Title 58 — INSURANCE
79 chapters · 3,532 sections in this title.
SDCL § 58-17E-44 Contents of written materials
1.7K chars
The written materials required under this chapter shall be clear and include information on: (1) The name of the member; (2) The benefits to be provided under the discount medical plan; (3) Any processing fees and periodic charges associated with the discount medical plan; (4) Th…
SDCL § 58-17E-45 Consumer's right to return plan or program--Refund
0.6K chars
Any plan or program offered by a person subject to registration pursuant to § 58-17E-9 shall provide thirty days from the date of the signed consumer contract or agreement, or thirty days from the receipt of the disclosures required by § 58-17E-41 if the consumer purchased the pl…
SDCL § 58-17E-46 Notice to director of change in plan
0.3K chars
Each discount medical plan organization shall provide the director at least thirty days advance notice of any change in the discount medical plan organization's name, principal business address, mailing address, or internet website address. Source: SL 2006, ch 257 , § 43.
SDCL § 58-17E-47 Construction with trade practices statute
0.1K chars
Nothing in this chapter may be construed to discharge any requirements imposed by subdivision 37-24-6(12). Source: SL 2006, ch 257 , § 46.
SDCL § 58-17E-5 Definitions
2.8K chars
Terms used in this chapter mean: (1) "Ancillary services," includes audiology, dental, vision, mental health, substance abuse, chiropractic, and podiatry services; (2) "Facility," an institution providing medical or ancillary services or a health care setting. The term includes: …
SDCL § 58-17E-6 Application of chapter
0.1K chars
This chapter applies to all discount medical plan organizations doing business in South Dakota. Source: SL 2006, ch 257 , § 6.
SDCL § 58-17E-7 Registration exception and compliance requirements for otherwise registered health carriers
0.5K chars
A discount medical plan organization that is a health carrier registered pursuant to Title 58: (1) Is not required to register as a discount medical plan organization. However, any of its affiliates that operate as a discount medical plan organization in this state shall comply w…
SDCL § 58-17E-8 Notification of director required where discount medical plan organization loses registration or is subject to disciplinary proceeding in another state
0.4K chars
If a discount medical plan organization loses its registration, or other form of authority to operate as a discount medical plan organization in another state, or is the subject of any disciplinary administrative proceeding related to the organization's operating as a discount me…
SDCL § 58-17E-9 Registration of discount medical plan organization
0.3K chars
Any discount medical plan organization that is not offered directly by a health carrier as provided by this chapter, shall register in a format as prescribed by the director and shall file reports and conduct business under the same standards as required of utilization review org…
SDCL § 58-17F-1 Definitions
6.0K chars
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
2.9K chars
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
4.4K chars
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
2.4K chars
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
1.4K chars
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
0.9K chars
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
1.4K chars
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
1.4K chars
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
0.8K chars
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
0.8K chars
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
0.9K chars
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
3.3K chars
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
0.8K chars
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
1.1K chars
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
1.0K chars
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
3.2K chars
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
1.4K chars
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
0.9K chars
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
0.7K chars
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
0.8K chars
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
0.8K chars
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…
SDCL § 58-17G-1 Definitions
5.4K chars
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 § 58-17G-2 Health benefit plan defined
3.3K chars
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 § 58-17G-3 Health carrier to develop and maintain systems to measure quality of services--System requirements--Description of quality assessment program to be filed with director
1.7K chars
Any health carrier that provides managed care plans shall develop and maintain the infrastructure and disclosure systems necessary to measure the quality of health care services provided to covered persons on a regular basis and appropriate to the types of plans offered by the he…
SDCL § 58-17G-4 Health carrier issuing closed plan to develop quality improvement activities--Minimum requirements of quality improvement activities
1.6K chars
Any health carrier that issues a closed plan, or a combination plan having a closed component, shall, in addition to complying with the requirements of § 58-17G-3 , develop and maintain the internal structures and activities necessary to improve the quality of care being provided…
SDCL § 58-17G-5 Carrier may be deemed in compliance if private accrediting body meets requirements
0.9K chars
If the director and secretary find that the requirements of any private accrediting body meet the requirements of network adequacy, quality assurance, or quality improvement as set forth in this chapter, the carrier may, at the discretion of the director and secretary, be deemed …
SDCL § 58-17G-6 Division to monitor complaints regarding managed care policies
0.6K chars
The Division of Insurance shall separately monitor complaints regarding managed care policies. Source: SL 2011, ch 219 , § 26. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protectio…
SDCL § 58-17G-7 Promulgation of rules
1.1K chars
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 assuring quality of health care to the public t…
SDCL § 58-17H-1 Definitions
11.9K chars
Terms used in this chapter mean: (1) "Adverse determination," any of the following: (a) A determination by a health carrier or the carrier's designee utilization review organization that, based upon the information provided, a request by a covered person for a benefit under the h…
SDCL § 58-17H-10 Negotiated amounts for in-network providers for a particular emergency service
0.7K chars
If a health benefit plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subdivision 58-17H-8 (1) is the median of these negotiated amounts. Source: SL 2011, ch 219 , § 35. Commission Note: SL 2012, ch 239, § 1 provid…
SDCL § 58-17H-11 General cost-sharing requirements allowed
1.1K chars
Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to emergency services provided out-of-network if the cost-sharing requirement generally applies to out-of-network benefits. A…
SDCL § 58-17H-12 Access to representative for post-evaluation or post-stabilization services
0.8K chars
For immediately required post-evaluation or post-stabilization services, a health carrier shall provide access to a designated representative twenty-four hours a day, seven days a week, to facilitate review, or otherwise provide coverage with no financial penalty to the covered p…
SDCL § 58-17H-13 Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body
0.9K chars
If the director and the secretary find that the requirements of any private accrediting body meet the requirements of coverage of emergency medical services as set forth in §§ 58-17H-4 to 58-17H-12 , inclusive, the health carrier may, at the discretion of the director and secreta…
SDCL § 58-17H-14 Health carrier responsibility for utilization review activities
0.9K chars
A health carrier is responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter and applicable rules are met. The health carrier shall also ensure that appropriate personne…
SDCL § 58-17H-15 Director to hold health carrier responsible for utilization review performance of contractor
1.0K chars
If a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, or applicable rules, the director shall hold the health carrier responsible for monitoring the activities of the utilization …
SDCL § 58-17H-16 Written utilization review program required--Contents of program document
2.3K chars
A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit …
SDCL § 58-17H-17 Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request
1.0K chars
A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical re…
SDCL § 58-17H-18 Program to be administered by qualified licensed health care professionals
0.8K chars
Qualified licensed health care professionals shall administer the utilization review program and oversee review decisions. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care provider. Source: SL 2011, ch 219 , § 43. Comm…
SDCL § 58-17H-19 Determinations to be issued in timely manner--Process to ensure consistency
1.9K chars
A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§ 58-17H-27 to 58-17H-32 , inclusive, and §§ 58-17H-40 to 58-17H-48 , inclusive. A health carrier shall have a process to ensure that utilization reviewe…
SDCL § 58-17H-2 Health benefit plan defined
3.3K chars
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 § 58-17H-20 Effectiveness and efficiency of program to be routinely reviewed
0.6K chars
Any health carrier shall routinely assess the effectiveness and efficiency of its utilization review program. Source: SL 2011, ch 219 , § 45. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Pa…