reglab/statecodes huggingface dataset:
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-740. Restrictions on mass-marketed insurance.

No mass-marketed accident, health, or accident and health insurance may be effected on a person in this State if the charges to the individual insureds are unreasonable in relation to the benefits provided. "Mass-marketed accident, health, or accident and health insurance" for purposes of this chapter means coverage under any group or blanket policy which is offered by means of direct response solicitation whether through a sponsoring organization or the mails or other media, except that it does not include coverage offered to an employee or union member through his employer or union, to a member of a professional association, to a member of a national association of retired or aged persons through the association, or to a member of a national association of war veterans either chartered by Congress or composed of veterans of a particular ethnic, racial, or religious background through the association. This coverage offered through a trust formed by one or more employers, labor unions, or both, or by a professional association or association of retired or aged persons or war veterans to provide insurance coverage for employees, union members, and their dependents, or for association members and their dependents, is considered to be offered through the employer, union, or association respectively. "Direct response solicitation" means any offer by an insurer to persons in this State to effect such insurance coverage which enables the individual to apply or enroll for the insurance on the basis of that offer.
HISTORY: Former 1976 Code Section 38-35-942 [1962 Code Section 37-532.3; 1976 Act No. 732 Section 7] recodified as Section 38-35-942 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-750. Requirements of group policies extended to group policies issued outside State to residents; approval required for mass-marketed policies and certificates.

(1) No group accident, group health, or group accident and health insurance coverage may be extended to residents of this State under a policy issued outside this State which does not provide in substance the provisions of this article unless the director or his designee determines that certain provisions are not appropriate for the coverage provided.
(2) Any insurer extending blanket or group accident, health, or accident and health insurance under a policy issued outside this State to residents of this State shall comply with the requirements of this State relating to advertising and to claims settlement practices with respect to the insurance.
(3) Upon request of the director or his designee, copies of policies and certificates under a policy of group accident, group health, or group accident and health insurance issued outside this State and covering residents of this State must be made available on an informational basis only. However, mass-marketed accident, health, or accident and health insurance policies and certificates must receive approval of the director or his designee pursuant to Section 38-71-720 before they can be offered for sale to residents of this State.
HISTORY: Former 1976 Code Section 38-35-944 [1962 Code Section 37-532.4; 1976 Act No. 732 Section 7; 1985 Act No. 131, Section 2] recodified as Section 38-71-750 by 1987 Act No. 155, Section 1; 1993 Act No. 181, Section 769, eff July 1, 1995; 2001 Act No. 82, Section 25, eff July 20, 2001.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-770. Mandatory continuation privileges.

A group policy issued for delivery or renewed in this State which provides hospital, surgical, or major medical expense insurance, or any combination of these coverages, on an expense incurred basis must provide that an employee or member who has been insured continuously under the group policy for at least six months whose insurance under the group policy has been terminated for any reason other than nonpayment of the required contribution is entitled to continue coverage under the group policy for the fractional policy month remaining at termination plus six additional policy months. A group policy is considered to be a successor policy within the meaning of this section if the effective date of the coverage provided by it is sixty-two days or less after the date of termination of coverage of the prior carrier. The employee or member is not entitled to have his coverage continued if the employee or member was entitled under federal law to continuation of his coverage for a period of greater duration than provided by this section. Continuation of coverage is subject to the group policy or a successor policy remaining in force and the employee paying the entire group premium, including any portion usually paid by the former employer, before the date each month that the group policy month begins. Policies which provide benefits for other than hospital, surgical, major medical, or which provide benefits for specific diseases or accidental injuries only are not affected by this section.
A notification of the privilege to continue coverage after termination must be included in each certificate of coverage. In addition, the employer shall clearly and meaningfully advise an employee upon termination of the right to continue insurance and shall advise the employee of the amount of premium required and of the employee's responsibility to pay the premium each month before the date that the policy month begins. An employee is not entitled to continue coverage under the group if eligible for other group coverage which provides similar benefits nor if the person is eligible for medicare benefits provided by Title XVIII of the United States Social Security Act or of any successor acts. Any benefits, except extended benefits payable by the policy during the period of continuation, are considered secondary to benefits under any other group health policy that is in force on a person insured through this continuation privilege.
HISTORY: Former 1976 Code Section 38-35-946 [1978 Act No. 547, 1979 Act No. 149 Section 1] recodified as Section 38-71-770 by 1987 Act No. 155, Section 1; 1989 Act No. 127, Section 9; 1991 Act No. 131, Section 10.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-780. Required provision for continuation of coverage for handicapped and dependent children.

A group hospital or medical expense insurance policy, hospital service plan contract, or medical service plan contract delivered or issued for delivery in this State which provides that coverage of a dependent child of an employee or other member of the coverage group terminates upon attainment of the limiting age for dependent children specified in the policy or contract shall also provide in substance that attainment of the limiting age does not operate to terminate the coverage of the child while the child is and continues to be both (a) incapable of self-sustaining employment by reason of intellectual disability or physical handicap, and (b) chiefly dependent upon the employee or member for support and maintenance, as long as proof of the incapacity and dependency is furnished to the insurer by the employee or member within thirty-one days of the child's attainment of the limiting age and subsequently as may be required by the insurer, but not more frequently than annually after the two-year period following the child's attainment of the limiting age.
HISTORY: Former 1976 Code Section 38-35-950 [1962 Code Section 37-532.2; 1970 (56) 2465] recodified as Section 38-71-780 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-790. Payment of benefits.

The benefits payable under any policy or contract of group accident, group health, and group accident and health insurance are payable to the employee or to some beneficiary or beneficiaries designated by him, other than the employer. However, if there is no designated beneficiary as to all or any part of the insurance at the death of the employee or member, then the amount of insurance payable for which there is no designated beneficiary is payable to the estate of the employee or member, except that:
(1) the insurer may in such case, at its option, pay the insurance to any one or more of the following surviving relatives of the employee or member: wife, husband, mother, father, child or children, or brothers or sisters; and
(2) payment of benefits for expenses incurred on account of hospitalization or medical or surgical aid, as provided in Section 38-71-800, may be made by the insurer to the hospital or other person furnishing the aid. Payment so made discharges the insurer's obligation with respect to the amount of insurance so paid.
HISTORY: Former 1976 Code Section 38-35-960 [1947 (45) 322; 1952 Code Section 37-534; 1962 Code Section 37-534] recodified as Section 38-71-790 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-800. Hospital and medical expenses.

Any policy or contract of group accident, group health, or group accident and health insurance may include provisions for the payment by the insurer of benefits to the employee or other member of the insured group on account of hospitalization or medical or surgical aid for himself, his spouse, his child or children, or other individuals chiefly dependent upon him for support and maintenance.
HISTORY: Former 1976 Code Section 38-35-970 [1947 (45) 322; 1952 Code Section 37-535; 1962 Code Section 37-535] recodified as Section 38-71-800 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-810. Readjustment of rates or refunds or dividends.

Any policy or contract of group accident, group health, or group accident and health insurance may provide for readjustment of the rate of premium based on experience thereunder at the end of the first year or of any subsequent year of insurance thereunder. The readjustment may be retroactive only for that policy year. Any refund under any plan for readjustment of the rate of premium based on the experience under group policies and any dividend paid under these policies may be used to reduce the policyholder's contribution to group insurance for the insureds of the policyholder and the excess over the contribution by the employer must be applied by the policyholder for the sole benefit of the insureds.
HISTORY: Former 1976 Code Section 38-35-980 [1947 (45) 322; 1952 Code Section 37-536; 1962 Code Section 37-536] recodified as Section 38-71-810 by 1987 Act No. 155, Section 1; 1988 Act No. 394, Section 11.
Subarticle 2
Requirements for Issuers and Group Health Insurance Coverage Under the Health Insurance Portability and Accountability Act of 1996
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-860. Health status-related factors in relation to individual enrollees and their dependents; restrictions on eligibility rules and premium charges.

(A)(1) Subject to item (2), a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
(a) health status;
(b) medical condition, including both physical and mental illnesses;
(c) claims experience;
(d) receipt of health care;
(e) medical history;
(f) genetic information;
(g) evidence of insurability, including conditions arising out of acts of domestic violence;
(h) disability.
(2) To the extent consistent with Sections 38-71-850 and 38-71-1360 and any other applicable state law, item (1) shall not be construed:
(a) to require group health insurance coverage to provide particular benefits other than those provided under the terms of such coverage; or
(b) to prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.
(3) For purposes of item (1), rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for the enrollment.
(B)(1) A health insurance issuer offering health insurance coverage in connection with a group health plan, may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay a premium or contribution which is greater than the premium or contribution for a similarly situated individual enrolled in the plan on the basis of any health status-related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual.
(2) To the extent consistent with Sections 38-71-940, 38-71-200, and 38-55-50 and any other applicable state law, nothing in item (1) shall be construed to:
(a) restrict the amount that an employer may be charged for coverage under a group health plan under applicable state law; or
(b) prevent a group health plan, and a health insurance issuer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention, in accordance with applicable state law.
HISTORY: 1997 Act No. 5, Section 3.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-910. Legislative intent.

The intent of this subarticle is to promote the availability of health insurance coverage to small employers, to prevent abusive rating practices, to require disclosure of rating practices to purchasers, to establish rules for continuity of coverage for employers and covered individuals, and to improve the efficiency and fairness of the small group health insurance marketplace.
HISTORY: 1991 Act No. 131, Section 5.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-930. Application of this subarticle.

(A) Except as provided in subsection (B), the provisions of this subarticle apply to any health insurance plan which provides coverage to one or more employees of a small employer.
(B) The provisions of this subarticle do not apply to individual health insurance policies which are subject to policy form and premium rate approval as may be provided in Title 38.
HISTORY: 1991 Act No. 131, Section 5.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-960. Required disclosure in solicitation and sales materials; proprietary or trade secret information.

In connection with offering any health insurance plans to small employers, each small employer insurer shall make reasonable disclosure in solicitation and sales materials provided to small employers of:
(1) the extent to which premium rates for a specific small employer are established or adjusted due to case characteristics, family composition, class of business, and the claim experience, health status, or duration of coverage of the employees or dependents of the small employer;
(2) the provisions concerning the insurer's right to change premium rates and the factors, including case characteristics, which affect changes in premium rates;
(3) a description of the class of business in which the small employer is or will be included, including the applicable grouping of plans;
(4) the provisions relating to renewability of coverage;
(5) the provisions relating to any preexisting condition exclusion; and
(6) the benefits and premiums available under all health insurance plans for which the employer is qualified.
Information under this section must be provided to small employers in a manner determined to be understandable by the average small employer and must be sufficient to reasonably inform small employers of their rights and obligations under the health insurance coverage.
An insurer is not required under this section to disclose any information that is proprietary or trade secret information under applicable law.
HISTORY: 1991 Act No. 131, Section 5; 1997 Act No. 5, Section 11; 1997 Act No. 70, Section 4.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-970. Insurer rating and renewal records; filing of certification; confidentiality.

(A) A small employer insurer shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation which demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
(B) Each small employer insurer shall file each March first with the department an actuarial certification certifying that the insurer is in compliance with this section and that the rating methods of the insurer are actuarially sound. A copy of the certification must be retained by the insurer at its principal place of business.
(C) A small employer insurer shall make the information and documentation described in subsection (A) available to the director or his designee upon request. The information must be considered proprietary and trade secret information and is not subject to disclosure by the director or his designee to persons outside of the department except as agreed to by the insurer or as ordered by a court of competent jurisdiction.
HISTORY: 1991 Act No. 131, Section 5; 1993 Act No. 181, Section 774.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-980. Suspension of premium rate restrictions upon request of certain insurers.

The director or his designee may suspend all or any part of Section 38-71-940 as to the premium rates applicable to one or more small employers for one or more rating periods upon a filing by the small employer insurer and a finding by the director or his designee that either the suspension is reasonable in light of the financial condition of the insurer or that the suspension would enhance the efficiency and fairness of the marketplace for small employer health insurance.
HISTORY: 1991 Act No. 131, Section 5; 1993 Act No. 181, Section 775.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-990. Effective date of this subarticle.

The provisions of this subarticle apply to each health insurance plan for a small employer that is delivered, issued for delivery, renewed, or continued in this State after the effective date of this subarticle. For purposes of this section, the date a plan is continued is the first rating period which commences after the effective date of this subarticle.
HISTORY: 1991 Act No. 131, Section 5.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1010. "Blanket accident and health insurance" defined.

"Blanket accident and health insurance" is defined to be that form of accident and health insurance covering special groups of individuals as enumerated in one of the following items:
(1) under a policy or contract issued to any common carrier, which must be considered the policyholder, covering a group defined as all individuals who may become passengers on the common carrier;
(2) under a policy or contract issued to an employer, who must be considered the policyholder, covering any group of employees defined by reference to exceptional hazards incident to the employment;
(3) under a policy or contract issued to an employer, who is considered the policyholder, covering employees or independent contractors, or both, under contract to the employer while traveling to and from and while attending meetings at a common location as a group or in groups incident to their employment or contractual arrangement;
(4) under a policy or contract issued to a college, school, or other institution of learning or to the head or principal thereof, which or who must be considered the policyholder, covering students or teachers;
(5) under a policy or contract issued in the name of any volunteer fire department, first aid, or other such volunteer group, which must be considered the policyholder, covering all of the members of the department or group;
(6) under a policy or contract issued to any other similar group which, in the discretion of the director or his designee, may be eligible for issuance of a blanket accident and health policy or contract either under special circumstances, exceptional hazards, or for short periods of duration.
HISTORY: Former 1976 Code Section 38-35-710 [1947 (45) 322; 1952 Code Section 37-521; 1962 Code Section 37-521; 1970 (56) 2319; 1979 Act No. 26] recodified as Section 38-71-1010 by 1987 Act No. 155, Section 1; 1988 Act No. 394, Section 12; 1993 Act No. 181, Section 776.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1020. Requirements as to policies.

All blanket accident and health insurance policies are subject to the provisions of Articles 1 and 3 of this chapter. However, no policy is required to contain any of the required policy provisions set forth in Section 38-71-340. However, no policy may contain any provision relative to notice of claim, proofs of loss or time of payment of claims, or the time within which suit may be brought upon the policy which, in the opinion of the director or his designee, is less favorable to the insured than would be permitted by the required policy provisions.
HISTORY: Former 1976 Code Section 38-35-720 [1947 (45) 322; 1952 Code Section 37-522; 1956 (49) 2029; 1962 Code Section 37-522] recodified as Section 38-71-1020 by 1987 Act No. 155, Section 1; 1993 Act No. 181, Section 777.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1030. Individual applications and certificates not required.

An individual application is not required from an individual covered under a blanket accident and health policy or contract, nor is it necessary for the insurer to furnish each individual a certificate.
HISTORY: Former 1976 Code Section 38-35-730 [1947 (45) 322; 1952 Code Section 37-523; 1962 Code Section 37-523] recodified as Section 38-71-1030 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1040. Payment of benefits.

All benefits under any blanket accident and health policy are payable to the individual insured, to his designated beneficiary or beneficiaries, or to his estate, except that if the individual insured is a minor, the benefits may be made payable to his parent, guardian, or other person actually supporting him.
HISTORY: Former 1976 Code Section 38-35-740 [1947 (45) 322; 1952 Code Section 37-524; 1962 Code Section 37-524] recodified as Section 38-71-1040 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1050. Legal liability of policyholders not affected.

Nothing contained in this article affects the legal liability of policyholders for the death of, or injury to, any member of the group.
HISTORY: Former 1976 Code Section 38-35-750 [1947 (45) 322; 1952 Code Section 37-525; 1962 Code Section 37-525] recodified as Section 38-71-1050 by 1987 Act No. 155, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1110. "Franchise accident and health insurance" defined.

"Accident and health insurance on a franchise plan" is that form of accident and health insurance issued to: (1) three or more employees of any corporation, copartnership, or individual employer or any governmental corporation, agency, or department; or (2) ten or more members of any trade or professional association, labor union, or any other association having had an active existence for at least two years when the association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance, when: (a) the insureds, with or without their dependents, are issued the same form of an individual policy varying only as to amounts and kinds of coverage applied for by the insureds; and (b) the employer, union, or association has approved and endorsed the policy being sold to its employees or members. Accident and health insurance on a franchise plan may be written under rates less than the usual rates for the insurance, but all premium rates and discounts the insurer proposes to use must be filed with the department and approved by the director or his designee as required by Section 38-71-310.
HISTORY: Former 1976 Code Section 38-35-1110 [1947 (45) 322; 1952 Code Section 37-551; 1962 Code Section 37-551] recodified as Section 38-71-1110 by 1987 Act No. 155, Section 1; 1988 Act No. 394, Section 13; 1993 Act No. 181, Section 778.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1320. Purpose and intent.

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 insurance plans to be offered to all small employers, to provide for establishment of a reinsurance program, to improve the overall fairness and efficiency of the small group health insurance market, and to allow small employers to form cooperatives for the purpose of providing health insurance to their employees.
HISTORY: 1994 Act No. 339, Section 2; 2008 Act No. 180, Section 2, eff February 19, 2008.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1340. Application of article; group size for health group cooperative.

(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 form and premium rate approval as may be provided in this title.
(C) For health group cooperatives, the applicable group size is two to fifty. Health group cooperatives are permitted to attempt to obtain coverage for small employer groups that contain fewer than two eligible employees; however, such attempt to obtain coverage is subject to the medical underwriting requirements and policies of the small employer insurer.
HISTORY: 1994 Act No. 339, Section 4; 2008 Act No. 180, Section 2, eff February 19, 2008.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1350. Premium rates; requirements.

(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 section notwithstanding any reinsurance premiums or assessments paid or payable by small employer insurers pursuant to Section 38-71-1410.
HISTORY: 1994 Act No. 339, Section 5; 2008 Act No. 180, Section 2, eff February 19, 2008.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1355. Health group cooperative; powers and duties.

(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 premiums to cover the cost of:
(a) group health insurance plan coverage purchased through the cooperative; and
(b) the cooperative's administrative expenses;
(3) may contract with agents to market coverage issued through the cooperative;
(4) shall establish administrative and accounting procedures for the operation of the cooperative;
(5) shall establish procedures under which an applicant for or participant in coverage issued through the cooperative may have a grievance reviewed by an impartial person;
(6) may contract with a small employer insurer or third-party administrator to provide administrative services to the cooperative;
(7) shall contract with small employer insurers for the provision of services to small employers covered through the cooperative;
(8) shall develop and implement a plan to maintain public awareness of the cooperative and publicize the eligibility requirements and the procedures for enrollment in coverage through the cooperative;
(9) may negotiate the premiums paid by its members; and
(10) may offer other ancillary products and services to its members as are customarily offered in conjunction with group health insurance plans.
HISTORY: 2008 Act No. 180, Section 1, eff February 19, 2008.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1365. Small employer insurer requirements; compliance with federal laws applicable to cooperatives.

(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 plans;
(3) the ability to monitor and evaluate the quality and cost effectiveness of care and applicable procedures;
(4) the ability to conduct utilization management and applicable procedures and policies;
(5) the ability to assure enrollees a sufficient number of health care providers, including specialty providers; and
(6) a satisfactory grievance procedure and the ability to respond to enrollees' calls, questions, and complaints.
(B) A health group cooperative shall comply with federal laws applicable to cooperatives and group health insurance plans issued through cooperatives, to the extent required by this title or regulations adopted under them.
HISTORY: 2008 Act No. 180, Section 1, eff February 19, 2008.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1370. Applicability of certain code sections; late enrollees.

(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 months or an eighteen month preexisting condition exclusion; however, if both a period of exclusion from coverage and a preexisting condition exclusion are applicable to a late enrollee, the combined period may not exceed eighteen months.
HISTORY: 1994 Act No. 339, Section 7; 1997 Act No. 5, Section 14; 2001 Act No. 82, Section 26, eff July 20, 2001.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1380. Notification of intent to operate; certain reinsuring insurers not permitted to continue to reinsure health insurance plan.

(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 seeking to operate as a risk-assuming insurer shall make an application pursuant to Section 38-71-1390.
(2) The decision shall be binding for a five-year period except that the initial decision shall be binding for two years. The director may permit an insurer to modify its decision at any time for good cause shown.
(3) The director shall establish an application process for small employer insurers seeking to change their status under this subsection. In the case of a small employer insurer that has been acquired by another such insurer, the director may waive or modify the time periods established in item (2).
(B) A reinsuring insurer that applies and is approved to operate as a risk-assuming insurer shall not be permitted to continue to reinsure any health insurance plan with the program. Such an insurer shall pay a prorated assessment based upon business issued as a reinsuring insurer for any portion of the year that the business was reinsured.
HISTORY: 1994 Act No. 339, Section 8.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1390. Application to become risk-assuming insurer; approval or denial; factors to consider.

(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 pursuant to the criteria set forth in subsection (B) of this section. The insurer shall provide public notice of its application to become a risk-assuming insurer. A small employer insurer's application to be a risk-assuming insurer shall be approved unless disapproved by the director within sixty days after the insurer's application. A small employer insurer that has had its application to be a risk-assuming insurer disapproved may request and shall be granted a public hearing within sixty days after the disapproval.
(B) In determining whether or not to approve an application by a small employer insurer to become a risk-assuming insurer, the director shall consider the insurer's financial condition and the financial condition of its parent or guaranteeing corporation, if any; its history of assuming and managing risk; its ability to assume and manage the risk of enrolling small employers without the protection of the reinsurance provided in Section 38-71-1410; and its commitment to fairly market to all small employers.
HISTORY: 1994 Act No. 339, Section 9.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1400. Election to become reinsuring insurer.

(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 program, in the same manner as it would administer health claims that it writes without reinsurance.
HISTORY: 1994 Act No. 339, Section 10, eff July 1, 1995.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1420. Advisory committee.

(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 insurance agent who represents multiple health and accident insurance carriers. In preparing its initial recommendations, the advisory committee shall build on the work of the Governor's Committee on Basic Health Services.
(B) The committee shall recommend benefit levels, cost-sharing levels, exclusions and limitations for the basic health insurance plan and the standard health insurance plan. The committee shall specifically recommend which, if any, mandated coverages of health care services or health care providers should be included in the basic and standard health insurance plans and shall recommend as well whether the plans should be exempt from any other statutory provisions otherwise applicable to group health insurance policies. Section 38-71-200 is applicable to the basic and standard health insurance plans and is not subject to exemption. The committee also shall design a basic health insurance plan and a standard health insurance plan which contain benefit and cost-sharing levels that are consistent with the basic method of operation and the benefit plans of health maintenance organizations, including any restrictions imposed by federal law.
(1) The plans recommended by the committee may include cost containment features such as:
(a) utilization review of health care services, including review of medical necessity of hospital and physician services;
(b) case management;
(c) selective contracting with hospitals, physicians, and other health care providers;
(d) reasonable benefit differentials applicable to providers that participate or do not participate in arrangements using restricted network provisions; and
(e) other managed care provisions.
(2) The committee shall submit the health insurance plans described in paragraphs (A) and (B) to the director for approval by January 1, 1995. If, for any reason, the committee does not provide the director with a recommendation as to the form and level of coverages to be made available pursuant to this article, the board shall make such recommendation to the director. If, subsequent to the approval of the benefit levels of the basic and standard health insurance plans, amendments to the plans become necessary, the board shall make such recommendations to the director for his approval.
HISTORY: 1994 Act No. 339, Section 12.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1430. Annual public report.

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 affordability. The report shall include the total number of basic and standard policies sold in the State noting whether these insureds have ever been denied coverage before July 1, 1995. The report shall contain a detailed analysis of the financial condition of the reinsurance pool including losses and assessments by year. The report may contain recommendations for actions to improve the overall effectiveness, efficiency, and fairness of the small group health insurance marketplace. The report shall address whether insurers and agents are fairly marketing or issuing health insurance plans to small employers in fulfillment of the purposes of this article. The report may contain recommendations for market conduct or other regulatory standards or action.
HISTORY: 1994 Act No. 339, Section 13.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1445. Report on effectiveness of health group cooperatives.

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 coverage for small employers.
HISTORY: 2008 Act No. 180, Section 1, eff February 19, 2008.
Code Commissioner's Note
At the direction of the Code Commissioner, references in this section to the offices of the former State Budget and Control Board, Office of the Governor, or other agencies, were changed to reflect the transfer of them to the Department of Administration or other entities, pursuant to the directive of the South Carolina Restructuring Act, 2014 Act No. 121, Section 5(D)(1).
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1520. Definitions.

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 of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
(a) placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part.
(3) "Emergency medical provider" means hospitals licensed by the South Carolina Department of Health and Environmental Control, hospital-based services, physicians licensed by the State Board of Medical Examiners, and oral surgeons and dentists licensed by the State Board of Dentistry who provide emergency medical care.
(4) "Managed care organization" means a licensed insurance company, a hospital or medical services plan contract, a health maintenance organization, or any other entity which is subject to regulation by the department and which operates a managed care plan.
(5) "Managed care plan" means a plan operated by a managed care organization which provides for the financing and delivery of health care and treatment services to individuals enrolled in the plan through its own employed health care providers or contracting with selected specific providers that conform to explicit selection standards, or both. A managed care plan also customarily has a formal organizational structure for continual quality assurance, a certified utilization review program, dispute resolution, and financial incentives for individual enrollees to use the plan's participating providers and procedures.
HISTORY: 1998 Act No. 326, Section 1; 2016 Act No. 172 (H.5100), Section 1, eff May 12, 2016.
Effect of Amendment
2016 Act No. 172, Section 1, in (3), inserted reference to oral surgeons and dentists.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1530. Screening; initial intervention; role of managed care organization; payments to providers.

(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, sickness, or injury and radiographic procedures and interpretation.
(B) Appropriate intervention must be initiated by medical personnel to stabilize any emergency medical condition before requesting authorization for the treatment by a managed care organization.
(C) A managed care organization shall inform its insureds, enrollees, patients, and affiliated providers about all policies related to emergency medical care access, coverage, payment, and grievance procedures. It is the ultimate responsibility of the managed care organization to inform any contracted third party administrator, independent contractor, or primary care provider about the emergency medical care provisions contained in this subsection.
(D) A managed care organization which includes emergency medical care services as part of its policy or contract shall provide coverage and shall subsequently pay providers for emergency medical care services provided to an insured, enrollee, or patient who presents an emergency medical condition. This subsection must not be construed to require coverage for illnesses, diseases, equipment, supplies, or procedures or treatments which are not otherwise covered under the terms of the insured's policy or contract.
(E) A managed care organization may not retrospectively deny or reduce payments to providers for emergency medical care of an insured, enrollee, or patient even if it is determined that the emergency medical condition initially presented is later identified through screening not to be an actual emergency, except in these cases:
(1) material misrepresentation, fraud, omission, or clerical error;
(2) a payment reduction due to applicable co-payments, coinsurance, or deductibles which may be the responsibility of the insured;
(3) cases in which the insured does not meet the emergency medical condition definition, unless the insured has been referred to the emergency department by the insured's primary care physician or other agent acting on behalf of the insurer.
HISTORY: 1998 Act No. 326, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1540. Practice of discouraging use of 911 telephone system prohibited.

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.
HISTORY: 1998 Act No. 326, Section 1.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1545. Exclusion of certain insurance policies.

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 coverage issued as a supplement to Medicare.
HISTORY: 2016 Act No. 172 (H.5100), Section 2, eff May 12, 2016.
2023 South Carolina Code of Laws › Title 38 - Insurance › Chapter 71 - Accident And Health Insurance › Section 38-71-1550. Severability.

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 end the provisions of this article are severable.
HISTORY: 1998 Act No. 326, Section 1.