Section 38-74-10 - DefinitionsAs used in this chapter:
(1) "Pool" means the South Carolina Health Insurance Pool.(2) "Board" means the board of directors of the pool.(3) "Insured" means any individual resident of this State who is eligible to receive benefits from any insurer.(4) "Insurer" means any entity that provides health insurance in this State. For purposes of this section, insurer includes an insurance company, a health maintenance organization, and any other entity providing health insurance which is licensed to engage in the business of insurance in this State and which is subject to state insurance regulation.(5) "Health insurance" or "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, Title 10 of the United States Code.(6) "Medicare" means Title XVIII of the Social Security Act, 42 U.S.C. 1395, et seq., as amended.(7) "Physician" means any practitioner of the healing arts, other than an insured person or a person related to an insured person, who is legally licensed to perform any service for which benefits are provided by the insurance policy issued by the pool.(8) "Hospital" means an institution operated pursuant to law under the supervision of a staff of duly licensed physicians which is primarily and continuously engaged in providing or operating, either on its premises or in facilities available to the public on a prearranged basis, medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an inpatient basis for which a charge is made and provides twenty-four hour nursing service under the supervision of registered nurses.(9) "Health maintenance organization" means an organization as defined in Section 38-33-20(7).(10) "Plan of operation" means the plan of operation of the pool, including articles, bylaws, and operating rules adopted by the board.(11) "Benefits plan" means the coverages to be offered by the pool to eligible persons.(12) "Department" means the South Carolina Insurance Department.(13) "Director" means the person who is appointed by the Governor upon the advice and consent of the Senate and who is responsible for the operation and management of the Department of Insurance, including all of its divisions. The director may appoint or designate the person or persons who shall serve at the pleasure of the director to carry out the objectives or duties of the department as provided by law. Furthermore, the director may bestow upon his designee or deputy director any duty or function required of him by law in managing or supervising the Insurance Department.(14) "Member" means each insurer participating in the pool.(15) "Net loss" means the excess of incurred claims plus expenses over the sum of earned premiums, accrued investment income, and other appropriate gains and losses.(16) "Affiliation period" means a period which, under the terms of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective. The organization is not required to provide health care services or benefits during this period and no premium shall be charged to the participant or beneficiary for any coverage during the period. The period begins on the enrollment date and runs concurrently with any waiting period under the plan.(17) "Beneficiary" has the meaning given under Section 3(8) of the Employee Retirement Income Security Act of 1974.(18) "COBRA continuation provision" means:(a) Part 6 of subtitle B of Title I of the Employee Retirement Income Security Act of 1974, other than Section 609 of the act;(b) Section 4908B of the Internal Revenue Code of 1986, other than subsection (f)(1) of the section insofar as it relates to pediatric vaccines; or(c) Title XXII of the Public Health Service Act.(19) "Church plan" has the meaning given the term under Section 3(33) of the Employee Retirement Income Security Act of 1974.(20) "Creditable coverage" means, with respect to an individual, coverage of the individual under: (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, 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, 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.S.C. 2504(e)); or(k) Title XXI of the Social Security Act (State Children's Health Insurance Program). The term does not include coverage consisting only of those benefits excepted from the definition of health insurance.
A period of creditable coverage is not counted if, after such period and before the enrollment date, there was a sixty-three day period during all of which the individual was not covered under any creditable coverage. However, in determining whether there has been continuous coverage, no period must be taken into account during which the individual is in a waiting period for any coverage under a group health plan or for group health insurance coverage or is in an affiliation period.
Periods of creditable coverage with respect to an individual must be established through presentation of certifications as described in Section 38-71-850(D) or in a manner specified in regulations.
(21) "Employee" has the meaning given the term under Section 3(6) of the Employee Retirement Income Security Act of 1974.(22) "Enrollment date" means, with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for the enrollment.(23) "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.(24) "Governmental plan" has the meaning given the term under Section 3(32) of the Employee Retirement Income Security Act of 1974 and any governmental plan established or maintained for its employees by the government of the United States or by an agency or instrumentality of the government.(25) "Group health insurance coverage" means, in connection with a group health plan, health insurance offered by an insurer in connection with the plan.(26) "Group health plan" means an employee welfare benefit plan, as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974, to the extent that the plan provides medical care, including items and services paid for as medical care, to employees or their dependents, as defined under the terms of the plan, directly or through insurance, reimbursement, or otherwise.(27) "Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan. The term includes coverage offered in connection with a group health plan that has fewer than two participants as current employees on the first day of the plan year unless the State elects to regulate the coverage as coverage issued to small employers as defined in Section 38-71-1330.(28) "Medical care" means amounts paid for: (a) the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;(b) amounts paid for transportation primarily for and essential to medical care referred to in subitem (a); and(c) amounts paid for insurance covering medical care referred to in subitems (a) and (b).(29) "Participant" has the meaning given the term under Section 3(7) of the Employee Retirement Income Security Act of 1974.(30) "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. Genetic information may not be treated as a preexisting condition in the absence of a diagnosis of the condition related to the information.(31) "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.(32) "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.Amended by 2010 S.C. Acts, Act No. 217 (SB 1224), s 6, eff. 6/7/2010.2003 Act No. 73, Section 24.H, eff 6/25/2003; 2002 Act No. 240, Section 1, eff 1/1/2003; 1997 Act No. 4, Sections 2, 3; 1993 Act No. 181, Section 788; 1989 Act No. 127, Section 1.