reglab/statecodes huggingface dataset:
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-35.5 - Grandfathered contracts required to cover low-dose mammography--Extent of coverage.

58-41-35.5. Grandfathered contracts required to cover low-dose mammography--Extent of coverage.
Each health maintenance contract that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening by low-dose mammography for the presence of occult breast cancer that is subject to the same dollar limits, deductibles, and coinsurance factors as for other radiological examinations. Coverage for the screening shall be provided as follows: ages thirty-five to thirty-nine, one baseline mammography; ages forty to forty-nine, a mammography every other year; and age fifty and older, a mammography every year.
As used in this section, "low-dose mammography" means the X ray examination of the breast using equipment dedicated specifically for mammography, including the X ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad midbreast, with two views for each breast and with interpretation by a qualified radiologist.
The provisions of this section apply only to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§54 and 602, 29 C.F.R. §2590, and 45 C.F.R. §147.
Source: SL 1990, ch 397, §§1, 7; SL 1991, ch 400, §7; SL 2011, ch 216, §12.
Commission Note: SL 2011, ch 216, §19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub.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 41 - Health Maintenance Organizations › Section 58-41-35.6 - Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony.

58-41-35.6. 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 maintenance contract 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 health maintenance contract from excluding coverage for an insured for any sickness or injury caused in the commission of a felony.
Source:
SL 1997, ch 290, §§6, 7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-35.7 - Contracts required to cover occult breast cancer screening.

58-41-35.7.Contracts required to cover occult breast cancer screening.
Each health maintenance contract that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening for the presence of occult breast cancer.
The provisions of this section apply only to plans that are not grandfathered pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§54 and 602, 29 C.F.R. §2590, and 45 C.F. R. §147.
Source: SL 2011, ch 216, §17.
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 41 - Health Maintenance Organizations › Section 58-41-36 - Unfair and misleading information in evidence of coverage as misdemeanor.

58-41-36. Unfair and misleading information in evidence of coverage as misdemeanor.
No evidence of coverage shall contain provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive, as defined in §§58-41-37 to 58-41-40, inclusive. Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§19 (1), 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-37 - Deceptive advertising or evidence of coverage as misdemeanor.

58-41-37. Deceptive advertising or evidence of coverage as misdemeanor.
No health maintenance organization or representative thereof may cause or knowingly permit the use of advertising or solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§32 (1), 50; SDCL, §58-41-77; SL 1978, ch 359, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-38 - Statements deemed untrue.

58-41-38. Statements deemed untrue.
For the purposes of this chapter, a statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health maintenance organization.
Source:
SL 1974, ch 321, §32 (1) (a).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-39 - Statements deemed misleading.

58-41-39. Statements deemed misleading.
For the purposes of this chapter, a statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health care plan, if such benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist.
Source:
SL 1974, ch 321, §32 (1) (b).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-40 - Evidence of coverage deemed deceptive.

58-41-40. Evidence of coverage deemed deceptive.
For the purposes of this chapter, an evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health care plans and evidences of coverage therefor, to expect benefits, services, charges, or other advantages which the evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.
Source:
SL 1974, ch 321, §32 (1) (c).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-41 - Issuance to enrollees of change in evidence of coverage.

58-41-41. Issuance to enrollees of change in evidence of coverage.
Any approved change in evidence of coverage shall be issued to each enrollee.
Source:
SL 1974, ch 321, §21.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-42 - Evidence of coverage to be approved before use--Violation as misdemeanor.

58-41-42. Evidence of coverage to be approved before use--Violation as misdemeanor.
No evidence of coverage or amendment thereto shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment thereto has been filed with and approved by the director. Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§20, 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-43 - Filing and approval requirements applicable.

58-41-43. Filing and approval requirements applicable.
A copy of the form of evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing and approval requirements of §58-41-42 unless it is subject to the jurisdiction of the director under the laws governing health insurance or hospital or medical service corporations in which event the filing and approval provisions of such laws shall apply. To the extent, however, that such provisions do not fulfill the requirements of §§58-41-35 and 58-41-36, the requirements of said sections shall be applicable.
Source:
SL 1974, ch 321, §22.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-44 - Charges to enrollees--Fairness--Actuary's certificate.

58-41-44. Charges to enrollees--Fairness--Actuary's certificate.
Charges for comprehensive health maintenance services may be established in accordance with actuarial principles for various categories of enrollees, provided that such charges applicable to an enrollee shall not be individually determined based on the status of his health. However, the charges shall not be excessive, inadequate, or unfairly discriminatory. A certification, by a qualified actuary, to the appropriateness of the charges, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.
Source:
SL 1974, ch 321, §23 (1).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-45 - Discrimination as misdemeanor.

58-41-45. Discrimination as misdemeanor.
No health maintenance organization or representative thereof may discriminate in the rates charged enrollees except in accordance with accepted actuarial principles.
Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§32 (6), (7), 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2; SL 2013, ch 256, §11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-50 - Authorized expenses.

58-41-50. Authorized expenses.
Authorized expenses of health maintenance organizations include:
(1)Cash rebates to enrollees, or to persons who have made payments on behalf of enrollees;
(2)Free or reduced cost health service to enrollees; or
(3)Payments to providers or other persons based upon the efficient provision of services or as incentives to provide quality care.
Source:
SL 1974, ch 321, §§32 (8), 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2; SL 1985, ch 393, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-51.1 - Individual policy required for covered spouse of insured--Eligibility--Coverage--Waiting periods.

58-41-51.1. Individual policy required for covered spouse of insured--Eligibility--Coverage--Waiting periods.
No accident or health insurance policy providing coverage of hospital or medical expense which in addition to covering the insured also provides coverage to the spouse of the insured shall be issued without a provision that provides that upon eligibility for medicare or social security disability benefits by one spouse the other spouse shall be entitled to have issued to him or her, without evidence of insurability, upon application to the company within sixty days following the eligibility, and upon payment of the appropriate premium, an individual policy of accident or health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to the existing coverages. This obligation can be met by continuation of coverage for spouse under existing policy at the appropriate premium. Any and all probationary or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy.
Source:
SL 1979, ch 343.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-51.2 - Conversion privileges of insured's spouse upon divorce.

58-41-51.2. Conversion privileges of insured's spouse upon divorce.
No accident or health insurance policy providing coverage of hospital or medical expense which in addition to covering the insured also provides coverage to the spouse of the insured shall be issued without a provision that provides that upon divorce of the insured and the insured's spouse, the spouse is entitled to have issued to him or her, without evidence of insurability, upon application to the company within thirty days following the eligibility, and upon payment of the appropriate premium, an individual policy of accident or health insurance. Such policy shall provide the coverage then being issued by the insurer which is most nearly similar to the existing coverages. This obligation can be met by continuation of coverage for spouse under existing policy at the appropriate premium. Any and all probationary or waiting periods set forth in such policy shall be considered as being met to the extent coverage was in force under the prior policy.
Source:
SL 1980, ch 354.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-51.3 - Continuation and conversion coverage to be offered.

58-41-51.3. Continuation and conversion coverage to be offered.
At the time of negotiation of any health maintenance contract, the health maintenance organization shall offer, in writing, to provide the coverage prescribed by §§58-18-7.5 to 58-18-7.15, inclusive.
Source:
SL 1985, ch 393, §13.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-52 - Contracts with providers of health care services.

58-41-52. Contracts with providers of health care services.
A health maintenance organization may contract with providers of health care services to render the services the health maintenance organization has promised to provide under the terms of its health maintenance contracts.
Source:
SL 1974, ch 321, §13.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-52.1 - Collection for covered services prohibited.

58-41-52.1  .  Collection for covered services prohibited.
Except for coinsurance, deductibles, or copayments as specifically provided in the evidence of coverage, in no event, including nonpayment by the health maintenance organization, insolvency of the health maintenance organization, or breach of contract among the health maintenance organization, risk bearing entity, or participating provider, may a risk bearing entity or participating provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against an enrollee or a person other than the health maintenance organization acting on behalf of   the enrollee for covered services provided. No risk bearing entity or participating provider, nor any agent, trustee or assignee of the risk bearing entity or participating provider may maintain an action at law against an enrollee to collect sums owed by the health maintenance organization.
Source:  SL 2020, ch 210, § 10.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-52.2 - Contracts--Hold harmless provision.

58-41-52.2  .  Contracts--Hold harmless provision.
All contracts among health maintenance organizations, risk bearing entities, and participating providers shall include a hold harmless provision specifying protection for enrollees consistent with §§  58-41-52.1   to 58-41-52.3, inclusive. Any attempted waiver or amendment in a manner materially adverse to the interests of enrollees of a hold harmless provision are null and void and unenforceable. Any violation of the provisions of this section constitutes an unfair trade practice under chapter   58-33  .
Source:  SL 2020, ch 210, § 11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-52.3 - Hold harmless provision--Language of provision.

58-41-52.3  .  Hold harmless provision--Language of provision.
The requirements of §  58-41-52.2   shall be met by including a provision substantially similar to the following:
Provider agrees that in no event, including but not limited to nonpayment by the health maintenance organization or intermediary organization, insolvency of the health maintenance organization or intermediary organization, or breach of this agreement, may the provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against an enrollee or a person (other than the health maintenance organization or intermediary organization) acting on behalf of the enrollee for covered services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles, copayments or services in excess of limits, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to enrollees.
Source:  SL 2020, ch 210, § 12.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-54 - Contracts with insurance companies and nonprofit health service plan corporations authorized--Limitations.

58-41-54. Contracts with insurance companies and nonprofit health service plan corporations authorized--Limitations.
A health maintenance organization may, subject to the limitations of subdivision 58-41-17(5) and of §58-41-19, contract with insurance companies and nonprofit health service plan corporations for insurance, indemnity, or reimbursement of its cost of providing health care services for enrollees or against the risks incurred by the health maintenance organization and may contract with insurance companies and nonprofit health service plan corporations to insure or cover the enrollees' costs and expenses in the health maintenance organization, including the customary prepayment amount and any copayment obligations. If contracts are made with insurance companies or nonprofit health service plan corporations, such companies or corporations must be authorized to transact business in this state.
Source:
SL 1974, ch 321, §§13, 14.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-55 - Insurance contracts authorized--Group coverage--Benefit payments.

58-41-55. Insurance contracts authorized--Group coverage--Benefit payments.
Notwithstanding any law to the contrary, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group for group coverage under the insurance laws and the health service plan corporation laws of this state. Under such contracts, the insurer or health service plan corporation may make benefit payments to health maintenance organizations for health care services rendered, or to be rendered, by providers pursuant to the health care plan. Any insurer, or health service plan corporation, licensed to do business in this state, is authorized to provide the types of coverages described in §58-41-54.
Source:
SL 1974, ch 321, §35.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-56 - Contracts for management and administrative services authorized.

58-41-56. Contracts for management and administrative services authorized.
A health maintenance organization may contract with other persons for the provision of services, including, but not limited to, managerial and administration, marketing and enrolling, data processing, actuarial analysis, and billing services.
Source:
SL 1974, ch 321, §14.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-57 - Payment of unreasonably high expenses as misdemeanor.

58-41-57. Payment of unreasonably high expenses as misdemeanor.
No health maintenance organization shall incur or pay for any expense of any nature which is unreasonably high in relation to the value of the service or goods provided. Violation of this section is a Class 2 misdemeanor.
Source:
SL 1974, ch 321, §§41, 50; SDCL Supp, §58-41-77; SL 1978, ch 359, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-63 - General annual report required--Form and contents.

58-41-63. General annual report required--Form and contents.
Every health maintenance organization shall annually, on or before March first, file a report verified by at least two principal officers with the director, covering the preceding calendar year. Such report shall be on forms prescribed by the director and shall include:
(1)A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent certified public accountant licensed by an appropriate jurisdiction, reflecting at least:
(a)Prepayment and other payments received for health care services rendered;
(b)Expenditures to all providers, by classes or groups of providers, and insurance companies or nonprofit health service plan corporations engaged to fulfill obligations arising out of the health maintenance contract; and
(c)Expenditures for capital improvements, or additions thereto, including but not limited to construction, renovation or purchase of facilities and capital equipment;
(2)Any material changes in the information submitted pursuant to §§58-41-6 to 58-41-9, inclusive;
(3)The number of new enrollees enrolled during the year, the number of enrollees as of the end of the year and the number of enrollees terminated during the year;
(4)A summary of information compiled pursuant to subdivision 58-41-12(3) on such form as may be required by the director;
(5)A report of the names and residence addresses of all persons set forth in subdivision 58-41-6(3), who were associated with the health maintenance organization during the preceding year, and the amount of wages, expense reimbursements, or other payments to such individuals for services to the health maintenance organization, including a full disclosure of all financial arrangements during the preceding year required to be disclosed pursuant to subdivision 58-41-6(3); and
(6)Such other information relating to the performance of the health maintenance organization as is reasonably necessary to enable the director to carry out his duties under this chapter.
Source:
SL 1974, ch 321, §24; SL 2013, ch 256, §17.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-65 - Applications, filings and reports as public documents.

58-41-65. Applications, filings and reports as public documents.
All applications, filings, and reports required under this chapter are public documents except as provided for by §1-27-30.
Source:
SL 1974, ch 321, §57; SL 2013, ch 256, §18.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-66 - Annual summary for enrollees required--Contents.

58-41-66. Annual summary for enrollees required--Contents.
Every health maintenance organization or its representative shall annually, before April first, provide to its enrollees a summary of:
(1)Its most recent annual financial statement, including a balance sheet and statement of receipts and disbursements;
(2)A description of the health maintenance organization, its health care plan or plans, its facilities and personnel, and any material changes therein since the last report;
(3)The current evidence of coverage; and
(4)The health maintenance organization's method for resolving enrollee complaints.
Source:
SL 1974, ch 321, §25.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-67 - Promulgation of rules.

58-41-67. Promulgation of rules.
The director may, pursuant to chapter 1-26, promulgate such reasonable rules as are necessary to carry out the provisions of this chapter. Included among such rules shall be those which provide minimum requirements for the provision of comprehensive health maintenance services, as defined in subdivision 58-41-1(1), and reasonable exclusions therefrom.
Source:
SL 1974, ch 321, §42; SL 1986, ch 22, §43; SL 2013, ch 256, §19.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-73 - Physician-patient privileges.

58-41-73. Physician-patient privileges.
A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished such information to the health maintenance organization is entitled to claim.
Source:
SL 1974, ch 321, §36 (5).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-74 - Confidential data--Exceptions.

58-41-74. Confidential data--Exceptions.
Any data or information pertaining to the diagnosis, treatment, or health of any enrollee, or any application obtained from any person, shall be confidential and shall not be disclosed to any person except:
(1)To the extent that it may be necessary to carry out the purposes of this chapter;
(2)Upon the express consent of the enrollee or applicant;
(3)Pursuant to statute or court order for the production of evidence or the discovery thereof; or
(4)In the event of a claim or litigation between such person and the provider or health maintenance organization wherein such data or information is pertinent.
Source:
SL 1974, ch 321, §36 (5).
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-78 - Cease and desist orders.

58-41-78. Cease and desist orders.
The director may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provision of this chapter.
Source:
SL 1974, ch 321, §47.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-79 - Hearing on cease and desist order--Procedure--Judicial review.

58-41-79. Hearing on cease and desist order--Procedure--Judicial review.
Within twenty days after service of the order to cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this chapter have occurred. Such hearings shall be conducted pursuant to, and judicial review shall be available as provided by, chapter 1-26.
Source:
SL 1974, ch 321, §48.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-80 - Injunctive relief against violations--Venue.

58-41-80. Injunctive relief against violations--Venue.
In the event of any violation of the provisions of this chapter, if the director elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order pursuant to §58-41-79, the director may institute a proceeding to obtain injunctive relief or other appropriate relief in the circuit court serving Hughes County.
Source:
SL 1974, ch 321, §49.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-81 - Suspension or revocation of certificate of authority on findings by director.

58-41-81. Suspension or revocation of certificate of authority on findings by director.
The director may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if the director finds that any of the following conditions exists:
(1)The health maintenance organization is operating significantly in contravention of its basic organizational document, its health maintenance contract, or in a manner contrary to that described in and reasonably inferred from any other information submitted under this chapter, unless amendments to such submissions have been filed with and approved by the director;
(2)The health maintenance organization issues evidence of coverage or uses a schedule or charges for health care services which do not comply with the requirements of §§58-41-34 to 58-41-45, inclusive;
(3)The health care plan does not provide or arrange for comprehensive health maintenance services;
(4)The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(5)The health maintenance organization has failed to implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation under the provisions of §§58-41-23 and 58-41-24;
(6)The health maintenance organization has failed to implement the complaint system in a manner designed to reasonably resolve valid complaints;
(7)The health maintenance organization, or any person acting with its sanction, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;
(8)The continued operation of the health maintenance organization would be hazardous to its enrollees; or
(9)The health maintenance organization has otherwise failed to substantially comply with this chapter, has violated a provision of chapter 58-33 or any other provision of law applicable to health maintenance organizations, or has submitted false information in any report required hereunder.
Source:
SL 1974, ch 321, §37; SL 2000, ch 235, §3; SL 2013, ch 256, §27.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-82 - Additional grounds for suspension or revocation.

58-41-82. Additional grounds for suspension or revocation.
The director may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if:
(1)The health maintenance organization does not meet the requirements of §58-41-12; or
(2)The health maintenance organization is unable to fulfill its obligations to furnish comprehensive health maintenance services as required under its health maintenance contract.
Source:
SL 1974, ch 321, §37 (4); SL 2013, ch 256, §28.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-83 - Voluntary conference before commencing actions for violation.

58-41-83. Voluntary conference before commencing actions for violation.
If the director, for any reason, has cause to believe that any violation of this chapter has occurred or is threatened, the director may, before commencing action under §58-41-81, 58-41-82, 58-41-85, or 58-41-87, give notice to the health maintenance organization and to the representatives, or other persons who appear to be involved in such suspected violations, to arrange a voluntary conference with the alleged violators or their authorized representatives for the purpose of attempting to ascertain the fact that any violation has occurred or is threatened, to arrive at an adequate and effective means of correcting or preventing such violation.
Source:
SL 1974, ch 321, §45; SL 2013, ch 256, §29.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-84 - Informality in voluntary conferences.

58-41-84. Informality in voluntary conferences.
Proceedings under §58-41-83 are not governed by any formal procedural requirements, and may be conducted in such manner as the director finds appropriate under the circumstances.
Source:
SL 1974, ch 321, §46; SL 2013, ch 256, §30.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-85 - Money penalty in lieu of suspension or revocation.

58-41-85. Money penalty in lieu of suspension or revocation.
The director may, in lieu of suspension or revocation of a certificate of authority under 58-41-81 or 58-41-82, levy a money penalty pursuant to §58-4-28.1.
Source:
SL 1974, ch 321, §44; SL 2000, ch 235, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-86 - Requirements for suspension or revocation.

58-41-86. Requirements for suspension or revocation.
A certificate of authority shall be suspended or revoked only after compliance with the requirements of §§58-41-87 to 58-41-91, inclusive.
Source:
SL 1974, ch 321, §37.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-86.1 - Suspension without notice or hearing.

58-41-86.1. Suspension without notice or hearing.
The director of the Division of Insurance may, without advance notice or a hearing thereon, immediately suspend the certificate of authority of a health maintenance organization as to which proceedings for receivership, conservatorship, rehabilitation, or other delinquency proceedings have been commenced in any state by the public supervisory official of such state. Proceedings in such actions shall be conducted in accordance with §§58-6-49 to 58-6-61, inclusive.
Source:
SL 1985, ch 393, §12.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-87 - Notice of grounds for denial, suspension, or revocation of certificate--Time of hearing--Summary proceedings excepted.

58-41-87. Notice of grounds for denial, suspension, or revocation of certificate--Time of hearing--Summary proceedings excepted.
If the director has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, the director shall notify the health maintenance organization in writing specifically stating the grounds for denial, suspension, or revocation and fixing a time of at least twenty days thereafter for a hearing on the matter, except in summary proceedings as provided in §58-41-94.
Source:
SL 1974, ch 321, §39; SL 2013, ch 256, §31.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-88 - Administrative procedure and rules.

58-41-88. Administrative procedure and rules.
The provisions of chapter 1-26, including the right of judicial review, apply to proceedings under §§58-41-85 to 58-41-91, inclusive, to the extent those provisions are not in conflict with other provisions of such sections.
Source:
SL 1974, ch 321, §39 (4); SL 2000, ch 235, §5.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-90 - Action of director after hearing--Written findings.

58-41-90. Action of director after hearing--Written findings.
After hearing pursuant to §§58-41-87 and 58-41-88, or upon the failure of the health maintenance organization to appear at such hearing, the director shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization.
Source:
SL 1974, ch 321, §39 (2); SL 2013, ch 256, §33.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-91 - Judicial review.

58-41-91. Judicial review.
The action of the director is subject to the court of primary jurisdiction for claims of the nature and magnitude described. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the director in whole or in part.
Source:
SL 1974, ch 321, §39 (3); SL 2013, ch 256, §34.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-92 - Activities prohibited during suspension of certificate.

58-41-92. Activities prohibited during suspension of certificate.
When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization may not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and may not engage in any advertising or solicitation whatsoever. A health maintenance organization may not enroll such additional enrollees if it is suspended on those grounds in subdivisions 58-41-81(4) and (8) and §58-41-86.1.
Source:
SL 1974, ch 321, §38; SL 1985, ch 393, §11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-93 - Winding up after revocation of certificate--Continued operation to protect enrollees.

58-41-93. Winding up after revocation of certificate--Continued operation to protect enrollees.
When the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The director may, by written order, permit further operation of the organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage.
Source:
SL 1974, ch 321, §38.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-94 - Summary proceeding to reorganize organization--Grounds.

58-41-94. Summary proceeding to reorganize organization--Grounds.
The director may apply for an order directing him to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more of the grounds set out in chapter 58-29B, or when in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or the people of this state.
Source:
SL 1974, ch 321, §40.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-95 - Rehabilitation, liquidation, or conservation under insurance company laws.

58-41-95. Rehabilitation, liquidation, or conservation under insurance company laws.
Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the director pursuant to chapter 58-29B, except to the extent that the nature of health maintenance organizations renders such law clearly inappropriate.
Source:
SL 1974, ch 321, §40.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-96 - Severability of provisions.

58-41-96. Severability of provisions.
If a part of this chapter is invalid, all valid parts that are severable from the invalid part remain in effect. If a part of this chapter is invalid in one or more of its applications, the part remains in effect in all valid applications that are severable from the invalid applications.
Source:
SL 1974, ch 321, §58.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-98 - Coverage for phenylketonuria.

58-41-98. Coverage for phenylketonuria.
Every health maintenance contract that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall offer coverage for testing, diagnosis, and treatment of phenylketonuria including dietary management, formulas, case management, intake and screening, assessment, comprehensive care planning, and service referral.
Source:
SL 1992, ch 348, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-99 - Formation of voluntary health insurance purchasing organizations.

58-41-99. Formation of voluntary health insurance purchasing organizations.
Notwithstanding the provisions of chapter 47-34A and §§ 47-15-2 and 47-22-4, any organization may form for the purposes of purchasing group health insurance on a voluntary basis. For purposes of §§58-41-99 to 58-41-109, inclusive, an organization means any nonprofit organization or nonprofit corporation formed under South Dakota law.
Source:
SL 1994, ch 382, §1; SL 2021, ch 210, § 24.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-100 - Membership of voluntary health insurance purchasing organizations.

58-41-100. Membership of voluntary health insurance purchasing organizations.
Any organization may have a group health insurance policy issued to that organization on behalf of its members who would be insured under such policy. Members may join the organization, for the purpose of obtaining group health insurance, as individuals, employers, labor unions, associations, or substantially similar groups.
Source:
SL 1994, ch 382, §2.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-101 - Purchasing organization's responsibility for negotiating terms and conditions.

58-41-101. Purchasing organization's responsibility for negotiating terms and conditions.
The organization shall be responsible for negotiating the terms and conditions of insurance contracts, collection of premiums, and providing notice to members.
Source:
SL 1994, ch 382, §3.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-102 - Purchasing organization's notice of premium charge.

58-41-102. Purchasing organization's notice of premium charge.
The organization may provide not less than forty-five days advance notice of any benefit or premium change to its members.
Source:
SL 1994, ch 382, §4.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-104 - Approval of purchasing organization by Division of Insurance.

58-41-104. Approval of purchasing organization by Division of Insurance.
Any organization shall, prior to its engaging in the business of insurance, obtain approval from the Division of Insurance. The division may deny approval or withdraw approval of an organization to engage in the business of insurance for any of the following reasons:
(1)Any of the grounds specified in §58-6-8;
(2)Insufficient membership control of the organization;
(3)Unreasonable compensation to officers, directors, or employees of the organization;
(4)Misuse of premiums; or
(5)Refusal to be examined or to cooperate in an examination.
Source:
SL 1994, ch 382, §6.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-105 - Premiums held in trust by purchasing organization.

58-41-105. Premiums held in trust by purchasing organization.
The organization shall hold all premiums received in trust and promptly remit premiums to the person entitled thereto.
Source:
SL 1994, ch 382, §7.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-106 - Rates for group health insurance issued to purchasing organizations.

58-41-106. Rates for group health insurance issued to purchasing organizations.
Any insurer issuing group health insurance pursuant to §§58-41-99 to 58-41-109, inclusive, is subject to all of the provisions of chapter 58-18B relating to rates.
Source:
SL 1994, ch 382, §8.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-107 - Reasonable participation requirements for group members of purchasing organizations.

58-41-107. Reasonable participation requirements for group members of purchasing organizations.
An insurer may as a condition of offering coverage or continuing coverage require reasonable participation requirements of groups who become members of an organization.
Source:
SL 1994, ch 382, §9.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-108 - Purchasing organizations exempt from antitrust provisions.

58-41-108. Purchasing organizations exempt from antitrust provisions.
Any organization formed pursuant to §§58-41-99 to 58-41-109, inclusive, is exempt from the antitrust provisions under chapter 37-1.
Source:
SL 1994, ch 382, §10.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-109 - Promulgation of rules for purchasing organizations.

58-41-109. Promulgation of rules for purchasing organizations.
The director may promulgate rules pursuant to chapter 1-26 to further the provisions of §§58-41-99 to 58-41-109, inclusive, and for purposes of carrying out the provisions of §§58-18-1 to 58-18-6, inclusive, and to ensure that group health insurance coverage is issued to eligible groups and that organizations are formed and operated to further the purpose of providing economical group health insurance for its members. The rules may include:
(1)Definition of terms;
(2)Criteria for determining groups, associations, organizations, and trusts and their eligibility for coverage;
(3)Criteria for determining substantially similar groups or for determining related industries;
(4)Application requirements and procedures;
(5)Reasonable compensation; and
(6)Organizational structure.
Source:
SL 1994, ch 382, §11.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-110 - Application of chapter to provider contracting with state.

58-41-110. Application of chapter to provider contracting with state.
Nothing in this chapter applies to a medical provider who enters into a contract with the State of South Dakota for services pursuant to chapter 3-12A.
Source:
SL 1995, ch 294, §1.
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 41 - Health Maintenance Organizations › Section 58-41-111 - Application of chapter to provider contracting with licensed health maintenance organization.

58-41-111. Application of chapter to provider contracting with licensed health maintenance organization.
Any medical provider who enters into a contract for medical services with a licensed health maintenance organization or a health insurer licensed pursuant to this title is not required to be licensed pursuant to this chapter.
Source:
SL 1995, ch 294, §2.