South Carolina has no DPC laws at present but multiple DPC practices are operating within the state, and House Bill 4643 has been introduced in the 2018 session. Be sure to review the South Carolina Insurance Code when planning your DPC practice. You will want to be certain that the design of your practice does not include any "transfer of risk" that would constitute insurance or arrange for basic health services that would result in it being defined as a health maintenance organization. Our thanks go out to Dee Carter, MD of Living Well Family Medicine for tackling an insurance commissioner inquiry about the design of her practice. This letter from the state insurance commissioner should prove useful to other DPC practices throughout the state. The insurance commissioner highlighted the following details when describing why her practice was permitted to proceed:
1) The services to be provided under the DPC agreement are limited to medical care provided by DPC physicians.
2) Monthly membership dues will be paid in arrears for access to the services under the agreement.
3) The agreement does not involve a risk transfer but rather operates as a payment to secure access to physician’s services.
4) The fact that this plan is not health insurance will be printed in bold type on the membership agreement signed by members and printed on materials associated with the program.
5) Program materials will not be distributed to insurance agents and no solicitation or contract will be made with insurance agents to promote program membership.
Helpful references include:
S.C. Code Ann § 38-1-20(25) "Insurance" means a contract where one undertakes to indemnify another or pay a specified amount upon determinable contingencies. The term "insurance" includes annuities.
S.C. Code Ann § 38-33-20(8) "Health maintenance organization" means a person who undertakes to provide or arrange for basic health care services to enrollees for a fixed prepaid premium.
S.C. Code Ann § 38-33-20(1) "Basic health care services" means emergency care, inpatient hospital and physician care, and outpatient medical services. It does not include dental services, mental health services, or services for alcohol or drug abuse, although a health maintenance organization at its option may elect to provide these services in its coverage.