2013 South Carolina Code of Laws
Title 38 - Insurance
CHAPTER 71 - ACCIDENT AND HEALTH INSURANCE

ARTICLE 1. GENERAL PROVISIONS

• SECTION 38-71-10. Coverages which may be written by licensed accident and health insurers.
• SECTION 38-71-20. Insurers may act as administering agency for government-sponsored health, hospital, and medical service programs.
• SECTION 38-71-30. Whole contract, including application, must appear in policy; oral applications.
• SECTION 38-71-40. Effect of false statement in application.
• SECTION 38-71-46. Diabetes Mellitus coverage in health insurance policies; diabetes education.
• SECTION 38-71-50. Alteration of application.
• SECTION 38-71-60. Certain acts do not constitute a waiver by insurer.
• SECTION 38-71-70. Certain policies may conform to laws of other states.
• SECTION 38-71-80. Construction of policy issued in violation of chapter.
• SECTION 38-71-90. Penalty for violation of chapter.
• SECTION 38-71-100. Policies exempt from chapter.
• SECTION 38-71-110. Notice of failure of employer to remit deducted premium required before forfeiture.
• SECTION 38-71-120. Repealed by 2006 Act No. 332, Section 31, eff June 1, 2006.
• SECTION 38-71-125. Mastectomies; hospitalization requirements; early release provisions.
• SECTION 38-71-130. Breast reconstruction and prosthetic devices; coverage following mastectomy surgery.
• SECTION 38-71-135. Minimum postpartum hospitalization and attendant services for mothers and newborns.
• SECTION 38-71-140. Coverage of newborn children.
• SECTION 38-71-143. Health plans must provide same coverage for children placed for adoption.
• SECTION 38-71-145. Required coverage for mammograms, pap smears, and prostate cancer examinations; limitations.
• 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 38-71-150. Required provision in policies as to examination and surrender of policy for return of premium.
• SECTION 38-71-160. When policy sold on direct response basis considered to be returned.
• SECTION 38-71-170. Required provision in policies for conversion privileges for former spouses.
• SECTION 38-71-190. Subrogation of insurer to insured's rights against third party.
• SECTION 38-71-200. Discrimination forbidden; benefits for services of podiatrist, oral surgeon, or optometrist.
• SECTION 38-71-210. Health insurance policies to include chiropractic services.
• SECTION 38-71-215. Dermatology referrals.
• SECTION 38-71-220. Misrepresentations to induce termination or conversion of disability insurance policies.
• SECTION 38-71-230. Written notice of health insurance claim policies and procedures; adoption of standardized claim forms; addition of logo to form.
• SECTION 38-71-238. Abortion coverage prohibitions; exceptions.
• SECTION 38-71-240. Coverage required for cleft lip and palate; certain policies exempt.
• SECTION 38-71-241. Percentage copayment and deductible must be applied to negotiated rate or lesser charge of that provider.
• SECTION 38-71-242. Specified disease insurance policies; payment of claims and benefits.
• SECTION 38-71-243. Continuation of care; definitions; applicability; requirements.
• SECTION 38-71-245. Prohibited grounds for denial of enrollment to child of health plan participant.
• SECTION 38-71-246. Continuation of care; provider contract requirements.
• SECTION 38-71-247. Continuation of care; plain language description requirement.
• SECTION 38-71-250. Duties of insurer as to court-ordered health care coverage for child of eligible parent.
• SECTION 38-71-255. Health insurer may not impose different requirements on state agency.
• SECTION 38-71-260. Duties of health insurer of child to custodial parent.
• SECTION 38-71-265. Health insurer not to consider State medical assistance; subrogation of state to right to insurance payment for health care.
• SECTION 38-71-275. Insurance coverage for certain drugs not to be excluded from policy definitions.
• SECTION 38-71-280. Autism spectrum disorder; coverage; eligibility for benefits.
• SECTION 38-71-285. Repealed by 2002 Act No. 338, Section 2, eff June 30, 2007.
• SECTION 38-71-290. Mental health coverage; definitions; treatment requirements; exceptions

ARTICLE 3. INDIVIDUAL ACCIDENT AND HEALTH POLICIES SUBARTICLE 1. POLICY FORMS AND RATES

• SECTION 38-71-310. Filing of forms and rates; approval or disapproval; withdrawal of approval; exceptions; loss ratio guarantee.
• SECTION 38-71-315. Decrease of premium charges.
• SECTION 38-71-320. Policies issued for delivery in another state.
• SECTION 38-71-325. Requirements for approval of new individual major medical expense coverage policies.
• SECTION 38-71-330. Form of policies.
• SECTION 38-71-335. Accident and/or health insurance cancellation provision prohibited; optionally renewable policies prohibited; notice of nonrenewal.
• SECTION 38-71-340. Required provisions.
• SECTION 38-71-350. Required provision for continuation of coverage for handicapped and dependent children of policyholder.
• SECTION 38-71-355. Dependent child; medically necessary leave of absence.
• SECTION 38-71-360. Continuation of coverage for nonhandicapped dependent children.
• SECTION 38-71-370. Optional provisions.
• SECTION 38-71-410. Omission or modification of required or optional provisions.
• SECTION 38-71-420. Placement of required and optional provisions in policy.
• SECTION 38-71-430. Additional provisions may not make policy less favorable.
• SECTION 38-71-440. HMO's and health benefit plans offering medical eye care or vision care benefits; prohibited actions.

SUBARTICLE 3. STANDARDIZATION AND SIMPLIFICATION OF TERMS AND COVERAGES

• SECTION 38-71-510. Declaration of purpose.
• SECTION 38-71-520. Definitions.
• SECTION 38-71-530. Regulations establishing specific standards that set forth manner, content, and required disclosure for sale of individual policies.
• SECTION 38-71-540. Regulations establishing minimum standards for benefits.
• SECTION 38-71-550. Outline of coverage required.
• SECTION 38-71-560. Effect of use of simplified application form.

SUBARTICLE 5. GENERAL PROVISIONS

• SECTION 38-71-610. Notice of premiums due required.
• SECTION 38-71-620. Advance notice required for increase in premium.
• SECTION 38-71-630. Acceptance of premium for period beyond expiration date of policy.
• SECTION 38-71-640. Person with insurable interest may take out policy on insured.
• SECTION 38-71-650. Right to transfer to policy of equal or lesser benefits with same insurer.

SUBARTICLE 7. REQUIREMENTS FOR ISSUERS AND INDIVIDUAL HEALTH INSURANCE COVERAGE UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

• SECTION 38-71-670. Definitions.
• SECTION 38-71-675. Renewal or continuance of coverage at option of insurer; conditions for nonrenewal or discontinuance; modification of coverage.
• SECTION 38-71-680. Application of Section 38-71-850(D).

ARTICLE 5. GROUP ACCIDENT AND HEALTH INSURANCE SUBARTICLE 1. GENERAL PROVISIONS

• SECTION 38-71-710. Definitions.
• SECTION 38-71-720. Approval of forms required; refusal or withdrawal of approval; optional life insurance riders.
• SECTION 38-71-730. Requirements for group accident, group health, and group accident and health policies.
• SECTION 38-71-735. Required provisions.
• SECTION 38-71-737. Requirement of coverage for psychiatric conditions in group health insurance policies; "psychiatric conditions" defined.
• SECTION 38-71-740. Restrictions on mass-marketed 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.
• SECTION 38-71-760. Standards for group accident and health insurance coverage, discontinuance, and replacement.
• SECTION 38-71-770. Mandatory continuation privileges.
• SECTION 38-71-780. Required provision for continuation of coverage for handicapped and dependent children.
• SECTION 38-71-785. Dependent child; medically necessary leave of absence.
• SECTION 38-71-790. Payment of benefits.
• SECTION 38-71-800. Hospital and medical expenses.
• SECTION 38-71-810. Readjustment of rates or refunds or dividends.

SUBARTICLE 2. REQUIREMENTS FOR ISSUERS AND GROUP HEALTH INSURANCE COVERAGE UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

• SECTION 38-71-840. Definitions.
• SECTION 38-71-850. Preexisting condition exclusion; limitations; creditable coverage; certification; enrollment for coverage.
• SECTION 38-71-860. Health status-related factors in relation to individual enrollees and their dependents; restrictions on eligibility rules and premium charges.
• SECTION 38-71-870. Coverage in small or large group market in connection with group health plan; nonrenewal or discontinuance; restrictions; modification of coverage; plan sponsor.
• SECTION 38-71-880. Medical and surgical benefits and mental health or substance use disorder benefits; aggregate lifetime limits.

SUBARTICLE 3. SMALL GROUP HEALTH INSURANCE

• SECTION 38-71-910. Legislative intent.
• SECTION 38-71-920. Definitions.
• SECTION 38-71-930. Application of this subarticle.
• SECTION 38-71-940. Premium rates for health insurance plans; rating factors; involuntary business class transfer prohibited.
• SECTION 38-71-960. Required disclosure in solicitation and sales materials; proprietary or trade secret information.
• SECTION 38-71-970. Insurer rating and renewal records; filing of certification; confidentiality.
• SECTION 38-71-980. Suspension of premium rate restrictions upon request of certain insurers.
• SECTION 38-71-990. Effective date of this subarticle.

ARTICLE 9. BLANKET ACCIDENT AND HEALTH INSURANCE

• SECTION 38-71-1010. "Blanket accident and health insurance" defined.
• SECTION 38-71-1020. Requirements as to policies.
• SECTION 38-71-1030. Individual applications and certificates not required.
• SECTION 38-71-1040. Payment of benefits.
• SECTION 38-71-1050. Legal liability of policyholders not affected.

ARTICLE 11. FRANCHISE ACCIDENT AND HEALTH INSURANCE

• SECTION 38-71-1110. "Franchise accident and health insurance" defined.

ARTICLE 13. SMALL EMPLOYER HEALTH INSURANCE AVAILABILITY ACT

• SECTION 38-71-1310. Short title.
• SECTION 38-71-1320. Purpose and intent.
• SECTION 38-71-1330. Definitions.
• SECTION 38-71-1340. Application of article; group size for health group cooperative.
• SECTION 38-71-1345. Formation of health group cooperative; requirements; registration; organization as nonprofit corporation.
• SECTION 38-71-1350. Premium rates; requirements.
• SECTION 38-71-1355. Health group cooperative; powers and duties.
• SECTION 38-71-1360. Insurers required to offer all plans actively marketed to small employers; availability to all eligible employees; network plans; denial of coverage.
• SECTION 38-71-1365. Small employer insurer requirements; compliance with federal laws applicable to cooperatives.
• SECTION 38-71-1370. Applicability of certain code sections; late enrollees.
• SECTION 38-71-1380. Notification of intent to operate; certain reinsuring insurers not permitted to continue to reinsure health insurance plan.
• SECTION 38-71-1390. Application to become risk-assuming insurer; approval or denial; factors to consider.
• SECTION 38-71-1400. Election to become reinsuring insurer.
• SECTION 38-71-1410. South Carolina Small Employer Insurer Reinsurance Program.
• SECTION 38-71-1420. Advisory committee.
• SECTION 38-71-1430. Annual public report.
• SECTION 38-71-1440. Requirements upon small employer insurers.
• SECTION 38-71-1445. Report on effectiveness of health group cooperatives.
• SECTION 38-71-1450. Promulgation of regulations.

ARTICLE 15. ACCESS TO EMERGENCY MEDICAL CARE

• SECTION 38-71-1510. Short title.
• SECTION 38-71-1520. Definitions.
• SECTION 38-71-1530. Screening; initial intervention; role of managed care organization; payments to providers.
• SECTION 38-71-1540. Practice of discouraging use of 911 telephone system prohibited.
• SECTION 38-71-1550. Severability.

ARTICLE 17. PATIENTS' INSURANCE AND BENEFITS PROTECTION

• SECTION 38-71-1710. Short title.
• SECTION 38-71-1720. Definitions.
• SECTION 38-71-1730. Employers offering closed panel health plans; employee options and payments; use of provider who has discontinued participation in plan; exclusion of certain providers; services of pharmacists and advanced practice nurses; effect of this article on other plans and coverages.
• SECTION 38-71-1740. Responsibility for errors and omissions by parties to managed care participating provider agreements; limitations on network providers to discuss treatments, risks and legal obligations with an insured or member prohibited; permissible limitations.
• SECTION 38-71-1750. Disclosures required of network plans.
• SECTION 38-71-1760. Promulgation of regulations.

ARTICLE 18. PHARMACY AUDIT RIGHTS

• SECTION 38-71-1810. Pharmacy audit rights.
• SECTION 38-71-1820. Appeals process; dismissal; copy of audit findings.
• SECTION 38-71-1830. Recoupment.
• SECTION 38-71-1840. Exemptions.

ARTICLE 19. HEALTH CARRIER EXTERNAL REVIEW ACT

• SECTION 38-71-1910. Short title.
• SECTION 38-71-1920. Definitions.
• SECTION 38-71-1930. Application of this article.
• SECTION 38-71-1940. Notice of right to request a review; notice of adverse determination.
• SECTION 38-71-1950. Requests for external review.
• SECTION 38-71-1960. Exhaustion of internal appeal process.
• SECTION 38-71-1970. Requests for external review.
• SECTION 38-71-1980. Expedited external review.
• SECTION 38-71-1990. External review decisions final; exceptions.
• SECTION 38-71-2000. Approval of independent review organizations.
• SECTION 38-71-2010. Standards for approval of independent review organizations.
• SECTION 38-71-2020. Liability of independent review organizations and personnel.
• SECTION 38-71-2030. External review; written records; reports.
• SECTION 38-71-2040. Health carrier to pay for external review.
• SECTION 38-71-2050. Health carrier to inform covered persons of rights related to external review.
• SECTION 38-71-2060. Regulations.