reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:32 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
(1) "Exchange," individual and SHOP Exchange;
(2) "HHS," United States Department of Health and Human Services;
(3) "Health insurance issuer," any person that provides health insurance in this state including an insurance company, a prepaid hospital, or similar plan, a health maintenance organization, a multiple employer welfare arrangement, or any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. A health insurance issuer does not include a person providing only excepted benefits;
(4) "Individual Exchange," an Exchange as provided for by section 1311 of PPACA to provide coverage to individuals;
(5) "PPACA," means the Patient Protection and Affordable Care Act (P.L. 111-148, 2010), as amended by the Health Care and Education Reconciliation Act (P.L. 111-152, 2010);
(6) "SHOP Exchange," an Exchange provided for by section 1311 of PPACA to provide coverage to small employers.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:33 - Certifying qualified health plans

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer selling plans in an Exchange may offer only health plans which have in effect a certification issued by the director as a qualified health plan, unless specifically provided for otherwise. A stand-alone dental plan must be certified by the director to participate in an Exchange.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:34 - Issuer standards and certification criteria

Current through Register Vol. 51, page 10, July 15, 2024
In order to participate in an Exchange, a health insurance issuer must have in effect a certification issued or recognized by the director to demonstrate that each health plan it offers in an Exchange is a qualified health plan. The director may certify a health plan as a qualified health plan if the requirements of §
									20:06:55:35  are met or the director determines that making the health plan available is in the interest of the qualified individuals and qualified employers. The director may not exclude a health plan on the following basis:
(1) Such plan is a fee-for-service plan;
(2) Through the imposition of premium price controls; or
(3) That the health plan provides treatments necessary to prevent patients' deaths in circumstances determined to be inappropriate or too costly.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:35 - Qualified health plan defined

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan is a health plan that has been certified by the division that such plan meets the following criteria:
(1) Provides the essential health benefits package described in §
									20:06:56:03;
(2) Meets actuarial value standards as described in §
									20:06:56:11;
(3) Is licensed by and in good standing with the director;
(4) Includes a network that is compliant with SDCL chapter 58-17 F, §
									20:06:55:36  and §
									20:06:55:37;
(5) Complies with marketing laws;
(6) Is accredited based on local performance by an accrediting entity recognized by HHS as described in §
									20:06:56:12;
(7) The rates comply with chapter 20:06:22 and §
									20:06:55:45;
(8) Is non-discrimination compliant with chapter 20:06:45;
(9) Includes plan variations for individuals eligible for cost-sharing reductions and for American Indian and Alaska Native populations;
(10) Complies with the benefit design standards, as defined in §
									20:06:56:08;
(11) Implements and reports on a quality improvement strategy or strategies to disclose and report information on health care quality and outcomes;
(12) Complies with the standards related to the risk adjustment program under 45 CFR part 153 (March 12, 2012).
Stand-alone dental plans are not required to comply with subdivisions (1),(2),(6),(7),(9),(10),(11), and (12). Stand-alone dental plans must meet the plan criteria identified in §
										20:06:56:06.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:36 - Exchange network adequacy standards

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must ensure that the provider network of each qualified health plan meets the standards specified in SDCL chapter 58-17 F. A qualified health plan in an Exchange may contract with any essential community provider. The service area of a qualified health plan is subject to the approval of the director and must cover a minimum geographical area that is at least the entire geographic area of a county, or a group of counties defined by the director. The service area of a qualified health plan must be established without regard to racial, ethnic, language, health status-related factors or other factors that exclude specific high utilizing, high cost or medically-underserved populations.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:37 - Network adequacy standards

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must ensure that the provider network of each of its qualified health plans meets the following standards:
(1) Includes essential community providers in accordance with §§
									20:06:55:38  and 20:06:55:39;
(2) Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services are accessible without unreasonable delay; and
(3) Is consistent with the network adequacy provisions of SDCL chapter 58-17 F.
A qualified health plan issuer must make its provider directory for a qualified health plan available for publication online to potential enrollees in hard copy upon request. In the provider directory, a qualified health plan issuer must identify providers that are not accepting new patients.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:38 - Essential community providers defined

Current through Register Vol. 51, page 10, July 15, 2024
Essential community providers are providers that serve predominantly low-income, medically underserved individuals, unless the provider lost its status as a result of a violation of Federal law:
(1) Health care providers defined in section 340B(a)(4) of the Public Health Service Act (Pub. L. 102-585), as amended by PPACA, Health Care and Education Reconciliation Act (Pub. L. 111-152), and Medicare and Medicaid Extenders Act of 2010 (Pub. L. 111-309); and
(2) Providers described in section 1927(c)(1)(D)(i)(IV) of the Public Health Service Act as set forth by section 221 of Pub. L. 111-8 (March 11, 2009).
Nothing in this section shall be construed to require a qualified health plan issuer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of such issuer.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:39 - Essential community providers

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the qualified health plan's service area.
A qualified health plan issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may, with approval from the director, as an alternative to the standard set forth above comply as follows:
A qualified health plan issuer must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the qualified health plans service area.
Nothing in this section shall be construed to require any qualified health plan to provide coverage for any specific medical procedure provided by the essential community provider.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:40 - Payment of federally-qualified health centers

Current through Register Vol. 51, page 10, July 15, 2024
If an item or service covered by a qualified health plan is provided by a federally-qualified health center to an enrollee of a qualified health plan, the qualified health plan issuer must pay the federally-qualified health center for the item or service an amount that is not less than the amount of payment that would be required to be paid to the center under section 1902(bb) of PPACA for such item or service. Nothing in this section would preclude a qualified health plan issuer and federally-qualified health center from mutually agreeing upon payment rates other than those that would be paid to the center under section 1902(bb) of PPACA, as long as such mutually agreed upon rates are at least equal to the generally applicable payment rates of the issuer.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:41 - Treatment of direct primary care medical homes

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer may provide coverage through a direct primary care medical home that meets the criteria established by HHS, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the direct primary care medical home are coordinated with the qualified health plan issuer.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:42 - Recertification of qualified health plans

Current through Register Vol. 51, page 10, July 15, 2024
Each qualified health plan offered in an Exchange must obtain annual recertification from the director in accordance with the criteria as outlined in §
									20:06:55:35  each year. Upon determining the recertification status of a qualified health plan the director shall notify qualified health plan issuers.
If a qualified health plan issuer elects not to seek recertification with an Exchange for its qualified health plan, the qualified health plan issuer must provide written notice of the election to each enrollee.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:43 - Decertification of qualified health plan

Current through Register Vol. 51, page 10, July 15, 2024
If an issuer offering a qualified health plan is no longer in compliance with the general certification criteria as outlined in §
									20:06:55:35  the issuer may not offer coverage through an Exchange.
If a qualified health plan is decertified or otherwise not approved to offer coverage through an Exchange the qualified health plan issuer must terminate coverage for enrollees only after:
(1) The plan provides notification as described in §
									20:06:55:46; and
(2) Enrollees have an opportunity to enroll in other coverage.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:44 - Non-renewal and decertification of qualified health plans

Current through Register Vol. 51, page 10, July 15, 2024
If a qualified health plan issuer elects not to seek recertification with the director, the qualified health plan issuer must:
(1) Notify the director of its decision prior to the beginning of the recertification process;
(2) Fulfill its obligation to cover benefits for each enrollee through the end of the plan or benefit year;
(3) Fulfill data reporting obligations from the last plan or benefit year of the certification;
(4) Provide notice to enrollee in writing; and
(5) Terminate coverage for enrollees in the qualified health plan once enrollees have an opportunity to enroll in other coverage.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:45 - Rates

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must set rates for an entire benefit year, or for the SHOP Exchange, plan year. An issuer must submit rate and benefit information to the director. A qualified health plan issuer must submit to the director a justification for a rate increase prior to the implementation of the increase. A qualified health plan issuer must prominently post the justification for a rate increase on its website. A qualified health plan issuer may vary premiums by the geographic rating area described in §
									20:06:22:29.
Stand-alone dental plans are not subject to §
									20:06:22:29. Stand-alone dental must file rates in accordance with SDCL  58-17-4.1 and SDCL  58-39-8. Any stand-alone dental plan that is not subject to rate approval pursuant to SDCL  58-17-4.1 or SDCL  58-39-8 must file rates with the director for informational purposes only.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:46 - Health plan applications and notices

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must provide all applications and notices to enrollees in plain language and in a manner that is accessible and timely to individuals living with disabilities including accessible websites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act, Pub. L. No. 101-336 (1990), as amended, and section 504 of the Rehabilitation Act, Pub. L. No. 93-112 (1973), as amended. Individuals who are limited English proficient through the provision of language services at no cost to the individual.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:47 - Accreditation of qualified health plan issuers

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must be accredited on the basis of local performance of a qualified health plan in accordance with §
									20:06:56:12.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:48

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:49 - Annual open enrollment period

Current through Register Vol. 51, page 10, July 15, 2024
All health insurance issuers must provide for an annual open enrollment period for the individual market inside the Exchange
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:50 - Changing qualified health plans

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer must allow a qualified individual or enrollee in an Exchange to enroll in or change from one qualified health plan to another as a result of the following triggering events:
(1) The qualified individual or his or her dependent either:
(i) Loses minimum essential coverage except for in the case of nonpayment of premium. The date of the loss of coverage is the last day the consumer would have coverage under their previous plan or coverage;
(ii) Is enrolled in any non-calendar year health insurance policy, even if the qualified individual or their dependent has the option to renew such coverage. The date of the loss of coverage is the last day of the plan or policy year;
(iii) Loses pregnancy-related coverage described under section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX) (July 1, 2018). The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage; or
(iv) Loses medically needy coverage as described under section 1902(a)(10)(C) of the Social Security Act only once per calendar year. The date of the loss of coverage is the last day the consumer would have medically needy coverage;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:50.01 - Loss of coverage

Current through Register Vol. 51, page 10, July 15, 2024
Loss of coverage does not include termination or loss due to:
(1) Failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or
(2) Situations allowing for a rescission.
If the triggering event is loss of qualified health plan a qualified individual or enrollee may only move to a different plan at the same level of coverage as the enrollees current plan.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:51 - Compensation

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must pay the same broker compensation for a qualified health plan offered through an Exchange that the qualified health plan issuer pays for a similar health plan offered outside an Exchange.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:52 - Plan offerings in the exchange

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan issuer must offer at least one qualified health plan in the silver level and at least one plan in the gold level to participate in an Exchange.
Sections 20:06:55:25, 20:06:55:28, 20:06:55:29, 20:06:55:30, and 20:06:55:31 are repealed effective January 1, 2014.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:53 - Applicability and effective dates

Current through Register Vol. 51, page 10, July 15, 2024
The open enrollment provisions of §§
									20:06:55:48  and 20:06:55:49  do not apply to any coverage issued to an employer that covers at least two individuals.
Sections 20:06:55:25, 20:06:55:28, 20:06:55:29, 20:06:55:30, and 20:06:55:31 are repealed effective January 1, 2014.
Sections 20:06:55:33 to 20:06:55:52, inclusive, are effective January 1, 2014.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Appendix A - Model Choice of Health Care Professional Notice Language

Current through Register Vol. 51, page 10, July 15, 2024
Appendix A - Model Choice of Health Care Professional Notice Language
. For health carries that require or allow for the designation of primary care health care professionals, beneficiaries or enrollees, insert:
[Name of health insurance issuer] generally [requires/allows] the designation of a primary care health care professional. You have the right to designate any primary care health care professional who participates in our network and who is available to accept you or your family members.
[If the health insurance issuer designates a primary care health care professional automatically, insert:
Until you make this designation, [name of health insurance issuer] designates one for you.] For information on how to select a primary care health care professional, and for a list of participating primary care health care professionals, contact the [health insurance issuer] at [insert contact information].
. For health insurance issuers that require or allow for the designation of a primary care health care professional for a child, add:
For children, you may designate a pediatrician as the primary care health care professional.
. For health insurance issuers that provide coverage for obstetric or gynecological care and require the designation by a participant, beneficiary or enrollee of a primary care health care professional, add:
You do not need prior authorization from [name of health insurance issuer] or from any other person, including a primary care health care professional, in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [health insurance issuer] at [insert contact information].
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
(1) "Actuarial value," a measure of the percentage of expected health care costs a health plan will cover for a standard population and can be considered a general summary measure of health plan generosity;
(2) "Actuarial value calculator," used to determine the actuarial value of applicable plans. It is developed using a set of claims data weighted to reflect the standard population projected to enroll in the individual and small group markets for the identified year of enrollment;
(3) "Base-benchmark plan," the plan that is selected by the state from the options described in 45 CFR §
										156.100(a), or a default benchmark plan, as described in 45 CFR §
										156.100(c), prior to any adjustments made pursuant to the benchmark standards described in 45 CFR §
										156.110;
(4) "De minimis variation," is the allowable variation in the actuarial value of a health plan that does not result in a material difference in the true dollar value of the health plan is +/-2 percentage points;
(5) "Essential health benefits benchmark plan," is the standardized set of essential health benefits that must be met by a qualified health plan;
(6) "HHS," United States Department of Health and Human Services;
(7) "Premium adjustment percentage," the percentage by which the average per capita premium for health insurance coverage for the preceding calendar year exceeds such average per capita premium for health insurance.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:02 - Covering essential health benefits

Current through Register Vol. 51, page 10, July 15, 2024
Health insurance coverage in the individual and small group markets must cover essential health benefits for plan years beginning after December 31, 2013. Sections 20:06:56:01 through 20:06:56:10 apply to those plans offered inside an Exchange and those offered outside an Exchange.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:03 - Essential health benefit packages

Current through Register Vol. 51, page 10, July 15, 2024
The essential health benefits package consists of the following categories of benefits:
(1) Ambulatory patient services;
(2) Emergency services;
(3) Hospitalization;
(4) Maternity and newborn care;
(5) Mental health and substance use disorder services, including behavioral health treatment;
(6) Prescription drugs;
(7) Rehabilitative and habilitative services and devices;
(8) Laboratory services;
(9) Preventive and wellness services and chronic disease management; and
(10) Pediatric services, including oral and vision care.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:04 - Substantially equal benefits

Current through Register Vol. 51, page 10, July 15, 2024
Plans must provide for benefits that are substantially equal to the essential health benefits-benchmark plan including:
(1) Covered benefits listed in §
									20:06:56:02;
(2) Limitations on coverage including coverage of benefit amount, duration, and scope; and
(3) Prescription drug benefits described in §
									20:06:56:08.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:05 - Substituted benefits

Current through Register Vol. 51, page 10, July 15, 2024
A plan may substitute benefits from the essential health benefits benchmark benefit plan if it meets the following conditions:
(1) The substitute benefit is actuarial equivalent to the essential health benefit;
(2) The substitute benefit is made only within the same essential benefit category; and
(3) The benefit is not a prescription drug benefit.
The plan must submit evidence of the actuarial equivalence of the substituted benefit to the director. The certification must be conducted by a member of the American Academy of Actuaries, be based on an analysis performed in accordance with generally accepted actuarial principles and methodologies, and use a standardized plan population. Actuarial equivalence of benefits is determined regardless of cost sharing.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:06 - Pediatric dental

Current through Register Vol. 51, page 10, July 15, 2024
A stand-alone dental plan covering pediatric dental may be used to cover the pediatric dental component of essential health benefits required by §
									20:06:56:02. A stand-alone dental plan covering the pediatric dental category under §
									20:06:56:02  must demonstrate to the director that it has a reasonable annual limitation on cost-sharing. An issuer must demonstrate that the stand-alone dental plan offers the pediatric dental essential health benefit within a de minimis variation of +/-2 percentage points of the level of coverage in subsections (1) and (2) at either:
(1) A low level of coverage with an AV of 70 percent; or
(2) A high level of coverage with an AV of 85 percent.
The coverage levels described above must be certified by a member of the American Academy of Actuaries using generally accepted actuarial principles and provided to the division.
A health benefit plan offered in the small group or individual market, which does not include minimum essential pediatric dental benefits, offers the minimum essential health benefits required under law only, if:
(1) There is at least one dental benefits carrier offering the federally-required minimum pediatric dental benefits in the state;
(2) The health benefit plan makes prominent disclosure at the time that it offers the plan, in a form approved by the director, that the health benefit plan does not provide the essential pediatric dental benefits; and
(3) That the dental benefits carriers providing the federally required minimum pediatric dental benefits and other dental benefits are licensed to offer dental benefits in the state.
For health benefit plans offered outside an exchange, pediatric dental coverage may only be excluded when an issuer is reasonably assured an individual has obtained such coverage through an exchange certified stand-alone dental plan being offered outside the exchange. A carrier may use any reasonable method for obtaining reasonable assurance including an attestation on an insurance application or other documentation from the applicant or the applicant's dental insurer.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:07 - Prohibited benefits

Current through Register Vol. 51, page 10, July 15, 2024
An issuer of a plan offering essential health benefits may not include routine non-pediatric dental services, routine non-pediatric eye exam services, or long-term/custodial nursing home care benefits, or not medically necessary orthodontia as essential health benefits.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:08 - Prescription drug benefits

Current through Register Vol. 51, page 10, July 15, 2024
A health plan does not provide essential health benefits unless it covers at least the greater of:
(1) One drug in every United States Pharmacopeia (USP) category and class; or
(2) The same number of prescription drugs in each category and class as the essential health benefits benchmark.
The plan is required to submit its drug list to the director. A health plan does not fail to provide essential health benefits for prescription drug solely because it does not offer drugs for services prohibited under SDCL  58-17-147. A health plan providing essential health benefits as defined in §
									20:06:56:03  must have procedures in place that allow an enrollee to request clinically appropriate drugs not covered by the health plan. Such procedures must include a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician or other prescriber to request an expedited review based on exigent circumstances.
Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug.
A health plan must make its coverage determination on an expedited review request based on exigent circumstances and notify the enrollee or the enrollee's designee and the prescribing physician or other prescriber, as appropriate of its coverage determination no later than 24 hours after it receives the request.
A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
United States Pharmacopeia (USP).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:09 - Prohibited discriminatory benefit design

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer does not provide essential health benefits if its benefit design, or the implementation of its benefit design, discriminates based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions. An issuer must not employ discriminatory marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs in nongrandfathered health plans. Issuers may continue to use reasonable medical management techniques that are evidence based.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:10 - Actuarial value calculator

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer may use the actuarial value calculator to determine the actuarial value of a health plan made available by Health and Human Services. Actuarial Value within a de minimis variation determines whether a health plan offers a bronze, silver, gold, or platinum level of coverage.
If a health plan's design is not compatible with the actuarial value calculator, the issuer must meet the following:
(1) Submit the actuarial certification from an actuary, who is a member of the American Academy of Actuaries, on the chosen methodology identified in subdivisions (2) and (3) of this section;
(2) Calculate the plan's actuarial value by estimating a fit of its plan design into the parameters of the actuarial value calculator and having an actuary, who is a member of the American Academy of Actuaries, certify that the plan design was fit appropriately in accordance with generally accepted actuarial principles and methodologies; or
(3) Use the actuarial value calculator to determine the actuarial value for the plan provisions that fit within the calculator parameters and have an actuary, who is a member of the American Academy of Actuaries, calculate and certify, in accordance with generally accepted actuarial principles and methodologies, appropriate adjustments to the actuarial value identified by the calculator, for plan design features that deviate substantially from the parameters of the actuarial value calculator.
The calculation methods described in subdivisions (2) and (3) of this section may include only in-network cost-sharing, including multi-tier networks.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:11 - Levels of coverage

Current through Register Vol. 51, page 10, July 15, 2024
The levels of coverage are calculated as follows:
(1) A bronze health plan is a health plan that has an actuarial value of 60 percent;
(2) A silver health plan is a health plan that has an actuarial value of 70 percent;
(3) A gold health plan is a health plan that has an actuarial value of 80 percent; and
(4) A platinum health plan is a health plan that has an actuarial value of 90 percent.
Actuarial value within a de minimis variation determines whether a health plan offers a bronze, silver, gold, or platinum level of coverage.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:12 - Accreditation

Current through Register Vol. 51, page 10, July 15, 2024
A qualified health plan must be accredited in the following categories by an accrediting entity recognized by HHS prior to certification:
(1) Clinical quality measures, such as the healthcare effectiveness Data and Information Set;
(2) Patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems survey;
(3) Consumer access;
(4) Utilization management;
(5) Quality assurance;
(6) Provider credentialing;
(7) Complaints and appeals;
(8) Network adequacy and access; and
(9) Patient information programs.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:13 - Accreditation timeline

Current through Register Vol. 51, page 10, July 15, 2024
During certification for an issuer's initial year of qualified health plan certification a qualified health plan issuer without existing commercial, Medicaid, or Exchange health plan accreditation granted by a recognized accrediting entity for the same state in which the issuer is applying to offer coverage must have scheduled or plan to schedule a review of qualified health plan policies and procedures of the applying qualified health plan issuer with a recognized accrediting entity.
Prior to a qualified health plan issuer's second year and third year of qualified health plan certification, a qualified health plan issuer must be accredited by a recognized accrediting entity on the policies and procedures that are applicable to their Exchange products, or a qualified health plan issuer must have commercial or Medicaid health plan accreditation granted by a recognized accrediting entity for the same state in which the issuer is offering Exchange coverage and the administrative policies and procedures underlying that accreditation must be the same or similar to the administrative policies and procedures used in connection with the qualified health plan.
Prior to the qualified health plan issuer's fourth year of qualified health plan certification and in every subsequent year of certification, a qualified health plan issuer must be accredited in accordance with §
									20:06:56:12.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:14 - Provider credentialing

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer's selection standards for participating providers shall be developed for primary care professionals and each health care professional specialty. The standards shall be used in determining the selection of health care professionals by the health insurance issuer, its intermediaries, and any provider networks with which it contracts. The standards shall meet the requirements of the National Association of Insurance Commissioners Health Care Professional Credentialing Verification Model Act.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
National Association of Insurance Commissioners Health Care Professional Credentialing Verification Model Act.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:15 - Annual limitation on cost sharing

Current through Register Vol. 51, page 10, July 15, 2024
For a plan year beginning in calendar year 2014, cost sharing may not exceed the following:
(1) For self-only coverage--the annual dollar limit as described in 26 U.S.C. §
										223(c)(2)(A)(ii)(I) of the Internal Revenue Code of 1986 as amended, for self-only coverage that is in effect for 2014; or
(2) For other than self-only coverage--the annual dollar limit in 26 U.S.C §
										223(c)(2)(A)(ii)(II) of the Internal Revenue Code of 1986 as amended, for non-self-only coverage that is in effect for 2014.
For a plan year beginning in a calendar year after December 31, 2014, cost sharing may not exceed the following:
(1) For self-only coverage--the dollar amount limit for calendar year 2014 increased by an amount equal to the product of that amount and the premium adjustment percentage;
(2) For other than self-only coverage--twice the dollar limit for self-only coverage described in subsection 1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:16 - Annual limitation on deductibles for plans in the small group market

Current through Register Vol. 51, page 10, July 15, 2024
For a plan year beginning in calendar year 2014, the annual deductible for a health plan in the small group market may not exceed the following
(1) For self-only coverage--$2,000; or
(2) For coverage other than self-only--$4,000.
For a plan year beginning in a calendar year after 2014, the annual deductible for a health plan in the small group market may not exceed the following:
(1) For self-only coverage--the annual limitation on deductibles for calendar year 2014 increased by an amount equal to the product of that amount and the premium adjustment percentage; and
(2) For other than self-only coverage--twice the annual deductible limit for self-only coverage.
A health plan's annual deductible may exceed the annual deductible limit if that plan may not reasonably reach the actuarial value of a given level of coverage without exceeding the annual deductible limit.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:17 - Network plan cost sharing

Current through Register Vol. 51, page 10, July 15, 2024
In the case of a plan using a network of providers, cost-sharing paid by, or on behalf of, an enrollee for benefits provided outside of such network shall not count towards the annual limitation on cost-sharing or the annual limitation on deductibles.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:18 - Increase annual dollar limits in multiples of 50

Current through Register Vol. 51, page 10, July 15, 2024
For a plan year beginning in a calendar year after December 31, 2014, any increase in the annual dollar limits that do not result in a multiple of 50 dollars must be rounded to the next lowest multiple of 50 dollars.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:19 - Catastrophic plan

Current through Register Vol. 51, page 10, July 15, 2024
A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if:
(1) The only individuals who are eligible to enroll in the plan are individuals described in 1302 (e); and
(2) The plan provides except as provided in clause 1302 (e), the essential health benefits determined under section 1302 of the ACA, except that the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) of section 1302 for the plan year except as provided for in section 2713; and coverage for at least three primary care visits. An individual is described in this paragraph for any plan year if the individual has not attained the age of 30 before the beginning of the plan year; or has a certification in effect for any plan year under this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of section 5000A(e)(1) of such Code relating to individuals without affordable coverage; or section 5000A(e)(5) of such Code relating to individuals with hardships.
If a health insurance issuer offers a health plan described in this section, the issuer may only offer the plan in the individual market.
The cost-sharing incurred under a health plan described in this section with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2014 shall not exceed the dollar amounts in effect under section 223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, for taxable years beginning in 2014.
In the case of any plan year beginning in a calendar year after December 31, 2014, the limitation under this section shall in the case of self-only coverage, be equal to the dollar amount under described above for self-only coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage for the calendar year; and in the case of other coverage, twice the amount in effect. If the amount of any increase is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:20 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of §§
									20:06:56:01  to 20:06:56:19, inclusive, only apply to non-grandfathered plans effective January 1, 2014, and does not apply to an excepted benefit as defined in §
									20:06:55:27.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.