media, your facility’s website and educate your community. Consider having educational pieces in your facility and signs posted notifying patients that the redetermination process has been reinitiated and to complete all the steps necessary for the Medicaid agency to make an accurate eligibility determination. Member and provider-facing material about the annual review process is available at 

Can hospitals and healthcare providers do anything to advance the process? 

This is a yearlong effort, and some Medicaid beneficiaries may not have reached the month when they go through their review. However, it’s important to make sure their correct address is on file with the Medicaid agency so they will receive their review form when it is mailed. It may also be helpful for providers to verify with their Medicaid patients that they have updated their information with the agency. Providers are encouraged to direct Medicaid patients to update their contact information at 

What other information is available to assist hospitals with this issue? 

SCHA is in the process of creating a series of resources that will be made available to our members soon!