South Carolina

There are several sections of the state insurance law relevant to parity and another section about autism coverage. None of these sections apply to individual plans and only one section applies to behavioral health coverage for small employer fully-insured plans. The section for autism coverage only applies to large employer fully-insured plans and state employee plans.

The sections of the state insurance law relevant to parity requires large employer fully-insured plans to cover the following mental health conditions:

• Bipolar Disorder
• Major Depressive Disorder
• Obsessive Compulsive Disorder
• Paranoid and Other Psychotic Disorder
• Schizoaffective Disorder
• Schizophrenia
• Anxiety Disorder
• Post-traumatic Stress Disorder
• Depression in childhood and adolescence

For these conditions plans cannot have any financial requirements that are more expensive than those in place for treatment of other medical conditions. Deductibles and other out-of-pocketannual maximums or lifetime maximums for these conditions must be part of the same deductibles or out-of-pocket maximums that are in place for all other medical services.

For all other behavioral health conditions, if they are covered, plans cannot use annual maximums and lifetime maximums for behavioral health services or have annual limits and lifetime limits if they aren’t in place for other medical services. If a plan does have these in place for other medical services, they can do either of the following:

• Make it so that both behavioral health services and other medical services count towards combined limits and maximums

OR

• Make the limits and maximums for behavioral health services no less than the ones in place for other medical services

For plans that have many different limits and maximums for different categories of medical care, the law requires the Director of the South Carolina Department of Insurance to use a mathematical formula to decide what the limits and maximums should be for behavioral health services.

Plans must also make sure that financial requirements and treatment limitations for all behavioral health conditions are “no more restrictive” than those used for treatment of other medical conditions.

Plans can file for an exemption if their costs rise by two percent in the first year of providing this coverage or if costs increase by one percent in any other year.

Small employer fully-insured plans and exempted large employer fully-insured plans must offer optional behavioral health coverage to employers. The section of the law that applies to these plans specifically states that these plans can use different deductibles and coinsurance for behavioral health services than those used for other medical services.

These plans must have an annual maximum of $2,000 and a lifetime maximum of $10,000 for behavioral health services.

Unfortunately it is not possible to provide direct links to the specific sections in question because of the structure of South Carolina’s state website. To find the relevant section, go to this link. Here is how you can find the relevant sections:

– Scroll to 38-71-290 for the section that requires large employer fully-insured plans to cover certain mental health conditions
– Scroll to 38-71-880 for the section that requires large employer fully-insured plans that offer behavioral health coverage to meet certain standards
– Scroll to 38-71-737 for the section that applies to small employer fully-insured plans and exempted large employer fully-insured plans

The section of the state insurance law about autism coverage requires large employer fully-insured plans and state employee plans must cover autism services. This section of the law defines autism spectrum disorder as one of the following three conditions:

• Autistic disorder
• Asperger’s syndrome
• Pervasive developmental disorder not otherwise specified

Plans are required to cover a $50,000 annual maximum for behavioral therapy for children through age 15 (this section does not specifically call this applied behavior analysis ). However, children must be diagnosed with autism spectrum disorder before the age of 8. This can be adjusted for inflation each year.

Deductibles and coinsurance for autism services must be the same as those used for other medical services.

Insurance plans can only review a child’s treatment plan once every six months.

Unfortunately it is not possible to provide the direct link to this specific section because of the structure of South Carolina’s state website. To find the relevant section, go to this link and then scroll to 38-71-280.