South Carolina Code 38-71-1360. Insurers required to offer all plans actively marketed to small employers; availability to all eligible employees; network plans; denial of coverage
(2) Coverage under such health insurance plan must be offered to every eligible employee of a small employer and his or her dependents who apply for enrollment during the period in which the employee first becomes eligible to enroll under the terms of the health insurance plan and may not place any restriction which is inconsistent with § 38-71-860 on an eligible employee being a participant or beneficiary. A small employer insurer may not offer coverage only to certain individuals in a small employer group, or to only part of the group, except as provided in § 38-71-850 for late enrollees.
Terms Used In South Carolina Code 38-71-1360
- Basic health insurance plan: means a lower cost health insurance plan developed pursuant to § 38-71-1420. See South Carolina Code 38-71-1330
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Contract: A legal written agreement that becomes binding when signed.
- Director: means the Director of the Department of Insurance of this State. See South Carolina Code 38-71-1330
- Eligible employee: means an employee:
(a) as defined in § 38-71-710(1) or § 38-71-840(7) who works on a full-time basis and has a normal workweek of thirty or more hours; or
(b) who is a licensed real estate person engaged in the sale, leasing, or rental of real estate for a licensed real estate broker on a straight commission basis, who has signed a valid independent contractor agreement with the broker who works on a full-time basis and has a normal workweek of thirty or more hours. See South Carolina Code 38-71-1330 - insurance: includes annuities. See South Carolina Code 38-1-20
- Insurer: means an entity that provides health insurance in this State. See South Carolina Code 38-71-1330
- Network plan: means a health insurance plan issued by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. See South Carolina Code 38-71-1330
- plan: means any hospital or medical policy or certificate, major medical expense insurance, hospital or medical service plan contract, or health maintenance organization subscriber contract that provides benefits consisting of medical care provided directly through insurance or reimbursement, or otherwise and including items and services paid for medical care. See South Carolina Code 38-71-1330
- Premium: means payment given in consideration of a contract of insurance. See South Carolina Code 38-1-20
- Program: means the South Carolina Small Employer Insurer Reinsurance Program pursuant to § 38-71-1410. See South Carolina Code 38-71-1330
- Small employer: means , in connection with a health insurance plan with respect to a calendar year and a plan year, any person, firm, corporation, partnership, association, or employer, as defined in Section 3(5) of the Employee Retirement Income Security Act of 1974, that is actively engaged in business that, on at least fifty percent of its working days during the preceding calendar year, employed no more than fifty eligible employees or employed an average of not more than fifty employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year. See South Carolina Code 38-71-1330
- Small employer insurer: means an insurer that offers health insurance plans covering eligible employees of one or more small employers in this State. See South Carolina Code 38-71-1330
- Standard health insurance plan: means a health insurance plan developed pursuant to § 38-71-1420. See South Carolina Code 38-71-1330
(3) Except with respect to applicable preexisting condition limitation periods or late enrollees as provided in § 38-71-850, a small employer insurer shall not modify a health insurance plan with respect to a small employer or any eligible employee or dependent through rider, endorsement, or otherwise, to restrict or exclude coverage or benefits for specific diseases, medical conditions or services otherwise covered under the plan.
(4)(a) Except as provided in subsections (C) and (D), a small employer insurer shall issue these health insurance plans to any eligible small employer that applies for any such plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health insurance plan relating to employer contribution rules and group participation rules and not inconsistent with this article.
(b) In the case of a small employer insurer that establishes more than one class of business pursuant to § 38-71-920, the small employer insurer shall maintain and issue to eligible small employers these health insurance plans in addition to at least one basic health insurance plan and at least one standard health insurance plan in each class of business so established. A small employer insurer may apply reasonable criteria in determining whether to accept a small employer into a class of business, provided that:
(i) the criteria are not intended to discourage or prevent acceptance of small employers applying for a basic or standard health insurance plan;
(ii) the criteria are not related to the health status or claim experience of the small employer;
(iii) the criteria are applied consistently to all small employers applying for coverage in the class of business; and
(iv) the small employer insurer provides for the acceptance of all eligible small employers into one or more classes of business.
The requirement to offer these health insurance plans to small employers shall not apply to a class of business into which the small employer insurer is no longer enrolling new small businesses.
(5) The provisions of this subsection (A) of this section shall be effective one hundred eighty days after the director‘s approval of the basic health insurance plan and the standard health insurance plan developed pursuant to § 38-71-1420; provided that if the Small Employer Insurer Reinsurance Program created pursuant to § 38-71-1410 is not yet operative on that date, the provisions of this paragraph shall be effective on the date that the program begins operation.
(B)(1) After the director’s approval of the basic health insurance plan and the standard health insurance plan developed pursuant to § 38-71-1420, a small employer insurer shall file with the director, in the form and manner prescribed by the director, the basic and standard health insurance plans to be used by the insurer. The insurer shall certify to the director that the plans as filed are in substantial compliance with the provisions as approved by the director. Upon the director’s receipt of the certification, the insurer may use the certified plans unless their use is disapproved by the director.
(2) The director may, at any time, after providing notice and an opportunity for hearing, disapprove the continued use by a small employer insurer of a basic or standard health insurance plan on the grounds that the plan does not meet the requirements of this article.
(C)(1) In the case of a small employer insurer that offers health insurance coverage through a network plan, the small employer insurer may:
(a) limit the employers that may apply for such coverage to those with eligible employees who live, work, or reside in the service area for such network plan; and
(b) within the service area of any such plan, deny such coverage to such employers if such insurer has demonstrated to the satisfaction of the director that:
(i) it will not have the capacity to deliver services adequately to members of any additional groups because of its obligations to existing group contract holders and enrollees; and
(ii) it is applying this item uniformly to all employers without regard to claims experience of those employers and their employees and their dependents or any health status-related factors relating to such employees and dependents.
(2) A small employer insurer that offers health insurance coverage through a network plan that cannot offer coverage pursuant to item (1)(b) may not offer coverage in the applicable area to new cases of employer groups with more than fifty eligible employees or to any small employer groups until the later of one hundred eighty days following each such refusal or the date on which the insurer notifies the director that it has regained capacity to deliver services to small employer groups.
(D)(1) A small employer insurer may deny health insurance coverage to small employers for any period of time for which the director determines that requiring the acceptance of small employers in accordance with the provisions of subsection (A) would place the small employer insurer in a financially impaired condition or if the small employer insurer has demonstrated to the director that it:
(a) does not have the financial reserves necessary to underwrite additional coverage; and
(b) is applying this item uniformly to all small employers in the State without regard to claims experience of those employers and their employees and their dependents or any health status-related factor relating to such employees and dependents.
(2) A small employer insurer that denies coverage to a small employer pursuant to item (1) may not offer coverage in the State to new cases of employer groups with more than fifty eligible employees or to any small employer groups until the later of one hundred eighty days following each such refusal or the date on which the small employer insurer demonstrates to the director that it has sufficient financial reserves to underwrite additional coverage. The director may provide for the application of this subsection on a service-area-specific basis.