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Rule 20:06:54 PREVENTIVE SERVICES

CHAPTER 20:06:54

PREVENTIVE SERVICES

Section

20:06:54:01 Coverage for preventive items and services.

20:06:54:02 Coverage for office visits in conjunction with preventive items and services.

20:06:54:03 Preventive items and services with out-of-network providers.

20:06:54:04 Reasonable medical management allowed.

20:06:54:05 Additional services not prohibited.

20:06:54:06 Applicability.

Appendix A Grade A and B Recommendations of the United States Preventive Services Task Force.

Rule 20:06:54:0A Grade A and B Recommendations of the United States Preventive Services Task Force.

DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

GRADE A AND B RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE

Chapter 20:06:54

APPENDIX A

SEE: § 20:06:54:01

Source: 37 SDR 63, effective September 27, 2010; 37 SDR 111, effective December 7, 2010.

Appendix A

Grade A and B Recommendations of the United States Preventive Services Task Force

Topic	Text	Grade	Date in Effect
Screening for abdominal aortic aneurysm	The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.	B	Feb 28, 2005
Screening and counseling to reduce alcohol misuse	The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings.	B	April 30, 2004
Aspirin to prevent CVD: men	The USPSTF recommends the use of aspirin for men age 45 to79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage.	A	March 30, 2009
Aspirin to prevent CVD: women	The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.	A	March 30, 2009
Screening for bacteriuria	The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.	A	July 31, 2008
Screening for high blood pressure	The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older.	A	Dec 31, 2007
Counseling related to BRCA screening	The USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.	B	Sept 30, 2005
Screening for breast cancer (mammography)	The USPSTF recommends screening mammography for women with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.	B	Sept 30, 2002
Chemoprevention of breast cancer	The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention.	B	July 31, 2002
Interventions to support breast feeding	The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.	B	Oct 31, 2008
Screening for cervical cancer	The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.	A	Jan 31, 2003
Screening for chlamydial infection: non- pregnant women	The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk.	A	June 30, 2007
Screening for chlamydial infection: pregnant women	The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk.	B	June 30, 2007

Screening for cholesterol abnormalities: men 35 and older	The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders.	A	June 30, 2008
Screening for cholesterol abnormalities: men younger than 35	The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease.	B	June 30, 2008
Screening for cholesterol abnormalities: women 45 and older	The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.	A	June 30, 2008
Screening for cholesterol abnormalities: women younger than 45	The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease.	B	June 30, 2008
Screening for colorectal cancer	The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.	A	Oct 31, 2008
Chemoprevention of dental caries	The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride.	B	April 30, 2004
Screening for depression: adults	The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.	B	Dec 31, 2009
Screening for depression: adolescents	The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.	B	March 30, 2009
Screening for diabetes	The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.	B	June 30, 2008
Counseling for a healthy diet	The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.	B	Jan 30, 2003
Supplementation with folic acid	The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.	A	May 31, 2009
Screening for gonorrhea: wp,em	The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors; go to Clinical Considerations for further discussion of risk factors).	B	May 31, 2005
Prophylactic medication for gonorrhea: newborns	The USPSTF strongly recommends prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum.	A	May 31, 2005
Screening for hearing loss	The USPSTF recommends screening for hearing loss in all newborn infants.	B	July 31, 2008
Screening for hemoglobinopathies	The U.S. Preventive Services Task Force (USPSTF) recommends screening for sickle cell disease in newborns.	A	Sept 30, 2007
Screening for hepatitis B	The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.	A	June 30, 2009
Screening for HIV	The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection (go to Clinical Considerations for discussion of risk factors).	A	July 31, 2005
Screening for congenital hypothyroidism	The USPSTF recommends screening for congenital hypothyroidism (CH) in newborns.	A	March 31, 2008
Screening for iron deficiency anemia	The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women.	B	May 31, 2006
Iron supplementation in children	The U.S. Preventive Services Task Force (USPSTF) recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia (go to Clinical Considerations for a discussion of increased risk).	B	May 30, 2006
Screening and counseling for obesity: adults	The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.	B	Dec 31, 2003
Screening and counseling for obesity: children	The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.	B	Jan 31, 2010
Screening for osteoporosis	The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. (Go to Clinical Considerations for discussion of women at increased risk.)	B	Sept 30, 2002
Screening for PKU	The USPSTF recommends screening for phenylketonuria (PKU) in newborns.	A	March 31, 2008
Screening for Rh incompatibility: first pregnancy visit	The U.S. Preventive Services Task Force (USPSTF) strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.	A	Feb 29, 2004
Screening for Rh incompatibility: 24-28 weeks gestation	The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative.	B	Feb 29, 2004
Counseling for STIs	The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs.	B	Oct 31, 2008
Screening for syphilis: non- pregnant persons	The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen persons at increased risk for syphilis infection.	A	July 31, 2004
Screening for syphilis: pregnant women	The USPSTF recommends that clinicians screen all pregnant women for syphilis infection.	A	July 31, 2004
Counseling for tobacco use	The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.	A	April 30, 2009
Counseling for tobacco use	The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.	A	April 30, 2009
Screening for visual acuity in children	The USPSTF recommends screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years.	B	May 31, 2004

Rule 20:06:54:01 Coverage for preventive items and services.

20:06:54:01. Coverage for preventive items and services. A group health plan, or a health insurance issuer offering group or individual health insurance coverage, shall provide coverage for all of the following items and services, and may not impose any cost-sharing requirements such as a copayment, coinsurance, or deductible with respect to the following items or services:

(1) Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force as of July 1, 2018, and as appearing in Appendix A with respect to the individual involved;

(2) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. For this purpose, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention;

(3) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration; and

(4) With respect to women, to the extent not described in subdivision 20:06:54:01(1), evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

A health carrier shall at least annually at the beginning of each new plan year or policy year, whichever is applicable, revise the preventive services covered under its health insurance policies pursuant to this section consistent with the recommendations of the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the guidelines with respect to infants, children, adolescents, and women, evidenced-based preventive care and screenings by the Health Resources and Services Administration in effect at the time.

Source: 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010; 45 SDR 45, effective October 10, 2018.

General Authority: SDCL 58-17-87, 58-18-79.

Law Implemented: SDCL 58-17-1.1, 58-17-1.2, 58-17-62, 58-17-87, 58-17-98, 58-18-36, 58-18-41, 58-18-79, 58-18-80, 58-18-83.

Reference: The Guide to Clinical Preventive Services, 2014. Recommendation of the U.S. Preventive Services Task Force. Copies can be obtained by contacting the Agency for Healthcare Research and Quality Publications Clearinghouse, on a single copy basis. Mail AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547. Online: http://www.ahrq.gov/. Telephone: 800-358-9295, E-mail: ahrqpubs@ahrq.hhs.gov. You may also view online at http://www.uspreventiveservicestaskforce.org/Page/Name/recommendations.

Rule 20:06:54:02 Coverage for office visits in conjunction with preventive items and services.

20:06:54:02. Coverage for office visits in conjunction with preventive items and services. If an item or service described in § 20:06:54:01 is billed separately or is tracked as individual encounter data separately from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit.

If an item or service described in § 20:06:54:01 is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a plan or issuer may not impose cost-sharing requirements with respect to the office visit. If an item or service described in § 20:06:54:01 is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a plan or issuer may impose cost-sharing requirements with respect to the office visit.