South Carolina H 4562: Healthcare Services

Bill Text

2025-2026 Bill 4562 Text of Previous Version (May. 08, 2025) - South Carolina Legislature Online 

South Carolina General Assembly
126th Session, 2025-2026

Bill 4562

Indicates Matter Stricken
Indicates New Matter

(Text matches printed bills. Document has been reformatted to meet World Wide Web specifications.)

A bill

TO AMEND THE SOUTH 
CAROLINA CODE OF LAWS BY ENACTING THE "PATIENTS' RIGHT TO TRANSPARENCY AND 
TIMELY ACCESS TO HEALTHCARE SERVICES ACT" BY ADDING CHAPTER 116 TO TITLE 44 SO 
AS TO DEFINE NECESSARY TERMS; TO EXCLUDE CERTAIN HEALTHCARE PROVIDERS FROM 
PREAUTHORIZATION REQUIREMENTS WHO MEET AN EIGHTY PERCENT THRESHOLD OF 
PREAUTHORIZATION REQUESTS FOR MEDICATIONS AND TREATMENTS DURING A PARTICULAR 
TIME PERIOD; TO REQUIRE A FAIR AND TRANSPARENT PRIOR AUTHORIZATION PROCESS FOR 
MEDICATIONS AND TREATMENTS; TO ESTABLISH TIMELINES FOR PREAUTHORIZATION 
DECISIONS; TO PROHIBIT ONGOING PRIOR AUTHORIZATION REQUIREMENTS FOR PATIENTS 
LIVING WITH CHRONIC CONDITIONS AFTER PRIOR AUTHORIZATION HAS BEEN PROVIDED 
UNDER CERTAIN CIRCUMSTANCES; TO PROHIBIT INSURANCE COMPANIES FROM SWITCHING 
PHARMACEUTICALS DURING A POLICY YEAR; TO ALLOW FOR STEP THERAPY EXCEPTIONS; TO 
PROVIDE THAT ONCE PRIOR AUTHORIZATION IS GRANTED, HEALTH CARRIERS MUST PAY FOR 
THE SERVICE WITH EXCEPTIONS; TO REQUIRE CONTINUITY OF CARE WHEN A PATIENT 
CHANGES INSURANCE POLICIES; TO REQUIRE CERTAIN FILINGS FOR INSURANCE COMPANIES 
FOR TRANSPARENCY CONCERNING APPROVAL AND DENIAL RATES; AND TO PROVIDE FOR 
ENFORCEMENT OF THE CHAPTER.

Be it enacted by the 
General Assembly of the State of South Carolina:

SECTION 1. This act may be cited as the "Patients' Right to Transparency and Timely 
Access to Healthcare Services Act."

SECTION 2. Title 44 of the S.C. Code is amended by adding:

CHAPTER 116

Patients' Right to Transparency and Timely Access to 
Healthcare Services

 Section 
44-116-10. For the purposes of this chapter:

 (1) 
"Administrators of insurance benefit plans" means an administrator licensed 
pursuant to Chapter 51, Title 38.

 (2) 
"Adverse determination" means a determination by a health carrier or its 
designee that an admission, availability of care, continued stay, or other 
healthcare service that is a covered benefit has been reviewed and, based upon 
the information provided, does not meet the health carrier's requirements for 
medical necessity, appropriateness, healthcare setting, level of care, or 
effectiveness; or is experimental or investigational and involves a condition 
that is life-threatening or seriously disabling, and the requested service or 
payment for the service is, therefore, denied, reduced, or terminated.

 (3) 
"Authorization" means a determination by a health carrier or its designee that 
an admission, availability of care, continued stay, or other healthcare service 
has been reviewed and, based on the information provided, is a covered benefit 
and satisfies the health carrier's requirements for medical necessity and 
appropriateness and that payment will be made for that healthcare service.

 (4) 
"Authorized representative" means a person to whom a covered person has given 
express written consent to represent the covered person, a person authorized by 
law to provide substituted consent for a covered person, or a family member of 
the covered person, or, when the covered person is unable to provide consent, the 
covered person's treating healthcare professional.

 (5) "Chronic 
health condition" means a physical or mental condition that is expected by a 
patient's treating physician to last one year or more and that requires ongoing 
medical attention to effectively manage or prevent an adverse health event from 
or that limits one or more activities of daily living.

 (6) 
"Clinical review criteria" means the written clinical policies, written 
clinical screening procedures, drug formularies, or lists of covered drugs, 
determination rules, determination abstracts, clinical protocols, practice 
guidelines, medical protocols, and any other criteria or rationale used by the 
health carrier or its designee to determine the necessity and appropriateness 
of healthcare services.

 (7) 
"Covered benefits" means those healthcare services to which a covered person is 
entitled under the terms of a health benefit plan.

 (8) 
"Covered person" means an insured, subscriber, enrollee, or other individual 
entitled to covered benefits under a health benefit plan.

 (9) 
"Designee" means an entity, including an administrator of insurance benefit 
plans, pharmacy benefit managers, or a utilization review entity that performs 
utilization review, including prior authorization and step therapy, on behalf 
of a health carrier or other organization providing a health benefit plan.

 (10) 
"Effectiveness" means a determination based on clinical considerations, not based 
on cost determination.

 (11) 
"Emergency medical care" means healthcare services provided in an emergency 
facility to evaluate and treat a