South Carolina health-insurance questions blend national medical-plan design with a layer of South Carolina-specific continuation, conversion, and mandated-benefit rules. This guide reviews the building blocks every health agent needs—plan types and cost-sharing—then makes the South Carolina overlay the spine: the state's group continuation for smaller employers, the conversion privilege, Medicaid through SCDHHS, and the policy provisions the South Carolina Department of Insurance enforces.

The national base: types of medical plans

Most health questions begin with how a plan balances cost, choice, and network:

• Indemnity / fee-for-service — pays a share of covered charges with broad provider choice; now uncommon.
• HMO (Health Maintenance Organization) — lowest cost, network-only care through a primary care physician (PCP) gatekeeper with referrals to specialists; often uses capitation (a set payment per member per period).
• PPO (Preferred Provider Organization) — a network with lower in-network cost but out-of-network access at a higher cost share, usually without referrals.
• EPO (Exclusive Provider Organization) — network-only like an HMO but typically no PCP/referral requirement.
• POS (Point of Service) — a hybrid using a PCP gatekeeper like an HMO while allowing out-of-network care like a PPO, with the choice made at the time of service.

Universal cost-sharing terms apply across all designs: the premium (what you pay to have coverage), the deductible (paid before the plan shares), the copay (a flat per-visit charge), coinsurance (a percentage split after the deductible), and the out-of-pocket (OOP) maximum (the annual cap after which the plan pays 100% of covered, in-network care). A health savings account (HSA) must be paired with a qualified high-deductible health plan. Coordination of benefits prevents an insured from collecting more than 100% of covered expenses across multiple plans. Coverage is sold group (employer-sponsored, group-underwritten, lower cost) versus individual (bought directly, now guaranteed issue under federal law).

The ACA floor (federal minimums)

The Affordable Care Act sets a national floor every South Carolina plan must meet:

• Guaranteed issue — insurers cannot decline an applicant for health reasons.
• No health rating — premiums vary only by age, geography, tobacco use, and family size, not health status.
• Pre-existing conditions covered — no exclusions or waiting periods for prior conditions.
• Essential health benefits — ten required categories (e.g., hospitalization, maternity, prescriptions, mental health, preventive care).
• Dependents to age 26 — adult children may stay on a parent's plan.

South Carolina builds on top of this floor; it does not subtract from it. For the ACA marketplace, South Carolina relies on the federal exchange (HealthCare.gov) rather than operating its own state-based exchange—verify the current status.

South Carolina mandated benefits

Like every state, South Carolina requires insured (non-self-funded) health plans to include certain state-mandated benefits that often exceed the federal minimum. Treat these by category rather than memorizing dollar caps, which change:

• Mental health and substance use coverage consistent with parity rules.
• Mammography and other cancer screenings; childhood immunizations.
• Maternity and newborn care, including a newborn covered from the moment of birth (subject to notice).
• Diabetes self-management, supplies, and education.

Self-funded ERISA plans are generally exempt from state mandates—a common exam distinction.

South Carolina group continuation

Federal COBRA applies to employers with 20 or more employees and allows continuation generally up to 18 months (or 36 months for certain events such as divorce, death, or a dependent aging out). South Carolina fills the gap below the federal threshold with its own group continuation law for smaller employers:

• Who: employees of smaller employers (generally those not subject to federal COBRA) who would otherwise lose group coverage.
• Eligibility: generally requires a period of prior continuous coverage (verify the current figure).
• How long: South Carolina continuation runs for a limited period (commonly cited as several months—verify the current duration).
• Cost: the participant generally pays the full premium themselves.
• Notice/election: the employee must elect within the statutory window after notice of the right.

The exam loves the size split: 20+ employees → federal COBRA; smaller employers → South Carolina state continuation. Confirm the exact employee threshold and durations, which can change.

Conversion privilege

Separate from continuation, South Carolina group health coverage generally carries a conversion privilege. When group coverage (or continuation) ends, the insured may convert to an individual policy on a guaranteed-issue basis—without new evidence of insurability. Conversion coverage may offer narrower benefits, but it preserves access. On the exam, distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy).

South Carolina Medicaid and the marketplace

• Medicaid in South Carolina is administered by the South Carolina Department of Health and Human Services (SCDHHS)—the income- and resource-based public program (distinct from Medicare). SCDHHS, not the Department of Insurance, runs Medicaid. The program is often marketed in South Carolina as "Healthy Connections."
• The ACA marketplace for South Carolina operates through HealthCare.gov (federal platform)—verify the current operational status.

Required policy provisions and timelines

The South Carolina Department of Insurance enforces standard health-policy provisions, including:

• Grace period — extra time to pay a late premium before the policy lapses; its length commonly varies by the premium payment mode (weekly, monthly, annual).
• Free look — a window to return an individual policy for a full refund; the exact figure should be verified (Medicare supplement policies commonly use 30 days).
• Time limit on certain defenses / incontestability — after the policy has been in force the stated period, the insurer generally cannot contest it for misstatements (except as allowed for fraud).
• Prompt-pay / time of payment of claims — insurers must pay clean claims within set timeframes.
• Guaranteed renewable vs. noncancelable — guaranteed renewable policies must be renewed (premiums may change only by class), while noncancelable policies also lock the premium.

Key South Carolina numbers to memorize

Common exam traps

• Confusing COBRA and state continuation. Federal COBRA = 20+ employees; South Carolina continuation reaches smaller employers.
• Mixing up continuation and conversion. Continuation keeps the group plan temporarily; conversion moves to an individual policy with no new evidence of insurability.
• Sending Medicaid questions to the Department of Insurance. South Carolina Medicaid is run by SCDHHS.
• Assuming the ACA floor can be undercut. Guaranteed issue, no health rating, and pre-existing coverage are federal minimums South Carolina cannot reduce.
• Asserting exact mandate caps, free-look days, or durations. Treat figures as statutory and subject to change—hedge and verify.
• Forgetting self-funded ERISA plans are usually exempt from state mandates.

Quick recap

South Carolina medical-plan questions start with national design—HMO, PPO, EPO, POS, and indemnity—and the universal cost-sharing terms (premium, deductible, copay, coinsurance, OOP max), plus the ACA floor: guaranteed issue, no health rating, pre-existing coverage, essential health benefits, and dependents to age 26. The South Carolina overlay is the spine: state continuation for smaller employers (where federal COBRA's 20+ rule does not reach), a conversion privilege to individual coverage on a guaranteed-issue basis, Medicaid through SCDHHS, and the HealthCare.gov marketplace. Round it out with required provisions the Department of Insurance enforces—grace period, free look, incontestability, and prompt-pay—verify any specific number, and the South Carolina health section becomes manageable.