South Carolina Code 38-71-1420. Advisory committee
(B) The committee shall recommend benefit levels, cost-sharing levels, exclusions and limitations for the basic health insurance plan and the standard health insurance plan. The committee shall specifically recommend which, if any, mandated coverages of health care services or health care providers should be included in the basic and standard health insurance plans and shall recommend as well whether the plans should be exempt from any other statutory provisions otherwise applicable to group health insurance policies. § 38-71-200 is applicable to the basic and standard health insurance plans and is not subject to exemption. The committee also shall design a basic health insurance plan and a standard health insurance plan which contain benefit and cost-sharing levels that are consistent with the basic method of operation and the benefit plans of health maintenance organizations, including any restrictions imposed by federal law.
Terms Used In South Carolina Code 38-71-1420
- Basic health insurance plan: means a lower cost health insurance plan developed pursuant to § 38-71-1420. See South Carolina Code 38-71-1330
- Board: means the board of directors of the program established pursuant to § 38-71-1410. See South Carolina Code 38-71-1330
- Committee: means the advisory committee to the commissioner referred to in § 38-71-1420. See South Carolina Code 38-71-1330
- Director: means the Director of the Department of Insurance of this State. See South Carolina Code 38-71-1330
- insurance: includes annuities. See South Carolina Code 38-1-20
- 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
- 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
- Standard health insurance plan: means a health insurance plan developed pursuant to § 38-71-1420. See South Carolina Code 38-71-1330
(1) The plans recommended by the committee may include cost containment features such as:
(a) utilization review of health care services, including review of medical necessity of hospital and physician services;
(b) case management;
(c) selective contracting with hospitals, physicians, and other health care providers;
(d) reasonable benefit differentials applicable to providers that participate or do not participate in arrangements using restricted network provisions; and
(e) other managed care provisions.
(2) The committee shall submit the health insurance plans described in paragraphs (A) and (B) to the director for approval by January 1, 1995. If, for any reason, the committee does not provide the director with a recommendation as to the form and level of coverages to be made available pursuant to this article, the board shall make such recommendation to the director. If, subsequent to the approval of the benefit levels of the basic and standard health insurance plans, amendments to the plans become necessary, the board shall make such recommendations to the director for his approval.