Key Takeaways
- South Carolina Department of Insurance (SCDOI) regulates health insurance
- South Carolina uses the federally-facilitated exchange (HealthCare.gov)
- Pre-existing condition exclusions are prohibited in individual and small group markets
- Guaranteed renewability protects consumers from arbitrary cancellations
- Essential health benefits are required in ACA-compliant plans
Last updated: January 2026
South Carolina Health Insurance Policy Requirements
South Carolina has comprehensive health insurance regulations under Title 38 of the South Carolina Code of Laws.
Regulatory Structure
South Carolina health coverage is regulated by:
| Agency | Responsibility |
|---|---|
| South Carolina Department of Insurance (SCDOI) | Regulates all health insurance |
| Life, Accident & Health Division | Oversees policy forms and rates |
| HealthCare.gov | Federal marketplace for enrollment |
Department of Insurance Role
The SCDOI:
- Reviews and approves policy forms and rates
- Licenses insurance producers and companies
- Handles consumer complaints
- Enforces insurance laws and regulations
Health Insurance Marketplace
South Carolina uses the federally-facilitated exchange (HealthCare.gov):
Key Features
- Federal marketplace for individual health insurance
- Premium tax credits available for qualifying applicants
- Plans certified as Qualified Health Plans (QHPs)
- Multiple private insurers participate
Enrollment Periods
- Annual open enrollment each fall
- Special enrollment for qualifying life events
- Financial assistance based on income
Consumer Rights
South Carolina provides health insurance consumer protections:
Guaranteed Renewability
Insurers may not cancel a health plan unless:
- Beneficiary fails to pay premiums
- Fraud or misrepresentation
- Insurer stops doing business in the market
Pre-Existing Condition Protections
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited (ACA plans) |
| Small Group | Prohibited (ACA plans) |
| Large Group | Limited to 12 months maximum |
Required Coverage
South Carolina ACA-compliant plans must cover Essential Health Benefits:
Essential Health Benefits
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
State-Specific Requirements
South Carolina also requires or regulates:
- Mental health parity
- Mammography screening coverage
- Diabetes coverage and supplies
- Emergency services coverage
Rate Review
South Carolina requires rate review for health insurance:
- All ACA plan rates must be submitted for review
- Rate increases over 10% require public justification
- SCDOI reviews for compliance with law
Filing Requirements
Insurance companies must:
- Submit all rate and form filings through SERFF
- Provide justification for rate changes
- File separately by insurer and line of business
- Obtain approval before use in South Carolina
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Test Your Knowledge
Which marketplace does South Carolina use for individual health insurance enrollment?
A
B
C
D
Test Your Knowledge
Can a South Carolina health insurer cancel coverage for a pre-existing condition in the individual market?
A
B
C
D