South Carolina S 531: Healthcare Services

Bill Text

2025-2026 Bill 531 Text of Previous Version (Apr. 02, 2025) - South Carolina Legislature Online 

South Carolina General Assembly
126th Session, 2025-2026

Bill 531

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 SO AS TO ENACT 
THE "PATIENTS' RIGHT TO TRANSPARENCY AND TIMELY ACCESS TO HEALTHCARE SERVICES 
ACT"; BY ADDING SECTION 44-116-10 SO AS TO DEFINE NECESSARY TERMS; BY ADDING SECTION 
44-116-20 SO AS TO EXCLUDE CERTAIN HEALTHCARE PROVIDERS FROM PREAUTHORIZATION 
REQUIREMENTS WHO MEET A NINETY PERCENT THRESHOLD OF PREAUTHORIZATION REQUESTS 
FOR MEDICATIONS AND TREATMENTS DURING A PARTICULAR TIME PERIOD; BY ADDING 
SECTION 44-116-30 SO AS TO REQUIRE A FAIR AND TRANSPARENT PRIOR AUTHORIZATION 
PROCESS FOR MEDICATIONS AND TREATMENTS; BY ADDING SECTION 44-116-40 SO AS TO 
ESTABLISH TIMELINES FOR PREAUTHORIZATION DECISIONS; BY ADDING SECTION 44-116-50 
SO AS TO PROHIBIT ONGOING PRIOR AUTHORIZATION REQUIREMENTS FOR PATIENTS LIVING 
WITH CHRONIC CONDITIONS AFTER PRIOR AUTHORIZATION HAS BEEN PROVIDED UNDER 
CERTAIN CIRCUMSTANCES; BY ADDING SECTION 44-116-60 SO AS TO PROHIBIT INSURANCE 
COMPANIES FROM SWITCHING PHARMACEUTICALS DURING A POLICY YEAR; BY ADDING 
SECTION 44-116-70 SO AS TO ALLOW FOR STEP THERAPY EXCEPTIONS; BY ADDING SECTION 
44-116-80 SO AS TO PROVIDE THAT ONCE PRIOR AUTHORIZATION IS GRANTED, HEALTH 
CARRIERS MUST PAY FOR THE SERVICE WITH EXCEPTIONS; BY ADDING SECTION 44-116-90 
SO AS TO REQUIRE CONTINUITY OF CARE WHEN A PATIENT CHANGES INSURANCE POLICIES; 
BY ADDING SECTION 44-116-100 SO AS TO REQUIRE CERTAIN FILINGS FOR INSURANCE 
COMPANIES FOR TRANSPARENCY CONCERNING APPROVAL AND DENIAL RATES; AND BY ADDING 
SECTION 44-116-110 SO AS 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 Title 38, Chapter 51.

 (2) 
"Adverse determination" means a determination by a health carrier or its 
designee that an admission, availability of care, continued stay, or other 
health care 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 health care 
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 health care 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 health care services.

 (7) 
"Covered benefits" means those health care 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 auth