Title 58 — INSURANCE
79 chapters · 3,532 sections in this title.
SDCL § 58-18A-69 Plan covering person other than as dependent
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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…
SDCL § 58-18A-70 Plan covering dependent child
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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 …
SDCL § 58-18A-71 Plan covering person as active employee
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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…
SDCL § 58-18A-72 Coverage under COBRA or right of continuation
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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 …
SDCL § 58-18A-73 Plan covering person for longer period of time
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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…
SDCL § 58-18A-74 Sharing of allowable expenses equally
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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.
SDCL § 58-18A-75 Calculation of amount to be paid by secondary plan
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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…
SDCL § 58-18A-76 Plan providing benefits as services
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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…
SDCL § 58-18A-77 Coordination of benefits of complying and noncomplying plans
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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…
SDCL § 58-18A-78 Noncomplying secondary plan to advance difference covered person would have received if complying plan had been secondary plan
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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…
SDCL § 58-18A-79 Subrogation distinguished
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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.
SDCL § 58-18A-80 Paying of claim where plans disagree on order of benefits
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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…
SDCL § 58-18A-81 Time for bringing existing contract into compliance with statutory requirements
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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, …
SDCL § 58-18A-82 Proceedings not subject to statutory requirements
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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.
SDCL § 58-18A-83 Duties, rights accrued, and offenses committed prior to July 1, 2007
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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…
SDCL § 58-18B-1 Definition of terms
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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…
SDCL § 58-18B-11 Health maintenance organization considered separate carrier
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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.
SDCL § 58-18B-12 Ceding arrangements resulting in less than fifty percent of obligation or risk retained by carrier prohibited
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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 …
SDCL § 58-18B-13 Transition period when acquiring additional class of business
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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…
SDCL § 58-18B-14 Rate changes only for small employer business
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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.
SDCL § 58-18B-15 Provisions for premium rates
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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…
SDCL § 58-18B-17 Limit on premium rates
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The premium rates for an individual covered in a small employer plan may not exceed the premium rate for any other individual covered under the same small employer carrier because of age alone by a factor of 3:1. A small employer carrier may not require any individual to pay any …
SDCL § 58-18B-18 Promulgation of rules for rating practices
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The director may promulgate rules pursuant to chapter 1-26 to implement the provisions of §§ 58-18B-1 to 58-18B-3 , inclusive, § 58-18B-7 , §§ 58-18B-15 to 58-18B-18 , inclusive, and to assure that rating practices used by small employer carriers are consistent with the purposes …
SDCL § 58-18B-2 Chapter applicable to small employer benefit plans
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This chapter is applicable to any health benefit plan which provides coverage to two or more employees of a small employer and policies which meet the following criteria: (1) Any portion of the premium or benefits is paid by or on behalf of the small employer; or (2) The health b…
SDCL § 58-18B-20 Small employer carrier to issue plan to any small employer--Criteria--Exceptions--Two percent earned premium threshold
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A small employer carrier shall issue health benefit plans to any small employer that applies for a plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health benefit plan not inconsistent with this chapter. If, on the first …
SDCL § 58-18B-23 Uniform application of requirements used to determine eligibility of employers
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Except as provided in § 58-18B-26 , requirements used by a small employer carrier in determining whether to provide coverage to a small employer, including requirements for minimum participation of eligible employees and minimum employer contributions, shall be applied uniformly …
SDCL § 58-18B-24 Application of minimum participation and minimum employer contribution requirements
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A small employer carrier may vary application of minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group or by the class of business. Source: SL 1995, ch 281 , § 18.
SDCL § 58-18B-25 Considerations in applying minimum participation requirements--Premium discounts
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In applying minimum participation requirements with respect to a small employer, a small employer carrier may consider employees or dependents who have creditable coverage in determining whether the applicable percentage of participation is met. If any employee or dependent with …
SDCL § 58-18B-26 Increase in minimum requirements for employee participation or employer contribution prohibited after acceptance for coverage
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No small employer carrier may increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has been accepted for coverage. Source: SL 1995, ch 281 , § 20.
SDCL § 58-18B-27 Modification to exclude certain diseases prohibited
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No small employer carrier may modify a health benefit plan with respect to a small employer or any eligible employee or dependent through riders, endorsements, or otherwise, to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the health…
SDCL § 58-18B-27.1 Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony
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A health benefit plan of a small employer carrier 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 §
SDCL § 58-18B-28 Requirements lifted from small employer carrier in financially impaired condition
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No small employer carrier may be required to provide coverage to small employers pursuant to § 58-18B-20 , for any period of time for which the director determines that requiring the acceptance of small employers in accordance with the provisions of § 58-18B-20 , would place the …
SDCL § 58-18B-3 Regulations on premium rates
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Premium rates for health benefit plans subject to this chapter are subject to the following provisions: (1) The index rate for a rating period for any class of business may not exceed the index rate for any other class of business by more than twenty percent unless: (a) The class…
SDCL § 58-18B-3.1 Base rate increase to be filed with director--Approval or disapproval
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No small employer carrier may increase its small employer base rates unless the small employer carrier has filed the base rate increase with the director for review at least thirty days prior to the implementation of the rate increase. The base rates are deemed approved at the ex…
SDCL § 58-18B-35 Director to promulgate rules regulating sale of multiple employer trusts and welfare arrangements--Scope of rules
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The director shall promulgate rules pursuant to chapter 1-26 regulating the solicitation and sale of multiple employer trusts and multiple employer welfare arrangements. In considering the promulgation of rules pursuant to this section, the director shall take into consideration,…
SDCL § 58-18B-36 Rules governing implementation and administration of this chapter
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The director shall promulgate rules pursuant to chapter 1-26 to provide for the implementation and administration of this chapter. The rules shall cover: (1) Terms of renewability; (2) Initial and subsequent conditions of eligibility; (3) Probationary periods; (4) Benefit limitat…
SDCL § 58-18B-37 Marketing health benefit plans--Denial of coverage to employer
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Each small employer carrier shall actively market health benefit plan coverage, to eligible small employers in the state. A small employer carrier may not deny coverage to a small employer on the basis of the health status or claims experience of the small employer or its employe…
SDCL § 58-18B-38 Prohibited activities of small employer carriers or insurance producers
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No small employer carrier or insurance producer may, directly or indirectly, engage in the following activities: (1) Encouraging or directing small employers to refrain from filing an application for coverage with the small employer carrier because of the health status, claims ex…
SDCL § 58-18B-39 Information regarding restricted network provision of carrier
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The provisions of § 58-18B-38 do not apply with respect to information provided by a small employer carrier or insurance producer to a small employer regarding a restricted network provision of a small employer carrier. Source: SL 1995, ch 281 , § 34; SL 2001, ch 286 , § 124.
SDCL § 58-18B-40 Agent compensation based on characteristics of small employer prohibited--Commission on sale of health insurance plan through exchange
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No small employer carrier may, directly or indirectly, enter into any contract, agreement, or arrangement with an insurance producer that provides for or results in the compensation paid to an agent for the sale of a health benefit plan to be varied because of the health status, …
SDCL § 58-18B-41 Compensation of insurance producer based on percentage of premium
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The provisions of § 58-18B-40 do not apply with respect to a compensation arrangement that provides compensation to an insurance producer on the basis of percentage of premium, if the percentage does not vary because of the health status, claims experience, industry, occupation, …
SDCL § 58-18B-43 Status of insurance producer's employment may not be affected by health status, claims experience, occupation, or location of small employer placed with carrier
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No small employer carrier may terminate, fail to renew, or limit its contract or agreement of representation with an insurance producer for any reason related to the health status, claims experience, occupation, or geographic location of the small employers placed by the agent wi…
SDCL § 58-18B-44 Carrier or agent not to induce or encourage employer to exclude employee from coverage
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No small employer carrier or agent may induce or otherwise encourage a small employer to separate or otherwise exclude an employee from health coverage or benefits provided in connection with the employee's employment. Source: SL 1995, ch 281 , § 39.
SDCL § 58-18B-45 Reasons for denial of coverage to be in writing
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If a small employer carrier denies an application for coverage from a small employer, the denial shall be in writing and shall state the reason or reasons for the denial. Source: SL 1995, ch 281 , § 40.
SDCL § 58-18B-46 Rules for additional standards for fair marketing and broad availability of benefit plans to small employers--Penalties
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The director may promulgate rules pursuant to chapter 1-26 setting forth additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers in the state. Any violation of §§ 58-18B-37 to 58-18B-48 , inclusive, by a small emplo…
SDCL § 58-18B-47 Third - party administrator treated as small employer carrier
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If a small employer carrier enters into a contract, agreement, or other arrangement with a third - party administrator to provide administrative, marketing, or other services related to the offering of health benefit plans to small employers in the state, the third - party admini…
SDCL § 58-18B-48 Chapter not applicable to certain group health insurance plans
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Unless the carrier otherwise subjects itself to this chapter, this chapter does not apply to any bona fide association insurance plan or to the insurance carrier underwriting the group plan if the bona fide association meets the following criteria: (1) The association has been ac…
SDCL § 58-18B-49 Establishing risk adjusters
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The director may establish a payment mechanism to adjust for the amount of risk covered by each small employer carrier. The director may appoint an advisory committee composed of individuals that have risk adjustment and actuarial expertise to help establish the risk adjusters. S…
SDCL § 58-18B-50 Minimum inpatient care coverage following delivery
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If a health benefit plan of a small employer carrier that is issued or renewed on or after July 1, 1996, provides maternity coverage, the plan shall provide coverage for a minimum of forty - eight hours of inpatient care following a vaginal delivery and a minimum of ninety - six …
SDCL § 58-18B-51 Shorter hospital stay permitted--Follow - up visit within forty - eight hours required
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If the treating physician determines that the mother and the newborn meet medical criteria contained in Guidelines for Perinatal Care, Third Edition, of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists as in effect on January 1, 1996,…