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TO AMEND CHAPTER 71 OF TITLE 38, 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" OR "ACTUAL FEE" WHEN USED IN INDIVIDUAL OR GROUP SPECIFIED DISEASE INSURANCE POLICIES AND TO REQUIRE THAT NO INSURER OR ISSUER OF ANY INDIVIDUAL OR GROUP SPECIFIED DISEASE INSURANCE POLICY PAY ANY CLAIM OR BENEFITS UNDER THE APPLICABLE POLICY IN AN AMOUNT IN EXCESS OF ACTUAL CHARGE OR ACTUAL FEE AS DEFINED.
SECTION 1. Chapter 71, Title 38 of the 1976 Code is amended by adding:
"Section 38-71-242. (A) The terms 'actual charge' or 'actual fee,' when used in any individual or group specified disease insurance policy in connection with the benefits payable for services rendered by any health care provider or other designated person or entity, shall mean the amount that the health care provider or other designated person or entity:
(1) agreed to accept, pursuant to a network or other participation agreement with a health insurer, third-party administrator, other third-party payor, or any other person, including the insured, as payment in full for the goods or services provided to the insured; or
(2) 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 such program.
(B) In the event that both items (1) and (2) of subsection (A) apply, the 'actual charge ' or 'actual fee' shall be the lesser of the amounts determined under the two clauses.
(C) This section applies to any individual or group specified disease insurance policy issued to any resident of this State if the policy does not contain an express definition for 'actual charge' or 'actual fee.'
(D) Notwithstanding any other provision of law, after the effective date of this section, no insurer or issuer of any individual or group specified disease insurance policy shall pay any claim or benefits under the applicable policy in an amount in excess of actual charge or actual fee 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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