South Carolina § 43-7-465 - Insurers providing coverage to persons receiving Medicaid; requirements for doing business in State.

§ 43-7-465. Insurers providing coverage to persons receiving Medicaid; requirements for doing business in State.

A health insurer, including a self-insured plan, group health plan as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service-benefit plan, managed-care organization, pharmacy benefit manager, or another party that is legally responsible by statute, contract, or agreement for payment of a claim for a health care item or service, as a condition of doing business in this State, shall:

(1) provide, with respect to an individual eligible for or receiving medical assistance under the state plan, on request of the single-state agency, information to determine during what period the individual or his spouse or dependent may be, or may have been, covered by a health insurer and the nature of coverage provided or that may have been provided by the insurer in a manner prescribed by the Secretary of the United States Department of Health and Human Services or by the single-state agency. This information must include the insured's name, address, and the plan's identifying number;

(2) accept the state's right of recovery and the assignment to the State of an individual or another entity's right to payment for a health care item or service for which payment was made under the state plan (or under a waiver of such plan);

(3) in the case of a responsible third party (other than the original Medicare fee-for-service program under parts A and B of subchapter XVIII of the Social Security Act, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of subchapter XVIII of the Social Security Act, a reasonable cost reimbursement plan under Section 1395mm of Title XVIII of the Social Security Act, a health care prepayment plan under Section 1395I of Title XVIII of the Social Security Act, or a prescription drug plan offered by a PDP sponsor under part D of subchapter XVIII of the Social Security Act) that requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance under this subchapter, accept authorization provided by the State that the item or service is covered under the state plan (or waiver of such plan) for such individual, as if such authorization were the prior authorization made by the third party for such item or service;

(4) not later than sixty days after receiving any inquiry by the State regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of such health care item or service, respond to such inquiry; and

(5) agree not to deny a claim submitted by the State solely on the basis of the date of submission of the claim, the type or format of the claim form, a failure to present proper documentation at the point-of-sale that is the basis of the claim, or in the case of a responsible third party (other than the original Medicare fee-for-service program under parts A and B of subchapter XVIII of the Social Security Act, a Medicare Advantage plan offered by a Medicare Advantage organization under part C of subchapter XVIII of the Social Security Act, a reasonable cost reimbursement plan under Section 1395mm of Title XVIII of the Social Security Act, a health care prepayment plan under Section 1395I of Title XVIII of the Social Security Act, or a prescription drug plan offered by a PDP sponsor under part D of such title) a failure to obtain prior authorization for the item or service for which the claim is being submitted, if:

(a) the claim is submitted by the State within the three-year period beginning on the date on which the item or service was furnished; and

(b) any action by the State to enforce its rights with respect to such claim is commenced within six years of the State submission of such claim.

HISTORY: 2008 Act No. 348, SECTION 1, eff June 16, 2008; 2024 Act No. 184 (H.5235), SECTION 1, eff May 20, 2024.

Effect of Amendment

2024 Act No. 184, SECTION 1, rewrote the section.