South Carolina Legislature MobileReference is to Printer's Date 2/23/11-H.
Amend the bill, as and if amended, by adding an appropriately numbered SECTION to read:
/ SECTION __. Title 38 of the 1976 Code is amended by adding:
"Section 38-96-10. This chapter may be cited as the 'South Carolina Health Benefit Exchange Act'.
Section 38-96-20. The purpose of this chapter is to provide for the establishment of the South Carolina Health Benefit Exchange pursuant to the federal health care act in order to facilitate the purchase and sale of qualified health plans in the individual market in this State and to provide for the establishment of a Small Employer Exchange to assist qualified small employers in this State in facilitating the enrollment of their employees in qualified health plans offered in the small group market. The intent of the exchange is to reduce the number of uninsured, provide a transparent consumer driven marketplace, increase competition, reduce health care costs, establish portability and simplicity in accessing health coverage, and assist individuals with access to programs, premium assistance tax credits, and cost-sharing reductions.
Section 38-96-30. As
used in this chapter:
(1) 'Board' means the
South Carolina Health Benefit Exchange Board of Directors.
(2) 'Exchange' means
the South Carolina Health Benefit Exchange established pursuant
to Section 38-96-40.
(3) 'Federal health
care act' means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health
Care and Education Reconciliation Act of 2010 (Public Law
111-152), and any amendments to either, or regulations or
guidance issued under those acts.
(4) 'Health benefit
plan' means a policy, contract, certificate, or agreement
offered or issued by a health insurance carrier to provide,
deliver, arrange for, pay for, or reimburse any of the costs of
health care services.
(a)
'Health benefit plan' does not include:
(i)
coverage only for accident or disability income insurance
or any combination of these;
(ii)
coverage issued as a supplement to liability
insurance;
(iii)
liability insurance, including general liability insurance
and automobile liability insurance;
(iv)
workers' compensation or similar insurance;
(v)
automobile medical payment insurance;
(vi)
credit-only insurance;
(vii)
other similar insurance coverage, specified in federal
regulations issued pursuant to Public Law 104-191, under which
benefits for health care services are secondary or incidental to
other insurance benefits.
(b)
'Health benefit plan' does not include the following
benefits if they are provided under a separate policy,
certificate, or contract of insurance or are otherwise not an
integral part of the plan;
(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 of these;
or
(iii)
other similar, limited benefits specified in federal
regulations issued pursuant to Public Law 104-191.
(c)
'Health benefit plan' does not include the following
benefits if the benefits are provided under a separate policy,
certificate, or contract of insurance, there is no coordination
between the provisions of the benefits and any exclusion of
benefits under any group health plan maintained by the same plan
sponsor, and the benefits are paid with respect to an event
without regard to whether benefits are provided with respect to
such an event under any group health plan maintained by the same
plan sponsor:
(i)
coverage only for a specified disease or illness; or
(ii)
hospital indemnity or other fixed indemnity insurance.
(d)
'Health benefit plan' does not include the following if
offered as a separate policy, certificate, or contract of
insurance:
(i)
Medicare supplemental health insurance as defined under
section 1882(g)(1) of the Social Security Act;
(ii)
coverage supplemental to the coverage provided under
Chapter 55 of title 10, United States Code (Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS)); or
(iii)
similar supplemental coverage provided to the coverage
under a group health plan.
(5) 'Health insurance
carrier' or 'carrier' means an entity subject to the insurance
laws and regulations of this State, or subject to the
jurisdiction of the Department of Insurance, that contracts or
offers to contract to provide, deliver, arrange for, pay for, or
reimburse any of the costs of health care services, including a
health and accident insurance company, a health maintenance
organization, a nonprofit hospital, a health service
corporation, or any other entity providing a plan of health
insurance, health benefits, or health services.
(6) 'Qualified dental
plan' means a limited scope dental plan that has been certified
in accordance with regulations promulgated pursuant to this
chapter.
(7) 'Qualified
employer' means a small employer that elects to make its
full-time employees eligible for one or more qualified health
plans offered through the small employer exchange, and at the
option of the employer, some or all of its part-time employees
if the employer:
(a)
has its principal place of business in this State and
elects to provide coverage through the small employer exchange
to all of its eligible employees, wherever employed; or
(b)
elects to provide coverage through the small employer
exchange to all of its eligible employees who are principally
employed in this State.
(8) 'Qualified health
plan' means a health benefit plan that has in effect a
certification that the plan meets the criteria for certification
as provided for in regulation.
(9) 'Qualified
individual' means an individual, including a minor, who:
(a)
is seeking to enroll in a qualified health plan offered to
individuals through the exchange;
(b)
resides in the State of South Carolina;
(c)
at the time of enrollment, is not incarcerated, other than
incarceration pending the disposition of charges; and
(d)
is, and is reasonably expected to be, for the entire
period for which enrollment is sought, a citizen or national of
the United States or an alien lawfully present in the United
States.
(10) 'Small employer'
means an employer that employed an average of not more than
fifty employees during the preceding calendar year. However,
beginning on January 1, 2016, 'small employer' means an employer
that employed an average of not more than one hundred employees
during the preceding calendar year. For purposes of this
item:
(a)
All persons treated as a single employer under subsection
(b), (c), (m), or (o) of section 414 of the Internal Revenue
Code of 1986 must be treated as a single employer.
(b)
An employer and any predecessor employer must be treated
as a single employer.
(c)
All employees must be counted, including part-time
employees and employees who are not eligible for coverage
through the employer.
(d)
If an employer was not in existence throughout the
preceding calendar year, the determination of whether this
employer is a small employer must be based on the average number
of employees this employer is reasonably expected to employ on
business days in the current calendar year.
(e)
An employer that makes enrollment in qualified health
plans available to its employees through the small employer
exchange, and would cease to be a small employer by reason of an
increase in the number of its employees, shall continue to be
treated as a small employer for purposes of this chapter as long
as it continuously makes enrollment through the small employer
exchange available to its employees.
Section 38-96-40. (A)
There is established the South Carolina
Health Benefit Exchange within the Office of the Governor to
effectuate the purposes provided for in this chapter.
(B) The exchange must
be governed by the Health Benefit Exchange Board of Directors,
the members of which must be appointed by the Governor with the
advice and consent of the Senate. The board must be composed of
the following members:
(1)
Director of the Department of Insurance, or his designee,
who shall serve ex officio;
(2)
Director of the Department of Health and Human Services,
or his designee, who shall serve ex officio;
(3)
Chairman of the House Labor, Commerce and Industry
Committee, or his designee, who shall serve ex officio;
(4)
Chairman of the Senate Banking and Insurance Committee, or
his designee, who shall serve ex officio;
(5)
three representatives of the health insurance industry,
upon the recommendation of the Director of the Department of
Insurance; one of whom must represent a company providing health
insurance that is domiciled in this State and one of whom must
represent a company providing health insurance that holds less
than five percent of the market share of health insurance in
this State;
(6)
two insurance producers, both of whom must have no fewer
than ten years experience in the health insurance industry, one
of whom must be recommended by the Professional Insurance Agents
of South Carolina and one of whom must be recommended by the
Independent Insurance Agents and Brokers of South Carolina;
(7)
three consumer advocates;
(8)
one business owner;
(9)
one business owner recommended by the National Federation
of Independent Business;
(10)
one member recommended by the South Carolina Small
Business Chamber of Commerce;
(11)
one member recommended by the South Carolina Chamber of
Commerce;
(12)
one member recommended by the South Carolina Nurses
Association;
(13)
one member recommended by the South Carolina Primary Care
Association;
(14)
one physician recommended by the South Carolina Medical
Association;
(15)
one member recommended by the South Carolina Hospital
Association;
(16)
one actuary recommended by the American Academy of
Actuaries.
(C) A person appointed
to the board of directors must not be employed by, a consultant
to, on the board of, or a lobbyist or other representative for
an entity in the business of, or potentially in the business of,
selling products or services of significant value to the
exchange. These entities include, but are not limited to,
insurance carriers that provide coverage of health benefits,
producers, vendors, and health care providers selling services
directly to the exchange.
(D) As designated by
the Governor, of the initial appointees, seven shall serve terms
of four years, five shall serve terms of three years, and five
shall serve terms of two years. Thereafter members shall serve
terms of four years and until their successors are appointed and
qualify. If a vacancy occurs on the board, the member must be
appointed in the manner of the original appointment for the
unexpired portion of the term. Members may serve two
consecutive four year terms; however, the initial appointees
only may serve one four year term following the expiration of
their initial term.
(E) The Governor shall
appoint a member of the board to serve as chairman of the board
and the board shall elect from its membership a vice chairman.
The board shall adopt rules for its governance and shall meet at
least once each quarter and at such other times as determined to
be necessary.
(F) Members of the
board are entitled to receive mileage, per diem, and subsistence
as provided by law for members of state boards, commissions, and
committees.
(G) Board members are
immune from liability in any suit at law or in equity for any
conduct performed in good faith and which is within the scope of
authority provided board members pursuant to this chapter.
Section 38-96-50. The
Governor shall appoint the Director of the Health Benefit
Exchange who shall serve as the chief executive officer of the
exchange. The director shall:
(1) administer all of
the exchange's activities and contracts;
(2) hire and supervise
the staff of the exchange;
(3) advise the board on
all matters related to the exchange.
Section 38-96-60. The
exchange has the authority to:
(1) promulgate
regulations necessary for the implementation and operation of
the exchange and the powers and duties provided pursuant to this
chapter.
(2) enforce all state
and federal laws and regulations concerning the exchange;
(3) apply for and
expend any state, federal, or private grant funds available to
assist with the implementation and operation of the
exchange;
(4) contract with any
and all vendors necessary to assist with the implementation and
operation of the exchange.
Section 38-96-70. The
exchange shall:
(1) implement
procedures for the certification, recertification, and
decertification of health benefit plans as qualified plans;
(2) provide for the
operation of a toll-free telephone hotline to receive and
respond to requests for assistance;
(3) provide for
enrollment periods;
(4) maintain an
Internet website through which enrollees and prospective
enrollees of qualified health plans may obtain standardized
comparative information on these plans and may enroll in these
plans;
(5) assign a rating to
each qualified health plan offered through the exchange and
determine each qualified health plan's level of coverage;
(6) use a standardized
format for presenting health benefit options in the
exchange;
(7) inform individuals
of eligibility requirements for the Medicaid program under Title
XIX of the Social Security Act, the Children's Health Insurance
Program (CHIP) under Title XXI of the Social Security Act, and
any applicable state or local public program; and if through
screening of the application by the exchange, the exchange
determines that any individual is eligible for any state or
local public program, shall refer that individual to the program
so that he or she may have access to enrollment in the
program;
(8) establish and make
available by electronic means a calculator to determine the
actual cost of coverage after application of any premium tax
credit under Section 36B of the Internal Revenue Code of 1986
and any state or federal cost-sharing reduction;
(9) facilitate the
purchase and sale of qualified health plans;
(10) establish a small
employer exchange through which qualified employers may access
coverage for their employees, which shall enable any qualified
employer to specify a level of coverage so that any of its
employees may enroll in any qualified health plan offered
through the small employer exchange at the specified level of
coverage;
(11) review the rate of
premium growth within the exchange and outside the exchange;
(12) receive and
process any federal or state tax credits or other premium
support payments for health insurance as may be provided for in
law;
(13) create advisory
committees to the board consisting of stakeholders relevant to
carrying out the activities required under this chapter;
(14) meet the
requirements of this chapter and fully comply with all
requirements established by state and federal law and
regulations.
Section 38-96-80. The
exchange may select entities to serve as consumer information
specialists to:
(1) conduct public
education activities to raise awareness of the availability of
qualified health plans;
(2) distribute fair and
impartial information concerning enrollment in qualified health
plans, the availability of premium tax credits under Section 36B
of the Internal Revenue Code of 1986, and any cost-sharing
reductions;
(3) facilitate
enrollment in qualified health plans; however, a person must not
receive any form of compensation as consideration for the
facilitation of enrollment of a person in a qualified health
plan through the exchange unless that person is an insurance
producer that is licensed by the Department of Insurance
pursuant to law;
(4) provide referrals
to licensed insurance producers to facilitate enrollment in
qualified health plans;
(5) provide referrals
to any applicable office of health insurance consumer assistance
or health insurance ombudsman or any other appropriate state
agency, for any enrollee with a grievance, complaint, or
question regarding their health benefit plan, coverage, or a
determination under that plan or coverage; and
(6) provide information
in a manner that is culturally and linguistically appropriate to
the needs of the population being served by the exchange.
Section 38-96-90. (A)
The exchange may contract with an eligible
entity to perform any of its functions described in this
chapter. An eligible entity includes, but is not limited to, an
entity that has experience in individual and small group health
insurance, benefit administration, or other experience relevant
to the responsibilities to be assumed by the entity, but a
health insurance carrier or an affiliate of a health insurance
carrier is not an eligible entity.
(B) The exchange may
enter into information-sharing agreements with federal and state
agencies and other state exchanges to carry out its
responsibilities under this chapter if these agreements include
adequate protections with respect to the confidentiality of the
information to be shared and comply with all state and federal
laws and regulations.
Section 38-96-100. (A)
The exchange shall make qualified health
plans available to qualified individuals and qualified employers
with effective dates commencing on January 1, 2014.
(B)(1) The exchange
must not make available any health benefit plan that is not a
qualified health plan.
(2)
The exchange may allow a health insurance carrier to offer
a plan that provides limited scope dental benefits meeting the
requirements of Section 9832(c)(2)(A) of the Internal Revenue
Code of 1986 through the exchange, either separately or in
conjunction with a qualified health plan, if the plan provides
pediatric dental benefits as may be provided for in
regulation.
(C) Neither the
exchange nor the carrier offering health benefit plans through
the exchange may charge an individual a fee or penalty for
termination of coverage if the individual enrolls in another
type of minimum essential coverage because the individual has
become newly eligible for that coverage or because the
individual's employer-sponsored coverage has become affordable
under the standards of Section 36B(c)(2)(C) of the Internal
Revenue Code of 1986.
Section 38-96-110. (A)
The exchange may charge assessments or user
fees to health insurance carriers or otherwise may generate
funding necessary to support its operation pursuant to this
chapter.
(B) The exchange shall
publish the average costs of licensing, regulatory fees, and any
other payments required by the exchange, and the administrative
costs of the exchange, on an Internet website to educate
consumers on these costs. This information must include
information on monies lost to waste, fraud, and abuse." /
Renumber sections to conform.
Amend title to conform.