(A) Premium rates for health insurance plans subject to this subarticle are subject to the following requirements:
(1) The index rate for a rating period for a class of business may not exceed the index rate for any other class of business by more than twenty percent.
(2) For a class of business, the premium rates charged during a rating period to small employers with similar case characteristics for the same or similar coverage, or the rates which could be charged to these employers under the rating system for that class of business, may not vary from the index rate by more than twenty-five percent of the index rate.
(3) The percentage increase in the renewal premium rate charged to a small employer for a new rating period may not exceed the sum of:
(a) the percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period. In the case of a class of business for which the small employer insurer is not issuing new policies, the insurer shall use the percentage change in the base premium rate. However, in the case of health insurance plans issued prior to the effective date of this section, if the change in the new business premium rate used to determine the maximum percentage increase in the premium rate is less than zero percent, then zero percent may be used as the percentage change in the new business premium rate during the first twelve-month period from the effective date of this section;
(b) an adjustment, not to exceed fifteen percent annually and adjusted pro rata for rating periods of less than one year, due to the claim experience, health status, or duration of coverage of the employees or dependents of the small employer as determined from the insurer's rate manual for the class of business;
(c) any adjustment due to change in coverage or change in the case characteristics of the small employer as determined from the insurer's rate manual for the class of business.
(4) A health insurance plan that contains a restricted network provision shall not be considered similar coverage to a health insurance plan that does not contain such a provision, provided that the restriction of benefits to network providers results in substantial differences in claim costs.
(5) If group size is used as a case characteristic by a small employer insurer, the highest rate factor associated with a group size classification may not exceed the lowest rate factor associated with such a classification by more than twenty percent.
(B) Nothing in this section is intended to affect the use by a small employer insurer of legitimate rating factors other than claim experience, health status, or duration of coverage in the determination of premium rates. Small employer insurers shall apply rating factors, including case characteristics, consistently with respect to all small employers within a class of business.
(C) Unless the small employer no longer meets the criteria established for its existing class of business:
(1) a small employer insurer may not transfer involuntarily a small employer into or out of a class of business; and
(2) a small employer insurer may not offer to transfer a small employer into or out of a class of business, unless the offer is made to transfer all small employers in the class of business without regard to case characteristics, claim experience, health status, or duration since issue.
HISTORY: 1991 Act No. 131, Section 5; 1997 Act No. 70, Section 3.
Structure South Carolina Code of Laws
Chapter 71 - Accident And Health Insurance
Section 38-71-10. Coverages which may be written by licensed accident and health insurers.
Section 38-71-30. Whole contract, including application, must appear in policy; oral applications.
Section 38-71-40. Effect of false statement in application.
Section 38-71-46. Diabetes Mellitus coverage in health insurance policies; diabetes education.
Section 38-71-50. Alteration of application.
Section 38-71-60. Certain acts do not constitute a waiver by insurer.
Section 38-71-70. Certain policies may conform to laws of other states.
Section 38-71-80. Construction of policy issued in violation of chapter.
Section 38-71-90. Penalty for violation of chapter.
Section 38-71-100. Policies exempt from chapter.
Section 38-71-125. Mastectomies; hospitalization requirements; early release provisions.
Section 38-71-140. Coverage of newborn children.
Section 38-71-143. Health plans must provide same coverage for children placed for adoption.
Section 38-71-160. When policy sold on direct response basis considered to be returned.
Section 38-71-170. Required provision in policies for conversion privileges for former spouses.
Section 38-71-190. Subrogation of insurer to insured's rights against third party.
Section 38-71-210. Health insurance policies to include chiropractic services.
Section 38-71-215. Dermatology referrals.
Section 38-71-238. Abortion coverage prohibitions; exceptions.
Section 38-71-240. Coverage required for cleft lip and palate; certain policies exempt.
Section 38-71-242. Specified disease insurance policies; payment of claims and benefits.
Section 38-71-243. Continuation of care; definitions; applicability; requirements.
Section 38-71-245. Prohibited grounds for denial of enrollment to child of health plan participant.
Section 38-71-246. Continuation of care; provider contract requirements.
Section 38-71-247. Continuation of care; plain language description requirement.
Section 38-71-255. Health insurer may not impose different requirements on state agency.
Section 38-71-260. Duties of health insurer of child to custodial parent.
Section 38-71-275. Insurance coverage for certain drugs not to be excluded from policy definitions.
Section 38-71-280. Autism spectrum disorder; coverage; eligibility for benefits.
Section 38-71-290. Mental health coverage; definitions; treatment requirements; exceptions
Section 38-71-315. Decrease of premium charges.
Section 38-71-320. Policies issued for delivery in another state.
Section 38-71-330. Form of policies.
Section 38-71-340. Required provisions.
Section 38-71-355. Dependent child; medically necessary leave of absence.
Section 38-71-360. Continuation of coverage for nonhandicapped dependent children.
Section 38-71-370. Optional provisions.
Section 38-71-410. Omission or modification of required or optional provisions.
Section 38-71-420. Placement of required and optional provisions in policy.
Section 38-71-430. Additional provisions may not make policy less favorable.
Section 38-71-510. Declaration of purpose.
Section 38-71-520. Definitions.
Section 38-71-540. Regulations establishing minimum standards for benefits.
Section 38-71-550. Outline of coverage required.
Section 38-71-560. Effect of use of simplified application form.
Section 38-71-610. Notice of premiums due required.
Section 38-71-620. Advance notice required for increase in premium.
Section 38-71-630. Acceptance of premium for period beyond expiration date of policy.
Section 38-71-640. Person with insurable interest may take out policy on insured.
Section 38-71-650. Right to transfer to policy of equal or lesser benefits with same insurer.
Section 38-71-670. Definitions.
Section 38-71-680. Application of Section 38-71-850(D).
Section 38-71-710. Definitions.
Section 38-71-735. Required provisions.
Section 38-71-740. Restrictions on mass-marketed insurance.
Section 38-71-770. Mandatory continuation privileges.
Section 38-71-785. Dependent child; medically necessary leave of absence.
Section 38-71-790. Payment of benefits.
Section 38-71-800. Hospital and medical expenses.
Section 38-71-810. Readjustment of rates or refunds or dividends.
Section 38-71-840. Definitions.
Section 38-71-910. Legislative intent.
Section 38-71-920. Definitions.
Section 38-71-930. Application of this subarticle.
Section 38-71-970. Insurer rating and renewal records; filing of certification; confidentiality.
Section 38-71-980. Suspension of premium rate restrictions upon request of certain insurers.
Section 38-71-990. Effective date of this subarticle.
Section 38-71-1010. "Blanket accident and health insurance" defined.
Section 38-71-1020. Requirements as to policies.
Section 38-71-1030. Individual applications and certificates not required.
Section 38-71-1040. Payment of benefits.
Section 38-71-1050. Legal liability of policyholders not affected.
Section 38-71-1110. "Franchise accident and health insurance" defined.
Section 38-71-1310. Short title.
Section 38-71-1320. Purpose and intent.
Section 38-71-1330. Definitions.
Section 38-71-1340. Application of article; group size for health group cooperative.
Section 38-71-1350. Premium rates; requirements.
Section 38-71-1355. Health group cooperative; powers and duties.
Section 38-71-1370. Applicability of certain code sections; late enrollees.
Section 38-71-1400. Election to become reinsuring insurer.
Section 38-71-1410. South Carolina Small Employer Insurer Reinsurance Program.
Section 38-71-1420. Advisory committee.
Section 38-71-1430. Annual public report.
Section 38-71-1440. Requirements upon small employer insurers.
Section 38-71-1445. Report on effectiveness of health group cooperatives.
Section 38-71-1450. Promulgation of regulations.
Section 38-71-1510. Short title.
Section 38-71-1520. Definitions.
Section 38-71-1540. Practice of discouraging use of 911 telephone system prohibited.
Section 38-71-1545. Exclusion of certain insurance policies.
Section 38-71-1550. Severability.
Section 38-71-1710. Short title.
Section 38-71-1720. Definitions.
Section 38-71-1750. Disclosures required of network plans.
Section 38-71-1760. Promulgation of regulations.
Section 38-71-1810. Pharmacy audit rights.
Section 38-71-1820. Appeals process; dismissal; copy of audit findings.
Section 38-71-1830. Recoupment.
Section 38-71-1840. Exemptions.
Section 38-71-1910. Short title.
Section 38-71-1920. Definitions.
Section 38-71-1930. Application of this article.
Section 38-71-1940. Notice of right to request a review; notice of adverse determination.
Section 38-71-1950. Requests for external review.
Section 38-71-1960. Exhaustion of internal appeal process.
Section 38-71-1970. Requests for external review.
Section 38-71-1980. Expedited external review.
Section 38-71-1990. External review decisions final; exceptions.
Section 38-71-2000. Approval of independent review organizations.
Section 38-71-2010. Standards for approval of independent review organizations.
Section 38-71-2020. Liability of independent review organizations and personnel.
Section 38-71-2030. External review; written records; reports.
Section 38-71-2040. Health carrier to pay for external review.
Section 38-71-2050. Health carrier to inform covered persons of rights related to external review.
Section 38-71-2060. Regulations.
Section 38-71-2110 to 38-71-2150. Repealed.
Section 38-71-2200. Definitions.
Section 38-71-2210. License requirement for pharmacy benefits managers.
Section 38-71-2230. Pharmacy benefits manager prohibited from taking certain actions.
Section 38-71-2240. Placement of drug on Maximum Allowable Cost List.