South Carolina Code of Laws
Chapter 33 - Health Maintenance Organizations
Section 38-33-80. Enrollee entitled to evidence of coverage; contents of evidence of coverage; discontinuance or replacement of coverage; charges for services.

(A)(1) Every enrollee is entitled to an evidence of coverage issued by the health maintenance organization. If any of the enrollee's benefits are provided through an insurance policy, the insurer shall issue a separate evidence of coverage for those benefits provided. However, for a point of service option offered jointly by a health maintenance organization and an insurer, only one evidence of coverage is required, as long as the benefits provided by each party are clearly identified therein.
(2) Evidence of coverage, or an amendment to it, may not be issued or delivered to a person in this State until a copy of the form of the evidence of coverage, or amendment to it, has been filed with and approved by the director or his designee pursuant to Section 38-71-310(A) or 38-71-720(A).
(3) No evidence of coverage may contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation, or which are untrue, misleading, or deceptive as defined in Section 38-33-140; and
(4) An evidence of coverage must contain a clear and concise statement, if a contract, a summary, or a certificate, of:
(a) the health care services and the insurance or other benefits, if any, to which the enrollee is entitled;
(b) any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or co-payment feature;
(c) where and in what manner information is available as to how services may be obtained;
(d) the total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts;
(e) clear and understandable description of the health maintenance organization's method for resolving enrollee complaints; and
(f) the contract period during which the enrollee is entitled to health care services and benefits, the applicable charges for coverage during that contract period, and the time and manner in which charges and benefits under the contract or certificate can be changed. Any subsequent change may be evidenced in a separate document issued to the enrollee.
(5) The director or his designee may require additional provisions in the evidence of coverage as may be necessary to the fair, just, and equitable treatment of enrollees. The additional provisions may include, but are not limited to, any of the provisions required of health insurance policies in Chapter 71 of Title 38 and regulations promulgated thereunder, if in the opinion of the director or his designee, the provisions are appropriate for the coverages provided under the health maintenance organization's evidence of coverage.
(6) The provisions of Section 38-71-760 governing discontinuance and replacement of coverage are applicable to group health maintenance organization contracts, except to the extent that the director or his designee determines the provisions to be inappropriate to the coverage provided.
(7) A health maintenance organization that issues a health maintenance organization contract which requires the enrollee to pay a specified percentage of the cost of covered health care services shall calculate those copayments and deductibles on the negotiated rate or lesser charge of the provider. Nothing in this section precludes a health maintenance organization from issuing a contract which contains fixed dollar copayments and deductibles.
(B) No schedule of charges applicable to individual health maintenance organization contracts may be used until a copy of the schedule has been filed with and approved by the director or his designee. The director or his designee may disapprove this schedule of charges if it is determined that the benefits provided in the contracts are unreasonable in relation to the charges.
(C) The director or his designee shall approve within thirty days any form if the requirements of subsection (A) are met. The director or his designee, in his discretion, may extend for up to an additional sixty days the period within which he shall approve or disapprove the form. The director or his designee shall approve, within a reasonable period, any schedule of charges if the requirements of subsection (B) are met. It is unlawful to issue a form or to use a schedule of charges until approved. If the director or his designee disapproves the filing, he shall notify the filer. The notice must contain the reasons for disapproval, and the filer, upon request in writing, is entitled to a public hearing on it. If action is not taken to approve or disapprove any form within thirty days of the filing of the form, if the period is not extended, or at the expiration of the extended period, if any, the filing is deemed approved. If action is not taken to approve or disapprove any schedule of charges within ninety days of the filing of the charges, the filing is deemed approved. An organization may not use a form or schedule of charges deemed approved pursuant to the default provision of this section until the organization has filed with the director or his designee a written notice of its intent to use the form or schedule of charges. The notice must be filed in the office of the director at least ten days before the organization uses the form or schedule of charges.
(D) At any time the director or his designee, after a public hearing of which at least thirty days' notice has been given, may withdraw approval of a schedule of charges previously approved under subsection (B) or an evidence of coverage approved under subsection (A) if he determined that the schedule of charges or evidence of coverage no longer meets the standards for approval specified in this section.
HISTORY: Former 1976 Code Section 38-25-80 [1986 Act No. 440; repealed by 1987 Act No. 155, Section 25 (f)] recodified as Section 38-33-80 by 1987 Act No. 155, Section 1, and substance transferred to Section 38-33-290 by 1987 Act No. 83, Section 1; New Section 38-33-80 enacted by 1987 Act No. 83, Section 1; 1993 Act No. 181, Section 633; 1995 Act No. 58, Section 4; 1995 Act No. 58, Section 2; 1999 Act No. 98, Section 2; 2001 Act No. 82, Section 15, eff July 20, 2001.

Structure South Carolina Code of Laws

South Carolina Code of Laws

Title 38 - Insurance

Chapter 33 - Health Maintenance Organizations

Section 38-33-10. Short title.

Section 38-33-20. Definitions.

Section 38-33-30. Necessity of certificate of authority; foreign corporation.

Section 38-33-40. Issuance of certificate of authority; criteria and considerations; arrangements for participation of providers in each geographic area served.

Section 38-33-50. Powers of health maintenance organization; notice prior to exercise of powers.

Section 38-33-60. Members of governing body; advisory panels, etc.

Section 38-33-70. Fiduciary relationship in handling of funds.

Section 38-33-80. Enrollee entitled to evidence of coverage; contents of evidence of coverage; discontinuance or replacement of coverage; charges for services.

Section 38-33-90. Statements and reports.

Section 38-33-100. Financial requirements before issuance of certificate of authority to health maintenance organization.

Section 38-33-110. Complaint procedures; reports; malpractice claims; applicability of Freedom of Information Act.

Section 38-33-120. Investment of funds.

Section 38-33-130. Security deposit; individual stop-loss coverage; provisions for unpaid claim liability; individual conversion policy.

Section 38-33-140. Advertisements; application of provisions relating to trade practices; use of term "insurer" or "health maintenance organization".

Section 38-33-150. Agent for organization; exemption from licensing requirements.

Section 38-33-160. Operation of health maintenance organization by insurance company; contracts for cost of care.

Section 38-33-170. Examination of affairs of organization; quality of health care services; books and records; expense of examination; reports.

Section 38-33-180. Suspension or revocation of certificate of authority.

Section 38-33-190. Rehabilitation, liquidation, or conservation of a health maintenance organization; priorities.

Section 38-33-200. Implementation of regulations.

Section 38-33-210. Notification of grounds for denial, suspension or revocation of certificate of authority; hearings; judicial review.

Section 38-33-220. Fees.

Section 38-33-230. Levy of administrative penalty in lieu of revocation or suspension of certificate of authority; monetary penalty; notice and hearings; injunctions.

Section 38-33-240. Application of provisions of insurance law or law relating to solicitation or advertising by health professionals; practice of medicine, dentistry or other healing profession.

Section 38-33-250. Records of organization as public documents; trade secrets, etc.

Section 38-33-260. Confidentiality of health records.

Section 38-33-270. Contractual powers of Department to assist in investigative duties; assessments for consulting expenses.

Section 38-33-280. Acquisition or exchange of securities of a health maintenance organization; merger or consolidation of HMO.

Section 38-33-290. Participation by physician, podiatrist, optometrist, or oral surgeon as provided in HMO.

Section 38-33-300. Liability for participation in quality of care or utilization review.

Section 38-33-310. HMO may contract with out-of-state provider.

Section 38-33-325. Obstetrician-gynecologist services; referrals; authorization for services; member notification of plan provisions.