reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:56 - Minimum benefit standards › Section 20:06:56:21 - Exception for uniform modification of coverage

Current through Register Vol. 51, page 10, July 15, 2024
Only at the time of coverage renewal may issuers modify the health insurance coverage for a product offered to a group health plan or an individual, as applicable, in the large group market, the individual market, and the small group market if, for coverage available in this market, other than only through one or more bona fide associations.
Modifications made uniformly and solely pursuant to applicable federal or state requirements are considered a uniform modification of coverage in the small group and individual market if:
(1) The modification is made within a reasonable time period after the imposition or modification of the federal or state requirement;
(2) The modification is directly related to the imposition or modification of the federal or state requirement;
(3) Other types of modifications made uniformly are considered a uniform modification of coverage if the health insurance coverage for the product in the individual or small group market meets all of the following criteria:
(i) The product is offered by the same health insurance issuer;
(ii) The product is offered as the same product network type;
(iii) The product continues to cover at least a majority of the same service area;
(iv) Within the product, each plan has the same cost-sharing structure as before the modification, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in sections 1302(d) and (e) of the Affordable Care Act (December 3, 2014); and
(v) The product provides the same covered benefits, except for any changes in benefits that cumulatively impact the plan-adjusted index rate for any plan within the product within an allowable variation of +/- two percentage points.
The director may broaden the standards in subsection 3(iii) and (iv) of this section after consideration of the impact on the insurance-buying public.
If an issuer in the individual market is renewing non-grandfathered coverage or uniformly modifying non-grandfathered coverage the issuer must provide to each individual written notice of the renewal before the date of the first day of the next annual open enrollment period.
If an issuer in the small group market is renewing coverage or uniformly modifying coverage the issuer must provide to each plan sponsor or individual written notice of the renewal at least 60 calendar days before the date of the coverage will be renewed.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
(1) "Multiple employer trust," a self-funded entity which obtains authorization pursuant to SDCL  58-18-88 and this chapter to operate in South Dakota.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:02 - Authorization

Current through Register Vol. 51, page 10, July 15, 2024
No person may establish or maintain a self-insured employee benefit plan for the purpose of providing health insurance which is a multiple employer trust in this state unless the multiple employer trust first obtains and maintains authorization pursuant to SDCL  58-18-88 and this chapter.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:03 - Application for authorization

Current through Register Vol. 51, page 10, July 15, 2024
A person applying for authorization pursuant to SDCL 58-18-88 shall submit a plan of operation with the director. The application and plan of operation shall include the following:
(1) A business plan including a copy of all contracts or other instruments which the multiple employer trust proposes to make with or sell to its members, a copy of the plan description, and the printed materials to be used in the solicitation of members;
(2) Copies of all articles, bylaws, agreements, trust documents, or other documents or instruments describing the rights and obligations of employers, employees, and beneficiaries;
(3) A current list of all members of the employer group or association sponsoring the multiple employer trust and a description of the relationship among the employers which serves as the basis for the formation of the association or employer group;
(4) A description of the activities of the association or group of employers on behalf of its members other than the sponsorship of the multiple employer trust;
(5) Current financial statements of the multiple employer trust which shall include, at a minimum, balance sheets, income statement, cash flow statement, and a detailed listing of assets;
(6) An actuarial opinion prepared, signed, and dated by a member of the American Academy of Actuaries which states that appropriate loss and loss adjustment reserves have been established, that adequate premiums are being charged, and that the association multiple employer trust is operating in accordance with sound actuarial principles;
(7) A statement from an authorized representative of the applicant which certifies all of the following:
(a) The multiple employer trust is administered by an authorized insurer or an authorized third-party administrator;
(b) The multiple employer trust is eligible for authorization pursuant to SDCL 58-18-88;
(c) The association or group of employers sponsoring the multiple employer trust is engaged in substantial activity for its members other than sponsorship of an employer benefit plan; and
(d) The association is a nonprofit entity organized and authorized to do business under applicable South Dakota law;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:03.01 - Waiver for out-of-state association plans

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the information required by 20:06:57:03, an association not formed in South Dakota which is seeking a waiver must include the following information in its application:
(1) A narrative statement describing the associations activities and the reasons a waiver should be granted;
(2) A certification attesting that the association is in full compliance with the laws of all the states where the association does business, including, where applicable, copies of all licenses or other approvals to operate in those states;
(3) A certification attesting that the association and all health plans sponsored by the association are in full compliance with the laws of all stated where the association does business; and
(4) Any further information requested by the director.
General Authority:
SDCL  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:03.02 - Coverage eligibility

Current through Register Vol. 51, page 10, July 15, 2024
Multiple employer trusts must be sponsored by associations meeting the requirements of §
									20:06:42:01  to provide coverage to members. Multiple employer trusts providing coverage to working owners must comply with §
									20:06:42:01.01 in the same manner as fully-insured association plans.
General Authority:
SDCL  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:03.03 - Eligibility determinations for coverage of working owners

Current through Register Vol. 51, page 10, July 15, 2024
The multiple employer trust must determine eligibility of working owners for plan coverage when the working owner first becomes eligible for coverage under the group health plan. Continued eligibility must be periodically confirmed pursuant to reasonable monitoring procedures. The trust documents must include reasonable provisions regarding approval and expulsion of working owners from plan coverage.
General Authority:
SDCL  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:04 - Investigation of application

Current through Register Vol. 51, page 10, July 15, 2024
The director shall investigate the application and supporting documents submitted by the applicant pursuant to SDCL  58-18-88 and this chapter and may conduct any investigation which the director may deem necessary and to examine under oath any persons interested in or connected with the multiple employer trust.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:05 - Issuance of authorization

Current through Register Vol. 51, page 10, July 15, 2024
The director may issue an authorization to the multiple employer trust upon finding that the applicant multiple employer trust has met all requirements of SDCL  58-18-88 and this chapter. The director shall notify denied applicants of the reasons for denial. An unsuccessful applicant may file a new application for an authorization at any time, but not within 60 days of a previous denial by the director.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:06 - Report to director of modification

Current through Register Vol. 51, page 10, July 15, 2024
A multiple employer trust shall immediately notify the director of any material change in ownership, control, or other fact or circumstance that may affect qualification for an authorization in this state.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:07 - Surplus

Current through Register Vol. 51, page 10, July 15, 2024
Unless otherwise provided in this section, a multiple employer trust shall deposit with an organization or trustee meeting the requirements of SDCL chapter 58-7 cash, securities, or any combination of these that is acceptable in the same amount provided in SDCL  58-6-23 for insurers. The director may increase the amount required to be deposited based on the director's written determination that such an increase is necessary to adequately secure any potential liability of the multiple employer trust to its enrollees, subject to SDCL chapter 58-29 B proceedings.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-6-23, ch 58-7, 58-18-88, 58-18-89, ch 58-29B.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:08 - Reserves and stop-loss coverage

Current through Register Vol. 51, page 10, July 15, 2024
(1) A multiple employer trust shall have at all times aggregate excess stop-loss coverage providing the multiple employer trust with coverage for risks in this state with an attachment point which is not greater than:
(a) 120 percent of actuarially projected losses on a calendar-year basis; or
(b) Five percent of annual expected claims for purposes of this section and shall provide for adjustments in the amount of that percentage as may be necessary to carry out the purposes of this section as determined by sound actuarial principles;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:08.01 - Multiple employer trust minimum loss ratio

Current through Register Vol. 51, page 10, July 15, 2024
A multiple employer trust which does not utilize community rating for its membership must maintain a minimum loss ratio of eighty-five percent. Minimum loss ratio (MLR) shall be calculated as follows: (Claims + Claims Adjustment Expenses) / (Premium Received - Applicable Taxes & Fees)
General Authority:
SDCL  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:08.02 - Multiple employer trust dividends

Current through Register Vol. 51, page 10, July 15, 2024
A multiple employer trust may provide dividends to employer members in the same manner as domestic insurers.
General Authority:
SDCL  58-18-79,  58-18-89.
Law Implemented:
SDCL  58-18-3,  58-18-6,  58-18-88.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:09 - Annual report

Current through Register Vol. 51, page 10, July 15, 2024
A multiple employer trust shall file an annual report on or before the first day of March. The annual reports must be submitted for the preceding calendar year and must be verified by at least two of the trust's principal officers. The annual report shall be on the form designated by the director. The annual report shall be completed using statutory accounting practices and shall include information required by the director. The director may request additional reports and information from a multiple employer trust as deemed necessary to supplement the annual report. The annual report shall include:
(1) An independent actuarial opinion prepared in conformance with SDCL chapter 58-26 and ARSD chapter 20:06:37. The director may conduct an independent actuarial review of a multiple employer trust in addition to the actuarial opinion required by this rule. The cost of any actuarial review shall be paid by the multiple employer trust;
(2) A certificate of compliance signed and dated by the appropriate official representing the multiple employer trust that certifies the following:
(a) That the plan meets the requirements of this rule and the applicable provisions of the South Dakota statutes and regulations;
(b) That an independent actuarial opinion is attached to the certificate which attests to the adequacy of reserves, rates, and the financial condition of the plan. The actuarial opinion must include a brief commentary about the adequacy of the reserves, rates, and other financial condition of the plan, a test of the prior year's claim reserve, a brief description of how the reserves were calculated, and whether the plan is able to cover all reasonably anticipated expenses. The actuarial opinion shall be prepared, signed, and dated by a member of the American Academy of Actuaries;
(c) That a written complaint procedure for reviewing and resolving grievances from covered persons in accordance with SDCL chapter 58-17 I has been implemented. The certificate shall list the number of complaints filed by participants under the written complaint procedure and the percentage of participants filing written complaints in the prior calendar year; and
(d) That the multiple employer trust has contracted with an insurer authorized to do business in this state or with a third-party administrator who holds a current license or registration pursuant to SDCL chapter 58-29 D.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:10 - Contracts by multiple employer trusts

Current through Register Vol. 51, page 10, July 15, 2024
All contracts issued by a multiple employer trust shall comply with the following:
(1) Each multiple employer trust application for insurance and each policy and certificate issued by a multiple employer trust shall contain in ten-point type on the front page the following notice prominently displayed:
NOTICE
This policy is issued by a multiple employer trust. Multiple employer trusts are not subject to all of the insurance laws and regulations of South Dakota. This policy is not covered by the South Dakota Life and Health Insurance Guaranty Association in the event of plan failure. Your participation in this plan makes you subject to assessments for health plan costs. By accepting coverage, you must participate in this plan for a minimum of three years to avoid penalties for early departure.
(2) A multiple employer trust must offer on a guarantee-issue basis health benefits to all individuals who qualify as members or enrollees of the association;
(3) A multiple employer trust may offer only medical, dental, optical, surgical, hospital, accident and sickness, prescription, or disability benefits;
(4) All contracts or policies issued by a multiple employer trust shall:
(a) Conform to all the provisions of P.L. 104-191, the Health Insurance Portability and Accountability Act of 1996, including guaranteed issue of all products, preexisting condition limitations, renewability, and portability provisions as well as the issuance of prior coverage certificates to enrollees no longer eligible for plan coverage; and
(b) Comply with all coverage mandates that are applicable to group health insurance under this title.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:11 - Disclosure

Current through Register Vol. 51, page 10, July 15, 2024
A multiple employer trust shall make the following disclosure to each employer member of the multiple employer trust:
The benefits and coverages described herein are provided through a self-insured trust fund established and funded in full or in part by a group of employers. It is not a licensed insurance company.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:12 - Agreements and management contracts

Current through Register Vol. 51, page 10, July 15, 2024
Any agreement between a multiple employer trust and any administrator, service company, or other entity shall be filed with the director for approval.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:13 - Examination

Current through Register Vol. 51, page 10, July 15, 2024
Each multiple employer trust is subject to examination by the director in accordance with SDCL chapter 58-3. Chapter 58-3 governs all aspects of the examination. The director may make an examination of a multiple employer trust as often as the director considers it necessary, but not less frequently than once every five years. The expenses of the examination shall be assessed against the multiple employer trust being examined in a manner in which expenses of examinations are assessed against an insurance company under SDCL chapter 58-3. Multiple employer trusts are subject to the examination fund assessment pursuant to SDCL  58-3-3.1.
General Authority:
SDCL  58-3-26,  58-18-89.
Law Implemented:
SDCL ch 58-3, 58-18-88, 58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:14 - Independent audit

Current through Register Vol. 51, page 10, July 15, 2024
Multiple employer trusts are subject to SDCL chapter 58-43.
General Authority:
SDCL  58-18-89,  58-43-24.
Law Implemented:
SDCL  58-18-88,  58-18-89, ch 58-43.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:15 - Trade practices

Current through Register Vol. 51, page 10, July 15, 2024
Multiple employer trusts are subject to applicable provisions of the Unfair Trade Practices Act, SDCL chapter 58-33.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89, ch 58-33.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:16 - Insolvency

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of SDCL chapter 58-29 B apply to multiple employer trusts which are considered insurers for purposes of that chapter.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89, ch 58-29B.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:17 - Minimum coverage standards for health policies

Current through Register Vol. 51, page 10, July 15, 2024
The minimum coverage standards for health policies offered by multiple employer trusts are those of a bronze plan as delineated in ARSD 20:06:56:11.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:57 - Self-funded multiple employer trusts › Section 20:06:57:18 - Applicability of chapter

Current through Register Vol. 51, page 10, July 15, 2024
This chapter does not apply to fully-insured entities.
General Authority:
SDCL  58-18-89.
Law Implemented:
SDCL  58-18-88,  58-18-89.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:02 - Parity requirements with respect to aggregate lifetime and annual dollar limits

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, or heath insurance coverage offered by an issuer in connection with a group health plan, that provides medical or surgical benefits and mental health or substance use disorder benefits must comply with §
									20:06:58:03, 20:06:58:04, or 20:06:58:06. However, §§
									20:06:58:01  to 20:06:58:45, inclusive, do not apply if a plan, or health insurance coverage, satisfies the requirements of §
									20:06:58:32  or §
									20:06:58:34, relative to exemptions for small employers and for increased costs.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:03 - Plan with no limit or limits on less than one-third of all medical or surgical benefits

Current through Register Vol. 51, page 10, July 15, 2024
If a plan, or health insurance coverage, does not include an aggregate lifetime or annual dollar limit on any medical or surgical benefits or includes an aggregate lifetime or annual dollar limit that applies to less than one-third of all medical or surgical benefits, it may not impose an aggregate lifetime or annual dollar limit, respectively, on mental health or substance use disorder benefits.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:04 - Plan with a limit on at least two-thirds of all medical or surgical benefits

Current through Register Vol. 51, page 10, July 15, 2024
If a plan, or health insurance coverage, includes an aggregate lifetime or annual dollar limit on at least two-thirds of all medical or surgical benefits, it must either:
(1) Apply the aggregate lifetime or annual dollar limit both to the medical or surgical benefits to which the limit would otherwise apply and to mental health or substance use disorder benefits in a manner that does not distinguish between the medical or surgical benefits and mental health or substance use disorder benefits; or
(2) Not include an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is less than the aggregate lifetime or annual dollar limit, respectively, on medical or surgical benefits;
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
No separate cumulative financial requirements or cumulative quantitative treatment limitations, §
											20:06:58:22.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:05 - Determining one-third and two-thirds of all medical or surgical benefits

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:58:01  to 20:06:58:45, inclusive, the determination of whether the portion of medical or surgical benefits subject to an aggregate lifetime or annual dollar limit represents one-third or two-thirds of all medical or surgical benefits, is based on the dollar amount of all plan payments for medical or surgical benefits expected to be paid under the plan for the plan year, or for the portion of the plan year after a change in plan benefits that affects the applicability of the aggregate lifetime or annual dollar limits. Any reasonable method may be used to determine whether the dollar amount expected to be paid under the plan will constitute one-third or two-thirds of the dollar amount of all plan payments for medical or surgical benefits.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:06 - Plan not described in sections 20:06:58:03 or 20:06:58:04 of this chapter

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, or health insurance coverage, that is not described in §
									20:06:58:03  or 20:06:58:04  with respect to aggregate lifetime or annual dollar limits on medical or surgical benefits must either:
(1) Impose no aggregate lifetime or annual dollar limit, as appropriate, on mental health or substance use disorder benefits; or
(2) Impose an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no less than an average limit calculated for medical or surgical benefits in the following manner. The average limit is calculated by taking into account the weighted average of the aggregate lifetime or annual dollar limits, as appropriate, that are applicable to the categories of medical or surgical benefits. Limits based on delivery systems, such as inpatient, outpatient treatment or normal treatment of common, low-cost conditions such as treatment of normal births, do not constitute categories for purposes of subdivision 20:06:58:06(2). In addition, for purposes of determining weighted averages, any benefits that are not within a category that is subject to a separately-designated dollar limit under the plan are taken into account as a single separate category by using an estimate of the upper limit on the dollar amount that a plan may reasonably expect to incur with respect to such benefits, taking into account any other applicable restrictions under the plan.
For purposes of this section, the weighting applicable to any category of medical or surgical benefits is determined in the manner set forth in §
									20:06:58:05  for determining one-third or two-thirds of all medical or surgical benefits.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:07 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of classification of benefits

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§ 20:06:58:07  to 20:06:58:25, inclusive, when referring to a classification of benefits, the term "classification" means a classification as described in §§
									20:06:58:12  and 20:06:58:13.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(1),  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:08 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of type of financial requirement or treatment limitation

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:58:07  to 20:06:58:25, inclusive, when referring to a type of financial requirement or treatment limitation, the type means its nature. Types of financial requirements include deductibles, co-payments, coinsurance, and out-of-pocket maximums. Types of quantitative treatment limitations include annual, episode, and lifetime day and visit limits.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(1),  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
Illustrative list of nonquantitative treatment limitations, §
											20:06:58:24.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:09 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of level of a type of financial requirement or treatment limitation

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:58:07  to 20:06:58:25, inclusive, when referring to a level of a type of financial requirement or treatment limitation, level is the magnitude of the type of financial requirement of treatment limitation. For example, different levels of coinsurance include 20 percent and 30 percent; different levels of a co-payment include $15 and $20; different levels of a deductible include $250 and $500; and different levels of an episode limit include 21 inpatient days per episode and 30 inpatient days per episode.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79(1),  58-18-79(15),  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:10 - Parity requirements with respect to financial requirements and treatment limitations - Clarification of coverage unit

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:58:01  to 20:06:58:45, inclusive, a coverage unit means the way in which a plan, or health insurance coverage, groups individuals for purposes of determining benefits, premiums, or contributions. For example, different coverage units include self-only, family, and employee-plus-spouse.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79(1),  58-18-79(15),  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:11 - General parity requirement

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, or health insurance coverage offered by an issuer in connection with a group health plan, that provides both medical or surgical benefits and mental health or substance use disorder benefits may not apply any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification this is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all, medical or surgical benefits, in the same classification. Whether a financial requirement or treatment limitation is a predominant financial requirement or treatment limitation that applies to substantially all medical surgical benefits in a classification is determined separately for each type of financial requirement or treatment limitation. The application of the rules found in §§ 20:06:58:11  to 20:06:58:13, inclusive, to financial requirements and quantitative treatment limitation is addressed in §§
									20:06:58:14  to 20:06:58:22, inclusive; the application of the rules of §§ 20:06:58:11  to 20:06:58:13, inclusive, to nonquantitative treatment limitations is addressed in §§
									20:06:58:24  and 20:06:58:25.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:12 - Classifications of benefits used for applying rules

Current through Register Vol. 51, page 10, July 15, 2024
If a plan, or health insurance coverage, provides mental health or substance use disorder benefits in any classification of benefits described in §§ 20:06:58:12  and 20:06:58:13, mental health or substance use disorder benefits must be provided in every classification in which medical or surgical benefits are provided. In determining the classification in which a particular benefit belongs, a plan, or health insurance issuer, must apply the same standards to medical or surgical benefits and to mental health or substance use disorder benefits. To the extent that a plan, or health insurance coverage, provides benefits in a classification and imposes any separate financial requirement or treatment limitation, or separate level of a financial requirement or treatment limitation, for benefits in the classification, the rules of §§
									20:06:58:07  to 20:06:58:25, inclusive, apply separately with respect to that classification for all financial requirement or treatment limitations.
The following classifications of benefits are the only classifications used in applying the rules of §§
									20:06:58:07  to 20:06:58:25, inclusive:
(1) "Inpatient, in-network," benefits furnished on an inpatient basis and within a network of providers established or recognized under a plan or health insurance coverage;
(2) "Inpatient, out-of-network," benefits furnished on an inpatient basis and outside any network of providers established or recognized under a plan or health insurance coverage. This classification includes inpatient benefits under a plan, or health insurance coverage, that has no network or providers;
(3) "Outpatient, in-network," benefits furnished on an outpatient basis and within a network of providers established or recognized under a plan or health insurance coverage;
(4) "Outpatient, out-of-network," benefits furnished on an outpatient basis and outside any network of providers established or recognized under a plan or health insurance coverage. This classification includes outpatient benefits under a plan, or health insurance coverage, that has no network of providers;
(5) "Emergency care," benefits for emergency care;
(6) "Prescription drugs," benefits for prescription drugs.
If a plan, or health insurance coverage, provides benefits only to the extent required under the PHS Act, 29 CFR 2713 (December 3, 2014), this section is not intended to require the plan, or health insurance coverage, to provide additional mental health or substance use disorder benefits in any classification.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
Special rule for multi-tiered prescription drug benefits, §
											20:06:58:19.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:13 - Application to out-of-network providers

Current through Register Vol. 51, page 10, July 15, 2024
A plan, or health insurance coverage, that provides mental health or substance use disorder benefits in any classification of benefits must provide mental health or substance use disorder benefits in every classification in which medical or surgical benefits are provided, including out-of-network classifications.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:14 - Financial requirements and quantitative treatment limitations - Determining substantially all

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:58:07  to 20:06:58:25, inclusive, a type of financial requirement or quantitative treatment limitation is considered to apply to substantially all medical or surgical benefits in a classification of benefits if it applies to at least two-thirds of all medical or surgical benefits in that classification. Benefits expressed as subject to a zero level of a type of financial requirement are treated as benefits not subject to that type of financial requirement, and benefits expressed as subject to a quantitative treatment limitation that is unlimited are treated as benefits not subject to that type of quantitative treatment limitation. If a type of financial requirement or quantitative treatment limitation does not apply to at least two-thirds of all medical or surgical benefits in a classification, then that type cannot be applied to mental health or substance use disorder benefits in that classification.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:15 - Financial requirements and quantitative treatment limitations - Determining predominant

Current through Register Vol. 51, page 10, July 15, 2024
If a type of financial requirement or quantitative treatment limitation applies to at least two-thirds of all medical or surgical benefits in a classification as determined under §
									20:06:58:17, the level of the financial requirement or quantitative treatment limitation that is considered the predominant level of that type in a classification of benefits is the level that applies to more than one-half of medical or surgical benefits in that classification subject to the financial requirement or quantitative treatment limitation.
If, with respect to a type of financial requirement or quantitative treatment limitation that applies to at least two-thirds of all medical or surgical benefits in a classification, there is no single level that applies to more than one-half of medical or surgical benefits in the classification subject to the financial requirement or quantitative treatment limitation, the plan, or health insurance issuer, may combine levels until the combination of levels applies to more than one-half of medical or surgical benefits subject to the financial requirement or quantitative treatment limitation in the classification. The least restrictive level within the combination is considered the predominate level of that type in the classification. A plan may combine the most restrictive levels first, with each less restrictive level added to the combination until the combination applies to more than one-half of the benefits subject to the financial requirement or treatment limitation.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:16 - Financial requirements and quantitative treatment limitations - Determining portion based on plan payments

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§
									20:06:58:07  to 20:06:58:25, inclusive, the determination of the portion of medical or surgical benefits in a classification of benefits subject to a financial requirement or quantitative treatment limitation, or subject to any level of a financial requirement or quantitative treatment limitation, is based on the dollar amount of all plan payments for medical or surgical benefits in the classification expected to be paid under the plan for the plan year or for the portion of the plan year after a change in plan benefits that affects the applicability of the financial requirement or quantitative treatment limitation.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:17 - Financial requirements and quantitative treatment limitations - Determining clarifications for certain threshold requirements and dollar amount of plan payments

Current through Register Vol. 51, page 10, July 15, 2024
For any deductible, the dollar amount of plan payments includes all plan payments with respect to claims that would be subject to the deductible if it had not been satisfied. For any out-of-pocket maximum, the dollar amount of plan payments includes all plan payments associated with out-of-pocket payments that are taken into account towards the out-of-pocket maximum as well as all plan payments associated with out-of-pocket payments that would have been made towards the out-of-pocket maximum if it had not been satisfied.
Any reasonable method may be used to determine the dollar amount expected to be paid under a plan for medical or surgical benefits subject to a financial requirement or quantitative treatment limitation or subject to any level of a financial requirement or quantitative treatment limitation.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:18 - Application to different coverage units

Current through Register Vol. 51, page 10, July 15, 2024
If a plan, or health insurance coverage, applies different levels of a financial requirement or quantitative treatment limitation to different coverage units in a classification of medical or surgical benefits, the predominant level that applies to substantially all medical or surgical benefits in the classification is determined separately for each coverage unit.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:19 - Special rule for multi-tiered prescription drug benefits

Current through Register Vol. 51, page 10, July 15, 2024
If a plan, or health insurance coverage, applies different levels of financial requirements to different tiers of prescription drug benefits based on reasonable factors determined in accordance with §
									20:06:58:23, relating to requirements for nonquantitative treatment limitations, and without regard to whether a drug is generally prescribed with respect to medical or surgical benefits or with respect to mental health or substance use disorder benefits, the plan, or health insurance coverage, satisfies the parity requirements of §§
									20:06:58:07  to 20:06:58:25, inclusive, with respect to prescription drug benefits. Reasonable factors include cost, efficacy, generic versus brand name, and mail order versus pharmacy pick-up.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:20 - Special rule for multiple network tiers

Current through Register Vol. 51, page 10, July 15, 2024
If a plan, or health insurance coverage, provides benefits through multiple tiers of in-network providers, such as an in-network tier of preferred providers with more generous cost-sharing to participants than a separate in-network tier of participating providers, the plan may divide its benefits furnished on an in-network basis into sub-classifications that reflect network tiers, if the tiering is based on reasonable factors determined in accordance with §
									20:06:58:23  and without regard to whether a provider provides services with respect to medical or surgical benefits or mental health or substance use disorder benefits. After the sub-classifications are established, the plan or issuer may not impose any financial requirement or treatment limitation on mental health or substance use disorder benefits in any sub-classification that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical or surgical benefits in the sub-classification using the methodology set forth in §§
									20:06:58:14  to 20:06:58:17, inclusive.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:21 - Special rule for sub-classifications permitted for office visits, separate from other outpatient services

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of applying the financial requirement and treatment limitation rules of §§
									20:06:58:07  to 20:06:58:25, inclusive, a plan or issuer may divide its benefits furnished on an outpatient basis into the two sub-classifications described in this section. After the sub-classifications are established, the plan or issuer may not impose any financial requirement or quantitative treatment limitation on mental health or substance use disorder benefits in any sub-classification that is more restrictive than the predominant financial requirement or quantitative treatment limitation that applies to substantially all medical or surgical benefits in the sub-classification using the methodology set forth in paragraphs §§
									20:06:58:14  to 20:06:58:17, inclusive. Sub-classifications other than these special rules, such as separate sub-classifications for generalists and specialists, are not permitted. The two sub-classifications permitted under this section are:
(1) Office visits, such as physician visits; and
(2) All other outpatient items and services, such as outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:58 - Mental Health Parity › Section 20:06:58:22 - No separate cumulative financial requirements or cumulative quantitative treatment limitations

Current through Register Vol. 51, page 10, July 15, 2024
A group health plan, or health insurance coverage, offered in connection with a group health plan, may not apply any cumulative financial requirement or cumulative quantitative treatment limitation for mental health or substance use disorder benefits in a classification that accumulates separately from any established for medical or surgical benefits in the same classification.
General Authority:
SDCL  58-17-87,  58-18-79,  58-18-79(15).
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-18-80.