reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:39 - General exception for certain small group health plans

Current through Register Vol. 51, page 10, July 15, 2024
The requirements of §§
									20:06:40:29  to 20:06:40:41, inclusive, do not apply to any group health plan and group health insurance coverage for any plan year, if on the first day of the plan year, the plan has fewer than two participants who are current employees. However, the following requirements apply without regard to this exception:
(1) SDCL  58-18-45(4);
(2)
									§§
									20:06:46:03  to 20:06:46:08, inclusive, as they apply with respect to genetic information as a health factor;
(3)
									§
									20:06:46:04, as it applies with respect to genetic information as a health factor;
(4)
									§§
									20:06:46:10  and 20:06:46:13  to 20:06:46:15, inclusive, as they apply with respect to genetic information as a health factor;
(5)
									§
									20:06:40:31;
(6)
									§§
									20:06:40:32  and 20:06:40:33;
(7)
									§§
									20:06:40:35  to 20:06:40:38, inclusive, and §
									20:06:40:29(12).
This section applies to group health plans, and health insurance issuers offering group health insurance coverage, for plan years beginning on or after the effective date of those sections.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:40 - Applicability to excepted benefits

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:40:29 to 20:06:40:41, inclusive, do not apply to excepted benefits as defined by 29 USC 1191 b(c), as of August 1, 2010.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:41 - Effective date

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:40:29 to 20:06:40:41, inclusive, apply for plan years beginning on or after the effective date of those sections.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:42 - Definitions. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-79(1),  58-18-79(15),  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:43 - Parity requirements with respect to aggregate lifetime and annual dollar limits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:44 - Plan with no limit or limits on less than one-third of all medical or surgical benefits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:45 - Plan with a limit on at least two-thirds of all medical or surgical benefits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:46 - Determining one-third and two-thirds of all medical or surgical benefits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:47 - Plan not described in sections 20:06:40:44 or 20:06:40:45 of this chapter. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:48 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of classification of benefits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(1),  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:49 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of type of financial requirement or treatment limitation. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(1),  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:50 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of level of a type of financial requirement or treatment limitation. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79(1),  58-18-79(15),  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:51 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of coverage unit. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79(1),  58-18-79(15),  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:52 - General parity requirement. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:53 - Classifications of benefits used for applying rules. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:54 - Application to out-of-network providers. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:55 - Financial requirements and quantitative treatment limitations - Determining substantially all. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:56 - Financial requirements and quantitative treatment limitations - Determining predominant. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:57 - Financial requirements and quantitative treatment limitations - Determining portion based on plan payments. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:58 - Financial requirements and quantitative treatment limitations - Determining clarifications for certain threshold requirements. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:59 - Application to different coverage units. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:60 - Special rule for multi-tiered prescription drug benefits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:61 - No separate cumulative financial requirements or cumulative quantitative treatment limitations. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:62 - Nonquantitative treatment limitations. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:63 - Illustrative list of nonquantitative treatment limitations. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:64 - Exemptions. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:65 - Availability of plan information - Criteria for medical necessity determinations. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:66 - Availability of plan information - Reasons for denial. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:67 - Applicability - Group health plans. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:68 - Applicability - Health insurance issuers. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:69 - Scope. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:70 - Small employer exemption. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:71 - Determining employer size. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:72 - Sale of nonparity health insurance coverage. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:73 - Special effective date for certain collectively-bargained plans. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:74 - Establishment of sub-classifications for determining parity for outpatient benefits. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-18-79,  58-18-80.
International Classification of Disease
, 9th Revision, Clinical Modification (ICD-9-CM), 2010. Copies may be obtained from Optum, Inc., P.O. Box 27116, Salt Lake City, Utah 84127-0116; $99.95.
DSM-IV-TR--Diagnostic and Statistical Manual of Mental Disorders
, Fourth Edition, Text Revision, published by the American Psychiatric Association. Copies may be obtained from Optum, Inc., P.O. Box 27116, Salt Lake City, Utah 84127-0116; $99.95.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:75 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
(1) "Employer contribution rule," a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of participants and beneficiaries;
(2) "Group participation rule," a requirement relating to the minimum number of participants or beneficiaries that must be enrolled in relation to a specified percentage or number of eligible individuals or employees of an employer;
(3) "Health insurance issuer," any person that provides health insurance in this state including an insurance company, a prepaid hospital or similar plan, a health maintenance organization, a multiple employer welfare arrangement, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. A health insurance issuer does not include a person providing only excepted benefits; and
(4) "Small employer," in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least one but not more than 50 employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year.
General Authority:
SDCL  58-18B-36(7)(8)(11),  58-18B-46.
Law Implemented:
SDCL  58-18B-36,  58-18B-37,  58-18B-46.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:76 - Guaranteed issue

Current through Register Vol. 51, page 10, July 15, 2024
A small employer health insurance issuer must offer each of its small employer plans to any eligible small employer on a guaranteed issue basis without medical underwriting. A small employer health insurance issuer may use reasonable contribution and participation requirements that are consistent between small employers and which do not relate to the health status or health history of the employees or dependents of a small employer or the risk characteristics of the small employer as a whole. A health insurance issuer may limit the availability of health insurance coverage offered in the small group market to an annual enrollment period that begins November 15 and extends through December 15 of each year if a plan sponsor is unable to comply with a material plan provision relating to employer contribution or group participation rules as required by SDCL 58-18B-24 to 58-18B-26, inclusive. With respect to coverage in the small group market, and in the large group market if such coverage is offered in a Small Business Health Options Program (SHOP) as defined in §
									20:06:55:32  in this state, coverage must become effective consistent with the dates described in 45 CFR §
										155.725(h).
General Authority:
SDCL  58-18B-36(7)(8)(11),  58-18B-46.
Law Implemented:
SDCL  58-18B-36,  58-18B-37,  58-18B-46.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:77 - Disclosure requirements

Current through Register Vol. 51, page 10, July 15, 2024
In its sales and solicitation materials, a health insurance issuer must disclose that the following specific materials are available upon request:
(1) A statement detailing the health insurance issuer's right to change premium rates and the factors that may affect changes in premium rates;
(2) A notice detailing renewability of coverage;
(3) A description of the geographic area served by the Health Maintenance Organization; and
(4) A statement of the benefits and premiums available for all health insurance coverage for which the employer is qualified under permitted contribution and participation requirements.
This section does not require the disclosure of proprietary information or trade secrets. The disclosure information provided must be in a format that is understandable by the average small employer and sufficient to reasonably inform small employers of their rights and obligations under the health insurance coverage. Examples of reasonable information that may be provided pursuant to this section include rating schedules for each product for which more than one rate applies and maps of the service areas or lists of counties served by a network plan.
General Authority:
SDCL  58-18B-36(8),(9),  58-18B-46.
Law Implemented:
SDCL  58-18B-6,  58-18B-36,  58-18B-46.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:78 - Guaranteed availability of coverage in the group market

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer that offers health insurance in the group market in this state must offer to any individual or employer in the state all products that are approved for sale in the applicable market, and must accept any individual or employer that applies for any of those products.
A health insurance issuer offering health insurance coverage in the small group market must ensure that such coverage includes the essential health benefits package as defined in §
									20:06:56:03  effective for plan or policy years beginning after December 31, 2013. Except for catastrophic plans, any plans not providing at least a bronze level of coverage or not providing essential health benefits as defined in §
									20:06:56:03  must be issued as a supplement to other health insurance coverage and may not be used to replace essential health benefits coverage, a grandfathered health benefit plan or a catastrophic plan.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:79 - Denial of coverage

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer may deny health insurance coverage in the group market if the issuer demonstrates to the director the following:
(1) The health insurance issuer does not have the financial reserves necessary to underwrite additional coverage; and
(2) The health insurance issuer is applying the denial uniformly to all employers or individuals in the group or individual market, as applicable, in this state without regard to the claims experience of those individuals, employers, and their employees and their employees' dependents or any health status-related factor relating to such individuals, employees, and dependents.
An issuer that denies group health insurance coverage to any employer may not offer coverage in the group market in this state before the later of the following dates:
(1) The 181st day after the date the issuer denies coverage, or
(2) The date the issuer demonstrates to the applicable state authority that the issue has sufficient financial reserves to underwrite additional coverage.
Nothing in this section limits the issuer's ability to renew coverage already in force or relieve the issuer of the responsibility to renew that coverage. Coverage offered after the 180-day period specified in this section is subject to the requirements of this section and §
											20:06:55:42. The ability to offer or renew coverage as specified by this section and §
											20:06:55:42  is subject to all applicable service area requirements and restrictions.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:80 - Special enrollment period effective dates

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer must provide special enrollment periods consistent with this section, during which qualified individuals and enrollees may enroll in plans or change enrollment from one nongrandfathered health plan to another. Once a qualified individual is determined eligible for a special enrollment period, the health insurance issuer must ensure that the qualified individual's effective date of coverage is:
(1) Between the first and the fifteenth day of any month, the plan must ensure a coverage effective date of the first day of the following month;
(2) Between the sixteenth and the last day of any month, the plan must ensure a coverage effective date of the first day of the second following month;
(3) In the case of birth, adoption, or placement for adoption, the plan must ensure that coverage is effective on the date of birth, adoption, or placement for adoption; and
(4) In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, the plan must ensure coverage is effective on the first day of the following month.
Unless specifically stated otherwise herein, a qualified individual or enrollee has 30 days from the date of a triggered event to select a plan.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:81 - Special enrollment triggers

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer offering health insurance coverage in the group market and SHOP Exchange as defined in §
									20:06:55:32  must allow for an individual to enroll or change from one nongrandfathered health plan to another as a result of the following triggers:
(1) The death of the covered individual;
(2) The termination of individual's employer coverage other than by reason of gross misconduct, or reduction of hours of the covered employee's spouse;
(3) The divorce or legal separation;
(4) Individual becoming entitled to benefits under XVII of the Social Security Act;
(5) Dependent child ceasing to be dependent child;
(6) A proceeding in a case under Title 11, United States Code, commencing on or after July 1, 1986, with respect to the employer from whose employment the covered individual retired at any time;
(7) An individual gains a dependent or becomes a dependent through marriage, birth adoption or placement for adoption;
(8) An individual, who was not previously a citizen, national, or lawfully present individual gains such status; and
(9) A qualified individual or enrollee gains access to nongrandfathered health plan as a result of a permanent move.
This section does not apply to grandfathered plans.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:82 - Nonrenew or discontinuance of coverage

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer offering health insurance coverage in the group market is required to renew or continue in force the coverage at the option of the plan sponsor or the employer, as applicable. An issuer may nonrenew or discontinue health insurance coverage offered in the group market based only on one or more of the following:
(1) Nonpayment of premiums. The plan sponsor or employer, as applicable, fails to pay premiums or contributions in accordance with the terms of the health insurance coverage, including any timeliness requirements;
(2) Fraud. The plan sponsor or employer, as applicable, performs an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact in connection with the coverage;
(3) Violation of participation or contribution rules. In the case of group health insurance coverage, the plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules;
(4) Termination of plan. The issuer ceases to offer coverage in the market;
(5) Enrollees' movement outside service area. For network plans, there is no longer any enrollee under the plan who lives, resides, or works in the service area of the issuer or in the area for which the issuer is authorized to do business; and in the case of the small group market, the issuer applies the same criteria it would apply in denying enrollment in the plan under 45 CFR §
										147.104(c)(1)(i);
(6) Association membership ceases. For coverage made available in the small or large group market only through one or more bona fide associations, if the employer's membership in the bona fide association ceases, but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:83 - Discontinuing a particular product

Current through Register Vol. 51, page 10, July 15, 2024
If an issuer discontinues offering a particular product in the group market, that product may be discontinued by the issuer in the applicable market only if the following occurs:
(1) The issuer provides notice in writing to each plan sponsor, as applicable, provided that particular product in that market and to all participants and beneficiaries covered under such coverage of the discontinuation at least 90 calendar days before the date the coverage will be discontinued;
(2) The issuer offers to each plan sponsor, as applicable, provided that particular product the option, on a guaranteed issue basis, to purchase all or, in the case of the large group market, any other health insurance coverage currently being offered by the issuer to a group health plan or individual health insurance coverage in that market; and
(3) In exercising the option to discontinue that product and in offering the option of coverage, the issuer acts uniformly without regard to the claims experience of those sponsors or individuals, as applicable, or any health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for such coverage.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:84 - Discontinuing all coverage

Current through Register Vol. 51, page 10, July 15, 2024
An issuer may elect to discontinue offering all health insurance coverage in the group market, or all markets, in a state in accordance with applicable state law only if the issuer meets all of the following conditions:
(1) The issuer provides notice in writing to the applicable state authority and to each plan sponsor or individual, as applicable, and all participants and beneficiaries covered under the coverage of the discontinuation at least 180 calendar days prior to the date the coverage will be discontinued;
(2) All health insurance policies issued or delivered for issuance in the state in the applicable market or markets are discontinued and not renewed; and
(3) An issuer that elects to discontinue offering all health insurance coverage in a market or markets may not issue coverage in the applicable market or markets and state involved during the 5-year period beginning on the date of discontinuation of the last coverage not renewed.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:85 - Exception for uniform modification of coverage

Current through Register Vol. 51, page 10, July 15, 2024
Only at the time of coverage renewal may issuers modify the health insurance coverage for a product offered to a group health plan in the following:
(1) Large group market; and
(2) Small group market if, for coverage available in this market other than only through one or more bona fide associations, the modification is consistent with state law and is effective uniformly among group health plans with that product.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:86 - Preexisting condition exclusion and waiting period prohibited

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer offering a group health benefit plan may not impose any preexisting condition exclusion or preexisting condition waiting period with respect to such coverage.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:87 - Clinical trial

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer that offers a health benefit plan providing group market health insurance coverage in this state may not:
(1) Deny participation by a qualified individual in an approved clinical trial;
(2) Deny, limit or impose additional conditions on the coverage of routine patient costs for items or services furnished in connection with participation in the trial; or
(3) Discriminate against an individual on the basis of the individual's participation in an approved clinical trial.
A network plan may require a qualified individual who wishes to participate in an approved clinical trial to participate in a trial that is offered through a health care provider who is part of the network plan if the provider is participating in the trial and the provider accepts the individual as a participant in the trial.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:88 - Full-time equivalents treated as full-time employees

Current through Register Vol. 51, page 10, July 15, 2024
Solely for purposes of determining whether an employer is an applicable large employer under this paragraph, an employer shall, in addition to the number of full-time employees for any month otherwise determined, include for such month a number of full-time employees determined by dividing the aggregate number of hours of service of employees who are not full-time employees for the month by 120.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:89 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of §§
									20:06:40:75  to 20:06:40:88  apply for plan years beginning after December 31, 2013. Except as otherwise specified in this chapter, the chapter applies to small and large employers. Sections 20:06:40:75 to 20:06:40:88 do not apply to grandfathered health plans.
Sections 20:06:40:01, 20:06:40:03, 20:06:40:06, 20:06:40:08, 20:06:40:09, 20:06:40:10, 20:06:40:11, 20:06:40:12, and 20:06:40:14 are repealed effective January 1, 2014.
Sections 20:06:40:01.01 and 20:06:40:03.01 are effective January 1, 2014.
Section 20:06:40:04 only applies to grandfathered plans.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Appendix B - Notice of Research Exception

Current through Register Vol. 51, page 10, July 15, 2024
Notice of Research Exception
PART I: Entity Classification and Identification
1. Date of submission: ________________________
2. Specify whether the entity claiming the research exception is:
(A) [] A group health plan (plan); or
(B) [] A health insurance issuer (issuer).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:41 - HIPAA rules - Small employer › Section 20:06:41:11 - Effective dates

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:41:01 to 20:06:41:11, inclusive, are repealed effective January 1, 2014.
General Authority:
SDCL  58-18B-20.
Law Implemented:
SDCL  58-18B-20.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:42 - Associations eligible for group health insurance › Section 20:06:42:01 - Eligible associations defined

Current through Register Vol. 51, page 10, July 15, 2024
A bona fide association is a group of persons who have joined for some common purpose or goal. A bona fide association is eligible for the issuance of group health insurance if all of the following factors are met and filed for approval by the director:
(1) There is a shared or common purpose that is not generally applicable to the population at large;
(2) There is a constitution and by-laws which indicate a legitimate purpose other than the purchase of insurance with at least one substantial business purpose unrelated to obtaining insurance;
(3) The primary method of obtaining new members is not through, or in conjunction with, the solicitation of insurance. However, solicitation of insurance may be one of the methods of obtaining new members;
(4) The functions and activities of the group or association are controlled by its employer members. The associations employer members that participate in the group health plan must control the plan in form and in substance;
(5) Employer members must be in the same trade, industry, line of business, or profession; and
(6) Each employer member has a principal place of business in the same geographic region.
When determining eligibility for the issuance of group health insurance, the division may consider whether the association ever existed independently of an insurance product.
General Authority:
SDCL  58-18-62,  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:42 - Associations eligible for group health insurance › Section 20:06:42:01.01 - Working owner defined

Current through Register Vol. 51, page 10, July 15, 2024
A working owner is an individual who:
(1) Has an ownership right of any nature in a trade or business, whether incorporated or unincorporated, including a partner and other self-employed individual which is in the same trade, industry, line of business, or profession as the association sponsoring the multiple employer trust;
(2) Has no employees under common law; and
(3) Earns wages or self-employment income from the trade or business for providing personal services to the trade or business and who:
(a) Works on average at least twenty hours per week or at least eighty hours per month providing personal services to the trade or business; or
(b) Has wages or self-employment income from such trade or business that at least equals the working owner's cost of coverage for participation by the working owner and any covered beneficiaries in the group health plan sponsored by the group or association in which the individual is participating.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:42 - Associations eligible for group health insurance › Section 20:06:42:01.02 - Eligibility determinations for coverage of working owners

Current through Register Vol. 51, page 10, July 15, 2024
The association must determine eligibility of working owners for plan coverage when the working owner first becomes eligible for coverage under the group health plan. Continued eligibility must be periodically confirmed pursuant to reasonable monitoring procedures. The associations governing documents must include reasonable provisions regarding approval and expulsion of working owners from plan coverage.
General Authority:
SDCL  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:42 - Associations eligible for group health insurance › Section 20:06:42:01.03 - Notification to association members

Current through Register Vol. 51, page 10, July 15, 2024
Each application for insurance and each policy and certificate issued by an insurer through an association plan shall contain in ten-point type on the front page the following notice prominently displayed:
NOTICE
This policy is issued through an association. By accepting coverage, you must participate in this plan for a minimum of three years to avoid penalties for early departure.
General Authority:
SDCL  58-18-62,  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:42 - Associations eligible for group health insurance › Section 20:06:42:02 - Credit unions

Current through Register Vol. 51, page 10, July 15, 2024
Credit unions formed pursuant to state or federal law are associations eligible for the issuance of group health insurance.
General Authority:
SDCL  58-18-62.
Law Implemented:
SDCL  58-18-3,  58-18-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:43 - Annuity mortality tables › Section 20:06:43:02 - Individual annuity or pure endowment contracts

Current through Register Vol. 51, page 10, July 15, 2024
(1) Except as provided in subdivision 2 of this section, the 1983 Table "a" and the Annuity 2000 Mortality Table are recognized and approved as individual annuity mortality tables for valuation and, at the option of the company, either of these tables may be used for purposes of determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after July 1, 1978.
(2) Except as provided in subdivision 3 of this section, the Annuity 2000 Mortality Table shall be used for determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after January 1, 2001.
(3) Except as provided in subdivision 4 of this section, the 2012 IAR Mortality Table shall be used for determining the minimum standard of valuation for any individual annuity or pure endowment contract issued on or after January 1, 2015.
(4) The 1983 Table "a" without projection is to be used for determining the minimum standards of valuation for an individual annuity or pure endowment contract issued on or after January 1, 2001, solely when the contract is based on life contingencies and is issued to fund periodic benefits arising from:
(a) Settlements of various forms of claims pertaining to court settlements or out of court settlements from tort actions;
(b) Settlements involving similar actions such as workers compensation claims; or
(c) Settlements of long term disability claims where a temporary or life annuity has been used in lieu of continuing disability payments.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:43 - Annuity mortality tables › Section 20:06:43:02.01 - Application of the 2012 IAR Mortality Table

Current through Register Vol. 51, page 10, July 15, 2024
In using the 2012 IAR Mortality Table, the mortality rate for a person age x in year (2012 + n) is calculated as follows:
qx2012+n=qx2012(1-G2 x)n
The resulting qx2012+n shall be rounded to three decimal places per 1,000, e.g., 0.741 deaths per 1,000. Also, the rounding shall occur according to the formula above, starting at the 2012 period table rate.
General Authority:
SDCL  58-26-69.
Law Implemented:
SDCL  58-26-69.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:43 - Annuity mortality tables › Section 20:06:43:03 - Group annuity or pure endowment contracts

Current through Register Vol. 51, page 10, July 15, 2024
(1) Except as provided in subdivision 2 of this section, the 1983 GAM Table, the 1983 Table "a", and the 1994 GAR Table are recognized and approved as group annuity mortality tables for valuation and, at the option of the company, any one of these tables may be used for the purposes of valuation for an annuity or pure endowment purchased on or after July 1, 1978, under a group annuity or pure endowment contract.
(2) The 1994 GAR Table shall be used for determining the minimum standard of valuation for any annuity or pure endowment purchased on or after July 1, 2001, under a group annuity or pure endowment contract.
General Authority:
SDCL  58-26-69.
Law Implemented:
SDCL  58-26-69.
For 1983 Table "a",
1982 Proceedings of the NAIC
, Volume II, page 454, National Association of Insurance Commissioners. Copies of the entire volume may be obtained from the National Association of Insurance Commissioners, Attention Publications Department, 120 West Twelfth Street, Suite 1100, Kansas City, MO 64105, Telephone Number (816) 374-7259. Cost: Free for members; $180 for nonmembers. Copies of individual pages may be obtained from the National Association of Insurance Commissioners, Attention Research Library, 120 West Twelfth Street, Suite 1100, Kansas City, MO 64105, Telephone Number (816) 374-7175. Cost: Free for members; $10 flat fee plus 30 cents per page certain for nonmembers (with a higher charge for pages not certain). For 1983 GAM Table,
1984 Proceedings of the NAIC
, Volume I, pages 414-415, National Association of Insurance Commissioners. Copies of the entire volume may be obtained from the National Association of Insurance Commissioners, Attention Publications Department, 120 West Twelfth Street, Suite 1100, Kansas City, MO 64105, Telephone Number (816) 374-7259. Cost: Free for members; $180 for nonmembers. Copies of individual pages may be obtained from the National Association of Insurance Commissioners, Attention Research Library, 120 West Twelfth Street, Suite 1100, Kansas City, MO 64105, Telephone Number (816) 374-7175. Cost: Free for members; $10 flat fee plus 30 cents per page certain for nonmembers (with a higher charge for pages uncertain). For 1994 GAR Table,
Transactions of the Society of Actuaries
, Volume XLVII, 1995, pages 865-919, Society of Actuaries. Copies may be obtained from the Society of Actuaries, Attention Publications Department, 475 North Martingale Road, Suite 800, Schaumburg, IL 60173-2226, Telephone Number (847) 706-3526. Cost: $55 per book. For copies of tables, first 40 pages, $10 for members and $20 for nonmembers; each additional page, 25 cents for members and 50 cents for nonmembers.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:43 - Annuity mortality tables › Section 20:06:43:04 - Application of the 1994 GAR Table

Current through Register Vol. 51, page 10, July 15, 2024
In using the 1994 GAR Table, the mortality rate for a person age x in year (1994 + n) is calculated as follow:
qx
1994+n
=qx
1994
(1-AA x)
n
where the qx
1994
s and AAxs are as specified in the 1994 GAR Table.
General Authority:
SDCL  58-26-69.
Law Implemented:
SDCL  58-26-69.
Transactions of the Society of Actuaries
, Volume XLVII, 1995, pages 865-919, Society of Actuaries. Copies may be obtained from Society of Actuaries, Attention Publications Department, 475 Martingale Road, Suite 800, Schaumburg, IL 60173-2226, Telephone Number (847) 706-3526. Cost: $55 per book. For copies of tables, first 40 pages, $10 for members and $20 for nonmembers; each additional page, 25 cents for members and 50 cents for nonmembers.