South Dakota Administrative Code

Rule 20:06:55:36 Exchange network adequacy standards. 20:06:55:36. Exchange network adequacy standards. A qualified health plan issuer must ensure that the provider network of each qualified health plan meets the standards specified in SDCL chapter 58-17F. A qualified health plan…

Rule 20:06:55:37 Network adequacy standards. 20:06:55:37. Network adequacy standards. A qualified health plan issuer must ensure that the provider network of each of its qualified health plans meets the following standards: (1) Includes essential community providers in accordance…

Rule 20:06:55:38 Essential community providers defined. 20:06:55:38. Essential community providers defined. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, unless the provider lost its status as a result of a vio…

Rule 20:06:55:39 Essential community providers. 20:06:55:39. Essential community providers. A qualified health plan issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broa…

Rule 20:06:55:40 Payment of federally-qualified health centers. 20:06:55:40. Payment of federally-qualified health centers. If an item or service covered by a qualified health plan is provided by a federally-qualified health center to an enrollee of a qualified health plan, the q…

Rule 20:06:55:41 Treatment of direct primary care medical homes. 20:06:55:41. Treatment of direct primary care medical homes. A qualified health plan issuer may provide coverage through a direct primary care medical home that meets the criteria established by HHS, so long as the …

Rule 20:06:55:42 Recertification of qualified health plans. 20:06:55:42. Recertification of qualified health plans. Each qualified health plan offered in an Exchange must obtain annual recertification from the director in accordance with the criteria as outlined in § 20:06:55:35 …

Rule 20:06:55:43 Decertification of qualified health plan. 20:06:55:43. Decertification of qualified health plan. If an issuer offering a qualified health plan is no longer in compliance with the general certification criteria as outlined in § 20:06:55:35 the issuer may not offer…

Rule 20:06:55:44 Non-renewal and decertification of qualified health plans. 20:06:55:44. Non-renewal and decertification of qualified health plans. If a qualified health plan issuer elects not to seek recertification with the director, the qualified health plan issuer must: (1) N…

Rule 20:06:55:45 Rates. 20:06:55:45. Rates. A qualified health plan issuer must set rates for an entire benefit year, or for the SHOP Exchange, plan year. An issuer must submit rate and benefit information to the director. A qualified health plan issuer must submit to the directo…

Rule 20:06:55:46 Health plan applications and notices. 20:06:55:46. Health plan applications and notices. A qualified health plan issuer must provide all applications and notices to enrollees in plain language and in a manner that is accessible and timely to individuals living wi…

Rule 20:06:55:47 Accreditation of qualified health plan issuers. 20:06:55:47. Accreditation of qualified health plan issuers. A qualified health plan issuer must be accredited on the basis of local performance of a qualified health plan in accordance with § 20:06:56:12. Source: 3…

Rule 20:06:55:48 Repealed. 20:06:55:48. Initial open enrollment period. Repealed. Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 45 SDR 45, effective October 10, 2018.

Rule 20:06:55:49 Annual open enrollment period. 20:06:55:49. Annual open enrollment period. All health insurance issuers must provide for an annual open enrollment period for the individual market inside the Exchange. Source: 39 SDR 203, adopted June 10, 2013, effective January 1…

Rule 20:06:55:50 Changing qualified health plans. 20:06:55:50. Changing qualified health plans. A health insurance issuer must allow a qualified individual or enrollee in an Exchange to enroll in or change from one qualified health plan (QHP) to another as a result of the followi…

Rule 20:06:55:50.01 Loss of coverage. 20:06:55:50.01. Loss of coverage. Loss of coverage does not include termination or loss due to: (1) Failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or (2) Situations allowing for a re…

Rule 20:06:55:50.02 Special enrollment period effective dates. 20:06:55:50.02. Special enrollment period effective dates. After December 31, 2013, a health insurance issuer must provide special enrollment periods consistent with this section inside the Exchange, during which qual…

Rule 20:06:55:51 Compensation. 20:06:55:51. Compensation. A qualified health plan issuer must pay the same broker compensation for a qualified health plan offered through an Exchange that the qualified health plan issuer pays for a similar health plan offered outside an Exchange.…

Rule 20:06:55:52 Plan offerings in the exchange. 20:06:55:52. Plan offerings in the exchange. A qualified health plan issuer must offer at least one qualified health plan in the silver level and at least one plan in the gold level to participate in an Exchange. Sections 20:06:55:…

Rule 20:06:55:53 Applicability and effective dates. 20:06:55:53. Applicability and effective dates. The open enrollment provisions of §§ 20:06:55:48 and 20:06:55:49 do not apply to any coverage issued to an employer that covers at least two individuals. Sections 20:06:55:25, 20:0…

Rule 20:06:56:01 Definitions. 20:06:56:01. Definitions. (1) "Actuarial value," a measure of the percentage of expected health care costs a health plan will cover for a standard population and can be considered a general summary measure of health plan generosity; (2) "Actuarial va…

Rule 20:06:56:02 Covering essential health benefits. 20:06:56:02. Covering essential health benefits. Health insurance coverage in the individual and small group markets must cover essential health benefits for plan years beginning after December 31, 2013. Sections 20:06:56:01 th…

Rule 20:06:56:03 Essential health benefit packages. 20:06:56:03. Essential health benefit packages. The essential health benefits package consists of the following categories of benefits: (1) Ambulatory patient services; (2) Emergency services; (3) Hospitalization; (4) Maternity …

Rule 20:06:56:04 Substantially equal benefits. 20:06:56:04. Substantially equal benefits. Plans must provide for benefits that are substantially equal to the essential health benefits-benchmark plan including: (1) Covered benefits listed in § 20:06:56:02; (2) Limitations on cover…

Rule 20:06:56:05 Substituted benefits. 20:06:56:05. Substituted benefits. A plan may substitute benefits from the essential health benefits benchmark benefit plan if it meets the following conditions: (1) The substitute benefit is actuarial equivalent to the essential health bene…

Rule 20:06:56:06 Pediatric dental. 20:06:56:06. Pediatric dental. A stand-alone dental plan covering pediatric dental may be used to cover the pediatric dental component of essential health benefits required by § 20:06:56:02. A stand-alone dental plan covering the pediatric denta…

Rule 20:06:56:07 Prohibited benefits. 20:06:56:07. Prohibited benefits. An issuer of a plan offering essential health benefits may not include routine non-pediatric dental services, routine non-pediatric eye exam services, or long-term/custodial nursing home care benefits, or not…

Rule 20:06:56:08 Prescription drug benefits. 20:06:56:08. Prescription drug benefits. A health plan does not provide essential health benefits unless it covers at least the greater of: (1) One drug in every United States Pharmacopeia (USP) category and class; or (2) The same numb…

Rule 20:06:56:09 Prohibited discriminatory benefit design. 20:06:56:09. Prohibited discriminatory benefit design. A health insurance issuer does not provide essential health benefits if its benefit design, or the implementation of its benefit design, discriminates based on an ind…

Rule 20:06:56:10 Actuarial value calculator. 20:06:56:10. Actuarial value calculator. A health insurance issuer may use the actuarial value calculator to determine the actuarial value of a health plan made available by Health and Human Services. Actuarial Value within a de minimi…

Rule 20:06:56:11 Levels of coverage. 20:06:56:11. Levels of coverage. The levels of coverage are calculated as follows: (1) A bronze health plan is a health plan that has an actuarial value of 60 percent; (2) A silver health plan is a health plan that has an actuarial value of 70…

Rule 20:06:56:12 Accreditation. 20:06:56:12. Accreditation. A qualified health plan must be accredited in the following categories by an accrediting entity recognized by HHS prior to certification: (1) Clinical quality measures, such as the healthcare effectiveness Data and Infor…

Rule 20:06:56:13 Accreditation timeline. 20:06:56:13. Accreditation timeline. During certification for an issuer's initial year of qualified health plan certification a qualified health plan issuer without existing commercial, Medicaid, or Exchange health plan accreditation grant…

Rule 20:06:56:14 Provider credentialing. 20:06:56:14. Provider credentialing. A health insurance issuer's selection standards for participating providers shall be developed for primary care professionals and each health care professional specialty. The standards shall be used in …

Rule 20:06:56:15 Annual limitation on cost sharing. 20:06:56:15. Annual limitation on cost sharing. For a plan year beginning in calendar year 2014, cost sharing may not exceed the following: (1) For self-only coverage--the annual dollar limit as described in 26 U.S.C. § 223(c)(2…

Rule 20:06:56:16 Annual limitation on deductibles for plans in the small group market. 20:06:56:16. Annual limitation on deductibles for plans in the small group market. For a plan year beginning in calendar year 2014, the annual deductible for a health plan in the small group ma…

Rule 20:06:56:17 Network plan cost sharing. 20:06:56:17. Network plan cost sharing. In the case of a plan using a network of providers, cost-sharing paid by, or on behalf of, an enrollee for benefits provided outside of such network shall not count towards the annual limitation o…

Rule 20:06:56:18 Increase annual dollar limits in multiples of 50. 20:06:56:18. Increase annual dollar limits in multiples of 50. For a plan year beginning in a calendar year after December 31, 2014, any increase in the annual dollar limits that do not result in a multiple of 50 …

Rule 20:06:56:19 Catastrophic plan. 20:06:56:19. Catastrophic plan. A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if: (1) The only individuals who are …

Rule 20:06:56:20 Applicability. 20:06:56:20. Applicability. The provisions of §§ 20:06:56:01 to 20:06:56:19, inclusive, only apply to non-grandfathered plans effective January 1, 2014, and does not apply to an excepted benefit as defined in § 20:06:55:27. Source: 39 SDR 203, effe…

Rule 20:06:56:21 Exception for uniform modification of coverage. 20:06:56:21. Exception for uniform modification of coverage. Only at the time of coverage renewal may issuers modify the health insurance coverage for a product offered to a group health plan or an individual, as ap…

Rule 20:06:57:01 Definitions. 20:06:57:01. Definitions. (1) "Multiple employer trust," a self-funded entity which obtains authorization pursuant to SDCL 58-18-88 and this chapter to operate in South Dakota. Source: 40 SDR 102, effective December 3, 2013. General Authority: SDCL 5…

Rule 20:06:57:02 Authorization. 20:06:57:02. Authorization. No person may establish or maintain a self-insured employee benefit plan for the purpose of providing health insurance which is a multiple employer trust in this state unless the multiple employer trust first obtains and…

Rule 20:06:57:03 Application for authorization. 20:06:57:03. Application for authorization. A person applying for authorization pursuant to SDCL 58-18-88 shall submit a plan of operation with the director. The application and plan of operation shall include the following: (1) A b…

Rule 20:06:57:03.01 Waiver for out-of-state association plans. 20:06:57:03.01. Waiver for out-of-state association plans. In addition to the information required by § 20:06:57:03, an association not formed in South Dakota which is seeking a waiver must include the following infor…

Rule 20:06:57:03.02 Coverage eligibility. 20:06:57:03.02. Coverage eligibility. Multiple employer trusts must be sponsored by associations meeting the requirements of § 20:06:42:01 to provide coverage to members. Source: 45 SDR 158, effective June 27, 2019. General Authority: SDC…

Rule 20:06:57:04 Investigation of application. 20:06:57:04. Investigation of application. The director shall investigate the application and supporting documents submitted by the applicant pursuant to SDCL 58-18-88 and this chapter and may conduct any investigation which the dire…

Rule 20:06:57:05 Issuance of authorization. 20:06:57:05. Issuance of authorization. The director may issue an authorization to the multiple employer trust upon finding that the applicant multiple employer trust has met all requirements of SDCL 58-18-88 and this chapter. The direc…

Rule 20:06:57:06 Report to director of modification. 20:06:57:06. Report to director of modification. A multiple employer trust shall immediately notify the director of any material change in ownership, control, or other fact or circumstance that may affect qualification for an a…

Rule 20:06:57:07 Surplus. 20:06:57:07. Surplus. Unless otherwise provided in this section, a multiple employer trust shall deposit with an organization or trustee meeting the requirements of SDCL chapter 58-7 cash, securities, or any combination of these that is acceptable in the…