South Carolina Health Insurance Coverage...
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• What are your protections when buying individual health insurance in the State of South Carolina?
     If you do not have access to employer-sponsored group insurance, you may want to buy an individual health plan from a private health insurance company. However, in South Carolina – as in most other states – you have limited guaranteed access to individual health insurance. There are some alternatives to individual health insurance coverage – such as COBRA coverage and SCHIP coverage.
• When do individual health insurers have to sell you coverage?
     In South Carolina, your ability to buy individual health coverage may depend on your health status.
• In general, companies that sell individual health insurance in South Carolina are free to turn you down because of your health status and other factors.
     When applying for individual coverage, you may be asked questions about health conditions you have now or had in the past. Depending on your health status, insurers might refuse to sell you coverage or offer to sell you a policy that has special limitations on what it covers. If you are turned down or offered insurance with a reduction or exclusion for a pre-existing condition exceeding 12 months, you may be eligible for SCHIP coverage.
• Under South Carolina law, newborns and adopted children are automatically covered under the parents’ individual health plan for the first 31 days, if the plan covers dependents.
     The insurer may require that the parent enroll the child and pay the required premium within the 31 days in order to continue coverage beyond the 31 days.
• In South Carolina, mentally retarded and physically disabled dependents are permitted to remain insured under their parent’s individual health insurance policy after they reach the age at which dependent coverage is usually terminated.
     The adult dependent must be incapable of self-support and must rely on the policyholder for support. In addition, proof of dependency and disability must be provided to the insurer within 31 days of the dependent reaching the limiting age.
• What will your individual health plan cover?
     It depends on what you buy. South Carolina does not require health insurers in the individual market to sell standardized policies. Health plans can design different policies and you will have to read and compare them carefully. However, South Carolina does require all health plans to cover certain mandated benefits. Check with the South Carolina Insurance Department for more information about mandated benefits.
• If you have a pre-existing condition, what kind of coverage can you expect?
     The definition of pre-existing condition varies by type of individual health plan. Individual HMO plans can count as pre-existing any condition for which medical advice, treatment or diagnosis was actually received or recommended during the 12- month period immediately before you enrolled. Pre-existing condition periods in HMO individual health plans can be no longer than 12 months.
• If you apply for an individual indemnity plan, the rules regarding preexisting conditions depend on the kind of form you completed when you applied for coverage.
     There are two types of forms that an indemnity plan can use. One, a comprehensive form, will ask you detailed questions regarding your medical history. The other, a simplified form, will ask minimal questions regarding your medical history. The insurance company selling the policy decides which form it will use at the time you apply.
     If the plan uses a comprehensive form, then for the first 24 months it can refuse to cover any condition that you disclose, or it can impose an elimination rider, which is an amendment to your health insurance contract that permanently excludes coverage for a health condition, body part, or body system.
     In addition, if you make a claim during the first 2 years the plan can refuse to pay that claim and others related to the condition if it determines the condition was pre-existing. In individual health plans, pre-existing conditions include those that were not previously diagnosed, but caused symptoms for which most people would have sought care. This is called the prudent person rule.
     If the individual indemnity plan used a simplified form when you applied for insurance then a different set of rules apply. Contact the South Carolina Insurance Department for more information.
• In South Carolina, pregnancy can be considered a pre-existing condition in all individual health plans.
     Genetic information cannot be considered a pre-existing condition.
• Individual health plans do not have to give credit for your prior coverage, unlike group health plans and SCHIP coverage.

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