Regulatory research · Act 20 of 2023
South Carolina's Certificate of Need repeal — what actually changed
In May 2023, South Carolina enacted one of the broadest Certificate of Need repeals in decades (Act 20 / S.164). Law firms have covered the compliance details; what nobody connects is the real-estate consequence: once the state stops vetoing market entry, where you put the facility becomes the binding decision. This page covers both accurately.
What the repeal did
- Repealed CON for most healthcare facilities and services — including ambulatory surgical facilities and physician offices — effective with the act (signed May 2023). The prior $600,000 hospital equipment-approval cap was also repealed.
- Hospitals kept CON temporarily: new hospitals and bed-complement changes still require a CON until January 1, 2027, when the hospital requirement sunsets. Interim exceptions: same-county hospital relocation, a new hospital of up to 50 beds in a county without one, and mergers/acquisitions.
- Nursing homes and home health agencies continue to require CON — the repeal never covered them.
What the repeal did not do
"No CON" does not mean "easy surgery center." Everything below still applies to an ambulatory surgical facility in South Carolina:
- Facility licensure under the Standards for Licensing Ambulatory Surgical Facilities (SC Regulation 61-91), now administered by the SC Department of Public Health (DPH) after the 2024 DHEC split — including construction plan review before building.
- Physical-plant standards: construction and life-safety codes, medical gas systems, emergency power, ventilation/air-handling requirements, sterile processing, recovery areas, infection-control design, ADA access.
- Indigent-care obligation: ASCs licensed after the act owe charity/indigent care of 2% of adjusted gross revenue (Medicaid-participating) or 3% (non-participating), beginning after their second year of operation.
- Professional licensure, DEA/pharmacy, accreditation for reimbursement, and payer credentialing — untouched by the repeal.
What happened after repeal
South Carolina's licensed-ASC count has grown materially since 2023 — trade and advocacy reporting describes growth on the order of +40–50% statewide, strongest in underserved areas. We treat those growth figures as directionally credible secondary reporting; the authoritative census is the DPH facility directory at any given date.
The real-estate consequence
Before Act 20, the scarce asset was the CON itself. After Act 20, the scarce assets are buildings that can physically and economically become licensed facilities, and sites near referral sources. Three practical implications for anyone siting outpatient facilities in SC:
- The building decides the budget. Procedure facilities have physical-plant requirements most 1980s office stock cannot meet without near-total reconstruction. A cheap building is not a cheap facility. (Our feasibility study of a specific 1985 building works through this arithmetic, including which uses fit such a building without conversion.)
- Non-procedure outpatient uses gained the most. Clinics, physician offices, behavioral-health, and diagnostic uses never needed CON — but the repeal accelerates the outpatient shift that raises demand for ordinary medical office space near hospitals.
- Watch January 1, 2027. When hospital CON sunsets, hospital systems gain freedom to add capacity — which can both anchor corridors (more referrals) and compete with independents.
What could make this page wrong
- Legislative amendment before the 2027 hospital sunset (the General Assembly could extend or modify it).
- DPH regulatory updates to Reg 61-91 standards or the licensure process.
- The post-repeal ASC growth figures are secondary reporting; verify against the DPH directory before relying on them.
Related research: ASC feasibility at 125 Dillon Drive (the honest building-level answer), the Spartanburg medical-office market, and the property fact ledger.
- Act 20 of 2023 (S.164) — South Carolina General Assembly [T1 statute · 2023]
- SC Code Title 44, Chapter 7 (State Certification of Need and Health Facility Licensure Act) [T1 statute]
- Governor of South Carolina — CON repeal signing announcement [T1 · 2023]
- SC DPH — Standards for Licensing Ambulatory Surgical Facilities (Regulation 61-91) [T1 regulator]
- Maynard Nexsen & Nelson Mullins analyses of Act 20 (hospital sunset, indigent-care provisions) [T3 · 2023–2024]
- Becker’s ASC and advocacy reporting on post-repeal ASC growth (secondary, directional) [T3 · 2024–2026]
Last reviewed 2026-08-23. Not legal advice.