On Sept. 28, South Carolina regulators approved Roper St. Francis Healthcare’s plan to create a 12-bed hospital for women and newborns by moving beds from its Berkeley County hospital. It may be one of the last Charleston-area hospital projects that has to ask.

Under a 2023 state law, the requirement that hospitals get a certificate of need from the state before building or changing their bed counts is repealed effective Jan. 1, 2027.

Today, state law requires a certificate before “the construction or other establishment of a hospital” and before any change in a hospital’s bed complement, whether by adding beds or changing how beds are classified. The same section of the code says, “Effective January 1, 2027, Section 44-7-160(B) is repealed.” That subsection is the hospital requirement.

Nursing homes will still need certificates. So will home health agencies, which lawmakers have not removed from the program, according to a May 2026 follow-up report by the Legislative Audit Council.

The last round

A Charleston Business Report tally of the S.C. Department of Public Health’s monthly certificate of need reports, from January 2025 through September 2026, found five hospital projects approved in Charleston, Berkeley and Dorchester counties. The reports show no Charleston-area hospital project denied in that span.

The first, approved July 2, 2025, added 24 psychiatric beds at Trident Medical Center’s Live Oak Mental Health & Wellness, for 84 in all, at a cost of about $125,000.

On Dec. 15, 2025, the state approved 12 pediatric medical and surgical beds and six pediatric intensive care beds at MUSC Shawn Jenkins Children’s Hospital. The $19.5 million project brings MUSC Medical Center to 743 beds, according to the department.

Bon Secours St. Francis Xavier Hospital in West Ashley won approval May 12 to add nine Level III neonatal intensive care bassinets, along with renovations, for about $8.1 million.

On June 30, HCA Healthcare Trident Hospital got the go-ahead to reclassify four medical and surgical beds as inpatient rehabilitation beds, a $374,488 project. The state lists the North Charleston hospital at 284 hospital beds plus 28 rehabilitation beds.

Then came Roper’s specialty hospital, a $2.5 million project approved Sept. 28. The state’s September report listed no projects under appeal anywhere in South Carolina.

One more Charleston-area approval in the period is a reminder of what stays regulated. In January, the state approved a 40-bed skilled nursing facility, a $28.6 million project, inside The Peninsula of Charleston, a planned retirement community on King Street that its website says is scheduled to open in 2028. That kind of project will still need a certificate after Jan. 1.

When a certificate meant years in court

The rule could turn expansion into a long legal fight. One Charleston-area case shows how long. It began in December 2017, when MUSC’s hospital authority applied for a certificate to build a general hospital in the Nexton community in Berkeley County, to ease capacity problems at its downtown hospital, according to a 2024 S.C. Supreme Court opinion.

The state health agency at the time, the Department of Health and Environmental Control, approved it. Colleton Medical Center and Trident Medical Center, which also runs Summerville Medical Center, challenged the decision. After a year of discovery and an 11-day hearing, an administrative law judge approved the certificate. The Supreme Court upheld that ruling in January 2024, more than six years after MUSC applied.

The justices were blunt about the agency’s original review, which the opinion said ran five pages.

“DHEC’s decision is patently insufficient and constitutes an abdication of the responsibility the General Assembly placed on DHEC,” Justice John Few wrote. The approval survived because the judge had reviewed the case anew, the court said.

MUSC said Oct. 22 that its 70-bed MUSC Health Nexton Medical Center is expected to open in summer 2028.

What the 2023 law already changed

Gov. Henry McMaster signed the law, Act 20, on May 16, 2023. It removed certificate requirements for many facilities, including ambulatory surgery centers, cardiovascular care services and hospice facilities, according to the Legislative Audit Council. It limited equipment reviews to nursing homes and raised the threshold for them from $600,000 to $3 million, the council said.

It also sped up appeals. The law cut the time limit for contested case hearings before the Administrative Law Court from 18 months to 12 and sent appeals straight to the Supreme Court, skipping the Court of Appeals, the audit council found.

Some hospital projects are already exempt from review under state law. They include relocating a licensed hospital within the same county, if certain conditions are met; buying an existing hospital; and building a hospital of up to 50 beds in a county that has none.

What doesn’t go away

Hospitals will still need a state license to operate, under a separate section of the law.

MUSC will also face an extra step. A provision added in 2023 requires the medical university, its hospital authority and affiliates to submit any hospital acquisition, a term the law defines to include new construction, to the legislature’s Joint Bond Review Committee for review and to get approval from the Fiscal Accountability Authority. The Jan. 1 repeal does not remove that section.

After that date, a Charleston hospital adding beds will no longer show up in the state’s monthly certificate of need report.