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Summary of differences between federal and state regulations
Federal HIPAA portability provisions limit exclusions for preexisting conditions; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances.
States are allowed to go beyond the federal requirements. South Carolina has laws that govern HIPAA, and they include the following provisions:
- Health insurance issuers offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if the:
- Exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date;
- Exclusion extends for not more than twelve months without medical care, treatment, or supplies ending after the effective date of coverage or twelve months after the enrollment date, whichever occurs first, or eighteen months after the enrollment date in the case of a late enrollee; and
- Period of any preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the participant or beneficiary as of the enrollment date. (§38-71-850)
- A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after the period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage. (§38-71-850)
- Health insurance issuers may not impose any preexisting condition exclusion in the case of an individual who, as of the last day of the 31-day period beginning with the date of birth, is covered under creditable coverage. (§38-71-850)
- Health insurance issuers may not impose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining eighteen years of age and who, as of the last day of the 31-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. (§38-71-850)
- Health insurance issuers may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition. (§38-71-850)
- Health insurance issuers must provide written certification of creditable coverage at the following times:
- At the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision;
- In the case of an individual becoming covered under such a provision, at the time the individual ceases to be covered under such provision; and
- On the request on behalf of an individual made not later than 24 months after the date of cessation of the coverage. (§38-71-850)
- Health insurance issuers may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan based on any health status-related factors in relation to the individual or a dependent of the individual. (§38-71-860)
State
Contact
South Carolina Department of Insurance
Regulations
South Carolina Code
Title 38 Insurance
SUBARTICLE 2. Requirements for issuers and group health insurance coverage under the Health Insurance Portability and Accountability Act of 1996
§38-71-840 - Definitions
§38-71-850 - Preexisting condition exclusion; limitations; creditable coverage; certification; enrollment for coverage
§38-71-860 - Health status-related factors in relation to individual enrollees and their dependents; restrictions on eligibility rules and premium charges
§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
§38-71-880 - Medical and surgical benefits and mental health benefits coverage; aggregate lifetime limits; application to small employers; applicability of section