reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:71 - Avoiding conflicts of interest

Current through Register Vol. 51, page 10, July 15, 2024
The plan or issuer must ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. Therefore, any decision regarding hiring, compensation, termination, promotion, or any other similar matter with respect to any individual may not be made based upon the likelihood that the individual will support a denial of benefits. A plan or issuer may not provide bonuses based on the number of denials made by a claims adjudicator. Similarly, a plan or issuer may not contract with a medical expert based on the expert's reputation for outcomes in contested cases, rather than based on the expert's professional qualifications.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:72 - Notice to enrollee

Current through Register Vol. 51, page 10, July 15, 2024
A plan or issuer shall provide notice to enrollees, in a culturally and linguistically appropriate manner, if ten percent or more of the population residing in the claimants county are literate only in the same non-English language, as determined based on American Community Survey data published by United States Census Bureau.
Plans and issuers must provide notice in accordance with SDCL  58-17H-32 and  58-17H-48. Insurers may comply with the notice requirements required in SDCL  58-17H-32 and  58-17H-48 by providing notification of the right to request and receive diagnoses and treatment codes and their meanings in all notices of adverse benefit determinations and final adverse benefit determinations.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-17H-48,  58-18-79.
American Community Survey data published by United States Census Bureau.
www.census.gov
.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:73 - Failure to comply with internal claims and appeal process

Current through Register Vol. 51, page 10, July 15, 2024
If a plan or issuer fails to strictly adhere to all the requirements of the internal claims and appeals process with respect to a claim, the claimant is deemed to have exhausted the internal claims and appeals process, regardless of whether the plan or issuer asserts that it substantially complied with these requirements. Upon the failure to strictly adhere to the requirements of the internal claims and appeals process, the claimant may initiate an external review and pursue any available remedies under applicable law, such as judicial review.
The claimant is entitled upon written request to an explanation of the plan's or issuer's basis for asserting that it meets this standard. If the external review or the court rejects the claimant's request for immediate review on the basis that the plan met this standard, the claimant has the right to resubmit and pursue the internal appeal under SDCL  58-17I-7.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:74 - Continued coverage and ongoing treatment

Current through Register Vol. 51, page 10, July 15, 2024
A plan and issuer must provide continued coverage pending the outcome of an internal appeal of a concurrent review. A plan or issuer may not reduce or terminate an ongoing course of treatment without providing advance notice and an opportunity for advance review.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:75 - One level of internal appeals

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer offering individual health insurance coverage may only have one level of internal appeals. A claimant may seek either external review or judicial review immediately after an adverse benefit determination is upheld in the first level of the internal appeals process.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:76 - Record keeping

Current through Register Vol. 51, page 10, July 15, 2024
Each health insurance issuer offering individual health insurance coverage shall maintain records of all claims and notices associated with its internal claims and appeals processes. The records must be maintained for at least six years. An issuer must make such records available to the director for examination upon request. Any request for a first level review of a grievance involving an adverse benefit determination and any request for a voluntary review of a grievance involving an adverse benefit determination must be included in the health carrier's grievance register, which must be maintained in a reasonably clear and accessible manner and must contain, at a minimum, the following:
(1) A general description of the reason for the grievance;
(2) The date received;
(3) The date of each review or, if applicable, review meeting;
(4) Resolution at each level of the grievance, if applicable;
(5) Date of resolution at each level, if applicable; and
(6) Name of the covered person for whom the grievance was filed.
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 20:06:53 - External and internal review › Section 20:06:53:77 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in §§
									20:06:53:68  to 20:06:53:76, inclusive, applies to grandfathered plans pursuant to 26 C.F.R. 54.9815-2719 T, 29 C.F.R. 2590.715-27109, or 45 C.F.R. 147.36 . Sections 20:06:53:68 to 20:06:53:76, inclusive, apply to any plan of individual health coverage, including any health benefit plans subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive, that is not an excepted benefit pursuant to SDCL subdivision 58-17-69(13). Sections 20:06:53:68 to 20:06:53:74, inclusive, apply to any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42. This chapter does not apply to self-funded plans preempted from state regulation pursuant to the Employee Retirement Income Security Act of 1974.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-51.1,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:78 - Strictly adhere - Defined

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:53:68  to 20:06:53:77  minor non-prejudicial errors attributable to good cause or matters beyond the plan or issuer's control in the context of ongoing good faith exchange of information and not evidence of pattern or practice of non-compliance with the internal claims and appeal process meet the strict adherence requirements of the internal claims and appeal process.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:79 - Written explanation of violation

Current through Register Vol. 51, page 10, July 15, 2024
A covered person may request a written explanation of the violation from the health carrier. The health carrier shall provide the written explanation within ten days of receiving the request. The written explanation shall include a specific description of its bases, if any, for asserting that the violation does not deem the provisions of SDCL  58-17I-1 to  58-17I-16 have been exhausted.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:80 - Procedure when immediate review request denied

Current through Register Vol. 51, page 10, July 15, 2024
If an independent reviewer or a court of competent jurisdiction rejects the grievance involving an adverse determination for immediate review on the basis that the health carrier met the requirements of the exception provided in §
									20:06:53:78  the covered person has the right to resubmit and pursue a review of the grievance under SDCL  58-17I-1 to  58-17I-16. Within a reasonable time, after the independent reviewer or the court rejects the grievance involving an adverse determination for immediate review, but not exceeding ten days, the health carrier shall provide to the covered person or, if applicable, the covered person's authorized representative notice of the opportunity to resubmit and, as appropriate, pursue a review of the grievance under SDCL  58-17I-1 to  58-17I-16.
For purposes of calculating the time period for re-filing the benefit request or claim under this subparagraph, the time period shall begin to run upon the covered person's or, if applicable, the covered person's authorized representative receipt of the notice of opportunity to resubmit.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Appendix D - Model health carrier external review annual report form

Current through Register Vol. 51, page 10, July 15, 2024
Health Carrier External Review Division of Insurance Annual Report Form
External Review Annual Summary for 20_____
Due on ___________for previous calendar
year.
Each health carrier shall submit an annual report with information in the aggregate by state and by type of health benefit plan.
1. Health carrier name:
Filing Date:
2. Health carrier
address:
City, State, ZIP:
3. Health carrier Web
site:
4. Name, email address, phone and fax number of the person completing this form:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Total number of external review requests received from the South Dakota Division
of Insurance during the reporting period:
_______
6. From the total number of external review requests provided in Question 5, the
number of requests determined eligible for a full external review:
_______
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:54 - Preventive services › Section 20:06:54:02 - Coverage for office visits in conjunction with preventive items and services

Current through Register Vol. 51, page 10, July 15, 2024
If an item or service described in §
									20:06:54:01  is billed separately or is tracked as individual encounter data separately from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit.
If an item or service described in §
									20:06:54:01  is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a plan or issuer may not impose cost-sharing requirements with respect to the office visit. If an item or service described in §
									20:06:54:01  is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a plan or issuer may impose cost-sharing requirements with respect to the office visit.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-1.1,  58-17-1.2,  58-17-62,  58-17-87,  58-17-98,  58-18-36,  58-18-41,  58-18-79,  58-18-80,  58-18-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:54 - Preventive services › Section 20:06:54:03 - Preventive items and services with out-of-network providers

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in this section requires a plan or issuer that has a network of providers to provide benefits for items or services described in §
									20:06:54:01  that are delivered by an out-of-network provider. Moreover, nothing in this section precludes a plan or issuer that has a network of providers from imposing cost-sharing requirements for items or services described in §
									20:06:54:01  that are delivered by an out-of-network provider.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-1.1,  58-17-1.2,  58-17-62,  58-17-87,  58-17-98,  58-18-36,  58-18-41,  58-18-79,  58-18-80,  58-18-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:54 - Preventive services › Section 20:06:54:04 - Reasonable medical management allowed

Current through Register Vol. 51, page 10, July 15, 2024
Nothing prevents a plan or issuer from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service described in §
									20:06:54:01  to the extent not specified in the recommendation or guideline.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-1.1,  58-17-1.2,  58-17-62,  58-17-87,  58-17-98,  58-18-36,  58-18-41,  58-18-79,  58-18-80,  58-18-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:54 - Preventive services › Section 20:06:54:05 - Additional services not prohibited

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in this section prohibits a plan or issuer from providing coverage for items and services in addition to those recommended by the United States Preventive Services Task Force or the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention or provided for by guidelines supported by the Health Resources and Services Administration, or from denying coverage for items and services that are not recommended by that task force or that advisory committee or supported by the HRSA guidelines. A plan or issuer may impose cost-sharing requirements for a treatment not described in §
									20:06:54:01, even if the treatment results from an item or service described in §
									20:06:54:01.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-1.1,  58-17-1.2,  58-17-62,  58-17-87,  58-17-98,  58-18-36,  58-18-41,  58-18-79,  58-18-80,  58-18-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:54 - Preventive services › Section 20:06:54:06 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
A plan or issuer must provide coverage pursuant to §§
									20:06:54:01  to 20:06:54:05, inclusive, for the group market for plan years and in the individual market policy years, beginning after September 22, 2010. Nothing in §§
									20:06:54:01  to 20:06:54:05, inclusive, applies to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147 . This chapter applies to any plan of individual health coverage, including any health benefit plans subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive, that is not an excepted benefit pursuant to SDCL subdivision 58-17-69(13) and any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42. This chapter does not apply to self-funded plans preempted from state regulation pursuant to the Employee Retirement Income Security Act of 1974.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-1.1,  58-17-1.2,  58-17-62,  58-17-87,  58-17-98,  58-18-36,  58-18-41,  58-18-51.1,  58-18-79,  58-18-80,  58-18-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:01 - Eligibility of children up to age 26

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, or a health insurance issuer offering group or individual health insurance coverage, that makes available dependent coverage of children must make such coverage available for children until attainment of 26 years of age. The provisions of §§ 20:06:55:01  to 20:06:55:10, inclusive, apply for plan years, in the individual market policy years, beginning after September 22, 2010. Nothing in this section alters the requirements of SDCL  58-17-2.3 or  58-18-31.1 as it relates to any dependent who is over the age of 25 but has not reached the age of 30.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:02 - Restrictions on plan definition of dependent

Current through Register Vol. 51, page 10, July 15, 2024
With respect to a child who has not attained age 26, a plan or issuer may not define dependent for purposes of eligibility for dependent coverage of children other than in terms of a relationship between a child and the participant, and in the individual market, the primary subscriber. A plan or issuer may not deny or restrict coverage for a child who has not attained age 26 based on the presence or absence of the child's financial dependency upon the participant, primary subscriber, or with any other person; residency with the participant and in the individual market the primary subscriber, or any other person; student status; marital status; employment; or any combination of those factors. In addition, a plan or issuer may not deny or restrict coverage of a child based on eligibility for other coverage, except as provided in §
									20:06:55:10.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:03 - Coverage of grandchildren not required

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in §§
									20:06:55:01  to 20:06:55:10, inclusive, requires a plan or issuer to make coverage available for the child of a child receiving dependent coverage, unless the grandparent becomes the legal guardian or adoptive parent of that grandchild.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:04 - Uniformity irrespective of age

Current through Register Vol. 51, page 10, July 15, 2024
The terms of the plan or health insurance coverage providing dependent coverage of children may not vary based on age except for children who are age 26 or older. Nothing in this section applies to premium rates.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:05 - Individuals whose coverage ended by reason of reaching a dependent eligibility threshold - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:55:05 to 20:06:55:09, inclusive, apply to any child whose coverage ended, or who was denied coverage or was not eligible for coverage under a group health plan or group or individual health insurance coverage because, under the terms of the plan or coverage, the availability of dependent coverage of children ended before the attainment of age 26 and who becomes eligible or is required to become eligible for coverage under a group health plan or group or individual health insurance coverage on the first day of the first plan year and in the individual market the first day of the first policy year, beginning after September 22, 2010.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:06 - Individuals whose coverage ended by reason of reaching a dependent eligibility threshold - Opportunity to enroll required

Current through Register Vol. 51, page 10, July 15, 2024
If a group health plan, or group or individual health insurance coverage, in which a child described in §
									20:06:55:05  is eligible to enroll or is required to become eligible to enroll in the plan, or coverage in which the child's coverage ended or did not begin for the reasons described in §
									20:06:55:05, and if the plan, or the issuer of such coverage, is subject to the requirements of §§
									20:06:55:05  to 20:06:55:09, inclusive, the plan and the issuer are required to give the child an opportunity to enroll that continues for at least 30 days including written notice of the opportunity to enroll as described in §
									20:06:55:10. The opportunity to enroll must be provided beginning not later than the first day of the first plan year and in the individual market the first day of the first policy year, beginning after September 22, 2010.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:07 - Individuals whose coverage ended by reason of reaching a dependent eligibility threshold - Written notice

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:55:05  to 20:06:55:09, inclusive, the written notice must include a statement that children whose coverage ended, who were denied coverage or were not eligible for coverage, because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in the plan or coverage. The notice may be provided to an employee on behalf of the employee's child and in the individual market, to the primary subscriber on behalf of the primary subscriber's child. In addition, for a group health plan or group health insurance coverage, the notice may be included with other enrollment materials that a plan distributes to employees, provided the statement is prominent. For a group health plan or group health insurance coverage, if a notice satisfying the requirements of this section is provided to an employee whose child is entitled to an enrollment opportunity pursuant to §
									20:06:55:05, the obligation to provide the notice of enrollment opportunity pursuant to §
									20:06:55:05  with respect to that child is satisfied for both the plan and the issuer. The written notice must be provided beginning not later than the first day of the first plan year and in the individual market the first day of the first policy year, beginning after September 22, 2010.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:08 - Individuals whose coverage ended by reason of reaching a dependent eligibility threshold - Effective date

Current through Register Vol. 51, page 10, July 15, 2024
In the case of an individual who enrolls pursuant to §
									20:06:55:05, coverage must take effect in the group market not later than the first day of the first plan year and in the individual market, the first day of the first policy year, beginning after September 22, 2010.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:09 - Individuals whose coverage ended by reason of reaching a dependent eligibility threshold - Group health plan special enrollee

Current through Register Vol. 51, page 10, July 15, 2024
Any child enrolling in a group health plan pursuant to §
									20:06:55:05  must be treated as if the child were a special enrollee, as provided under the rules of 45 C.F.R. §
										146.117(d). Accordingly, the child and, if the child would not be a participant once enrolled in the plan, the participant through whom the child is otherwise eligible for coverage under the plan, must be offered all the benefit packages available to similarly situated individuals who did not lose coverage by reason of cessation of dependent status. For this purpose, any difference in benefits or cost-sharing requirements constitutes a different benefit package. The child also cannot be required to pay more for coverage than similarly situated individuals who did not lose coverage by reason of cessation of dependent status.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:10 - Special rule for grandfathered group health plans

Current through Register Vol. 51, page 10, July 15, 2024
For plan years beginning before January 1, 2014, a group health plan that qualifies as a grandfathered health plan pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147, and that makes available dependent coverage of children may exclude an adult child who has not attained age 26 from coverage only if the adult child is eligible to enroll in an eligible employer-sponsored health plan, as defined in section 5000A(f)(2) of the Internal Revenue Code, other than a group health plan of a parent.
For plan years beginning after December 31, 2013, a group health plan that qualifies as a grandfathered health plan pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147 must comply with the requirements of §§
									20:06:55:01  to 20:06:55:04, inclusive.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:11 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), §§
									20:06:55:01  to 20:06:55:08, inclusive, apply to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive.
Sections 20:06:55:01 to 20:06:55:10, inclusive, apply to any employer based health plan, including any health benefit plan subject to the provisions of SDCL  58-18-42. This chapter does not apply to self funded plans preempted from state regulation pursuant to the Employee Retirement Income Security Act of 1974.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-51.1,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:13 - Emergency services

Current through Register Vol. 51, page 10, July 15, 2024
No prior authorization of emergency services may be required by a health carrier either for in-network or out-of-network emergency services. A plan must provide for the payment of emergency services by an out-of-network provider in an amount not less than the greatest of the following:
(1) The amount negotiated with in-network providers for emergency services excluding any in-network co-payment on coinsurance imposed with respect to the covered person;
(2) The amount for the emergency service calculated and excluding any in-network co-payment or coinsurance, using the same method the plan uses to determine payments for out-of-network services but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or
(3) The amount that would be paid under Medicare part A or part B for the emergency service and excluding any in-network co-payment or coinsurance.
For capitated and other plans that do not have a negotiated per-service amount for in-network providers, subdivision (1) does not apply. If a plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount of subdivision (1) is the median of these negotiated amounts. Nothing in this section applies to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147 . Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), this section applies to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive, and applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-51.1,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:14 - Rescissions

Current through Register Vol. 51, page 10, July 15, 2024
A policy, certificate, or contract of insurance may not be rescinded unless the individual performs an act, practice, or omission that constitutes fraud or unless the individual makes an intentional misrepresentation of a material fact. A rescission is any cancellation or discontinuance of coverage under any individual or group health insurance policy or certificate, other than a plan of excepted benefits, that has a retroactive effect. Rescission does not include a cancellation or discontinuance of coverage under a health policy or certificate if:
(1) The cancellation or discontinuance of coverage has only a prospective effect;
(2) The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage; or
(3) The health benefit plan covers only active employees and, if applicable, dependents and those covered under continuation coverage provisions, the employee pays no premiums for coverage after termination of employment and the cancellation or discontinuance of coverage is effective retroactively back to the date of termination of employment due to a delay in administrative record-keeping.
A health carrier shall provide at least thirty days advance notice to each plan enrollee or covered person who would be affected by the proposed rescission of coverage before coverage under the plan may be rescinded. If the proposed rescission is with respect to a group plan, the notice is required regardless of whether the rescission applies only to an individual within the group or to the entire group.
Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), this section applies to any plan of individual or group health insurance coverage and to any health benefit plan subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive, and also applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-51.1,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:15 - Group plans - Lifetime limits

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan may not establish any lifetime limit or any annual limit on the dollar amount of essential benefits for any individual except as permitted in §
									20:06:55:16. However, a flexible spending arrangement may have an annual limit on the dollar amount of benefits. Nothing in this section prohibits a group health plan from placing annual or lifetime limits on specific covered benefits that are not essential benefits. Essential benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care. Nothing in this section prohibits a group health plan from excluding all benefits for a given condition.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:16 - Group plans - Annual limits

Current through Register Vol. 51, page 10, July 15, 2024
With respect to plan years beginning prior to January 1, 2014, a group health plan may establish, for any individual, an annual limit on the dollar amount of benefits that are essential health benefits if the limit is no less than the following:
(1) For a plan year beginning after September 22, 2010, but before September 23, 2011, $750,000;
(2) For a plan year beginning after September 22, 2011, but before September 23, 2012, $1,250,000;
(3) For plan years beginning after September 22, 2012, but before January 1, 2014, $2,000,000.
In determining whether an individual has received benefits that meet or exceed the allowable annual limits as required by this section the plan or issuer may only take into account essential health benefits.
For plan years beginning after December 31, 2013, no annual dollar limit is permitted for essential health benefits.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:17 - Group plans - Eligibility

Current through Register Vol. 51, page 10, July 15, 2024
An individual who meets the requirements of this section is eligible for benefits under a group health plan as described in §
									20:06:55:18. This section applies to any individual:
(1) Whose coverage or benefits under a group health plan ended by reason of reaching a lifetime limit on the dollar value of all benefits for any individual; and
(2) Who becomes eligible, or is required to become eligible, for benefits not subject to a lifetime limit on the dollar value of all benefits under the group health plan on the first day of the first plan year beginning after September 22, 2010, by reason of the application of this section.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:18 - Group plans - Notices and enrollment

Current through Register Vol. 51, page 10, July 15, 2024
If an individual described in §
									20:06:55:17  is eligible for benefits or is required to become eligible for benefits under the group health plan, the group health plan is required to give the individual written notice that the lifetime limit on the dollar value of all benefits no longer applies and that the individual, if covered, is once again eligible for benefits under the plan. If the individual is not enrolled in the plan or if an enrolled individual is eligible for but not enrolled in any benefit package under the plan, then the plan must also give such individual an opportunity to enroll that continues for at least thirty days. The notices and enrollment opportunity required under this section must be provided beginning no later than the first day of the first plan year beginning after September 22, 2010. In the case of an individual who enrolls pursuant to this section, coverage must take effect no later than the first day of the first plan year beginning after September 22, 2010.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:19 - Group plans - Special enrollment

Current through Register Vol. 51, page 10, July 15, 2024
An individual enrolling in a group health plan pursuant to §
									20:06:55:18  must be treated as if the individual were a special enrollee pursuant to §§
									20:06:40:05  and 20:06:40:05.01. The individual eligible for special enrollment must be offered all the benefit packages available to similarly situated individuals who did not lose coverage by reason of reaching a lifetime limit on the dollar value of all benefits. Any difference in benefits or cost-sharing constitutes a different benefit package. The individual may not be required to pay more for coverage than similarly situated individuals who did not lose coverage by reason of reaching a lifetime limit on the dollar value of all benefits.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:20 - Group plans - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:55:15 to 20:06:55:19, inclusive, apply for plan years beginning after September 22, 2010, and apply to any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42 but do not apply to excepted benefits.
For plan or policy years beginning prior to January 1, 2014, a group health insurance policy is exempt from the annual limit requirements if the policy is approved for a waiver from such requirements by the U.S. Department of Health and Human Services but such exemption only applies for the specified period of time that the waiver from the U.S. Department of Health and Human Services is applicable.
At the time a policy receives a waiver from the U.S. Department of Health and Human Services, the health carrier shall notify prospective applicants and affected policyholders and the commissioner in each state where prospective applicants and any affected insured are known to reside.
At the time the waiver expires or is otherwise no longer in effect, the health carrier shall notify affected policyholders and the commissioner in each state where any affected insured is known to reside.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-43,  58-18-44,  58-18-45,  58-18-48,  58-18-51.1,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:21 - Individual plans - Lifetime limits

Current through Register Vol. 51, page 10, July 15, 2024
No individual policy of insurance may establish a lifetime limit on the dollar value of essential benefits for any covered person or an unreasonable annual limit on the dollar value of essential benefits for any covered person. Nothing in this section prohibits a health plan from placing annual or lifetime limits on specific covered benefits that are not essential benefits. Essential benefits include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care. Nothing in this section prohibits a health plan from excluding all benefits for a given condition. The written notice requirements described in §
									20:06:55:18  apply to individual plans of 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 20:06:55 - Market regulations › Section 20:06:55:22 - Individual plans - Annual limits

Current through Register Vol. 51, page 10, July 15, 2024
With respect to policy years beginning prior to January 1, 2014, a health plan may establish, for any individual, an annual limit on the dollar amount of benefits that are essential health benefits provided the limit is no less than the following:
(1) For a plan year beginning after September 22, 2010, but before September 23, 2011, $750,000;
(2) For a plan year beginning after September 22, 2011, but before September 23, 2012, $1,250,000;
(3) For plan years beginning after September 22, 2012, but before January 1, 2014, $2,000,000.
In determining whether an individual has received benefits that meet or exceed the allowable annual limits as required by this section the plan or issuer may only take into account essential health benefits.
For plan years beginning after December 31, 2013, no annual dollar limit is permitted for essential health benefits.
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 20:06:55 - Market regulations › Section 20:06:55:23 - Reinstatement of coverage

Current through Register Vol. 51, page 10, July 15, 2024
An individual whose coverage or benefits under a health plan ended by reason of reaching a lifetime limit on the dollar value of all benefits for the individual must be provided an opportunity for reinstatement of coverage provided that the individual policy or the group health plan remains in force.
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 20:06:55 - Market regulations › Section 20:06:55:24 - Individual plans - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), §§
									20:06:55:21  to 20:06:55:23, inclusive, apply to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive.
Sections 20:06:55:21 to 20:06:55:23, inclusive, do not apply to individual plans with respect to annual limits if the plans are grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147.
For plan or policy years beginning prior to January 1, 2014, an individual health insurance policy is exempt from the annual limit requirements if the policy is approved for a waiver from such requirements by the U.S. Department of Health and Human Services but such exemption only applies for the specified period of time that the waiver from the U.S. Department of Health and Human Services is applicable.
At the time a policy receives a waiver from the U.S. Department of Health and Human Services, the health carrier shall notify prospective applicants and affected policyholders and the commissioner in each state where prospective applicants and any affected insured are known to reside.
At the time the waiver expires or is otherwise no longer in effect, the health carrier shall notify affected policyholders and the commissioner in each state where any affected insured is known to reside.
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 20:06:55 - Market regulations › Section 20:06:55:25.01 - Individual plans - No preexisting condition

Current through Register Vol. 51, page 10, July 15, 2024
No health policy, certificate, or plan may limit or exclude coverage based upon a preexisting condition for a person. For policies issued after March 23, 2010, but before September 23, 2010, any remaining preexisting condition waiting period must be removed beginning on the first day of the policy year following September 22, 2010. For individual policies issued after September 22, 2010, no preexisting waiting period for persons under the age of 19 may be applied. For persons who are age 19 or over no preexisting condition may apply after December 31, 2013. This section does not apply to grandfathered plans.
If a health insurance issuer offers health insurance coverage in any level of coverage other than excepted benefits, the issuer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21.
This section does not apply to a plan that is stand-alone dental.
Except for those coverages that are excepted benefits pursuant to §
									20:06:55:27, this section applies to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-84,  58-17-87,  58-17-97.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:26 - Group plans - No preexisting condition for a person under the age of 19

Current through Register Vol. 51, page 10, July 15, 2024
No health policy, certificate, or plan may limit or exclude coverage based upon a preexisting condition for a person under the age of 19. Any prexisting condition waiting period for a covered person under the age of 19 must be removed no later than the first day of the plan year following September 22, 2010.
This section applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42 and plans that are either grandfathered or not grandfathered.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-48,  58-18-51.1,  58-18-79,  58-18-86.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:55 - Market regulations › Section 20:06:55:27 - Excepted benefits - Defined

Current through Register Vol. 51, page 10, July 15, 2024
For any health insurance policy or certificate subject to the provisions of Title 58 the term excepted benefits are those benefits as defined in section 2791 (c) of the Public Health Service Act.
General Authority:
SDCL  58-11-63,  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-11-44,  58-17-69,  58-17-87,  58-18-31,  58-18-45,  58-18-79.