South Dakota Administrative Code

Rule 20:06:53:73 Failure to comply with internal claims and appeal process. 20:06:53:73. Failure to comply with internal claims and appeal process. If a plan or issuer fails to strictly adhere to all the requirements of the internal claims and appeals process with respect to a cl…

Rule 20:06:53:74 Continued coverage and ongoing treatment. 20:06:53:74. Continued coverage and ongoing treatment. A plan and issuer must provide continued coverage pending the outcome of an internal appeal of a concurrent review. A plan or issuer may not reduce or terminate an on…

Rule 20:06:53:75 One level of internal appeals. 20:06:53:75. One level of internal appeals. A health insurance issuer offering individual health insurance coverage may only have one level of internal appeals. A claimant may seek either external review or judicial review immediate…

Rule 20:06:53:76 Record keeping. 20:06:53:76. Record keeping. Each health insurance issuer offering individual health insurance coverage shall maintain records of all claims and notices associated with its internal claims and appeals processes. The records must be maintained for …

Rule 20:06:53:77 Applicability. 20:06:53:77. Applicability. Nothing in §§ 20:06:53:68 to 20:06:53:76, inclusive, applies to grandfathered plans pursuant to 26 C.F.R. 54.9815-2719T, 29 C.F.R. 2590.715-27109, or 45 C.F.R. 147.36. Sections 20:06:53:68 to 20:06:53:76, inclusive, appl…

Rule 20:06:53:78 Strictly adhere -- Defined. 20:06:53:78. Strictly adhere -- Defined. For purposes of §§ 20:06:53:68 to 20:06:53:77 minor non-prejudicial errors attributable to good cause or matters beyond the plan or issuer's control in the context of ongoing good faith exchange…

Rule 20:06:53:79 Written explanation of violation. 20:06:53:79. Written explanation of violation. A covered person may request a written explanation of the violation from the health carrier. The health carrier shall provide the written explanation within ten days of receiving the…

Rule 20:06:53:80 Procedure when immediate review request denied. 20:06:53:80. Procedure when immediate review request denied. If an independent reviewer or a court of competent jurisdiction rejects the grievance involving an adverse determination for immediate review on the basis…

Rule 20:06:54:01 Coverage for preventive items and services. 20:06:54:01. Coverage for preventive items and services. A group health plan, or a health insurance issuer offering group or individual health insurance coverage, shall provide coverage for all of the following items an…

Rule 20:06:54:02 Coverage for office visits in conjunction with preventive items and services. 20:06:54:02. Coverage for office visits in conjunction with preventive items and services. If an item or service described in § 20:06:54:01 is billed separately or is tracked as individ…

Rule 20:06:54:03 Preventive items and services with out-of-network providers. 20:06:54:03. Preventive items and services with out-of-network providers. Nothing in this section requires a plan or issuer that has a network of providers to provide benefits for items or services desc…

Rule 20:06:54:04 Reasonable medical management allowed. 20:06:54:04. Reasonable medical management allowed. Nothing prevents a plan or issuer from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service descr…

Rule 20:06:54:05 Additional services not prohibited. 20:06:54:05. Additional services not prohibited. Nothing in this section prohibits a plan or issuer from providing coverage for items and services in addition to those recommended by the United States Preventive Services Task F…

Rule 20:06:54:06 Applicability. 20:06:54:06. Applicability. A plan or issuer must provide coverage pursuant to §§ 20:06:54:01 to 20:06:54:05, inclusive, for the group market for plan years and in the individual market policy years, beginning after September 22, 2010. Nothing in §…

Rule 20:06:55:01 Eligibility of children up to age 26. 20:06:55:01. Eligibility of children up to age 26. A group health plan, or a health insurance issuer offering group or individual health insurance coverage, that makes available dependent coverage of children must make such c…

Rule 20:06:55:02 Restrictions on plan definition of dependent. 20:06:55:02. Restrictions on plan definition of dependent. With respect to a child who has not attained age 26, a plan or issuer may not define dependent for purposes of eligibility for dependent coverage of children …

Rule 20:06:55:03 Coverage of grandchildren not required. 20:06:55:03. Coverage of grandchildren not required. Nothing in §§ 20:06:55:01 to 20:06:55:10, inclusive, requires a plan or issuer to make coverage available for the child of a child receiving dependent coverage, unless th…

Rule 20:06:55:04 Uniformity irrespective of age. 20:06:55:04. Uniformity irrespective of age. The terms of the plan or health insurance coverage providing dependent coverage of children may not vary based on age except for children who are age 26 or older. Nothing in this section…

Rule 20:06:55:05 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Applicability. 20:06:55:05. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Applicability. Sections 20:06:55:05 to 20:06:55:09,…

Rule 20:06:55:06 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Opportunity to enroll required. 20:06:55:06. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Opportunity to enroll required. If…

Rule 20:06:55:07 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Written notice. 20:06:55:07. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Written notice. For purposes of §§ 20:06:55:05 to …

Rule 20:06:55:08 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Effective date. 20:06:55:08. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Effective date. In the case of an individual who e…

Rule 20:06:55:09 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Group health plan special enrollee. 20:06:55:09. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Group health plan special enro…

Rule 20:06:55:10 Special rule for grandfathered group health plans. 20:06:55:10. Special rule for grandfathered group health plans. For plan years beginning before January 1, 2014, a group health plan that qualifies as a grandfathered health plan pursuant to 75 Fed. Reg. 116 (201…

Rule 20:06:55:11 Applicability. 20:06:55:11. Applicability. Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), §§ 20:06:55:01 to 20:06:55:08, inclusive, apply to any plan of individual health insurance coverage and to any health benef…

Rule 20:06:55:12 Choice of primary care providers. 20:06:55:12. Choice of primary care providers. If a health carrier offering group or individual health insurance coverage requires or provides for the designation by a covered person of a participating primary care health care pr…

Rule 20:06:55:13 Emergency services. 20:06:55:13. Emergency services. No prior authorization of emergency services may be required by a health carrier either for in-network or out-of-network emergency services. A plan must provide for the payment of emergency services by an out-o…

Rule 20:06:55:14 Rescissions. 20:06:55:14. Rescissions. A policy, certificate, or contract of insurance may not be rescinded unless the individual performs an act, practice, or omission that constitutes fraud or unless the individual makes an intentional misrepresentation of a ma…

Rule 20:06:55:15 Group plans -- Lifetime limits. 20:06:55:15. Group plans -- Lifetime limits. A group health plan may not establish any lifetime limit or any annual limit on the dollar amount of essential benefits for any individual except as permitted in § 20:06:55:16. However, …

Rule 20:06:55:16 Group plans -- Annual limits. 20:06:55:16. Group plans -- Annual limits. With respect to plan years beginning prior to January 1, 2014, a group health plan may establish, for any individual, an annual limit on the dollar amount of benefits that are essential heal…

Rule 20:06:55:17 Group plans -- Eligibility. 20:06:55:17. Group plans -- Eligibility. An individual who meets the requirements of this section is eligible for benefits under a group health plan as described in § 20:06:55:18. This section applies to any individual: (1) Whose cover…

Rule 20:06:55:18 Group plans -- Notices and enrollment. 20:06:55:18. Group plans -- Notices and enrollment. If an individual described in § 20:06:55:17 is eligible for benefits or is required to become eligible for benefits under the group health plan, the group health plan is re…

Rule 20:06:55:19 Group plans -- Special enrollment. 20:06:55:19. Group plans -- Special enrollment. An individual enrolling in a group health plan pursuant to § 20:06:55:18 must be treated as if the individual were a special enrollee pursuant to §§ 20:06:40:05 and 20:06:40:05.01.…

Rule 20:06:55:20 Group plans -- Applicability. 20:06:55:20. Group plans -- Applicability. Sections 20:06:55:15 to 20:06:55:19, inclusive, apply for plan years beginning after September 22, 2010, and apply to any employer based health plan, including health benefit plans subject t…

Rule 20:06:55:21 Individual plans -- Lifetime limits. 20:06:55:21. Individual plans -- Lifetime limits. No individual policy of insurance may establish a lifetime limit on the dollar value of essential benefits for any covered person or an unreasonable annual limit on the dollar …

Rule 20:06:55:22 Individual plans -- Annual limits. 20:06:55:22. Individual plans -- Annual limits. With respect to policy years beginning prior to January 1, 2014, a health plan may establish, for any individual, an annual limit on the dollar amount of benefits that are essentia…

Rule 20:06:55:23 Reinstatement of coverage. 20:06:55:23. Reinstatement of coverage. An individual whose coverage or benefits under a health plan ended by reason of reaching a lifetime limit on the dollar value of all benefits for the individual must be provided an opportunity for…

Rule 20:06:55:24 Individual plans -- Applicability. 20:06:55:24. Individual plans -- Applicability. Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), §§ 20:06:55:21 to 20:06:55:23, inclusive, apply to any plan of individual health in…

Rule 20:06:55:25 Repealed.. 20:06:55:25. Individual plans -- No preexisting condition for a person under the age of 19 -- Open enrollment. Repealed. Source: 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010; 37 SDR 215, effective May 31, 2011; 38 SDR…

Rule 20:06:55:25.01 Individual plans -- No preexisting condition. 20:06:55:25.01. Individual plans -- No preexisting condition. No health policy, certificate, or plan may limit or exclude coverage based upon a preexisting condition for a person. For policies issued after March 23…

Rule 20:06:55:26 Group plans -- No preexisting condition for a person under the age of 19. 20:06:55:26. Group plans -- No preexisting condition for a person under the age of 19. No health policy, certificate, or plan may limit or exclude coverage based upon a preexisting conditio…

Rule 20:06:55:27 Excepted benefits -- Defined. 20:06:55:27. Excepted benefits -- Defined. For any health insurance policy or certificate subject to the provisions of Title 58 the term excepted benefits are those benefits as defined in section 2791 (c) of the Public Health Service…

Rule 20:06:55:28 Repealed. 20:06:55:28. Disproportionate share reporting. Repealed. Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.

Rule 20:06:55:29 Repealed. 20:06:55:29. Disproportionate share based on loss ratio. Repealed. Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed, January 1, 2014.

Rule 20:06:55:30 Repealed. 20:06:55:30. Disproportionate share based upon earned premium. Repealed. Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed, January 1, 2014.

Rule 20:06:55:31 Repealed. 20:06:55:31. Length of disproportionate share approval. Repealed. Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.

Rule 20:06:55:32 Definitions. 20:06:55:32. Definitions. (1) "Exchange," individual and SHOP Exchange; (2) "HHS," United States Department of Health and Human Services; (3) "Health insurance issuer," any person that provides health insurance in this state including an insurance co…

Rule 20:06:55:33 Certifying qualified health plans. 20:06:55:33. Certifying qualified health plans. A health insurance issuer selling plans in an Exchange may offer only health plans which have in effect a certification issued by the director as a qualified health plan, unless sp…

Rule 20:06:55:34 Issuer standards and certification criteria. 20:06:55:34. Issuer standards and certification criteria. In order to participate in an Exchange, a health insurance issuer must have in effect a certification issued or recognized by the director to demonstrate that e…

Rule 20:06:55:35 Qualified health plan defined. 20:06:55:35. Qualified health plan defined. A qualified health plan is a health plan that has been certified by the division that such plan meets the following criteria: (1) Provides the essential health benefits package described i…