South Carolina maintains a high-risk pool, called the South Carolina Health Insurance Pool or SCHIP, to provide insurance for residents of South Carolina with health conditions who are unable to by private health insurance and for people who are HIPAA eligible and TAA eligible.
When can I get health insurance from SCHIP?
- If you are HIPAA eligible, you can buy health insurance from the South Carolina Health Insurance Pool (SCHIP).
- If you are eligible for the federal health coverage tax credit (HCTC), you can buy health insurance from the South Carolina Health Insurance Pool (SCHIP).
- If you are not HIPAA eligible or eligible for HCTC, you can buy coverage from SCHIP if you have been a resident of South Carolina for at least 30 days and can demonstrate proof of eligibility. There are several different ways to show eligibility:
- o You have been turned down for coverage by at least one insurance company because of a health condition;
- o You are unable to find private coverage insurance that is cheaper than 150% of the cost of SCHIP health insurance;
- o You have been offered individual health insurance, but it contains a coverage reduction or exclusion for a pre-existing condition that exceeds 12 months.
You only need to show that you are eligible in one of these ways in order to get SCHIP coverage
To be HIPAA eligible, you must meet certain criteria
No matter where you live in the U.S., if you are HIPAA eligible you are guaranteed the right to buy individual health insurance of some kind with no pre-existing condition exclusion period. In South Carolina, you are only guaranteed the right to buy SCHIP coverage. To be HIPAA eligible, you must meet all of the following:
- You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
- You also must have used up any COBRA or state continuation coverage for which you were eligible.
- You must not be eligible for Medicare, Medicaid or a group health plan.
- You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage as you will be HIPAA eligible.)
- You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.
Federal eligibility ends when you enroll in an individual plan, because the last day of your continuous health coverage must have been in a group plan. You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.
- SCHIP does not offer family coverage. Each member of your family will have to qualify on his or her own.
What will health insurance from SCHIP cover?
- Health insurance purchased through SCHIP includes hospital and physician care, prescription drugs, maternity care, and other services. Total coverage is subject to a lifetime maximum of $1,000,000.
- SCHIP offers two cost sharing options. Under the 80/80 cost sharing option, the plan pays 80% of all in-network and out-of-network care with a $1,500 out-of-pocket maximum. Under the 80/60 cost sharing option, the plan pays 80% of in-network care with a $2,000 out-of-pocket maximum and 60% of out-of-network care with a $7,000 out-of-pocket maximum.
- Each cost sharing option requires a $500 deductible.
What about coverage for my pre-existing condition?
- If you are HIPAA eligible, you will not have a pre-existing condition exclusion when you enroll in the SCHIP.
- If you are not HIPAA eligible, you may have a 6-month pre-existing condition exclusion period when you first enroll in the SCHIP. When you enroll, SCHIP will look back 6 months to see if you had a condition for which you actually received a diagnosis, medical advice, or treatment- or for which most people would have sought-a diagnosis, medical advice, or treatment. Pregnancy can be considered a pre-existing condition.
- In limited situations, SCHIP will waive the pre-existing condition period if you had continuous coverage under another health plan.
If you satisfied similar exclusions under prior health insurance and 1) your previous health coverage was involuntarily terminated and you have no break in coverage; or 2) if the premium for your previous comparable health insurance was greater than 150% than the pool rate, then your prior coverage will count to waive the pre-existing condition exclusion period.
If you are eligible for SCHIP because you are eligible for the federal health coverage tax credit (HCTC) and you maintained 3 months of creditable coverage prior to applying, then you will not have a pre-existing condition exclusion period when you enroll in SCHIP.
What can I be charged for health insurance purchased through SCHIP?
- SCHIP premiums are limited to about twice the amount that a healthy person would pay if he or she bought a similar plan sold by a private insurer. Premiums will vary based on your age, gender, and the cost sharing option that you choose.
For example, the monthly premium for a 24 year old single man ranges from $347 to $438, depending on the cost sharing option he chooses. By contrast, the monthly premium for a 64 year old single man ranges from $1,322 to $1,668, depending on the cost sharing option he chooses.
- People who qualify for SCHIP because they were offered private coverage that costs more than 150% of the SCHIP premium must pay an additional 25% for the first six months.
How long does Health Insurance from SCHIP last?
- SCHIP policies are renewable as long as you pay your premiums, continue to reside in South Carolina at least six months of each calendar year, and meet other eligibility requirements.