Overview of South Carolina’s Healthy Connections Prime Program
South Carolina’s Healthy Connections Prime (HCP) Program is a voluntary statewide managed care program for seniors (65+ years old) who are “dual eligible” (eligible and enrolled in both Medicaid and Medicare). Program participants receive a variety of benefits, including medical care, hospitalization, prescription drugs, nursing home care, and home and community based services (HCBS). HCBS may include adult day health care, personal care assistance, personal emergency response systems, respite care, and home modifications to delay and prevent the need for nursing home admission. Supplemental benefits, such as annual vision and hearing exams, gym memberships, and incentive gift cards (for service completion), may also also available.
Program participants receive all of their Medicaid and Medicare benefits, including Medicare Part D (drug coverage), via a single Medicare-Medicaid Plan (MMP) provided by a Coordinated & Integrated Care Organization (CICO). A CICO is essentially a private healthcare company that provides healthcare plans. The CICO has a network of care providers and program participants receive services via these providers. There are three MMPs from which to choose: Wellcare Prime by Absolute Total Care, First Choice VIP Care Plus, and Molina Dual Options. All three options may not be available in all SC counties. See available MMPs by county.
Personal assistance services offered via Healthy Connections Prime can be participant-directed. This means program participants can hire the home care attendant (caregiver) of their choosing to provide care rather than have their care provided by licensed agency workers. Friends, and some relatives, such as adult children, can be hired. Spouses, unfortunately, cannot be hired. A Financial Management Services Agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.
Program participants can reside in their own private home or that of a loved one. They can also live in an adult foster care home or a community residential care facility (assisted living residence), although Healthy Connections Prime will not pay for room and board. While nursing facility care is an available benefit via HCP, one cannot be residing in a nursing home facility upon enrollment into the program.
Healthy Connections Prime is an entitlement program. As long as an applicant meets eligibility criteria, benefits will be received. Home and community based services, however, are available via South Carolina Medicaid Waivers, which include the Community Choices Waiver, the HIV/AIDS Waiver, and the Mechanical Ventilator Dependent Waiver. These are not entitlement programs. The state limits the number of program participant slots, and when they are filled, a waitlist for HCBS forms.
South Carolina’s Healthy Connections Prime is a dual demonstration project that operates under a Section 1115 Demonstration Waiver. Home and community based services operate under 1915(c) Medicaid Waivers. In SC, the Medicaid program is called Healthy Connections.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of the Healthy Connections Prime Program
Program participants receive all of their Medicaid and Medicare (Parts A, B, and D) benefits through a single Medicare-Medicaid plan. There is no monthly premium to participate. Benefits may include the following.
– Behavioral Health Services
– Care Coordinator / Care Manager
– Dental Services
– Hospital Care
– Community Long Term Care / Home and Community Based Services – long-term services and supports provided via a Medicaid Waiver, like Community Choices. This may include adult day health care, personal care services (at home or in a community residential care facility), home delivered meals, home modifications, personal emergency response systems, and respite care.
– Medical Equipment (i.e., wheelchairs, walkers, blood sugar monitors)
– Nursing Home Care
– Physician Visits
– Prescription / Over-the-Counter Medications
– Transportation (medical – emergency and non-emergency)
Medicare-Medicaid Plans may also offer additional benefits, such as vision and hearing services, health club memberships, and incentive gift cards (for completing services).
Eligibility Requirements for Healthy Connections Prime Program
Applicants must be 65+ years old, living in the community, and enrolled in SC Medicaid / Healthy Connections and Medicare Parts A, B, and D. They cannot be in a nursing home facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), getting treatment for End Stage Renal Disease, nor receiving hospice services. However, if the need for these services develops after one is a program participant, they are available. Additionally, program participants cannot be enrolled in a Medicaid Waiver aside from the Community Choices Waiver, Mechanical Ventilation Waiver, or the HIV/ADIS Waiver. The Medicaid eligibility criteria that follows is relevant for seniors.
Financial Criteria: Income, Assets & Home Ownership
Income
Effective 3/1/24 – 2/28/25, the income limit for a single applicant is $1,255 / month. When an applicant is married, regardless of whether or not their spouse is also an applicant, there is a couple income limit of $1,703 / month.
For home and community based services via the Community Choices Waiver, which is the waiver most relevant to aging seniors, applicants are permitted a higher income. In 2024, the individual applicant limit is $2,829 / month. When both spouses of a married couple are applicants, there is a couple income limit of $5,658 / month. When only one spouse is an applicant, the individual income limit of $2,829 / month applies and the income of the non-applicant spouse is disregarded. However, in some cases, income can be allocated to the non-applicant spouse from the applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance (MMNA).
In SC, the MMNA is $3,853.50 / month, allowing up to this amount to be transferred to the non-applicant spouse. To be clear, this allowance is intended to bring a non-applicant’s monthly income up to $3,853.50. If a non-applicant’s own income is equal to or greater than this amount, they are not entitled to a Spousal Income Allowance.
Assets
In 2024, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is $4,000, regardless of if one or both spouses are applicants.
There is, however, an exception if only one spouse is applying and requires long-term services and supports via a Medicaid Waiver, such as the Community Choices Waiver. While the assets of both the applicant and non-applicant spouse are still limited, the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA). In 2024, the CSRA allows the non-applicant spouse to keep up to $66,480 in assets. This is in addition to the $2,000 in assets the applicant spouse can retain.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.
While there is a Medicaid Estate Recovery Program (MERP) in which the Medicaid agency attempts reimbursement of long-term care costs for which it paid for a beneficiary after their death, this is not relevant for Healthy Connections Prime. There is no estate recovery for participants of this program. However, if persons receive some of these same services, such as nursing home care, outside of Healthy Connections Prime, the state may attempt to recover costs.
Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, Medicaid in SC considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $713,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child living in the home.
– The applicant has a disabled child living in the home.
Learn more about the potential of Medicaid taking the home.
Medical Criteria: Functional Need
If an applicant does not require Community Long Term Care / Home and Community Based Services or nursing home care, there is no functional need criteria. If they do, a Nursing Facility Level of Care (NFLOC) is required. An inability to independently complete Activities of Daily Living (ADLs) are frequently indicative of a NFLOC need. ADLs include mobility, eating, toileting, bathing, dressing, and transitioning. Persons with Alzheimer’s disease or a related dementia may be eligible for program services if NFLOC is met. However, a diagnosis of dementia, in and of itself, does not mean one will meet this level of care need.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for SC Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limits, Miller Trusts, also called Income Trusts in SC, may allow persons who require home and community based services or nursing home care to be income-eligible. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts (IFTs) are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts (MAPTs), which protect assets from being counted, can also be utilized, but must be created well in advance of the need for long-term care. Persons may also “spend down” extra assets on non-countable ones, such as household appliances and furnishings or making home reparations. There are additional Medicaid planning strategies available when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in South Carolina to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of the strategies violate Medicaid’s 60-month Look-Back Rule, and therefore, should only be implemented with careful planning. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s).
How to Apply for South Carolina’s Healthy Connections Prime Program
Before You Apply
Prior to submitting an application for SC Medicaid / Healthy Connections, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.\
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. A common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
Application Process
Persons must be eligible for South Carolina Medicaid / Healthy Connections in order to enroll in Healthy Connections Prime. Persons can apply for Heathy Connections online or complete and submit an Application for Medicaid and Affordable Health Coverage. Persons can receive application assistance by calling the Help Center at 888-549-0820.
Persons who are enrolled in SC Medicaid / Healthy Connections and eligible for Healthy Connections Prime should be contacted with enrollment options. Persons can also call 800-726-8774 to reach an enrollment counselor at SC Thrive Customer Service Center, or alternatively, call 877-552-4642 to reach an enrollment counselor at South Carolina Healthy Connections Choices Customer Service Center.
Persons can learn more about Healthy Connections Prime and see a program brochure. Additionally, persons can call the SC Thrive Customer Service Center at 800-726-8774 or South Carolina Healthy Connections Choices Customer Service Center at 877-552-4242 for more information.
The South Carolina Department of Health and Human Services (SCDHHS) and the Centers for Medicare and Medicaid Services (CMS) administer Healthy Connections Prime.
Approval Process & Timing
The Healthy Connections / SC Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as a waiting list for home and community based services may exist, approved applicants may spend many months waiting to receive benefits.