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H. 5036
STATUS INFORMATION
General Bill
Sponsors: Rep. Scarborough
Document Path: l:\council\bills\dka\3850dw08.doc
Companion/Similar bill(s): 1104
Introduced in the House on April 16, 2008
Currently residing in the House Committee on Labor, Commerce and Industry
Summary: Insurance policies
HISTORY OF LEGISLATIVE ACTIONS
Date Body Action Description with journal page number
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4/16/2008 House Introduced and read first time HJ-8
4/16/2008 House Referred to Committee on Labor, Commerce and Industry
HJ-8
View the latest legislative information at the LPITS web site
VERSIONS OF THIS BILL
TO AMEND THE CODE OF LAWS OF SOUTH CAROLINA, 1976, BY ADDING SECTION 38-71-242 SO AS TO PROVIDE FOR THE DEFINITION OF THE TERMS "ACTUAL CHARGE", "ACTUAL CHARGES", "ACTUAL FEE", OR "ACTUAL FEES" AND "PAYMENT IN FULL" WHEN USED IN AN INDIVIDUAL OR A GROUP SPECIFIED DISEASE INSURANCE POLICY AND TO REQUIRE THAT AN INSURER OR ISSUER OF AN INDIVIDUAL OR A GROUP SPECIFIED DISEASE INSURANCE POLICY MAY NOT PAY ANY CLAIM OR BENEFITS UNDER THE APPLICABLE POLICY IN AN AMOUNT IN EXCESS OF ACTUAL CHARGE OR ACTUAL FEE AS DEFINED.
Be it enacted by the General Assembly of the State of South Carolina:
SECTION 1. Chapter 71, Title 38 of the 1976 Code is amended by adding:
"Section 38-71-242. (A) As used in this section:
(1) 'Actual charge', 'actual charges', 'actual fee', or 'actual fees', when used in an individual or a group specified disease insurance policy in connection with the benefits payable for services rendered by a health care provider or other designated person or entity, mean the amount that the health care provider or other designated person or entity:
(a) agreed to accept, pursuant to a network or other participation agreement with a health insurer, third-party administrator, other third-party payor, or other person, including the insured, as payment in full for the goods or services provided to the insured; or
(b) agreed or is obligated by operation of law to accept as payment in full for the goods or services provided to the insured pursuant to a provider, participation or supplier agreement under Medicare, Medicaid, or any other government administered health care program, where the insured is covered or reimbursed by this program.
(2) 'Payment in full' includes the portion of the actual charge, actual charges, actual fee, or actual fees, that was actually paid for the health care provider's goods or services on behalf of the insured by Medicare, Medicaid, any other government administered health care program, any other health insurer, third-party administrator; or other third party payor, and, where applicable, any remaining portion of the actual charge, actual charges, actual fee, or actual fees that was applied or assessed against the insured by Medicare, Medicaid, any other government administered health care program, any other health insurer, third party administrator, or other third party payor for any applicable deductibles, co-insurance requirements, or co-pay requirements.
(B) If both subitems (a) and (b) of Section (A)(1) apply, the actual charge, actual charges, actual fee, or actual fees must be the lesser of the amounts determined under the two subitems.
(C) This section applies to an individual or a group specified disease insurance policy issued to any resident of this State that contains the terms actual charge, actual charges, actual fee, or actual fees without containing an express definition for the term.
(D) Notwithstanding another provision of law, after the effective date of this section, an insurer or issuer of an individual or a group specified disease insurance policy may not pay a claim or benefits based upon an actual charge, actual charges, actual fee, or actual fees under the applicable policy in an amount in excess of the actual charge, actual charges, actual fee, or actual fees as defined in this section."
SECTION 2. If any section, subsection, item, subitem, paragraph, subparagraph, sentence, clause, phrase, or word of this act is for any reason held to be unconstitutional or invalid, such holding shall not affect the constitutionality or validity of the remaining portions of this act, the General Assembly hereby declaring that it would have passed this chapter, and each and every section, subsection, item, subitem, paragraph, subparagraph, sentence, clause, phrase, and word thereof, irrespective of the fact that any one or more other sections, subsections, paragraphs, subparagraphs, sentences, clauses, phrases, or words hereof may be declared to be unconstitutional, invalid, or otherwise ineffective.
SECTION 3. This act takes effect upon approval of the Governor.
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