reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:63 - Coverage issued outside open enrollment

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer may issue a health plan to any individual applying for coverage outside of an insurance Exchange and outside of an open enrollment period. For health plans offered outside the exchange and outside an open enrollment the following apply:
(1) For those that are uninsured the issuer may require a waiting period of not more than 90 days from the date of application until coverage is effective;
(2) For uninsured applicants only a bronze level plan or, if eligible, a catastrophic plan may be issued with an effective date consistent with open enrollment standards;
(3) For those with creditable coverage within 63 days of the date of application, only coverage in the same metal level as the applicant's prior coverage may be issued. This section applies to all applications received after March 31, 2014, in the individual market outside the Exchange that are not received during an open enrollment period. For purposes of this section an uninsured does not include a person who lapsed or voluntarily terminated coverage in the past 12 months prior to applying.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:64 - Enrollment in catastrophic plans

Current through Register Vol. 51, page 10, July 15, 2024
A health plan is a catastrophic plan if it meets the following conditions:
(1) Meets all applicable requirements for health insurance coverage in the individual market and is offered only in the individual market;
(2) Does not provide a bronze, silver, gold, or platinum level of coverage described in §
									20:06:56:11;
(3) Provides coverage of the essential health benefits under §
									20:06:56:03  once the annual limitation on cost sharing is reached;
(4) Provides coverage for at least three primary care visits per year before reaching the deductible; and
(5) Covers only individuals who meet either of the following conditions:
(a) Have not attained the age of 30 prior to the first day of the plan year;
(b) Have received a certificate of exemption for the reasons identified in section 1302(e)(2)(B)(i) or (ii) of PPACA as defined in §
										20:06:55:32.
A catastrophic plan may not impose any cost-sharing requirements, such as a copayment, coinsurance, or deductible, for preventive services, in accordance with §
											20:06:56:03. For other than self-only coverage, each individual enrolled must meet the requirements.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:65 - Student health insurance coverage

Current through Register Vol. 51, page 10, July 15, 2024
Student health insurance coverage is considered to be available only through a bona fide association. A health insurance issuer that offers student health insurance coverage is not required to accept persons who are not students or dependents of students in such coverage.
A health insurance issuer that offers student health insurance coverage is not required to renew or continue coverage for individuals who are no longer students or dependents of students.
This section applies to any non-grandfathered student health coverage issued or renewed after December 31, 2013.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:66 - Clinical trial

Current through Register Vol. 51, page 10, July 15, 2024
After December 31, 2013, a health insurance issuer that offers a health benefit plan providing health insurance coverage individual market in this state may not:
(1) Deny participation by a qualified individual in an approved clinical trial;
(2) Deny, limit or impose additional conditions on the coverage of routine patient costs for items or services furnished in connection with participation in the trial; or
(3) Discriminate against an individual on the basis of the individual's participation in an approved clinical trial.
A network plan may require a qualified individual who wishes to participate in an approved clinical trial to participate in a trial that is offered through a health care provider who is part of the network plan if the provider is participating in the trial and the provider accepts the individual as a participant in the trial.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:67 - Nonrenewal of coverage

Current through Register Vol. 51, page 10, July 15, 2024
After December 31, 2013, a health insurance issuer offering health insurance coverage in the individual market is required to renew or continue in force the coverage at the option of the individual. An issuer may nonrenew or discontinue health insurance coverage offered in the individual market based only on the occurrence of one or more of the following:
(1) Nonpayment of premiums. The plan sponsor or individual, as applicable, has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage, including any timeliness requirements;
(2) Fraud. The plan sponsor or individual, as applicable, has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact in connection with the coverage;
(3) Termination of plan. The issuer is ceasing to offer coverage in the market in accordance with §
									20:06:39:58;
(4) Enrollees' movement outside service area. For network plans, there is no longer any enrollee under the plan who lives, resides, or works in the service area of the issuer; and
(5) Association membership ceases. For coverage made available in the small or large group market only through one or more bona fide associations, if the employer's membership in the bona fide association ceases, but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual.
This section does not apply to grandfathered plans.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:68 - Discontinuing a particular product

Current through Register Vol. 51, page 10, July 15, 2024
After December 31, 2013, in any case in which a health insurance issuer elects to discontinue offering a particular product in the individual market, that product may only be discontinued by the issuer if the following occurs:
(1) The issuer provides notice in writing to each individual provided that particular product in that market covered under such coverage of the discontinuation at least 90 calendar days before the date the coverage will be discontinued;
(2) The issuer offers to each individual provided that particular product the option, on a guaranteed issue basis, to purchase all health insurance coverage currently being offered by the issuer to an individual health insurance coverage; and
(3) In exercising the option to discontinue that product and in offering the option of coverage, the issuer acts uniformly without regard to the claims experience of those individuals, or any health status-related factor relating to any participant or beneficiary covered or new participant or beneficiary who may become eligible for such coverage.
This section does not apply to grandfathered plans.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:69 - Discontinuing all coverage

Current through Register Vol. 51, page 10, July 15, 2024
After December 31, 2013, an issuer may elect to discontinue offering all health insurance coverage in the individual market, or all markets, in a state in accordance with applicable state law only if the issuer meets all of the following conditions:
(1) The issuer provides notice in writing to the director and to each individual covered under the discontinued coverage at least 180 calendar days prior to the date the coverage will be discontinued; and
(2) All health insurance policies issued or delivered for issuance by the issuer in the state in the applicable market or markets are discontinued and not renewed.
An issuer that elects to discontinue offering all health insurance coverage in a market or markets in a state may not issue coverage in the applicable market or markets in the state for a period of five years beginning on the date of discontinuation for the last coverage discontinued.
This section does not apply to grandfathered plans.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:70 - Special enrollment periods for marriage, birth, and adoption

Current through Register Vol. 51, page 10, July 15, 2024
After December 31, 2013, a special enrollment period occurs for the individual, the individual's spouse, and the individual's dependents if the following conditions are met:
(1) A group health benefit plan makes coverage available with respect to a dependent of an individual;
(2) The individual is an employee; and
(3) The individual becomes married or a child becomes a new dependent as a result of marriage, birth, adoption, or placement for adoption.
The special enrollment period must be at least 60 days in length and must begin 30 days after the qualifying event. If coverage required pursuant to this section is applied for, the effective date for coverage in the case of a marriage may be no later than the first day of the first calendar month after the date the completed request is received by the plan or, in the case of a dependent, the date of birth or the start of the adoption bonding period.
This section does not apply to grandfathered plans.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:71 - Special enrollment triggers

Current through Register Vol. 51, page 10, July 15, 2024
After December 31, 2013, a health insurance issuer offering health insurance coverage in the individual market outside the Exchange must allow for an individual or dependent to enroll or change from one plan to another as a result of the following qualifying events:
(1) The death of the covered individual;
(2) The termination of individual's employer coverage other than by reason of gross misconduct, or reduction of hours of the covered employee's spouse;
(3) The divorce or legal separation;
(4) Individual becoming entitled to benefits under XVII of the Social Security Act;
(5) Dependent child ceasing to be dependent child;
(6) A proceeding in a case under Title 11, United States Code, commencing on or after July 1, 1986, with respect to the employer from whose employment the covered individual retired at any time;
(7) An individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption;
(8) An individual, who was not previously a citizen, national, or lawfully present individual gains such status; and
(9) A qualified individual or enrollee gains access to nongrandfathered health plan as a result of a permanent move.
A health insurance issuer in the individual market must provide, with respect to individuals enrolled in non-calendar year, a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.
This section does not apply to grandfathered plans.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:72 - Preexisting condition exclusion and waiting period prohibited

Current through Register Vol. 51, page 10, July 15, 2024
No health insurance issuer offering an individual health benefit plan may impose any preexisting condition exclusion or preexisting condition waiting period with respect to such coverage.
Grandfathered plans are not required to remove preexisting condition waiting periods on exclusionary riders.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:73 - Health insurance issuer defined

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer is any person that provides health insurance in this state including an insurance company, a prepaid hospital, or similar plan, a health maintenance organization, a multiple employer welfare arrangement, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. A health insurance issuer does not include a person providing only excepted benefits.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Section 20:06:39:74 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Effective January 1, 2014, §§
									20:06:39:03, 20:06:39:05, 20:06:39:07, 20:06:39:10, 20:06:39:19, 20:06:39:20, 20:06:39:20.05, and 20:06:39:30, only apply to grandfathered plans.
Sections 20:06:39:04, 20:06:39:06, 20:06:39:08, and 20:06:39:34 are repealed effective January 1, 2014.
Sections 20:06:39:04.01, 20:06:39:06.01, 20:06:39:08.01, and 20:06:39:34.01 are effective January 1, 2014.
General Authority:
SDCL  58-17-87.
Law Implemented:
SDCL  58-17-87.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Appendix A

Current through Register Vol. 51, page 10, July 15, 2024
CERTIFICATE OF INDIVIDUAL HEALTH INSURANCE COVERAGE
IMPORTANT
- This certificate provides evidence of your health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for medical conditions you have before you enroll, if medical advice, diagnosis, care, or treatment is recommended or received for the condition during the 6 months before you enroll in the new plan. If you become covered under another group health plan, check with the plan administrator to see if you need to provide this certificate. You may also need this certificate to establish your right to buy coverage for yourself or your family.
1. Date of this certificate: _______________.
2. Name of policyholder: ________________________________________________.
3. Identification number of policyholder: ___________________________________.
4. Name of any dependents to whom this certificate applies: ________________
_____________________________________.
5. Name, address, and telephone number of issuer responsible for providing this certificate: ________________________________________________________
___________________________________________________________________
___________________________________________________________________
6. For further information, call: __________________________________________.
7. If all individual(s) identified in items 2 and 4 have at least 18 months of creditable coverage (disregarding periods of coverage before a 63-day break), check here ___ and skip items 8 and 9.
8. Date coverage began: _______________.
9. Date that a substantially completed application was received from the policyholder: ______
10. Date coverage ended: _______________ (or check here if coverage is continuing as of the date of this certificate: _______).
Note
: Separate certificates will be furnished if information is not identical for the policyholder and each dependent.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:39 - Individual plans › Appendix B - Notice of Research Exception

Current through Register Vol. 51, page 10, July 15, 2024
Notice of Research Exception
PART I: Entity Classification and Identification
1. Date of submission: ________________________
2. Specify whether the entity claiming the research exception is:
(A) [] A group health plan (plan); or
(B) [] A health insurance issuer (issuer).
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:01.01 - Waiting periods and affiliation periods relating to breaks in coverage

Current through Register Vol. 51, page 10, July 15, 2024
Waiting periods and delays in the provision of coverage by the employer do not count toward the maximum break in coverage of 63 days for purposes of individual market enrollment. An affiliation period may not be used in counting toward the maximum break in coverage. For employees who have a waiting period after employment to qualify for coverage under the employer's health benefit plan, the enrollment date is the date of employment. For late enrollees, the enrollment date is the date coverage begins.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-43,  58-18-44,  58-18-45,  58-18-48,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:02 - Short-term, limited duration policies

Current through Register Vol. 51, page 10, July 15, 2024
Creditable coverage includes short-term limited duration policies. Short-term, limited duration insurance means health insurance coverage provided under a contract with a health insurance issuer that has an expiration date specified in the contract that is less than 12 months after the original effective date of the contract and, taking into account renewals or extensions, has a duration of no longer than 36 months in total, including any extensions or renewals offered by the issuer or those that may be elected by the policyholder without the health insurance issuer's consent.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-44,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:03.01 - Certificates required upon losing coverage

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer must provide a certificate or simply certify that the individual has creditable coverage to any individual losing coverage or qualifying for continuation under the Consolidated Omnibus Budget Reconciliation Act (COBRA), 29 U.S.C.S. § 1163, as in effect July 1, 1997, or SDCL chapter 58-18 upon requests by or on behalf of an individual. At any time within 24 months after coverage ceases, a health insurance issuer must also provide additional certificates or certifications upon requests by or on behalf of an individual. Each certificate or certification must be provided in a reasonable and prompt fashion. A separate fee may not be charged for the provision of a certificate or certification, but the cost of this service may be factored into the policy premium.
If a health insurance issuer provides coverage in connection with another type of creditable coverage, the health insurance issuer must provide a certificate or certification as required by this section.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-11-1,  58-18-44,  58-18-45,  58-18-48,  58-18-79,  58-33-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:04 - Standards for determinations on length of preexisting waiting periods

Current through Register Vol. 51, page 10, July 15, 2024
A carrier must determine whether an individual is eligible for coverage pursuant to SDCL  58-18-48. In making that determination a carrier must exercise reasonable diligence. Reasonable diligence may include questions on an application for insurance designed to elicit information on the individual's eligibility for coverage under SDCL  58-18-48. A carrier may not use the absence of a certificate described in §
									20:06:39:04  or 20:06:40:03  as the only method of determining eligibility for coverage pursuant to SDCL  58-18-48. The carrier must take into account all information presented by the individual. The carrier must consider the individual to have furnished a certificate if the individual attests to the period of creditable coverage, presents relevant corroborating evidence of some creditable coverage during the period, and cooperates with the carrier's efforts to verify the individual's coverage. The provisions of this section also apply to complete or partial waivers of preexisting condition waiting periods.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-44,  58-18-45,  58-18-48,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:05 - Special enrollment periods for marriage, birth, and adoption

Current through Register Vol. 51, page 10, July 15, 2024
A special enrollment period occurs for the individual, the individual's spouse, and the individual's dependents if the following conditions are met:
(1) A group health benefit plan makes coverage available with respect to a dependent of an individual;
(2) The individual is an employee; and
(3) The individual becomes married or a child becomes a new dependent as a result of marriage, birth, adoption, or placement for adoption.
The special enrollment period must be at least 31 days in length and must begin 30 days after the qualifying event. If coverage required pursuant to this section is applied for, the effective date for coverage in the case of a marriage may be no later than the first day of the first calendar month after the date the completed request is received by the plan or, in the case of a dependent, the date of birth or the start of the adoption bonding period.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-43,  58-18-44,  58-18-45,  58-18-48,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:05.01 - Special enrollment periods for loss of other coverage

Current through Register Vol. 51, page 10, July 15, 2024
If an individual was eligible for coverage and declined coverage due to the existence of other coverage in force, the individual, the individual's spouse, and the individual's dependents are eligible for a special enrollment period on loss of the other coverage, in addition to those events listed as exceptions to being a late enrollee under SDCL  58-18-43.
The special enrollment period must be at least 31 days in length. If coverage required pursuant to this section is applied for, the effective date for coverage may be no later than the first day of the first calendar month after the date the completed request is received by the plan.
A plan may require an employee who declines coverage during the initial enrollment period to declare the reason in writing to be eligible for a special enrollment period as described in this section. If a declaration is required, the plan must provide notice of the requirement and disclose the consequences of the employee's failure to provide the statement.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-43,  58-18-44,  58-18-45,  58-18-48,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:13 - Public health plan defined

Current through Register Vol. 51, page 10, July 15, 2024
A public health plan for purposes of SDCL  58-18-44 is any plan established or maintained by a state, county, or other political subdivision of a state that provides health insurance coverage to enrolled individuals.
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-44,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:16 - Notice describing plan's special enrollment required

Current through Register Vol. 51, page 10, July 15, 2024
By the time an employee is offered the opportunity to enroll in a group health plan, the plan must provide the employee with a written notice containing a description of the plans special enrollment rules. A plan or health insurance issuer may use the following model notice:
"If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan if you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents if you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption."
General Authority:
SDCL  58-18-79.
Law Implemented:
SDCL  58-18-48,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:17 - Group health plans to offer breast reconstruction options after covered mastectomy

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, as defined by SDCL  58-18-42, and a health insurance issuer providing health insurance coverage in connection with a group health plan that provides medical and surgical benefits with respect to a mastectomy, shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for:
(1) Reconstruction of the breast on which the mastectomy has been performed;
(2) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
(3) Prostheses and physical complications at all stages of a mastectomy, including lymphedemas.
Coverage shall be provided in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.
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 20:06:40 - Employer plans › Section 20:06:40:17.01 - Written notification regarding coverage of reconstructive surgery after a mastectomy required

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, and a health insurance issuer providing insurance coverage in connection with a group health plan, shall provide notice to each participant and beneficiary under such plan regarding the coverage required by §
									20:06:40:17. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan or issuer and shall be transmitted:
(1) In the first mailing made by the plan or issuer to the participant or beneficiary after September 6, 2000; and
(2) As a part of any yearly informational packet sent to the participant or beneficiary.
If a plan or issuer has made a mailing prior to September 6, 2000, that complies with subdivision (1), the requirement of subdivision (1) is met.
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 20:06:40 - Employer plans › Section 20:06:40:17.02 - Prohibited practices

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not:
(1) Deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of §
									20:06:40:17; or
(2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with §
									20:06:40:17.
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 20:06:40 - Employer plans › Section 20:06:40:17.03 - Not a termination of collective bargaining agreement

Current through Register Vol. 51, page 10, July 15, 2024
In the case of a group health plan maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers, any plan amendment which amends the plan solely to conform to any requirement added by §§
									20:06:40:17  to 20:06:40:17.02, inclusive, may not be treated as a termination of such collective bargaining agreement.
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 20:06:40 - Employer plans › Section 20:06:40:17.04 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of §§
									20:06:40:17  to 20:06:40:17.03, inclusive, apply to all group plans issued or renewed.
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 20:06:40 - Employer plans › Section 20:06:40:18 - Claims experience defined

Current through Register Vol. 51, page 10, July 15, 2024
For employers with one to fifty enrolled employees, claims experience is the amount of paid claims for the employer and the time period that the claims were incurred and paid. For employers with fifty-one or more enrolled employees, claims experience is the amount of paid claims for the employer, the time period that the claims were incurred and paid, and a listing of claims of $10,000 or more for any person covered by the employer in a manner consistent with applicable state and federal laws. A paid claim is the actual payment or settlement amount paid by the health insurance issuer and excludes all noncovered services, provider discounts, and member liability amounts. The change from one to two, regarding the size of an employer, is effective after December 31, 2013.
General Authority:
SDCL  58-18-79(1).
Law Implemented:
SDCL  58-18-82.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:23 - Medically necessary leave of absence defined

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:40:24  to 20:06:40:26, inclusive, the phrase medically necessary leave of absence means a leave of absence from an accredited institution of higher learning or any other change in enrollment of such child at such an institution, that
(1) Commences while a qualifying child is suffering from a serious illness or injury;
(2) Is medically necessary; and
(3) Causes the qualifying child to lose student status for purposes of coverage under the terms of the plan.
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 20:06:40 - Employer plans › Section 20:06:40:24 - Dependent coverage

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer issuing a health benefit plan that provides dependent coverage for any qualifying child may not terminate coverage due to a medically necessary leave of absence for a period of twelve months after the first day of leave or the date on which such coverage would otherwise terminate under the terms of the plan, whichever is earlier. A qualifying child whose benefits are continued under this section is entitled to the same benefits as if the qualifying child continued to be a covered student and was not on a medically necessary leave of absence.
The health benefit plan must receive written certification of the medically necessary leave of absence by a treating physician of the qualifying child that states that the child is suffering from a serious illness or injury and that the leave of absence or other change of enrollment is medically necessary.
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 20:06:40 - Employer plans › Section 20:06:40:25 - Notification

Current through Register Vol. 51, page 10, July 15, 2024
Any health insurance issuer providing health insurance coverage in connection with a group health plan shall include, with any notice regarding a requirement for certification of student status for coverage under the plan, a description of the terms of §
									20:06:40:24  for continued coverage during any medically necessary leave of absence. Such description shall be in language that is understandable to the typical plan participant.
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 20:06:40 - Employer plans › Section 20:06:40:26 - Continued application in case of changed coverage

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of §§
									20:06:40:24  and 20:06:40:25  apply if there is a change in coverage for the dependent child and the following occur:
(1) Dependent child of a participant or beneficiary is in a period of coverage under a health benefit plan offered in connection with such a plan, pursuant to a medically necessary leave of absence of the child;
(2) The manner in which the participant or beneficiary is covered under the plan changes, whether through a change in health insurance coverage or health insurance issuer, a change between health insurance coverage and self-insured coverage, or otherwise; and
(3) The coverage as so changed continues to provide coverage of beneficiaries as dependent children.
This section applies to coverage of the child under the changed coverage for the remainder of the period of the medically necessary leave of absence of the dependent child under the plan in the same manner as it would have applied if the changed coverage had been the previous coverage.
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 20:06:40 - Employer plans › Section 20:06:40:27 - Effective date

Current through Register Vol. 51, page 10, July 15, 2024
Sections 20:06:40:23 to 20:06:40:26, inclusive, apply to plan years beginning after December 31, 2009.
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 20:06:40 - Employer plans › Section 20:06:40:28 - 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 20:06:40 - Employer plans › Section 20:06:40:29 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Unless otherwise provided, the following terms are defined for purposes of §§ 20:06:40:29  to 20:06:40:41, inclusive:
(1) "Collect," with respect to information, to request, require, or purchase such information;
(2) "Family member," with respect to an individual, a dependent of the individual or any other person who is a first-degree, second-degree, third-degree, or fourth-degree relative of the individual or of a dependent of the individual. Relatives by affinity such as by marriage or adoption are treated the same as relatives by consanguinity that is, relatives who share a common biological ancestor. In determining the degree of the relationship, relatives by less than full consanguinity such as half-siblings, who share only one parent are treated the same as relatives by full consanguinity such as siblings who share both parents;
(3) "First-degree relatives," parents, spouses, siblings, and children;
(4) "Fourth-degree relatives," great-great grandparents, great-great grandchildren, and children of first cousins;
(5) "Genetic information":
(a) The individual's genetic tests;
(b) The genetic tests of family members of the individual;
(c) The manifestation of a disease or disorder in family members of the individual; or
(d) Any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by the individual or any family member of the individual.
With respect to a pregnant woman (or a family member of the pregnant woman), the term includes genetic information of any fetus carried by the pregnant woman. With respect to an individual (or a family member of the individual) who is utilizing an assisted reproductive technology, the term includes genetic information of any embryo legally held by the individual or family member. However, the term does not include information about sex or age of any individual;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:30 - Group rating based on health factors

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in §§
									20:06:40:29  to 20:06:40:41, inclusive, restricts the aggregate amount that an employer may be charged for coverage under a group health plan, but §
									20:06:40:31  prohibits adjustments in group premium or contribution rates based on genetic information.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:31 - No group-based discrimination based on genetic information

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not adjust premium or contribution amounts for the plan, or any group of similarly situated individuals under the plan, on the basis of genetic information. Similarly situated individuals are determined pursuant to §§
									20:06:46:09  to 20:06:46:12, inclusive. Nothing in this section limits the ability of a health insurance issuer offering health insurance coverage in connection with a group health plan to increase the premium for a group health plan, or any group of similarly situated individuals under the plan based on the manifestation of a disease or disorder of an individual who is enrolled in the plan. In such a case, however, the manifestation of a disease or disorder in one individual cannot be used as genetic information about other group members to further increase the premium for a group health plan or a group of similarly situated individuals under the plan.
General Authority:
SDCL  58-18-79, 59-18-79(9),  58-18-87.
Law Implemented:
SDCL  58-18-79,  58-33-13.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:32 - Limitation on requesting or requiring genetic testing

Current through Register Vol. 51, page 10, July 15, 2024
Except as otherwise provided, a group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not request or require an individual or a family member of the individual to undergo a genetic test.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:33 - Exceptions to requiring genetic testing

Current through Register Vol. 51, page 10, July 15, 2024
Nothing in §
									20:06:40:32  limits the authority of a health care professional who is providing health care services to an individual to request that the individual undergo a genetic test.
Additionally, nothing in §
									20:06:40:32  precludes a plan or issuer from obtaining and using the results of a genetic test in making a determination regarding payment. Therefore, if a plan or issuer conditions payment for an item or service based on its medical appropriateness and the medical appropriateness of the item or service depends on the genetic makeup of a patient, then the plan or issuer is permitted to condition payment for the item or service on the outcome of a genetic test. The plan or issuer may also refuse payment if the patient does not undergo the genetic test.
A plan or an issuer may only request the minimum amount of information necessary to make a determination regarding payment. The minimum amount of information necessary is determined in accordance with the minimum necessary standard in 45 CFR 164.502(b) of the privacy regulations issued under the Health Insurance Portability and Accountability Act.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:34 - Research exception

Current through Register Vol. 51, page 10, July 15, 2024
A plan or an issuer may request, but not require, that a participant or beneficiary undergo a genetic test if all of the following conditions are met:
(1) The plan or issuer makes the request pursuant to research, as defined in 45 CFR 46.102(d), that complies with 45 CFR Part 46 or equivalent federal regulations, and any applicable state or local law or regulations for the protection of human subjects in research; and
(2) The plan or issuer makes the request in writing, and the request clearly indicates to each participant or beneficiary or, in the case of a minor child, to the legal guardian of the beneficiary that:
(a) Compliance with the request is voluntary; and
(b) Noncompliance will have no effect on eligibility for benefits or premium or contribution amounts.
The issuer must complete a copy of the Notice of Research Exception form found in Appendix B and submit the form to the federal Secretary of Health and Human Services. No genetic information collected or acquired under this section may be used for underwriting purposes.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:35 - Prohibitions on collection of genetic information for underwriting purposes

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not collect genetic information for underwriting purposes.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:36 - Medical appropriateness

Current through Register Vol. 51, page 10, July 15, 2024
If an individual seeks a benefit under a group health plan or other health insurance coverage, the plan or coverage may limit or exclude the benefit based on whether the benefit is medically appropriate. The determination of whether the benefit is medically appropriate is not within the meaning of underwriting purposes. Therefore, if an individual seeks a benefit under the plan and the plan or issuer conditions the benefit based on its medical appropriateness and the medical appropriateness of the benefit depends on genetic information of the individual, then the plan or issuer may condition the benefit on the genetic information. A plan or issuer may only request the minimum amount of genetic information necessary to determine medical appropriateness. The plan or issuer may deny the benefit if the patient does not provide the genetic information required to determine medical appropriateness. If an individual is not seeking a benefit, the medical appropriateness exception of this section to the definition of underwriting purposes does not apply.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:37 - Collection of genetic information prior to or in connection with enrollment

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not collect genetic information with respect to any individual prior to that individual's effective date of coverage under that plan, nor in connection with the rules for eligibility that apply to the individual. Whether or not an individual's information is collected prior to that individual's effective date of coverage is determined based upon the time of collection.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-48,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:40 - Employer plans › Section 20:06:40:38 - Incidental collection exception

Current through Register Vol. 51, page 10, July 15, 2024
If a group health plan, or a health insurance issuer offering health insurance coverage in connection with a group health plan, obtains genetic information incidental to the collection of other information concerning any individual, the collection is not a violation of §
									20:06:40:37, as long as the collection is not for underwriting purposes in violation of §§
									20:06:40:35  and 20:06:40:36.
The incidental collection exception in this section does not apply with respect to any collection where it is reasonable to anticipate that health information will be received, unless the issuer explicitly states that genetic information should not be provided to the issuer.
General Authority:
SDCL  58-18-79,  58-18-87.
Law Implemented:
SDCL  58-18-79.