reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:21 - Loss ratio standards

Current through Register Vol. 51, page 10, July 15, 2024
A Medicare supplement policy form or certificate form may not be delivered or issued for delivery in this state unless the policy form or certificate form can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return the following to policyholders and certificateholders in the form of aggregate benefits provided under the policy form or certificate form, not including anticipated refunds or credits, at least 75 percent of the aggregate amount of premiums earned in the case of group policies or at least 65 percent of the aggregate amount of premiums earned in the case of individual policies.
The ratios in this section shall be based on incurred claims experience or incurred health care expenses if coverage is provided by a health maintenance organization on a service rather than reimbursement basis and on earned premiums for the period in accordance with accepted actuarial principles and practices. Incurred health care expenses where coverage is provided by a health maintenance organization may not include home office and overhead costs; advertising costs; commissions and other acquisition costs; taxes; capital costs; administrative costs; and claim processing costs.
All filings of rates and rating schedules must demonstrate that expected claims in relation to premiums comply with the requirements of this section when combined with actual experience to date. Filings of rate revisions must also demonstrate that the anticipated loss ratio over the entire future period for which the revised rates are computed to provide coverage can be expected to meet the applicable loss ratio standards. Policies issued as a result of solicitations of individuals through the mail or by mass media advertising, including both print and broadcast advertising, shall be deemed to be individual policies.
For policies issued before July 17, 1992, expected claims in relation to premiums must meet the following requirements:
(1) The originally filed anticipated loss ratio when combined with the actual experience since inception;
(2) The applicable loss ratio requirement from the first paragraph of this section, when combined with actual experience to date, beginning with the effective date of this amendment; and
(3) The applicable loss ratio requirement from the first paragraph of this section over the entire future period for which the rates are computed to provide coverage.
In meeting these requirements and for the purpose of attaining credibility, an insurer may combine experience under policy forms which provide substantially similar coverage. Once a combined form is adopted, the insurer may not separate the experience except with the approval of the director.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:21.01 - Refund or credit calculation

Current through Register Vol. 51, page 10, July 15, 2024
An issuer shall collect and file with the director by May 31 of each year the data required on the forms in Appendix A at the end of this chapter for each type in a standard Medicare supplement benefit plan.
If, on the basis of the experience as reported, the benchmark ratio since inception (ratio 1) exceeds the adjusted experience ratio since inception (ratio 3), a refund or credit calculation is required. The refund or credit calculation shall be done on a statewide basis for each type in a standard Medicare supplement benefit plan. For purposes of the refund or credit calculation, experience on policies issued with the reporting year shall be excluded.
For purposes of this section, for policies or certificates issued before July 17, 1992, the issuer shall make the refund or credit calculation separately for all individual policies combined, including all group policies subject to an individual loss ratio standard when issued, and all other group policies combined for experience after the effective date of this amendment. The first such report affected by this paragraph is due May 31, 1998.
The issuer may refund or credit only when the benchmark loss ratio exceeds the adjusted experience loss ratio and the amount to be refunded or credited exceeds the sum of $5. The refund shall include interest from the end of the calendar year to the date of the refund or credit at a rate specified by the secretary of health and human services, but it may not be less than the average rate of interest for 13-week treasury notes on the date of refund or credit calculation as established by the federal reserve board and published in the Wall Street Journal. The issuer shall make a refund or credit against premiums due by September 30 following the experience year upon which the refund or credit is based.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
Notes:
As of the effective date of this rule, the secretary of the U.S. Department of Health and Human Services had not specified an interest rate.
Forms may be obtained from the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501, (605) 773-3563, free of charge.
Combination of experience for calculation of refund or credit, §
											20:06:13:22.06.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22 - Annual filing of premium rates

Current through Register Vol. 51, page 10, July 15, 2024
An issuer of Medicare supplement policies and certificates issued either before or after the effective date of this rule must file its rates, rating schedule, and supporting documentation annually, including ratios of incurred losses to earned premiums by policy duration, for approval by the director in accordance with SDCL  58-17A-4,  58-17-4.1,  58-17-4.2, ARSD chapter 20:06:22, and this chapter. The supporting documentation must also demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the applicable loss ratio standards can be expected to be met over the entire period for which rates are computed. The demonstration shall exclude active life reserves. An expected third-year loss ratio which is greater than or equal to the applicable percentage must be demonstrated for policies or certificates in force less than 3 years.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.01 - Filing of premium adjustments after Medicare benefit change

Current through Register Vol. 51, page 10, July 15, 2024
As soon as practicable, but prior to the effective date of enhancements in Medicare benefits, each issuer of Medicare supplement policies or certificates in this state shall file the following with the director, in accordance with the applicable provisions of SDCL  58-17A-4,  58-17-4.1,  58-17-4.2, ARSD chapter 20:06:22, and this chapter:
(1) The premium adjustments necessary to produce loss ratios as anticipated for the current premium for the applicable policies or certificates. Supporting documents necessary to justify the adjustment must accompany the filing.
An issuer shall make the premium adjustments necessary to produce an expected loss ratio under the policy or certificate that will conform with minimum loss ratio standards for Medicare supplement policies in §
										20:06:13:21  and which are expected to result in a loss ratio at least as great as that originally anticipated in the rates used to produce current premiums by the issuer for the Medicare supplement policies or certificates. No premium adjustment which would modify the loss ratio experience under the policy other than the adjustments described in this section may be made to a policy at any time other than upon its renewal date or anniversary date.
If an issuer fails to make premium adjustments acceptable to the director, the director may order premium adjustments, refunds, or premium credits considered necessary to achieve the loss ratio required by this section;
(2) Any riders, endorsements, or policy forms needed to accomplish the Medicare supplement policy or certificate modifications necessary to eliminate benefit duplications with Medicare. The riders, endorsements, or policy forms must provide a clear description of the Medicare supplement benefits provided by the policy or certificate.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.02 - Public hearings

Current through Register Vol. 51, page 10, July 15, 2024
The director may conduct a public hearing to gather information concerning a request by an issuer for an increase in a rate for a policy form or certificate form issued either before or after the effective date of this rule if the experience of the form for the previous reporting period is not in compliance with the applicable loss ratio standard. The determination of compliance is made without consideration of any refund or credit for the reporting period. Public notices of the hearing shall be furnished by the director in compliance with SDCL  1-26-16.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.03 - Filing and approval of policies and certificates and of premium rates required

Current through Register Vol. 51, page 10, July 15, 2024
An issuer may not deliver or issue for delivery a policy or certificate to a resident of this state unless the policy form or certificate form has been filed with and approved by the director in accordance with SDCL  58-17A-4,  58-17-4.1,  58-17-4.2, ARSD chapter 20:06:22 and this chapter.
An issuer may not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule, and supporting documentation have been filed with and approved by the director in accordance with the applicable provisions of SDCL  58-17A-4,  58-17-4.1,  58-17-4.2, ARSD chapter 20:06:22, and this chapter.
An issuer shall not present for filing or approval a rate structure for its Medicare supplement policies or certificates issued after January 1, 2006, based upon a structure or methodology with any groupings of attained ages greater than one year. The ratio between rates for successive ages shall increase smoothly as age increases.
General Authority:
SDCL  58-4-1,  58-17A-2,  58-17A-5.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.04 - One policy or certificate form allowed - Exceptions

Current through Register Vol. 51, page 10, July 15, 2024
An issuer may not file for approval more than one form of a policy or certificate of each type for each standard Medicare supplement benefit plan except as provided in this section.
An issuer may offer, with the approval of the director, up to four additional policy forms or certificate forms of the same type for the same standard Medicare supplement benefit plan, one for each of the following cases:
(1) The inclusion of new or innovative benefits;
(2) The addition of either direct response or agent marketing methods;
(3) The addition of either guaranteed issue or underwritten coverage; and
(4) The offering of coverage to individuals eligible for Medicare by reasons of disability.
General Authority:
SDCL  58-4-1,  58-17A-2,  58-17A-5.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.05 - Discontinuance of availability

Current through Register Vol. 51, page 10, July 15, 2024
An issuer shall continue to make available for purchase any policy form or certificate form issued after the effective date of this rule that has been approved by the director, unless the issuer notifies the director of its discontinuance in accordance with this section. A policy form or certificate form is not considered to be available for purchase unless the issuer has actively offered it for sale in the previous 12 months.
An issuer may discontinue the availability of a policy form or certificate form if the issuer provides notice of its decision to do so to the director in writing at least 30 days prior to discontinuance. After receipt of the notice by the director, the issuer may no longer offer for sale the policy form or certificate form in this state.
An issuer that discontinues the availability of a policy form or certificate form pursuant to the notice procedure in this section may not file for approval a new policy form or certificate form of the same type for the same standard Medicare supplement benefit plan as the discontinued form for five years after the issuer provides notice to the director of the discontinuance. The period of discontinuance may be reduced by the director at the director's discretion.
The sale or other transfer of Medicare supplement business to another issuer is considered a discontinuance for the purposes of this section.
A change in the rating structure or methodology is considered a discontinuance under the first paragraph of this section unless the issuer provides an actuarial memorandum describing the manner in which the revised rating methodology and resultant rates differ from the existing rating methodology and existing rates; and the issuer does not subsequently put into effect a change of rates or rating factors that would cause a change in the percentage differential between the discontinued and subsequent rates as described in the actuarial memorandum. The director may approve a change to the differential which is in the public interest.
General Authority:
SDCL  58-4-1,  58-17A-2,  58-17A-5.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.06 - Combination of experience for calculation of refund or credit

Current through Register Vol. 51, page 10, July 15, 2024
The experience of all policy forms or certificate forms of the same type in a standard Medicare supplement benefit plan shall be combined for purposes of the refund or credit calculation prescribed in §
									20:06:13:21.01. Forms assumed under an assumption reinsurance agreement may not be combined with the experience of other forms for purposes of the refund or credit calculation.
General Authority:
SDCL  58-4-1,  58-17A-2,  58-17A-5.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:22.07 - New or innovative benefits - Policy or certificate form allowed - Exceptions - issued after May 31, 2010

Current through Register Vol. 51, page 10, July 15, 2024
An issuer may, with the prior approval of the director, offer policies or certificates with new or innovative benefits in addition to the standardized benefits provided in a policy or certificate that otherwise complies with the applicable standards. Such new or innovative benefits shall include only benefits that are applicable to Medicare supplement insurance, are new or innovative, are not otherwise available, and are cost-effective. Approval of new or innovative benefits shall not adversely impact the goal of Medicare supplement simplification. New or innovative benefits shall not include an outpatient prescription drug benefit. New or innovative benefits shall not be used to change or reduce benefits, including a change of any cost-sharing provision, in any standardized plan.
General Authority:
SDCL  58-4-1,  58-17A-2,  58-17A-5.
Law Implemented:
SDCL  58-17A-2,  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:24 - Disclosure of preexisting conditions

Current through Register Vol. 51, page 10, July 15, 2024
A policy containing a preexisting condition limitation shall display the preexisting condition limitation as a separate paragraph labeled "Preexisting Condition Limitations."
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:25 - Increased benefits after issue

Current through Register Vol. 51, page 10, July 15, 2024
A rider attached to a policy after issue which increases benefits with an increase in premium shall be agreed to in writing and signed by the insured. This section does not apply to increases in benefits required by law, increases to meet changes in Medicare deductibles or copayments, or increases in benefits requested by the insured in writing.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:26 - Separate additional premium disclosure

Current through Register Vol. 51, page 10, July 15, 2024
A rider or endorsement requiring an additional premium shall display its premium prominently in the policy. The premium may not be displayed as part of an aggregate premium.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:27 - Buyer's guide

Current through Register Vol. 51, page 10, July 15, 2024
Issuers of accident and sickness policies or certificates which provide hospital or medical expense coverage on an expense-incurred or indemnity basis to persons eligible for Medicare shall provide to applicants a copy of the most recent guide as approved by the director in a type size no smaller than 12-point type.
General Authority:
SDCL  58-17A-6.
Law Implemented:
SDCL  58-17A-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:28 - Delivery of buyer's guide

Current through Register Vol. 51, page 10, July 15, 2024
A policy sold through an agent shall include a buyer's guide at the time of application. The agent shall obtain a signed acknowledgment of receipt from the applicant. The insurer shall maintain the acknowledgment of receipt on file for five years. The insurer shall make the file, in whole or part, accessible to the division on request.
Direct response insurers shall deliver a buyer's guide to the applicant upon request. The offer to provide a buyer's guide to the applicant shall be in writing on the application unless a buyer's guide is delivered to all insured. A requested buyer's guide may not be delivered later than the time of delivery of the policy.
Delivery of the buyer's guide shall be made whether or not such policies or certificates are advertised, solicited, or issued as Medicare supplement policies or certificates as defined in this chapter. Except for direct response issuers, delivery of the buyer's guide shall be made to the applicant at the time of application and acknowledgment of receipt of the buyer's guide shall be obtained by the issuer. Direct response issuers shall deliver the buyer's guide to the applicant upon request, but not later than at the time the policy is delivered.
General Authority:
SDCL  58-17A-6.
Law Implemented:
SDCL  58-17A-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:29 - Use of term "Medicare supplement."

Current through Register Vol. 51, page 10, July 15, 2024
A policy or insurance contract not in compliance with this chapter may not use the terms "Medicare supplement," "medigap," "Medicare wrap-around," or words of similar meaning and may not be advertised, solicited, or issued for delivery in this state as a Medicare supplement policy. "Medicare" must be defined in the policy.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:30 - Disclosure requirements for policies or subscriber contracts that are not Medicare supplement policies

Current through Register Vol. 51, page 10, July 15, 2024
Any issuer selling an accident and sickness insurance policy or subscriber contract, other than a Medicare supplement policy or a risk-sharing contract or reasonable cost reimbursement contract; a Medicare Advantage policy; disability income policy; or certificates issued under group Medicare supplement policies or subscriber contracts which have been delivered or issued for delivery in this state to persons eligible for Medicare shall notify insureds that the policy, certificate, or subscriber contract is not a Medicare supplement policy.
General Authority:
SDCL  58-17A-7.
Law Implemented:
SDCL  58-17A-7.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:31 - Notice requirements for policies or certificates that are not Medicare supplement policies

Current through Register Vol. 51, page 10, July 15, 2024
The disclosure notice required by §
									20:06:13:30  must be in at least twelve-point type. The notice must be printed on or attached to the first page of the policy, subscriber contract, or certificate or the first page of an outline of coverage under a policy, subscriber contract, or certificate if an outline is provided at the time of application. The notice must contain the following language:
"THIS (POLICY OR CERTIFICATE) IS NOT A MEDICARE SUPPLEMENT (POLICY OR CONTRACT). If you are eligible for Medicare, review the [insert the most recent guide as approved by the director] available from the company."
Applications provided to persons eligible for Medicare for the health insurance policies or certificates described in §
									20:06:13:30  must disclose, using the applicable statement in Appendix E at the end of this chapter, the extent to which the policy duplicates Medicare. Disclosure used by an issuer must be in substantially the same form and in no less than twelve-point type. For purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, line spacing, and usage of boxes around text. The issuer shall provide the disclosure statement as a part of, or together with, the application for the policy or certificate.
General Authority:
SDCL  58-17A-7.
Law Implemented:
SDCL  58-17A-7.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:31.01 - Disclosure requirements for Medicare supplement policies - Riders and endorsements

Current through Register Vol. 51, page 10, July 15, 2024
Medicare supplement policies shall include a renewal, continuation, or nonrenewal provision. The language or specifications of the provision must be consistent with the type of contract to be issued. The provision must be captioned as applicable, must appear on the cover page of the policy, and must clearly state the duration, limitations, or terms of renewal, continuation, or nonrenewal of the policy, any reservation by the issuer of the right to change premiums, and any automatic renewal premium increases based on the policyholder's age.
Except for riders or endorsements by which the issuer effectuates a request made in writing by the insured or exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing signed by the insured, unless the increased benefits or coverage is required by changes to the minimum benefit standards in §
									20:06:13:17  or required by law. If a separate additional premium is charged for benefits provided in connection with riders or endorsements, the premium must be set forth in the policy.
General Authority:
SDCL  58-17A-7.
Law Implemented:
SDCL  58-17A-7.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:31.02 - "Usual," "customary," and "reasonable" requirements prohibited

Current through Register Vol. 51, page 10, July 15, 2024
Medicare supplement policies or certificates may not provide for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or words of similar import.
General Authority:
SDCL  58-17A-7.
Law Implemented:
SDCL  58-17A-7.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:31.03 - Right of return

Current through Register Vol. 51, page 10, July 15, 2024
Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate, or attached thereto, stating in substance that the policyholder or certificateholder has the right to return the policy or certificate within 30 days after its delivery and to have the premium refunded if, after examination of the policy or certificate, the insured person is not satisfied for any reason.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:32.02 - Disclosure by agent

Current through Register Vol. 51, page 10, July 15, 2024
On the application or the supplementary application or form, agents shall list any health insurance policies they have sold to the applicant. The list shall contain policies still in force and policies sold in the past five years which are no longer in force.
General Authority:
SDCL  58-17A-2,  58-17A-7.
Law Implemented:
SDCL  58-17A-2,  58-17A-7.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:34 - Replacement requirements for direct response insurers

Current through Register Vol. 51, page 10, July 15, 2024
Direct response insurers shall deliver a notice regarding replacement of coverage to the applicant at the time the policy is issued.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:35 - Notice of replacement

Current through Register Vol. 51, page 10, July 15, 2024
Upon determining that a sale will involve replacement of Medicare supplement coverage, any issuer, other than a direct response issuer, or its agent, shall furnish the applicant, prior to issuance or delivery of the Medicare supplement policy or certificate, a notice regarding replacement of Medicare supplement coverage. One copy of the notice signed by the applicant and the agent, unless the coverage is sold without an agent, must be provided to the applicant and an additional signed copy must be retained by the issuer. A direct response issuer shall deliver to the applicant at the time of the issuance of the policy the notice regarding replacement of Medicare supplement coverage.
The notice required by this section is in Appendix C at the end of this chapter. Notice used by an issuer must be in substantially the same form and in no less than twelve-point type. For purposes of this section, "form" means the language, format, type size, type proportional spacing, bold character, and line spacing.
Unless the coverage is direct marketed, the agent must ask and record the answers to all questions on the forms.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
Note:
A copy of the notice that meets the requirements of this section may be obtained by writing or calling the Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501 ( 605-773-3563) or writing NAIC, P.O. Box 38, Kansas City, MO 64183-0108.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:36 - Outline of coverage requirements

Current through Register Vol. 51, page 10, July 15, 2024
An outline of coverage for Medicare supplement policies, as found in Appendix D at the end of this chapter, must be provided. The outline of coverage provided to applicants pursuant to this section consists of four parts: a cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage shall be printed in no less than 12-point type. All plans shall be shown on the cover page, and the plan or plans that are offered by the issuer shall be prominently identified. Premium information for plans that are offered shall be shown on the cover page or immediately following the cover page and shall be prominently displayed. The premium and mode shall be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant shall be illustrated.
General Authority:
SDCL  58-17A-2,  58-17A-5.
Law Implemented:
SDCL  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:37 - Delivery of outline of coverage

Current through Register Vol. 51, page 10, July 15, 2024
Issuers issuing Medicare supplement policies for delivery in this state shall provide the outline of coverage at the time the application is taken. Except for direct response policies, the issuer shall obtain a written acknowledgment of receipt from the applicant. The issuer shall retain written acknowledgments of receipt for at least four years.
General Authority:
SDCL  58-17A-2,  58-17A-7.
Law Implemented:
SDCL  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:38 - Revisions of outline of coverage

Current through Register Vol. 51, page 10, July 15, 2024
If the coverage actually provided is different from the coverage outlined at the time of application, a substitute outline of coverage showing the coverage actually issued shall accompany the policy or certificate at the time of delivery. The substitute outline of coverage must have the following statement: "Notice: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued." The required statement must appear immediately above the company name and must be in at least twelve-point type.
General Authority:
SDCL  58-17A-2,  58-17A-7.
Law Implemented:
SDCL  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:40 - Style and arrangement for outline of coverage

Current through Register Vol. 51, page 10, July 15, 2024
The style, arrangement, and overall appearance of a policy may not give undue prominence to any portion of the text. Every portion of the text must be clearly printed in medium-faced type. The size of the type must be uniform. All print must be twelve-point at a minimum. This section does not apply to any policy required to comply with SDCL  58-17-6.
General Authority:
SDCL  58-17A-2,  58-17A-7.
Law Implemented:
SDCL  58-17A-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:43 - Overinsurance

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance policy issued to a Medicaid recipient or to a person who already possesses insurance substantially covering the same risk and paying for the same coverage is overinsurance. If the director determines after investigation that overinsurance exists and provides notice, the duplicating insurer must offer a full refund less benefits paid. Any sale of a Medicare supplement policy or certificate that will provide an individual more than one Medicare supplement policy or certificate is prohibited.
Duplication of Medicare supplement insurance, as prohibited by §58-17A-15, exists whenever an insured has more than one Medicare supplement policy or certificate in force, regardless of the number of days in which multiple policies or certificates are in force, including any duplication of coverage that is 30 days or less. Any overlap of coverage requires the replacing or subsequent issuer, upon notice from the policyholder, to adjust the dates of coverage and provide credit for premiums paid during the period of duplication. Any such refund or credit shall be reduced by the amount of any claims paid by the replacing or subsequent issuer during the period of duplication. The replacing or subsequent issuer is not in violation of this rule if the effective date of the policy or contract does not precede the paid to or expiration date of the prior policy as shown on the application, provided that upon notice to the issuer of overinsurance, refunds are made or offered pursuant to this section.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2,  58-17A-15,  58-33-5,  58-33-6,  58-33-8.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:43.01 - Misrepresentation - Unfair or deceptive trade practices

Current through Register Vol. 51, page 10, July 15, 2024
An agent is presumed to have violated SDCL  58-33-5 when the agent knowingly solicits, procures, or sells to any prospective insured who has an existing policy in force a Medicare supplement policy, long term care policy, or other type of health insurance policy designed specifically to be marketed to individuals who qualify for Medicare because of their age unless the agent informs the insured in writing either separately or on the face of the application that the new policy is intended to replace the existing policy. The agent must ensure that the prospective insured understands that the policy is a replacement of an existing policy.
An agent who engages in the sale or solicitation of such policies when the purchase is not reasonable or prudent or is otherwise not in the prospective insured's best interest has engaged in an unfair or deceptive trade practice in violation of SDCL  58-33-2.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2,  58-33-2,  58-33-5,  58-33-6,  58-33-8.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:43.02 - Determination of suitability

Current through Register Vol. 51, page 10, July 15, 2024
To determine whether the sale or solicitation of policies described in §
									20:06:13:43.01 is reasonable, prudent, or in the prospective insured's best interest, the agent, if any, shall examine the totality of the prospective insured's circumstances, including the following:
(1) The prospective insured's financial condition, i.e., is the person on a fixed income, premium cost;
(2) The prospective insured's need for insurance at the time of sale, i.e., existing policies, insured's finances; and
(3) The values, benefits, and costs of the prospective insured's existing insurance program, if any, when compared to the values, benefits, and costs of the recommended policy or policies.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:43.03 - Medicare supplement and Medicare Part C (Medicare Advantage) or Medicare Cost duplication

Current through Register Vol. 51, page 10, July 15, 2024
Duplication of coverage between Medicare supplement insurance and coverage issued pursuant to Medicare Part C or Medicare Cost requires adjustment of the coverage dates by the Medicare supplement issuer regardless of whether the Medicare supplement coverage is replacing Medicare Part C coverage or Medicare Cost or is being replaced by Medicare Part C or Medicare Cost coverage. If the issuer's Medicare supplement coverage is being replaced by Medicare Part C or Medicare Cost, the issuer must, upon receipt of written notice from the policyholder that he or she desires to terminate the policy and of documentation substantiating the Medicare Part C coverage or Medicare Cost, adjust the coverage dates so as to terminate coverage on the date that coincides with the effective date of the Medicare Part C or Medicare Cost coverage and must refund any unearned premium based upon that revised termination date to the insured. The issuer may deduct claims paid from the refund amount for any claims incurred during the adjusted coverage time frame. Nothing in this section requires a refund of premium for any time frame in excess of five years prior to the date of written notice. If the Medicare supplement plan is replacing a Medicare Part C or Medicare Cost plan then the procedures for replacing issuer pursuant to §
									20:06:13:43  apply.
General Authority:
SDCL  58-17A-2(3).
Law Implemented:
SDCL  58-17A-2(3).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:44 - Failure to provide required forms

Current through Register Vol. 51, page 10, July 15, 2024
Failure of an insurance agent to provide any forms required by this chapter is a violation of this state's Unfair Trade Practices Act. Failure of a direct response insurer to provide any forms or failure to maintain any files required by this chapter shall be viewed by the division as contrary to the public interest.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:45 - Refund in replacement situations

Current through Register Vol. 51, page 10, July 15, 2024
An insurer issuing a Medicare supplement policy replacing a Medicare supplement policy shall allow for a full refund of premium if the refund is requested within 30 days after the insured receives the policy.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:46 - Coverage replaced within the same company

Current through Register Vol. 51, page 10, July 15, 2024
An insurer issuing new insurance replacing insurance with the same insurer shall allow the insured 30 days to reinstate the replaced coverage without evidence of insurability if the new insurance is not accepted by the insurer or the insured. The 30-day period shall begin on the date the replaced coverage lapses or the date the insurer refuses to insure, whichever is more beneficial to the insured.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:47 - Insurance replaced by the same agent

Current through Register Vol. 51, page 10, July 15, 2024
If an agent replaces insurance originally placed by that agent, the insured shall be allowed to reinstate the replaced coverage if application is made within 30 days after the replaced policy lapses. The right to reinstate shall be made without evidence of insurability. The reinstated coverage may exclude payment for any injury or sickness starting after the policy lapsed and prior to reinstatement or for sickness starting within 10 days after reinstatement.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:49 - Requirements for claims payment

Current through Register Vol. 51, page 10, July 15, 2024
An issuer shall comply with § 1882(c)(3) of the Social Security Act {as enacted by § 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203 }, 42 U.S.C. §
										1395 etseq, as in effect on July 1, 1992, by:
(1) Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;
(2) Notifying the participating physician or supplier and the beneficiary of the payment determination;
(3) Paying the participating physicians or supplier directly;
(4) Furnishing each enrollee at the time of enrollment with a card listing the policy name and number and a central mailing address to which notices from a Medicare carrier may be sent;
(5) Paying user fees for claim notices that are transmitted electronically or otherwise; and
(6) Providing to the secretary of health and human services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.
The issuer shall certify compliance with the requirements set forth in this section on the Medicare supplement insurance experience reporting form.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:50 - Policy classification - Requirements and limitations

Current through Register Vol. 51, page 10, July 15, 2024
No agent or insurer may classify a Medicare supplement policy as a 100 percent policy or describe any benefit as paying 100 percent unless the policy, without exception, pays 100 percent of the difference between the medical charges incurred and the amount Medicare pays.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:51 - Notice of benefit change

Current through Register Vol. 51, page 10, July 15, 2024
At least 30 days before the annual effective date of Medicare benefit changes each issuer, health care service plan, or other entity providing Medicare supplement insurance or benefits to a resident of this state shall notify its policyholders and certificate holders of modifications it has made to Medicare supplement insurance policies or certificates in a format acceptable to the director or adopted by the NAIC. The notice must contain the following information:
(1) A description of revisions to the Medicare program and a description of each modification made to the coverage provided under the Medicare supplement insurance policy or certificate;
(2) Information for each covered person about when any premium adjustment due to changes in Medicare benefits will be made; and
(3) Benefit modifications and any premium adjustments in outline form stated in clear and simple terms.
The notice may not contain or be accompanied by a solicitation.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
Note:
A copy of a notice that meets the requirements of this section may be obtained from the Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501 ( 605-773-3563), free of charge.
Policy forms -- Filing with and approved by the director, SDCL  58-11-12.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:53 - Duplication of coverage prohibited

Current through Register Vol. 51, page 10, July 15, 2024
No Medicare supplement insurance policy, contract, or certificate may be issued or issued for delivery in this state which provides benefits which duplicate benefits provided by Medicare.
An issuer may not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare part C unless the effective date of the coverage is after the termination date of the individual's part C coverage.
In addition, issuers must comply with the requirements of §
									20:06:13:59  and this section by the annual filing of the form in Appendix B at the end of this chapter each March 1.
General Authority:
SDCL  58-4-1,  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:55 - Exception to reinstitution of coverage

Current through Register Vol. 51, page 10, July 15, 2024
An insurer is not required to make the offer under §
									20:06:13:54  to an individual who is a policyholder or certificateholder in another Medicare supplement policy as of January 1, 1990, if the individual is not subject to a waiting period for treatment of a preexisting condition under the other policy.
General Authority:
SDCL  58-17A-2.
Law Implemented:
SDCL  58-17A-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:13 - Medicare supplement insurance › Section 20:06:13:56 - Continuation and conversion rights

Current through Register Vol. 51, page 10, July 15, 2024
Group members of a group Medicare supplement insurance policy may continue or convert their rights under the following conditions:
(1) If a group Medicare supplement insurance policy is terminated by the group policyholder and not replaced as provided in subdivision (3) of this section, the issuer shall offer certificateholders an individual Medicare supplement policy. The issuer shall offer certificateholders at least the following choices:
(a) Continuation of benefits contained in the group policy; or
(b) An individual policy which provides for benefits which otherwise meets the requirements of this section;