reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:46 - HIPAA rules - Nondiscrimination in the group market › Section 20:06:46:10 - Employment based factors in determining two or more distinct groups of participants

Current through Register Vol. 51, page 10, July 15, 2024
Subject to §
									20:06:46:12, §
									20:06:46:03  does not prohibit a carrier subject to this chapter from treating participants as two or more distinct groups of similarly situated individuals if the distinction made between or among groups of participants is based on a bona fide employment-based classification that is consistent with the employer's usual business practice. Whether an employment-based classification is bona fide shall be determined based on all of the relevant facts and circumstances. Relevant facts and circumstances include whether the employer uses the classification for purposes independent of qualification for health coverages. Such classifications may include:
(1) Full-time versus part-time status;
(2) Membership in a collective bargaining unit;
(3) Date of hire;
(4) Length of service; and
(5) Current employee versus former employee status.
A classification based on a health factor may not be determined to be a bona fide employment-based classification for purposes of §§
										20:06:46:09  to 20:06:46:12, inclusive, unless the requirements of §
										20:06:46:03  are satisfied.
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 20:06:46 - HIPAA rules - Nondiscrimination in the group market › Section 20:06:46:11 - Beneficiaries treated as two or more distinct groups

Current through Register Vol. 51, page 10, July 15, 2024
Subject to §
									20:06:46:12, §
									20:06:46:03  does not prohibit a carrier subject to this chapter from treating beneficiaries as two or more distinct groups of similarly situated individuals if the distinction made between or among the groups of beneficiaries is based on any of the following factors:
(1) A bona fide employment-based classification of the participant through whom the beneficiary is receiving coverage;
(2) Relationship to the participant (e.g., as spouse or as a dependent child);
(3) Marital status;
(4) With respect to a child of the participant, age or student status; or
(5) Any other factor, if the factor is not a health factor.
This section may not be construed to prevent a carrier subject to this chapter from providing more favorable treatment of individuals under the plan with adverse health factors in accordance with §
										20:06:46:03.
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 20:06:46 - HIPAA rules - Nondiscrimination in the group market › Section 20:06:46:12 - Creation or modification of an employment or coverage classification not permitted

Current through Register Vol. 51, page 10, July 15, 2024
Notwithstanding §§
									20:06:46:10  and 20:06:46:11, unless permitted under §
									20:06:46:03, if the creation or modification of an employment or coverage classification is directed at individual participants or beneficiaries based on a health factor of the participants or beneficiaries, the classification is not permitted under §§
									20:06:46:09  to 20:06:46:12, inclusive.
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 20:06:46 - HIPAA rules - Nondiscrimination in the group market › Section 20:06:46:13 - Rule of eligibility or individual's premium or contribution rate

Current through Register Vol. 51, page 10, July 15, 2024
Except to the extent permitted under §
									20:06:46:14  or 20:06:46:15, in accordance with §§
									20:06:46:03  to 20:06:46:05, inclusive, a carrier subject to this chapter may not establish a rule of eligibility or set an individual's premium or contribution rate based on:
(1) Whether the individual is confined in a hospital or other health care institution; or
(2) The individual's ability to engage in normal life activities.
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 20:06:46 - HIPAA rules - Nondiscrimination in the group market › Section 20:06:46:14 - Actively-at-work not a condition of eligibility or premium or contribution rate

Current through Register Vol. 51, page 10, July 15, 2024
In accordance with §§
									20:06:46:03  to 20:06:46:05, inclusive, a carrier subject to this chapter may not establish a rule for eligibility or set an individual's premium or contribution rate based on whether the individual is actively-at-work, including whether an individual is continuously employed, unless absence from work due to any health factor is treated, for purposes of the plan, as being actively-at-work. However, a carrier subject to this chapter may establish a rule for eligibility that requires an individual to begin work for the employer sponsoring the plan before coverage under the plan becomes effective if the rule for eligibility applies regardless of the reasons for the absence.
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 20:06:46 - HIPAA rules - Nondiscrimination in the group market › Section 20:06:46:15 - Rule of eligibility or individual premium or contribution permitted

Current through Register Vol. 51, page 10, July 15, 2024
Notwithstanding §§
									20:06:46:13  and 20:06:46:14, a carrier subject to this chapter may establish a rule of eligibility or set an individual's premium or contribution rate with respect to similarly situated individuals, if the rule is in compliance with SDCL  58-18-48,  58-18B-3, and  58-18B-15, as those groups are determined under §§
									20:06:46:09  to 20:06:46:12, inclusive.
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 20:06:47 - Group disability benefits › Section 20:06:47:01 - Scope

Current through Register Vol. 51, page 10, July 15, 2024
This chapter applies to group disability income insurance policies as defined in SDCL  58-17-108.
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:02 - Establishment of claims procedures

Current through Register Vol. 51, page 10, July 15, 2024
Any plan providing disability benefits shall establish and maintain reasonable claim procedures. The procedures shall include the following:
(1) A description of all claim procedures including, but not limited to, any procedures for obtaining prior authorization as a prerequisite for obtaining a benefit and adverse determination review procedures;
(2) Applicable time frames;
(3) Administrative processes and safeguards to ensure consistent benefit determinations for similar situations;
(4) In regard to voluntary appeal:
(a) The plan waives any right to assert that a covered person has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal provided by the plan;
(b) The plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that any such voluntary appeal is pending;
(c) The plan provides that a covered person may elect to submit a benefit dispute to such voluntary level of appeal only after the exhaustion of the appeals; and
(d) The plan provides to any covered person, upon request, sufficient information relating to the voluntary level of appeal to enable the covered person to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal, including a statement that the decision of a covered person as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on the covered person's right to representation, the process for selecting the decision maker, and the circumstances, if any, that may affect the impartiality of the decision maker, such as any financial or personal interests in the result or any past or present relationship with any party to the review process.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:03 - Unacceptable claims procedures

Current through Register Vol. 51, page 10, July 15, 2024
The claims procedures may not contain any provisions or be administered in a method that unduly inhibits or hampers the initiation or processing of claims for benefits such as:
(1) Denying a claim for lack of prior authorization in circumstances where obtaining authorization could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function;
(2) Precluding an authorized representative from acting on behalf of a covered person;
(3) Requiring the filing of more than two appeals of an adverse benefit determination prior to taking civil action;
(4) Requiring arbitration; and
(5) Imposing fees or costs for voluntary appeals.
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:04 - Initial benefit determination

Current through Register Vol. 51, page 10, July 15, 2024
Any plan providing disability benefits shall notify a covered person, or if applicable, the covered person's authorized representative, of a benefit determination within a reasonable time period, but not later than 45 days after receipt of the claim. This time period for making a determination and notifying the covered person or their authorized representative may be extended for up to 30 days when necessary due to matters beyond the control of the plan. If the plan is unable to render a determination within 45 days, the plan must notify the covered person in writing, prior to the end of the initial 45-day period of that fact, and include the following:
(1) The standards used to determine benefit entitlement;
(2) The issues preventing benefit determination;
(3) Any additional information or materials needed to complete the determination;
(4) The time period, which may not be less than 45 days, that the covered person or the person's authorized representative has to submit additional information; and
(5) The date by which the plan expects to render determination.
If the plan is unable to render a determination, due to matters beyond its control, the time period may be extended for a second 30-day period, providing the plan notifies the covered person in writing, prior to the end of the initial 30-day extension and includes the notification requirements listed above. The toll of the time periods begins at the time the claim is filed in accordance with plan procedures without regard to whether all the information necessary accompanies the filing. In regard to time period extensions, the time is tolled from the date on which notice of the extension is sent to the covered person until the date on which the covered person responds to the request for additional information.
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:05 - Adverse benefit notification

Current through Register Vol. 51, page 10, July 15, 2024
The plan shall provide a covered person or, if applicable, the person's authorized representative, with written or electronic notification of any adverse benefit determination in a manner calculated to be understood by the covered person. The notification shall include the following:
(1) The specific reason or reasons for the determination;
(2) Reference to the specific plan provision on which the determination was based;
(3) A description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary;
(4) A description of review procedures and applicable time frames;
(5) A statement of the person's right to bring a civil action under applicable law;
(6) The specific rule, guideline, protocol, or other similar criterion used in making the adverse determination, or a statement that such items were relied upon and are available free of charge to the covered person upon request;
(7) An explanation of the scientific or clinical judgment used in the determination based on medical necessity or experimental treatment or similar exclusion or limitation, or a statement that such explanation will be provided free of charge upon request; and
(8) The statement "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and the South Dakota Division of Insurance."
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:06 - Appeal of adverse benefit determination

Current through Register Vol. 51, page 10, July 15, 2024
Any plan providing disability benefits, upon receipt of an appeal of an adverse benefit determination, shall notify a covered person or, if applicable, the covered person's authorized representative, of the benefit determination within a reasonable time period, but not later than 45 days after receipt of the request, without regard to whether all the information necessary to make a benefit determination accompanies the filing. This time period for making a determination and notifying the covered person of the covered person's authorized representative may be extended for up to 45 days when necessary due to matters beyond the control of the plan. If the plan is unable to render a determination within the 45 days, the plan must notify the covered person in writing, prior to the end of the initial 45-day period of that fact, and include the following:
(1) The special circumstances requiring an extension of time; and
(2) The date by which the plan expects to render a determination.
The time period for extensions due to the covered person's failure to submit information necessary to decide a claim shall be tolled from the date on which the notification of the extension is sent until the date on which the covered person responds to the request for additional information.
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:07 - Full and fair review

Current through Register Vol. 51, page 10, July 15, 2024
The plan shall provide full and fair review of an adverse benefit determination. Evidence of a full and fair review consists of the following:
(1) A reasonable opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;
(2) Reasonable access to copies of any documents, records, and other information relevant to the claim for benefits upon request and free of charge;
(3) Consideration of all comments, documents, records, and other information submitted by the covered person relating to the claim for benefits without regard to whether such information was considered or available in the initial determination;
(4) A minimum of 180 days following notification of an adverse determination in which to appeal;
(5) No deference to the initial determination and a review that is conducted by neither the individual who made the adverse determination or a subordinate of that individual;
(6) Consultation by the individual reviewing the appeal with a health care professional of appropriate training and experience in the field of medicine involved when the determination is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate. However, the professional may not be the individual consulted in the initial determination or a subordinate of that individual; and
(7) The identification of medical or vocational experts whose advice was obtained in regard to the determination, regardless if the advice was relied upon in making the determination.
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:47 - Group disability benefits › Section 20:06:47:08 - Relevant claim information

Current through Register Vol. 51, page 10, July 15, 2024
A document, record, or other information shall be considered relevant to a claim if such document, record, or other information:
(1) Was relied upon in making the benefit determination;
(2) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;
(3) Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination; and
(4) Constitutes statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the covered person's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.
General Authority:
SDCL  58-17H-49.
Law Implemented:
SDCL  58-17H-49.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:01 - Eligible person - Defined

Current through Register Vol. 51, page 10, July 15, 2024
An eligible person is a person eligible for risk pool coverage pursuant to SDCL 58-17-85 and 58-17-136.
General Authority:
SDCL 58-17-124(1).
Law Implemented:
SDCL 58-17-85, 58-17-124(1).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:02 - Enrollment forms

Current through Register Vol. 51, page 10, July 15, 2024
Any person applying for coverage under the risk pool shall complete the application form specifically designed for the risk pool and a health risk assessment form. The information contained on the health risk assessment form may not be used to determine eligibility for the risk pool.
General Authority:
SDCL 58-17-124(5)(6).
Law Implemented:
SDCL 58-17-124(5)(6).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:03 - Tolling of 63-day timeframe

Current through Register Vol. 51, page 10, July 15, 2024
Any substantially completed application, whether an underwritten application or one specifically designed for the risk pool, tolls the 63-day timeframe. If the application results in coverage, the days starting on the date of the substantially completed application through the date coverage begins, are not taken into account in determining whether the 63-day timeframe has been reached. If the application does not result in coverage, the tolling of the 63-day timeframe ends on the date the application is denied by the issuer or on the date the offer of coverage lapses. This section does not reduce the timeframes allowed for a risk pool applicant to apply as provided for in §§
									20:06:48:04  to 20:06:48:06, inclusive, or effect eligibility as provided for by §
									20:06:48:17.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85, 58-17-124(5).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:04 - Risk pool application timeframe

Current through Register Vol. 51, page 10, July 15, 2024
An eligible person who is rejected by a carrier due to medical underwriting may submit an application to the risk pool board after the 63-day timeframe, if the application is made within 30 days of receiving notice of the rejection from the carrier, in order to maintain eligibility pursuant to SDCL 58-17-85. However, an eligible person who is within the 63-day timeframe following loss of creditable coverage is not disqualified from coverage under the risk pool plan if the eligible person applies for coverage under the risk pool plan more than 30 days after receiving a notice of rejection.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85, 58-17-124(5).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:05 - Effective date of risk pool coverage

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of an application from an eligible person, the risk pool board shall issue the plan with an effective date corresponding to the date of the application. If an eligible person makes the application prior to the actual date of termination of existing creditable coverage, the risk pool board may issue the plan with an effective date coinciding with the termination date of the creditable coverage. The effective date of risk pool coverage may not be any earlier than August 1, 2003, regardless of the qualifying circumstances. The risk pool board and the eligible person may agree to an effective date other than what is required by this section.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85, 58-17-124.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:06 - Prior application for major medical coverage

Current through Register Vol. 51, page 10, July 15, 2024
If prior to application to the risk pool, an eligible person applies for major medical coverage subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive, and the application is rejected by the carrier, the date of the application to the carrier is the date the risk pool shall use for purposes of §
									20:06:48:05  as long as the eligible person applies to the risk pool within 30 days of the date of the carrier's rejection.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85, 58-17-124.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:07 - Payment of insurance producer commission

Current through Register Vol. 51, page 10, July 15, 2024
An insurance producer shall be paid the commission for placement of risk pool coverage on a quarterly basis.
General Authority:
SDCL 58-17-124(9)
Law Implemented:
SDCL 58-17-141.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:08 - Denial of claim

Current through Register Vol. 51, page 10, July 15, 2024
A risk pool enrollee shall be notified in writing if the enrollee's claim for benefits is denied. The explanation of benefits (EOB) shall include the specific reason the claim was denied and the address for making an appeal.
General Authority:
SDCL 58-17-124(6)(7).
Law Implemented:
SDCL 58-17-124(6) )7).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:09 - Appeals

Current through Register Vol. 51, page 10, July 15, 2024
If a claim is denied, the aggrieved party may appeal in writing to the claims administrator within 180 days of the date of the denial at the address listed on the explanation of benefits (EOB) or in the written utilization review denial. If the claims administrator again denies the claim, the aggrieved party may appeal in writing to the administrator of the risk pool, c/o the Bureau of Human Resources, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501, within 30 days of receiving notification of the denial. The administrator of the risk pool shall issue a written decision within 30 days from the date that the appeal is received. If the administrator of the risk pool denies the claim, the aggrieved party may appeal in writing to the risk pool board within 30 days of receiving notification of the denial and the board shall issue a written decision on the appeal. If the risk pool board denies the claim, the aggrieved party may request a hearing before the Office of Hearing Examiners within 30 days of receiving notification of the denial.
If the subject matter of the appeal is not a claim, the aggrieved party shall file an appeal directly to the administrator of the risk pool within 180 days of the date of the decision, and if not satisfied with the decision of the administrator of the risk pool, may appeal to the board within 30 days of the date of that decision. If the aggrieved party is not satisfied with the decision of the board, the aggrieved party may request a hearing before the Office of Hearing Examiners within 30 days of receiving notification of the board's decision.
Prior to the board hearing an appeal the chair of the risk pool board shall appoint a member of the board to serve as the final decision maker. The final decision maker may not participate in the appeal or in any discussions related to the appeal. The final decision maker may accept, reject, or modify the findings, conclusions, and decisions of the hearing examiner pursuant to SDCL  1-26D-6. The aggrieved party may appeal any final decision to the circuit court in accordance with SDCL chapter 1-26.
If an aggrieved party fails to appeal within the time limits provided in this section, no further action is required.
General Authority:
SDCL 58-17-124(5)(7)(9).
Law Implemented:
SDCL 58-17-124(5)(7)(9).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:10 - Payment of risk pool premiums

Current through Register Vol. 51, page 10, July 15, 2024
Unless other arrangements have been made through the director of the risk pool benefits, an eligible person shall include with the application an automated clearing house (ACH) form and payment for the current month's and the subsequent month's premium. After the initial premium payment, any premium payment must be made by automatic withdrawal, unless specific arrangements have been made with the director of risk pool benefits. Each monthly withdrawal shall equal the premium payment due to provide coverage for the subsequent month.
General Authority:
SDCL 58-17-124(7).
Law Implemented:
SDCL 58-17-124(7).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:11 - Coverage cancellation for nonpayment of premium

Current through Register Vol. 51, page 10, July 15, 2024
If an account has insufficient funds to allow the automatic withdrawal of the monthly premium, a second attempt to collect the premium shall be made within four to six days of the original deduction date. If the account still has insufficient funds, the risk pool coverage shall be canceled. If a premium payment is made through any method other than automatic withdrawal, any failure to make the required premium payment by the premium due date may result in the risk pool coverage being canceled at the discretion of the risk pool plan. An enrollee who fails to make a required premium payment shall receive one grace period in each calendar year. Such enrollee shall be notified of the once-a-year grace period in writing. The grace period is an additional 15 days after the cancellation date specified in this section.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-124(5), 58-17-136.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:12 - Lifetime benefit limit

Current through Register Vol. 51, page 10, July 15, 2024
The two million dollar lifetime maximum for an enrollee applies to all plans in the aggregate that an enrollee may have under the risk pool. A separate lifetime maximum does not start if the enrollee changes plans or if the enrollee leaves the pool and subsequently enrolls in the risk pool again.
General Authority:
SDCL 58-17-124(7).
Law Implemented:
SDCL 58-17-124(7), 58-17-134.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:13 - Changing plans

Current through Register Vol. 51, page 10, July 15, 2024
After an enrollee has selected one of the plans available, the enrollee may not change plans except at the beginning of a new fiscal year and only if the plan change involves an increase in the deductible. The enrollee shall provide written notification to the risk pool board of the enrollee's request to change plans prior to the beginning of the new fiscal year.
General Authority:
SDCL 58-17-124(7).
Law Implemented:
SDCL 58-17-124, 58-17-130.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:14 - One-person group ineligible

Current through Register Vol. 51, page 10, July 15, 2024
A one-person employer group plan that terminates group coverage either by formal notice by the employer to terminate coverage or by failure to pay premiums is ineligible for risk pool coverage. For purposes of this section, a one-person group is one in which the covered employee and the employer are the same person.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85, 58-17-124(5), 58-17-136.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:15 - Cooperation required

Current through Register Vol. 51, page 10, July 15, 2024
An enrollee must cooperate with the risk pool board by providing information, upon request, that shows continued eligibility for the risk pool and by submitting applications for health insurance and other applicable programs. Cooperation, in the form of payment of copayments, coinsurance and deductible amounts to a provider for services covered by the risk pool, is required for continued eligibility for the risk pool. The failure of an enrollee, upon notice by the plan, to remit to a provider copayments, coinsurance, and deductibles for services covered by the risk pool in a manner satisfactory to the risk pool administrator is sufficient grounds for the termination of coverage in the risk pool for that enrollee.
General Authority:
SDCL 58-17-124(5)(7).
Law Implemented:
SDCL 58-17-124(5)(7), 58-17-136.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:16 - Preexisting condition waiting period prohibited

Current through Register Vol. 51, page 10, July 15, 2024
No plan of coverage provided through the risk pool may contain any waiting period for preexisting conditions for individuals eligible for coverage pursuant to SDCL 58-17-85.
General Authority:
SDCL 58-17-124(7).
Law Implemented:
SDCL 58-17-130.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:17 - Eligibility - Exclusionary rider

Current through Register Vol. 51, page 10, July 15, 2024
A person otherwise eligible for coverage pursuant to SDCL 58-17-85 does not lose eligibility for the risk pool if the other coverage offered or issued to the person is a policy or certificate that contains any exclusionary rider based upon the person's health history.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:18 - Public health plans

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of this chapter, a public health plan is any plan established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country that provides health coverage to individuals who are enrolled in the plan.
The term, public health plan, includes coverage provided for under the public health system of a foreign country. For purposes of eligibility under SDCL 58-17-85, coverage provided under the public health system of a foreign country as a public health plan may not be the person's last coverage unless the public health plan also constitutes a group health plan.
General Authority:
SDCL 58-17-124(5).
Law Implemented:
SDCL 58-17-85, 58-17-124(5).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:19 - Eligibility based upon residence

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of SDCL 58-17-85 a person is not eligible for enrollment into the risk pool if the person does not have a physical residence in South Dakota such as a house, apartment, condominium, or other similar place where the person resides. A physical residence does not include a post office box or the address of another mail service purchased by the person. A person who maintained a physical residence in South Dakota for at least one year in the prior ten years and subsequent to maintaining the physical residence in South Dakota has had no physical residence in any other state is considered to be a resident of this state pursuant to SDCL 58-17-85.
General Authority:
SDCL  58-17-87, 58-17-124.
Law Implemented:
SDCL 58-17-85.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:20 - Termination of coverage due to fraud

Current through Register Vol. 51, page 10, July 15, 2024
Any coverage or benefits provided by the risk pool shall terminate when the enrollee acts in a fraudulent manner or makes an intentional misrepresentation of a material of fact, including falsifying information.
General Authority:
SDCL 58-17-124(7).
Law Implemented:
SDCL 58-17-85.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:21 - Claims paid in error - Debt subject to recovery

Current through Register Vol. 51, page 10, July 15, 2024
If any claim is paid on behalf of an individual and the administrator subsequently finds that the individual was ineligible for the benefits paid due to fraud, the claim was paid in error. A claim paid in error constitutes a debt to the plan and is subject to recovery from the individual by the plan.
General Authority:
SDCL 58-17-124(7).
Law Implemented:
SDCL 58-17-85.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:48 - Health insurance risk pool › Section 20:06:48:22 - Creditable coverage - Children's Health Insurance Program

Current through Register Vol. 51, page 10, July 15, 2024
Coverage provided pursuant to a state's Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act is creditable coverage.
General Authority:
SDCL  58-17-87(13).
Law Implemented:
SDCL  58-17-69, 58-17-85,  58-18-44.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:49 - Discount plans › Section 20:06:49:01 - Nominal processing fee

Current through Register Vol. 51, page 10, July 15, 2024
A discount plan subject to the registration provisions of SDCL  58-17E-9 may withhold a nominal processing fee not to exceed $25.
General Authority:
SDCL  58-17E-45.
Law Implemented:
SDCL  58-17E-41,  58-17E-45.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:50 - Coordination of benefits › Section 20:06:50:01 - Permissible policy language and disclosure forms

Current through Register Vol. 51, page 10, July 15, 2024
Appendices A and B are samples of permissible policy language and disclosure forms in reference to coordination of benefits.
General Authority:
SDCL  58-18A-61.
Law Implemented:
SDCL  58-18A-61.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:51 - Mortality tables for use in determining minimum reserve liabilities › Section 20:06:51:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in §§ 20:06:51:01  to 20:06:51:06, inclusive, mean:
(1) "2001 CSO Mortality Table," that mortality table, consisting of separate rates of mortality for male and female lives, developed by the American Academy of Actuaries CSO Task Force from the Valuation Basic Mortality Table developed by the Society of Actuaries Individual Life Insurance Valuation Mortality Task Force, and adopted by the NAIC in December 2002. The 2001 CSO Mortality Table is included in the
Proceedings of the NAIC (2nd Quarter 2002
) and supplemented by the 2001 CSO Preferred Class Structure Mortality Table. Unless the context indicates otherwise, the "2001 CSO Mortality Table" includes both the ultimate form of that table and the select and ultimate form of that table and includes both the smoker and nonsmoker mortality tables and the composite mortality tables. It also includes both the age-nearest-birthday and age-last-birthday bases of the mortality tables. Mortality tables in the 2001 CSO Mortality Table include the following:
(a) 2001 CSO Mortality Table (F), means that mortality table consisting of the rates of mortality for female lives from the 2001 CSO Mortality Table;
(b) 2001 CSO Mortality Table (M) means that mortality table consisting of the rates of mortality for male lives from the 2001 CSO Mortality Table;
(c) Composite mortality tables means mortality tables with rates of mortality that do not distinguish between smokers and nonsmokers;
(d) Smoker and nonsmoker mortality tables means mortality tables with separate rates of mortality for smokers and nonsmokers;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:51 - Mortality tables for use in determining minimum reserve liabilities › Section 20:06:51:02 - Election of mortality table

Current through Register Vol. 51, page 10, July 15, 2024
At the election of the insurer for each calendar year of issue, for any one or more specified plans of insurance and subject to satisfying the conditions stated in this chapter, the 2001 CSO Preferred Class Structure Mortality Table may be substituted in place of the 2001 CSO Smoker or Nonsmoker Mortality Table as the minimum valuation standard for policies issued after December 31, 2006. No such election may be made until the company demonstrates at least 20 percent of the business to be valued on this table is in one or more of the preferred classes. A table from the 2001 CSO Preferred Class Structure Mortality Table used in place of a 2001 CSO Mortality Table, pursuant to this chapter shall be treated as part of the 2001 CSO Mortality Table only for purposes of reserve valuation pursuant to the requirements of the NAIC model regulation, "Recognition of the 2001 CSO Mortality Table For Use in Determining Minimum Reserve Liabilities and Nonforfeiture Benefits Model Regulation."
General Authority:
SDCL  58-26-83.
Law Implemented:
SDCL  58-26-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:51 - Mortality tables for use in determining minimum reserve liabilities › Section 20:06:51:03 - Separate rates for preferred and standard nonsmoker lives

Current through Register Vol. 51, page 10, July 15, 2024
For each plan of insurance with separate rates for preferred and standard nonsmoker lives, an insurer may use the Super Preferred Nonsmoker, Preferred Nonsmoker, and Residual Standard Nonsmoker tables to substitute for the Nonsmoker Mortality Table found in the 2001 CSO Mortality Table to determine minimum reserves. At the time of election and annually thereafter, except for business valued under the Residual Standard Nonsmoker Table, the appointed actuary shall certify that:
(1) The present value of death benefits over the next ten years after the valuation date, using the anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the valuation basic table corresponding to the valuation table being used for that class;
(2) The present value of death benefits over the future life of the contracts, using anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the valuation basic table corresponding to the valuation table being used for that class.
General Authority:
SDCL  58-26-83.
Law Implemented:
SDCL  58-26-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:51 - Mortality tables for use in determining minimum reserve liabilities › Section 20:06:51:04 - Separate rates for preferred and standard smoker lives

Current through Register Vol. 51, page 10, July 15, 2024
For each plan of insurance with separate rates for preferred and standard smoker lives, an insurer may use the Preferred Smoker and Residual Standard Smoker tables to substitute for the Smoker Mortality Table found in the 2001 CSO Mortality Table to determine minimum reserves. At the time of election and annually thereafter, for business valued under the Preferred Smoker Table, the appointed actuary shall certify that:
(1) The present value of death benefits over the next ten years after the valuation date, using the anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the preferred smoker valuation basis table corresponding to the valuation table being used for that class;
(2) The present value of death benefits over the future life of the contracts, using anticipated mortality experience without recognition of mortality improvement beyond the valuation date for each class, is less than the present value of death benefits using the preferred smoker valuation basic table.
General Authority:
SDCL  58-26-83.
Law Implemented:
SDCL  58-26-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:51 - Mortality tables for use in determining minimum reserve liabilities › Section 20:06:51:05 - Filing of reports

Current through Register Vol. 51, page 10, July 15, 2024
Unless exempted by the director, every authorized insurer using the 2001 CSO Preferred Class Structure Table shall annually file statistical reports showing mortality and such other information as the director may deem necessary or expedient for the administration of the provisions of §§
									20:06:51:01  to 20:06:51:05, inclusive. The form of the reports shall be established by the director who shall consider the use of any form established by the NAIC or a statistical agent and designated by the NAIC.
General Authority:
SDCL  58-26-83.
Law Implemented:
SDCL  58-26-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:51 - Mortality tables for use in determining minimum reserve liabilities › Section 20:06:51:06 - Minimum valuation mortality standards for preneed insurance policies

Current through Register Vol. 51, page 10, July 15, 2024
For preneed insurance and similar policies, the minimum mortality standard for determining reserve liabilities and nonforfeiture values for both male and female insureds is the Ultimate 1980 CSO. However, for preneed insurance policies issued after December 31, 2008, and before January 1, 2012, the 2001 CSO may be used as the minimum standard for reserves and minimum standard for nonforfeiture benefits for both male and female insureds.
If an insurer elects to use the 2001 CSO as a minimum standard for any policy issued on or after December 31, 2008, and before January 1, 2012, the insurer shall provide, as a part of the actuarial opinion memorandum submitted in support of the company's asset adequacy testing, an annual written notification to the domiciliary commissioner. The notification shall include:
(1) A complete list of all preneed policy forms that use the 2001 CSO as a minimum standard;
(2) A certification signed by the appointed actuary stating that the reserve methodology employed by the company in determining reserves for the preneed policies issued after December 31, 2008, and using the 2001 CSO as a minimum standard, develops adequate reserves. For the purposes of this certification, the preneed insurance policies using the 2001 CSO as a minimum standard cannot be aggregated with any other policies; and
(3) Supporting information regarding the adequacy of reserves for preneed insurance policies issued after December 31, 2008, and using the 2001 CSO as a minimum standard for reserves.
Preneed insurance policies issued after December 31, 2011, must use the Ultimate 1980 CSO in the calculation of minimum nonforfeiture values and minimum reserves.
This rule applies to preneed insurance policies issued after December 31, 2008.
General Authority:
SDCL  58-15-43.12,  58-26-49,  58-26-83.
Law Implemented:
SDCL  58-15-43.8,  58-26-45,  58-26-46,  58-26-49,  58-26-83.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:52 - Discretionary clauses › Section 20:06:52:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Appeal," any review or appeal before an administrative agency, arbitrator, court or mediator;
(2) "Discretionary clause," a provision in a policy that purports to bind the claimant to, or grant deference in, proceedings subsequent to the insurer's decision, denial, or interpretation on terms, coverage, or eligibility for benefits, including a policy provision that provides any of the following:
(a) A policyholder or other claimant may not appeal a denial of a claim;
(b) The insurer's decision to deny policy coverage is binding upon a policyholder or other claimant or is otherwise entitled to deference upon appeal or review;
(c) On appeal or review the insurer's decision-making power as to policy coverage is binding or otherwise entitled to deference;
(d) The insurer's interpretation of the terms of a policy is binding upon a policyholder or other claimant or is otherwise entitled to deference;
(e) On appeal the insurer's interpretation of the terms of a policy is binding or is otherwise entitled to deference;
(f) A standard of review on appeal that gives deference in the original claim decision, or gives rise to such standard of review;
(g) A standard of review on appeal other than a de novo review, or gives rise to a standard of review other than de novo;
(h) The insurer has discretion to determine whether a claim is compensable or to interpret the provisions of the policy or certificate;