reglab/statecodes huggingface dataset:
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 69 - Individual Annuities › Section 38-69-290. Statements required in certain contracts.

Any contract which does not provide cash surrender benefits or does not provide death benefits at least equal to the minimum nonforfeiture amount prior to the commencement of any annuity payments shall include a statement in a prominent place in the contract that those benefits are not provided.
HISTORY: Former 1976 Code Section 38-8-90 [1978 Act No. 517 Section 9] recodified as Section 38-69-290 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 69 - Individual Annuities › Section 38-69-300. Calculating benefits available other than on anniversary date.

Any paid-up annuity, cash surrender, or death benefits available at any time, other than on the contract anniversary under any contract with fixed scheduled considerations, must be calculated with allowance for the lapse of time and the payment of any scheduled considerations beyond the beginning of the contract year in which cessation of payment of considerations under the contract occurs.
HISTORY: Former 1976 Code Section 38-8-100 [1978 Act No. 517 Section 10] recodified as Section 38-69-300 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 69 - Individual Annuities › Section 38-69-310. Contracts providing annuity and insurance benefits.

For any contract which provides, within the same contract by rider or supplemental contract provision, both annuity benefits and life insurance benefits that are in excess of the greater of cash surrender benefits or a return of the gross considerations with interest, the minimum nonforfeiture benefits must be equal to the sum of the minimum nonforfeiture benefits for the annuity portion and the minimum nonforfeiture benefits, if any, for the life insurance portion computed as if each portion were a separate contract. Notwithstanding the provisions of Sections 38-69-250, 38-69-260, 38-69-270, 38-69-280, and 38-69-300, additional benefits payable (a) in the event of total and permanent disability, (b) as reversionary annuity or deferred reversionary annuity benefits, or (c) as other policy benefits additional to life insurance, endowment and annuity benefits, and considerations for all such additional benefits, must be disregarded in ascertaining the minimum nonforfeiture amounts and paid-up annuity, cash surrender, and death benefits that may be required by this section. The inclusion of such additional benefits is not required in any paid-up benefits, unless such additional benefits separately would require minimum nonforfeiture amounts and paid-up annuity, cash surrender, and death benefits.
HISTORY: Former 1976 Code Section 38-8-110 [1978 Act No. 517 Section 11] recodified as Section 38-69-310 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 69 - Individual Annuities › Section 38-69-320. Effective date of article as to insurer.

After May 31, 1978, an insurer may file with the department a written notice of its election to comply with the provisions of this article after a specified date before May 31, 1980. After the filing of the notice, upon the specified date, which is the operative date of this article for the insurer, this article becomes operative with respect to annuity contracts thereafter issued by the insurer. If an insurer makes no election, the operative date of this article for the insurer is May 31, 1980.
HISTORY: Former 1976 Code Section 38-8-120 [1978 Act No. 517 Section 12] recodified as Section 38-69-320 by 1987 Act No. 155, Section 1; 1993 Act No. 181, Section 743.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 70 - Utilization Reviews And Private Review Agents › Section 38-70-10. Definitions.

As used in this chapter:
(1) "Utilization review" means a system for reviewing the necessary, appropriate, and efficient allocation of health care resources and services given or proposed to be given to a patient or group of patients.
(2) "Private review agent" means a person performing utilization reviews who is either under contract with or acting on behalf of, but not employed by:
(a) a South Carolina business entity;
(b) the State of South Carolina; or
(c) a hospital.
(3) "Utilization review program" means an overview of the activities performed by the private review agent.
(4) "Director or his designee" means the director or his designee of the South Carolina Department of Insurance. The director may appoint a designee or deputy director to assist in the management and operation of the department. If the director does not appoint a designee or deputy director, the term "director or his designee" shall be construed to refer to the director of the department.
(5) "Certificate" means a renewable certificate of registration granted by the director or his designee to a private review agent, authorizing the agent to perform utilization review activities in this State for two years. This certificate is not transferable.
HISTORY: 1990 Act No. 311, Section 2; 1993 Act No. 181, Sections 744, 745; 1994 Act No. 339, Section 18.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 70 - Utilization Reviews And Private Review Agents › Section 38-70-15. Applicability of chapter.

This chapter applies to insurance companies, administrators of insurance benefit plans, and health maintenance organizations licensed and regulated by the South Carolina Department of Insurance. Insurance companies, administrators of insurance benefit plans, and health maintenance organizations so regulated are exempt from the provisions of Sections 38-70-20(A) and (B), 38-70-30, and 38-70-50.
HISTORY: 1990 Act No. 311, Section 2; 1994 Act No. 339, Section 19.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 70 - Utilization Reviews And Private Review Agents › Section 38-70-20. Certificate to perform activities; applications; fees; minimum standards; confidentiality of records.

(A) No private review agent may conduct utilization reviews in this State unless the director or his designee has granted the private review agent a certificate to perform these activities. The director or his designee, in his discretion, may approve or deny certificate applications.
(B) An applicant for a certificate shall pay the director or his designee the application fee as provided in Section 38-70-50 and shall submit an application to the director or his designee on forms and with any supporting documentation that the director or his designee requires. The application must contain information regarding the utilization review programs to be conducted by the applicant which must meet the requirements contained in subsection (C).
(C) A utilization review program of the applicant must meet the following minimum standards:
(1) notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within five business days;
(2) all utilization review agents shall maintain a procedure by which insured or providers may seek reconsideration of appeal of determinations of the utilization review agent;
(3) a representative of the utilization review agent must be accessible by telephone to insureds or providers in South Carolina, at least forty hours each week during normal business hours;
(4) the type and qualification of the personnel either employed or under contract to perform the utilization reviews must be included in the utilization review program information submitted to the director or his designee;
(5) a copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan must be provided interested parties upon request; and
(6) an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.
HISTORY: 1990 Act No. 311, Section 2; 1993 Act No. 181, Section 746.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 70 - Utilization Reviews And Private Review Agents › Section 38-70-30. Renewal of certificate.

A certificate must be renewed on the second anniversary of its effective date and is considered to be approved upon payment of the fee unless the director or his designee takes action to withdraw or cancel the certificate.
HISTORY: 1990 Act No. 311, Section 2; 1993 Act No. 181, Section 747.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 70 - Utilization Reviews And Private Review Agents › Section 38-70-50. Application and registration fees.

(A) Every private review agent, before transacting business in this State, shall pay an application fee of not more than four hundred dollars and a registration fee of not more than eight hundred dollars to the department by July first each even-numbered year. The certificate year runs July first to the following June thirtieth.
(B) The department shall promulgate regulations necessary to establish these registration and application fees.
HISTORY: 1990 Act No. 311, Section 2; 1992 Act No. 501, Part II Section 11Q; 1993 Act No. 181, Section 749.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 70 - Utilization Reviews And Private Review Agents › Section 38-70-60. Promulgation of regulations to enforce chapter.

The department, after consultation with payers, providers, utilization review agents, the Department of Health and Environmental Control and other interested parties, shall promulgate regulations to implement and enforce the requirements of this chapter in accordance with the State Administrative Procedures Act.
HISTORY: 1990 Act No. 311, Section 2; 1993 Act No. 181, Section 750.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-10. Coverages which may be written by licensed accident and health insurers.

All licensed accident and health insurers are entitled to:
(a) issue and deliver service benefit contracts to provide for prepayment of any health care service and to make payment directly to the provider of the services, in whole or in part, including, but not limited to, professional services, any institutional care, personal services, and supplies;
(b) issue and deliver contracts of indemnity or contracts providing for payment of money directly to the insureds or for them for health care services.
HISTORY: Former 1976 Code Section 38-35-20 [1962 Code Section 37-442; 1968 (55) 2584] recodified as Section 38-71-10 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-20. Insurers may act as administering agency for government-sponsored health, hospital, and medical service programs.

Insurers licensed to do business in this State have the corporate power to contract to act as agent in the administration of programs of health, hospital, and medical insurance sponsored or financed by an agency of the United States Government or any political subdivision.
HISTORY: Former 1976 Code Section 38-35-50 [1962 Code Section 37-444; 1968 (55) 2569] recodified as Section 38-71-20 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-30. Whole contract, including application, must appear in policy; oral applications.

Every insurer doing accident or health insurance business in the State shall deliver with each policy of insurance issued by it a copy of the application made by the insured so that the whole contract appears in the application and policy of insurance. If the insurer violates this requirement, no defense is allowed to the policy on account of anything contained in or omitted from the application. If the insurance policy is issued upon an oral application, no defense is allowed to the policy on account of anything contained in or omitted from the oral application.
HISTORY: Former 1976 Code Section 38-9-70 [1947 (45) 322; 1949 (46) 600; 1952 Code Section 37-146; 1962 Code Section 37-146; 1980 Act No. 305, Section 1] recodified as Section 38-71-30 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-40. Effect of false statement in application.

The falsity of any statement in the application for any policy covered by this chapter does not bar the right to recovery thereunder unless the false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer.
HISTORY: Former 1976 Code Section 38-35-180 [1947 (45) 322; 1952 Code Section 37-451; 1962 Code Section 37-451] recodified as Section 38-71-40 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-46. Diabetes Mellitus coverage in health insurance policies; diabetes education.

(A) On or after January 1, 2000, every health maintenance organization, individual and group health insurance policy, or contract issued or renewed in this State must provide coverage for the equipment, supplies, Food and Drug Administration-approved medication indicated for the treatment of diabetes, and outpatient self-management training and education for the treatment of people with diabetes mellitus, if medically necessary, and prescribed by a health care professional who is legally authorized to prescribe such items and who demonstrates adherence to minimum standards of care for diabetes mellitus as adopted and published by the Diabetes Initiative of South Carolina. This subsection does not prohibit a health maintenance organization or an individual or a group health insurance policy from providing coverage for medication according to formulary or using network providers. Coverage must not be denied unless the health care professional demonstrates a persistent pattern of failure to adhere to the minimal standards of care and unless the health maintenance organization or insurer has first provided written notice to the health care professional that coverage will be denied if the health care professional fails to adhere to the minimal standards of care.
(B) Services and payment for diabetes education programs shall conform to regulations of the Health Care Financing Administration, US Department of Health and Human Services, pursuant to Section 4105 of the Balanced Budget Act of 1997. Diabetes outpatient self-management training and education shall be provided by a registered or licensed health care professional with certification in diabetes by the National Certification Board of Diabetes Educators, or other accredited program approved by the Diabetes Initiative of South Carolina, or by the Diabetes Control Program of the SC Department of Health and Environmental Control in order to meet the needs of rural communities wherein certified health care professionals providing this service are not available.
(C) Nothing contained in this section may be construed to affect in any way the ability of a managed care plan to credential or recredential a provider.
(D) For purposes of this section: "health insurance policy" means a health benefit plan, contract, or evidence of coverage providing health insurance coverage as defined in Section 38-71-670(6) and Section 38-71-840(14).
HISTORY: 1999 Act No. 98, Section 5; 2000 Act No. 348, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-50. Alteration of application.

No alteration of any written application for insurance by erasure, insertion, or otherwise may be made by any person other than the applicant without his written consent, and the making of any such alteration without the consent of the applicant is a misdemeanor. However, insertions may be made by the insurer, for administrative purposes only, in a manner that clearly indicates that the insertions are not to be ascribed to the applicant.
HISTORY: Former 1976 Code Section 38-35-190 [1947 (45) 322; 1952 Code Section 37-452; 1962 Code Section 37-452] recodified as Section 38-71-50 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-60. Certain acts do not constitute a waiver by insurer.

The acknowledgment of any insurer of the receipt of notice given under any policy covered by this chapter, the furnishing of forms for filing proofs of loss, the acceptance of proofs of loss, or the investigation of any claim thereunder does not operate as a waiver of any of the rights of the insurer in defense of any claim arising under the policy.
HISTORY: Former 1976 Code Section 38-35-200 [1947 (45) 322; 1952 Code Section 37-458; 1962 Code Section 37-458] recodified as Section 38-71-60 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-70. Certain policies may conform to laws of other states.

Any foreign insurer authorized to do business in this State may, with the approval of the director or his designee, insert in any policy covered by this chapter so issued or delivered any provision required by the laws of any state or country in which the insurer is licensed, if the provision is not substantially in conflict with any law of this State. A domestic insurer may insert in any policy covered by this chapter issued for delivery in another state or foreign country and governed by the laws thereof any provision required by the laws of the other state or country applicable to the policy.
HISTORY: Former 1976 Code Section 38-35-40 [1947 (45) 322; 1952 Code Section 37-453; 1962 Code Section 37-453] recodified as Section 38-71-70 by 1987 Act No. 155, Section 1; 1993 Act No. 181, Section 751.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-80. Construction of policy issued in violation of chapter.

A policy issued in violation of this chapter is held valid but must be construed as provided in this chapter, and, when any provision in the policy is in conflict with any provision of this chapter, the rights, duties, and obligations of the insurer, the policyholder, and the beneficiary are governed by the provisions of this chapter.
HISTORY: Former 1976 Code Section 38-35-210 [1947 (45) 322; 1952 Code Section 37-454; 1962 Code Section 37-454] recodified as Section 38-71-80 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-90. Penalty for violation of chapter.

An insurer, health maintenance organization, or its officer or agent that issues or delivers to any person in this State any policy in wilful violation of any of the provisions of this chapter or any other applicable state or federal law governing the transaction of business of insurance the Department of Insurance is authorized to enforce is subject to the provisions of Section 38-2-10 for each offense.
HISTORY: Former 1976 Code Section 38-35-220 [1947 (45) 322; 1952 Code Section 37-459; 1962 Code Section 37-459] recodified as Section 38-71-90 by 1987 Act No. 155, Section 1; 1988 Act No. 374, Section 38; 2018 Act No. 219 (H.4657), Section 6, eff May 18, 2018.
Effect of Amendment
2018 Act No. 219, Section 6, inserted ", health maintenance organization," following "An insurer", and inserted "or any other applicable state or federal law governing the transaction of business of insurance the Department of Insurance is authorized to enforce" following "provisions of this chapter".
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-100. Policies exempt from chapter.

Nothing in this chapter applies to or affects:
(1) any policy of workers' compensation insurance or any policy of liability insurance with or without supplementary coverage therein;
(2) any policy or contract of reinsurance;
(3) any blanket or group policy of insurance, except as specifically required in this chapter; or
(4) life insurance, endowment, or annuity contracts or contracts supplemental thereto which contain only such provisions relating to accident and health insurance as (a) provide additional benefits in case of death or dismemberment or loss of sight by accident or (b) operate to safeguard the contracts against lapse or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.
HISTORY: Former 1976 Code Section 38-35-230 [1947 (45) 322; 1952 Code Sections 37-460 and 37-461; 1956 (49) 2029; 1962 Code Section 37-460] recodified as Section 38-71-100 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-110. Notice of failure of employer to remit deducted premium required before forfeiture.

No insurer doing business in this State and issuing health or accident insurance policies, other than contracts of group insurance of disability, accidental death, or disability and accidental death benefits in connection with policies of life insurance, the premium for which is to be collected in weekly, monthly, or other periodic installments by authority of a payroll deduction order executed by the insured and delivered to the insurer or the insured's employer authorizing the deduction of premium installments from the insured's salary or wages, may, during the period for which the policy is issued and while the insured remains employed by the authorized employer, declare forfeited or lapsed the policy until and unless a written or printed notice of the failure of the employer to remit the premium or installment thereof, stating the amount or portion thereof due on the policy and to whom it must be paid, has been duly addressed and mailed to the person who is insured under the policy at least fifteen days before the policy is terminated or lapsed.
HISTORY: Former 1976 Code Section 38-35-170 [1947 (45) 322; 1952 Code Section 37-457; 1962 Code Section 37-457] recodified as Section 38-71-110 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-125. Mastectomies; hospitalization requirements; early release provisions.

All individual and group health insurance policies and health maintenance organizations providing coverage for the hospitalization for mastectomies must provide benefits for hospitalization for at least forty-eight hours following a mastectomy. Nothing in this section shall be construed to prohibit an attending physician from releasing the patient prior to the expiration of the time provided herein. In the case of an early release, coverage shall include at least one home care visit if ordered by the attending physician.
HISTORY: 1998 Act No. 329, Section 3.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-130. Breast reconstruction and prosthetic devices; coverage following mastectomy surgery.

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 reconstruction of the non-diseased breast, if determined medically necessary by the patient's attending physician with the approval of the insurer or HMO. The provisions of this section shall not require supplemental health insurance policies to provide coverage for reconstruction of the nondiseased breast.
HISTORY: 1998 Act No. 329, Section 4.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-135. Minimum postpartum hospitalization and attendant services for mothers and newborns.

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 remain in the hospital for at least forty-eight hours after a vaginal delivery, not including the day of delivery, and at least ninety-six hours following a Cesarean Section, not including the day of surgery. Nothing in this section shall be construed to prohibit the attending physician, in consultation with the mother, from requesting additional time for hospitalization or from releasing the mother or her newborn child or children prior to the expiration of time provided herein.
HISTORY: 1996 Act No. 335, Section 1; 1997 Act No. 5, Section 4.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-140. Coverage of newborn children.

(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 family member's coverage, also must provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth.
(B) The coverage for a newly born child consists of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
(C) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to the insurer or nonprofit service or indemnity corporation within thirty-one days after the date of birth in order to have the coverage continue beyond the thirty-one-day period.
(D)(1) The provisions of this section apply to a child with respect to whom a decree of adoption by the insured or subscriber has been entered within thirty-one days after the date of his birth and to a child with respect to whom:
(a) adoption proceedings have been instituted by the insured or subscriber within thirty-one days after the date of his birth and the insured or subscriber has temporary custody pursuant to Section 63-9-510;
(b) the adoption proceedings have been completed and a decree of adoption entered within one year from the institution of proceedings, unless extended by order of the court by reason of the special needs of the child pursuant to Section 63-9-750.
(2) Coverage must be provided as long as the insured or subscriber has custody of the child pursuant to decree of the court and the required premiums or fees are furnished to the insurer or nonprofit service or indemnity corporation.
HISTORY: Former 1976 Code Section 38-35-70 [1962 Code Section 37-446; 1974 (58) 2247] recodified as Section 38-71-140 by 1987 Act No. 155, Section 1; 1990 Act No. 417, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-143. Health plans must provide same coverage for children placed for adoption.

(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 natural, dependent children of the participants and beneficiaries, irrespective of whether the adoption has become final.
(B) A group health plan may not restrict coverage under the plan of a dependent child adopted by a participant or beneficiary or placed with a participant or beneficiary for adoption solely on the basis of a preexisting condition of the child at the time that the child would otherwise become eligible for coverage under the plan, if the adoption or placement for adoption occurs while the participant or beneficiary is eligible for coverage under the plan.
(C) For the purposes of this section:
(1) "child" means, in connection with an adoption or placement for adoption of the child, an individual who has not attained age eighteen as of the date of the adoption or placement for adoption;
(2) "placement for adoption" means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of the adoption of the child. The child's placement with a person terminates upon the termination of the legal obligations.
HISTORY: 1994 Act No. 481, Section 2, eff July 14, 1994.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-144. Expedited external reviews of certain health benefit plan cancer diagnostic service denials.

(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 services performed on behalf of a self-funded plan subject to the Employee Retirement Income Security Act (ERISA) of 1974 or other plans exempted by Section 38-71-1920(9).
(2) "Stage four advanced, metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.
(3) "Recognized diagnostic imaging service" means a diagnostic imaging service for the diagnosis and treatment of stage four advanced, metastatic cancer for which the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology provide a uniform consensus that the proposed use of the diagnostic imaging service is appropriate and is supported by peer-reviewed literature.
(B) If a health benefit plan that covers the treatment of stage four advanced, metastatic cancer denies a prior authorization request or a claim for a recognized diagnostic imaging service for a covered person's stage four advanced metastatic cancer based upon an adverse medical necessity determination, then the covered person shall have a right to an expedited external review in accordance with Section 38-71-1980.
HISTORY: 2022 Act No. 187 (H.3775), Section 1, eff May 16, 2022.
Editor's Note
2022 Act No. 187, Section 2, provides as follows:
"SECTION 2. This act takes effect upon approval by the Governor, and applies to health benefit plans issued, renewed, delivered, or entered into on or after the effective date of this act."
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-145. Required coverage for mammograms, pap smears, and prostate cancer examinations; limitations.

(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 accordance with the most recent published guidelines of the American Cancer Society.
(B) The coverage required to be offered under subsection (A) may not contain any exclusions, reductions, or other limitations as to coverages, deductibles, or coinsurance provisions which apply to that coverage unless these provisions apply generally to other similar benefits provided and paid for under the health insurance policy.
(C) Nothing in this section prohibits a health insurance policy from providing benefits greater than those required to be offered by subsections (A) and (B) or more favorable to the enrollee than those required to be offered by subsections (A) and (B).
(D) This section applies to individual and group health insurance policies issued by a fraternal benefit society, an insurer, a health maintenance organization, or any similar entity, except as exempted by ERISA.
(E) For purposes of this section:
(1) "Mammogram" means a radiological examination of the breast for purposes of detecting breast cancer when performed as a result of a physician referral or by a health testing service which utilizes radiological equipment approved by the Department of Health and Environmental Control, which examination may be made with the following minimum frequency:
(a) once as a base-line mammogram for a female who is at least thirty-five years of age but less than forty years of age;
(b) once every two years for a female who is at least forty years of age but less than fifty years of age;
(c) once a year for a female who is at least fifty years of age; or
(d) in accordance with the most recent published guidelines of the American Cancer Society.
(2) "Pap smear" means an examination of the tissues of the cervix of the uterus for the purpose of detecting cancer when performed upon the recommendation of a medical doctor, which examination may be made once a year or more often if recommended by a medical doctor.
(3) "Health insurance policy" means a health benefit plan, contract, or evidence of coverage providing health insurance coverage as defined in Section 38-71-670(6) and Section 38-71-840(14).
HISTORY: 1998 Act No. 329, Section 5.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-146. Required coverage for contraceptives.

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, fertilization, or implantation in the uterus. A contraceptive does not include any drug, device, or medication used with the intent of terminating a pregnancy of a woman known to be pregnant. This section does not apply if an individual or entity asserts a sincerely held religious belief regarding the use of contraception.
HISTORY: 2023 Act No. 70 (S.474), Section 5, eff May 25, 2023.
Editor's Note
2023 Act No. 70, Sections 11 and 12, provide as follows:
"SECTION 11. The Public Employee Benefit Authority and the State Health Plan shall cover prescribed contraceptives for dependents under the same terms and conditions that the Plan provides contraceptive coverage for employees and spouses. The State Health Plan shall not apply patient cost sharing provisions to covered contraceptives.
"SECTION 12. The President of the Senate, on behalf of the Senate, and the Speaker of the House of Representatives, on behalf of the House of Representatives have an unconditional right to intervene on behalf of their respective bodies in a state court action and may provide evidence or argument, written or oral, if a party to that court action challenges the constitutionality of this act. In a federal court action that challenges the constitutionality of this act the Legislature may seek to intervene, to file an amicus brief, or to present arguments in accordance with federal rules of procedure. Intervention by the Legislature pursuant to this provision does not limit the duty of the Attorney General to appear and prosecute legal actions or defend state agencies, officers or employees as otherwise provided. In any action in which the Legislature intervenes or participates, the Senate and the House of Representatives shall function independently from each other in the representation of their respective clients."
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-147. Freedom of selection and participation in individual or group accident and health or health insurance policy or health maintenance organization plan.

Section effective until January 1, 2024.
An individual or group accident and health or health insurance policy or a health maintenance organization plan may not:
(1) prohibit or limit a person who is a participant or beneficiary of the policy or plan from selecting a pharmacy or pharmacist of the person's choice who has agreed to participate in the plan according to the terms offered by the insurer; or
(2) deny a pharmacy or pharmacist the right to participate as a contract provider under the policy or plan if the pharmacy or pharmacist agrees to provide pharmacy services including, but not limited to, prescription drugs that meet the terms and requirements set forth by the insurer under the policy or plan and agrees to the terms of reimbursement set forth by the insurer.
HISTORY: 1994 Act No. 394, Section 1; 1994 Act No. 394, Section 2; 1997 Act No. 67, Section 1.
Editor's Note
2023 Act No. 30, Sections 4 and 7, provide as follows:
"SECTION 4. Section 38-71-147 of the S.C. Code is repealed."
"SECTION 7. This act takes effect January 1, 2024, but the recurring examinations by the Department of Insurance provided for in Sections 38-71-2250(B)(1) and 38-71-2340(B)(1) must not begin before January 1, 2025."
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-150. Required provision in policies as to examination and surrender of policy for return of premium.

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, from the date of the receipt of the policy to examine its provisions and that the insured may for any reason surrender the policy to the insurer. In addition, if the policy was solicited by a direct response insurer, rather than through a licensed insurance agent, the policy, certificate, contract, or plan shall have printed thereon or attached thereto a notice to the insured that thirty days are allowed from the date of the receipt of the policy to examine its provisions and that the insured may for any reason surrender the policy to the insurer. Any premium advanced by the insured, upon appropriate surrender as provided herein, must be immediately returned in full by the insurer to the insured.
HISTORY: Former 1976 Code Section 38-35-140 [1956 (49) 1840; 1962 Code Section 37-456.4; 1982 Act No. 284, Section 1] recodified as Section 38-71-150 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-160. When policy sold on direct response basis considered to be returned.

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 want the policy, whichever is the earlier.
HISTORY: Former 1976 Code Section 38-35-141 [1982 Act No. 284, Section 2] recodified as Section 38-71-160 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-170. Required provision in policies for conversion privileges for former spouses.

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 under the policy solely as a result of a break in the marital relationship except by reason of an entry of a valid decree of divorce between the parties.
Every policy which contains a provision for termination of coverage of the spouse upon divorce shall contain a provision to the effect that upon the entry of a valid decree of divorce between the insured parties the divorced spouse is entitled to have issued to him or her, without evidence of insurability, upon application made to the insurer within sixty days following the entry of the decree, and upon payment of the appropriate premium, an individual policy of accident and health insurance. The policy shall provide the coverage then being issued by the insurer which is most nearly similar to, but not greater than, the terminated coverages. Any probationary or waiting periods set forth in the policy are considered as being met to the extent coverage was in force under the prior policy.
HISTORY: Former 1976 Code Section 38-35-145 [1978 Act No. 434] recodified as Section 38-71-170 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-190. Subrogation of insurer to insured's rights against third party.

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 previously in relation to the insured's injury by the liable third party. If the director or his designee, upon being petitioned by the insured, determines that the exercise of subrogation by an insurer is inequitable and commits an injustice to the insured, subrogation is not allowed. Attorneys' fees and costs must be paid by the insurer from the amounts recovered. This determination by the director or his designee may be appealed to the Administrative Law Court as provided by law in accordance with Section 38-3-210.
HISTORY: Former 1976 Code Section 38-35-100 [1962 Code Section 37-447; 1974 (58) 2608] recodified as Section 38-71-190 by 1987 Act No. 155, Section 1; 1988 Act No. 394, Section 1; 1993 Act No. 181, Section 752.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-200. Discrimination forbidden; benefits for services of podiatrist, oral surgeon, or optometrist.

Discrimination between individuals of the same class in the amount of premiums or rates charged for a policy of insurance covered by this chapter, in the benefits payable on the policy, in terms or conditions of the policy, or in another manner is prohibited except as provided in Sections 38-57-140 and 38-71-1110. If a policy of insurance governed by this chapter provides for payment or reimbursement for a service which is within the scope of practice of a licensed podiatrist, licensed oral surgeon, licensed optometrist, or licensed doctoral psychologist, the insured or other person entitled to benefits under the policy is entitled to payment or reimbursement in accordance with the usual and customary fee for the services whether the services are performed by a licensed physician or a licensed podiatrist, a licensed oral surgeon, a licensed optometrist, or a licensed doctoral psychologist, notwithstanding a provision in the policy, and the policyholder, insured, or beneficiary may choose the provider of the services.
HISTORY: Former 1976 Code Section 38-35-90 [1947 (45) 322; 1952 Code Section 37-455; 1962 Code Section 37-455; 1972 (57) 2454; 1980 Act No. 339; 1985 Act No. 66] recodified as Section 38-71-200 by 1987 Act No. 155, Section 1; 1988 Act No. 394, Section 15; 1994 Act No. 396, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-210. Health insurance policies to include chiropractic services.

If an insurer offers a policy containing a provision for medical expense benefits that does not provide payment for chiropractic services, it shall offer as a part thereof an optional rider or endorsement, if specifically requested by the insured or subscriber under an individual policy or a certificate holder or subscriber under a master policy, which defines such benefits as including payment to a chiropractor for procedures specified in the policy which are within the scope of the practice of chiropractic. Any additional cost to the insured or certificate holder must be reasonably related to benefits provided.
HISTORY: Former 1976 Code Section 38-35-445 [1980 Act No. 307, Section 10] recodified as Section 38-71-210 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-215. Dermatology referrals.

(A) If a primary care physician makes a referral to a dermatologist, the enrollee in a managed care plan may see the in-network dermatologist to whom the enrollee is referred, without further referral, for a minimum of six months or four visits, whichever first occurs, for diagnosis, medical treatment, or surgical procedures for the referral problem or related complications.
(B) Written communication from the dermatologist should be sent to the primary care physician after each visit.
(C) An enrollee with a documented past history of malignant melanoma may be referred by his or her primary care physician to an in-network dermatologist for an annual evaluation and, as necessary, biopsy or surgery, or both.
(D) All services provided pursuant to this section are subject to contractual provisions regarding medical necessity and benefit coverage.
(E) Nothing in this section may be construed to extend benefits to an enrollee past the contract period.
HISTORY: 1998 Act No. 353, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-220. Misrepresentations to induce termination or conversion of disability insurance policies.

No insurer, or its employee or agent, may make any misleading representations or incomplete or fraudulent comparisons of any disability insurance policies or insurers for the purpose of inducing, or which may tend to induce, any person to lapse, forfeit, surrender, terminate, return, or convert any disability insurance policy.
HISTORY: Former 1976 Code Section 38-9-50 [1956 (49) 1814; 1962 Code Section 37-144.1] recodified as Section 38-71-220 by 1987 Act No. 155, Section 1; 1988 Act No. 374, Section 39.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-230. Written notice of health insurance claim policies and procedures; adoption of standardized claim forms; addition of logo to form.

(A) All licensed health care providers are required to provide written notice of the policies and procedures with regard to health insurance claims. The notice may take the form of a patient information card or notice clearly posted in all patient waiting areas of the providers' place of business.
(B) An organization providing payment or reimbursement for diagnosis and treatment of a condition or a complaint by a licensed physician in South Carolina must accept the standardized CMS 1500 claim form, or its successor as it may be amended from time to time. An organization providing payment or reimbursement for diagnosis and treatment of a condition or a complaint by a hospital licensed in South Carolina shall accept the standardized UB 04 claim form, or its successor as it may be amended from time to time.
(C) The CMS 1500 or the UB 04 claim form or the successor of each or as either may be amended from time to time may be altered only with a customized logo which must appear in the top portion of the claim form one inch vertical from the top.
HISTORY: 1992 Act No. 295, Section 1; 2008 Act No. 356, Section 2, eff one year after approval by the Governor (approved June 11, 2008).