South Carolina § 38-74-30 - Eligibility for pool coverage.

§ 38-74-30. Eligibility for pool coverage.

(A) A person who is a resident of this State for thirty days, except that for a federally defined eligible individual or a Qualified TAA eligible individual, there shall not be a thirty-day requirement, and his newborn child is eligible for pool coverage:

(1) upon providing evidence of any of the following actions by an insurer on an application for health insurance comparable to that provided by the pool submitted on behalf of the person:

(a) a refusal to issue the insurance for health reasons;

(b) a refusal to issue the insurance except with a reduction or exclusion of coverage for a preexisting health condition for a period exceeding twelve months, unless it is determined that the person voluntarily terminated his or did not seek any health insurance coverage before being refused issuance except with a reduction or exclusion for a preexisting health condition, and then seeks to be eligible for pool coverage after the health condition develops. This determination must be made by the board;

(c) a refusal to issue insurance coverage comparable to that provided by the pool except at a rate exceeding one hundred fifty percent of the pool rate; or

(2) if the individual is a federally defined eligible individual or a Qualified TAA eligible individual, as defined in Section 38-74-10, who is and continues to be a resident of this State; or

(3) if the individual is under the age of sixty-five and covered under Medicare Parts A and B for reasons other than age.

(B) A person whose health insurance coverage is terminated involuntarily for any reason other than nonpayment of premium may apply for coverage under the plan but shall submit proof of eligibility according to subsection (A) of this section. If proof is supplied and if coverage is applied for within sixty days after the involuntary termination and if premiums are paid for the entire coverage period, the effective date of the coverage is the date of termination of the previous coverage. Waiting period and preexisting condition exclusions are waived to the extent to which similar exclusions, if any, have been satisfied under the prior health insurance coverage. The waiver does not apply to a person whose policy has been terminated or rescinded involuntarily because of a material misrepresentation.

(C) A person who is paying a premium for health insurance comparable to the pool plan in excess of one hundred fifty percent of the pool rate or who has received notice that the premium for a policy would be in excess of one hundred fifty percent of the pool rate may make application for coverage under the pool. The effective date of coverage is the date of the application, or the date that the premium is paid if later, and any waiting period or preexisting condition exclusion is waived to the extent to which similar exclusions, if any, were satisfied under the prior health insurance plan. Benefits payable under the pool plan are secondary to benefits payable by the previous plan. The board shall require an additional premium for coverage effected under the plan in this manner notwithstanding the premium limitation stated in Section 38-74-60.

(D)(1) The waiting period and preexisting condition exclusions are waived for a federally defined eligible individual.

(2) The waiting period and preexisting condition exclusions are waived for a Qualified TAA eligible individual if the individual maintained creditable coverage for an aggregate period of three months as of the date on which the individual seeks to enroll in pool coverage, not counting any period prior to a sixty-three-day break in coverage.

(E) A person not eligible for pool coverage is one who meets any one of the following criteria:

(1) a person who has coverage under health insurance comparable to that offered by the pool from an insurer or any other source except a person who would be eligible under subsection (C);

(2) a person who is eligible for health insurance comparable to that offered by the pool from an insurer or any other source except a person who would be eligible for pool coverage under subsection (A)(1)(b), (A)(1)(c), (A)(2), or (A)(3);

(3) a person who at the time of pool application is eligible for health care benefits under state Medicaid or eligible for health care benefits under Medicare and age sixty-five or older;

(4) a person having terminated coverage in the pool unless twelve months have lapsed since termination unless termination was because of ineligibility, except that this item shall not apply with respect to an applicant who is a federally defined eligible individual;

(5) a person on whose behalf the pool has paid out one million dollars in benefits;

(6) inmates of public institutions and persons eligible for public programs, except that this item shall not apply with respect to an applicant who is a federally defined eligible individual;

(7) a person who fails to maintain South Carolina residency.

(F) A person who ceases to meet the eligibility requirements of this section may be terminated at the end of the policy period.

HISTORY: 1989 Act No. 127, SECTION 3; 1990 Act No. 568, SECTION 4; 1991 Act No. 74, SECTIONS 2, 3; 1997 Act No. 4, SECTION 4; 2002 Act No. 240, SECTION 2, eff January 1, 2003; 2003 Act No. 73, SECTION 24.I, eff June 25, 2003; 2006 Act No. 332, SECTION 12, eff June 1, 2006.