reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Activities of daily living," bathing, dressing, eating, maintaining continence, toileting, and transferring;
(2) "Acute condition," a medically unstable condition that requires frequent monitoring of an individual by medical professionals, such as physicians and registered nurses;
(3) "Adult day care," a program of social and health-related services provided for six or more individuals during the day in a community group setting for the purpose of supporting frail, impaired elderly or other adults with disabilities who can benefit from care in a group setting outside the home;
(4) "Bathing," washing oneself by sponge bath or in a tub or shower, including the task of getting into or out of the tub or shower;
(5) "Chronically ill individual," any individual who has been certified by a licensed health care practitioner as:
(a) Being unable to perform (without substantial assistance from another individual) at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity; or
(b) Requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment.
The term, chronically ill individual, does not include an individual otherwise meeting these requirements unless within the preceding twelve-month period a licensed health care practitioner has certified that the individual meets these requirements;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01.01 - Nature of care - How defined

Current through Register Vol. 51, page 10, July 15, 2024
The policy or certificate shall contain definitions for the terms, skilled nursing care, personal care, specialized care, assisted living care, home care, and other services, in relation to the level of skill required, the nature of the care, and the setting in which care must be delivered.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-2,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01.02 - Service providers - How defined

Current through Register Vol. 51, page 10, July 15, 2024
The policy or certificate shall contain definitions for all providers of services, including skilled nursing facilities, extended care facilities, convalescent nursing homes, personal care facilities, specialized care providers, assisted living facilities, and home health care agencies in relation to the services and facilities required to be available and the licensure, certification, or registration or degree status of those providing or supervising the services. When the definition requires that the provider be appropriately licensed, certified, or registered, it shall also state what requirements a provider must meet in lieu of licensure, certification or registration when the state in which the service is to be furnished does not require a provider of these services to be licensed, certified or registered, or when the other state licenses, certifies, or registers the provider of services under another classification.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  28-6-38,  58-17B-2,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01.03 - Long-term care insurance

Current through Register Vol. 51, page 10, July 15, 2024
The term, long-term care insurance, includes group and individual annuities and life insurance policies or riders that provide direct coverage or supplement long-term care insurance. The term also includes a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term also includes qualified long-term care insurance contracts. Long-term care insurance does not include any insurance policy that is offered primarily to provide hospital confinement indemnity coverage, major medical expense coverage, or disability income or related asset-protection coverage. With regard to life insurance, this term does not include life insurance policies that accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement, and that provide the option of a lump-sum payment for those benefits, and where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. However, any rider to a life insurance policy that accelerates benefits and:
(1) the amount of the accelerated benefit is unrelated to the reimbursement of long-term care services;
(2) contains no separate premium for the rider; and
(3) is not marketed as long-term care insurance
is not subject to the requirements for long-term care insurance.
Notwithstanding any other provision of SDCL chapter 58-17 B, any product advertised, marketed, or offered as long-term care insurance or as an alternative to long-term care or nursing home insurance that conditions benefits based upon activities of daily living (ADLs) is subject to the provisions of chapter 20:06:21.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01.04 - Similar policy forms

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of this chapter, similar policy forms, are all of the long-term care insurance policies and certificates issued by an insurer in the same long-term care benefit classification as the policy form being considered. Certificates of groups that meet the definition in SDCL  58-17B-2(4)(a)  are not considered similar to certificates or policies otherwise issued as long-term care insurance, but are similar to other comparable certificates with the same long-term care benefit classifications. For purposes of determining similar policy forms, long-term care benefit classifications are defined as follows: institutional long-term care benefits only, non-institutional long-term care benefits only, or comprehensive long-term care benefits.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01.05 - Treatment of accelerated benefits in life insurance

Current through Register Vol. 51, page 10, July 15, 2024
Accelerated benefits payable under a life insurance contract:
(1) To a policyowner or certificateholder, during the lifetime of the insured, in anticipation of death or upon the occurrence of specified life-threatening or catastrophic conditions as defined by the policy or rider; and
(2) That reduce the death benefit otherwise payable under the life insurance contract; and
(3) That are payable upon the occurrence of a single qualifying event that results in the payment of a benefit amount determined at the time of acceleration
are not considered to be charging a separate premium pursuant to §
										20:06:21:01.03.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:01.06 - Claim and clean claim - Defined

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:21:104  to 20:06:21:108, inclusive, terms used mean:
(1) "Claim," a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met;
(2) "Clean claim," a claim that has no defect or impropriety, including any lack of required substantiating documentation, such as satisfactory evidence of expenses incurred, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:02 - Minimum standards for long-term care insurance policies

Current through Register Vol. 51, page 10, July 15, 2024
Long-term care insurance policies shall contain benefits that are reasonable in relation to the premium charged. Long-term care insurance policies that require prior hospitalization or institutionalization as a condition of coverage may not require that the present hospitalization or institutionalization be for the same condition for which the insured was previously hospitalized or institutionalized. Long-term care insurance policies may not require, as a condition of coverage, that rehabilitation received by the insured demonstrably improve the insured's condition. The elimination period for any one confinement may not exceed 100 days for a long-term care insurance policy or one year for a long-term care insurance rider.
An insurer may make application for an elimination period in excess of 100 days, provided that specific suitability criteria or underwriting procedures are filed with the application. If the director finds that the procedures or criteria provide adequate protection for consumers, the director may approve the application.
Long-term care policies which condition payment of benefits on the inability to perform activities of daily living (ADLs) may not be so restrictive that they exclude coverage of services provided at least at the level of intermediate care and may not be used to restrict coverage for organic brain disorders, including Alzheimer's disease and senile dementia. This paragraph also applies to policies basing benefits on functional incapacity. Long-term care policies or portions thereof that condition the receipt of benefits on ADLs or functional incapacity may not also condition benefits on a certain level of care.
General Authority:
SDCL  58-4-1,  58-17B-4,  58-17B-15.
Law Implemented:
SDCL  58-17B-3,  58-17B-6,  58-17B-7.
Intermediate care services, §
											67:16:04:18.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:02.01 - Annuity policies with long-term care benefits subject to waiting period

Current through Register Vol. 51, page 10, July 15, 2024
An annuity policy that provides long-term care benefits may contain a waiting period before long-term care benefits are payable in addition to an elimination period. The waiting period may not exceed two years and may only be issued to applicants who are determined to be able to self fund the long-term care benefit during the waiting period pursuant to suitability guidelines as approved by the director. Any waiting periods or any other limitations on the use of annuity proceeds to fund long-term care must be prominently disclosed in advertising and solicitation materials.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:03 - Renewability of group policies - Required disclosures

Current through Register Vol. 51, page 10, July 15, 2024
Group long-term care insurance policies that are issued in this state or filed for approval pursuant to SDCL  58-17B-14 and that are neither guaranteed renewable or noncancelable shall prominently state on the front page of each certificate that the coverage is conditionally renewable and shall state in clear and concise language the conditions for nonrenewal.
General Authority:
SDCL  58-4-1,  58-17B-4,  58-17B-15.
Law Implemented:
SDCL  58-17B-3,  58-17B-12.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:04 - Permissible exclusions from coverage

Current through Register Vol. 51, page 10, July 15, 2024
A long-term care insurance policy may exclude or limit coverage for the following:
(1) Declared or undeclared war;
(2) Suicide or self-inflicted injuries;
(3) Alcoholism or drug abuse. This subdivision does not permit an exclusion or limitation for long-term care services due to the insured's alcoholism or drug abuse, other than for the treatment of alcoholism or drug abuse;
(4) Mental or emotional disorder;
(5) Pre-existing conditions;
(6) Participation in a felony, riot, or insurrection;
(7) Treatment in a government facility at no charge to the insured or that portion of any treatment which is paid by a government plan;
(8) Limitations based on territory;
(9) Mental or nervous disorders. This subdivision does not permit exclusion or limitation of benefits because of Alzheimer's disease;
(10) Aviation. This exclusion applies only to passengers who have not paid fares;
(11) Workers' compensation. Work-related injuries or illnesses if benefits are paid under workers' compensation or other similar laws;
(12) Service or care provided by a family member unless:
(a) The family member is a regular employee of the service or care provider furnishing the service or care;
(b) The service or care provider receives the payment for the service or care; and
(c) The family member receives no compensation other than the normal compensation for an employee in his or her job category; or
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:05 - Loss ratios

Current through Register Vol. 51, page 10, July 15, 2024
This section applies to all long-term care insurance policies or certificates except those covered under §
									20:06:21:61  and §§
									20:06:21:63  to 20:06:21:69, inclusive.
A long-term care insurance policy sold in this state shall meet or exceed the minimum loss ratio. The minimum loss ratio for an individual policy is 60 percent. The minimum loss ratio for a group policy is 65 percent. Long-term care insurance coverage sold through the mail or mass media advertising is considered an individual policy and not a group policy. The loss ratio shall be calculated based on earned premium and incurred loss in the aggregate. The premium shall be designed to develop at least the minimum loss ratio over the lifetime of the policy. An anticipated loss ratio shall be based on generally accepted actuarial principles and practices as published in the
Actuarial Standards of Practice
.
All filings of rates and rating schedules shall demonstrate that actual and expected losses, in relation to premiums, comply with the requirements of this section.
Loss ratio requirements do not apply to long-term care riders attached to or provisions included in life insurance policies.
In evaluating the expected loss ratio, consideration shall be given to all relevant factors, including:
(1) Statistical credibility of incurred claims experience and earned premiums;
(2) The period for which rates are computed to provide coverage;
(3) Experienced and projected trends;
(4) Concentration of experience within early policy duration;
(5) Expected claim fluctuation;
(6) Experience refunds, adjustments, or dividends;
(7) Renewability features;
(8) All appropriate expense factors;
(9) Interest;
(10) Experimental nature of the coverage;
(11) Policy reserves;
(12) Mix of business by risk classification; and
(13) Product features such as long elimination periods, high deductibles, and high maximum limits.
General Authority:
SDCL  58-17B-8.
Law Implemented:
SDCL  58-17B-8.
Actuarial Standards of Practice
, American Academy of Actuaries. Copies may be obtained free of charge on the website: http:/www.actuarialstandardsboard.org/asops.htm [File Link Not Available].
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:05.01 - Relation of benefits to premium for accelerated death benefit on life insurance

Current through Register Vol. 51, page 10, July 15, 2024
A life insurance policy that funds long-term care benefits entirely by accelerating the death benefit is considered to provide reasonable benefits in relation to premiums paid, if the policy complies with all of the following provisions:
(1) The interest credited internally to determine cash value accumulations, including long-term care, if any, are guaranteed not to be less than the minimum guaranteed interest rate for cash value accumulations without long-term care set forth in the policy;
(2) The portion of the policy that provides life insurance benefits meets the nonforfeiture requirements of SDCL  58-15-31;
(3) The policy meets the disclosure requirements of §§
									20:06:21:44.01, 20:06:21:47, and 20:06:21:48;
(4) Any policy illustration that meets the applicable requirements of chapter 20:06:38; and
(5) An actuarial memorandum is filed with the Division of Insurance that includes:
(a) A description of the basis on which the long-term care rates were determined;
(b) A description of the basis for the reserves;
(c) A summary of the type of policy, benefits, renewability, general marketing method, and limits on ages of issuance;
(d) A description and a table of each actuarial assumption used. For expenses, an insurer must include percent of premium dollars per policy and dollars per unit of benefits, if any;
(e) A description and a table of the anticipated policy reserves and additional reserves to be held in each future year for active lives;
(f) The estimated average annual premium per policy and the average issue age;
(g) A statement as to whether underwriting is performed at the time of application. If underwriting is used the statement shall include a description of the type or types of underwriting used, such as medical underwriting or functional assessment underwriting. Concerning a group policy, the statement shall indicate whether the enrollee or any dependent will be underwritten and when underwriting occurs; and
(h) A description of the effect of the long-term policy provision on the required premiums, nonforfeiture values and reserves on the underlying life insurance policy, both for active lives and those in long-term care claim status.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:06 - Cost-of-living adjustments - Basis

Current through Register Vol. 51, page 10, July 15, 2024
The annual cost-of-living adjustment may be based on either the medical care component of the federal consumer price index or may be based on a fixed percentage increase of not less than five percent or more than ten percent. The adjustment period must continue for at least ten years or to age 85, whichever is sooner. The maximum lifetime benefit, if any, must be increased by the same percentage as the daily benefit. Annual adjustments must continue during the entire adjustment period regardless of the claims status of the policy.
An insurer may offer periodic adjustments in lieu of annual adjustments if the adjustments offered are at intervals of no more than three years. If the periodic adjustment is based on a fixed percentage, the adjustment must be at a rate which complies with the annual fixed percentage total over the period used.
If a company already offers a cost-of-living adjustment endorsement that meets the requirements of this section, other adjustment endorsements may be offered if the director determines that the endorsements are in the public interest.
If a policy states the maximum policy limit as a time interval, the maximum policy limit is not required to be adjusted. The daily benefit is required to be adjusted.
Notwithstanding any other provision, an insurer may not be required to increase its maximum lifetime benefit beyond $500,000.
General Authority:
SDCL  58-17B-4,  58-17B-13.1.
Law Implemented:
SDCL  58-17B-13.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:06.01 - Cost-of-living adjustments - Minimum standards

Current through Register Vol. 51, page 10, July 15, 2024
An insurer may not offer a long-term care insurance policy unless the insurer also offers to the policyholder, in addition to any other inflation protection, the option to purchase a policy that provides for benefit levels along with benefit maximums to increase. The timing of increases in benefits must be related to reasonably anticipated increases in the costs of long-term care services covered by the policy. Insurers must offer to each policy holder, at the time of purchase, the option to purchase a policy with an inflation protection feature no less favorable than one of the following:
(1) An option which guarantees the insured individual the right to periodically increase benefit levels without providing evidence of insurability or health status if the option for the previous period was not declined. The amount of the additional benefit must be no less than the difference between the existing policy benefit and that benefit compounded annually at a rate of at least five percent for the period beginning with the purchase of the existing benefit and extending until the year in which the offer is made;
(2) An option which covers a specified percentage of actual or customary and reasonable charges and does not include a maximum specified indemnity amount or limit; or
(3) An option which increases benefit levels annually in a manner so that the increases are compounded annually at a rate not less than five percent;
(4) The offer may not be required of life insurance policies or riders containing accelerated long-term care benefits.
General Authority:
SDCL  58-17B-4,  58-17B-13.1.
Law Implemented:
SDCL  58-17B-13,  58-17B-13.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:06.02 - Group cost-of-living adjustments - Exceptions

Current through Register Vol. 51, page 10, July 15, 2024
If the policy is issued to a group, the offer required in SDCL  58-17B-13 and  58-17B-13.1 and in §
									20:06:21:06.01 shall be made to the group policyholder. However, if the policy is issued to a group as defined in SDCL  58-17B-2(4)(d), other than a continuing care retirement community, the offering shall be made to each proposed certificateholder.
General Authority:
SDCL  58-17B-13.1.
Law Implemented:
SDCL  58-17B-13.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:06.03 - Cost-of-living adjustments - Continuation of benefit increases

Current through Register Vol. 51, page 10, July 15, 2024
Inflation protection benefit increases under a policy which contains such benefits shall continue without regard to an insured's age, claim status, or claim history or the length of time the person has been insured under the policy.
General Authority:
SDCL  58-17B-13.1.
Law Implemented:
SDCL  58-17B-13.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:06.04 - Cost-of-living adjustments - Automatic increases - Conspicuous offer of constant premium

Current through Register Vol. 51, page 10, July 15, 2024
An offer of inflation protection which provides for automatic benefit increases shall include an offer of a premium which the insurer expects to remain constant. The offer must disclose in a conspicuous manner that the premium may change in the future unless the premium is guaranteed to remain constant.
General Authority:
SDCL  58-17B-13.1.
Law Implemented:
SDCL  58-17B-13.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:06.05 - Cost-of-living adjustments - Rejection by policyholder

Current through Register Vol. 51, page 10, July 15, 2024
Inflation protection as provided in §§
									20:06:21:06  to 20:06:21:06.04, inclusive, shall be included in a long-term care insurance policy unless an insurer obtains a rejection of inflation protection signed by the policyholder. The rejection shall be considered a part of the application and shall state: "I have reviewed the outline of coverage and the graphs that compare the benefits and premiums of this policy with and without inflation protection. Specifically, I have reviewed Plans (identify the plans) and I reject inflation protection."
General Authority:
SDCL  58-17B-13.1.
Law Implemented:
SDCL  58-17B-13.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:07 - Applicability of rules to long-term care insurance riders

Current through Register Vol. 51, page 10, July 15, 2024
Long-term care riders attached to or included in life insurance policies must comply with the long-term care rules in this chapter unless specifically excluded.
General Authority:
SDCL  58-4-1,  58-17B-4,  58-17B-15.
Law Implemented:
SDCL  58-17B-2,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:08 - "Medically necessary" defined

Current through Register Vol. 51, page 10, July 15, 2024
When "medically necessary" is used as a condition to qualify for benefits, it may not be defined more restrictively than as requiring the certification of the insured's physician.
If a policy does not have a prior hospitalization requirement, then the following definition of medical necessity may be used: Treatment that is appropriate and consistent with the diagnosed condition. This is treatment, that, in accordance with accepted medical standards, could not have been omitted without adversely affecting the patient's condition. This definition of medical necessity may not be used for policies which condition benefits on inability to perform ADLs or functional incapacity.
General Authority:
SDCL  58-4-1,  58-17B-4,  58-17B-15.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:09 - Basis for conversion of coverage from group defined

Current through Register Vol. 51, page 10, July 15, 2024
For the purposes of §§ 20:06:21:09  to 20:06:21:17, inclusive, a basis for conversion of coverage means a policy provision that entitles an individual, under the following conditions, to the issuance, without evidence of insurability, of a converted policy by the insurer under whose group policy the insured is covered:
(1) The individual's coverage under the group policy would otherwise terminate or has been terminated for any reason, including discontinuance of the group policy in its entirety or for an insured class; and
(2) The individual has been continuously insured under the group policy and any group policy that it replaced, for at least six months immediately preceding termination.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:10 - Converted policy from group defined

Current through Register Vol. 51, page 10, July 15, 2024
For the purposes of §§
									20:06:21:09  to 21:06:21:17, inclusive, a converted policy from group is an individual policy of long-term care insurance providing benefits identical to or benefits determined by the director to be substantially equivalent to or in excess of those provided under the group policy from which conversion is made.
If the group policy from which conversion is made restricts provision of benefits and services to, or contains incentives to use, certain providers or facilities, the director, in determining the substantial equivalence of benefits, shall take into consideration the differences between managed care and nonmanaged care plans, including provider system arrangements; service availability; benefit levels; and administrative complexity.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:11 - Converted policy from group - Time allowed for written application

Current through Register Vol. 51, page 10, July 15, 2024
The individual, or someone acting on the individual's behalf, must apply for the converted policy in writing and must pay the first premium due, if any, as directed by the insurer not later than 31 days after termination of coverage under the group policy. The insurer shall issue the converted policy effective on the day following the termination of coverage under the group policy. The converted policy must be renewable annually.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:12 - Converted policy from group - Calculation of policy premium

Current through Register Vol. 51, page 10, July 15, 2024
Unless the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured's age at inception of coverage under the group policy from which conversion is made. If the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured's age at inception of the insured's coverage under the previous group policy.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:13 - Continuation or conversion is mandatory - Exceptions

Current through Register Vol. 51, page 10, July 15, 2024
Continuation of coverage or issuance of a converted policy is mandatory, except as follows:
(1) Termination of group coverage resulted from an individual's failure to make a required payment of premium or contribution when due; or
(2) The terminating coverage is replaced not later than 31 days after termination by group coverage which is effective on the day following the termination of coverage and meets the following requirements:
(a) The replacement coverage provides benefits identical to or benefits determined by the director to be substantially equivalent to or in excess of those provided by the terminating coverage; and
(b) The premium for the replacement coverage is calculated in a manner consistent with the requirements of §
										20:06:21:12.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:14 - Converted policy from group to individual - Reduction of benefits - Exception

Current through Register Vol. 51, page 10, July 15, 2024
Notwithstanding any other provision of §§
									20:06:21:09  to 20:06:21:17, inclusive, a converted policy issued to an individual who at the time of conversion is covered by another long-term care insurance policy which provides benefits on the basis of incurred expenses may contain a provision which results in a reduction of benefits payable if the benefits provided under the additional coverage, together with the full benefits provided by the converted policy, would result in payment of more than 100 percent of incurred expenses. The provision may only be included in the converted policy if the converted policy also provides for a premium decrease or refund which reflects the reduction in benefits payable.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:15 - Converted policy from group - Benefits payable

Current through Register Vol. 51, page 10, July 15, 2024
The converted policy may provide that the benefits payable under the converted policy, together with the benefits payable under the group policy from which conversion is made, may not exceed those that would have been payable had the individual's coverage under the group policy remained in force.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:16 - Converted policy from group - Eligibility for coverage of relatives

Current through Register Vol. 51, page 10, July 15, 2024
Notwithstanding any other provision of §
									20:06:21:17, any insured individual whose eligibility for group long-term care coverage is based upon a relationship to another person is entitled to continuation of coverage under the group policy on termination of the qualifying relationship by death or dissolution of marriage.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:17 - Converted policy from group - Managed care plan defined

Current through Register Vol. 51, page 10, July 15, 2024
For the purposes of §§
									20:06:21:09  to 20:06:21:16, inclusive, a managed-care plan is a health care or assisted living arrangement designed to coordinate patient care or control costs through utilization review, case management, or use of specific provider networks.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:18 - Discontinuance and replacement of a group policy

Current through Register Vol. 51, page 10, July 15, 2024
If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy on its date of termination. Coverage provided or offered to individuals by the insurer and premiums charged to persons under the new group policy may not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced and may not vary or otherwise depend on the individual's health or disability status, claim experience, or use of long-term care services.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5,  58-17B-5.1,  58-17B-6.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:19 - Premium increase prohibitions

Current through Register Vol. 51, page 10, July 15, 2024
The premiums charged to an insured for long-term care insurance may not increase due to either the increasing age of the insured at ages beyond 65 or the duration the insured has been covered under the policy.
(1) The purchase of additional coverage may not be considered a premium rate increase, but for purposes of the calculation required under §
									20:06:21:58, the portion of the premium attributable to the additional coverage shall be added to and considered part of the initial annual premium.
(2) A reduction in benefits may not be considered a premium change, but for purpose of the calculation required under §
									20:06:21:58, the initial annual premium shall be based on the reduced benefits.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-1,  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:20 - Lapse or termination notice required

Current through Register Vol. 51, page 10, July 15, 2024
An individual long-term care policy or certificate may not be issued until the insurer has received from the applicant either a written designation of at least one person, in addition to the applicant, who is to receive notice of lapse or termination of the policy or certificate for nonpayment of premium or a written waiver dated and signed by the applicant electing not to designate additional persons to receive notice. The applicant may designate at least one person who is to receive the notice of termination, in addition to the insured. Designation does not constitute acceptance by the third party of any liability for services provided to the insured.
The form used for the written designation must provide space clearly designated for listing at least one person. The designation shall include each person's full name and home address.
If an applicant elects not to designate an additional person, the waiver shall state: "Protection against unintended lapse. I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long-term care insurance policy for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect NOT to designate any person to receive such a notice."
The insurer shall notify the insured of the right to change the written designation at least once every two years.
When soliciting a long-term care insurance application an agent must affirmatively offer lapse designation as provided for by this section and may not encourage or influence an applicant not to designate another person to receive notice of lapse or termination. An agent will be presumed to either have not offered or to have encouraged or influenced a person not to designate another person for lapse designation if at least one-half of the applications for that agent submitted during any year's period of time fail to list a lapse or termination designee. This presumption may be rebutted by a preponderance of evidence showing that the agent both offered the lapse designation and did not encourage or influence the person not to designate another person for notice of lapse or termination.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:21 - Lapse or termination for payment through payroll or pension deduction plan

Current through Register Vol. 51, page 10, July 15, 2024
If the policyholder or certificateholder pays the premium for a long-term care insurance policy or certificate through a payroll or pension deduction plan, the requirements contained in §
									20:06:21:20  need not be met until 60 days after the policyholder or certificateholder is no longer on such a payment plan. The application or enrollment form for the policies or certificates shall clearly indicate the payment plan selected by the applicant.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:22 - Lapse or termination for nonpayment of premium

Current through Register Vol. 51, page 10, July 15, 2024
An individual long-term care policy or certificate may not lapse or be terminated for nonpayment of premium unless the insurer, at least 30 days before the effective date of the lapse or termination, has given notice to the insured and to those persons designated pursuant to §
									20:06:21:20  at the address provided by the insured for purposes of receiving notice of lapse or termination. Notice shall be given by first class United States mail, postage prepaid. Notice may not be given until 30 days after a premium is due and unpaid. Notice is considered given five days after the date of mailing.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-5.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:23 - Disclosure of renewability

Current through Register Vol. 51, page 10, July 15, 2024
Individual long-term care insurance policies shall contain a renewability provision. The provision must be captioned, must appear on the first page of the policy, and must clearly state that the coverage is guaranteed renewable or noncancellable.
This section does not apply to policies under which the right to nonrenew is reserved solely to the policyholder and which do not contain a renewability provision. This paragraph applies to long-term care policies which are part of or combined with life insurance policies which do not contain renewability provisions.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:24 - Disclosure of payment of benefits based on certain standards

Current through Register Vol. 51, page 10, July 15, 2024
A long-term care insurance policy which provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or similar words must include a definition of the terms and an explanation of the terms in its accompanying outline of coverage.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:25 - Disclosure of limitations on preexisting conditions

Current through Register Vol. 51, page 10, July 15, 2024
If a long-term care insurance policy or certificate contains any limitations on preexisting conditions, the limitations must appear as a separate paragraph of the policy or certificate and must be labeled as "Preexisting Condition Limitations."
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:26 - Disclosure of other limitations or conditions on eligibility for benefits

Current through Register Vol. 51, page 10, July 15, 2024
A long-term care insurance policy or certificate containing any limitations or conditions for eligibility other than those prohibited in SDCL  58-17B-7 must contain a description of the limitations or conditions, including any required number of days of confinement in a separate paragraph of the policy or certificate, and shall clearly label such paragraph.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:26.01 - Notice to claimants - Temporary leave

Current through Register Vol. 51, page 10, July 15, 2024
Within 30 days of receiving a claim or other written notice that an insured has entered a nursing home or assisted living center, the insurer must provide notice to the insured of the applicable policy or certificate provisions that would apply should the insured temporarily leave the nursing home or assisted living center. If benefits are provided through a bed reservation benefit or other policy provision, the notice must explain the extent of such coverage. If benefits are excluded, the notice must advise the insured of the scope of the exclusion and identify any applicable policy or certificate provision. If a temporary absence from the nursing home or assisted living center affects other policy or certificate benefits or conditions such as waiver of premium, that effect must also be explained in the notice. If, as of the effective date of this rule, an insured had been in a nursing home or assisted living center for 30 or more days and the insurer had received notice of the nursing home or assisted living center stay, the notice required pursuant to this section must be provided to that insured. An insurer may satisfy the requirements of this section by including the notice requirements in other written communications, including claim communications, sent to the insured. No filing of the notice to the director is required. The provisions of this section will be effective October 1, 2005.
The following sample language of notices may be used by insurers to comply with the notice requirements of this section provided that it is consistent with the provisions of the policy or contract:
(1) Your [policy] has a bed reservation benefit. If you leave the nursing home or assisted living center for a period of not more than [X] days during a 12-month period, those days are payable subject to other [policy] limitations that may apply.
(2) Your [policy] does not contain bed reservation benefits. If you leave the nursing home or assisted living center and are not provided care by that facility, you will not be covered for the days that your were absent from the facility. The absence [will/will not] result in your having to again satisfy the waiver of premium waiting period.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:27 - Outline of coverage

Current through Register Vol. 51, page 10, July 15, 2024
Insurers shall include the following information in or with the outline of coverage:
(1) A graphic comparison of the benefit levels of a policy that increases benefits over the policy period with a policy that does not increase benefits. The graphic comparison must show benefit levels over at least a 20-year period; and
(2) Any expected premium increases or additional premiums to pay for automatic or optional benefit increases.
An insurer may use a reasonable hypothetical or a graphic demonstration for the purposes of this disclosure.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-10.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:28 - Outline of coverage - Standard format

Current through Register Vol. 51, page 10, July 15, 2024
The outline of coverage shall be a freestanding document, using no smaller than ten-point type. Text that is capitalized or underscored in the standard format outline or coverage may be emphasized by other means that provide prominence equivalent to the capitalization or underscoring. Use of the text and sequence of text of the standard format outline of coverage is mandatory, unless otherwise specifically indicated. The outline of coverage shall contain no material of an advertising nature. The standard format for an outline of coverage complying with SDCL  58-17B-10 is as follows:
(1) Company name;
(2) Address - city and state.
(3) Telephone number;
(4) Designate the product as long-term care insurance;
(5) Outline of coverage; and
(6) Policy number or group master policy and certificate number.
Except for policies or certificates which are guaranteed issue, a caution statement as set forth in Appendix A at the end of this chapter, or language substantially similar, must appear in the outline of coverage.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-10.