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South Carolina and the ACA’s Medicaid expansion

South Carolina was the first non-expansion states to receive federal approval for a Medicaid work requirement, but the Biden administration is reconsidering that approval

Key takeaways

No Medicaid expansion in South Carolina

South Carolina’s governor and legislature have strongly rejected Medicaid expansion under the Affordable Care Act (ACA). As a result, there are about 105,000 people in the state who are in the “coverage gap.” They are the state’s poorest residents, with incomes under the poverty level, and they have no realistic access to health coverage. They do not qualify for subsidies in the exchange and they also do not qualify for Medicaid. In many cases, they rely on emergency rooms and community health clinics, but future funding for those clinics is in jeopardy too.

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Since 2017, Republican Henry McMaster has been the governor of South Carolina (McMaster was the lieutenant governor and took office as the governor when Nikki Haley was appointed by President Trump to be the U.S. Ambassador to the United Nations). McMaster is opposed to Medicaid expansion, as was Haley.

South Carolina’s legislature has not changed its stance on Medicaid expansion; the most recent legislation aimed at expanding Medicaid eligibility (S.3226, introduced in early 2021), has not advanced out of committee. But the U.S. Senate is working on a reconciliation bill that would provide coverage to more than 4 million people in the dozen states, including South Carolina, that have continued to resist Medicaid expansion.

CMS approves Medicaid work requirement for low-income parents, but it has not been implemented and the Biden administration is reconsidering the approval

The Trump administration approved Medicaid work requirements in several states, although most were either overturned by court rulings or pended by the states, and the rest were suspended amid the COVID pandemic (to receive the additional federal Medicaid funding provided by the Families First Coronavirus Response Act, states cannot disenroll people from their Medicaid rolls until the end of the COVID public health emergency period, which essentially makes work requirements a non-starter during the pandemic).

In December 2019, when CMS approved South Carolina’s Medicaid work requirement (“community engagement”) proposal, it was the first such approval for a state that hadn’t expanded Medicaid. Because South Carolina hasn’t expanded Medicaid, the state’s Medicaid population consists of low-income people who are children, elderly, disabled, pregnant, or parents of minor children. Adults who don’t fit into one of these categories are not eligible for coverage, no matter how low their income is.

(Medicaid expansion provides coverage for non-elderly adults who don’t fall into the existing eligibility categories (disabled, pregnant, very low-income parents), so the idea behind the work requirements in most states was that since Medicaid expansion applies mostly to able-bodied adults, they should have to work in order to maintain coverage. This logic is flawed in many ways, which have been covered extensively by consumer advocates, but it was the stated premise behind the work requirements that were approved prior to December 2019.)

So if it were to be implemented, South Carolina’s Medicaid work requirement will primarily apply to low-income parents of minor children. Under existing rules, these parents are eligible for Medicaid with income up to the poverty level (about $1,830/month for a family of three). They are not currently subject to a work requirement, but that would change if the work requirement waiver were to be implemented.

South Carolina’s Medicaid work requirement proposal noted that the requirement would not be implemented before July 2020, and it’s still pending as of mid-2021. The state’s community engagement resource page notes that no time frames have been specified yet for compliance or reporting requirements.

In early 2021, the Biden administration notified South Carolina that the approved Medicaid work requirement waiver was being reconsidered to determine whether it fits with the objectives of Medicaid. The state soon sent a reply, asking CMS to maintain approval for the work requirement. The status of the reconsideration is still pending, but CMS has already officially withdrawn approval for some other states’ Medicaid work requirement waivers, and it’s unlikely that South Carolina’s will ever be implemented.

Medicaid eligibility for low-income parents extended to include families with household income up to the poverty level

When South Carolina’s Medicaid work requirement waiver was approved, Medicaid eligibility for low-income parents was set at 67% of the poverty level.

A separate waiver was approved that grants Medicaid eligibility to South Carolina parents with income as high as 100% of the poverty level. The idea was that parents would have to comply with the state’s new Medicaid work requirement in order to have coverage. Consumer advocates noted that this could have eventually resulted in as many as 26,000 fewer low-income parents covered under South Carolina’s Medicaid program (the specifics of this were not addressed in the federal approval, as noted here by Georgetown University’s Joan Alker).

But since the Medicaid work requirement has not been implemented, low-income parents with income up to the poverty level are currently eligible for Medicaid in South Carolina without strings attached.

The second waiver also grants Medicaid eligibility to a “Targeted Adult” population, including those who are chronically homeless, involved with the justice system (as a defendant), or in need of substance use disorder (SUD) treatment. As is the case for low-income parents, these individuals were expected to comply with the work requirement unless they qualified for an exemption. But again, the work requirement has not been implemented and is being reconsidered by the Biden administration.

The state estimated that between those two populations (i.e., parents with income that makes them newly-eligible for Medicaid, and the Targeted Adult group), 45,100 people would potentially gain eligibility for Medicaid. The work requirements would have added a layer of complexity resulting in some people losing coverage (including children, who may lose coverage if a parent is confused about the eligibility rules), but it appears unlikely to be implemented.

Who is eligible for Medicaid in South Carolina?

Although South Carolina still has not accepted federal funding to expand Medicaid eligibility under the ACA, the state did increase the income limits for low-income parents to qualify for coverage. Under the terms of a waiver that was approved by CMS in late 2019, parents and caretakers of minor children are eligible for Medicaid in South Carolina with income as high as 100 percent of the poverty level.

(this expansion of coverage for low-income parents was supposed to be implemented in conjunction with a work requirement — approved as part of a separate waiver — for parents who weren’t exempt from the work requirement. But the work requirement has not been implemented and is unlikely to be implemented due to the COVID pandemic and the Biden administration’s review of pending work requirements).

Here are the current eligibility guidelines, which include a 5% income disregard (the state also has a resource that shows these limits in terms of monthly income):

  • Children with household incomes up to 213% of poverty.
  • Parents/caretakers with dependent children, if their household incomes do not exceed 100% of poverty.
  • Pregnant women with household incomes up to 199% of poverty.

Medicaid coverage in South Carolina is not available for non-disabled childless adults, regardless of how low their income is. This is the group most likely to fall into the Medicaid coverage gap and have little in the way of realistic options for health coverage. This problem would be remedied if South Carolina were to accept federal funding to expand Medicaid, but the state has thus far rejected that option.

As noted above, the U.S. Senate is working on a potential solution as of 2021, which would provide federally-funded coverage to people who would otherwise be eligible for Medicaid if the state had expanded coverage.

How does Medicaid provide financial assistance to Medicare beneficiaries in South Carolina?

Many Medicare beneficiaries receive Medicaid’s help with paying for Medicare premiums, affording prescription drug costs, and covering expenses not covered by Medicare – such as long-term care.

Our guide to financial assistance for Medicare enrollees in South Carolina includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

How do I enroll in Medicaid in South Carolina?

Despite political leadership’s opposition to expanding Medicaid, the state has taken steps to overhaul its Medicaid enrollment process and is actively working to enroll people who are eligible based on the existing guidelines. There are additional employees in the state’s Medicaid call center, an online application process (in addition to HealthCare.gov) and the state is using databases of people who already qualify for other income-based programs like SNAP to help identify residents who are eligible for Medicaid.

  • South Carolina Healthy Connections Medicaid has a website where you can enroll online.  You can also reach them by phone at 1-888-549-0820.
  • You can enroll in Medicaid through HealthCare.gov
  • You can enroll over the phone via HealthCare.gov by calling 1-800-318-2596

Medicaid enrollment is available year-round.

South Carolina Medicaid enrollment

Medicaid enrollment continues year-round, and South Carolina’s poverty rate is 13.8% as of 2019, which is higher than the national average. From the fall of 2013 through early 2020, the population covered by Medicaid in South Carolina grew by more than 245,000 people — a 28% increase — despite the fact that Medicaid eligibility as called for in the ACA has still not bee implemented.

The increase is due largely to the state’s expansion of coverage for low-income parents, as well as the COVID pandemic and the widespread job losses that it caused.

South Carolina Medicaid history

Medicaid became effective in South Carolina in July 1968, two and a half years after it was available in the first states that implemented it. Eligibility has been improved and expanded over the years through federal mandates that required coverage for children and pregnant women.

A primary provision of the ACA was to expand Medicaid to cover all legally-present residents with incomes up to 138 percent of poverty, with the federal government paying the full cost of expansion through 2016. After that, the states have gradually taken on a small portion of the cost, but it will never exceed ten percent. It was expected that this landmark expansion of Medicaid would be implemented in every state.

But in 2012, the Supreme Court ruled that states could not be penalized if they chose to not expand their Medicaid programs, and South Carolina is one of the 14 states that has not yet expanded Medicaid.

Former Governor Nikki Haley was staunch in her opposition to Medicaid expansion, although her comments on the issue seemed to indicate that her primary objective was opposing President Obama. In 2013, Haley stated that South Carolina “will not expand Medicaid on President Obama’s watch. We will not expand Medicaid ever.” And Gov. McMaster has maintained that approach. Unfortunately, this means that South Carolina residents are paying federal taxes that are being used to fund Medicaid expansion in other states — and they’re getting nothing for themselves. The state is missing out on $15.8 billion in federal funding over the next decade by not expanding Medicaid.

In addition to the financial impact, there’s a human cost to not expanding Medicaid. A White House report in June 2015 noted that expanding Medicaid in South Carolina would save 200 lives per year. Democrats in the state legislature renewed their calls to expand coverage in 2015, but no progress was made during the 2016 legislative session. That has continued to be the case in subsequent sessions, which is unsurprising given the strong Republican majority in the state’s legislature.

Although Medicaid coverage in South Carolina is still limited to a small number of adults in South Carolina, a slight improvement came in December 2014 for Medicaid-eligible adults. Preventive dental care, including cleanings, fillings, and extractions, was added to the existing Medicaid benefits, with up to $750 in annual benefits per member. Previously, this benefit was only provided for children.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Apply for Medicaid in South Carolina

Enroll online at South Carolina Healthy Connections Medicaid or by phone at 1-888-549-0820; or enroll in Medicaid through HealthCare.gov or by phone at 1-800-318-2596

Eligibility: The aged, blind, and disabled.  Also children with household incomes up to 208% of FPL; working parents with dependent children with household incomes up to  89% of FPL; jobless parents with dependent children with household incomes up to 50% of FPL; pregnant women with household incomes up to 194% of FPL.

South Carolina section

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