Policy Options

1. South Carolina Small Employer Health Plan Option

The goal of this program is to provide a state-wide small employer coverage option that will cover all of the employees in a group, subsidize the premium for covered individuals/families under 150% FPL and does not look like a public program. The benefit plan is limited, but still covers the basic health care services used by the average South Carolinian. Premiums will be kept at an affordable level for the employer and employee, allowing currently uninsured individuals to have access to health care. In addition, the program will provide reimbursement for provider services that has not previously been available from this uninsured population.

Eligibility

Employers with 1 to 100 employees must have:

• A South Carolina business license and a physical address in South Carolina
• No previous group coverage in the previous 6 months
• An average income limit TBD
• Employees with South Carolina residency
• Employees who are ineligible for Medicaid
• Employees who work an average of 25 hours per week

Plan Design

The plan design was created to keep costs at $1,000 per year, with one-third paid by existing federal money, one-third paid for by federal match, and one-third paid by the employer/employee. The benefit plan is based on average utilization by services by the SC Employee plan (Year 2002/individuals under 65). The proposed South Carolina Base Benefit Plan (per year per covered member) includes:

• 1 hospitalization
• Unlimited ER visits if approved by a physician
• Twelve physician visits/Managed medical home required
• Four prescriptions per month
• Mandatory generic prescriptions must be filled at 340B entities
• Mail order available for maintenance drugs
• Covered well-childcare visits (EPSDT)
• Short-term therapy (PT/OT/ST) limited to 20 visits at 50% coinsurance
• Required reinsurance

Funding

Application will be made for a Section 1115 waiver.

Supporting Data

• 60% of the uninsured are hard working citizens of South Carolina

Why They Are Not Insured Through Private Insurance Plans:

• 72% of the uninsured list affordability as the reason they have not purchased health insurance.
• 38% of the uninsured who are eligible for an employer-sponsored plan listed affordability as the reason they were not enrolled.
• 68% of small employers with 1 - 10 employees do not offer group-sponsored health insurance to their employees.
• 9% of small employers with 11 - 20 employees do not offer group-sponsored health insurance to their employees.
• 5% of small employers with 21 - 50 employees do not offer group-sponsored health insurance to their employees.
• 17% of small employers with 51 - 100 employees do not offer group-sponsored health insurance to their employees.

Why They Are Not Covered Through Public Programs:

• 50% of eligible individuals do not enroll in public programs because they do not want to receive government support or don't want government to provide health coverage.

2. Health Care Utilization Education Programs

The goals of this policy option are (1) to develop educational programs that educate South Carolinians to be good healthcare consumers and (2) teach appropriate utilization of healthcare services and providers.

To aid in these goals, the project will include a website that supports education and provides appropriate information on access and eligibility to small employers, employees, and citizens of South Carolina.

TBD based on existing programs, community and statewide needs, partners (hospitals, community health programs, schools, business, etc.).

3. South Carolina Community Health Plan Partnership

The goal of this policy option is to allow existing and new non-profit community based health care programs to raise funds through prepayment fees to assist uninsured patients in obtaining access to affordable health care. In addition, these pre-payment fees can be used to increase provider reimbursement and/or increase the number of patients served by the community health entity.

Eligibility

• Individuals must be uninsured
• Not eligible for Medicaid, Medicare or any other existing public or private program
• Income level restriction TBD

Plan Design

The plan will be flexible, allowing communities to determine fees, benefit plans, networks, etc.

Supporting Data

29% of the uninsured are not employed.

Why Are They Uninsured?

A few of these individuals may be eligible for Medicaid, but not enrolled. More than likely these individuals are between jobs and cannot afford COBRA or state continuation. Our safety net providers now serve many of the uninsured, who are not eligible for Medicaid.