South Carolina medical-plan questions focus on a short list of state mandates:

• Newborns and adopted children.
• Maternity and mastectomy stays.
• Mammograms and Pap smears.
• Prompt payment of health claims.
• Overpayment recovery and subrogation limits.

The general material (indemnity vs. managed care, HMOs and PPOs, cost sharing, HDHPs and HSAs, the ACA) is in the national Medical Plans guide.

Children

Newborns (38-71-140)

• A policy covering family members must cover a newborn from the moment of birth, including medically diagnosed congenital defects.
• If a specific premium is required, the insured gives notice of birth and pays within 31 days to continue coverage.

Adopted children (38-71-143)

• Covered the same as natural children, starting on placement, even before the adoption is final.

Disabled children (38-71-350, 38-71-780)

• Coverage continues past the limiting age for a child who can't support themself because of a disability, if proof is given within 31 days of reaching that age.

Other dependent rules (38-71-355, 38-71-360)

• When a non-disabled child ages off an individual medical policy, the child may buy an individual policy without evidence of insurability within 30 days.
• A dependent college student on a medically necessary leave may keep coverage for up to 1 year after the leave begins, or until coverage would otherwise end if sooner.

Mandated benefits

• Maternity: policies covering maternity must allow mother and newborn at least 96 hours in the hospital after a cesarean, not counting the day of surgery (38-71-135).
• Mastectomy:
  • At least 48 hours of hospital benefits after the surgery (38-71-125).
  • Breast reconstruction and prosthetic devices (38-71-130).
• Mammograms: women 50 and older get coverage at least once a year (38-71-145(E)).
• Pap smears: individual and group policies must cover annual Pap smears (38-71-145(A)).

Paying health claims (38-59-200 et seq.)

• Overpayments: except in cases such as suspected fraud, an insurer can't start recovering an overpayment from a provider more than 18 months after the provider was paid (38-59-250).
• Enforcement: the Department of Insurance enforces the prompt payment article.
• Subrogation: an A&H insurer's recovery against a liable third party is limited to the benefits it already paid (38-71-190).

Applications and underwriting

• A false statement bars recovery only if made with intent to deceive or if it materially affected acceptance of the risk (38-71-40).
• An insurer that doesn't deliver a copy of the application can't base a defense on it (38-71-30).
• Altering an applicant's written application without written consent is a misdemeanor (38-71-50).
• Living organ donors: a disability income insurer may not decline coverage solely because the applicant is a living organ donor (38-71-105).

Guaranty protection

• The South Carolina Life and Accident and Health Insurance Guaranty Association covers health benefit plans up to $500,000 per individual (38-29-40).

Common exam traps

• Prompt pay is counted in business days: 20 electronic, 40 paper.
• Overpayment look-back: 18 months.
• Newborns: covered from birth. The 31-day window is for notice and premium.
• C-section stay: 96 hours, not counting the day of surgery. Mastectomy: 48 hours.
• Mammograms: annual from 50.