Health plans - South Carolina

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. South Carolina laws include the following provisions under Title 38:

Chapter 71:

• The plan must cover 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. (§38-71-46)
• If the plan provides coverage on an expense-incurred basis and covers family members, it must cover newly born child of the insured or subscriber from the moment of birth, and include injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. These provisions also apply to adopted children for whom a decree of adoption has been entered within 31 days after the date of the birth. (§38-71-140)
• The plan must provide the same coverage for children placed for adoption as it does for natural children. (§38-71-143)
• The plan must cover prostate cancer examinations, screenings, and laboratory work for diagnostic purposes. (§38-71-145)
• The plan may not prohibit or limit participant or beneficiary 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 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. (§38-71-147)
• 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. If the plan provides for payment or reimbursement for a service of a licensed podiatrist, licensed oral surgeon, licensed optometrist, or licensed doctoral psychologist, it must provide payment or reimbursement 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. (§38-71-200)
• If the plan does not cover chiropractic services, it must offer an optional rider or endorsement defining such benefits as including payment to a chiropractor. (§38-71-210)
• 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. (§38-71-215)
• If the plan covers dependents, it must cover the medically necessary care and treatment of cleft lip and palate and any condition or illness which is related to or developed as a result of a cleft lip and palate. (§38-71-240)
• The plan cannot deny dependent coverage because the child was born out of wedlock, is not claimed as a dependent on the parent's federal tax return; or does not reside with the parent or in the insurer's service area. (§38-71-245)
• If the plan covers prescriptions, it cannot deny coverage for any such drug used for the treatment of cancer on the grounds that the drug has not been approved by the Federal Food and Drug Administration for the treatment of the specific type of cancer for which the drug has been prescribed. (§38-71-275)
• As of June 30, 2006, plans must provide coverage for treatment of a mental health condition and may not establish a rate, term, or condition that places a greater financial burden on an insured for access to treatment for a mental health condition than for access to treatment for a physical health condition in similar settings and treatment modalities. Any deductible or out of pocket limits required under a health insurance plan must be comprehensive for coverage of both mental health and physical health conditions. (§38-71-290)
• No health maintenance organization or health benefit plan which maintains or contracts with a network of ophthalmologists or optometrists, or both, to provide medical eye care or vision care benefits, or both, shall prohibit a participating optometrist from performing medical services within that optometrist's scope of practice. (§38-71-440)
• Issuers must offer optional benefits for psychiatric conditions. (§38-71-737)
• If the plan covers dependents, whose coverage terminates at a certain age, must cover dependents who are incapable of self-sustaining employment by reason of mental retardation or physical handicap, and chiefly dependent upon the employee or member for support and maintenance, regardless of age. (§38-71-780)
• 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. (§38-71-1530)
• Employers who employ more than 50 eligible employees and who offer to employees major medical, hospitalization, and surgical health insurance coverage only under a closed panel health plan, must offer to employees at the time of their eligibility as major medical, hospitalization, and surgical health insurance coverage a point-of-service option. (§38-71-1730)
• An employee, a spouse, or a dependent receiving treatment for an illness covered under a closed panel health plan may continue to receive services from a provider who elects to discontinue participation as a closed panel plan provider, subject to the terms of the contract between the provider and the health plan. This right of continuation is limited to a period of ninety days or the anniversary date of the plan, whichever occurs first. (§38-71-1730)
• A health care plan may not exclude physicians, podiatrists, optometrists, oral surgeons, or chiropractors from providing health care services in a point-of-service option or closed panel health plan. (§38-71-1730)
• For plans on and after 12/31/2010, they must have continuation of care provisions. Continuation of care is providing in-network level benefits for services rendered by certain out-of-network providers for a definite period of time in order to ensure continuity of care for covered persons for a serious medical condition. Continuation of care must be provided for 90 days or until the termination of the benefit period, whichever is greater. (§38-71-243 through §38-71-247)

Chapter 33:

• Health Maintenance Organizations may not prohibit any licensed physician, podiatrist, optometrist, or oral surgeon from participating as a provider in the organization on the basis of his profession. (§38-33-290)

For information on women’s health issues, see the Women’s Health Rights topic.

State

Contact

South Carolina Department of Insurance

Regulations

South Carolina Code

Title 38 Insurance

Chapter 71 Accident and Health Insurance

Chapter 33 Health Maintenance Organizations

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)