South Dakota Administrative Code

20:06:21:101. Certification of long-term care insurance independent review organizations. 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 …

20:06:21:102. Maintenance of records and reporting obligations by independent review organizations. Each insurer contracting with an independent review organization doing business in this state shall contractually ensure that the independent review organization complies with the …

20:06:21:103. Additional rights. 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 eligibi…

20:06:21:104. Applicability. 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. As used for purposes of independent review, a benefit trigger is a contractual pro…

20:06:21:105. Payment of a clean claim. 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 …

20:06:21:106. Claim timeframes. 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…

20:06:21:107. Unpaid claims. 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 …

20:06:21:108. Violations. 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…

20:06:21:11. Converted policy from group -- Time allowed for written application. The individual, or someone acting on the individual's behalf, must apply for the converted policy in writing and must pay the first premium due, if any, as directed by the insurer not later than 31 …

20:06:21:12. Converted policy from group -- Calculation of policy premium. Unless the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated on the basis of the insured's age at inception of coverage u…

20:06:21:13. Continuation or conversion is mandatory -- Exceptions. Continuation of coverage or issuance of a converted policy is mandatory, except as follows: (1) Termination of group coverage resulted from an individual's failure to make a required payment of premium or contrib…

20:06:21:14. Converted policy from group to individual -- Reduction of benefits -- Exception. Notwithstanding any other provision of §§ 20:06:21:09 to 20:06:21:17, inclusive, a converted policy issued to an individual who at the time of conversion is covered by another long-term …

20:06:21:15. Converted policy from group -- Benefits payable. The converted policy may provide that the benefits payable under the converted policy, together with the benefits payable under the group policy from which conversion is made, may not exceed those that would have been …

20:06:21:16. Converted policy from group -- Eligibility for coverage of relatives. Notwithstanding any other provision of § 20:06:21:17, any insured individual whose eligibility for group long-term care coverage is based upon a relationship to another person is entitled to contin…

20:06:21:17. Converted policy from group -- Managed care plan defined. For the purposes of §§ 20:06:21:09 to 20:06:21:16, inclusive, a managed-care plan is a health care or assisted living arrangement designed to coordinate patient care or control costs through utilization review…

20:06:21:18. Discontinuance and replacement of a group policy. If a group long-term care policy is replaced by another group long-term care policy issued to the same policyholder, the succeeding insurer shall offer coverage to all persons covered under the previous group policy o…

20:06:21:19. Premium increase prohibitions. The premiums charged to an insured for long-term care insurance may not increase due to either the increasing age of the insured at ages beyond 65 or the duration the insured has been covered under the policy. (1) The purchase of additi…

20:06:21:20. Lapse or termination notice required. An individual long-term care policy or certificate may not be issued until the insurer has received from the applicant either a written designation of at least one person, in addition to the applicant, who is to receive notice of…

20:06:21:21. Lapse or termination for payment through payroll or pension deduction plan. If the policyholder or certificateholder pays the premium for a long-term care insurance policy or certificate through a payroll or pension deduction plan, the requirements contained in § 20:…

20:06:21:22. Lapse or termination for nonpayment of premium. An individual long-term care policy or certificate may not lapse or be terminated for nonpayment of premium unless the insurer, at least 30 days before the effective date of the lapse or termination, has given notice to…

20:06:21:23. Disclosure of renewability. Individual long-term care insurance policies shall contain a renewability provision. The provision must be captioned, must appear on the first page of the policy, and must clearly state that the coverage is guaranteed renewable or noncance…

20:06:21:24. Disclosure of payment of benefits based on certain standards. A long-term care insurance policy which provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," or similar words must include a definition of…

20:06:21:25. Disclosure of limitations on preexisting conditions. If a long-term care insurance policy or certificate contains any limitations on preexisting conditions, the limitations must appear as a separate paragraph of the policy or certificate and must be labeled as "Preex…

20:06:21:26. Disclosure of other limitations or conditions on eligibility for benefits. A long-term care insurance policy or certificate containing any limitations or conditions for eligibility other than those prohibited in SDCL 58-17B-7 must contain a description of the limitat…

20:06:21:26.01. Notice to claimants -- Temporary leave. Within 30 days of receiving a claim or other written notice that an insured has entered a nursing home or assisted living center, the insurer must provide notice to the insured of the applicable policy or certificate provisi…

20:06:21:27. Outline of coverage. Insurers shall include the following information in or with the outline of coverage: (1) A graphic comparison of the benefit levels of a policy that increases benefits over the policy period with a policy that does not increase benefits. The grap…

20:06:21:28. Outline of coverage -- Standard format. The outline of coverage shall be a freestanding document, using no smaller than ten-point type. Text that is capitalized or underscored in the standard format outline or coverage may be emphasized by other means that provide pr…

20:06:21:28.01. Applications -- Questions about replacement. Application forms shall include questions designed to elicit information as to whether, as of the date of the application, the applicant has another long-term care insurance policy or certificate in force or whether a l…

20:06:21:29. Replacement notices. Upon determining that a sale will involve replacement, an insurer, other than an insurer using direct response solicitation methods or its agent, shall furnish the applicant, before issuance or delivery of the individual long-term care insurance …

20:06:21:30. Filing requirements for advertising -- Exemption. Each insurer, health care service plan, or other entity providing long-term care insurance or benefits in this state shall provide a copy of any long-term care insurance advertisement intended for use in this state, w…

20:06:21:31. Standards for marketing -- Requirements. Each insurer, health care service plan, or other entity marketing long-term care insurance coverage in this state, directly or through its producers, shall: (1) Establish marketing procedures and agent training requirements to…

20:06:21:32. Standards for marketing -- Prohibited practices. In addition to the practices prohibited in SDCL chapter 58-33, the following practices are prohibited: (1) Twisting. Knowingly making any misleading representation or incomplete or fraudulent comparison of any insuranc…

20:06:21:33. Standards for marketing -- Associations. If an association, as defined in SDCL 58-17B-2(4)(c), endorses or sells long-term care insurance, the primary responsibility of the association regarding the obligations set forth in this section is to educate its members conc…

20:06:21:34. Extension of benefits. Termination of long-term care insurance is without prejudice to any benefits payable for institutionalization if the institutionalization began while the long-term care insurance was in force and continues without interruption after termination…

20:06:21:35. Basis for continuation or conversion from group coverage required. Group long-term care insurance issued in this state after October 19, 1996, must provide covered individuals with a basis for continuation or conversion of coverage. Source: 23 SDR 55, effective Octob…

20:06:21:36. Basis for continuation of coverage from group defined. For the purposes of §§ 20:06:21:09 to 20:06:21:17, inclusive, § 20:06:21:35, and this section, a basis for continuation of coverage means a policy provision that maintains coverage under the existing group policy…

20:06:21:37. Reinstatement. In addition to the notice requirement in § 20:06:21:20, a long-term care insurance policy or certificate must include a provision for reinstatement of coverage in the event of lapse if the insurer is provided proof of cognitive impairment or the loss o…

20:06:21:38. Disclosure of riders and endorsements. Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured under an individual long-term care insurance policy, all riders or endorsements added to an individual long-term care in…

20:06:21:39. Disclosure of tax consequences. Life insurance policies which provide an accelerated benefit for long-term care must have a disclosure statement at the time of application for the policy or rider and at the time the accelerated benefit payment request is submitted th…

20:06:21:40. Applications -- Health and medication questions. All applications for long-term care insurance policies or certificates, except those which are guaranteed issue, must contain clear and unambiguous questions designed to ascertain the health condition of the applicant.…

20:06:21:41. Applications -- Notice about incorrect answers. Except for policies or certificates which are guaranteed issue, the following language must be set out conspicuously and in close conjunction with the applicant's signature block on an application for a long-term care i…

20:06:21:42. Policies -- Notice about incorrect answers on applications. Except for policies or certificates which are guaranteed issue, the following language must be set out conspicuously on the long-term care insurance policy or certificate: Caution: The issuance of this long-…

20:06:21:43. Elderly applicants -- Required information. Before issuance of a long-term care policy or certificate to an applicant age 80 or older, the insurer must obtain one of the following: (1) A report of a physical examination; (2) An assessment of functional capacity; (3) …

20:06:21:44. Applications -- Delivery. A copy of the completed application or enrollment form, as applicable, must be delivered to the insured no later than at the time of delivery of the policy or certificate unless it was retained by the applicant at the time of application. If…

20:06:21:44.01. Applications -- Delivery upon approval. Repealed. Source: 28 SDR 157, effective May 19, 2002; repealed, 30 SDR 89, effective December 9, 2003.

20:06:21:45. Records of rescissions -- Maintaining and filing records. Each insurer or other entity selling or issuing long-term care insurance benefits must maintain a record of all policy or certificate rescissions, both state and countrywide, except those which the insured vol…

20:06:21:46. Minimum standards for home health and community care benefits. The following minimum standards for home health and community care benefits must be complied with for long-term care policies, as well as for any policies or certificates that contain stand-alone home hea…