Title 58, INSURANCE

Each health maintenance organization, health maintenance contract, and evidence of coverage shall be subject to chapter 58-33 , relating to the regulation of trade practices, except to the extent that the director determines that the nature of health maintenance organizations, he…

Every enrollee residing in this state is entitled to evidence of coverage under a health maintenance contract. The health maintenance organization or its designated representative shall issue the evidence of coverage. Source: SL 1974, ch 321 , § 18.

An evidence of coverage shall contain a clear, concise, and complete statement of: (1) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan; (2) Any exclusions or limitations on the services, kind of se…

At the time of negotiation of any health maintenance contract, the health maintenance organization shall offer, in writing, to provide the coverage prescribed by §§ 58-17-30.5 and 58-18-7.1 . Source: SL 1979, ch 344 , § 12.

Each health maintenance contract that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening by low-dose mammo…

A health maintenance contract that is delivered, issued for delivery, or renewed in this state may not exclude the payment of benefits for injuries sustained by an insured person because the insured was under the influence of alcohol or drugs, as defined by § 32-23-1 . Nothing in…

Each health maintenance contract that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening for the presence …

No evidence of coverage shall contain provisions or statements which are unjust, unfair, inequitable, misleading, or deceptive, as defined in §§ 58-41-37 to 58-41-40 , inclusive. Violation of this section is a Class 2 misdemeanor. Source: SL 1974, ch 321 , §§ 19 (1), 50; SDCL Sup…

No health maintenance organization or representative thereof may cause or knowingly permit the use of advertising or solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. Violation of this section is a Class 2 misdemeanor. Source: SL …

For the purposes of this chapter, a statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health maintenance organization. Source: SL 197…

For the purposes of this chapter, a statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of inform…

Notwithstanding any law of this state to the contrary, any corporation organized to do so shall apply to the director of the Division of Insurance for a certificate of authority to establish and operate a health maintenance organization in compliance with the provisions of this c…

For the purposes of this chapter, an evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing specia…

Any approved change in evidence of coverage shall be issued to each enrollee. Source: SL 1974, ch 321 , § 21.

No evidence of coverage or amendment thereto shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment thereto has been filed with and approved by the director. Violation of this section is a Class 2 misdemeanor. So…

A copy of the form of evidence of coverage to be used in this state, and any amendment thereto, shall be subject to the filing and approval requirements of § 58-41-42 unless it is subject to the jurisdiction of the director under the laws governing health insurance or hospital or…

Charges for comprehensive health maintenance services may be established in accordance with actuarial principles for various categories of enrollees, provided that such charges applicable to an enrollee shall not be individually determined based on the status of his health. Howev…

No health maintenance organization or representative thereof may discriminate in the rates charged enrollees except in accordance with accepted actuarial principles. Violation of this section is a Class 2 misdemeanor. Source: SL 1974, ch 321 , §§ 32 (6), (7), 50; SDCL Supp, § 58-…

Authorized expenses of health maintenance organizations include: (1) Cash rebates to enrollees, or to persons who have made payments on behalf of enrollees; (2) Free or reduced cost health service to enrollees; or (3) Payments to providers or other persons based upon the efficien…

No accident or health insurance policy providing coverage of hospital or medical expense which in addition to covering the insured also provides coverage to the spouse of the insured shall be issued without a provision that provides that upon eligibility for medicare or social se…

No accident or health insurance policy providing coverage of hospital or medical expense which in addition to covering the insured also provides coverage to the spouse of the insured shall be issued without a provision that provides that upon divorce of the insured and the insure…

At the time of negotiation of any health maintenance contract, the health maintenance organization shall offer, in writing, to provide the coverage prescribed by §§ 58-18-7.5 to 58-18-7.15 , inclusive. Source: SL 1985, ch 393 , § 13.

A health maintenance organization may contract with providers of health care services to render the services the health maintenance organization has promised to provide under the terms of its health maintenance contracts. Source: SL 1974, ch 321 , § 13.

Except for coinsurance, deductibles, or copayments as specifically provided in the evidence of coverage, in no event, including nonpayment by the health maintenance organization, insolvency of the health maintenance organization, or breach of contract among the health maintenance…

All contracts among health maintenance organizations, risk bearing entities, and participating providers shall include a hold harmless provision specifying protection for enrollees consistent with §§ 58-41-52.1 to 58-41-52.3, inclusive. Any attempted waiver or amendment in a mann…

The requirements of § 58-41-52.2 shall be met by including a provision substantially similar to the following: Provider agrees that in no event, including but not limited to nonpayment by the health maintenance organization or intermediary organization, insolvency of the health m…

A health maintenance organization may, subject to the limitations of subdivision 58-41-17(5) and of § 58-41-19 , contract with insurance companies and nonprofit health service plan corporations for insurance, indemnity, or reimbursement of its cost of providing health care servic…

Notwithstanding any law to the contrary, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provid…

A health maintenance organization may contract with other persons for the provision of services, including, but not limited to, managerial and administration, marketing and enrolling, data processing, actuarial analysis, and billing services. Source: SL 1974, ch 321 , § 14.

No health maintenance organization shall incur or pay for any expense of any nature which is unreasonably high in relation to the value of the service or goods provided. Violation of this section is a Class 2 misdemeanor. Source: SL 1974, ch 321 , §§ 41, 50; SDCL Supp, § 58-41-77…

Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall include an application fee, and shall be in a form prescribed by the director. Each application shall include the following: (1) A copy of the basi…

Every health maintenance organization shall annually, on or before March first, file a report verified by at least two principal officers with the director, covering the preceding calendar year. Such report shall be on forms prescribed by the director and shall include: (1) A fin…

All applications, filings, and reports required under this chapter are public documents except as provided for by § 1-27-30 . Source: SL 1974, ch 321 , § 57; SL 2013, ch 256 , § 18.

Every health maintenance organization or its representative shall annually, before April first, provide to its enrollees a summary of: (1) Its most recent annual financial statement, including a balance sheet and statement of receipts and disbursements; (2) A description of the h…

The director may, pursuant to chapter 1-26 , promulgate such reasonable rules as are necessary to carry out the provisions of this chapter. Included among such rules shall be those which provide minimum requirements for the provision of comprehensive health maintenance services, …

Each application for a certificate of authority shall include financial statements showing the applicant's assets, liabilities, and sources of financial support. If the applicant's financial affairs are audited by independent certified public accountants, a copy of the applicant'…

A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished such information to the health maintenance organization is entitled to claim. Source: SL 1974, ch 321 , § 36 (5).

Any data or information pertaining to the diagnosis, treatment, or health of any enrollee, or any application obtained from any person, shall be confidential and shall not be disclosed to any person except: (1) To the extent that it may be necessary to carry out the purposes of t…

The director may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provision of this chapter. Source: SL 1974, ch 321 , § 47.

Within twenty days after service of the order to cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this chapter have occurred. Such hearings shall be conducted pursuant to, and judicial review shall be available as…

Each application for a certificate of authority shall include: (1) A copy of the form of each evidence of coverage to be issued to the enrollees; (2) A copy of the form of each individual or group health maintenance contract which is to be issued to enrollees or their representat…

In the event of any violation of the provisions of this chapter, if the director elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order pursuant to § 58-41-79 , the director may institute a proceeding to obtain injunctive reli…

The director may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if the director finds that any of the following conditions exists: (1) The health maintenance organization is operating significantly in contravention of…

The director may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if: (1) The health maintenance organization does not meet the requirements of § 58-41-12 ; or (2) The health maintenance organization is unable to fulfil…

If the director, for any reason, has cause to believe that any violation of this chapter has occurred or is threatened, the director may, before commencing action under § 58-41-81 , 58-41-82 , 58-41-85 , or 58-41-87 , give notice to the health maintenance organization and to the …

Proceedings under § 58-41-83 are not governed by any formal procedural requirements, and may be conducted in such manner as the director finds appropriate under the circumstances. Source: SL 1974, ch 321 , § 46; SL 2013, ch 256 , § 30.