reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:94 - Independent review notification

Current through Register Vol. 51, page 10, July 15, 2024
The insurer shall acknowledge in writing to the insured and the insured's authorized representative, if applicable, and the director that the request for independent review has been received, accepted, and forwarded to an independent review organization for review. Such notice shall include the name and address of the independent review organization.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:95 - Independent review organization selection

Current through Register Vol. 51, page 10, July 15, 2024
Within five business days of receipt of the request for independent review, the independent review organization assigned pursuant to this section shall notify the insured and the insured's authorized representative, if applicable, the insurer and the director that it has accepted the independent review request and identify the type of licensed health care professional assigned to the review. The assigned independent review organization shall include in the notice a statement that the insured or the insured's authorized representative may submit in writing to the independent review organization within seven days following the date of receipt of the notice additional information and supporting documentation that the independent review organization should consider when conducting its review.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:96 - Review of information

Current through Register Vol. 51, page 10, July 15, 2024
The independent review organization shall review all of the information and documents received pursuant to §
									20:06:21:95  that have been provided to the independent review organization. The independent review organization shall provide copies of any documentation or information provided by the insured or the insured's authorized representative to the insurer for its review, if it is not part of the information or documentation submitted by the insurer to the independent review organization. The insurer shall review the information and provide its analysis of the new information in accordance with §§
									20:06:21:97  and 20:06:21:98.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:97 - Additional information to independent review

Current through Register Vol. 51, page 10, July 15, 2024
The insured or the insured's authorized representative may submit, at any time, new or additional information not previously provided to the insurer but pertinent to the benefit trigger denial. The insurer shall consider such information and affirm or overturn its benefit trigger determination. If the insurer affirms its benefit trigger determination, the insurer shall promptly provide such new or additional information to the independent review organization for its review, along with the insurer's analysis of such information.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:98 - Process if determination overturned

Current through Register Vol. 51, page 10, July 15, 2024
If the insurer overturns its benefit trigger determination:
(1) The insurer shall provide notice to the independent review organization and the insured and the insured's authorized representative, if applicable, and the director of its decision; and
(2) The independent review process shall immediately cease.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:99 - Review decision requirements

Current through Register Vol. 51, page 10, July 15, 2024
The independent review organization shall provide the insured and the insured's authorized representative, if applicable, the insurer, and the director written notice of its decision, within 30 calendar days from receipt of the referral to the independent review organization by the insurer pursuant to §
									20:06:21:92. If the independent review organization overturns the insurer's decision, the independent review organization shall:
(1) Establish the precise date within the specific period of time under review that the benefit trigger was deemed to have been met;
(2) Specify the specific period of time under review for which the insurer declined eligibility, but during which the independent review organization deemed the benefit trigger to have been met; and
(3) For tax-qualified long-term care insurance contracts, provide a certification made by a licensed health care practitioner as defined by subdivision 20:06:21:01(21) that the insured is a chronically ill individual.
The independent review organization's determination shall be used solely to establish liability for benefit trigger decisions, and is intended to be admissible in any proceeding only to the extent it establishes the eligibility of benefits payable. Nothing in §§
										20:06:21:87  to 20:06:21:104, inclusive, restricts the insured's right to submit a new request for benefit trigger determination after the independent review decision, if the independent review organization upholds the insurer's decision.
The decision of the independent review organization with respect to whether the insured met the benefit trigger will be final and binding on the insurer, except to the extent the insurer has other remedies available under applicable state or federal law. However, if the decision of the independent review organization is that a benefit trigger has been met and the insurer has sought other applicable state or federal remedies in lieu of accepting the decision of the independent review organization, then the insurer shall provide notice to the director within 30 days of that decision. Nothing in this section prevents the director upon receipt of notice from initiating administrative proceedings pursuant to §
										20:06:21:108, SDCL  58-6-46,  58-6-47, or  58-33-67.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:100 - Acceptance of state certification

Current through Register Vol. 51, page 10, July 15, 2024
The director shall accept another state's certification of an independent review organization, if the state requires the independent review organization to meet substantially similar qualifications as those contained in Appendix M and as such state requires as provided §
									20:06:21:102.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:101 - Certification of long-term care insurance independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
The director shall consider a long-term care insurance independent review organization to be qualified in this state, if the independent review organization demonstrates that it is unbiased and has either been certified by another state with substantially similar qualifications as contained in Appendix M or meets the following qualifications:
(1) Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment (e.g. physical therapy, occupational therapy, neurology, physical medicine, and rehabilitation) to conduct the review;
(2) Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with an entity that previously provided medical care to the insured;
(3) Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured;
(4) Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review;
(5) Be state-approved or certified to conduct such reviews if the state requires such approvals or certifications;
(6) Provide a description of the fees to be charged by it for independent reviews of a long-term care insurance benefit trigger decision. Such fees shall be reasonable and customary for the type of long-term care insurance benefit trigger decision under review;
(7) Provide the name of the medical director or health care professional responsible for the supervision and oversight of the independent review procedure; and
(8) Have on staff or contract with a licensed health care practitioner as defined in subdivision 20:06:21:01(21), who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:102 - Maintenance of records and reporting obligations by independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
Each insurer contracting with an independent review organization doing business in this state shall contractually ensure that the independent review organization complies with the following:
(1) Maintain written documentation establishing the date it receives a request for independent review, the date each review is conducted, the resolution, the date such resolution was communicated to the insurer and the insured, the name and professional status of the reviewer conducting such review in an easily accessible and retrievable format for the year in which it received the information, plus two calendar years;
(2) Be able to document measures taken to appropriately safeguard the confidentiality of such records and prevent unauthorized use and disclosures in accordance with applicable federal and state law;
(3) Report annually to the director, by June 1, in the aggregate and for each long-term care insurer all of the following:
(a) The total number of requests received for independent review of long-term care benefit trigger decisions;
(b) The total number of reviews conducted and the resolution of such reviews (i.e., the number of reviews which upheld or overturned the long-term care insurer's determination that the benefit trigger was not met);
(c) The number of reviews withdrawn prior to review;
(d) The percentage of reviews conducted within the prescribed timeframe set forth in §
										20:06:21:99; and
(e) Such other information the director may require.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:103 - Additional rights

Current through Register Vol. 51, page 10, July 15, 2024
Nothing contained in §§
									20:06:21:87  to 20:06:21:104, inclusive, limits the ability of an insurer to assert any rights an insurer may have under the policy related to:
(1) An insured's misrepresentation;
(2) Changes in the insured's benefit eligibility; and
(3) Terms, conditions, and exclusions of the policy, other than failure to meet the benefit trigger.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:104 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
The requirements of §§
									20:06:21:87  to 20:06:21:103, inclusive, apply to a benefit trigger request made after December 31, 2010, under a long-term care insurance policy.
"Benefit trigger," for purposes of independent review, means a contractual provision in the insureds long-term care insurance conditioning the payment of benefits on a determination of the insureds ability to perform activities of daily living and on cognitive impairment. For purposes of a tax-qualified long term care insurance contract as defined in Section 7702B of the Internal Revenue Code of 1986, as amended, "benefit trigger" shall include a determination by a licensed health care practitioner that an insured is a chronically ill individual.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:105 - Payment of clean claim

Current through Register Vol. 51, page 10, July 15, 2024
Within 30 business days after receipt of a claim for benefits under a long-term care insurance policy or certificate, an insurer shall pay such claim if it is a clean claim, or send a written notice acknowledging the date of receipt of the claim and one of the following:
(1) The insurer is declining to pay all or part of the claim and each specific reason for the denial; or
(2) That additional information is necessary to determine if all or any part of the claim is payable and the specific additional information that is necessary.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:106 - Claim timeframes

Current through Register Vol. 51, page 10, July 15, 2024
Within 30 business days after receipt of all the requested additional information, an insurer shall pay a claim for benefits under a long-term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim, and the specific reason or reasons for denial.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:107 - Unpaid claims

Current through Register Vol. 51, page 10, July 15, 2024
If an insurer fails to comply with §
									20:06:21:105  or 20:06:21:106, the insurer shall pay interest at the rate of one percent per month on the amount of the claim that should have been paid but that remains unpaid 45 business days after the receipt of the claim with respect to §
									20:06:21:105  or all requested additional information with respect to §
									20:06:21:106. The interest payable pursuant to this section shall be included in any late reimbursement without requiring the person who filed the original claim to make any additional claim for such interest.
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Section 20:06:21:108 - Violations

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of §§
									20:06:21:105  to 20:06:21:107, inclusive, do not apply if the insurer has a reasonable basis supported by specific information that such claim was fraudulently submitted.
Any violation of §§
									20:06:21:105  to 20:06:21:107, inclusive, by an insurer if committed flagrantly and in conscious disregard of provisions of §§
									20:06:21:87  to 20:06:21:107, inclusive, or with such frequency as to constitute a general business practice shall be considered a violation of SDCL  58-6-47(3).
General Authority:
SDCL  58-17B-4.
Law Implemented:
SDCL  58-17B-4.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix C - Replacement of Accident and Sickness or Long-Term Care Coverage

Current through Register Vol. 51, page 10, July 15, 2024
Appendix C
NOTICE TO APPLICANT REGARDING REPLACEMENT OF
ACCIDENT AND SICKNESS OR LONG-TERM CARE INSURANCE
(Insurance Company's Name and Address)
SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.
According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness or long-term care insurance and replace it with the long-term care insurance policy delivered herewith issued by (company name) Insurance Company. Your new policy provides thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy.
You should review this new coverage carefully, comparing it with all accident and sickness or long-term care insurance coverage you now have, and terminate your present policy only if, after due consideration, you find that purchase of this long-term care coverage is a wise decision.
1) Health conditions which you may presently have (preexisting conditions), may not be immediately or fully covered under the new policy. This could result in denial or delay in payment of benefits under the new policy, whereas a similar claim might have been payable under your present policy.
2) State law provides that your replacement policy or certificate may not contain new preexisting or probationary periods. The insurer will waive any time periods applicable to preexisting conditions or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
3) If you are replacing existing long-term care insurance coverage, you may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interest to make sure you understand all the relevant factors involved in replacing your present coverage.
4) (To be included only if the application is attached to the policy.) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to (company name and address) within thirty (30) days if any information is not correct and complete, or if any past medical history has been left out of the application.
__________________________
(Company Name)
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix D - Rescission Reporting Form

Current through Register Vol. 51, page 10, July 15, 2024
Model Regulation Service--April 1995
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF ______________
FOR THE REPORTING YEAR 19____
Company Name: __________________________________________
Address: __________________________________________
__________________________________________
Phone Number: ___________________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of long-term insurance policies or certificates. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.
Date of Date/s
Policy Policy and Name of Policy Claim/s Date of
Form # Certificate # Insured Issuance Submitted Rescission
_______________________________________________________________________________
Detailed reason for rescission: ______________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_________________________________
Signature
_________________________________
Name and Title (please type)
_________________________________
Date
Copyright NAIC 1995 641-31
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix F - Disclosure Form

Current through Register Vol. 51, page 10, July 15, 2024
Things You Should Know Before You Buy
Long-Term Care Insurance
Long-Term
. A long-term care insurance policy may pay most of the costs for your care in
Care
a nursing home. Many policies also pay for care at home or other community
Insurance
settings. Since policies can vary in coverage, you should read this policy and
make sure you understand what it covers before you buy it.
. [You should
not
buy this insurance policy unless you can afford to pay the
premiums every year.] [Remember that the company can increase premiums
in the future.]
. The personal worksheet includes questions designed to help you and the
company determine whether this policy is suitable for your needs.
Medicare
. Medicare does
not
pay for most long-term care.
Medicaid
" Medicaid will generally pay for long-term care if you have very little income
and few assets. You probably should
not
buy this policy if you are now
eligible for Medicaid.
. Many people become eligible for Medicaid after they have used up their
own financial resources by paying for long-term care services.
. When Medicaid pays your spouse's nursing home bills, you are allowed to
keep your house and furniture, a living allowance, and some of your joint
assets.
. Your choice of long-term care services may be limited if you are receiving
Medicaid. To learn more about Medicaid, contact your local or state
Medicaid agency.
Shopper's
. Make sure the insurance company or agent gives you a copy of a book called
Guide
the National Association of Insurance Commissioners' "Shopper's Guide to
Long-Term Care Insurance." Read it carefully. If you have decided to apply
for long-term care insurance, you have the right to return the policy within
30 days and get back any premium you have paid if you are dissatisfied for
any reason or choose not to purchase the policy
Counseling
. Free counseling and additional information about long-term care insurance
are available through your state's insurance counseling program. Contact
your state insurance department or department on aging for more informa-
tion about the senior health insurance counseling program in your state.
Facilities
. Some long-term care insurance contracts provide for benefit payments in
certain facilities only if they are licensed or certified, such as in assisted
living centers. However, not all states regulate these facilities in the same
way. Also, many people move to a different state from where they purchased
their long-term care insurance policy. Read the policy carefully to determine
what types of facilities qualify for benefit payments, and to determine that
payment for a covered service will be made if you move to a state that has a
different licensing scheme for facilities than the one in which you purchased
the policy.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix G - Response Letter

Current through Register Vol. 51, page 10, July 15, 2024
Long-Term Care Insurance Suitability Letter
Dear [Applicant]:
Your recent application for long-term care insurance included a "personal worksheet," which asked questions about your finances and your reasons for buying long-term care insurance. For your protection, state law requires us to consider this information when we review your application, to avoid selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not meet your financial needs. We suggest that you review the information provided along with your application, including the booklet "Shopper's Guide to Long-Term Care Insurance" and the page titled "Things You Should Know Before Buying Long-Term Care Insurance." Your state insurance department also has information about long-term care insurance and may be able to refer you to a counselor free of charge who can help you decide whether to buy this policy.]
[You chose not to provide any financial information for us to review.]
We have suspended our final review of your application. If, after careful consideration, you still believe this policy is what you want, check the appropriate box below and return this letter to us within the next 60 days. We will then continue reviewing your application and issue a policy if you meet our medical standards.
If we do not hear from you within the next 60 days, we will close your file and not issue you a policy. You should understand that you will not have any coverage until we hear back from you, approve your application, and issue you a policy.
Please check one box and return in the enclosed envelope.
[]
Yes
, [although my worksheet indicates that long-term care insurance may not be a suitable purchase,] I wish to purchase this coverage. Please resume review of my application.
[]
No
. I have decided not to buy a policy at his time.
__________________________________________ ______________________________
APPLICANT'S SIGNATURE DATE
Please return to [issuer] at [address] by [date].
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix H - Sample Claims Denial Format

Current through Register Vol. 51, page 10, July 15, 2024
Claims Denial Reporting Form
Long-Term Care Insurance
For the State of ____________________
For the Reporting Year of ____________
Company Name: ______________________________________________ Due: June 30 annually
Company
Address: _______________________________________________________________________
_______________________________________________________________________________
Company NAIC
Number: _______________________________________________________________________
Contact Person: _____________________________________ Phone Number: ______________
Line of Business: Individual Group
Instructions
The purpose of this form is to report all long-term care claim denials under in force long-term care insurance policies.
Indicate the manner of reporting by checking one of the boxes below:
[] Per Claimant -- counts each individual who makes one or a series of claim requests.
[] Per Transaction -- counts each claim payment request.
"Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition. It does not include a request for payment that is in excess of the applicable contractual limits.
Inforce Data
State
Data
Nationwide Data
Total Number of Inforce Policies [Certificates] as of December 31
Claims & Denial Data
State
Data
Nationwide
Data
1
1
Total Number of Long-Term Care Claims Reported
2
Total Number of Long-Term Care Claims Denied/Not Paid
3
Number of Claims Not Paid due to Preexisting Condition
Exclusion
4
Number of Claims Not Paid due to Waiting (Elimination) Period
Not Met
5
Net Number of Long-Term Care Claims Denied for Reporting
Purposes (Line 2 Minus Line 3 Minus Line 4)
6
Percentage of Long-Term Care Claims Denied of Those
Reported (Line 5 Divided By Line 1)
7
Number of Long-Term Care Claims Denied due to:
8
. Long-Term Care Services Not Covered under the Policy2
9
. Provider/Facility Not Qualified under the Policy3
10
. Benefit Eligibility Criteria Not Met4
11
. Other
1.
The nationwide data may be viewed as a more representative and credible indicator
where the data for claims reported and denied for your state are small in number.
2.
Example-home health care claim filed under a nursing home only policy.
3.
Example-a facility that does not meet the minimum level of care requirements or the
licensing requirements as outlined in the policy.
4.
Examples-a benefit trigger not met, certification by a licensed health care practitioner
not provided, no plan of care.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:21 - Long-term care insurance › Appendix J - Replacement and Lapse Reporting Form

Current through Register Vol. 51, page 10, July 15, 2024
Long-Term Care Insurance
Replacement and Lapse Reporting Form
For the State of
_____________________
For the Reporting Year of
__________
Company Name: __________________________ Due: June 30 annually
Company Address: __________________________ Company NAIC Number: _________
Contact Person: __________________________ Phone Number: (____)___________
Instructions
The purpose of this form is to report on a statewide basis information regarding long-term care insurance policy replacements and lapses. Specifically, every insurer shall maintain records for each agent on that agent's amount of long-term care insurance replacement sales as a percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's agents with the greatest percentage of replacements and lapses.
Listing of the 10% of Agents with the Greatest Percentage of Replacements
Agent's Name
Number of Policies Sold
By This Agent
Number of Policies
Replaced by This Agent
Number of Replacements As % of Number Sold By This Agent
Listing of the 10% of Agents with the Greatest Percentage of Lapses
Agent's Name
Number of Policies Sold
By This Agent
Number of Policies
Lapsed By This Agent
Number of Lapses As % of Number Sold By This Agent
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales _____%
Percentage of Replacement Policies Sold to Policies in Force (as of the end of the preceding calendar year) _____%
Percentage of Lapsed Policies to Total Annual Sales _____%
Percentage of Lapsed Policies to Policies In Force (as of the end of the preceding calendar year) _____%
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:01 - Types of renewal clauses

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §
									20:06:22:02, the types of renewal clauses are as follows:
(1) Optionally Renewable (OR): renewal is at the option of the insurance company;
(2) Conditionally Renewable (CR): renewable, but may be declined by class, by geographic area, or for stated reasons other than deterioration of health;
(3) Guaranteed Renewable (GR): renewal may not be declined by the insurance company for any reason, but the insurance company may revise rates on a class basis;
(4) Noncancelable (NC): renewal may not be declined nor may rates be revised by the insurance company.
General Authority:
SDCL  58-4-1,  58-17-4.2.
Law Implemented:
SDCL  58-17-4.2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:02 - Anticipated loss ratio requirements - Exception

Current through Register Vol. 51, page 10, July 15, 2024
The anticipated loss ratio for a policy form of excepted benefits on which the average annual premium is expected to be $250 or more must be equal to or greater than the applicable percentage shown in the following table:
Type of Coverage Type of Renewal Clause
OR
CR
GR
NC
Medical Expense
70%
65%
65%
60%
Other
70%
65%
60%
55%
Disability Income
60%
55%
50%
45%
Special consideration may be given to disability policies in determining the timeframe in which the anticipated loss ratio is to be achieved.
If the expected average annual premium for a policy form is $150, but less than $250, subtract 5 percentage points from the numbers in the table in this section. If the expected average annual premium is less than $150, subtract 10 percentage points.
When justified by the insurer, the director may give special consideration and may permit anticipated loss ratios lower than those indicated in this section based on the type of coverage or a lower average annual premium, or both.
Nothing in this section applies to credit life, credit health, or credit unemployment insurance policies.
The loss ratio percentages required by this section apply to all policies issued after December 18, 1995, regardless of the date of approval of the policy form and accompanying rates.
For individual and small group policies other than excepted benefits, the minimum loss ratio is 80%. The minimum loss ratio for large group policies other than excepted benefits is 85%. In calculating the loss ratio for policies other than excepted benefits, the earned premium may be reduced by federal and state taxes and incurred claims may be increased by expenses to improve health care quality.
General Authority:
SDCL  58-4-1,  58-17-4.2,  58-17-64,  58-17-87,  58-18-63,  58-18-79.
Law Implemented:
SDCL  58-17-4.2,  58-17-64.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:03 - Rate filings

Current through Register Vol. 51, page 10, July 15, 2024
Every policy form affecting benefits which is submitted for approval must be accompanied by a rate filing unless the form does not require a change in the rate. Any subsequent addition to or change in rates applicable to the policy must also be filed.
The rate filing shall include the following:
(1) An actuarial memorandum describing the basis on which rates were determined;
(2) An indication and description of the calculation of the anticipated loss ratio over the entire period for which rates are computed to provide coverage;
(3) A certification by an actuary that, to the best of the actuary's knowledge and judgment, the entire rate filing is in compliance with the applicable laws and rules of South Dakota and that the benefits are reasonable in relation to premiums;
(4) A rate schedule based on the rates to be used from the effective date of the rate filing.
General Authority:
SDCL  58-17-87(5),  58-18B-18.
Law Implemented:
SDCL  58-11-76,  58-17-4.1,  58-17-4.2,  58-18B-3.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:04 - Filings of rate revisions

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the requirements in §
									20:06:22:05, filings of rate revisions for a previously approved policy form shall include the following:
(1) A statement of the scope and reason for the revision, and an estimate of the expected average effect on premiums, including the original anticipated loss ratio for the form;
(2) A statement of whether the filing applies only to new business, only to in-force business, or both, and the reason; and
(3) A history of the experience under existing rates.
General Authority:
SDCL  58-17-87(5),  58-18B-18.
Law Implemented:
SDCL  58-11-76,  58-17-4.1,  58-17-4.2,  58-18B-3.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:05 - Requirements for history of experience

Current through Register Vol. 51, page 10, July 15, 2024
The history of experience required by §
									20:06:22:04  shall include earned premium and incurred benefit information for each calendar year for each policy form, including data for rider and endorsement forms which are used with the policy form, on the same basis, including reserves. Subject to the approval of the director, an insurer may combine the premium and incurred benefit information on similar coverages. Separate data may be maintained for each rider or endorsement form to the extent appropriate.
Subject to approval of the director, experience under forms which provide substantially similar coverage and provisions and which are issued to substantially similar risk classes may be combined for purposes of evaluating experience data in relation to premium rates and rate revisions, particularly if statistical credibility would be materially improved by the combination. Once the insurer has combined forms, the insurer may not thereafter separate the experience, except with the approval of the director.
The history may also include, if available and appropriate, the ratios of actual claims to the claims expected according to the assumptions underlying the existing rates.
The data shall be presented using the following format:
(1) For all years of issue combined;
(2) For each calendar year of experience used in the rate determination process;
(3) For the last five years;
(4) The date and magnitude of each previous rate change, if any;
(5) The number of South Dakota policies affected by the rate revision.
General Authority:
SDCL  58-17-87(5),  58-18B-18.
Law Implemented:
SDCL  58-11-76,  58-17-4.1,  58-17-4.2,  58-18B-3.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:08 - Applicability of rules

Current through Register Vol. 51, page 10, July 15, 2024
These rules apply only to health insurance policies issued pursuant to SDCL 58-17.
General Authority:
SDCL  58-4-1,  58-17-4.1,  58-17-4.2.
Law Implemented:
SDCL  58-17-4.1,  58-17-4.2.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:27 - Rating bands

Current through Register Vol. 51, page 10, July 15, 2024
With respect to the premium rate a health insurance issuer charges for health insurance coverage offered in the individual or small group market, the rate may only vary with respect to the particular plan or coverage involved by the following factors:
(1) Whether the plan or coverage covers an individual or a family;
(2) Rating area;
(3) Age, except the rate may not vary by more the 3:1 for like individuals of different age who are age 21 and older. The variation in rate must be actuarially justified for individuals under age 21, consistent with the uniform age rating curve under §
									20:06:22:30. For purposes of identifying the appropriate age adjustment under this subdivision and the age band in §
									20:06:22:31, applicable to a specific enrollee, the enrollee's age as of the date of policy issuance or renewal shall be used; and
(4) Tobacco use, except such rate may not vary by more than 1.5:1 for like individuals who vary in tobacco usage and may only be applied with respect to individuals who may legally use tobacco under state law.
The rate may not vary with respect to the particular plan or coverage involved by any other factor not described in this section.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1. 58-17-87, 58-18B-18, 58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:27.01 - Tobacco use defined

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §
									20:06:22:27, tobacco use means use of any tobacco product on average four or more times per week within no longer than the past six months. Tobacco use does not include religious or ceremonial use of tobacco. Tobacco use must be defined in terms of when a tobacco product was last used.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1. 58-17-87, 58-18B-18, 58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:27.02 - Tobacco usage reporting

Current through Register Vol. 51, page 10, July 15, 2024
If an enrollee is found to have reported false or incorrect information about their tobacco use, the issuer may retroactively apply the appropriate tobacco use rating factor to the enrollee's premium as if the correct information had been accurately reported from the beginning of the plan year. An issuer must not rescind the coverage on this basis. Tobacco use is not a material fact for which an issuer may rescind coverage if there is a misrepresentation.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-17-87(5),  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1,  58-17-87,  58-18B-18,  58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:28 - Health status and gender factors precluded

Current through Register Vol. 51, page 10, July 15, 2024
A health insurance issuer may not use health status or gender as a factor in any premium rate in the individual or small group market.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1,  58-17-87,  58-18B-18,  58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:29 - Rating area

Current through Register Vol. 51, page 10, July 15, 2024
No health insurance issuer may vary rates based on geographical location in this state except as permitted by this section. The rating areas are on a county basis and are as follows:
(1) Harding, Butte, Perkins, Ziebach, Haakon, Jackson, Bennett, Oglala Lakota, Fall River, Custer, Pennington, Lawrence, Meade, Jones, Mellette, and Todd;
(2) Lake, Moody, McCook, Minnehaha, Turner, Lincoln, Clay, and Union;
(3) Campbell, Corson, Dewey, Walworth, Potter, McPherson, Edmunds, Faulk, Brown, Spink, Marshall, Roberts, Day, Grant, Codington, Clark, Hamlin, Deuel, Brookings, Kingsbury, and Beadle; and
(4) Sully, Hughes, Hyde, Hand, Buffalo, Jerauld, Sanborn, Lyman Miner, Brule, Aurora, Davison, Hanson, Douglas, Charles Mix, Hutchinson, Bon Homme, Stanley, Tripp, Gregory and Yankton.
Nothing in this section requires a health insurance issuer to use a different geographic rating factor for each rating area. A health insurance issuer may assign the same rating band for any or all of the rating areas specified in this section.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-4.3,  58-17-87,  58-18B-18,  58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:30 - Rating variations

Current through Register Vol. 51, page 10, July 15, 2024
With respect to family coverage under a health insurance plan, the rating variations permitted under §
									20:06:22:27(3)  and (4), must be applied based on the portion of the premium attributable to each family member covered under the coverage. The total premium for family coverage must be determined by summing the premiums for each individual family member. In determining the total premium for family members, premiums for no more than the three oldest covered children who are under age 21 may be taken into account.
In the case of the small group market, the total premium charged to the group shall be determined by summing the premiums of covered participants and beneficiaries in accordance with this section.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1. 58-17-87, 58-18B-18, 58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:31 - Uniform age bands

Current through Register Vol. 51, page 10, July 15, 2024
For rating purposes under §
									20:06:22:27(3)  uniform age bands are as follows:
AGE
PREMIUM RATIO
AGE
PREMIUM RATIO
AGE
PREMIUM RATIO
0-20
0.635
35
1.222
50
1.786
21
1.000
36
1.230
51
1.865
22
1.000
37
1.238
52
1.952
23
1.000
38
1.246
53
2.040
24
1.000
39
1.262
54
2.135
25
1.004
40
1.278
55
2.230
26
1.024
41
1.302
56
2.333
27
1.048
42
1.325
57
2.437
28
1.087
43
1.357
58
2.548
29
1.119
44
1.397
59
2.603
30
1.135
45
1.444
60
2.714
31
1.159
46
1.500
61
2.810
32
1.183
47
1.563
62
2.873
33
1.198
48
1.635
63
2.952
34
1.214
49
1.706
64 and older
ARSD
20:06:46
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1. 58-17-87, 58-18B-18, 58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:32 - Single risk pool

Current through Register Vol. 51, page 10, July 15, 2024
For the individual market, a health insurance issuer shall consider the claims experience of all individual health plans, other than those enrolled in grandfathered health plans and group plans subject to SDCL  58-17-70, and excepted benefits offered by such issuer in the individual market in a state, including those enrollees who do not enroll in such plans through an Exchange, to be members of a single risk pool.
For the small group market, a health insurance issuer shall consider the claims experience of all enrollees in all health plans, other than grandfathered health plans, subject to SDCL chapter 58-18 B and offered by such issuer in the small group market in a state, including those enrollees who do not enroll in such plans through an Exchange, to be members of a single risk pool.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1,  58-17-87,  58-18B-18,  58-18B-36.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:22 - Loss ratios for health insurance policies › Section 20:06:22:33 - Index rate

Current through Register Vol. 51, page 10, July 15, 2024
Each plan year or policy year, as applicable, each health insurance issuer shall establish its own index rate for this state based on the total combined claims costs for providing essential health benefits within the single risk pool of this state. Separate single risk pools are required for the individual and small group markets. Each health insurance issuer shall adjust the index rate on a market-wide basis based on the total expected market-wide payments and charges under the risk adjustment and reinsurance program in this state. The premium rate for all the plans the health insurance issuer offers in this state market must use the applicable index rate, as adjusted for total expected market-wide payments and charges under the risk adjustment and reinsurance programs, subject only to the adjustments permitted under §
									20:06:22:34.
General Authority:
SDCL  58-17-4.2,  58-17-87,  58-18B-18,  58-18B-36.
Law Implemented:
SDCL  58-17-74.1,  58-17-87,  58-18B-18,  58-18B-36.