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Indicates Matter Stricken
Indicates New Matter
AMENDED
May 18, 1999
H. 3928
S. Printed 5/18/99--S.
Read the first time May 11, 1999.
TO AMEND SECTION 38-33-50, AS AMENDED, CODE OF LAWS OF SOUTH CAROLINA, 1976, RELATING TO THE POWERS OF HEALTH MAINTENANCE ORGANIZATIONS, SO AS TO PROVIDE THAT THOSE POWERS INCLUDE THE OFFERING OF AN OUT-OF-NETWORK COVERAGE UNDER A POINT OF SERVICE OPTION, AND PROVIDE FOR THE PROMULGATION OF REGULATIONS; AND TO AMEND SECTION 38-33-80, AS AMENDED, RELATING TO THE PROVISION THAT EVERY ENROLLEE IN A HEALTH MAINTENANCE ORGANIZATION IS ENTITLED TO EVIDENCE OF COVERAGE, SO AS TO PROVIDE THAT FOR A POINT OF SERVICE OPTION OFFERED JOINTLY BY A HEALTH MAINTENANCE ORGANIZATION AND AN INSURER, ONLY ONE EVIDENCE OF COVERAGE IS REQUIRED.
Amend Title To Conform
Be it enacted by the General Assembly of the State of South Carolina:
SECTION 1. Section 38-33-50(A) of the 1976 Code is amended by adding:
"(8) the offering of an out-of-network coverage under a point of service option; the Director of the Department of Insurance shall, by regulations and/or policy bulletin, implement the provisions of this item."
SECTION 2. Section 38-33-80(A)(1) of the 1976 Code is amended to read:
"(1) Every enrollee is entitled to an evidence of coverage issued by the health maintenance organization. If any of the enrollee's benefits are provided through an insurance policy, the insurer shall issue a separate evidence of coverage for those benefits provided. However, for a point of service option offered jointly by a health maintenance organization and an insurer, only one evidence of coverage is required, as long as the benefits provided by each party are clearly identified therein."
SECTION 3. Section 38-33-20 of the 1976 Code is amended by adding an appropriately numbered subsection to read:
"(__) 'Employing entity' means a person employing one or more providers and agreeing to perform or provide a duty or function of the provider pursuant to this chapter, where the provider is prevented by contract with the employing entity or the employing entity's governing documents from performing such statutory duty or function individually. With respect to a statutory duty or function for which the employing entity acts for providers, an employing entity shall possess all corresponding rights and duties of its providers and shall be allowed to collectively satisfy such duty or function under this chapter as to all its providers (for example, by furnishing one hold harmless agreement and one participation agreement to a health maintenance organization on behalf of all the employing entity's providers)."
SECTION 4. Section 38-33-130(B) of the 1976 Code is amended to read:
"(B). Each health maintenance organization shall require every provider who participates in the health maintenance organization and furnishes health care services to the health maintenance organization's enrollees to execute an agreement not to bill the enrollees or otherwise hold the enrollees financially responsible for services rendered. Provided, an employing entity may execute one agreement on behalf of the employing entity and all of its providers. An employing entity may also execute one participation agreement and one of other similar required forms on behalf of the employing entity and all of its providers. The provider's agreement must be given on forms prescribed or approved by the director or his designee, shall extend to all services furnished to the enrollee during the time he was enrolled in the health maintenance organization, and shall apply even where the provider or employing entity had not been paid by the health maintenance organization."
SECTION 5. Chapter 71 of Title 38 is amended by adding the following:
"Section 38-71-46(A) On or after January 1, 2000, every health maintenance organization, individual and group health insurance policy or contract issued or renewed in this State shall provide coverage for the equipment, supplies, and outpatient self-management training and education for the treatment of people with diabetes mellitus, if medically necessary, and prescribed by a health care professional legally authorized to prescribe such items by law who demonstrates adherence to minimal standards of care for diabetes mellitus as adopted and published by the Diabetes Initiative of South Carolina.
(B) Services and payment for diabetes education programs shall conform to regulations of the Health Care Financing Administration, US Department of Health and Human Services, pursuant to Section 4105 of the Balanced Budget Act of 1997. Diabetes outpatient self-management training and education shall be provided by a registered or licensed health care professional with certification in diabetes by the National Certification Board of Diabetes Educators, or other accredited program approved by the Diabetes Initiative of South Carolina, or by the Diabetes Control Program of the SC Department of Health and Environmental Control in order to meet the needs of rural communities wherein certified health care professionals providing this service are not available.
(C) Nothing contained in this section may be construed to affect in any way the ability of a managed care plan to credential or re-credential a provider.
(D) For purposes of this section: 'Health insurance policy' means a health benefit plan, contract or evidence of coverage providing health insurance coverage as defined in Section 38-71-670(6) and Section 38-71-840(14)."
SECTION 6. This act takes effect upon approval by the Governor. Section 38-71-46 applies to all individual and group health insurance and health maintenance organization policies, as the case may be, issued, delivered, issued for delivery, or renewed in this State on or after January 1, 2000.
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