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SC Health Insurance Risk Pool



The South Carolina Health Insurance Pool (SCHIP) was created by the South Carolina General Assembly by Act 127 of 1989 in order to make health insurance coverage available to residents of South Carolina who are either unable to obtain health insurance because of a medical condition or whose premium for health coverage exceeds 150% of the Pool rate. Senate Bill 287, which contains the amendments to SCHIP deemed necessary to make it an acceptable alternative mechanism under the provisions of section 2744(a)(1) of the Public Health Service Act, was signed into law by the Governor on March 31, 1997.

South Carolina chose to enhance the SCHIP so that it meets the requirements of an acceptable alternative mechanism. This is known as the State Alternative Mechanism (SAM). The SCHIP coverage is not an insurance policy nor is it a Blue Cross Blue Shield of South Carolina policy. The SCHIP coverage is administered by Blue Cross Blue Shield of South Carolina. You may contact the SCHIP Administrator at
803-788-0500 EXt 46401 (Columbia) or 800-868-2500, ext. 46401 (Outside Columbia).

1. I qualify under the Trade Adjustment and Assistance Act of 2002 (TAA), the Alternative Trade Adjustment and Assistance Act (ATAA) or the Pension Benefit Guaranty Corporation (PBGC) for the Health Coverage Tax Credit (HCTC). I am not currently a South Carolina resident. Am I eligible for the SCHIP coverage?

Yes. Anyone eligible for the HCTC is eligible for the SCHIP coverage.
2. I have been advised that I am a Federally Defined Eligible Individual or a Health Insurance Portability and Accountability Act (HIPAA) Eligible Individual. Am I eligible for the SCHIP coverage?Yes. A HIPAA Eligible Individual is a person who is guaranteed the right to purchase coverage under the SCHIP in which the waiting period and pre-existing condition exclusions are waived. In order to be guaranteed the right to purchase the SCHIP coverage you must meet the definition of a Federally Defined Eligible Individual.  A Federally Defined Eligible Individual means an individual:

(a) for whom, as of the date on which the individual seeks coverage under this chapter, the aggregate of the periods of creditable coverage is eighteen or more months;

(b) whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan or health insurance coverage offered in connection with one of these plans;

(c) who is not eligible for coverage under a group health plan, part A or part B of Title XVIII of the Social Security Act, or a state plan under Title XIX of the Social Security Act or any successor program and who does not have other health insurance coverage;

(d) with respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud;

(e) who, if offered the option of continuation coverage under a COBRA continuation provision or under a similar state program, elected the coverage; and

(f) who, if the individual elected the continuation coverage, has exhausted the continuation coverage under the provision or program.

3. I am a HIPAA Eligible Individual and do not want to continue my COBRA coverage. Am I eligible for the SCHIP coverage?No. You may apply for the SCHIP coverage only after your COBRA or State Continuation benefit period ends.

4. My previous coverage was terminated involuntarily. I have conditions that prevent me from getting health insurance. Am I eligible for the SCHIP coverage?Yes. A person whose health insurance coverage is terminated involuntarily for any reason other than nonpayment of premium may apply for coverage under the plan but shall submit proof of eligibility. If proof is supplied and if coverage is applied for within sixty days after the involuntary termination and if premiums are paid for the entire coverage period, the effective date of the coverage is the date of termination of the previous coverage. Waiting period and preexisting condition exclusions are waived to the extent to which similar exclusions, if any, have been satisfied under the prior health insurance coverage. The waiver does not apply to a person whose policy has been terminated or rescinded involuntarily because of a material misrepresentation.

5. I have Medicare Part A only. Am I eligible for the SCHIP coverage?

No. You are not eligible for the SCHIP coverage if at the time of pool application you are eligible for health care benefits under Medicare and age sixty-five or older.

I have both Medicare Parts A and B. Am I eligible for the SCHIP coverage?

No. You are not eligible for the SCHIP coverage if at the time of pool application you are eligible for health care benefits under Medicare and age sixty-five or older.

6. My premiums are very high for my coverage. The SCHIP coverage premiums are cheaper. Do I qualify for the SCHIP coverage?A person who is paying a premium for health insurance comparable to the pool plan in excess of one hundred fifty percent of the pool rate or who has received notice that the premium for a policy would be in excess of one hundred fifty percent of the pool rate may make application for coverage under the pool. The effective date of coverage is the date of the application, or the date that the premium is paid if later, and any waiting period or preexisting condition exclusion is waived to the extent to which similar exclusions, if any, were satisfied under the prior health insurance plan. Benefits payable under the pool plan are secondary to benefits payable by the previous plan. Please refer to the Comparison Rate Sheets attached. You will pay Table 2 rates for the first six months the policy is in effect. Starting with the seventh month of the SCHIP coverage, Table 1 rates will apply.

7. My company paid out the maximum benefits under my health insurance coverage. Am I eligible for the SCHIP coverage?

Yes. You are eligible for the SCHIP coverage once your maximum benefits have been paid under the coverage. Once enrolled in SCHIP you will not have a 6 month pre-existing waiting period.
8. My company has maximum limits under the policy for benefits for certain conditions. I have reached the maximum benefit for one of these conditions. Am I eligible for the SCHIP coverage?

No. You are eligible for the SCHIP coverage once your maximum benefits for all conditions have been paid under the coverage. Once enrolled in SCHIP you will not have a 6 month preexisting waiting period.

Disclaimer:

These sample questions are only examples and the final determination regarding your eligibility will be determined by the SCHIP Administrator.

* Table 1 rates apply if the applicant:Has never had previous health insurance. The applicant will have a six month waiting period or pre-existing condition exclusion. Is a Federally Defined Eligible Individual a TAA, ATAA or PBGC Qualified Individual. Any waiting period or preexisting condition exclusion is waived to the extent to which similar exclusions, if any, were satisfied under the prior health insurance plan.

* Table 2 rates apply if the applicant:

Is paying a premium greater than 150% of the base rates for the SCHIP coverage (see the Comparison Rate Sheets). The Table 2 rates will apply for the first six months only. As of the seventh month of coverage, Table 1 rates will apply. Any waiting period or preexisting condition exclusion is waived to the extent to which similar exclusions, if any, were satisfied under the prior health insurance plan.
* Comparison Rate SheetsIf the monthly premium you are currently paying for your personal health insurance is equal to or greater than the comparison rates listed, you may be eligible for the SCHIP coverage. The comparison rates ARE NOT the premiums you will be paying if you are approved for the SCHIP coverage.

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