reglab/statecodes huggingface dataset:
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-20 - Grandfathered service and indemnity-type contracts required to cover low-dose mammography--Extent of coverage.

58-40-20. Grandfathered service and indemnity-type contracts required to cover low-dose mammography--Extent of coverage.
Each service or indemnity-type contract issued by a nonprofit hospital service plan corporation that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening by low-dose mammography for the presence of occult breast cancer that is subject to the same dollar limits, deductibles, and coinsurance factors as for other radiological examinations. Coverage for the screening shall be provided as follows: ages thirty-five to thirty-nine, one baseline mammography; ages forty to forty-nine, a mammography every other year; and age fifty and older, a mammography every year.
As used in this section, "low-dose mammography" means the X ray examination of the breast using equipment dedicated specifically for mammography, including the X ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad midbreast, with two views for each breast and with interpretation by a qualified radiologist.
The provisions of this section apply only to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§54 and 602, 29 C.F.R. §2590, and 45 C.F.R. §147.
Source: SL 1990, ch 397, §§1, 6; SL 1991, ch 400, §6; SL 2011, ch 216, §11.
Commission Note: SL 2011, ch 216, §19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-20.1 - Service and indemnity-type contracts required to cover occult breast cancer screening.

58-40-20.1. Service and indemnity-type contracts required to cover occult breast cancer screening.
Each service or indemnity-type contract issued by a nonprofit hospital service plan corporation that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening for the presence of occult breast cancer.
The provisions of this section apply only to plans that are not grandfathered pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§54 and 602, 29 C.F.R. §2590, and 45 C.F.R. §147.
Source: SL 2011, ch 216, §16.
Commission Note: SL 2011, ch 216, §19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-21 - Coverage for phenylketonuria.

58-40-21. Coverage for phenylketonuria.
Every service or indemnity-type contract issued by a nonprofit hospital service plan corporation that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall offer coverage for testing, diagnosis, and treatment of phenylketonuria including dietary management, formulas, case management, intake and screening, assessment, comprehensive care planning, and service referral.
Source:
SL 1992, ch 348, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-22 - Formation of voluntary health insurance purchasing organizations.

58-40-22. Formation of voluntary health insurance purchasing organizations.
Notwithstanding the provisions of chapter 47-34A and §§ 47-15-2 and 47-22-4, any organization may form for the purposes of purchasing group health insurance on a voluntary basis. For purposes of §§58-40-22 to 58-40-32, inclusive, an organization means any nonprofit organization or nonprofit corporation formed under South Dakota law.
Source:
SL 1994, ch 382, §1; SL 2021, ch 210, § 23.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-23 - Membership of voluntary health insurance purchasing organizations.

58-40-23. Membership of voluntary health insurance purchasing organizations.
Any organization may have a group health insurance policy issued to that organization on behalf of its members who would be insured under such policy. Members may join the organization, for the purpose of obtaining group health insurance, as individuals, employers, labor unions, associations, or substantially similar groups.
Source:
SL 1994, ch 382, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-24 - Purchasing organization's responsibility for negotiating terms and conditions.

58-40-24. Purchasing organization's responsibility for negotiating terms and conditions.
The organization shall be responsible for negotiating the terms and conditions of insurance contracts, collection of premiums, and providing notice to members.
Source:
SL 1994, ch 382, §3.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-25 - Purchasing organization's notice of premium charge.

58-40-25. Purchasing organization's notice of premium charge.
The organization may provide not less than forty-five days advance notice of any benefit or premium change to its members.
Source:
SL 1994, ch 382, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-27 - Approval of purchasing organization by Division of Insurance.

58-40-27. Approval of purchasing organization by Division of Insurance.
Any organization shall, prior to its engaging in the business of insurance, obtain approval from the Division of Insurance. The division may deny approval or withdraw approval of an organization to engage in the business of insurance for any of the following reasons:
(1)Any of the grounds specified in §58-6-8;
(2)Insufficient membership control of the organization;
(3)Unreasonable compensation to officers, directors, or employees of the organization;
(4)Misuse of premiums; or
(5)Refusal to be examined or to cooperate in an examination.
Source:
SL 1994, ch 382, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-28 - Premiums held in trust by purchasing organization.

58-40-28. Premiums held in trust by purchasing organization.
The organization shall hold all premiums received in trust and promptly remit premiums to the person entitled thereto.
Source:
SL 1994, ch 382, §7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-29 - Rates for group health insurance issued to purchasing organizations.

58-40-29. Rates for group health insurance issued to purchasing organizations.
Any insurer issuing group health insurance pursuant to §§58-40-22 to 58-40-32, inclusive, is subject to all of the provisions of chapter 58-18B relating to rates.
Source:
SL 1994, ch 382, §8.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-30 - Reasonable participation requirements for group members of purchasing organizations.

58-40-30. Reasonable participation requirements for group members of purchasing organizations.
An insurer may as a condition of offering coverage or continuing coverage require reasonable participation requirements of groups who become members of an organization.
Source:
SL 1994, ch 382, §9.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-31 - Purchasing organizations exempt from antitrust provisions.

58-40-31. Purchasing organizations exempt from antitrust provisions.
Any organization formed pursuant to §§58-40-22 to 58-40-32, inclusive, is exempt from the antitrust provisions under chapter 37-1.
Source:
SL 1994, ch 382, §10.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-32 - Promulgation of rules for purchasing organizations.

58-40-32. Promulgation of rules for purchasing organizations.
The director may promulgate rules pursuant to chapter 1-26 to further the provisions of §§58-40-22 to 58-40-32, inclusive, and for purposes of carrying out the provisions of §§58-18-1 to 58-18-6, inclusive, and to ensure that group health insurance coverage is issued to eligible groups and that organizations are formed and operated to further the purpose of providing economical group health insurance for its members. The rules may include:
(1)Definition of terms;
(2)Criteria for determining groups, associations, organizations, and trusts and their eligibility for coverage;
(3)Criteria for determining substantially similar groups or for determining related industries;
(4)Application requirements and procedures;
(5)Reasonable compensation; and
(6)Organizational structure.
Source:
SL 1994, ch 382, §11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-33 - Minimum loss ratio for small employer health benefit plans.

58-40-33. Minimum loss ratio for small employer health benefit plans.
Premium rates for individual health benefit plans shall produce a minimum lifetime loss ratio of not less than seventy-five percent. The director may promulgate rules pursuant to chapter 1-26 which modify the minimum loss ratio required based on the specific design of the product or other objective and pertinent criteria.
Source:
SL 1994, ch 381, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-34 - Minimum inpatient care coverage following delivery.

58-40-34. Minimum inpatient care coverage following delivery.
If a service or indemnity-type contract issued or renewed on or after July 1, 1996, by a nonprofit hospital service plan corporation provides maternity coverage, the contract shall provide coverage for a minimum of forty-eight hours of inpatient care following a vaginal delivery and a minimum of ninety-six hours of inpatient care following delivery by cesarean section for a mother and her newborn child in a health care facility licensed pursuant to chapter 34-12, except as otherwise provided in §58-40-35. Any individual policy and any policy issued to employers with less than fifteen employees that provides coverage for complications of pregnancy, and does not provide other maternity benefits, is not required to comply with this section.
Source:
SL 1996, ch 292, §13; SL 1998, ch 290, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-35 - Shorter hospital stay permitted--Follow-up visit within forty-eight hours required.

58-40-35. Shorter hospital stay permitted--Follow-up visit within forty-eight hours required.
If the treating physician determines that the mother and the newborn meet medical criteria contained in Guidelines for Perinatal Care, Third Edition, of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists as in effect on January 1, 1996, a service or indemnity-type contract issued by a nonprofit hospital service plan corporation may provide coverage for a shorter length of hospital inpatient stay for services related to maternity and newborn care than is required in §58-40-34 if the coverage includes one follow-up visit in the first forty-eight hours after discharge to verify the condition of the mother and newborn.
Source:
SL 1996, ch 292, §14.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-36 - Notice to subscribers--Disclosure.

58-40-36. Notice to subscribers--Disclosure.
The nonprofit hospital service plan corporation shall provide notice to subscribers regarding the coverage required by §58-40-34 in accordance with rules adopted by the director of the Division of Insurance pursuant to chapter 1-26. The notice shall be in writing and prominently positioned in any literature or correspondence. The notice shall be transmitted to subscribers in the next mailing to subscribers, in the yearly informational packet sent to subscribers, or by January 1, 1997, whichever is earliest.
Source:
SL 1996, ch 292, §15.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-37 - Health insurance policies to provide coverage for biologically-based mental illnesses.

58-40-37. Health insurance policies to provide coverage for biologically-based mental illnesses.
Every service or indemnity-type contract issued by a nonprofit hospital service plan corporation that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide, in writing, coverage for the treatment and diagnosis of biologically-based mental illnesses with the same dollar limits, deductibles, coinsurance factors, and restrictions as for other covered illnesses.
The term, biologically-based mental illness, means schizophrenia and other psychotic disorders, bipolar disorder, major depression, and obsessive-compulsive disorder.
Source:
SL 1998, ch 291, §5; SL 1999, ch 251, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-38 - Application--Exemptions.

58-40-38. Application--Exemptions.
The provisions of §58-40-37 do not apply to any plan, policy, or contract that provides coverage only for:
(1)Specified disease;
(2)Hospital indemnity;
(3)Fixed indemnity;
(4)Accident-only;
(5)Credit;
(6)Dental;
(7)Vision;
(8)Prescription drug;
(9)Medicare supplement;
(10)Long-term care;
(11)Disability income insurance;
(12)Coverage issued as a supplement to liability insurance;
(13)Workers' compensation or similar insurance;
(14)Automobile medical payment insurance; or
(15)Individual health benefit plans of six-months duration or less that are not renewable.
Source:
SL 1998, ch 291, §7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-39 - Policies to provide coverage for diabetes supplies, equipment, and education--Exceptions--Conditions and limitations.

58-40-39. Policies to provide coverage for diabetes supplies, equipment, and education--Exceptions--Conditions and limitations.
Every service or indemnity-type contract issued by a nonprofit hospital service plan corporation delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide, in writing, coverage for equipment, supplies, and self-management training and education, including medical nutrition therapy, for treatment of persons diagnosed with diabetes if prescribed by a physician or other licensed health care provider legally authorized to prescribe such treatment. Medical nutrition therapy does not include any food items or nonprescription drugs.
Coverage for medically necessary equipment and supplies shall include blood glucose monitors, blood glucose monitors for the legally blind, test strips for glucose monitors, urine testing strips, insulin, injection aids, lancets, lancet devices, syringes, insulin pumps and all supplies for the pump, insulin infusion devices, prescribed oral agents for controlling blood sugars, glucose agents, glucagon kits, insulin measurement and administration aids for the visually impaired, and other medical devices for treatment of diabetes.
Diabetes self-management training and education shall be covered if: (a) the service is provided by a physician, nurse, dietitian, pharmacist, or other licensed health care provider who satisfies the current academic eligibility requirements of the National Certification Board for Diabetic Educators and has completed a course in diabetes education and training or has been certified as a diabetes educator; and (b) the training and education is based upon a diabetes program recognized by the American Diabetes Association or a diabetes program with a curriculum approved by the American Diabetes Association or the South Dakota Department of Health.
Coverage of diabetes self-management training is limited to (a) persons who are newly diagnosed with diabetes or have received no prior diabetes education; (b) persons who require a change in current therapy; (c) persons who have a co-morbid condition such as heart disease or renal failure; or (d) persons whose diabetes condition is unstable. Under these circumstances, no more than two comprehensive education programs per lifetime and up to eight follow-up visits per year need be covered. Coverage is limited to the closest available qualified education program that provides the necessary management training to accomplish the prescribed treatment.
The benefits provided in this section are subject to the same dollar limits, deductibles, coinsurance, and other restrictions established for all other benefits covered in the contract.
Source:
SL 1999, ch 252, §9.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-40 - Diabetes coverage not required of certain plans and policies.

58-40-40. Diabetes coverage not required of certain plans and policies.
The provisions of §58-40-39 do not apply to any plan, policy, or contract that provides coverage only for:
(1)Specified disease;
(2)Hospital indemnity;
(3)Fixed indemnity;
(4)Accident-only;
(5)Credit;
(6)Dental;
(7)Vision;
(8)Prescription drug;
(9)Medicare supplement;
(10)Long-term care;
(11)Disability income insurance;
(12)Coverage issued as a supplement to liability insurance;
(13)Workers' compensation or similar insurance;
(14)Automobile medical payment insurance;
(15)Individual health benefit plans of six-months duration or less that are not renewable; or
(16)Individual nonmajor medical insurance.
Source:
SL 1999, ch 252, §10.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 40 - Nonprofit Hospital Service Plans › Section 58-40-41 - Contracts to provide coverage for prostate cancer screening.

58-40-41. Contracts to provide coverage for prostate cancer screening.
Every service or indemnity-type contract issued by a nonprofit hospital service plan or organization that covers a male and that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide the following coverage for diagnostic screening for prostate cancer:
(1)An annual medically recognized diagnostic examination, including a digital rectal examination and a prostate-specific antigen test, as follows:
(a)For asymptomatic men aged fifty and over; and
(b)For men aged forty-five and over at high risk for prostate cancer; and
(2)For males of any age who have a prior history of prostate cancer, medically indicated diagnostic testing at intervals recommended by a physician, including the digital rectal examination, prostate-specific antigen test, and bone scan.
Source:
SL 2001, ch 277, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-1 - Definition of terms.

58-41-1. Definition of terms.
Terms used in this chapter mean:
(1)"Comprehensive health maintenance services," a set of comprehensive health services which the enrollees might reasonably require to be maintained in good health, including as a minimum, but not limited to, emergency care, inpatient hospital and physician care, outpatient medical services, and preventive medical services;
(2)"Director," the director of the Division of Insurance or his designee;
(3)"Enrollee," any person who has entered into, or is covered by a health maintenance contract;
(4)"Evidence of coverage," any certificate, agreement, or contract issued to an enrollee which sets out the coverage to which he is entitled under the health maintenance contract which covers him;
(5)"Health maintenance contract," any contract whereby a health maintenance organization agrees to provide comprehensive health maintenance services to enrollees, provided that the contract may contain reasonable enrollee copayment provisions. Any contract may provide for health care services in addition to those set forth in subdivision (1);
(6)"Limited health service," dental care services, vision care services, mental health services, substance abuse services, pharmaceutical services, podiatric care services, and such other services as may be determined by the director to be limited health services. Limited health service does not include hospital, medical, surgical, or emergency services except as these services are provided incident to the limited health services;
(7)"Provider," any person who furnishes health services and is licensed or otherwise authorized to render such services in the state;
(8)"Risk bearing entity," an intermediary organization that is a financial risk for services provided through contractual assumption of the obligation for the delivery of specified health care services to covered persons of the health maintenance organization.
Source:
SL 1974, ch 321, §2; SL 2013, ch 256, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-2 - Organizations subject to chapter.

58-41-2. Organizations subject to chapter.
As used in this chapter a health maintenance organization is a corporation organized under Title 47, controlled and operated as provided in this chapter, which provides, either directly or through arrangements with providers or other persons, comprehensive health maintenance services, or arranges for the provision of such services, to enrollees on the basis of a fixed prepaid sum without regard to the frequency or extent of services furnished to any particular enrollee. A health maintenance organization may be organized pursuant to this chapter on a limited health service basis. Nothing in this chapter prohibits a health maintenance organization holding a certificate of authority in this state from issuing contracts to enrollees on a preferred provider, exclusive provider, or closed panel basis. Nothing in this chapter requires a licensed pharmacy benefit manager to obtain a certificate of authority as a health maintenance organization provided that the pharmacy benefit manager does not assume insurance risk directly from an insured.
Source:
SL 1974, ch 321, §2 (3); SL 1985, ch 393, §1; SL 2013, ch 256, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-3 - Certificate of authority required for health maintenance organization or contracts--Violation as misdemeanor.

58-41-3. Certificate of authority required for health maintenance organization or contracts--Violation as misdemeanor.
No person shall establish or operate a health maintenance organization in this state, nor sell or offer to sell, or solicit offers to purchase or receive advance or periodic consideration in conjunction with a health maintenance organization or health maintenance contract unless such organization has a certificate of authority under this chapter. Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§3, 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-4 - Application for certificate of authority required.

58-41-4. Application for certificate of authority required.
Notwithstanding any law of this state to the contrary, any corporation organized to do so shall apply to the director of the Division of Insurance for a certificate of authority to establish and operate a health maintenance organization in compliance with the provisions of this chapter.
Source:
SL 1974, ch 321, §3; SL 1985, ch 393, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-7 - Financial statements required with application.

58-41-7. Financial statements required with application.
Each application for a certificate of authority shall include financial statements showing the applicant's assets, liabilities, and sources of financial support. If the applicant's financial affairs are audited by independent certified public accountants, a copy of the applicant's most recent regular certified financial statement shall be deemed to satisfy this requirement unless the director directs that additional or more recent financial information is required for the proper administration of this chapter.
Source:
SL 1974, ch 321, §6 (7).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-8 - Copies of forms required with application.

58-41-8. Copies of forms required with application.
Each application for a certificate of authority shall include:
(1)A copy of the form of each evidence of coverage to be issued to the enrollees;
(2)A copy of the form of each individual or group health maintenance contract which is to be issued to enrollees or their representatives.
Source:
SL 1974, ch 321, §6 (5), (6).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-9 - Marketing, charges, and financial plans required with application.

58-41-9. Marketing, charges, and financial plans required with application.
Each application for a certificate of authority shall include a description of the proposed method of marketing the plan, a schedule of proposed charges, and a financial plan which includes a three-year projection of the expenses and income and other sources of future capital.
Source:
SL 1974, ch 321, §6 (8).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-10 - Appointment to receive process required of foreign applicant.

58-41-10. Appointment to receive process required of foreign applicant.
Each application for a certificate of authority by an applicant not domiciled in this state shall include a power of attorney duly executed by such applicant, appointing the director and his successors in office, and duly authorized deputies, as the true and lawful attorney of such applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served.
Source:
SL 1974, ch 321, §6 (9).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-11 - Surety bond or deposit required--Waiver.

58-41-11. Surety bond or deposit required--Waiver.
Each health maintenance organization shall furnish a surety bond in an amount satisfactory to the director or deposit with the director cash or securities acceptable to him in at least the same amount as a guarantee that the obligations to the enrollees will be performed. The director may waive this requirement whenever he is satisfied that the assets of the organization or its contracts with insurers, hospital or medical service corporations, governments, or other organizations are sufficient to reasonably assure the performance of its obligations.
Source:
SL 1974, ch 321, §31.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-12 - Determination of health care qualifications.

58-41-12. Determination of health care qualifications.
The director shall determine whether the applicant for a certificate of authority has:
(1)Demonstrated the willingness and potential ability to assure that health care services will be provided in a manner to assure both the availability and accessibility of adequate personnel and facilities consistent with the requirements of chapter 58-17F;
(2)Arrangements, established in accordance with regulations promulgated by the director for an ongoing quality of health care assurance program consistent with the requirements of chapter 58-17F, concerning health care processes and outcomes;
(3)A procedure, established in accordance with rules promulgated pursuant to chapter 1-26 by the director, to develop, compile, evaluate, and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services, and such other matters as may be reasonably required by the director; and
(4)Reasonable provisions for emergency and out-of-area health care services.
Source:
SL 1974, ch 321, §8; SL 1999, ch 245, §20; SL 2011, ch 219, §101; SL 2013, ch 256, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-13 - Coordination with federal professional standards review.

58-41-13.Coordination with federal professional standards review.
To the extent that it furthers the purposes of this chapter, the director shall attempt to coordinate the operations of this chapter relating to the quality of health care services with the operations of 42 U.S. C. sections 1320c to 1320c-19.
Source:
SL 1974, ch 321, §54; SL 2013, ch 256, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-15.1 - Certain healing arts practitioners to participate in alternate health care delivery systems.

58-41-15.1. Certain healing arts practitioners to participate in alternate health care delivery systems.
Any optometrist licensed pursuant to chapter 36-7, podiatrist licensed pursuant to chapter 36-8, chiropractor licensed pursuant to chapter 36-5, psychologist licensed pursuant to chapter 36-27A, dentist licensed pursuant to chapter 36-6A, or social worker licensed under §36-26-17, may organize or contract for services with a corporation organized under the laws of this state by licensed practitioners of the healing arts, for the purpose of negotiating group health care contracts and providing services within the scope of their respective licenses with alternate health care delivery systems, including health maintenance organizations, preferred provider organizations, individual practices organizations, or other similar entities.
Source:
SL 1987, ch 269, §2; SL 2013, ch 256, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-17 - Issuance or denial of certificate--Fee--Conditions for issuance.

58-41-17. Issuance or denial of certificate--Fee--Conditions for issuance.
The director of the Division of Insurance shall issue or deny a certificate of authority to any person filing an application pursuant to this chapter. Issuance of a certificate of authority shall be granted upon payment of the application fee prescribed in §58-41-26 if the director is satisfied that the following conditions are met:
(1)The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy, and possess good reputations;
(2)The health maintenance organization's proposed plan of operation meets the requirements of §58-41-12;
(3)The health maintenance contract constitutes an appropriate mechanism whereby the health maintenance organization will effectively provide or arrange for the provision of comprehensive health maintenance services on a prepaid basis, through insurance or otherwise, except to the extent of reasonable requirements for copayments;
(4)The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees;
(5)The health maintenance organization will assume full financial risk on a prospective basis for the provision of comprehensive health maintenance services, including hospital care;
(6)The enrollees will be afforded an opportunity to participate in matters of policy and operation pursuant to §§58-41-23 and 58-41-24; and
(7)Nothing in the proposed method of operation, as shown by the information submitted pursuant to §§58-41-4 to 58-41-10, inclusive, or by independent investigation, is contrary to the public interest.
A certificate of authority may be denied only after compliance with the requirements of §§58-41-87 to 58-41-90, inclusive.
Source:
SL 1974, ch 321, §10; SL 1985, ch 393, §15; SL 2013, ch 256, §8.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-18 - Factors considered in determining financial responsibility.

58-41-18. Factors considered in determining financial responsibility.
In making a determination under subdivision 58-41-17(4), the director may consider:
(1)The financial soundness of the applicant's arrangements for health care services and the proposed schedule of charges used in connection therewith;
(2)The adequacy of its working capital;
(3)Arrangements which will guarantee for a reasonable period of time the continued availability or payment of the cost of health care services in the event of discontinuance of the health maintenance organization;
(4)Agreements with providers for the provision of health care services; and
(5)Any surety bond or deposit of cash or securities submitted in accordance with §58-41-11 as a guarantee that the obligations will be duly performed.
Source:
SL 1974, ch 321, §10 (4).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-19 - Insurance arrangements permitted.

58-41-19. Insurance arrangements permitted.
The requirement of subdivision 58-41-17(5) shall not prohibit a health maintenance organization from obtaining insurance or making other arrangements:
(1)For the cost of providing to any enrollee comprehensive health maintenance services, the aggregate value of which exceeds five thousand dollars in any year;
(2)For the cost of providing comprehensive health care services to its members on a nonelective emergency basis, or while they are outside the area served by the organization; or
(3)For not more than ninety-five percent of the amount by which the health maintenance organization's costs for any of its fiscal years exceeds one hundred five percent of its income for such fiscal years.
Source:
SL 1974, ch 321, §10 (5).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-20 - Corporation operating after certification.

58-41-20. Corporation operating after certification.
Any corporation may, upon obtaining a certificate of authority as required in this chapter, operate as a health maintenance organization.
Source:
SL 1974, ch 321, §11; SL 1985, ch 393, §3.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-21 - Foreign corporations qualifying--Exemption from other requirements.

58-41-21. Foreign corporations qualifying--Exemption from other requirements.
A foreign corporation may qualify under this chapter, and if such corporation fully complies with the provisions of Title 58, then such corporation shall be exempt from complying with other provisions of the South Dakota Code concerning foreign corporations.
Source:
SL 1974, ch 321, §3; SL 1985, ch 393, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-22 - Filing of notice of modification of operation--Approval if not disapproved--Exemptions.

58-41-22. Filing of notice of modification of operation--Approval if not disapproved--Exemptions.
A health maintenance organization shall, unless otherwise provided for in this chapter, file a notice describing any modification of the operation set out in the information required by §§58-41-6 to 58-41-10, inclusive. Such a notice shall be filed with the director prior to the modification. If the director does not disapprove within thirty days of filing, such modification shall be deemed approved. The director may promulgate rules and regulations exempting from the filing requirements of this section those items he deems unnecessary.
Source:
SL 1974, ch 321, §7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-23 - Composition of governing body--Consumer representation.

58-41-23. Composition of governing body--Consumer representation.
The governing body of any health maintenance organization may include enrollees, providers, or other individuals. However, after a health maintenance organization has been authorized under this chapter for one year, at least twenty percent of the governing body of a health maintenance organization shall be composed of consumers. A consumer, is any person other than a person whose occupation involves the administration of health activities or the providing of health services.
Source:
SL 1974, ch 321, §§2 (9), 16; SL 1985, ch 393, §5; SL 2014, ch 244, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-24 - Mechanisms for enrollee participation in policy and operation of governing body.

58-41-24. Mechanisms for enrollee participation in policy and operation of governing body.
The governing body shall establish a mechanism to afford the enrollees an opportunity to express their opinions in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other mechanisms as may be prescribed or permitted by the director.
Source:
SL 1974, ch 321, §16; SL 2013, ch 256, §9.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-25 - Fiduciary responsibilities to enrollees.

58-41-25. Fiduciary responsibilities to enrollees.
Any director, officer, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of such organization shall be responsible for such funds in a fiduciary relationship to the enrollees.
Source:
SL 1974, ch 321, §17.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-25.1 - Investments.

58-41-25.1. Investments.
The funds of any corporation subject to the provisions of this chapter shall be invested only in securities permitted by the laws of this state for the investment of assets of life insurance companies.
Source:
SL 1985, ch 393, §14.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-26 - Exemption from insurance laws--Exceptions--Taxation.

58-41-26. Exemption from insurance laws--Exceptions--Taxation.
Any health maintenance organization is exempt from all provisions of the insurance laws of this state other than this chapter. However, the corporation is subject to the provisions of this title on matters and procedures of mergers and licensure of insurance producers. The corporation is also subject to fees and taxation as insurers under §58-2-29 and chapter 10-44. The corporation is also subject to §§58-17-53 and 58-17-54 if entering into a contract after July 1, 1990, with the State of South Dakota, counties, school districts, municipalities, and any other unit of state government using public funds. The state, however, may not collect premium taxes for insurance written on individuals residing outside this state or property located outside this state if no comparable tax is paid by the direct writing health maintenance organization to any appropriate taxing authority. Health maintenance organizations are also subject to the following chapters: 58-1, 58-2, 58-3, 58-4, 58-5, 58-5A, 58-6, 58-7, 58-11, 58-12, 58-14, 58-17, 58-17A, 58-17F, 58-17G, 58-17H, 58-17I, 58-18, 58-18A, 58-18B, 58-18C, 58-26, 58-27, 58-29B on the same basis as insurers, 58-30, 58-33A; and 58-43. Nothing in chapters 58-5 or 58-6 may be construed to prohibit a nonprofit health maintenance organization from transacting business under this title based upon its nonprofit status.
To the extent that a health maintenance organization is compliant with the provisions of chapters 58-17F to 58-17I, inclusive, for purposes of network adequacy, quality assessment and improvements, utilization review and benefit determinations, and grievance procedure, the health maintenance organization is compliant with the provisions of this chapter.
Source:
SL 1974, ch 321, §51; SL 1985, ch 393, §8; SL 1990, ch 411; SL 2001, ch 286, §226; SL 2007, ch 293, §1; SL 2013, ch 256, §10; SL 2020, ch 210, § 13.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-28 - Solicitation of enrollment not deemed professional advertising.

58-41-28. Solicitation of enrollment not deemed professional advertising.
Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
Source:
SL 1974, ch 321, §52.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-29 - Contracts and necessary activities.

58-41-29. Contracts and necessary activities.
A health maintenance organization may enter into health maintenance contracts in this state and engage in any other activities consistent with this chapter which are necessary to the performance of its obligations under such contracts or authorize its representatives to do so.
Source:
SL 1974, ch 321, §12.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-29.1 - Notice required for rate increase in health maintenance contract by a health maintenance organization.

58-41-29.1. Notice required for rate increase in health maintenance contract by a health maintenance organization.
Forty-five days before a health maintenance contract rate increase is effective, the health maintenance organization shall notify the enrolling unit in writing that the contract rate for the health maintenance contract offered by the organization will be increased.
Source:
SL 1989, ch 434, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-30 - Sources of payment for enrollee services--Application by medical assistance recipient.

58-41-30. Sources of payment for enrollee services--Application by medical assistance recipient.
Each health maintenance organization authorized to operate under this chapter or its representative, may accept from governmental agencies, private agencies, corporations, associations, groups, individuals, or other persons, payments covering all or part of the cost of health care service provided to enrollees. Any recipient of medical assistance, pursuant to Title 28, may make application to join a health maintenance organization which has been approved for medical assistance by the secretary of the Department of Social Services.
Source:
SL 1974, ch 321, §15.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-31 - Direct payments to enrollees prohibited.

58-41-31. Direct payments to enrollees prohibited.
No health maintenance organization or representative thereof may by a health maintenance contract or evidence of coverage provide for the reimbursement of an enrollee other than through a policy of insurance, except to refund payments made by or on behalf of an enrollee.
Source:
SL 1974, ch 321, §32 (4).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-32 - Use of words descriptive of insurance, casualty, or surety business as misdemeanor--Exception.

58-41-32. Use of words descriptive of insurance, casualty, or surety business as misdemeanor--Exception.
No health maintenance organization or representative thereof may use in its name, contracts, or literature any of the words "insurance," "casualty," "surety," "mutual," or any other words which are descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this state; provided, however, that when a health maintenance organization has contracted with an insurance company for any coverage permitted by this chapter, it may so state. Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§32 (3), 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-33 - Trade practice laws applicable.

58-41-33. Trade practice laws applicable.
Each health maintenance organization, health maintenance contract, and evidence of coverage shall be subject to chapter 58-33, relating to the regulation of trade practices, except to the extent that the director determines that the nature of health maintenance organizations, health maintenance contracts, and evidences of coverage render such chapter clearly inappropriate.
Source:
SL 1974, ch 321, §33.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-34 - Evidence of coverage issued to enrollees.

58-41-34. Evidence of coverage issued to enrollees.
Every enrollee residing in this state is entitled to evidence of coverage under a health maintenance contract. The health maintenance organization or its designated representative shall issue the evidence of coverage.
Source:
SL 1974, ch 321, §18.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-35 - Contents required in evidence of coverage.

58-41-35. Contents required in evidence of coverage.
An evidence of coverage shall contain a clear, concise, and complete statement of:
(1)The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan;
(2)Any exclusions or limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;
(3)Where and in what manner information is available as to how service, including emergency and out-of-area services, may be obtained;
(4)The total amount of payment and copayment if any, for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory with respect to group certificates; and
(5)A description of the health maintenance organization's method for resolving enrollee complaints.
Source:
SL 1974, ch 321, §19 (2).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-35.1 - Alcoholism coverage to be offered at time contract is negotiated.

58-41-35.1. Alcoholism coverage to be offered at time contract is negotiated.
At the time of negotiation of any health maintenance contract, the health maintenance organization shall offer, in writing, to provide the coverage prescribed by §§58-17-30.5 and 58-18-7.1.
Source:
SL 1979, ch 344, §12.