(A) A person who is a resident of this State for thirty days, except that for a federally defined eligible individual or a Qualified TAA eligible individual, there shall not be a thirty-day requirement, and his newborn child is eligible for pool coverage:

(1) upon providing evidence of any of the following actions by an insurer on an application for health insurance comparable to that provided by the pool submitted on behalf of the person:

Terms Used In South Carolina Code 38-74-30

  • Board: means the board of directors of the pool. See South Carolina Code 38-74-10
  • Creditable coverage: means , with respect to an individual, coverage of the individual under:

    (a) a group health plan;

    (b) health insurance;

    (c) Part A or B of Title XVIII of the Social Security Act;

    (d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under Section 1928;

    (e) Chapter 55 of Title 10 of the United States Code;

    (f) a medical care program of the Indian Health Service or of a tribal organization;

    (g) a state health benefits risk pool, including the South Carolina Health Insurance Pool;

    (h) a health plan offered under Chapter 89 of Title 5 of the United States Code;

    (i) a public health plan, as defined in regulations;

    (j) a health benefit plan under Section 5(e) of the Peace Corps Act (22 U. See South Carolina Code 38-74-10
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Federally defined eligible individual: means an individual:

    (a) for whom, as of the date on which the individual seeks coverage under this chapter, the aggregate of the periods of creditable coverage is eighteen or more months;

    (b) whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan or health insurance coverage offered in connection with one of these plans;

    (c) who is not eligible for coverage under a group health plan, part A or part B of Title XVIII of the Social Security Act, or a state plan under Title XIX of the Social Security Act or any successor program and who does not have other health insurance coverage;

    (d) with respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud;

    (e) who, if offered the option of continuation coverage under a COBRA continuation provision or under a similar state program, elected the coverage; and

    (f) who, if the individual elected the continuation coverage, has exhausted the continuation coverage under the provision or program. See South Carolina Code 38-74-10
  • health insurance coverage: means benefits consisting of medical care provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care under a hospital or medical service policy or certificate, hospital, or medical service plan contract, or health maintenance organization contract offered by an insurer, except:

    (a) coverage only for accident or disability income insurance, or any combination thereof;

    (b) coverage issued as a supplement to liability insurance;

    (c) liability insurance, including general liability insurance and automobile liability insurance;

    (d) workers' compensation or similar insurance;

    (e) automobile medical payment insurance;

    (f) credit-only insurance;

    (g) coverage for on-site medical clinics;

    (h) other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits;

    (i) if offered separately:

    (i) limited scope dental or vision benefits;

    (ii) benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;

    (iii) such other similar, limited benefits as are specified in regulations;

    (j) if offered as independent, noncoordinated benefits:

    (i) coverage only for a specified disease or illness; and

    (ii) hospital indemnity or other fixed indemnity insurance;

    (k) if offered as a separate insurance policy, coverage supplement to the coverage provided under Chapter 55 of Title 10 of the United States Code. See South Carolina Code 38-74-10
  • insurance: includes annuities. See South Carolina Code 38-1-20
  • Insurer: means any entity that provides health insurance in this State. See South Carolina Code 38-74-10
  • Medicare: means Title XVIII of the Social Security Act, 42 U. See South Carolina Code 38-74-10
  • Person: means a corporation, agency, partnership, association, voluntary organization, individual, or another entity, organization, or aggregation of individuals. See South Carolina Code 38-1-20
  • Policy: means a contract of insurance. See South Carolina Code 38-1-20
  • Pool: means the South Carolina Health Insurance Pool. See South Carolina Code 38-74-10
  • Preexisting condition exclusion: means , with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before the date. See South Carolina Code 38-74-10
  • Premium: means payment given in consideration of a contract of insurance. See South Carolina Code 38-1-20
  • Qualified TAA eligible individual: means an individual who is eligible for the credit for health insurance costs under Section 35 of the Internal Revenue Code of 1986. See South Carolina Code 38-74-10
  • Waiting period: means , with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. See South Carolina Code 38-74-10

(a) a refusal to issue the insurance for health reasons;

(b) a refusal to issue the insurance except with a reduction or exclusion of coverage for a preexisting health condition for a period exceeding twelve months, unless it is determined that the person voluntarily terminated his or did not seek any health insurance coverage before being refused issuance except with a reduction or exclusion for a preexisting health condition, and then seeks to be eligible for pool coverage after the health condition develops. This determination must be made by the board;

(c) a refusal to issue insurance coverage comparable to that provided by the pool except at a rate exceeding one hundred fifty percent of the pool rate; or

(2) if the individual is a federally defined eligible individual or a Qualified TAA eligible individual, as defined in § 38-74-10, who is and continues to be a resident of this State; or

(3) if the individual is under the age of sixty-five and covered under Medicare Parts A and B for reasons other than age.

(B) A person whose health insurance coverage is terminated involuntarily for any reason other than nonpayment of premium may apply for coverage under the plan but shall submit proof of eligibility according to subsection (A) of this section. If proof is supplied and if coverage is applied for within sixty days after the involuntary termination and if premiums are paid for the entire coverage period, the effective date of the coverage is the date of termination of the previous coverage. Waiting period and preexisting condition exclusions are waived to the extent to which similar exclusions, if any, have been satisfied under the prior health insurance coverage. The waiver does not apply to a person whose policy has been terminated or rescinded involuntarily because of a material misrepresentation.

(C) A person who is paying a premium for health insurance comparable to the pool plan in excess of one hundred fifty percent of the pool rate or who has received notice that the premium for a policy would be in excess of one hundred fifty percent of the pool rate may make application for coverage under the pool. The effective date of coverage is the date of the application, or the date that the premium is paid if later, and any waiting period or preexisting condition exclusion is waived to the extent to which similar exclusions, if any, were satisfied under the prior health insurance plan. Benefits payable under the pool plan are secondary to benefits payable by the previous plan. The board shall require an additional premium for coverage effected under the plan in this manner notwithstanding the premium limitation stated in § 38-74-60.

(D)(1) The waiting period and preexisting condition exclusions are waived for a federally defined eligible individual.

(2) The waiting period and preexisting condition exclusions are waived for a Qualified TAA eligible individual if the individual maintained creditable coverage for an aggregate period of three months as of the date on which the individual seeks to enroll in pool coverage, not counting any period prior to a sixty-three-day break in coverage.

(E) A person not eligible for pool coverage is one who meets any one of the following criteria:

(1) a person who has coverage under health insurance comparable to that offered by the pool from an insurer or any other source except a person who would be eligible under subsection (C);

(2) a person who is eligible for health insurance comparable to that offered by the pool from an insurer or any other source except a person who would be eligible for pool coverage under subsection (A)(1)(b), (A)(1)(c), (A)(2), or (A)(3);

(3) a person who at the time of pool application is eligible for health care benefits under state Medicaid or eligible for health care benefits under Medicare and age sixty-five or older;

(4) a person having terminated coverage in the pool unless twelve months have lapsed since termination unless termination was because of ineligibility, except that this item shall not apply with respect to an applicant who is a federally defined eligible individual;

(5) a person on whose behalf the pool has paid out one million dollars in benefits;

(6) inmates of public institutions and persons eligible for public programs, except that this item shall not apply with respect to an applicant who is a federally defined eligible individual;

(7) a person who fails to maintain South Carolina residency.

(F) A person who ceases to meet the eligibility requirements of this section may be terminated at the end of the policy period.

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