South Dakota Administrative Code

Rule 20:06:39:55 Applicability to excepted benefits. 20:06:39:55. Applicability to excepted benefits. Sections 20:06:39:43 to 20:06:39:54, inclusive, do not apply to excepted benefits as defined by 42 USC 300gg-91(c), as of August 1, 2010. Source: 37 SDR 47, effective September 2…

Rule 20:06:39:56 Effective date. 20:06:39:56. Effective date. Sections 20:06:39:43 to 20:06:39:54 apply for plan years beginning on or after the effective date of those sections. Source: 37 SDR 47, effective September 20, 2010. General Authority: SDCL 58-17-87. Law Implemented: S…

Rule 20:06:39:57 Guaranteed availability of coverage in the individual market. 20:06:39:57. Guaranteed availability of coverage in the individual market. After December 31, 2013, a health insurance issuer that offers health insurance coverage in the individual market in this stat…

Rule 20:06:39:58 Denial of coverage. 20:06:39:58. Denial of coverage. After December 31, 2013, a health insurance issuer may deny health insurance coverage in the individual market outside the Exchange if the issuer has demonstrated to the director the following: (1) The health i…

Rule 20:06:39:59 Open enrollment. 20:06:39:59. Open enrollment. After December 31, 2013, a health insurance issuer must provide an initial open enrollment period and annual open enrollment periods outside the individual Exchange, during which qualified individuals may enroll in a…

Rule 20:06:39:60 Initial open enrollment period. 20:06:39:60. Initial open enrollment period. The initial open enrollment period in the individual market outside the individual market Exchange begins October 1, 2013, and extends through March 31, 2014. The effective coverage date…

Rule 20:06:39:61 Annual open enrollment period. 20:06:39:61. Annual open enrollment period. Health insurance issuers must provide an annual open enrollment period for the individual market. Source: 39 SDR 203, effective June 10, 2013; 41 SDR 93, effective December 3, 2014; 45 SDR…

Rule 20:06:39:62 Special enrollment period effective dates. 20:06:39:62. Special enrollment period effective dates. After December 31, 2013, a health insurance issuer must provide special enrollment periods consistent with this section outside the Exchange, during which qualified…

Rule 20:06:39:63 Coverage issued outside open enrollment. 20:06:39:63. Coverage issued outside open enrollment. A health insurance issuer may issue a health plan to any individual applying for coverage outside of an insurance Exchange and outside of an open enrollment period. For…

Rule 20:06:39:64 Enrollment in catastrophic plans. 20:06:39:64. Enrollment in catastrophic plans. A health plan is a catastrophic plan if it meets the following conditions: (1) Meets all applicable requirements for health insurance coverage in the individual market and is offered…

Rule 20:06:39:65 Student health insurance coverage. 20:06:39:65. Student health insurance coverage. Student health insurance coverage is considered to be available only through a bona fide association. A health insurance issuer that offers student health insurance coverage is not…

Rule 20:06:39:66 Clinical trial. 20:06:39:66. Clinical trial. After December 31, 2013, a health insurance issuer that offers a health benefit plan providing health insurance coverage individual market in this state may not: (1) Deny participation by a qualified individual in an a…

Rule 20:06:39:67 Nonrenewal of coverage. 20:06:39:67. Nonrenewal of coverage. After December 31, 2013, a health insurance issuer offering health insurance coverage in the individual market is required to renew or continue in force the coverage at the option of the individual. An …

Rule 20:06:39:68 Discontinuing a particular product. 20:06:39:68. Discontinuing a particular product. After December 31, 2013, in any case in which a health insurance issuer elects to discontinue offering a particular product in the individual market, that product may only be dis…

Rule 20:06:39:69 Discontinuing all coverage. 20:06:39:69. Discontinuing all coverage. After December 31, 2013, an issuer may elect to discontinue offering all health insurance coverage in the individual market, or all markets, in a state in accordance with applicable state law on…

Rule 20:06:39:70 Special enrollment periods for marriage, birth, and adoption. 20:06:39:70. Special enrollment periods for marriage, birth, and adoption. After December 31, 2013, a special enrollment period occurs for the individual, the individual's spouse, and the individual's …

Rule 20:06:39:71 Special enrollment triggers. 20:06:39:71. Special enrollment triggers. After December 31, 2013, a health insurance issuer offering health insurance coverage in the individual market outside the Exchange must allow for an individual or dependent to enroll or chang…

Rule 20:06:39:72 Preexisting condition exclusion and waiting period prohibited. 20:06:39:72. Preexisting condition exclusion and waiting period prohibited. No health insurance issuer offering an individual health benefit plan may impose any preexisting condition exclusion or pree…

Rule 20:06:39:73 Health insurance issuer defined. 20:06:39:73. Health insurance issuer defined. A health insurance issuer is any person that provides health insurance in this state including an insurance company, a prepaid hospital, or similar plan, a health maintenance organizat…

Rule 20:06:39:74 Applicability. 20:06:39:74. Applicability. Effective January 1, 2014, §§ 20:06:39:03, 20:06:39:05, 20:06:39:07, 20:06:39:10, 20:06:39:19, 20:06:39:20, 20:06:39:20.05, and 20:06:39:30, only apply to grandfathered plans. Sections 20:06:39:04, 20:06:39:06, 20:06:39:…

Rule 20:06:40:01 Repealed. 20:06:40:01. Waiting periods, affiliation periods, and applications relating to breaks in coverage. Repealed. Source: 24 SDR 35, effective September 19, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014. Rule 20:06:40:01.01 Waiting perio…

Rule 20:06:40:01.01 Waiting periods and affiliation periods relating to breaks in coverage. 20:06:40:01.01. Waiting periods and affiliation periods relating to breaks in coverage. Waiting periods and delays in the provision of coverage by the employer do not count toward the maxi…

Rule 20:06:40:02 Short-term, limited duration policies. 20:06:40:02. Short-term, limited duration policies. Creditable coverage includes short-term limited duration policies. Short-term, limited duration insurance means health insurance coverage that is provided under a contract …

Rule 20:06:40:03 Repealed. 20:06:40:03. Certificates required upon losing coverage. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014. Rule 20:06:40:03.01 Certificates required upon losing coverage. 20:06:40:03.…

Rule 20:06:40:03.01 Certificates required upon losing coverage. 20:06:40:03.01. Certificates required upon losing coverage. A health insurance issuer must provide a certificate or simply certify that the individual has creditable coverage to any individual losing coverage or qual…

Rule 20:06:40:04 Standards for determinations on length of preexisting waiting periods. 20:06:40:04. Standards for determinations on length of preexisting waiting periods. A carrier must determine whether an individual is eligible for coverage pursuant to SDCL 58-18-48. In making…

Rule 20:06:40:05 Special enrollment periods for marriage, birth, and adoption. 20:06:40:05. Special enrollment periods for marriage, birth, and adoption. A special enrollment period occurs for the individual, the individual's spouse, and the individual's dependents if the followi…

Rule 20:06:40:05.01 Special enrollment periods for loss of other coverage. 20:06:40:05.01. Special enrollment periods for loss of other coverage. If an individual was eligible for coverage and declined coverage due to the existence of other coverage in force, the individual, the …

Rule 20:06:40:06 Repealed. 20:06:40:06. Affiliation periods for health maintenance organizations. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.

Rule 20:06:40:07 Repealed. 20:06:40:07. Nondiscrimination in determining eligibility for coverage.Repealed. Source: 24 SDR 35, effective September 29, 1997; repealed, 29 SDR 48, effective October 10, 2002.

Rule 20:06:40:08 Repealed. 20:06:40:08. Standards for determining when a condition is preexisting. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.

Rule 20:06:40:09 Repealed. 20:06:40:09. Notification of determinations on preexisting waiting periods and appeal and reconsideration procedures. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 13, 2013, repealed January 1, 2014.

Rule 20:06:40:10 Repealed. 20:06:40:10. Creditable coverage and preexisting waiting periods for newborn and adopted children. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.

Rule 20:06:40:11 Repealed. 20:06:40:11. Renewal rights under association plans. Repealed. Source: 23 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.

Rule 20:06:40:12 Repealed. 20:06:40:12. Health benefit arrangement defined. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.

Rule 20:06:40:13 Public health plan defined. 20:06:40:13. Public health plan defined. A public health plan for purposes of SDCL 58-18-44 is any plan established or maintained by a state, county, or other political subdivision of a state that provides health insurance coverage to …

Rule 20:06:40:14 Repealed. 20:06:40:14. Carrier defined. Repealed. Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed, effective January 1, 2014.

Rule 20:06:40:15 Repealed. 20:06:40:15. Permissible methods of crediting coverage -- Alternative method prohibited. Repealed. Source: 24 SDR 35, effective September 29, 1997; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:40:16 Notice describing plan’s special enrollment required. 20:06:40:16. Notice describing plan’s special enrollment required. By the time an employee is offered the opportunity to enroll in a group health plan, the plan must provide the employee with a written notice …

Rule 20:06:40:17 Group health plans to offer breast reconstruction options after covered mastectomy. 20:06:40:17. Group health plans to offer breast reconstruction options after covered mastectomy. A group health plan, as defined by SDCL 58-18-42, and a health insurance issuer pr…

Rule 20:06:40:17.01 Written notification regarding coverage of reconstructive surgery after a mastectomy required. 20:06:40:17.01. Written notification regarding coverage of reconstructive surgery after a mastectomy required. A group health plan, and a health insurance issuer pro…

Rule 20:06:40:17.02 Prohibited practices. 20:06:40:17.02. Prohibited practices. A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not: (1) Deny to a patient eligibility, or continued eligibility…

Rule 20:06:40:17.03 Not a termination of collective bargaining agreement. 20:06:40:17.03. Not a termination of collective bargaining agreement. In the case of a group health plan maintained pursuant to one or more collective bargaining agreements between employee representatives …

Rule 20:06:40:17.04 Applicability. 20:06:40:17.04. Applicability. The provisions of §§ 20:06:40:17 to 20:06:40:17.03, inclusive, apply to all group plans issued or renewed. Source: 27 SDR 15, effective September 6, 2000. General Authority: SDCL 58-18-79. Law Implemented: SDCL 58-…

Rule 20:06:40:18 Claims experience defined. 20:06:40:18. Claims experience defined. For employers with one to fifty enrolled employees, claims experience is the amount of paid claims for the employer and the time period that the claims were incurred and paid. For employers with f…

Rule 20:06:40:19 Repealed. 20:06:40:19. Additional continuation election. Repealed. Source: 35 SDR 234, effective April 2, 2009; 35 SDR 306, effective July 1, 2009; repealed, 39 SDR 203, effective June 10, 2013.

Rule 20:06:40:20 Repealed. 20:06:40:20. Period of special continuation. Repealed. Source: 34 SDR 234, effective April 2, 2009; 35 SDR 306, effective July 1, 2009; repealed, 39 SDR 203, effective June 10, 2013.