Title 58, INSURANCE

For an urgent care request, unless the covered person or the covered person's authorized representative has failed to provide sufficient information for the health carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the he…

The health carrier shall provide the covered person or, if applicable, the covered person's authorized representative, a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight hours after the dat…

The health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, of its determination with respect to the urgent care request as soon as possible, but in no event more than forty-eight hours after the earlier of: (1) The health…

For concurrent review urgent care requests involving a request by the covered person or the covered person's authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made at least twenty-four hour…

For purposes of calculating the time periods within which a determination is required to be made under §§ 58-17H-43 to 58-17H-45 , inclusive, the time period within which the determination is required to be made shall begin on the date the request is filed with the health carrier…

If a health carrier's determination with respect to §§ 58-17H-40 to 58-17H-47 , inclusive, is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with this section. A notification of an adverse determination under this sect…

The director may, after consultation with the secretary, promulgate rules, pursuant to chapter 1-26 , to carry out the provisions of this chapter. The rules shall provide for a timely administration of utilization review by the public and assure that utilization review decisions …

If conducting utilization review or making a benefit determination for emergency services, a health carrier that provides benefits for services in an emergency department of a hospital shall comply with the provisions of §§ 58-17H-5 to 58-17H-13 , inclusive. A health carrier shal…

Any health benefit plan as defined in § 58-17H-2 that provides benefits for injected or intravenously administered cancer treatment medication used to kill or slow the growth of cancerous cells shall provide no less favorable benefits for prescribed, orally administered anticance…

A health carrier may not reclassify benefits with respect to cancer treatment medications or increase a copayment, deductible, or coinsurance amount for covered cancer treatment medications that are injected or intravenously administered unless: (1) The increase is applied genera…

Nothing in §§ 58-17H-50 and 58-17H-51 prohibits a health carrier from performing medical management practices that comply with the provisions of this chapter. Source: SL 2015, ch 252 , § 3, eff. Jan. 1, 2016.

A health carrier, health benefit plan, or utilization review organization shall consider available recognized evidence-based and peer-reviewed clinical practice guidelines when establishing a step therapy protocol. Upon written request of a covered person, a health carrier, healt…

When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization through the use of a step therapy protocol, the covered person and the prescribing health care profes…

A step therapy override exception shall be approved by a health carrier, health benefit plan, or utilization review organization if any of the following circumstances apply: (1) The prescription drug required under the step therapy protocol is contraindicated pursuant to the drug…

Nothing in §§ 58-17H-53 to 55-17H-56 shall be construed to prevent: (1) A health carrier, health benefit plan, or utilization review organization from requiring a covered person to try a prescription drug with the same generic name and demonstrated bioavailability or biological p…

A utilization review organization or health carrier shall conduct an annual review and submit the findings in a report to the Division of Insurance, at the time and in the manner directed by the division. The report must contain the following information for the previous calendar…

A utilization review organization or health carrier shall annually review each health care service for which a health benefit plan requires prior authorization and shall eliminate the prior authorization requirement for any health care service if prior authorization requests are …

A utilization review organization or health carrier shall submit an annual report to the Division of Insurance, at the time and in the manner requested by the division, regarding the review required in accordance with § 58-17H-58 . The report must set forth: (1) The number of pri…

Coverage of in-network emergency services are subject to applicable copayments, coinsurance, and deductibles. Source: SL 2011, ch 219 , § 31. 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…

For purposes of §§ 58-17H-57 to 58-17H-59 , inclusive, “health care services” do not include dental services, pharmaceutical services, or the provision of prescription drug products or supplies. Source: SL 2026, ch 201 , § 4.

Cost-sharing requirements for out-of-network emergency services expressed as a copayment amount or coinsurance rate imposed with respect to a covered person cannot exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-networ…

Notwithstanding § 58-17H-7 , a covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount the health carrier is required to pay pursuant to this section. A health carrier complies…

For capitated or other health benefit plans that do not have a negotiated per-service amount for in-network providers, subdivision 58-17H-8 (1) does not apply. Source: SL 2011, ch 219 , § 34. Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 20…

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…

Prior to issuing a decision in accordance with the timeframes provided in § 58-17I-9 , the health carrier shall provide free of charge to covered person, or the covered person's authorized representative, any new or additional evidence, relied upon or generated by the health carr…

The decision issued pursuant to § 58-17I-9 shall set forth in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative and include the following: (1) The titles and qualifying credentials of any person participat…

Each health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. In addition, a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to…

In an expedited review that is not an initial determination for benefits, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or, if applicable, the covered person's authorized representative, …

An expedited review decision, that is not an initial determination for benefits, shall be made and the covered person or, if applicable, the covered person's authorized representative, shall be notified of the decision in accordance with § 58-17I-15 as expeditiously as the covere…

A notification of a decision under §§ 58-17I-12 to 58-17I-15 , inclusive, shall, in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative, set forth the following: (1) The titles and qualifying credentials of …

The director, in consultation with the secretary, shall promulgate rules, pursuant to chapter 1-26 , to establish time frames relative to the filing of grievances, the disposition of grievances, and the response to the aggrieved person. Rules may also be promulgated covering defi…

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…

For the purposes of this chapter, the term, urgent care request, means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination: (1) Could seriously jeopardize the life or health of the cov…

Each health carrier shall maintain in a register written records to document all grievances received including the notices and claims associated with the grievances during a calendar year. A request for a first level review of a grievance involving an adverse determination shall …

Except as specified in this chapter, each health carrier shall use written procedures for receiving and resolving grievances from covered persons, as provided in §§ 58-17I-7 to 58-17I-11 , inclusive. If a health carrier fails to strictly adhere to the requirements of §§ 58-17I-7 …

Within one hundred eighty days after the date of receipt of a notice of an adverse determination sent pursuant to chapter 58-17H , any covered person or the covered person's authorized representative may file a grievance with the health carrier requesting a first level review of …

No covered person has the right to attend, or to have a representative in attendance, at the first level review. However, the covered person or, if applicable, the covered person's authorized representative may: (1) Submit written comments, documents, records, and other material …

A health carrier shall notify and issue a decision in writing or electronically to the covered person or, if applicable, the covered person's authorized representative, within the following time frames: (1) With respect to a grievance requesting a first level review of an adverse…

Terms used in this chapter mean: (1) "Health benefit plan," any hospital or medical expense policy or certificate, hospital or medical service plan, nonprofit hospital, medical-surgical health service corporation contract or certificate, provider sponsored integrated health deliv…

No health insurer, including the South Dakota Medicaid program, may obstruct patient choice by excluding a health care provider licensed under the laws of this state from participating on the health insurer's panel of providers if the provider is located within the geographic cov…

Terms used in this chapter mean: (1) "Accumulated amount," the amount of financial responsibility an enrollee has incurred at the time a request for cost-sharing information is made, with respect to a deductible or out-of-pocket limit as calculated under rules promulgated by the …

The director shall promulgate rules, pursuant to chapter 1-26 , for the following: (1) The definition of terms; (2) Required cost-sharing liability disclosures; (3) The method and format requirements for disclosures; (4) Calculations pertaining to information, disclosure, and his…

The provisions of § 58-17K-5 are effective for plan years beginning on or after January 1, 2022. The provisions of §§ 58-17K-2 to 58-17K-4 , inclusive, are effective for plan years beginning on or after January 1, 2024. Source: SL 2021, ch 213 , § 11.

At the request of an enrollee, the health insurer shall provide: (1) An estimate, which is accurate at the time of the request, of the enrollee's cost-sharing liability for a requested covered item or service furnished by a provider reflecting any cost-sharing reductions the enro…

The cost-sharing information to be provided under this chapter shall be made available without a subscription or other fee through a self-service tool on a website that provides real-time responses based on cost-sharing information that is accurate at the time of request. A healt…

An enrollee may request, in accordance with § 58-17K-3 , the required cost-sharing information be provided in a paper form. In responding to such a request, a health insurer may limit the number of providers to no fewer than twenty providers per request. A health insurer shall di…