reglab/statecodes huggingface dataset:
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17I - Grievance Procedure › Section 58-17I-7 - Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review.

58-17I-7. Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review.
Within one hundred eighty days after the date of receipt of a notice of an adverse determination sent pursuant to chapter 58-17H, any covered person or the covered person's authorized representative may file a grievance with the health carrier requesting a first level review of the adverse determination. The health carrier shall provide the covered person with the name, address, and telephone number of a person or organizational unit designated to coordinate the first level review on behalf of the health carrier. In providing for a first level review under this section, the health carrier shall ensure that the review conducted in a manner under this section to ensure the independence and impartiality of the individuals involved in making the first level review decision. In ensuring the independence and impartiality of individuals involved in making the first level review decision, no health carrier may make decisions related to such individuals regarding hiring, compensation, termination, promotion or other similar matters based upon the likelihood that the individual will support the denial of benefits.
The health carrier shall designate one or more health care providers who have appropriate training and experience in the field of medicine involved in the medical judgment to evaluate the adverse determination. No health care provider may have been involved in the initial adverse determination. In conducting the review, a reviewer shall take into consideration all comments, documents, records, and other information regarding the request for services submitted by the covered person or the covered person's authorized representative, without regard to whether the information was submitted or considered in making the initial adverse determination.
Source: SL 2011, ch 219, §79.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub.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 17I - Grievance Procedure › Section 58-17I-8 - Rights of covered person or authorized representative on review--Access to documentation.

58-17I-8. Rights of covered person or authorized representative on review--Access to documentation.
No covered person has the right to attend, or to have a representative in attendance, at the first level review. However, the covered person or, if applicable, the covered person's authorized representative may:
(1)Submit written comments, documents, records, and other material relating to the request for benefits for the review or reviewers to consider when conducting the review; and
(2)Receive from the health carrier, upon request and free of charge, reasonable access to, and copies of all documents, records and other information relevant to the covered person's request for benefits. A document, record, or other information shall be considered relevant to a covered person's request for benefits if the document, record, or other information:
(a)Was relied upon in making the benefit determination;
(b)Was submitted, considered, or generated in the course of making the adverse determination, without regard to whether the document, record, or other information was relied upon in making the benefit determination;
(c)Demonstrates that, in making the benefit determination, the health carrier, or its designated representatives consistently applied required administrative procedures and safeguards with respect to the covered person as other similarly situated covered persons; or
(d)Constitutes a statement of policy or guidance with respect to the health benefit plan concerning the denied health care service or treatment for the covered person's diagnosis, without regard to whether the advice or statement was relied upon in making the benefit determination.
The health carrier shall make the provisions of this section known to the covered person or, if applicable, the covered person's authorized representative within three working days after the date of receipt of the grievance.
Source: SL 2011, ch 219, §80.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17I - Grievance Procedure › Section 58-17I-9 - Time for decision and notice--Calculation of time periods.

58-17I-9. Time for decision and notice--Calculation of time periods.
A health carrier shall notify and issue a decision in writing or electronically to the covered person or, if applicable, the covered person's authorized representative, within the following time frames:
(1)With respect to a grievance requesting a first level review of an adverse determination involving a prospective review request, the health carrier shall notify and issue a decision within a reasonable period of time that is appropriate given the covered person's medical condition, but no later than thirty days after the date of the health carrier's receipt of the grievance requesting the first level review made pursuant to §58-17I-7; or
(2)With respect to a grievance requesting a first level review of an adverse determination involving a retrospective review request, the health carrier shall notify and issue a decision within a reasonable period of time, but no later than sixty days after the date of the health carrier's receipt of the grievance requesting the first level review made pursuant to §58-17I-7.
For purposes of calculating the time periods within which a determination is required to be made and notice provided under this section, the time period shall begin on the date the grievance requesting the review is filed with the health carrier in accordance with the health carrier's procedures established pursuant to §58-17I-6 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing.
Source: SL 2011, ch 219, §81.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17I - Grievance Procedure › Section 58-17I-10 - Procedures for providing new or additional evidence.

58-17I-10. Procedures for providing new or additional evidence.
Prior to issuing a decision in accordance with the timeframes provided in §58-17I-9, the health carrier shall provide free of charge to covered person, or the covered person's authorized representative, any new or additional evidence, relied upon or generated by the health carrier, or at the direction of the health carrier, in connection with the grievance sufficiently in advance of the date the decision is required to be provided to permit the covered person, or the covered person's authorized representative, a reasonable opportunity to respond prior to that date.
Before the health carrier issues or provides notice of a final adverse determination in accordance with the timeframes provided in §58-17I-9 that is based on new or additional rationale, the health carrier shall provide the new or additional rationale to the covered person, or the covered person's authorized representative, free of charge as soon as possible and sufficiently in advance of the date the notice of final adverse determination is to be provided to permit the covered person, or the covered person's authorized representative a reasonable opportunity to respond prior to that date.
Source: SL 2011, ch 219, §82.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17I - Grievance Procedure › Section 58-17I-12 - Expedited review for adverse determinations involving urgent care requests--Appointment of peers for review.

58-17I-12. Expedited review for adverse determinations involving urgent care requests--Appointment of peers for review.
Each health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. In addition, a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to concurrent review urgent care requests involving an admission, availability of care, continued stay, or health care service for a covered person who has received emergency services, but has not been discharged from a facility. The procedures shall allow a covered person or the covered person's authorized representative to request an expedited review under this section orally or in writing.
Each health carrier shall appoint at least one appropriate clinical peer in the same or similar specialty as would typically manage the case being reviewed to review the adverse determination. The clinical peer may not have been involved in making the initial adverse determination.
Source: SL 2011, ch 219, §84.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17I - Grievance Procedure › Section 58-17I-13 - Transmission of necessary information for certain expedited reviews.

58-17I-13. Transmission of necessary information for certain expedited reviews.
In an expedited review that is not an initial determination for benefits, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or, if applicable, the covered person's authorized representative, by telephone, facsimile, or the most expeditious method available.
Source: SL 2011, ch 219, §85.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17I - Grievance Procedure › Section 58-17I-14 - Expedited review decision not initial determination for benefits--Notification--Time periods--Continuation of service involving concurrent review urgent care requests.

58-17I-14. Expedited review decision not initial determination for benefits--Notification--Time periods--Continuation of service involving concurrent review urgent care requests.
An expedited review decision, that is not an initial determination for benefits, shall be made and the covered person or, if applicable, the covered person's authorized representative, shall be notified of the decision in accordance with §58-17I-15 as expeditiously as the covered person's medical condition requires, but in no event more than seventy-two hours after the date of receipt of the request for the expedited review. If the expedited review is of a grievance involving an adverse determination with respect to a concurrent review urgent care request, the service shall be continued without liability to the covered person until the covered person has been notified of the determination.
For purposes of calculating the time periods within which a decision is required to be made under this section, the time period within which the decision is required to be made shall begin on the date the request is filed with the health carrier in accordance with the health carrier's procedures established pursuant to §58-17I-6 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing.
Source: SL 2011, ch 219, §86.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17I - Grievance Procedure › Section 58-17I-16 - Promulgation of rules.

58-17I-16. Promulgation of rules.
The director, in consultation with the secretary, shall promulgate rules, pursuant to chapter 1-26, to establish time frames relative to the filing of grievances, the disposition of grievances, and the response to the aggrieved person. Rules may also be promulgated covering definition of terms, grievance procedures, and content of reports.
Source: SL 2011, ch 219, §88.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed 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 17J - Patient Choice In Selection Of Health Care Provider › Section 58-17J-1 - Definitions.

58-17J-1. Definitions.
Terms used in this chapter mean:
(1)"Health benefit plan," any hospital or medical expense policy or certificate, hospital or medical service plan, nonprofit hospital, medical-surgical health service corporation contract or certificate, provider sponsored integrated health delivery network, self-insured plan or plan provided by multiple employer welfare arrangements, health maintenance organization subscriber contract of more than six-month duration, or any health benefit plan that affects the rights of a South Dakota insured and bears a reasonable relation to South Dakota, whether delivered or issued for delivery in South Dakota. The term does not include specified disease, hospital indemnity, fixed indemnity, accident only, credit, dental, vision, Medicare supplement, long-term care or disability income insurance, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, automobile medical payment insurance, or any plan or coverage exempted from state regulation by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 18;
(2)"Health insurer," any entity within the definitions set forth in subdivisions 58-17F-1(11), (12), and (15), any entity offering a health benefit plan as defined by §58-17F-2, all self-insurers or multiple employer welfare arrangements, and self-insured employer-organized associations. The term does not include any entity exempted from state regulation by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 18;
(3)"Health care provider," any individual or entity within the scope of the definition of health care provider as defined by subdivision 58-17F-1(9).
Source:
SL 2015, ch 278 (Initiated Measure 17), §2, eff. Nov. 13, 2014.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17J - Patient Choice In Selection Of Health Care Provider › Section 58-17J-2 - Patient choice--Health care provider participation.

58-17J-2. Patient choice--Health care provider participation.
No health insurer, including the South Dakota Medicaid program, may obstruct patient choice by excluding a health care provider licensed under the laws of this state from participating on the health insurer's panel of providers if the provider is located within the geographic coverage area of the health benefit plan and is willing and fully qualified to meet the terms and conditions of participation as established by the health insurer.
Source:
SL 2015, ch 278 (Initiated Measure 17), §1, eff. Nov. 13, 2014.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-2 - Cost-sharing information described--Required disclosure to enrollees.

58-17K-2. Cost-sharing information described--Required disclosure to enrollees.
At the request of an enrollee, the health insurer shall provide:
(1)An estimate, which is accurate at the time of the request, of the enrollee's cost-sharing liability for a requested covered item or service furnished by a provider reflecting any cost-sharing reductions the enrollee would receive that is calculated based on:
(a)Accumulated amounts;
(b)In-network negotiated rate, reflected as a dollar amount, or underlying fee schedule rate, reflected as a dollar amount, to the extent it is different from the negotiated rate; and
(c)Out-of-network allowed amount or any other rate that provides a more accurate estimate of an amount the health insurer will pay for the requested covered item or service, reflected as a dollar amount. In circumstances in which a health insurer reimburses an out-of-network provider a percentage of the billed charge for a covered item or service, the out-of-network allowed amount will be that percentage;
(2)Information for an item or service subject to a bundled payment arrangement and a list of the items and services included in the bundled payment arrangement for which cost-sharing information is being disclosed;
(3)If applicable, notification that coverage of a specific item or service is subject to a prerequisite; and
(4)Further information and consumer notices required for compliance with federal standards as provided under rules promulgated pursuant to chapter 1-26 by the director.
Source:
SL 2021, ch 213, § 2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-3 - Cost-sharing information disclosed--Required internet method and format.

58-17K-3. Cost-sharing information disclosed--Required internet method and format.
The cost-sharing information to be provided under this chapter shall be made available without a subscription or other fee through a self-service tool on a website that provides real-time responses based on cost-sharing information that is accurate at the time of request. A health insurer shall ensure the self-service tool allows enrollees to:
(1)Search for cost-sharing information for a covered item or service by an in-network provider by inputting:
(a)A billing code or a descriptive term;
(b)The name of an in-network provider; and
(c)Other factors utilized by the health insurer that are relevant for determining the applicable cost-sharing information;
(2)Search for an out-of-network allowed amount, percentage of billed charges, or other rate for a covered item or service by an out-of-network provider by inputting:
(a)A billing code or a descriptive term; and
(b)Other factors utilized by the health insurer that are relevant for determining the applicable out-of-network allowed amount or other rate; and
(3)Refine and reorder search results based on geographic proximity of in-network providers and the amount of the enrollee's estimated cost-sharing liability.
Source:
SL 2021, ch 213, § 3.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-4 - Cost-sharing information disclosed--Paper or other method on request--Limit on providers per request.

58-17K-4. Cost-sharing information disclosed--Paper or other method on request--Limit on providers per request.
An enrollee may request, in accordance with § 58-17K-3, the required cost-sharing information be provided in a paper form. In responding to such a request, a health insurer may limit the number of providers to no fewer than twenty providers per request. A health insurer shall disclose the applicable provider-per-request limit to the enrollee, provide the cost-sharing information in paper form, and mail the cost-sharing information no later than two business days after receiving a request without a subscription or other fee.
An enrollee may request to receive cost-sharing information through other methods, including phone or e-mail, as long as the enrollee agrees to the disclosure method and the required cost-sharing information request is fulfilled at least as rapidly as required by the paper method.
Source:
SL 2021, ch 213, § 4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-5 - Prescription drug file--Required public disclosure--Method, format, and updates.

58-17K-5. Prescription drug file--Required public disclosure--Method, format, and updates.
A health insurer shall make available to the public on a website a machine-readable prescription drug file that includes:
(1)A health insurance oversight identifier or employer identification number;
(2)The NDC and the proprietary and nonproprietary name assigned to the NDC by the Food and Drug Administration;
(3)A negotiated rate that is:
(a)Reflected as a dollar amount by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;
(b)Associated with the national provider identifier, tax identification number, or place of service code; and
(c)Associated with the last date of the contract term; and
(4)Historical net prices that are:
(a)Reflected as a dollar amount by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;
(b)Associated with the national provider identifier, tax identification number, or place of service code; and
(c)Associated with the ninety-day time period that begins one hundred eighty days prior to publication date of the machine-readable file for each provider-specific historical net price that applies to each NDC, unless a health insurer must omit data in relation to a particular NDC and provider when compliance with this subsection would require the health insurer to report payment of historical net prices calculated using fewer than twenty different claims for payments.
The prescription drug file shall be available in the method and format as promulgated by the director in rule pursuant to chapter 1-26. The prescription drug file shall be publicly available and accessible to any person free of charge and without conditions, including the establishment of a user account, password, or other credentials, or submission of personally identifiable information to access the file.
A health insurer shall update the prescription drug file monthly and indicate the date the file was most recently updated.
Source:
SL 2021, ch 213, § 5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-6 - Cost-sharing information or prescription drug file--Third party contract to provide information--Health insurer responsible.

58-17K-6. Cost-sharing information or prescription drug file--Third party contract to provide information--Health insurer responsible.
A health insurer may enter into a written agreement with a third-party administrator, health care claims clearinghouse, pharmacy benefit manager, or other third party to provide the required cost-sharing information or prescription drug file in compliance with this chapter. If a health insurer chooses to enter into an agreement and the contracted party fails to provide the information or file, the health insurer is in violation of this chapter.
Source:
SL 2021, ch 213, § 6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-7 - Acting in good faith--Error or omission--Reliance on other entity.

58-17K-7. Acting in good faith--Error or omission--Reliance on other entity.
A health insurer acting in good faith and with reasonable diligence is not in violation of this chapter solely because the health insurer:
(1)Makes an error or omission in a disclosure required in this chapter, provided the health insurer corrects the information as soon as practicable; or
(2)Maintains an internet website that is temporarily inaccessible, provided the health insurer makes the information available as soon as practicable.
To the extent this chapter requires a health insurer to obtain information from any other entity, the health insurer does not fail to comply with this chapter if the health insurer relies in good faith on the information from the other entity, unless the health insurer knows, or reasonably should know, the information is incomplete or inaccurate.
Source:
SL 2021, ch 213, § 7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-8 - Compliance with applicable laws required.

58-17K-8. Compliance with applicable laws required.
Nothing in this chapter alters or affects a health insurer's duty to comply with requirements under applicable state and federal laws, including those governing accessibility, privacy, or security of information required to be disclosed under this chapter, or those governing the ability of properly authorized representatives to access enrollee information held by a health insurer.
Source:
SL 2021, ch 213, § 8.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-9 - Applicability to certain plans.

58-17K-9. Applicability to certain plans.
Nothing in this chapter applies to:
(1)A grandfathered health plan;
(2)A health reimbursement arrangement or other account-based group health plan as defined in 29 CFR 2590.715-2711(d)(6) as of January 1, 2020;
(3)A short term limited duration plan;
(4)Accident insurance;
(5)Credit insurance;
(6)Disability income insurance;
(7)Specified disease insurance;
(8)Dental insurance;
(9)Vision insurance;
(10)Coverage issued as a supplement to liability insurance;
(11)A medical payment under automobile or homeowner's insurance;
(12)Insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability policy or equivalent self-insurance;
(13)Hospital income or indemnity insurance;
(14)Long-term care insurance; and
(15)Medicare supplement insurance.
Source:
SL 2021, ch 213, § 9.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-10 - Rules and regulations.

58-17K-10. Rules and regulations.
The director shall promulgate rules, pursuant to chapter 1-26, for the following:
(1)The definition of terms;
(2)Required cost-sharing liability disclosures;
(3)The method and format requirements for disclosures;
(4)Calculations pertaining to information, disclosure, and historical net prices under this chapter;
(5)Required information, including bundled payment arrangements, preventive services, and accumulated amounts;
(6)The applicability of this chapter to certain plans; and
(7)If any federal standards are in place which would require additional steps to meet those standards beyond what is required by this chapter, additional rules to require the price transparency in this state to minimally meet the federal standards.
Source:
SL 2021, ch 213, § 10.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17K - Health Care Cost Transparency › Section 58-17K-11 - Plan years effective.

58-17K-11. Plan years effective.
The provisions of § 58-17K-5 are effective for plan years beginning on or after January 1, 2022. The provisions of §§ 58-17K-2 to 58-17K-4, inclusive, are effective for plan years beginning on or after January 1, 2024.
Source:
SL 2021, ch 213, § 11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-1 - "Group health insurance" defined.

58-18-1. Group health insurance defined.
Group health insurance is that form of health insurance covering groups of persons as defined in §§58-18-2 to 58-18-6, inclusive, with or without one or more members of their families or one or more of their dependents, or covering one or more members of the families or one or more dependents of such groups of persons, and issued upon the basis set forth in §§58-18-2 to 58-18-7, inclusive. Insurance issued on a blanket basis pursuant to §58-18-12 is a form of group health insurance.
Source:
SL 1966, ch 111, ch 26, §1; SL 2000, ch 250, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-2 - Employee group insurance authorized--"Employees" defined.

58-18-2. Employee group insurance authorized--Employees defined.
Group health insurance may be under a policy issued to an employer or trustees of a fund established by an employer, who shall be deemed the policyholder, insuring employees of such employer for the benefit of persons other than the employer. The term "employees" as used herein shall be deemed to include the officers, managers, and employees of the employer, the individual proprietor or partner if the employer is an individual proprietor or partnership, the officers, managers, and employees of subsidiary or affiliated corporations, the individual proprietor or partners and employees of individuals and firms, if the business of the employer and such individual or firm is under common control through stock ownership, contract, or otherwise. The term "employees" as used herein may include retired employees. No director of a corporate employer shall be eligible for insurance under the policy unless such person is otherwise eligible as a bona fide employee of the corporation, by performing services other than the usual duties of a director. A policy issued to insure employees of a public body may provide that the term "employees" shall include elected or appointed officials. The policy may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally with such trusteeship.
Source:
SL 1966, ch 111, ch 26, §1 (1).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-3 - Employer association group health insurance authorized--Employees defined.

58-18-3. Employer association group health insurance authorized--Employees defined.
Group health insurance may be under a policy issued to a bona fide association of employers, including a labor union, that has a constitution and bylaws and that has been organized and is maintained in good faith with at least one substantial business purpose unrelated to obtaining insurance, insuring members, employees, or employees of members of the association for the benefit of persons other than the association or its officers or trustees. For the purposes of this section, the term, employees, may include retired employees, and the term, employers, includes working owners without employees who qualify as both an employer and employee.
Source:
SL 1966, ch 111, ch 26, §1 (2); SL 2019, ch 212, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-4 - Industry fund group insurance authorized--"Employees" defined.

58-18-4. Industry fund group insurance authorized--Employees defined.
Group health insurance may be under a policy issued to the trustees of a fund established by two or more employers in the same or related industry or by one or more labor unions or by one or more employers and one or more labor unions or by an association as defined in §58-18-3, which trustees shall be deemed the policyholder, to insure employees of the employers or members of the unions or of such association, or employees of members of such association, for the benefit of persons other than the employers or the unions or such association. The term "employees" as used herein may include the officers, managers and employees of the employer, and the individual proprietor or partners if the employer is an individual proprietor or partnership. The term "employees" as used herein may include retired employees. The policy may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship.
Source:
SL 1966, ch 111, ch 26, §1 (3).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-4.1 - Restrictions on issuance of group health insurance policy to association.

58-18-4.1. Restrictions on issuance of group health insurance policy to association.
A group health insurance policy may not be issued to an association under §§58-18-3 and 58-18-4 that is formed, owned, or controlled by any of the following, other than to the extent the entities participate in the group or association in their capacity as employer members of the group or association:
(1)A health insurance issuer;
(2)A subsidiary or affiliate of a health insurance issuer;
(3)A health care organization or network provider that is part of the health care delivery system; or
(4)An insurance producer, broker, or consultant.
Source:
SL 2019, ch 212, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-4.2 - Required duration of participation by employer member in association plan.

58-18-4.2. Required duration of participation by employer member in association plan.
An employer member that participates in an association under §§58-18-3 and 58-18-4 shall participate in the association plan for a period of not less than three consecutive calendar years. Any contract issued to an association shall contain reasonable enforcement provisions including reasonable fees or assessments for early departure or for enrollment in another multiple employer plan during the early departure date.
Source:
SL 2019, ch 212, §3.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-4.3 - Association plan covering state residents to comply with state law.

58-18-4.3. Association plan covering state residents to comply with state law.
An association plan based in this state or any other state shall follow all applicable South Dakota laws and administrative rules if the association plan covers South Dakota residents.
Source:
SL 2019, ch 212, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-4.4 - Requirements for insurer offering fully insured health benefit plan through association.

58-18-4.4. Requirements for insurer offering fully insured health benefit plan through association.
A health insurer offering a fully insured health benefit plan through an association shall:
(1)Guarantee acceptance of all eligible individuals under the employer members' association or fully insured multiple employer arrangement and, if coverage is offered to spouses and dependents, to all of the spouses and dependents;
(2)Provide a bronze health plan that has an actuarial value of sixty percent;
(3)Comply with all applicable state mandates; and
(4)Have premium rates that meet a minimum loss ratio of eighty-five percent.
Source:
SL 2019, ch 212, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-5 - Issuance to person or organization to which group life insurance policy may be issued.

58-18-5. Issuance to person or organization to which group life insurance policy may be issued.
Group health insurance may be under a policy issued to any person or organization to which a policy of group life insurance may be issued or delivered in this state to insure any class or classes of individuals that could be insured under such group life policy.
Source:
SL 1966, ch 111, ch 26, §1 (4).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-6 - Issuance to cover similar group subject to discretion of director.

58-18-6. Issuance to cover similar group subject to discretion of director.
Group health insurance may be under a policy issued to cover any other substantially similar group which, in the discretion of the director, may be subject to the issuance of a group health policy or contract.
Source:
SL 1966, ch 111, ch 26, §1 (5).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-6.1 - Coverage of proprietors, partners and executive corporate officer employees.

58-18-6.1. Coverage of proprietors, partners and executive corporate officer employees.
Group health insurance, as defined in §58-18-1, is required to offer to extend health insurance coverage to proprietors, partners, and executive corporate officer employees who are participating in such group insurance in their place of employment if such proprietor, partner, or executive officer elects not to be covered under workers' compensation.
Source:
SL 1981, ch 361.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7 - Continuation without evidence of insurability--Application.

58-18-7. Continuation without evidence of insurability--Application.
Any group health policy which contains provisions for the payment by the insurer of benefits for expenses incurred on account of hospital, nursing, medical, or surgical services shall provide for the continuation of benefit provisions, or any part or parts thereof, without evidence of insurability. The provisions of §§58-18-7.4 to 58-18-7.15, inclusive, apply to employers that have fewer than twenty employees employed.
Source:
SL 1966, ch 111, ch 26, §1 (6); SL 1989, ch 433, §2; SL 2005, ch 270, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.1 - Coverage for inpatient treatment of alcoholism to be offered in group policies--Treatment within state included.

58-18-7.1. Coverage for inpatient treatment of alcoholism to be offered in group policies--Treatment within state included.
Any insurer which delivers or issues for delivery in this state group accident and sickness insurance policies which provide coverage on an expense incurred basis shall offer, in writing, to include in such group policies or contracts issued or renewed on or after July 1, 1977, coverage for the inpatient treatment of alcoholism in licensed hospitals and residential primary treatment facilities approved by the State of South Dakota which are carrying out an approved program pursuant to diagnosis and recommendation of a doctor of medicine. However, when coverage for inpatient treatment of alcoholism is included in any group policy, such coverage shall include inpatient treatment at any South Dakota approved inpatient alcoholism treatment facility.
Source:
SL 1975, ch 314, §1; SL 1976, ch 314, §1; SL 1977, ch 411, §1; SL 1978, ch 362, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.2 - Benefits provided under alcoholism coverage--Maximum treatment periods permitted.

58-18-7.2. Benefits provided under alcoholism coverage--Maximum treatment periods permitted.
The alcoholism coverage shall provide benefits on the same basis as benefits provided for the treatment of other sicknesses covered under the group policy; provided, however, that the coverage by the insurance carrier need not exceed thirty days' care in any six-month period, and further provided that the total days' care per recipient need not exceed ninety days during the life of the contract.
Source:
SL 1975, ch 314, §2; SL 1977, ch 411, §2; SL 1978, ch 362, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.3 - Policies not within alcoholism coverage requirement.

58-18-7.3. Policies not within alcoholism coverage requirement.
Sections 58-18-7.1 and 58-18-7.2 do not apply to accident only, or limited or specified disease policies.
Source:
SL 1975, ch 314, §3; SL 1999, ch 249, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.4 - Coverage upon application by employee or beneficiary with right to convert following notice of termination.

58-18-7.4. Coverage upon application by employee or beneficiary with right to convert following notice of termination.
An employee or qualified beneficiary who has the right under the group policy to convert the group accident or health insurance plan shall be issued, without evidence of insurability, upon application to the company during the one hundred eighty days prior to expiration of coverage under continuation and upon payment of the appropriate premium, a policy of accident or health insurance. The conversion coverage shall provide the benefits which are available to others qualified for conversion under the policy.
Source:
SL 1980, ch 354; SL 1989, ch 433, §3; SL 2001, ch 280, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.5 - Continuation of coverage upon leaving employment or termination of coverage by insurer--Duration.

58-18-7.5. Continuation of coverage upon leaving employment or termination of coverage by insurer--Duration.
Every health benefit program that is self-insured, and every policy of group health insurance providing benefits for hospital or medical expenses delivered or issued for delivery in this state, by a commercial health insurance company, by a nonprofit medical and surgical service plan corporation, by a nonprofit hospital service plan corporation, by a health maintenance organization or by any other similar mechanism shall, in addition to the provisions required by law, include that employees have a right upon leaving employment or the termination of the coverage by the insurer, other than the termination of the policy or contract itself and the replacement thereof by similar coverage, to have the coverage continue for themselves and their eligible dependents for a period of eighteen months for which the employee shall be financially responsible. In the case of a qualified beneficiary who is determined under title II or XVI of the Social Security Act (42 U.S.C. 401) to have been disabled at any time during the first sixty days of continuation coverage, coverage can be continued for twenty-nine months. Nonpayment of the premium by the employer is termination by the employer.
Source:
SL 1984, ch 326, §1; SL 1988, ch 400, §1; SL 1989, ch 433, §4; SL 2001, ch 280, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.11 - Continuation or conversion policy not required under certain circumstances.

58-18-7.11. Continuation or conversion policy not required under certain circumstances.
No insurer may be required to offer or renew a continuation or conversion policy covering any person if:
(1)The person is covered for similar benefits by another individual or group policy;
(2)Similar benefits are provided for or available to such person, by reason of any state or federal law, except any person who becomes entitled to Medicare on or before continuation is elected or who is covered under another group plan on or before continuation is elected;
(3)The benefits under sources of the kind referred to in subdivision (1) for such person or benefits provided or available under sources of the kind referred to in subdivision (2) for such person, together with the continued or converted policy's benefits, would result in overinsurance according to the insurer's standards for overinsurance;
(4)There has been fraud or material misrepresentation in applying for any benefits under continued or converted policy;
(5)The person failed to pay any required contribution;
(6)There has been cancellation of all similar insurance policies in the entire state;
(7)For cause on the same basis, the plan could terminate the coverage of a similarly situated active employee;
(8)The person was terminated from employment for gross misconduct; or
(9)The group health insurance policy is terminated by an insurer as a result of the group not meeting an insurer's participation or eligibility requirements.
Source:
SL 1984, ch 326, §7; SL 1989, ch 433, §9; SL 2001, ch 280, §12; SL 2009, ch 265, §1; SL 2015, ch 249, §31.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.12 - Conditions for continuation.

58-18-7.12. Conditions for continuation.
Subject to the conditions set forth for continuation in §§58-18-7 to 58-18-7.11, inclusive, a qualified beneficiary may continue coverage for a total of thirty-six months under the following conditions:
(1)If at the death of the employee or member, the qualified beneficiary's coverage under the group policy terminates by reason of such death;
(2)If a qualified beneficiary ceases to be a qualified family member under the group policy, while the employee or member remains insured under the policy;
(3)Any medicare ineligible qualified beneficiary of a current employee;
(4)The qualified beneficiary of an employee who is eligible for medicare; or
(5)Divorce or legal separation of employee.
Source:
SL 1984, ch 326, §8; SL 1988, ch 400, §2; SL 1989, ch 433, §10; SL 2001, ch 280, §13.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18 - Group And Blanket Health Insurance Policies › Section 58-18-7.13 - Premium for conversion policy and continuation policy.

58-18-7.13. Premium for conversion policy and continuation policy.
The premium for the conversion policy shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk for each person to be covered under that policy and to the type and amount of insurance provided. The premium for a continuation policy may not be greater than one hundred two percent of the group rate under which a person is covered. For any month after the eighteenth month, the premium amount may not exceed one hundred fifty percent of the applicable premium.
Source:
SL 1984, ch 326, §9; SL 1987, ch 378, §1; SL 1988, ch 400, §3; SL 1989, ch 433, §11; SL 2001, ch 280, §14.