Title 58, INSURANCE

An association not formed in this state may request a waiver of subdivisions 58-18-88(3) and (5) regarding organization in South Dakota to sponsor a multiple employer trust in this state if the association provides sufficient evidence a waiver is in the best interests of the insu…

The director shall promulgate rules, pursuant to chapter 1-26 , pertaining to multiple employer trusts in the following areas: (1) Consumer protection issues including minimum coverage standards for health policies; claims processing and payment practices; resolution of consumer …

Each such group health insurance policy shall contain in substance a provision that the insurer will furnish to the policyholder for delivery to each employee or member of the insured group, a statement in summary form of the essential features of the insurance coverage of such e…

Except as otherwise provided in this chapter, an authorized multiple employer trust may not be determined to be or considered to be an insurance company or association of any kind or character under this title, or subject to the provisions of §§ 58-8-6 to 58-8-19 , inclusive. Sou…

A multiple employer trust authorized under this chapter may have its authorization suspended or revoked by the director for violating any applicable provision of this title. The director may take action in lieu of suspension or revocation as though the trust were an insurer as pr…

If not otherwise provided, a multiple employer trust doing business in this state on a self-funded basis shall pay premium taxes as required in chapter 10-44 based upon the amount each participating employer contributes, including any amounts contributed by employees and dependen…

No agent may sell, solicit, or negotiate a self-funded multiple employer trust authorized under this chapter unless the agent is licensed to sell life and health insurance pursuant to chapter 58-30 . Source: SL 2005, ch 272 , § 7; SL 2019, ch 212 , § 10.

The provisions of this chapter regarding multiple employer trusts do not apply to any single employer self-funded plan as preempted by Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1144 or any arrangement exempted pursuant to § 1-24-17 . An authorized self-funded m…

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…

Terms used in this chapter mean: (1) "Birthday," refers only to a month and day in a calendar year and does not include the year in which the person was born; (2) "Claim," a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of: (a) Servi…

For the purposes of this chapter, the term, allowable expense, means any health care expense, including coinsurance or copayments and without reduction for any applicable deductible, that is covered in full or in part by any of the plans covering the person. If a plan is advised …

The following are examples of expenses that are not allowable expenses: (1) If a person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room is not an allowable expense, unless one of the plans provide…

For the purposes of this chapter, the term, allowable expense, may exclude certain types of coverage or benefits such as dental care, vision care, prescription drugs, or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definit…

For the purposes of this chapter, the term, plan, means a form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are con…

For the purposes of this chapter, the term, plan, includes: (1) Group and nongroup insurance contracts and subscriber contracts; (2) Uninsured arrangements of group or group-type coverage; (3) Group and nongroup coverage through closed panel plans; (4) Group-type contracts; (5) T…

For the purposes of this chapter, the term, plan, does not include: (1) Hospital indemnity coverage benefits or other fixed indemnity coverage; (2) Accident only coverage; (3) Specified disease or specified accident coverage; (4) Limited benefit health coverage; (5) School accide…

Sections 58-18A-53 to 58-18A-83 , inclusive, apply to all plans that are issued on or after January 1, 2007. Source: SL 2006, ch 259 , § 8.

The director shall promulgate rules pursuant to chapter 1-26 to carry out the provisions of §§ 58-18A-53 to 58-18A-83 , inclusive. In promulgating any rules, the director shall give great weight to any national standards that may exist for the coordination of benefits for plans. …

No COB provision may be used that permits a plan to reduce its benefits on the basis that: (1) Another plan exists and the covered person did not enroll in that plan; (2) A person is or could have been covered under another plan, except with respect to Part B of Medicare; or (3) …

No plan may contain a provision that its benefits are always excess or always secondary except in accordance with the rules permitted by §§ 58-18A-53 to 58-18A-83 , inclusive. No plan is required to coordinate benefits provided that it pays benefits as a primary plan; but if the …

Under the terms of a closed panel plan, no benefits are payable if the covered person does not use the services of a closed panel provider. No COB occurs if a covered person is enrolled in two or more closed panel plans and obtains services from a provider in one of the closed pa…

No plan may use a COB provision, or any other provision, that allows it to reduce its benefits with respect to any other coverage its insured may have that does not meet the definition of a plan as provided by §§ 58-18A-53 to 58-18A-83 , inclusive. Source: SL 2006, ch 259 , § 13.

If a person is covered by two or more plans, the provisions for determining the order of benefit payments are as follows: (1) The primary plan shall pay or provide its benefits as if any secondary plan did not exist; (2) If the primary plan is a closed panel plan and the secondar…

A plan may take into consideration the benefits paid or provided by another plan only if, under the provisions of §§ 58-18A-53 to 58-18A-83 , inclusive, it is secondary to that other plan. Source: SL 2006, ch 259 , § 15.

Each plan shall determine its order of benefits using the first section of §§ 58-18A-69 to 58-18A-74 , inclusive, that applies. Source: SL 2006, ch 259 , § 16.

The plan that covers the person other than as a dependent, for example as an employee, member, subscriber, policyholder, or retiree, is the primary plan and the plan that covers the person as a dependent is the secondary plan. However, if the person is a medicare beneficiary, and…

Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows: (1) For a dependent child whose parents are married or are living together, whether or not they have ever been married: (a) The plan of the parent …

The plan that covers a person as an active employee that is, an employee who is neither laid off nor retired or as a dependent of an active employee is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-of…

If a person whose coverage is provided pursuant to COBRA or under a right of continuation pursuant to state or other federal law is covered under another plan, the plan covering the person as an employee, member, subscriber, or retiree or covering the person as a dependent of an …

If the preceding provisions in §§ 58-18A-69 to 58-18A-72 , inclusive, do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary pl…

If the preceding provisions of §§ 58-18A-69 to 58-18A-73 , inclusive, do not determine the order of benefits, the allowable expenses shall be shared equally between the plans. Source: SL 2006, ch 259 , § 22.

In determining the amount to be paid by the secondary plan on a claim, if the plan wishes to coordinate benefits, the secondary plan shall calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any a…

A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the primary plan…

A plan with order of benefit determination provisions that comply with §§ 58-18A-53 to 58-18A-83 , inclusive, may coordinate its benefits with a plan that is excess or always secondary or that uses order of benefit determination provisions that are inconsistent with those contain…

If the noncomplying plan reduces its benefits so that the covered person receives less in benefits than the covered person would have received had the complying plan paid or provided its benefits as the secondary plan and the noncomplying plan paid or provided its benefits as the…

COB differs from subrogation. Provisions for one may be included in health care benefits contracts without compelling the inclusion or exclusion of the other. Source: SL 2006, ch 259 , § 27.

If the plans cannot agree on the order of benefits within thirty calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and determine their relative liabilities following payment. Howev…

A contract that provides health care benefits and that was issued before July 1, 2006, shall be brought into compliance with §§ 58-18A-53 to 58-18A-83 , inclusive, by the later of: (1) The next anniversary date or renewal date of the contract; (2) Twelve months following July 1, …

Sections 58-18A-53 to 58-18A-83 , inclusive, do not affect an action or proceeding commenced before July 1, 2006. Source: SL 2006, ch 259 , § 30.

Sections 58-18A-53 to 58-18A-83 , inclusive, do not impair or affect any duty or act done, offense committed or right accruing, accrued or acquired or liability, penalty, forfeiture or punishment incurred prior to the date on or after July 1, 2007, but the same may be employed, a…

Terms used in this chapter mean: (1) "Actuarial certification," a written statement by a member of the American Academy of Actuaries or other individual approved by the director that a small employer carrier is in compliance with the provisions of this chapter, based upon the per…

An affiliated carrier that is a health maintenance organization having a certificate of authority under chapter 58-41 may be considered to be a separate carrier for the purposes of this chapter. Source: SL 1995, ch 281 , § 4.

Unless otherwise authorized by the director, no small employer carrier may enter into one or more ceding arrangements with respect to health benefit plans delivered or issued for delivery to small employers in the state if the arrangements would result in less than fifty percent …

The director may promulgate rules pursuant to chapter 1-26 to provide for a period of transition in order for a small employer carrier to come into compliance with subdivision 58-18B-1(5) when the carrier acquires an additional class of business from another small employer carrie…

Unless otherwise specified, nothing in this chapter requires a carrier to change any of its rates or rating methodologies for any business other than the small employer business subject to the provisions of this chapter. Source: SL 1995, ch 281 , § 7.

Premium rates for health benefit plans subject to this chapter are subject to the following provisions: (1) Adjustments in rates for claim experience, health status, and duration of coverage may not be charged to individual employees or dependents. Any such adjustments shall be a…