South Dakota Administrative Code

20:06:21:50. Assisted living center or facility defined. An assisted living center or facility is any institution, place, building, or agency licensed by the state if such a license is required, which is maintained and operated to provide to five or more individuals personal care…

20:06:21:51. Assisted living centers -- Minimum benefit standards. An insurer offering long-term care coverage to any person in this state must include benefits for assisted living centers. If coverage for assisted living centers is provided, the coverage must provide benefits fo…

20:06:21:52. Reporting requirements for insurers. Each insurer must comply with the following reporting requirements for long-term care policies: (1) The insurer must maintain records for each agent of that agent's amount of replacement sales as a percent of the agent's total ann…

20:06:21:53. Appropriateness of recommended purchase or replacement. In recommending the purchase or replacement of a long-term care insurance policy or certificate, an agent must make a reasonable effort to determine the appropriateness of a recommended purchase or replacement. …

20:06:21:53.01. Suitability standards. Every insurer, health care service plan or other entity marketing long-term care insurance, all referred to as the "issuer", shall: (1) Develop and use suitability standards to determine whether the purchase or replacement of long-term care …

20:06:21:53.02. Suitability - Long-term care insurance personal worksheet. The issuer, and when an agent is involved, the agent, shall make reasonable efforts to obtain the information set out in § 20:06:21:53.01. The efforts must include presentation to the applicant, at or prio…

20:06:21:53.03. Suitability -- Response letter. If the issuer determines that the applicant does not meet its financial suitability standards, or if the applicant has declined to provide the information, the issuer may reject the application. In the alternative, the issuer shall …

20:06:21:53.04. Suitability -- Policies not included. Sections 20:06:21:53.01 to 20:06:21:53.03, inclusive, do not apply to life insurance policies that accelerate benefits for long-term care. Source: 28 SDR 157, effective May 19, 2002. General Authority: SDCL 58-17B-4. Law Imple…

20:06:21:53.05. Suitability -- Overinsurance. A long-term care insurance policy issued to an individual who already possesses insurance substantially covering the same risk and paying for the same coverage may be deemed to be overinsurance by the director. The issuance of a long-…

20:06:21:54. Requirement to deliver shopper's guide. A long-term care insurance shopper's guide in the format as published by the National Association of Insurance Commissioners or a similar guide developed or approved by the director, must be provided to all prospective applican…

20:06:21:55. Standards for benefit triggers. Long-term care policies must comply with the following standards for benefit triggers: (1) A long-term care policy may require a recommendation by a physician that the services are necessary because of illness, injury, or infirmity, bu…

20:06:21:56. Additional standards for benefit triggers for qualified long-term care insurance contracts. A qualified long-term care insurance contract shall pay only for qualified long-term care services received a chronically ill individual provided pursuant to a plan of care pr…

20:06:21:57. Nonforfeiture benefits. (1) Except as provided in subdivision 20:06:21:57(2), a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy …

20:06:21:58. Nonforfeiture benefit requirement. (1) This section does not apply to life insurance policies or riders containing accelerated long-term care benefits. (2) To comply with the requirement to offer a nonforfeiture benefit pursuant to the provisions of § 20:06:21:57: (a…

20:06:21:59. Electronic enrollment for group policies. In the case of a group defined in SDCL 58-17B-2(4)(a), any requirement that a signature of an insured be obtained by an agent or insurer is deemed satisfied if: (1) The consent is obtained by telephonic or electronic enrollme…

20:06:21:60. Required disclosure of rating practices to consumers -- Rate stabilization. (1) This subdivision applies as follows: (a) Except as provided in subdivision (1)(b) of this section, this subdivision applies to any long-term care policy or certificate issued in this stat…

20:06:21:61. Initial filing requirements. (1) This section applies to any long-term care policy issued in this state on or after November 1, 2002; (2) An insurer shall provide the information listed in this section to the director 30 days prior to making a long-term care insuranc…

20:06:21:62. Reserve standards. (1) When long-term care benefits are provided through the acceleration of benefits under group or individual life policies or riders to such policies, policy reserves for the benefits shall be determined in accordance with accepted actuarial practi…

20:06:21:63. Premium rate schedule increases -- Notice of pending increase. An insurer shall provide notice of a pending premium rate schedule increase, including an exceptional increase, to the director at least 30 days prior to the notice to the policyholders, and shall include…

20:06:21:64. Premium rate schedule increase requirements. All premium rate schedule increases shall be determined in accordance with the following requirements: (1) Exceptional increases shall provide that 70% of the present value of projected additional premiums from the excepti…

20:06:21:65. Premium rate schedule increases - Review by the director. For each rate increase that is implemented, the insurer shall file for approval by the director updated projections, as defined in subdivision 20:06:21:63(3)(a), annually for the next three years and include a…

20:06:21:66. Premium rate schedule increases -- Adverse lapsation. (1) For a rate increase filing that meets the following criteria, the director shall review, for all policies included in the filing, the projected lapse rates and past lapse rates during the 12 months following e…

20:06:21:67. Premium rate schedule increases - Policies to which does not apply. Sections 20:06:21:63 to 20:06:21:66, inclusive, shall not apply to policies for which the long-term care benefits provided by the policy are incidental, as defined in subdivision 20:06:21:01(13), if …

20:06:21:68. Premium rate schedule increases -- Group insurance policies. Subdivisions 20:06:21:65(2) and 20:06:21:66(1) and (2) shall not apply to group insurance policies as defined in SDCL 58-17B-2(4)(a) where: (1) The policies insure 250 or more persons and the policyholder h…

20:06:21:69. Premium rate schedule increases -- Adoption of rules. (1) Except as provided in subdivision (2) of this section, §§ 20:06:21:63 to 20:06:21:69, inclusive, applies to any long-term care policy or certificate issued in this state on or after November 1, 2002; (2) For c…

20:06:21:70. Premium rate schedule increases -- Exceptional increases. Except as provided in §§ 20:06:21:63 to 20:06:21:69, inclusive, exceptional increases are subject to the same requirements as other premium rate schedule increases. The director may request a review by an inde…

20:06:21:71. Permitted compensation arrangements. No insurer or other entity may provide commission or other compensation greater than the renewal compensation, to a producer or other representative, for the sale of a long-term care insurance policy or certificate which replaces …

20:06:21:72. Disclosure to applicant for a claim denial. If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificateholder, or a representative thereof: (1) Provide a written …

20:06:21:73. Providers in a different state. No long-term care issuer may deny a claim because services are provided in a state other than the state of policy issue if the following conditions are met: (1) If the state other than the state of policy issue does not have the provid…

20:06:21:74. Producer training required to market long-term care plans. An individual may not sell, solicit, or negotiate long-term care insurance unless the individual: (1) Is licensed as a health or life producer; (2) Has completed a one-time, eight-hour training course prior t…

20:06:21:74.01. Long-term care plan training topics for producers. The training required under § 20:06:21:74 must consist of the following topics related to long-term care insurance and services, and, if applicable, qualified state long-term care insurance partnership programs: (…

20:06:21:75. Insurers required to verify agent training and maintain records. Any insurer subject to this chapter shall obtain verification that its agent receives training required by § 20:06:21:74 before the agent is permitted to sell, solicit, or negotiate the insurer's long-t…

20:06:21:76. Long-term care partnership policies -- Inflation protection requirements. An insurer may not issue a policy intended to qualify as a partnership policy unless in addition to the requirements of §§ 20:06:21:06 to 20:06:21:06.05, inclusive, the policy includes the foll…

20:06:21:77. Long-term care partnership policies -- Required policy disclosures. A policy, certificate, or contract designed or marketed as a long-term care partnership policy must prominently disclose on the schedule page the following: (1) The [policy, certificate, or contract]…

20:06:21:78. Long-term care partnership policies -- Filing requirements. Schedule pages issued in compliance with § 20:06:21:77 are not required to be re-filed for approval. An informational filing notifying the division that the language specified in § 20:06:21:78 will be used m…

20:06:21:79. Long-term care -- Minimum benefit requirements. Any long-term care policy, certificate, or contract issued in this state must contain at least one year of nursing facility coverage. A daily benefit of not less than $100 per day must be included in the policy, certifi…

20:06:21:80. Long-term care partnership policies -- Policy amendments. Any amendment to the policy that alters the status of a partnership policy so that it no longer meets the applicable partnership standards must affirmatively disclose that fact and include an amended schedule …

20:06:21:81. Long-term care policies -- Policy amendments. No long-term care policy, certificate, or contract may be amended or benefits reduced pursuant to § 20:06:21:86 to: (1) Reduce the nursing home benefit to less than one year; (2) Reduce or delete benefits for assisted liv…

20:06:21:82. Availability of new services or providers. An insurer shall notify policyholders of the availability of a new long-term care policy series that provides coverage for new long-term care services or providers material in nature and not previously available through the …

20:06:21:83. Policies issued considered exchanges. Policies issued pursuant to § 20:06:21:82 are considered exchanges and not replacements. These exchanges are not subject to §§ 20:06:21:28.01, 20:06:21:53.01 to 20:06:21:53.04, inclusive, and the reporting requirements of § 20:06…

20:06:21:84. Policies offered through employers, labor unions, and associations. If the policy is offered through an employer, a labor organization, or a professional, trade, or occupational association, the required notification in § 20:06:21:82 shall be made to the offering ent…

20:06:21:85. Applicability of new provider or service requirements. Nothing in §§ 20:06:21:82 to 20:06:21:84, inclusive, prohibits an insurer from offering any policy, rider, certificate, or coverage change to any policyholder or certificateholder. However, upon request any polic…

20:06:21:86. Right to reduce coverage and lower premiums. Each long-term care insurance policy and certificate shall include a provision that allows the policyholder or certificateholder to reduce coverage and lower the policy or certificate premium in at least one of the followi…

20:06:21:87. Authorized representative. For purposes of §§ 20:06:21:87 to 20:06:21:104, inclusive, an authorized representative is a person authorized to act as the covered person's personal representative within the meaning of 45 CFR 164.502(g) promulgated by the Secretary under…

20:06:21:88. Notice to insured. If an insurer determines that the benefit trigger of a long-term care insurance policy has not been met, the insurer shall provide a clear, written notice to the insured and the insured's authorized representative, if applicable, of all of the foll…

20:06:21:89. Internal appeal. The insured or the insured's authorized representative may appeal the insurer's adverse benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within 120 calendar days after the in…

20:06:21:90. Internal appeal notice requirements. If the insurer's original determination is upheld upon internal appeal, the notice of the internal appeal decision shall describe any additional internal appeal rights offered by the insurer. Nothing in this chapter requires the i…