Title 38, Insurance

All individual and group health insurance policies and health maintenance organizations providing coverage for mastectomy surgery must provide coverage for prosthetic devices and reconstruction of the breast on which surgery for breast cancer has been performed and surgery and re…

This article shall be known and may be cited as the "Small Employer Health Insurance Availability Act".

The purpose and intent of this article is to promote the availability of health insurance coverage to small employers, excluding individual health insurance plans, regardless of their health status or claims experience, to provide for development of "basic" and "standard" health …

As used in this article: (1) "Basic health insurance plan" means a lower cost health insurance plan developed pursuant to Section 38-71-1420. (2) "Board" means the board of directors of the program established pursuant to Section 38-71-1410. (3) "Director" means the Director of t…

(A) Except as provided in subsection (B), the provisions of this article apply to any health insurance plan that provides group coverage to groups of two to fifty. (B) The provisions of this article do not apply to individual health insurance policies that are subject to policy f…

(A) A health group cooperative of small employers may be formed only for the purpose of obtaining insurance. A health group cooperative: (1) shall contain at least one thousand eligible employees or must have at least ten participating employers; (2) shall establish requirements …

All individual and group health insurance and health maintenance organization policies providing coverage for the hospitalization and attendant professional services of a mother and her newborn child or children must provide for the mother and her newborn child or children to rem…

(A) Except as provided in Section 38-71-1345(A)(7)(b), premium rates for health insurance plans subject to this article are governed by the rating restrictions provided for in this chapter. (B) Premium rates for health insurance plans must comply with the requirements of this sec…

(1) shall arrange for group health insurance plan coverage for small employers who are members of the cooperative by contracting with small employer insurers who meet the criteria established by this chapter for coverage under group health insurance plans; (2) shall collect premi…

(A)(1) Every small employer insurer shall, as a condition of transacting business in this State with small employers, actively offer to small employers all health insurance plans actively marketed to small employers in this State, including at least two health insurance plans. On…

(A) A health group cooperative shall contract only with a small employer insurer that demonstrates: (1) that the insurer or health maintenance organization is licensed and in good standing with the Department of Insurance; (2) the capacity to administer the group health insurance…

(A) Except to the extent inconsistent with specific provisions of this article, all provisions of Article 5, are applicable to any insurance plans required to be offered by small employer insurers. (B) Late enrollees may be excluded from coverage for the greater of eighteen month…

(A)(1) Within sixty days after the plan of operation is approved by the director under Section 38-71-1410, each small employer insurer shall notify the director of the insurer's intention to operate as a risk-assuming insurer or a reinsuring insurer. A small employer insurer seek…

(A) Any small employer insurer may elect to become a risk-assuming insurer upon application to and approval by the director. A small employer insurer shall not be approved as a risk-assuming insurer if the director finds that the insurer is not capable of assuming that status pur…

(A) All individual and group health insurance policies providing coverage on an expense-incurred basis and individual and group service or indemnity-type contracts issued by a nonprofit corporation which provide coverage for a family member of the insured or subscriber, as to the…

(A) A small employer insurer may elect to become a reinsuring insurer and operate under the provisions of this section and Section 38-71-1410. (B) Each reinsuring insurer shall conduct business with its members and subscribers, and administer claims for coverage reinsured by the …

(A) There is hereby created a nonprofit entity to be known as the South Carolina Small Employer Insurer Reinsurance Program, which shall become operational on July 1, 1995. (B)(1) The program shall operate subject to the supervision and control of the board. Subject to the provis…

(A) The Governor shall appoint an advisory committee to the director which shall recommend the form and level of coverages to be made available by small employer insurers pursuant to Section 38-71-1360. At least one member of the committee shall be a licensed independent insuranc…

(A) If an individual or group health plan provides coverage for dependent children of participants or beneficiaries, the plan shall provide benefits to dependent children placed with participants or beneficiaries for adoption under the same terms and conditions as apply to the na…

The board, in consultation with members of the committee, shall study and make a public report each year to the director on the effectiveness of this article. The report shall analyze the effectiveness of the act in promoting rate stability, product availability, and coverage aff…

(A) For purposes of this section: (1) "Health benefit plan" means all individual and group health insurance policies and health maintenance organizations issued, delivered or renewed in this State, to include the State Health Plan, but otherwise not to include the administrative …

(A) Each small employer insurer shall fairly market health insurance plan coverage, including the basic and standard health insurance plans, to eligible small employers in the State. A small employer insurer shall not deny coverage to a small employer based solely on the employer…

The South Carolina Department of Insurance and Revenue and Fiscal Affairs Office shall submit to the Office of the Governor and the General Assembly by January 1, 2010, a report on the effectiveness of the health group cooperative in expanding the availability of health insurance…

(A) All individual and group health insurance and health maintenance organization policies in this State shall include coverage in the policy for: (1) mammograms; (2) annual pap smears; (3) prostate cancer examinations, screenings, and laboratory work for diagnostic purposes in a…

The Director of Insurance may promulgate regulations as may be necessary or appropriate to carry out the provisions of this article.

All individual and group health insurance and health maintenance organization policies in this State shall include coverage for contraceptives. For purposes of this section, "contraceptive" means the same as in Section 44-41-610(4). A contraceptive may prevent ovulation, fertiliz…

Every individual or family accident and health or hospitalization policy, certificate, contract, or plan, except trip or travel ticket policies, issued for delivery in this State shall have printed thereon or attached thereto a notice to the insured that ten days are allowed, fro…

This article may be cited as the "Access to Emergency Medical Care Act".

As used in this article: (1) "Emergency medical care" means those health care services provided in a hospital emergency facility to evaluate and treat an emergency medical condition. (2) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms …

(A) A patient who presents to an emergency department, by the Federal Social Security Act, must be screened to determine whether an emergency medical condition exists. This evaluation may include, but is not limited to, diagnostic testing to assess the extent of the condition, si…

No managed care organization may engage in any practice to prohibit or discourage the appropriate use of the 911 emergency telephone system which may adversely impact the health of its enrollees.

The provisions of this article do not apply to a policy which provides disability or income protection coverage, hospital confinement indemnity coverage, accident-only coverage, specified disease or specified accident coverage, long-term care coverage, vision-only coverage, or co…

If any provision of this article or the application of any provision to any person or circumstance is held invalid, the invalidity does not affect other provisions or applications of the article which can be given effect without the invalid provision or application, and to this e…

For purposes of SECTION 38-71-150, the insured is considered to have returned a policy sold on a direct response basis as of the date shown on the postmark or the date the insured notifies the insurer or an agent of the insurer, in writing or in person, that the insured does not …

No policy or certificate of accident, health, or accident and health insurance issued or delivered in this State which in addition to covering the insured also provides coverage to the spouse of the insured may contain a provision for termination of coverage for a spouse covered …

This article may be cited as the "South Carolina Patients' Insurance and Benefits Protection Act".

As used in this article: (1) "Closed panel health plan" means a network plan that requires an insured or a member to seek covered health care services or supplies, except in the case of emergency, exclusively from network providers. (2) "Eligibility" means the time at which an in…

(A) For purposes of health plans offered pursuant to this section: (1) An employer may require an employee who chooses a point-of-service option to be responsible for payment of premiums, deductibles, copayments, or other payments in excess of the benefits provided by the closed …

(A) For purposes of any health insurance plan, health maintenance organization, or any other health benefits plan offered in this State under the jurisdiction of South Carolina law: (1) Each party to a managed care participating provider agreement is responsible for the legal con…

A network plan must disclose in writing, using the plain and ordinary meaning of words so as reasonably to ensure comprehension by the insured or member, and make available to an insured or a member at the time of enrollment: (1) services or benefits under the plan, including lim…

The Director of the Department of Insurance or his designee shall promulgate regulations to implement the provisions of this chapter.

(A) For the purposes of this article: (1) "Insurer" means an entity that provides health insurance coverage in this State as defined in Section 38-71-670(7) and Section 38-71-840(16). (2) "Responsible party" means the entity responsible for payment of claims for health care servi…

(A) Each entity that conducts an audit of a pharmacy shall establish an appeals process under which a pharmacy may appeal an unfavorable preliminary audit report to the entity. (B) If, following the appeal, the entity finds that an unfavorable audit report or any portion of the u…

(A) Recoupments of any funds disputed on the basis of an audit must occur only after final internal disposition of the audit, including the appeals process as provided for in Section 38-71-1820 or the external review pursuant to Section 38-71-2240, unless fraud or misrepresentati…

The provisions of this article do not apply to an audit, review, or investigation: (1) that involves alleged insurance fraud or abuse, Medicare fraud or abuse, or other fraud or misrepresentation; (2) conducted by or on the behalf of the Department of Health and Human Services in…

Any policy or contract of accident and health insurance issued in this State may include provision for subrogation by the insurer to the insured's right of recovery against a liable third party for not more than the amount of insurance benefits that the insurer has paid previousl…