Title 58, INSURANCE

Terms used in this chapter mean: (1) "Comprehensive health maintenance services," a set of comprehensive health services which the enrollees might reasonably require to be maintained in good health, including as a minimum, but not limited to, emergency care, inpatient hospital an…

Each application for a certificate of authority by an applicant not domiciled in this state shall include a power of attorney duly executed by such applicant, appointing the director and his successors in office, and duly authorized deputies, as the true and lawful attorney of su…

Any organization may have a group health insurance policy issued to that organization on behalf of its members who would be insured under such policy. Members may join the organization, for the purpose of obtaining group health insurance, as individuals, employers, labor unions, …

The organization shall be responsible for negotiating the terms and conditions of insurance contracts, collection of premiums, and providing notice to members. Source: SL 1994, ch 382 , § 3.

The organization may provide not less than forty - five days advance notice of any benefit or premium change to its members. Source: SL 1994, ch 382 , § 4.

Any organization is subject to all applicable provisions of chapter 58-3 and chapter 58-33 . Source: SL 1994, ch 382 , § 5.

Any organization shall, prior to its engaging in the business of insurance, obtain approval from the Division of Insurance. The division may deny approval or withdraw approval of an organization to engage in the business of insurance for any of the following reasons: (1) Any of t…

The organization shall hold all premiums received in trust and promptly remit premiums to the person entitled thereto. Source: SL 1994, ch 382 , § 7.

Any insurer issuing group health insurance pursuant to §§ 58-41-99 to 58-41-109 , inclusive, is subject to all of the provisions of chapter 58-18B relating to rates. Source: SL 1994, ch 382 , § 8.

An insurer may as a condition of offering coverage or continuing coverage require reasonable participation requirements of groups who become members of an organization. Source: SL 1994, ch 382 , § 9.

Any organization formed pursuant to §§ 58-41-99 to 58-41-109 , inclusive, is exempt from the antitrust provisions under chapter 37-1 . Source: SL 1994, ch 382 , § 10.

The director may promulgate rules pursuant to chapter 1-26 to further the provisions of §§ 58-41-99 to 58-41-109 , inclusive, and for purposes of carrying out the provisions of §§ 58-18-1 to 58-18-6 , inclusive, and to ensure that group health insurance coverage is issued to elig…

Each health maintenance organization shall furnish a surety bond in an amount satisfactory to the director or deposit with the director cash or securities acceptable to him in at least the same amount as a guarantee that the obligations to the enrollees will be performed. The dir…

Nothing in this chapter applies to a medical provider who enters into a contract with the State of South Dakota for services pursuant to chapter 3-12A . Source: SL 1995, ch 294 , § 1.

Any medical provider who enters into a contract for medical services with a licensed health maintenance organization or a health insurer licensed pursuant to this title is not required to be licensed pursuant to this chapter. Source: SL 1995, ch 294 , § 2.

If a health maintenance contract issued or renewed on or after July 1, 1996, by a health maintenance organization provides maternity coverage, the contract shall provide coverage for a minimum of forty - eight hours of inpatient care following a vaginal delivery and a minimum of …

Source: SL 1996, ch 292 , § 16; SL 1998, ch 290 , § 6. 58-41-113 . Shorter hospital stay permitted--Follow - up visit within forty - eight hours required. If the treating physician determines that the mother and the newborn meet medical criteria contained in Guidelines for Perina…

The health maintenance organization shall provide notice to enrollees regarding the coverage required by § 58-41-112 in accordance with rules adopted by the director of the Division of Insurance pursuant to chapter 1-26 . The notice shall be in writing and prominently positioned …

Every health maintenance contract that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide, in writing, coverage for the treatment and diagnosis of biological…

The provisions of § 58-41-115 do not apply to any plan, policy, or contract that provides coverage only for: (1) Specified disease; (2) Hospital indemnity; (3) Fixed indemnity; (4) Accident - only; (5) Credit; (6) Dental; (7) Vision; (8) Prescription drug; (9) Medicare supplement…

Every health maintenance contract delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide, in writing, coverage for equipment, supplies, and self - management traini…

The provisions of § 58-41-117 do not apply to any plan, policy, or contract that provides coverage only for: (1) Specified disease; (2) Hospital indemnity; (3) Fixed indemnity; (4) Accident - only; (5) Credit; (6) Dental; (7) Vision; (8) Prescription drug; (9) Medicare supplement…

Every health maintenance contract that covers a male and that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall provide the following coverage for diagnostic screen…

The director shall determine whether the applicant for a certificate of authority has: (1) Demonstrated the willingness and potential ability to assure that health care services will be provided in a manner to assure both the availability and accessibility of adequate personnel a…

A health maintenance organization shall file annually, as part of its access plan, a list of all risk bearing entities with which it has an agreement or contract and the number of covered persons assigned or selected by each risk bearing entity. Source: SL 2013, ch 256 , § 35.

In entering into, amending, or renewing a contract with a risk bearing entity, a health maintenance organization shall, unless already specified in the contract, provide the following, upon request, to a risk bearing entity: (1) At the time the contract is entered into, a written…

A health maintenance organization shall include in any contract with a risk bearing entity a requirement that the risk bearing entity provide to the health maintenance organization at the time a contract is entered into and annually thereafter the following: (1) Annual audited GA…

A health maintenance organization shall require in any contract with a risk bearing entity that the risk bearing entity provide notice to the health maintenance organization within thirty days of: (1) Any changes involving the ownership structure of the risk bearing entity; or (2…

A health maintenance organization shall have procedures in place to notify the director within a reasonable time that a risk bearing entity has materially failed to perform under its contract with the health maintenance organization. A health maintenance organization is not in vi…

Any information provided to the director by a health maintenance organization relative to risk bearing entities with which it is contracted is confidential and may not be disclosed to any person except to the extent that it is necessary to carry out the purposes of §§ 58-41-120 t…

Notwithstanding any agreement to the contrary, the health maintenance organization shall: (1) Retain full responsibility on a prospective basis for the provision of health care services pursuant to any applicable health benefit plan; and (2) At all times, be able to demonstrate t…

Any qualified health plan issued on or after January 1, 2015, that offers coverage for professional audiology services shall include coverage for medically necessary physician services appropriate for the treatment of hearing impairment to a person under the age of nineteen. This…

To the extent that it furthers the purposes of this chapter, the director shall attempt to coordinate the operations of this chapter relating to the quality of health care services with the operations of 42 U.S.C. sections 1320c to 1320c-19. Source: SL 1974, ch 321 , § 54; SL 201…

Any health maintenance organization authorized under this chapter shall not be deemed to be practicing a healing art. Source: SL 1974, ch 321 , § 53.

Any optometrist licensed pursuant to chapter 36-7 , podiatrist licensed pursuant to chapter 36-8 , chiropractor licensed pursuant to chapter 36-5 , psychologist licensed pursuant to chapter 36-27A , dentist licensed pursuant to chapter 36-6A , or social worker licensed under § 36…

The director of the Division of Insurance shall issue or deny a certificate of authority to any person filing an application pursuant to this chapter. Issuance of a certificate of authority shall be granted upon payment of the application fee prescribed in § 58-41-26 if the direc…

In making a determination under subdivision 58-41-17(4), the director may consider: (1) The financial soundness of the applicant's arrangements for health care services and the proposed schedule of charges used in connection therewith; (2) The adequacy of its working capital; (3)…

The requirement of subdivision 58-41-17(5) shall not prohibit a health maintenance organization from obtaining insurance or making other arrangements: (1) For the cost of providing to any enrollee comprehensive health maintenance services, the aggregate value of which exceeds fiv…

As used in this chapter a health maintenance organization is a corporation organized under Title 47, controlled and operated as provided in this chapter, which provides, either directly or through arrangements with providers or other persons, comprehensive health maintenance serv…

Any corporation may, upon obtaining a certificate of authority as required in this chapter, operate as a health maintenance organization. Source: SL 1974, ch 321 , § 11; SL 1985, ch 393 , § 3.

A foreign corporation may qualify under this chapter, and if such corporation fully complies with the provisions of Title 58, then such corporation shall be exempt from complying with other provisions of the South Dakota Code concerning foreign corporations. Source: SL 1974, ch 3…

A health maintenance organization shall, unless otherwise provided for in this chapter, file a notice describing any modification of the operation set out in the information required by §§ 58-41-6 to 58-41-10 , inclusive. Such a notice shall be filed with the director prior to th…

The governing body of any health maintenance organization may include enrollees, providers, or other individuals. However, after a health maintenance organization has been authorized under this chapter for one year, at least twenty percent of the governing body of a health mainte…

The governing body shall establish a mechanism to afford the enrollees an opportunity to express their opinions in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other…

Any director, officer, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of such organization shall be responsible for such funds in a fiduciary relationship to the enrollees. Source: SL 1974, ch …

The funds of any corporation subject to the provisions of this chapter shall be invested only in securities permitted by the laws of this state for the investment of assets of life insurance companies. Source: SL 1985, ch 393 , § 14.

Any health maintenance organization is exempt from all provisions of the insurance laws of this state other than this chapter. However, the corporation is subject to the provisions of this title on matters and procedures of mergers and licensure of insurance producers. The corpor…

Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals. Source: SL 1974, ch 321 , § 52.

A health maintenance organization may enter into health maintenance contracts in this state and engage in any other activities consistent with this chapter which are necessary to the performance of its obligations under such contracts or authorize its representatives to do so. So…

Forty - five days before a health maintenance contract rate increase is effective, the health maintenance organization shall notify the enrolling unit in writing that the contract rate for the health maintenance contract offered by the organization will be increased. Source: SL 1…