South Dakota Administrative Code

Rule 20:06:57:08 Reserves and stop-loss coverage. 20:06:57:08. Reserves and stop-loss coverage. (1) A multiple employer trust shall have at all times aggregate excess stop-loss coverage providing the multiple employer trust with coverage for risks in this state with an attachment…

Rule 20:06:57:08.01 Multiple employer trust minimum loss ratio. 20:06:57:08.01. Multiple employer trust minimum loss ratio. A multiple employer trust that does not utilize community rating for its membership must maintain a minimum loss ratio (MLR) of eighty-five percent. MLR sha…

Rule 20:06:57:08.02 Multiple employer trust dividends. 20:06:57:08.02. Multiple employer trust dividends. A multiple employer trust may provide dividends to employer members in the same manner as domestic insurers. Source: 45 SDR 158, effective June 27, 2019. General Authority: S…

Rule 20:06:57:09 Annual report. 20:06:57:09. Annual report. A multiple employer trust shall file an annual report on or before the first day of March. The annual reports must be submitted for the preceding calendar year and must be verified by at least two of the trust's principa…

Rule 20:06:57:10 Contracts by multiple employer trusts. 20:06:57:10. Contracts by multiple employer trusts. All contracts issued by a multiple employer trust shall comply with the following: (1) Each multiple employer trust application for insurance and each policy and certificat…

Rule 20:06:57:11 Disclosure. 20:06:57:11. Disclosure. A multiple employer trust shall make the following disclosure to each employer member of the multiple employer trust: The benefits and coverages described herein are provided through a self-insured trust fund established and f…

Rule 20:06:57:12 Agreements and management contracts. 20:06:57:12. Agreements and management contracts. Any agreement between a multiple employer trust and any administrator, service company, or other entity shall be filed with the director for approval. Source: 40 SDR 102, effec…

Rule 20:06:57:13 Examination. 20:06:57:13. Examination. Each multiple employer trust is subject to examination by the director in accordance with SDCL chapter 58-3. Chapter 58-3 governs all aspects of the examination. The director may make an examination of a multiple employer tr…

Rule 20:06:57:14 Independent audit. 20:06:57:14. Independent audit. Multiple employer trusts are subject to SDCL chapter 58-43. Source: 40 SDR 102, effective December 3, 2013. General Authority: SDCL 58-18-89, 58-43-24. Law Implemented: SDCL 58-18-88, 58-18-89, ch 58-43.

Rule 20:06:57:15 Trade practices. 20:06:57:15. Trade practices. Multiple employer trusts are subject to applicable provisions of the Unfair Trade Practices Act, SDCL chapter 58-33. Source: 40 SDR 102, effective December 3, 2013. General Authority: SDCL 58-18-89. Law Implemented: …

Rule 20:06:57:16 Insolvency. Insolvency. 20:06:57:16. Insolvency. The provisions of SDCL chapter 58-29B apply to multiple employer trusts which are considered insurers for purposes of that chapter. Source: 40 SDR 102, effective December 3, 2013; 45 SDR 158, effective June 27, 201…

Rule 20:06:57:17 Minimum coverage standards for health policies. 20:06:57:17. Minimum coverage standards for health policies. The minimum coverage standards for health policies offered by multiple employer trusts are those of a bronze plan as delineated in ARSD 20:06:56:11. Sourc…

Rule 20:06:57:18 Applicability of chapter. 20:06:57:18. Applicability of chapter. This chapter does not apply to fully-insured entities. Source: 40 SDR 102, effective December 3, 2013. General Authority: SDCL 58-18-89. Law Implemented: SDCL 58-18-88, 58-18-89.

Rule 20:06:58:01 Definitions. 20:06:58:01. Definitions. Unless otherwise provided, terms used in this chapter mean: (1) "Aggregate lifetime dollar limit," a dollar limitation on the total amount of specified benefits that may be paid under a group health plan, or health insurance…

Rule 20:06:58:02 Parity requirements with respect to aggregate lifetime and annual dollar limits. 20:06:58:02. Parity requirements with respect to aggregate lifetime and annual dollar limits. A group health plan, or heath insurance coverage offered by an issuer in connection with…

Rule 20:06:58:03 Plan with no limit or limits on less than one-third of all medical or surgical benefits. 20:06:58:03. Plan with no limit or limits on less than one-third of all medical or surgical benefits. If a plan, or health insurance coverage, does not include an aggregate l…

Rule 20:06:58:04 Plan with a limit on at least two-thirds of all medical or surgical benefits. 20:06:58:04. Plan with a limit on at least two-thirds of all medical or surgical benefits. If a plan, or health insurance coverage, includes an aggregate lifetime or annual dollar limit…

Rule 20:06:58:05 Determining one-third and two-thirds of all medical or surgical benefits. 20:06:58:05. Determining one-third and two-thirds of all medical or surgical benefits. For purposes of §§ 20:06:58:01 to 20:06:58:45, inclusive, the determination of whether the portion of …

Rule 20:06:58:06 Plan not described in sections 20:06:58:03 or 20:06:58:04 of this chapter. 20:06:58:06. Plan not described in sections 20:06:58:03 or 20:06:58:04 of this chapter. A group health plan, or health insurance coverage, that is not described in § 20:06:58:03 or 20:06:5…

Rule 20:06:58:07 Parity requirements with respect to financial requirements and treatment limitations -- Clarification of classification of benefits. 20:06:58:07. Parity requirements with respect to financial requirements and treatment limitations -- Clarification of classificati…

Rule 20:06:58:08 Parity requirements with respect to financial requirements and treatment limitations -- Clarification of type of financial requirement or treatment limitation. 20:06:58:08. Parity requirements with respect to financial requirements and treatment limitations -- Cl…

Rule 20:06:58:09 Parity requirements with respect to financial requirements and treatment limitations -- Clarification of level of a type of financial requirement or treatment limitation. 20:06:58:09. Parity requirements with respect to financial requirements and treatment limita…

Rule 20:06:58:10 Parity requirements with respect to financial requirements and treatment limitations -- Clarification of coverage unit. 20:06:58:10. Parity requirements with respect to financial requirements and treatment limitations -- Clarification of coverage unit. For purpos…

Rule 20:06:58:11 General parity requirement. 20:06:58:11. General parity requirement. A group health plan, or health insurance coverage offered by an issuer in connection with a group health plan, that provides both medical or surgical benefits and mental health or substance use …

Rule 20:06:58:12 Classifications of benefits used for applying rules. 20:06:58:12. Classifications of benefits used for applying rules. If a plan, or health insurance coverage, provides mental health or substance use disorder benefits in any classification of benefits described i…

Rule 20:06:58:13 Application to out-of-network providers. 20:06:58:13. Application to out-of-network providers. A plan, or health insurance coverage, that provides mental health or substance use disorder benefits in any classification of benefits must provide mental health or sub…

Rule 20:06:58:14 Financial requirements and quantitative treatment limitations -- Determining substantially all. 20:06:58:14. Financial requirements and quantitative treatment limitations -- Determining substantially all. For purposes of §§ 20:06:58:07 to 20:06:58:25, inclusive, …

Rule 20:06:58:15 Financial requirements and quantitative treatment limitations -- Determining predominant. 20:06:58:15. Financial requirements and quantitative treatment limitations -- Determining predominant. If a type of financial requirement or quantitative treatment limitatio…

Rule 20:06:58:16 Financial requirements and quantitative treatment imiitations -- Determining portion based on plan payments. 20:06:58:16. Financial requirements and quantitative treatment limitations -- Determining portion based on plan payments. For purposes of §§ 20:06:58:07 t…

Rule 20:06:58:17 Financial requirements and quantitative treatment limitations -- Determining clarifications for certain threshold requirements and dollar amount of plan payments. 20:06:58:17. Financial requirements and quantitative treatment limitations -- Determining clarificat…

Rule 20:06:58:18 Application to different coverage units. 20:06:58:18. Application to different coverage units. If a plan, or health insurance coverage, applies different levels of a financial requirement or quantitative treatment limitation to different coverage units in a class…

Rule 20:06:58:19 Special rule for multi-tiered prescription drug benefits. 20:06:58:19. Special rule for multi-tiered prescription drug benefits. If a plan, or health insurance coverage, applies different levels of financial requirements to different tiers of prescription drug be…

Rule 20:06:58:20 Special rule for multiple network tiers. 20:06:58:20. Special rule for multiple network tiers. If a plan, or health insurance coverage, provides benefits through multiple tiers of in-network providers, such as an in-network tier of preferred providers with more g…

Rule 20:06:58:21 Special rule for sub-classifications permitted for office visits, separate from other outpatient services. 20:06:58:21. Special rule for sub-classifications permitted for office visits, separate from other outpatient services. For purposes of applying the financi…

Rule 20:06:58:22 No separate cumulative financial requirements or cumulative quantitative treatment limitations. 20:06:58:22. No separate cumulative financial requirements or cumulative quantitative treatment limitations. A group health plan, or health insurance coverage, offered…

Rule 20:06:58:23 Nonquantitive treatment limitations. 20:06:58:23. Nonquantitative treatment limitations. A group health plan, or health insurance coverage, may not impose a nonquantitative treatment limitation with respect to mental health or substance use disorder benefits in a…

Rule 20:06:58:24 Illustrative list of nonquantitative treatment limitations. 20:06:58:24. Illustrative list of nonquantitative treatment limitations. Nonquantitative treatment limitations include: (1) Medical management standards limiting or excluding benefits based on medical ne…

Rule 20:06:58:25 Exemptions. 20:06:58:25. Exemptions. The rules in §§ 20:06:58:07 to 20:06:58:25, inclusive, do not apply if a group health plan, or health insurance coverage, satisfies the requirements of §§ 20:06:58:32 and 20:06:58:33 or §§ 20:06:58:34 to 20:06:58:43, inclusive…

Rule 20:06:58:26 Availability of plan information -- Criteria for medical necessity determinations. 20:06:58:26. Availability of plan information -- Criteria for medical necessity determinations. The criteria for medical necessity determinations made under a group health plan wit…

Rule 20:06:58:27 Availability of plan information -- Reasons for denial. 20:06:58:27. Availability of plan information -- Reasons for denial. The reason for any denial under a group health plan, or health insurance coverage offered in connection with such plan, of reimbursement o…

Rule 20:06:58:28 Applicability and effective dates -- Group health plans. 20:06:58:28. Applicability and effective dates -- Group health plans. The requirements of §§ 20:06:58:01 to 20:06:58:45, inclusive, apply to a group health plan offering, medical or surgical benefits, and m…

Rule 20:06:58:29 Applicability and effective dates -- Health insurance issuers. 20:06:58:29. Applicability and effective dates -- Health insurance issuers. The requirements of §§ 20:06:58:01 to 20:06:58:45, inclusive, apply to a health insurance issuer offering health insurance c…

Rule 20:06:58:30 Scope. 20:06:58:30. Scope. Sections 20:06:58:01 to 20:06:58:45, inclusive, do not: (1) Require a group health plan, or health insurance issuer offering coverage in connection with a group health plan, to provide any mental health benefits or substance use disorde…

Rule 20:06:58:31 Coordination with EHB requirements. 20:06:58:31. Coordination with EHB requirements. Nothing in §§ 20:06:58:32 to 20:06:58:43, inclusive, changes the requirements of 45 CFR 147.150 and 45 CFR 156.115 (December 3, 2014), providing that a health insurance issuer of…

Rule 20:06:58:32 Small employer exemption. 20:06:58:32. Small employer exemption. The requirements of §§ 20:06:58:01 to 20:06:58:45, inclusive, do not apply to a group health plan, or health insurance issuer offering coverage in connection with a group health plan, for a plan yea…

Rule 20:06:58:33 Determining employer size. 20:06:58:33. Determining employer size. For purposes of § 20:06:58:32: (1) All persons treated as a single employer under subsections (b), (c), (m), and (o) of the Internal Revenue Code of 1986, codified at 26 U.S.C. 414, are treated as…

Rule 20:06:58:34 Increased cost exemption. 20:06:58:34. Increased cost exemption. If the application of §§ 20:06:58:01 to 20:06:58:45, inclusive, to a group health plan, or health insurance coverage offered in connection with such plans, results in an increase for the plan year i…

Rule 20:06:58:35 Applicable percentage. 20:06:58:35. Applicable percentage. With respect to a plan or coverage, the applicable percentage described in §§ 20:06:58:34 to 20:06:58:43, inclusive, is: (1) Two percent in the case of the first plan year in which this section is applied…

Rule 20:06:58:36 Determinations by actuaries. 20:06:58:36. Determinations by actuaries. Determinations as to increases in actual costs under a plan or coverage that are attributable to implementation of the requirements of §§ 20:06:58:01 to 20:06:58:45, inclusive, shall be made a…

Rule 20:06:58:37 Formula. 20:06:58:37. Formula. The formula to be used to make the determination under § 20:06:58:36 is expressed mathematically as [(E1 -- E0)/T0] -- D>k. The components mean: (1) E1 is the actual total cost of coverage with respect to mental health and substance…