South Carolina Medicaid managed care: what plans must pay
Managed-care plans don't publish their provider fee schedules. What is public is the rule each plan must follow, set in South Carolina's plan contracts, statutes and notices. For 0 of 15 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 0of 15
- Plans on record
- 13
- Directed payments
- 3
- Capitation cells
- 124$79.69–$7,262.97 PMPM
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 132,495 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 21,189 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 9,660 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 6,080 | |
| Hospital inpatient | Not classified yet | 2,845 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,418 | Paid by the state, outside plans |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,021 | |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 653 | Paid by the state, outside plans |
| Hospice | Paid by the state, outside plansPaid directly by the state, outside managed care | 298 | |
| Vision & hearing | Not classified yet | 232 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 175 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 81 | Plans negotiate; applies out of network |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 75 | |
| Other | State-directed paymentDirected payments add to plan rates | 56 | |
| Hospital outpatient | Not classified yet | 23 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 18 | |
| Transportation | Not classified yet | 12 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 10 | Plans negotiate; applies out of network |
| ABA / autism services | Not classified yet | 10 | |
| Clinics (FQHC/RHC) | Not classified yet | 4 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 3 |
State-directed payments
Payments CMS approved under 42 CFR 438.6(c) that plans must make on top of, or as a minimum for, their negotiated rates.
| Program | Amount | Effective |
|---|---|---|
| South Carolina Healthy Connections Medicaid Managed Care (five statewide MCOs) | 100% | 2026-01-01 |
| South Carolina Healthy Connections Medicaid Managed Care (five statewide MCOs) | 100% | 2026-01-01 |
| South Carolina Healthy Connections Medicaid Managed Care (five statewide MCOs) | 100% | 2023-07-01 |
Frequently asked questions
Do South Carolina Medicaid plans have to pay the state fee schedule?
The plan contracts we reviewed do not tie plan payment to the state's rates for most lines; plans negotiate rates with providers.
Where do these rules come from?
From South Carolina's managed-care plan contracts, state statutes and regulations, provider notices and CMS-approved directed-payment filings. Each rate in the workspace carries its citation.
Can I see what each plan actually pays?
No plan publishes its provider fee schedule. The closest public signals are the binding rules above, state-set rates, directed payments and the state's own payment-level estimates in its directed-payment filings.
← All South Carolina Medicaid rates