Title 58 — INSURANCE
79 chapters · 3,532 sections in this title.
SDCL § 58-17F-1 Definitions
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Terms used in this chapter mean: (1) "Closed plan," a managed care plan or health carrier that requires covered persons to use participating providers under the terms of the managed care plan or health carrier and does not provide any benefits for out-of-network services except f…
SDCL § 58-17F-10 Access plan required for managed care plans--Annual update--Contents--Exemptions for discounted fee-for-service networks
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The health carrier shall file with the director, in a manner and form defined by rules promulgated pursuant to chapter 1-26 by the director, an access plan meeting the requirements of this chapter, for each of the managed care plans that the carrier offers in this state. The carr…
SDCL § 58-17F-11 Requirements for health carrier and providers in managed care plans
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Any health carrier offering a managed care plan shall satisfy all the following requirements: (1) The health carrier shall establish a mechanism by which the participating provider will be notified on an ongoing basis of the specific covered health services for which the provider…
SDCL § 58-17F-12 Provisions governing contractual arrangements between health carriers and intermediaries
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In any contractual arrangement between a health carrier and an intermediary, the following shall apply: (1) The health carrier's ultimate statutory responsibility to monitor the offering of covered benefits to covered persons shall be maintained whether or not any functions or du…
SDCL § 58-17F-13 Sample contract forms to be filed with director--Material changes to be submitted--Certain changes not material--Director's inaction within certain time deemed approval--Contract copies to be provided upon request
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Any health carrier shall file with the director sample contract forms proposed for use with its participating providers and intermediaries. Any health carrier shall submit material changes to a sample contract that would affect a provision required by this chapter, or any rules p…
SDCL § 58-17F-14 Contract does not relieve health carrier of liability
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The execution of a contract by a health carrier does not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for compliance with the law or applicable regulations. Any contract shall be in …
SDCL § 58-17F-15 Remedies available to director against health carrier found not in compliance
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In addition to any other remedies permitted by law, if the director determines that a health carrier has not contracted with enough participating providers to assure that covered persons have accessible health care services in a geographic area, that a health carrier's access pla…
SDCL § 58-17F-16 Managed care contractor to register with director
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Each managed care contractor, as defined in § 58-17F-1 , shall register with the director prior to engaging in any managed care business in this state. The registration shall be in a format prescribed by the director. In prescribing the form or in carrying out other functions req…
SDCL § 58-17F-17 Filing changes in registration information
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Any managed care contractor which has previously registered in this state shall, on or before July first of each year, file with the Division of Insurance any changes to the initial or subsequent annual registration for the managed care contractor. Source: SL 2011, ch 219 , § 17.…
SDCL § 58-17F-18 Request for information from managed care contractor
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The director or the secretary may request information from any managed care contractor at any time pertaining to its activities in this state. The managed care contractor shall respond to all requests for information within twenty days. Source: SL 2011, ch 219 , § 18. Commission …
SDCL § 58-17F-19 Activities of nonregistered managed care contractor prohibited
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No managed care contractor may engage in managed care activities in this state unless the managed care contractor is properly registered. The director may issue a cease and desist order against any managed care contractor which fails to comply with the requirements of §§ 58-17F-1…
SDCL § 58-17F-2 Health benefit plan defined
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For the purposes of this chapter, the term, health benefit plan, means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term inc…
SDCL § 58-17F-20 Registration fee for managed care contractor
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The director may require the payment of a fee in conjunction with the initial or annual registration of a managed care contractor not to exceed two hundred fifty dollars per registration. The fee shall be established by rules promulgated pursuant to chapter 1-26 . Source: SL 2011…
SDCL § 58-17F-21 Promulgation of rules
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The director may, after consultation with the secretary, promulgate, pursuant to chapter 1-26 , reasonable rules to protect the public in its purchase of network health insurance products and to achieve the goals of this chapter, by ensuring adequate networks and by assuring qual…
SDCL § 58-17F-3 Medical director required for managed care plans
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Any managed care plan shall provide for the appointment of a medical director who has an unrestricted license to practice medicine. However, a managed care plan that specializes in a specific healing art shall provide for the appointment of a director who has an unrestricted lice…
SDCL § 58-17F-4 Health carrier to provide written information to prospective enrollees--Specific information required
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Any health carrier shall provide to any prospective enrollee written information describing the terms and conditions of the plan. If the plan is described orally, easily understood, truthful, objective terms shall be used. The written information need not be provided to any prosp…
SDCL § 58-17F-5 Health carrier to maintain provider network sufficient to assure services without unreasonable delay--Emergency services--Determination of sufficiency
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A health carrier providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all services to covered persons will be accessible without unreasonable delay. In the case of emergency services, covered persons shall have…
SDCL § 58-17F-6 Where provider network is insufficient, covered benefit to be made available at no greater cost
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In any case where the health carrier has an insufficient number or type of participating provider to provide a covered benefit, the health carrier shall ensure that the covered person obtains the covered benefit at no greater cost to the covered person than if the benefit were ob…
SDCL § 58-17F-7 Health carrier to ensure provider proximity to covered persons
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The health carrier shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers to the business or personal residence of covered persons. Source: SL 2011, ch 219 , § 7. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions…
SDCL § 58-17F-8 Health carrier to monitor provider ability, capacity, and authority--Financial capability to be monitored in capitated plans
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The health carrier shall monitor, on an ongoing basis, the ability, clinical capacity, and legal authority of its providers to furnish all contracted benefits to covered persons. In the case of capitated plans, the health carrier shall also monitor the financial capability of the…
SDCL § 58-17F-9 Factors to consider in determining network adequacy
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In determining whether a health carrier has complied with any network adequacy provision of this chapter, the director shall give due consideration to the relative availability of healthcare providers in the service area and to the willingness of providers to join a network. Sour…