reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:59 - Electronic enrollment for group policies

Current through Register Vol. 51, page 10, July 15, 2024
In the case of a group defined in SDCL  58-17B-2(4)(a), any requirement that a signature of an insured be obtained by an agent or insurer is deemed satisfied if:
(1) The consent is obtained by telephonic or electronic enrollment by the group policyholder or insurer. A verification of enrollment information shall be provided to the enrollee;
(2) The telephonic or electronic enrollment provides necessary and reasonable safeguards to assure the accuracy, retention, and prompt retrieval of records; and
(3) The telephonic or electronic enrollment provides necessary and reasonable safeguards to assure that the confidentiality of individually identifiable information and "privileged information."
The insurer shall make available, upon request of the director, records that will demonstrate the insurer's ability to confirm enrollment and coverage amounts.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:60 - Required disclosure of rating practices to consumers - Rate stabilization

Current through Register Vol. 51, page 10, July 15, 2024
(1) This subdivision applies as follows:
(a) Except as provided in subdivision (1)(b) of this section, this subdivision applies to any long-term care policy or certificate issued in this state on or after November 1, 2002;
(b) For certificates issued on or after May 19, 2002, under a group long-term care insurance policy as defined in SDCL  58-17B-2(4)(a), which policy was in force at the time this rule became effective, the provisions of this subdivision applies on the policy anniversary on or after May 1, 2003;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:62 - Reserve standards

Current through Register Vol. 51, page 10, July 15, 2024
(1) When long-term care benefits are provided through the acceleration of benefits under group or individual life policies or riders to such policies, policy reserves for the benefits shall be determined in accordance with accepted actuarial practices. Claim reserves shall also be established in the case when the policy or rider is in claim status.
Reserves for policies and riders subject to this section must be based on the multiple decrement model utilizing all relevant decrements except for voluntary termination rates. Single decrement approximations are acceptable if the calculation produces essentially similar reserves, if the reserve is clearly more conservative, or if the reserve is immaterial. The calculations may take into account the reduction in life insurance benefits due to the payment of long-term care benefits. However, in no event may the reserves for the long-term care benefit and the life insurance benefit be less than the reserves for the life insurance benefit assuming no long-term care benefit.
In the development and calculation of reserves for policies and riders subject to this section, due regard shall be given to the applicable policy provisions, marketing methods, administrative procedures, and all other considerations which have an impact on projected claim costs, including, but not limited to, the following:
(a) Definition of insured events;
(b) Covered long-term care facilities;
(c) Existence of home convalescence care coverage;
(d) Definition of facilities;
(e) Existence or absence of barriers to eligibility;
(f) Premium waiver provision;
(g) Renewability;
(h) Ability to raise premiums;
(i) Marketing method;
(j) Underwriting procedures;
(k) Claims adjustment procedures;
(l) Waiting period;
(m) Maximum benefit;
(n) Availability of eligible facilities;
(o) Margins in claim costs;
(p) Optional nature of benefit;
(q) Delay in eligibility for benefit;
(r) Inflation protection provisions; and
(s) Guaranteed insurability option.
Any applicable valuation morbidity table shall be certified as appropriate as a statutory valuation table by a member of the American Academy of Actuaries.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:63 - Premium rate schedule increases - Notice of pending increase

Current through Register Vol. 51, page 10, July 15, 2024
An insurer shall provide notice of a pending premium rate schedule increase, including an exceptional increase, to the director at least 30 days prior to the notice to the policyholders, and shall include:
(1) Information required by §
									20:06:21:60;
(2) Certification by a qualified actuary that:
(a) If the requested premium rate schedule increase is implemented and the underlying assumptions, which reflect moderately adverse conditions, are realized, no further premium rate schedule increases are anticipated;
(b) The premium rate filing is in compliance with the provisions of this section;
(c) The insurer may request a premium rate schedule increase less than what is required under this section and the director may approve such premium rate schedule increase, without submission of the certification in subparagraph (a) of this paragraph, if the actuarial memorandum discloses the premium rate schedule increase necessary to make the certification required under subparagraph (a) of this paragraph, the premium rate schedule increase filing satisfies all other requirements of this section, and is, in the opinion of the director, in the best interest of the policyholders;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:64 - Premium rate schedule increase requirements

Current through Register Vol. 51, page 10, July 15, 2024
All premium rate schedule increases shall be determined in accordance with the following requirements:
(1) Exceptional increases shall provide that 70 percent of the present value of projected additional premiums from the exceptional increase will be returned to policyholders in benefits;
(2) Premium rate schedule increases shall be calculated such that the sum of the accumulated value of incurred claims, without the inclusion of active life reserves, and the present value of future projected incurred claims, without the inclusion of active life reserves, will not be less than the sum of the following:
(a) The accumulated value of the initial earned premium times 58 percent;
(b) Eighty-five percent of the accumulated value of prior premium rate schedule increases on an earned basis;
(c) The present value of future projected initial earned premiums times 58 percent; and
(d) Eighty-five percent of the present value of future projected premiums not in subdivision (2)(c) of this section on an earned basis;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:65 - Premium rate schedule increases - Review by the director

Current through Register Vol. 51, page 10, July 15, 2024
For each rate increase that is implemented, the insurer shall file for approval by the director updated projections, as defined in subdivision 20:06:21:63(3)(a), annually for the next three years and include a comparison of actual results to projected values. The director may extend the period to greater than three (3) years if actual results are not consistent with projected values from prior projections. For group insurance policies that meet the conditions in §
									20:06:21:68, the projections required by this chapter shall be provided to the policyholder in lieu of filing with the director.
(1) If any premium rate in the revised premium rate schedule is greater than 200 percent of the comparable rate in the initial premium schedule, lifetime projections, as defined in subdivision 20:06:21:63(3)(a), shall be filed for approval by the director every five years following the end of the required period in the above paragraph. For group insurance policies that meet the conditions in §
									20:06:21:68, the projections required by this subdivision shall be provided to the policyholder in lieu of filing with the director;
(2)
(a) If the director has determined that the actual experience following a rate increase does not adequately match the projected experience and that the current projections under moderately adverse conditions demonstrate that incurred claims will not exceed proportions of premiums specified in §
										20:06:21:64, the director may require the insurer to implement any of the following:
(i) Premium rate schedule adjustments; or
(ii) Other measures to reduce the difference between the projected and actual experience;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:66 - Premium rate schedule increases - Adverse lapsation

Current through Register Vol. 51, page 10, July 15, 2024
(1) For a rate increase filing that meets the following criteria, the director shall review, for all policies included in the filing, the projected lapse rates and past lapse rates during the 12 months following each increase to determine if significant adverse lapsation has occurred or is anticipated:
(a) The rate increase is not the first rate increase requested for the specific policy form or forms;
(b) The rate increase is not an exceptional increase; and
(c) The majority of the policies or certificates to which the increase is applicable are eligible for the contingent benefit upon lapse;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:67 - Premium rate schedule increases - Policies to which does not apply

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:21:63 to 20:06:21:66, inclusive, shall not apply to policies for which the long-term care benefits provided by the policy are incidental, as defined in subdivision 20:06:21:01(13), if the policy complies with all of the following provisions:
(1) The interest credited internally to determine cash value accumulations, including long-term care, if any, are guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;
(2) The portion of the policy that provides insurance benefits other than long-term care coverage meets the nonforfeiture requirements as applicable in SDCL  58-15-31 and 58-15-72, and for variable annuities those nonforfeiture requirements as may be approved by the director;
(3) The policy meets the disclosure requirements of §§
									20:06:21:44, 20:06:21:47, and 20:06:21:48;
(4) The portion of the policy that provides insurance benefits other than long-term care coverage meets the requirements as applicable in the following:
(a) Policy illustrations as required by chapter 20:06:38;
(b) If long-term care benefits are funded through an annuity, the disclosure requirements are:
(i) The insurer must provide to all prospective purchasers a Buyer's Guide to Annuities and a Contract Summary, prior to accepting the applicants initial consideration, unless the annuity contract or associated life insurance policy provides for an unconditional refund period of at least ten days or unless the Contract Summary contains an unconditional refund offer;
(ii) The insurer shall provide a Buyer's Guide to Annuities and a Contract Summary to any prospective purchaser upon request;
(iii) A preneed funeral contract or prearrangement which is funded by an annuity contract shall be adequately disclosed at the time of application, prior to accepting the initial consideration. All relevant information shall be disclosed, including but not limited to merchandise, services, penalties or restrictions, impact of any changes in the annuity contract, relationship among agent(s), provider, and administrator; and
(c) Disclosure requirements in §
										20:06:07:05;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:68 - Premium rate schedule increases - Group insurance policies

Current through Register Vol. 51, page 10, July 15, 2024
Subdivisions 20:06:21:65(2) and 20:06:21:66(1) and (2) shall not apply to group insurance policies as defined in SDCL  58-17B-2(4)(a)  where:
(1) The policies insure 250 or more persons and the policyholder has 5,000 or more eligible employees of a single employer; or
(2) The policyholder, and not the certificateholders, pays a material portion of the premium, which shall not be less than twenty percent (20%) of the total premium for the group in the calendar year prior to the year a rate increase is filed.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:69 - Premium rate schedule increases - Adoption of rules

Current through Register Vol. 51, page 10, July 15, 2024
(1) Except as provided in subdivision (2) of this section, §§
									20:06:21:63  to 20:06:21:69, inclusive, applies to any long-term care policy or certificate issued in this state on or after November 1, 2002;
(2) For certificates issued on or after May 19, 2002, under a group long-term care insurance policy as defined in SDCL  58-17B-2(4)(a), which policy was in force on May 19, 2002, the provisions of §§
									20:06:21:63  to 20:06:21:69, inclusive, shall apply on the policy anniversary following May 1, 2003.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:70 - Premium rate schedule increases - Exceptional increases

Current through Register Vol. 51, page 10, July 15, 2024
Except as provided in §§
									20:06:21:63  to 20:06:21:69, inclusive, exceptional increases are subject to the same requirements as other premium rate schedule increases.
The director may request a review by an independent actuary or a professional actuarial body of the basis for a request that an increase be considered an exceptional increase.
The director, in determining that the necessary basis for an exceptional increase exists, shall also determine any potential offsets to higher claims costs.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:71 - Permitted compensation arrangements

Current through Register Vol. 51, page 10, July 15, 2024
No insurer or other entity may provide commission or other compensation greater than the renewal compensation, to a producer or other representative, for the sale of a long-term care insurance policy or certificate which replaces an existing long-term care insurance policy or certificate, unless the replacing policy contains clearly and substantially greater benefits than the replaced policy provided. The commission or other compensation provided in subsequent renewal years must be the same as that provided in the second year or period and must be provided for a reasonable number of renewal years.
Unless prohibited in this section or §
									20:06:21:53.03, the first year commission or other compensation provided may be greater than the renewal commission.
For purposes of this section, "compensation" includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate, including but not limited to bonuses, gifts, prizes, awards, and finders fees.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:72 - Disclosure to applicant for a claim denial

Current through Register Vol. 51, page 10, July 15, 2024
If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificateholder, or a representative thereof:
(1) Provide a written explanation of the reasons for the denial; and
(2) Make available all information directly related to the denial.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:73 - Providers in a different state

Current through Register Vol. 51, page 10, July 15, 2024
No long-term care issuer may deny a claim because services are provided in a state other than the state of policy issue if the following conditions are met:
(1) If the state other than the state of policy issue does not have the provider licensing, certification, or registration required in the policy, but the provider satisfies the policy requirements outlined for providers in lieu of licensure, certification, or registration; or
(2) If the state other than the state of policy issue licenses, certifies, or registers the provider under another classification.
For purposes of this section, "state of policy issue" means the state in which the individual policy or certificate was originally issued.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:74 - Agent training required to market long-term care plans

Current through Register Vol. 51, page 10, July 15, 2024
An individual may not sell, solicit, or negotiate long-term care insurance unless the individual is licensed as an insurance agent for health or life and has completed a one-time training course before July 1, 2008, and ongoing training every 24 months thereafter. The one-time training required by this section may not be less than eight hours and the ongoing training required by this section may not be less than four hours. Prior to July 1, 2008, those agents licensed as life or health agents selling partnership policies will be considered to have satisfied these requirements. For agents who become licensed after July 1, 2008, the eight hours of training must be completed prior to selling, soliciting, or negotiating long-term care insurance and the four hours of training must be completed by July 1 of every second year following 2008. The training required under this section shall consist of topics related to long-term care insurance, long-term care services, and, if applicable, qualified state long-term care insurance partnership programs, including:
(1) State and federal requirements and the relationship between qualified state long-term care insurance partnership programs and other public and private coverage of long-term care services, including Medicaid;
(2) Available long-term care services and providers;
(3) Changes or improvements in long-term care services or providers;
(4) Alternatives to the purchase of private long-term care insurance;
(5) The effect of inflation on benefits and the importance of inflation protection; and
(6) Consumer suitability standards and guidelines.
The training required by this section may not include training that is insurer or company product specific or that includes any sales or marketing information, materials, or training, other than those required by state or federal law. The training requirements of this section may be approved as continuing education courses pursuant to chapter 58-30.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:75 - Insurers required to verify agent training and maintain records

Current through Register Vol. 51, page 10, July 15, 2024
Any insurer subject to this chapter shall obtain verification that its agent receives training required by §
									20:06:21:74  before the agent is permitted to sell, solicit, or negotiate the insurer's long-term care insurance products, maintain records subject to the state's record retention requirements, and make that verification available to the director upon request.
Any insurer that markets long-term care partnership plans shall maintain records with respect to the training of its agents concerning the distribution of its partnership policies that will allow the director to provide assurance to the state Medicaid agency that the insurer's agents have received the training contained in §
									20:06:21:74  and that the insurer's agents have demonstrated an understanding of the partnership policies and their relationship to public and private coverage of long-term care, including Medicaid, in this state. These records shall be maintained in accordance with the state's record retention requirements and shall be made available to the director upon request.
The satisfaction of these training requirements in any state shall be deemed to satisfy the training requirements in this state.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:76 - Long-term care partnership policies - Inflation protection requirements

Current through Register Vol. 51, page 10, July 15, 2024
An insurer may not issue a policy intended to qualify as a partnership policy unless in addition to the requirements of §§
									20:06:21:06  to 20:06:21:06.05, inclusive, the policy includes the following inflation protection:
(1) For a person who is less than 61 years of age as of the date of purchase, the policy provides compound annual inflation protection; and
(2) For a person who is at least 61 years of age but less than 76 years of age, the policy provides some level of inflation protection that may not be less than one percent per year or a rate equal to the Consumer Price Index.
Inflation protection as required by this section may not be less than one percent per year or a rate equal to the Consumer Price Index. For any person who has attained the age of 76, inflation protection may be provided but is not required.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:77 - Long-term care partnership policies - Required policy disclosures

Current through Register Vol. 51, page 10, July 15, 2024
A policy, certificate, or contract designed or marketed as a long-term care partnership policy must prominently disclose on the schedule page the following:
(1) The [policy, certificate, or contract] is intended to meet the standards for the long-term care partnership program in this state;
(2) Nothing in this [policy, certificate, or contract] is a guarantee of Medicaid eligibility nor is it a guarantee of any ability to disregard assets for purposes of Medicaid eligibility. This notice is required by the State of South Dakota.
Any policy, certificate, or contract that is not designed or marketed as a long-term care partnership policy must prominently disclose that it is not a long-term care partnership policy. The disclosures required by this section must also be included in a separate disclosure document. Appendix K is a sample of an acceptable disclosure document.
General Authority:
SDCL  28-6-38,  58-17B-2,  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:78 - Long-term care partnership policies - Filing requirements

Current through Register Vol. 51, page 10, July 15, 2024
Schedule pages issued in compliance with §
									20:06:21:77  are not required to be re-filed for approval. An informational filing notifying the division that the language specified in § 20:06:21:78  will be used meets the requirements of this section. The informational filing may be included with the insurer's certification of forms that meet partnership standards and are intended to be used for the issuance of partnership policies in this state.
A partnership policy issued or issued for delivery in the State of South Dakota shall be accompanied by a Partnership Disclosure Notice, explaining the benefits associated with a partnership policy and indicating that at the time issued, the policy is a qualified state long-term care insurance partnership policy. If the company uses Appendix K, the company is not required to file it for approval by the division. If the company makes changes to the form, the company must file the form for approval by the director. The Partnership Disclosure Notice shall also include a statement indicating that by purchasing such partnership policy, the insured does not automatically qualify for Medicaid.
Any policy submitted for approval as a partnership policy shall be accompanied by a Partnership Certification Form.
Insurers requesting to make use of a previously approved policy form as a qualified state long-term care partnership policy shall submit to the director a Partnership Certification Form signed by an officer of the company. The Partnership Certification Form shall be accompanied by a copy of the policy or certificate form listed, the approval date, and a bookmark for each of the requirements listed in sections II and III of the form. A Partnership Certification Form shall be required for each policy form submitted for partnership qualification. Appendix L is a sample of a Partnership Certification Form that meets the requirements of this section.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:79 - Long-term care - Minimum benefit requirements

Current through Register Vol. 51, page 10, July 15, 2024
Any long-term care policy, certificate, or contract issued in this state must contain at least one year of nursing facility coverage. A daily benefit of not less than $100 per day must be included in the policy, certificate, or contract unless one of the following are met:
(1) A suitability form is completed showing that a lesser amount per day is suitable for the applicant and both of the following:
(a) The commissions paid to the agent are renewal commissions only; and
(b) The applicant acknowledges in writing that the applicant understands the daily benefits are less than the minimum otherwise required and are not sufficient to fund the per day costs in nursing homes based upon current data available;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:80 - Long-term care partnership policies - Policy amendments

Current through Register Vol. 51, page 10, July 15, 2024
Any amendment to the policy that alters the status of a partnership policy so that it no longer meets the applicable partnership standards must affirmatively disclose that fact and include an amended schedule page that removes the references to the long-term care partnership program.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:81 - Long-term care policies - Policy amendments

Current through Register Vol. 51, page 10, July 15, 2024
No long-term care policy, certificate, or contract may be amended or benefits reduced pursuant to §
									20:06:21:86  to:
(1) Reduce the nursing home benefit to less than one year;
(2) Reduce or delete benefits for assisted living in a manner not consistent with §§
									20:06:21:50  and 20:06:21:51; or
(3) Reduce or delete benefits for home health care in a manner not consistent with §
									20:06:21:46.
A policy, certificate, or contract issued prior to July 1, 2007, may be exchanged by amendment or endorsement to become a long-term care partnership policy provided that the requirements of this chapter are met with the endorsed or amended policy. The endorsements or amendments must identify the policy, certificate, or contract as required by §§
										20:06:21:77  and 20:06:21:78.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:82 - Availability of new services or providers

Current through Register Vol. 51, page 10, July 15, 2024
An insurer shall notify policyholders of the availability of a new long-term care policy series that provides coverage for new long-term care services or providers material in nature and not previously available through the insurer to the general public. The notice shall be provided within 12 months of the date the new policy series is made available for sale in this state.
Notification is not required for any policy issued prior to July 1, 2007, or to any policyholder or certificateholder who is currently eligible for benefits, within an elimination period or on claim, or who previously has been in claim status, or who would not be eligible to apply for coverage due to issue age limitations under the new policy. The insurer may require that policyholders meet all eligibility requirements, including underwriting and payment of the required premium to add such new services or providers.
The insurer shall make the new coverage available in one of the following ways:
(1) By adding a rider to the existing policy and charging a separate premium for the new rider based on the insured's attained age;
(2) By exchanging the existing policy or certificate for one with an issue age based on the present age of the insured and recognizing past insured status by granting premium credits toward the premiums for the new policy or certificate. The premium credits shall be based on premiums paid or reserves held for the prior policy or certificate;
(3) By exchanging the existing policy or certificate for a new policy or certificate in which consideration for past insured status shall be recognized by setting the premium for the new policy or certificate at the issue age of the policy or certificate being exchanged. The cost for the new policy or certificate may recognize the difference in reserves between the new policy or certificate and the original policy or certificate; or
(4) By an alternative program developed by the insurer that meets the intent of this section if the program is filed with and approved by the director.
An insurer is not required to notify policyholders of a new proprietary policy series created and filed for use in a limited distribution channel. For purposes of this section, the phrase, limited distribution channel, means through a discrete entity, such as a financial institution or brokerage, for which specialized products are available that are not available for sale to the general public. Policyholders that purchased such a proprietary policy shall be notified when a new long-term care policy series that provides coverage for new long-term care services or providers material in nature is made available to that limited distributed channel.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:83 - Policies issued considered exchanges

Current through Register Vol. 51, page 10, July 15, 2024
Policies issued pursuant to §
									20:06:21:82  are considered exchanges and not replacements. These exchanges are not subject to §§
									20:06:21:28.01, 20:06:21:53.01 to 20:06:21:53.04, inclusive, and the reporting requirements of §
									20:06:21:52.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:84 - Policies offered through employers, labor unions, and associations

Current through Register Vol. 51, page 10, July 15, 2024
If the policy is offered through an employer, a labor organization, or a professional, trade, or occupational association, the required notification in §
									20:06:21:82  shall be made to the offering entity. However, if the policy is issued to a group defined in SDCL  58-17B-2(4)(d), the notification shall be made to each certificateholder.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:85 - Applicability of new provider or service requirements

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in §§
									20:06:21:82  to 20:06:21:84, inclusive, prohibits an insurer from offering any policy, rider, certificate, or coverage change to any policyholder or certificateholder. However, upon request any policyholder may apply for currently available coverage that includes the new services or providers. The insurer may require that policyholders meet all eligibility requirements, including underwriting and payment of the required premium to add such new services or providers.
Nothing in §§
									20:06:21:82  to 20:06:21:84, inclusive, applies to life insurance policies or riders containing accelerated long-term care benefits.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:86 - Right to reduce coverage and lower premiums

Current through Register Vol. 51, page 10, July 15, 2024
Each long-term care insurance policy and certificate shall include a provision that allows the policyholder or certificateholder to reduce coverage and lower the policy or certificate premium in at least one of the following ways:
(1) Reducing the maximum benefit; or
(2) Reducing the daily, weekly, or monthly benefit amount.
The insurer may also offer other reduction options that are consistent with the policy or certificate design or the carrier's administrative processes. In the event the reduction in coverage involves the reduction or elimination of the inflation protection provision, the insurer shall allow the policyholder to continue the benefit amount in effect at the time of the reduction. The provision shall include a description of the ways in which coverage may be reduced and the process for requesting and implementing a reduction in coverage.
The premium for the reduced coverage shall be based on the same age and underwriting class used to determine the premium for the coverage currently in force and be consistent with the approved rate table.
The insurer may limit any reduction in coverage to plans or options available for that policy form and to those for which benefits will be available after consideration of claims paid or payable. If a policy or certificate is about to lapse, the insurer shall provide a written reminder to the policyholder or certificateholder of his or her right to reduce coverage and premiums in the notice required by §
										20:06:21:22.
This section does not apply to life insurance policies or riders containing accelerated long-term care benefits.
A premium increased notice required by §
									20:06:21:60(5)  must include:
(1) An offer to reduce policy benefits provided by the current coverage consistent with the requirements of this section,
(2) A disclosure stating that all options available to the policyholder may not be of equal value, and
(3) In the case of a partnership policy, a disclosure that some benefit reduction options may result in a loss in partnership status that may reduce policyholder protections.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:87 - Authorized representative

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§ 20:06:21:87  to 20:06:21:104, inclusive, an authorized representative is a person authorized to act as the covered person's personal representative within the meaning of 45 CFR 164.502(g) promulgated by the Secretary under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act and means the following:
(1) A person to whom a covered person has given express written consent to represent the covered person in an external review;
(2) A person authorized by law to provide substituted consent for a covered person; or
(3) A family member of the covered person or the covered person's treating health care professional if the covered person is unable to provide consent.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:88 - Notice to insured

Current through Register Vol. 51, page 10, July 15, 2024
If an insurer determines that the benefit trigger of a long-term care insurance policy has not been met, the insurer shall provide a clear, written notice to the insured and the insured's authorized representative, if applicable, of all of the following:
(1) The reason that the insurer determined that the insured's benefit trigger has not been met;
(2) The insured's right to internal appeal in accordance with §
									20:06:21:89, and the right to submit new or additional information relating to the benefit trigger denial with the appeal request; and
(3) The insured's right, after exhaustion of the insurer's internal appeal process, to have the benefit trigger determination reviewed under the independent review process in accordance with §§
									20:06:21:91  to 20:06:21:100, inclusive.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:89 - Internal appeal

Current through Register Vol. 51, page 10, July 15, 2024
The insured or the insured's authorized representative may appeal the insurer's adverse benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within 120 calendar days after the insured and the insured's authorized representative, if applicable, receives the insurer's benefit determination notice. The internal appeal shall be considered by an individual or group of individuals designated by the insurer. However, no individual involved in making the initial benefit determination may be involved in making the internal appeal decision. The internal appeal shall be completed and written notice of the internal appeal decision shall be sent to the insured and the insured's authorized representative, if applicable, within 30 calendar days of the insurer's receipt of all necessary information upon which a final determination can be made.
A rebuttable presumption that the notice was received by the insured within five days of mailing exists if the insurer can provide proof of actual properly addressed mailing or proof of standard office practice or procedure designed to ensure that items are properly addressed and mailed. If no proof of actual mailing or proof of standard office practice or procedure is provided, there is no presumption of receipt by the insured.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:90 - Internal appeal notice requirements

Current through Register Vol. 51, page 10, July 15, 2024
If the insurer's original determination is upheld upon internal appeal, the notice of the internal appeal decision shall describe any additional internal appeal rights offered by the insurer. Nothing in this chapter requires the insurer to offer any internal appeal rights other than those described in §§
									20:06:21:89  and 20:06:21:90.
If the insurer's original determination is upheld after the internal appeal process has been exhausted, and new or additional information has not been provided to the insurer, the insurer shall provide a written description of the insured's right to request an independent review of the benefit determination as described in §§
									20:06:21:91  to 20:06:21:100, inclusive, to the insured and the insured's authorized representative, if applicable.
As part of the written description of the insured's right to request an independent review, an insurer shall include the following, or substantially equivalent, language:
"We have determined that the benefit eligibility criteria ("benefit trigger") of your [policy] [certificate] has not been met. You have the right to an independent review of our decision conducted by long-term care professionals who are not associated with us. Please send a written request for independent review to us at [address]. You must inform us, in writing, of your election to have this decision reviewed within 120 days of receipt of this letter. Listed below are the names and contact information of the independent review organizations approved or certified by the director to conduct long-term care insurance benefit eligibility reviews. If you wish to request an independent review, please choose one of the listed organizations and include its name with your request for independent review. If you elect independent review, but do not choose an independent review organization with your request, we will choose one of the independent review organizations for you and refer the request for independent review to that organization."
If the insurer does not believe the benefit trigger decision is eligible for independent review, the insurer shall inform the insured and the insured's authorized representative, if applicable, and the director in writing and include in the notice the reasons for its determination of independent review ineligibility.
The appeal process described in §§
									20:06:21:89  and 20:06:21:90  is not deemed to be a new service or provider as referenced in §
									20:06:21:82; and therefore does not trigger the notice requirements of that section.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:91 - Independent review of benefit trigger determination

Current through Register Vol. 51, page 10, July 15, 2024
The insured or the insured's authorized representative may request an independent review of the insurer's benefit trigger determination after the internal appeal process outlined in §§
									20:06:21:89  and 20:06:21:90  has been exhausted. A written request for independent review may be made by the insured or the insured's authorized representative to the insurer within 120 calendar days after the insurer's written notice of the final internal appeal decision is received by the insured and insured's authorized representative, if applicable.
A rebuttable presumption that the notice was received by the insured within five days of mailing exists if the insurer can provide proof of actual properly addressed mailing or proof of standard office practice or procedure designed to ensure that items are properly addressed and mailed. If no proof of actual mailing or proof of standard office practice or procedure is provided, there is no presumption of receipt by the insured.
The cost of the independent review shall be borne by the insurer.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:92 - Independent review process

Current through Register Vol. 51, page 10, July 15, 2024
Within five business days of receiving a written request for independent review, the insurer shall refer the request to the independent review organization that the insured or the insured's authorized representative has chosen from the list of organizations the insurer has provided to the insured. If the insured or the insured's authorized representative does not choose an approved independent review organization to perform the review, the insurer shall choose an independent review organization approved or certified by the director. The insurer shall vary its selection of authorized independent review organizations on a rotating basis.
The insurer shall refer the request for independent review of a benefit trigger determination to an independent review organization, subject to the following:
(1) The independent review organization shall be on a list of certified or approved independent review organizations that satisfy the requirements of a qualified long-term care insurance independent review organization contained in §§
									20:06:21:87  to 20:06:21:104, inclusive;
(2) The independent review organization may not have any conflicts of interest with the insured, the insured's authorized representative, if applicable, or the insurer; and
(3) Such review shall be limited to the information or documentation provided to and considered by the insurer in making its determination, including any information or documentation considered as part of the internal appeal process.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:93 - Additional appeal information

Current through Register Vol. 51, page 10, July 15, 2024
If the insured or the insured's authorized representative has new or additional information not previously provided to the insurer, whether submitted to the insurer or the independent review organization, such information shall first be considered in the internal review process, as set forth in §
									20:06:21:89. While this information is being reviewed by the insurer, the independent review organization shall suspend its review and the time period for review is suspended until the insurer completes its review.
The insurer shall complete its review of the information and provide written notice of the results of the review to the insured and the insured's authorized representative, if applicable, and the independent review organization within five business days of the insurer's receipt of such new or additional information.
If the insurer maintains its denial after such review, the independent review organization shall continue its review, and render its decision within the time period specified in §
									20:06:21:99. If the insurer overturns its decision following its review, the independent review request shall be considered withdrawn.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.