South Dakota Administrative Code

20:06:21:91. Independent review of benefit trigger determination. The insured or the insured's authorized representative may request an independent review of the insurer's benefit trigger determination after the internal appeal process outlined in §§ 20:06:21:89 and 20:06:21:90 h…

20:06:21:92. Independent review process. Within five business days of receiving a written request for independent review, the insurer shall refer the request to the independent review organization that the insured or the insured's authorized representative has chosen from the lis…

20:06:21:93. Additional appeal information. If the insured or the insured's authorized representative has new or additional information not previously provided to the insurer, whether submitted to the insurer or the independent review organization, such information shall first be…

20:06:21:94. Independent review notification. 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 …

20:06:21:95. Independent review organization selection. 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 appli…

20:06:21:96. Review of information. 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…

20:06:21:97. Additional information to independent review. 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 …

20:06:21:98. Process if determination overturned. 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 o…

20:06:21:99. Review decision requirements. 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 …

Rule 20:06:22:01 Types of renewal clauses. 20:06:22:01. Types of renewal clauses. 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): renewa…

Rule 20:06:22:02 Anticipated loss ratio requirements -- Exception. 20:06:22:02. Anticipated loss ratio requirements -- Exception. 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 …

Rule 20:06:22:03 Rate filings. 20:06:22:03. Rate filings. 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 t…

Rule 20:06:22:04 Filings of rate revisions. 20:06:22:04. Filings of rate revisions. 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 revis…

Rule 20:06:22:05 Requirements for history of experience. 20:06:22:05. Requirements for history of experience. 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 d…

Rule 20:06:22:06 Repealed. 20:06:22:06. Maximum allowable rate increase per filing -- Exception.Repealed. Source: 16 SDR 208, effective June 3, 1990; repealed, 29 SDR 107, effective February 5, 2003.

Rule 20:06:22:07 Repealed. 20:06:22:07. Annual limitation on rate increases -- Exception.Repealed. Source: 16 SDR 208, effective June 3, 1990; repealed, 29 SDR 107, effective February 5, 2003.

Rule 20:06:22:08 Applicability of rules. 20:06:22:08. Applicability of rules. These rules apply only to health insurance policies issued pursuant to SDCL 58-17. Source: 16 SDR 208, effective June 3, 1990. General Authority: SDCL 58-4-1, 58-17-4.1, 58-17-4.2. Law Implemented: SDCL…

Rule 20:06:22:09 Repealed. 20:06:22:09. Definitions. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:10 Repealed. 20:06:22:10. Applicability. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:11 Repealed. 20:06:22:11. Levels of aggregation for medical loss ratio rebate calculations. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:12 Repealed. 20:06:22:12. Frequency and timing of medical loss ratio rebate calculations and rebate payments. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:13 Repealed. 20:06:22:13. Credibility adjustments to medical loss ratio. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:14 Repealed. 20:06:22:14. Medical loss ratio rebate calculation for plan year 2011. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:15 Repealed. 20:06:22:15. Single employer multi-state blended rates for plan year 2011. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:16 Repealed. 20:06:22:16. Dual option coverage for single employers at blended rate for plan year 2011. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:17 Repealed. 20:06:22:17. Loss ratio formula calculations for plan year 2011. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:18 Repealed. 20:06:22:18. Medical loss ratio rebate calculation for plan year 2012. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:19 Repealed. 20:06:22:19. Single employer multi-state blended rates for plan year 2012. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:20 Repealed. 20:06:22:20. Dual option coverage for single employers at blended rate for plan year 2012. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:21 Repealed. 20:06:22:21. Loss ratio formula calculations for plan year 2012. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:22 Repealed. 20:06:22:22. Medical loss ratio rebate calculation for plan year 2013. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:23 Repealed. 20:06:22:23. Single employer multi-state blended rates for plan year 2013. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:24 Repealed. 20:06:22:24. Dual option coverage for single employers at blended rate for plan year 2013. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:25 Repealed. 20:06:22:25. Loss ratio formula calculations for plan year 2013. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:26 Repealed. 20:06:22:26. Credibility adjusted medical loss ratio for plan year 2013. Repealed. Source: 37 SDR 131, effective January 11, 2011; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:22:27 Rating bands. 20:06:22:27. Rating bands. 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 invol…

Rule 20:06:22:27.01 Tobacco use defined. 20:06:22:27.01. Tobacco use defined. For purposes of § 20:06:22:27, tobacco use means the 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 o…

Rule 20:06:22:27.02 Tobacco usage reporting. Tobacco usage reporting. 20:06:22:27.02. Tobacco usage reporting. If an enrollee is found to have reported false or incorrect information about the enrollee's tobacco use, the issuer may retroactively apply the appropriate tobacco use …

Rule 20:06:22:28 Health status and gender factors precluded. 20:06:22:28. Health status and gender factors precluded. 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. Source: 39 SDR 203, effecti…

Rule 20:06:22:29 Rating area. 20:06:22:29. Rating area. 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, Haa…

Rule 20:06:22:30 Rating variations. 20:06:22:30. Rating variations. 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 membe…

Rule 20:06:22:31 Uniform age bands. 20:06:22:31. Uniform age bands. 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 1.95…

Rule 20:06:22:32 Single risk pool. Single risk pool 20:06:22:32. Single risk pool. 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 sub…

Rule 20:06:22:33 Index rate. 20:06:22:33. Index rate. For 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 singl…

Rule 20:06:22:34 Permitted plan-level adjustments to the index rate. 20:06:22:34. Permitted plan-level adjustments to the index rate. For each plan year or policy years beginning after December 31, 2013, a health insurance issuer may vary premium rates for a particular plan from …

Rule 20:06:22:35 Frequency of index rate and plan-level adjustments. 20:06:22:35. Frequency of index rate and plan-level adjustments. A health insurance issuer may not establish an index rate and make the market-wide adjustments pursuant to § 20:06:22:33, or make the plan-level a…

Rule 20:06:22:36 Applicability. 20:06:22:36. Applicability. The provisions of §§ 20:06:22:27 to 20:06:22:35, inclusive, apply for plan years beginning after December 31, 2013, in the small group market and for policy years beginning after December 31, 2013, for the individual mar…

Rule 20:06:23:01 Increase in capital and surplus. 20:06:23:01. Increase in capital and surplus. The division may require an insurer to increase its capital and surplus based on the type of risk it is writing, the amount of risk it is writing, a change in its investment portfolio,…

Rule 20:06:23:02 Standards for determining the hazardous financial condition of an insurer. 20:06:23:02. Standards for determining the hazardous financial condition of an insurer. The director may consider any one of the following standards to determine whether the continued oper…

Rule 20:06:23:03 Criteria for dividends. 20:06:23:03. Criteria for dividends. In determining whether any dividend should be paid, disallowed, or limited by an insurer, the director may consider the following: (1) If the insurer is in a hazardous financial condition under § 20:06:…