Health insurance in South Carolina
- Open enrollment for 2019 coverage in South Carolina ended on December 15, but BCBSSC is allowing people to enroll off-exchange until December 31.
- Enrollment is still possible for residents who have qualifying events.
- Short-term health plans are available in South Carolina with initial plan terms up to 11 months.
- Ambetter has joined Blue Cross Blue Shield of South Carolina in the exchange for 2019.
- BCBSSC’s average rates are 5.26% higher for 2019.
- Nearly 185,000 people had coverage in South Carolina’s exchange in 2018.
- Uninsured rate at 11 percent in 2017, versus national average of 8.7 percent.
- The majority of South Carolina lawmakers are Republicans opposed to the ACA, although Joe Cunningham has flipped the 1st Congressional District.
- South Carolina has not expanded Medicaid, leaving 92,000 people in a coverage gap.
- More than a million people – 20 percent of South Carolinians – are Medicare enrollees.
South Carolina health insurance at a glance
As of mid-2018, there were nearly 185,000 people enrolled in effectuated individual-market health insurance plans through South Carolina’s exchange. As is the case nationwide, the vast majority of the state’s population does not have individual market coverage – most people have employer-sponsored insurance or government-provided coverage (Medicare, Medicaid, CHIP, etc.)
South Carolina’s federally facilitated exchange had only one carrier offering 2018 health insurance coverage (Blue Cross and Blue Shield of South Carolina), but Ambetter (Absolute Total Care) has joined the exchange for 2019, offering plans in Charleston County. Off-exchange, there are three insurers (BCBSSC and Ambetter, along with Blue Choice Health Plan), which is down from six carriers that offered individual market plans off-exchange in 2017.
Of South Carolina’s exchange enrollees, 93 percent received premium subsidies in 2018. HHS estimated in 2016 that there were 21,000 people with off-exchange plans who would be subsidy-eligible if they switched to exchange plans.
Off-exchange plans are not eligible for Obamacare subsidies, so they’re really only a suitable alternative for people who wouldn’t otherwise qualify for premium subsidies and/or cost-sharing subsidies (premium subsidies extend up to 400 percent of the poverty level; for a family of four in 2019, that’s $100,400. This amount increases each year, to keep pace with the federal poverty level; 2019 is the first year that a family of four earning six figures is eligible for premium subsidies).
Open enrollment for 2019 coverage in the individual major medical market (both on- and off-exchange) ended December 15, 2018, as was the case in all states that use HealthCare.gov. But Blue Cross Blue Shield of South Carolina is allowing people to enroll in their plans, outside the exchange, until December 31, 2018. No financial assistance is available when people enroll outside the exchange. Blue Choice, which only offers plans outside the exchange, is also allowing people additional time to enroll in plans for 2019.
But in the exchange, individual market coverage for 2019 is now only available to people who experience a qualifying event. (Native Americans can enroll in individual-market plans year-round, however.)
And Medicaid/CHIP enrollment also continues year-round for people who are eligible. South Carolina has not expanded Medicaid under the Affordable Care Act, which means the state’s pre-ACA eligibility guidelines still apply.
South Carolina fares poorly in overall health ratings
South Carolina ranked 41st out of the 50 states and District of Columbia by The Commonwealth Fund’s Scorecard on State Health System Performance in 2017, which was unchanged from their ranking in 2015. The state was scored on health indicators related to five measures: Access, Prevention & Treatment, Avoidable Hospital Use & Costs, Healthy Lives, and Equity.
The 2017 edition of America’s Health Rankings placed South Carolina squarely in the bottom quartile, at 44th out of the 50 states in terms of overall health.
2019 SC health insurance carriers
Blue Cross and Blue Shield of South Carolina was the only carrier offering exchange plans in South Carolina in 2018, and for most of the state, that continues to be the case for 2019. But in Charleston County, Ambetter from Absolute Total Care is offering plans for 2019.
For 2019, average premiums in the South Carolina exchange increased by 5.26 percent (before premium subsidies are applied). That only applies to BCBSSC plans, since Ambetter’s plans are new for 2019 and thus have no applicable rate increase. For off-exchange BlueChoice plans, the average approved rate increase was just 3.22 percent.
Rates for BCBS of South Carolina plans sold through the state’s federally facilitated exchange increased an average of 31 percent for 2018, but most of that was due to the Trump Administration’s decision to eliminate federal funding for cost-sharing reductions (CSR). The cost of CSR is now being added to silver plan premiums, which makes plans at other metal levels particularly affordable for enrollees who qualify for premium subsidies.
Aetna (Coventry), BlueChoice, and UnitedHealthcare previously offered plans through South Carolina’s exchange but did not return for 2017. Blue Choice continues to offer coverage outside the exchange (as does BCBSSC), but the other individual market insurers left the state altogether.
How has Obamacare helped SC?
According to US Census data, the uninsured rate in South Carolina dropped from 15.8 percent in 2013 to 10 percent in 2016. The nation’s average dropped from 14.5 percent to 8.6 percent in the same time period. But while the national average uninsured rate increased slightly in 2017 (after the Trump Administration took office), to 8.7 percent, it increased more significantly in South Carolina, to 11 percent.
South Carolina leadership’s opposition to the ACA means the state has thus far refused to expand Medicaid, so a cornerstone of the law’s ability to reduce the uninsured rate is not being utilized. A Kaiser Family Foundation analysis estimates that there are 92,000 people in the coverage gap as a result of South Carolina’s refusal to accept federal funding to expand Medicaid.
But the ACA has made comprehensive individual market coverage more affordable for South Carolina families with income between the poverty level and 400 percent of the poverty level. Nearly 185,000 South Carolina residents were receiving premium subsidies in 2018 that amounted to an average of $582/month. After the subsidies, those enrollees had average net health insurance premiums of just $72/month.
South Carolina qualified health plan enrollment
In November 2013, the Kaiser Family Foundation estimated that 491,000 people could potentially buy qualified health plans (QHPs) through South Carolina’s health insurance exchange, and that 336,000 of them would qualify for premium subsidies.
By mid-2018, in the fifth year of exchange operation, a total of 184,980 people had effectuated coverage under private plans through South Carolina’s exchange. Of those individuals, 93 percent were receiving premium subsidies that covered the majority of their premium costs.
South Carolina and the Affordable Care Act
In 2018, South Carolina’s US congressional delegation is comprised almost entirely of Republicans. The GOP has both Senate seats, and six of the seven US representatives are Republican. Rep. Jim Clyburn, from the 6th District, is the lone Democrat. But Joe Cunningham, a Democrat, won an upset victory in District 1, in the 2018 election, so South Carolina’s House delegation will have two Democrats as of 2019. Cunningham, like Clyburn, supports the ACA. But he also wants to lower the Medicare eligibility age to 55, allow Medicare to negotiate with drug manufacturers, and limit skimpy policies like short-term health insurance.
Lindsay Graham, South Carolina’s Senior Senator, was instrumental in Senate Republicans’ last-ditch effort to repeal the ACA in September 2017 via the Graham-Cassidy Amendment. But Graham noted after the effort failed that he had essentially no understanding of health policy, saying “Well, I’ve been doing [healthcare reform policy] for about a month. I thought everybody else knew what the hell they were talking about, but apparently not.”
Nikki Haley was Governor when the ACA was enacted and implemented, and has long been fiercely opposed to the ACA, calling it “disastrous” and vowing to “continue to fight ObamaCare every step of the way.” Haley had a state legislature with a strong Republican majority, so her efforts to block ObamaCare in South Carolina were largely successful. The state defaulted to a federally run exchange, and has refused to expand Medicaid.
Haley is currently serving as Ambassador to the United Nations in the Trump Administration, although she’s leaving that position at the end of 2018. Henry McMaster is the current Governor of South Carolina, and won his re-election campaign in 2018. McMaster was Attorney General in South Carolina before becoming lieutenant governor and then governor. During his time as AG, McMaster organized a legal challenge against the ACA.
South Carolina also has a strong Republican majority in both chambers of the state legislature.
South Carolina Medicaid/CHIP enrollment
South Carolina is currently one of 14 states that have not yet expanded Medicaid. [There are 19 states where Medicaid hasn’t been expanded as of 2018, but Virginia‘s Medicaid expansion takes effect in January 2019, and four other states — Maine, Utah, Idaho, and Nebraska — are expected to expand Medicaid in 2019 under the terms of ballot initiatives that voters have passed.]
South Carolina has no pending plans to expand coverage, despite tireless work on the part of consumer advocates. The ACA would have expanded Medicaid to cover all legal residents with incomes up to 138 percent of poverty, but in 2012 the Supreme Court ruled that states could opt out of Medicaid expansion. Governor Haley, Governor McMaster, and the state’s Republican-led legislature have steadfastly refused expansion.
Despite this, total Medicaid/CHIP enrollment in South Carolina has increased by 14 percent from 2013 to August 2018, largely as a result of outreach and education due to the ACA.
The general consensus is that states like South Carolina will eventually expand Medicaid because of the economics involved. The question is really when, rather than if. But in states where political leadership is strongly opposed to Obamacare, South Carolina Medicaid expansion could still be several years away.
Roughly 224,000 additional people would be eligible to enroll in Medicaid if the state were to expand coverage guidelines. But instead, enrollment is still contingent on South Carolina’s strict eligibility guidelines: Non-disabled adults without dependent children are ineligible regardless of income, and parents with dependent children are only eligible if their household income doesn’t exceed 62 percent of poverty (a little over $1000/month for a family of three).
Because the state refused to expand Medicaid, South Carolina has 92,000 people – about 21 percent of its uninsured population – in the coverage gap, with no access to financial assistance with their health insurance. These residents would be eligible for Medicaid if the state were to accept federal funds to expand coverage. But for now, there are no realistic insurance options available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing guidelines.
South Carolina officials have said that instead of expanding Medicaid, they are focusing on their Healthy Outcomes program, which helps chronically ill people without health insurance get access to treatment through free clinics and hospital charity programs. Unfortunately, the program can only assist about 8,500 people – a tiny fraction of the people who are in the coverage gap in South Carolina.
Read more about Medicaid expansion in South Carolina.
South Carolina’s CO-OP
In 2014 and 2015, South Carolina residents could buy health insurance through Consumers Choice, the state’s Consumer Oriented and Operated Plan (CO-OP). The CO-OP was funded under the ACA with a grant from the federal government.
Nationwide, about $2 billion was awarded to CO-OPs in 22 states. In South Carolina, Consumers’ Choice Health Plan (CCHPSC) received about $87.6 million. However, by November 2015, officials had announced its closure. Heading into 2019, there were only four remaining CO-OPs offering plans in five states.
Short-term health insurance in South Carolina
South Carolina has its own state regulations regarding short-term health plans – and short-term plan terms can’t last more than 11 months in the state, with a total duration of 33 months (including renewals).
Read more about short-term health insurance in South Carolina.
Does South Carolina have a high-risk pool?
Prior to 2014, individual health insurance was underwritten in nearly every state, including South Carolina. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions.
The South Carolina Health Insurance Pool was created in 1989 to give people an alternative if they were unable to obtain individual health insurance because of their medical history.
Implementation of the ACA and a guaranteed issue individual market has made high-risk pools largely obsolete, but the South Carolina Health Insurance Pool is still operational and does not yet have plans to terminate coverage. HIPAA-eligible and TAA-eligible (Trade Adjustment and Assistance Act) enrollees can still obtain coverage for 2018. While SCHIP is still available for these applicants, they can also get policies in the individual market now, without having to worry about pre-existing conditions.
Medicare enrollment in South Carolina
South Carolina Medicare enrollment reached 1,034,894 as of September 2018, which was about 20 percent of the state’s population. 82 percent of South Carolina’s Medicare beneficiaries are eligible based on age alone, while the other 18 percent qualify as the result of a disability.
For Original Medicare beneficiaries in South Carolina, Medicare spending in 2016 amounted to an average of $9,014 per person — slightly lower than the $9,533 national average.
Medicare beneficiaries have the option to select a Medicare Advantage plan offered by a private insurance company, instead of using Original Medicare. In South Carolina, nearly 28 percent of Medicare recipients make this choice compared with 36 percent of all Medicare recipients nationwide.
Medicare Part D prescription drug plans are also an option for South Carolina Medicare beneficiaries who want to stand-alone prescription drug coverage. Roughly 47 percent of South Carolina Medicare enrollees also have a stand-alone prescription plan (this is in addition to the Medicare Advantage enrollees, most of whom have integrated Part D coverage with their Advantage plan).
State-based health reform legislation
Scroll to the bottom of this page for a summary of recent South Carolina bills related to healthcare reform.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.