reglab/statecodes huggingface dataset:
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-64 - Closed panel plans.

58-18A-64. Closed panel plans.
Under the terms of a closed panel plan, no benefits are payable if the covered person does not use the services of a closed panel provider. No COB occurs if a covered person is enrolled in two or more closed panel plans and obtains services from a provider in one of the closed panel plans because the other closed panel plan (the one whose providers were not used) has no liability. However, COB may occur during the plan year if the covered person receives emergency services that would have been covered by both plans. In such a case, the secondary plan shall use the provisions of §58-18A-75 to determine the amount it should pay for the benefit.
Source:
SL 2006, ch 259, §12.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-65 - Prohibition on reduction of benefits for coverage not qualifying as plan.

58-18A-65. Prohibition on reduction of benefits for coverage not qualifying as plan.
No plan may use a COB provision, or any other provision, that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of a plan as provided by §§58-18A-53 to 58-18A-83, inclusive.
Source:
SL 2006, ch 259, §13.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-66 - Order of benefit payments.

58-18A-66. Order of benefit payments.
If a person is covered by two or more plans, the provisions for determining the order of benefit payments are as follows:
(1)The primary plan shall pay or provide its benefits as if any secondary plan did not exist;
(2)If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered person uses a nonpanel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan;
(3)If multiple contracts providing coordinated coverage are treated as a single plan under §§58-18A-53 to 58-18A-83, inclusive, this section applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan shall be responsible for the plan's compliance with §§58-18A-53 to 58-18A-83, inclusive;
(4)If a person is covered by more than one secondary plan, the order of benefit determination provisions of §§58-18A-53 to 58-18A-83, inclusive, decide the order in which secondary plans benefits are determined in relation to each other. Each secondary plan shall take into consideration the benefits of any primary plan and the benefits of any other plan, which, under the provisions of §§58-18A-53 to 58-18A-83, inclusive, has its benefits determined before those of that secondary plan;
(5)Except as provided in subdivision (2) of this section, a plan that does not contain order of benefit determination provisions that are consistent with §§58-18A-53 to 58-18A-83, inclusive, is always the primary plan unless the provisions of both plans, regardless of the provisions of this section, state that the complying plan is primary;
(6)Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits.
Source:
SL 2006, ch 259, §14.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-67 - Coordination of benefits only available to secondary plans.

58-18A-67. Coordination of benefits only available to secondary plans.
A plan may take into consideration the benefits paid or provided by another plan only if, under the provisions of §§58-18A-53 to 58-18A-83, inclusive, it is secondary to that other plan.
Source:
SL 2006, ch 259, §15.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-68 - Order of benefits determined under §§ 58-18A-69 to 58-18A-74.

58-18A-68. Order of benefits determined under §§58-18A-69 to 58-18A-74.
Each plan shall determine its order of benefits using the first section of §§58-18A-69 to 58-18A-74, inclusive, that applies.
Source:
SL 2006, ch 259, §16.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-69 - Plan covering person other than as dependent.

58-18A-69.Plan covering person other than as dependent.
The plan that covers the person other than as a dependent, for example as an employee, member, subscriber, policyholder, or retiree, is the primary plan and the plan that covers the person as a dependent is the secondary plan.
However, if the person is a medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, medicare is:
(1)Secondary to the plan covering the person as a dependent; and
(2)Primary to the plan covering the person as other than a dependent (e. g. a retired employee);
then the order of benefits is reversed so that the plan covering the person as an employee, member, subscriber, policyholder, or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan.
Source:
SL 2006, ch 259, §17.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-70 - Plan covering dependent child.

58-18A-70. Plan covering dependent child.
Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:
(1)For a dependent child whose parents are married or are living together, whether or not they have ever been married:
(a)The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or
(b)If both parents have the same birthday, the plan that has covered the parent longest is the primary plan;
(2)For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:
(a)If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan. This item does not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;
(b)If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subdivision (1) of this section shall determine the order of benefits;
(c)If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subdivision (1) of this section shall determine the order of benefits; or
(d)If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows:
(i)The plan covering the custodial parent;
(ii)The plan covering the custodial parent's spouse;
(iii)The plan covering the noncustodial parent; and then
(iv)The plan covering the noncustodial parent's spouse;
(3)For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, pursuant to subdivision (1) or (2) of this section as if those individuals were parents of the child; and
(4)For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the provisions of §58-18A-73 apply. If the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or both parents' plans, the order of benefits shall be determined, as applicable, pursuant to the provisions of subdivision (1) of this section to the dependent child's parent or parents and the dependent's spouse.
Source:
SL 2006, ch 259, §18; SL 2015, ch 253, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-71 - Plan covering person as active employee.

58-18A-71. Plan covering person as active employee.
The plan that covers a person as an active employee that is, an employee who is neither laid off nor retired or as a dependent of an active employee is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee is the secondary plan.
If the other plan does not have the provisions of this section, and as a result, the plans do not agree on the order of benefits, the provisions of this section do not apply.
This section does not apply if the provisions in §58-18A-69 can determine the order of benefits.
Source:
SL 2006, ch 259, §19.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-72 - Coverage under COBRA or right of continuation.

58-18A-72. Coverage under COBRA or right of continuation.
If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another plan, the plan covering the person as an employee, member, subscriber, or retiree or covering the person as a dependent of an employee, member, subscriber, or retiree is the primary plan and the plan covering that same person pursuant to COBRA or under a right of continuation pursuant to state or other federal law is the secondary plan.
If the other plan does not have these provisions, and if, as a result, the plans do not agree on the order of benefits, these provisions do not apply.
This section does not apply if the provisions in §58-18A-69 determine the order of benefits.
Source:
SL 2006, ch 259, §20.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-73 - Plan covering person for longer period of time.

58-18A-73. Plan covering person for longer period of time.
If the preceding provisions in §§58-18A-69 to 58-18A-72, inclusive, do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.
To determine the length of time a person has been covered under a plan, two successive plans shall be treated as one if the covered person was eligible under the second plan within twenty-four hours after coverage under the first plan ended.
The start of a new plan does not include:
(1)A change in the amount or scope of a plan's benefits;
(2)A change in the entity that pays, provides, or administers the plan's benefits; or
(3)A change from one type of plan to another, such as, from a single employer plan to a multiple employer plan.
The person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available for a group plan, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person's coverage under the present plan has been in force.
Source:
SL 2006, ch 259, §21.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-74 - Sharing of allowable expenses equally.

58-18A-74. Sharing of allowable expenses equally.
If the preceding provisions of §§58-18A-69 to 58-18A-73, inclusive, do not determine the order of benefits, the allowable expenses shall be shared equally between the plans.
Source:
SL 2006, ch 259, §22.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-75 - Calculation of amount to be paid by secondary plan.

58-18A-75. Calculation of amount to be paid by secondary plan.
In determining the amount to be paid by the secondary plan on a claim, if the plan wishes to coordinate benefits, the secondary plan shall calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any allowable expense under its plan that is unpaid by the primary plan. The secondary plan may reduce its payment by the amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim do not exceed one hundred percent of the total allowable expense for that claim. In addition, the secondary plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.
Source:
SL 2006, ch 259, §23.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-76 - Plan providing benefits as services.

58-18A-76. Plan providing benefits as services.
A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary plan. Nothing in this section requires a plan to reimburse a covered person in cash for the value of services provided by a plan that provides benefits in the form of services.
Source:
SL 2006, ch 259, §24.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-77 - Coordination of benefits of complying and noncomplying plans.

58-18A-77. Coordination of benefits of complying and noncomplying plans.
A plan with order of benefit determination provisions that comply with §§58-18A-53 to 58-18A-83, inclusive, may coordinate its benefits with a plan that is excess or always secondary or that uses order of benefit determination provisions that are inconsistent with those contained in §§58-18A-53 to 58-18A-83, inclusive, on the following basis:
(1)If the complying plan is the primary plan, it shall pay or provide its benefits first;
(2)If the complying plan is the secondary plan, it shall pay or provide its benefits first, but the amount of the benefits payable shall be determined as if the complying plan were the secondary plan. In such a situation, the payment shall be the limit of the complying plan's liability; and
(3)If the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan shall assume that the benefits of the noncomplying plan are identical to its own, and shall pay its benefits accordingly. If, within two years of payment, the complying plan receives information as to the actual benefits of the noncomplying plan, it shall adjust payments accordingly.
Source:
SL 2006, ch 259, §25.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-78 - Noncomplying secondary plan to advance difference covered person would have received if complying plan had been secondary plan.

58-18A-78. Noncomplying secondary plan to advance difference covered person would have received if complying plan had been secondary plan.
If the noncomplying plan reduces its benefits so that the covered person receives less in benefits than the covered person would have received had the complying plan paid or provided its benefits as the secondary plan and the noncomplying plan paid or provided its benefits as the primary plan, then the complying plan shall advance to the covered person or on behalf of the covered person an amount equal to the difference.
In no event may the complying plan advance more than the complying plan would have paid had it been the primary plan less any amount it previously paid for the same expense or service. In consideration of the advance, the complying plan shall be subrogated to all rights of the covered person against the noncomplying plan. The advance by the complying plan shall also be without prejudice to any claim it may have against a noncomplying plan in the absence of subrogation.
Source:
SL 2006, ch 259, §26.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-79 - Subrogation distinguished.

58-18A-79. Subrogation distinguished.
COB differs from subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other.
Source:
SL 2006, ch 259, §27.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-80 - Paying of claim where plans disagree on order of benefits.

58-18A-80. Paying of claim where plans disagree on order of benefits.
If the plans cannot agree on the order of benefits within thirty calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment. However, no plan is required to pay more than it would have paid had it been the primary plan.
Source:
SL 2006, ch 259, §28.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-81 - Time for bringing existing contract into compliance with statutory requirements.

58-18A-81. Time for bringing existing contract into compliance with statutory requirements.
A contract that provides health care benefits and that was issued before July 1, 2006, shall be brought into compliance with §§58-18A-53 to 58-18A-83, inclusive, by the later of:
(1)The next anniversary date or renewal date of the contract;
(2)Twelve months following July 1, 2006; or
(3)The expiration of any applicable collectively bargained contract pursuant to which it was written.
For the transition period between the adoption of §§58-18A-53 to 58-18A-83, inclusive, and the timeframe for which plans are to be in compliance pursuant to this section, no plan that is subject to the prior COB requirements may be considered a noncomplying plan by a plan subject to the new COB requirements. If there is a conflict between the prior COB requirements under the prior act and the new COB requirements under §§58-18A-53 to 58-18A-83, inclusive, the prior COB requirements shall apply.
Source:
SL 2006, ch 259, §29.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-82 - Proceedings not subject to statutory requirements.

58-18A-82. Proceedings not subject to statutory requirements.
Sections 58-18A-53 to 58-18A-83, inclusive, do not affect an action or proceeding commenced before July 1, 2006.
Source:
SL 2006, ch 259, §30.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18A - Coordination Of Benefits Of Health Plans › Section 58-18A-83 - Duties, rights accrued, and offenses committed prior to July 1, 2007.

58-18A-83. Duties, rights accrued, and offenses committed prior to July 1, 2007.
Sections 58-18A-53 to 58-18A-83, inclusive, do not impair or affect any duty or act done, offense committed or right accruing, accrued or acquired or liability, penalty, forfeiture or punishment incurred prior to the date on or after July 1, 2007, but the same may be employed, asserted, enforced, prosecuted or inflicted, as fully and to the same extent as if this enactment had not been passed.
Source:
SL 2006, ch 259, §33.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-2 - Chapter applicable to small employer benefit plans.

58-18B-2. Chapter applicable to small employer benefit plans.
This chapter is applicable to any health benefit plan which provides coverage to two or more employees of a small employer and policies which meet the following criteria:
(1)Any portion of the premium or benefits is paid by or on behalf of the small employer; or
(2)The health benefit plan is treated by the employer or any of the eligible employees or dependents as part of a plan or program for the purposes of section 125 or section 106 of the United States Internal Revenue Code as of January 1, 1995.
This chapter does not apply to any employer plan with only one employee. Any employer plan with only one employee, even if the employer pays a portion or all of the premium, may be sold as individual policies subject to the provisions of chapter 58-17. If a plan covering one employee is sold as an individual plan and new employees are added which brings the number of employees to at least two but not more than fifty, then the individual carrier may nonrenew the coverage or accept those new employees and bring the plan into compliance with the applicable provisions of chapters 58-18 and 58-18B.
Source:
SL 1991, ch 402, §2; SL 1995, ch 281, §2; SL 1996, ch 298; SL 1998, ch 292, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-3.1 - Base rate increase to be filed with director--Approval or disapproval.

58-18B-3.1. Base rate increase to be filed with director--Approval or disapproval.
No small employer carrier may increase its small employer base rates unless the small employer carrier has filed the base rate increase with the director for review at least thirty days prior to the implementation of the rate increase. The base rates are deemed approved at the expiration of thirty days after the filing thereof unless disapproved by the director within thirty days after the date of filing. The filing of the base rate increase shall include documentation sufficient to actuarially justify the increase and a history of the earned premiums and incurred claims on the policy forms applicable to the rate increase. The base rates shall be reasonable in relation to the benefits.
Source: SL 2011, ch 216, §18.
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 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-6 - Disclosure in solicitation and sales materials.

58-18B-6. Disclosure in solicitation and sales materials.
Each small employer carrier shall make reasonable disclosure in solicitation and sales materials provided to small employers of the following:
(1)The extent to which premium rates for a specific small employer are established or adjusted due to the claim experience, health status or duration of coverage of the employees or dependents of the small employer;
(2)The provisions concerning the carrier's right to change premium rates and the factors, including case characteristics, which affect changes in premium rates;
(3)A description of the class of business in which the small employer is or will be included, including the applicable grouping of plans; and
(4)The provisions relating to renewability of coverage.
Source:
SL 1991, ch 402, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-7 - Information and documentation required--Disclosure.

58-18B-7. Information and documentation required--Disclosure.
Each small employer carrier shall maintain at the carrier's principal place of business a complete and detailed description of the carrier's rating practices and renewal underwriting practices, including information and documentation which demonstrate that the carrier's rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
A small employer carrier shall make the information and documentation required by this section available to the director upon request. Except in cases of violations of this chapter, the information shall be considered proprietary and trade secret information and is not subject to disclosure by the director to persons outside of the division except as agreed to by the carrier or by order of a court, or if requested by a law enforcement officer or another state insurance agency.
Source:
SL 1991, ch 402, §7; SL 1995, ch 281, §12; SL 2009, ch 262, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-8 - Suspension of rate requirements.

58-18B-8. Suspension of rate requirements.
The director may suspend all or any part of the premium rate requirements of §58-18B-3 applicable to one or more small employers for one or more rating periods upon a filing by the small employer carrier and a finding by the director that either the suspension is reasonable in light of the financial condition of the carrier or that the suspension would enhance the efficiency and fairness of the marketplace for small employer health insurance.
Source:
SL 1991, ch 402, §8.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-9 - Application of chapter.

58-18B-9. Application of chapter.
The provisions of this chapter apply to each health benefit plan for a small employer that is delivered, issued for delivery, renewed or continued in this state after July 1, 1992. The date a plan is continued is the first rating period which commences after July 1, 1992.
Source:
SL 1991, ch 402, §9.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-11 - Health maintenance organization considered separate carrier.

58-18B-11. Health maintenance organization considered separate carrier.
An affiliated carrier that is a health maintenance organization having a certificate of authority under chapter 58-41 may be considered to be a separate carrier for the purposes of this chapter.
Source:
SL 1995, ch 281, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-12 - Ceding arrangements resulting in less than fifty percent of obligation or risk retained by carrier prohibited.

58-18B-12. Ceding arrangements resulting in less than fifty percent of obligation or risk retained by carrier prohibited.
Unless otherwise authorized by the director, no small employer carrier may enter into one or more ceding arrangements with respect to health benefit plans delivered or issued for delivery to small employers in the state if the arrangements would result in less than fifty percent of the insurance obligation or risk for such health benefit plans being retained by the ceding carrier.
Source:
SL 1995, ch 281, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-13 - Transition period when acquiring additional class of business.

58-18B-13. Transition period when acquiring additional class of business.
The director may promulgate rules pursuant to chapter 1-26 to provide for a period of transition in order for a small employer carrier to come into compliance with subdivision 58-18B-1(5) when the carrier acquires an additional class of business from another small employer carrier.
Source:
SL 1995, ch 281, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-14 - Rate changes only for small employer business.

58-18B-14. Rate changes only for small employer business.
Unless otherwise specified, nothing in this chapter requires a carrier to change any of its rates or rating methodologies for any business other than the small employer business subject to the provisions of this chapter.
Source:
SL 1995, ch 281, §7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-15 - Provisions for premium rates.

58-18B-15. Provisions for premium rates.
Premium rates for health benefit plans subject to this chapter are subject to the following provisions:
(1)Adjustments in rates for claim experience, health status, and duration of coverage may not be charged to individual employees or dependents. Any such adjustments shall be applied uniformly to the rates charged for all employees and dependents of the small employer;
(2)A small employer carrier may utilize industry as a case characteristic in establishing premium rates, if the highest rate factor associated with any industry classification does not exceed the lowest rate factor associated with any industry classification by more than fifteen percent;
(3)Small employer carriers shall apply rating factors, including case characteristics, consistently with respect to all small employers in a class of business;
(4)For the purposes of this section, a health benefit plan that utilizes a restricted provider network is not considered similar coverage to a health benefit plan that does not utilize such a network, if utilization of the restricted provider network results in substantial differences in claims costs; and
(5)No small employer carrier may use case characteristics, other than age, gender, industry, family composition, and group size without prior approval of the director.
Source:
SL 1995, ch 281, §8.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-17 - Limit on premium rates.

58-18B-17. Limit on premium rates.
The premium rates for an individual covered in a small employer plan may not exceed the premium rate for any other individual covered under the same small employer carrier because of age alone by a factor of 3:1. A small employer carrier may not require any individual to pay any premium or contribution that is greater than that for a similarly situated individual enrolled in the plan. Nothing in this section prohibits a group health plan, and a health insurance issuer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion or disease prevention.
Source:
SL 1995, ch 281, §10; SL 1997, ch 289, §15; SL 2001, ch 279, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-18 - Promulgation of rules for rating practices.

58-18B-18. Promulgation of rules for rating practices.
The director may promulgate rules pursuant to chapter 1-26 to implement the provisions of §§58-18B-1 to 58-18B-3, inclusive, §58-18B-7, §§58-18B-15 to 58-18B-18, inclusive, and to assure that rating practices used by small employer carriers are consistent with the purposes of this chapter, including rules that:
(1)Assure that differences in rates charged for health benefit plans by small employer carriers are reasonable and reflect objective differences in plan design not including differences due to the nature of the groups assumed to select particular health benefit plans; and
(2)Prescribe the manner in which case characteristics may be used by small employer carriers.
Source:
SL 1995, ch 281, §11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-20 - Small employer carrier to issue plan to any small employer--Criteria--Exceptions--Two percent earned premium threshold.

58-18B-20. Small employer carrier to issue plan to any small employer--Criteria--Exceptions--Two percent earned premium threshold.
A small employer carrier shall issue health benefit plans to any small employer that applies for a plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health benefit plan not inconsistent with this chapter. If, on the first day of the plan year, a small employer plan has fewer than two participants who are current employees, the carrier is not required to issue a policy to the small employer. A small employer carrier may apply reasonable criteria in determining whether to accept a small employer into a particular class of business if:
(1)The criteria are not related to the health status or claim experience of the small employer;
(2)The criteria are applied consistently to all small employers applying for coverage in the class of business; and
(3)The small employer carrier provides for the acceptance of all eligible small employers into one or more classes of business.
The provisions of this section do not apply to a class of business into which the small employer carrier is no longer enrolling new small businesses. If the director determines that all carriers in the small employer market have met the two percent threshold, the threshold shall, upon order of the director, be expanded an additional two percent. The threshold shall be expanded in additional two percent increments if all small employer carriers meet the previous threshold. No small employer carrier is required to issue coverage to any small employer if the small employers who are at high-risk constitute two percent of that carrier's earned premium on an annual basis from small employer health benefit plans. The director may promulgate rules pursuant to chapter 1-26 to determine which policies may be used to determine the two percent threshold, the procedures involved, and the applicable time frames. In making that determination, the director shall develop a method designed to limit the number of high risk groups to which any one carrier may be required to issue coverage.
Source:
SL 1995, ch 281, §14; SL 1997, ch 289, §16; SL 1998, ch 289, §14; SL 2001, ch 279, §3.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-23 - Uniform application of requirements used to determine eligibility of employers.

58-18B-23. Uniform application of requirements used to determine eligibility of employers.
Except as provided in §58-18B-26, requirements used by a small employer carrier in determining whether to provide coverage to a small employer, including requirements for minimum participation of eligible employees and minimum employer contributions, shall be applied uniformly among all small employers with the same number of eligible employees applying for coverage or receiving coverage from the small employer carrier. An association of small employer plans may require, as a condition of obtaining or continuing coverage, membership in the association.
Source:
SL 1995, ch 281, §17.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-24 - Application of minimum participation and minimum employer contribution requirements.

58-18B-24. Application of minimum participation and minimum employer contribution requirements.
A small employer carrier may vary application of minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group or by the class of business.
Source:
SL 1995, ch 281, §18.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-25 - Considerations in applying minimum participation requirements--Premium discounts.

58-18B-25. Considerations in applying minimum participation requirements--Premium discounts.
In applying minimum participation requirements with respect to a small employer, a small employer carrier may consider employees or dependents who have creditable coverage in determining whether the applicable percentage of participation is met. If any employee or dependent with other creditable coverage is to be considered towards calculating the applicable percentage of participation, the employee or dependent shall be counted as participating in the plan.
A carrier may provide up to a twenty percent discount for any small employer who achieves a one hundred percent participation rate in the prior year. The discount may be less than the base rate by a factor up to twenty percent. However, no discount below the base rate may be used in determining the index rate for that class of business.
Source:
SL 1995, ch 281, §19; SL 1997, ch 289, §17; SL 2001, ch 279, §4; SL 2005, ch 271, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-26 - Increase in minimum requirements for employee participation or employer contribution prohibited after acceptance for coverage.

58-18B-26. Increase in minimum requirements for employee participation or employer contribution prohibited after acceptance for coverage.
No small employer carrier may increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has been accepted for coverage.
Source:
SL 1995, ch 281, §20.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-27 - Modification to exclude certain diseases prohibited.

58-18B-27. Modification to exclude certain diseases prohibited.
No small employer carrier may modify a health benefit plan with respect to a small employer or any eligible employee or dependent through riders, endorsements, or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the health benefit plan. A small employer carrier may not establish rules for eligibility for any individual to enroll under a plan, including continued eligibility, based on health status-related factors which include health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, including conditions arising out of acts of domestic violence, and disability.
Source:
SL 1995, ch 281, §22; SL 1997, ch 289, §18; SL 1998, ch 289, §17.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-27.1 - Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony.

58-18B-27.1. Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony.
A health benefit plan of a small employer carrier that is delivered, issued for delivery, or renewed in this state may not exclude the payment of benefits for injuries sustained by an insured person because the insured was under the influence of alcohol or drugs, as defined by §32-23-1.
Nothing in this section precludes a hospital or medical service plan from excluding coverage for an insured for any sickness or injury caused in the commission of a felony.
Source:
SL 1997, ch 290, §§3, 7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-28 - Requirements lifted from small employer carrier in financially impaired condition.

58-18B-28. Requirements lifted from small employer carrier in financially impaired condition.
No small employer carrier may be required to provide coverage to small employers pursuant to §58-18B-20, for any period of time for which the director determines that requiring the acceptance of small employers in accordance with the provisions of §58-18B-20, would place the small employer carrier in a financially impaired condition.
Source:
SL 1995, ch 281, §23.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-35 - Director to promulgate rules regulating sale of multiple employer trusts and welfare arrangements--Scope of rules.

58-18B-35. Director to promulgate rules regulating sale of multiple employer trusts and welfare arrangements--Scope of rules.
The director shall promulgate rules pursuant to chapter 1-26 regulating the solicitation and sale of multiple employer trusts and multiple employer welfare arrangements. In considering the promulgation of rules pursuant to this section, the director shall take into consideration, the status of the small employer market, the impact such rules would have on the availability of health insurance and the impact such rules may have on the fair marketing of health insurance in this state. Rules promulgated pursuant to this section may not directly or indirectly affect stop loss or excess insurance covering health claims of employees arising from self-funded employee health programs. The rules may cover:
(1)Suitability and eligibility of insureds for coverage;
(2)Method of premium payments;
(3)Contractual obligations and policy provisions of carriers;
(4)Form filing requirements, including those for approval and disapproval;
(5)Reporting and recordkeeping requirements;
(6)Definition of terms; and
(7)Eligibility of insurers.
Source:
SL 1995, ch 281, §30; SL 1997, ch 289, §20; SL 1998, ch 293, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-36 - Rules governing implementation and administration of this chapter.

58-18B-36. Rules governing implementation and administration of this chapter.
The director shall promulgate rules pursuant to chapter 1-26 to provide for the implementation and administration of this chapter. The rules shall cover:
(1)Terms of renewability;
(2)Initial and subsequent conditions of eligibility;
(3)Probationary periods;
(4)Benefit limitations, exceptions and reductions;
(5)Requirements for replacement;
(6)Participation and contribution requirements;
(7)Definition of terms;
(8)Marketing practices;
(9)Reporting and disclosure practices or requirements;
(10)Compensation arrangements between insurers or other entities and their agents, representatives, or producers;
(11)Guaranteed acceptance of small groups by small group carriers;
(12)Continuation and conversion rights; and
(13)Group discontinuance and replacement.
The director may promulgate rules pursuant to chapter 1-26 that specify prohibited policy or certificate provisions not otherwise specifically authorized by statute which, in the opinion of the director, are unjust, unfair, or unfairly discriminatory to any person insured or proposed for coverage under a policy or certificate. If any federal standards are in place which would require additional steps to meet those standards beyond what is required by this chapter, the director may promulgate rules to require the offering of health insurance plans, in addition to those specifically required by §58-18B-20, the underwriting criteria that may be utilized for such health insurance plans, and other requirements related to the availability of health insurance to individuals in this state in order to minimally meet the federal standards.
Source:
SL 1995, ch 281, §31; SL 1997, ch 289, §21; SL 1998, ch 289, §19.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-37 - Marketing health benefit plans--Denial of coverage to employer.

58-18B-37. Marketing health benefit plans--Denial of coverage to employer.
Each small employer carrier shall actively market health benefit plan coverage, to eligible small employers in the state. A small employer carrier may not deny coverage to a small employer on the basis of the health status or claims experience of the small employer or its employees or dependents. A network plan is not required to offer coverage to an employer whose employees do no work or reside within the carrier's established geographic service. A network plan may deny coverage to employers if it demonstrates it does not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees, and if it is applying this denial of coverage uniformly to all employers without regard to the claims experience of those employers, and their employees and their dependents, or any health status-related factor relating to the employees and dependents.
Source:
SL 1995, ch 281, §32; SL 1997, ch 289, §22; SL 1998, ch 289, §20.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-38 - Prohibited activities of small employer carriers or insurance producers.

58-18B-38. Prohibited activities of small employer carriers or insurance producers.
No small employer carrier or insurance producer may, directly or indirectly, engage in the following activities:
(1)Encouraging or directing small employers to refrain from filing an application for coverage with the small employer carrier because of the health status, claims experience, industry, occupation, or geographic location of the small employer; or
(2)Encouraging or directing small employers to seek coverage from another carrier because of the health status, claims experience, industry, occupation, or geographic location of the small employer.
Source:
SL 1995, ch 281, §33; SL 2001, ch 286, §123.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 18B - Regulation Of Small Businesses' Group And Blanket Health Insurance › Section 58-18B-39 - Information regarding restricted network provision of carrier.

58-18B-39. Information regarding restricted network provision of carrier.
The provisions of §58-18B-38 do not apply with respect to information provided by a small employer carrier or insurance producer to a small employer regarding a restricted network provision of a small employer carrier.
Source:
SL 1995, ch 281, §34; SL 2001, ch 286, §124.