DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
MODEL CHOICE OF HEALTH CARE PROFESSIONAL NOTICE LANGUAGE
Chapter 20:06:55
APPENDIX A
SEE § 20:06:55:12
Source: 37 SDR 111, effective December 7, 2010; 39 SDR 203, effective June 10, 2013.
Appendix A - Model Choice of Health Care Professional Notice Language
● For health carries that require or allow for the designation of primary care health care professionals, beneficiaries or enrollees, insert:
[Name of health insurance issuer] generally [requires/allows] the designation of a primary care health care professional. You have the right to designate any primary care health care professional who participates in our network and who is available to accept you or your family members. [If the health insurance issuer designates a primary care health care professional automatically, insert: Until you make this designation, [name of health insurance issuer] designates one for you.] For information on how to select a primary care health care professional, and for a list of participating primary care health care professionals, contact the [health insurance issuer] at [insert contact information].
● For health insurance issuers that require or allow for the designation of a primary care health care professional for a child, add:
For children, you may designate a pediatrician as the primary care health care professional.
● For health insurance issuers that provide coverage for obstetric or gynecological care and require the designation by a participant, beneficiary or enrollee of a primary care health care professional, add:
You do not need prior authorization from [name of health insurance issuer] or from any other person, including a primary care health care professional, in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [health insurance issuer] at [insert contact information].
CHAPTER 20:06:55
MARKET REGULATIONS
Section
20:06:55:01 Eligibility of children up to age 26.
20:06:55:02 Restrictions on plan definition of dependent.
20:06:55:03 Coverage of grandchildren not required.
20:06:55:04 Uniformity irrespective of age.
20:06:55:05 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Applicability.
20:06:55:06 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Opportunity to enroll required.
20:06:55:07 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Written notice.
20:06:55:08 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Effective date.
20:06:55:09 Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Group health plan special enrollee.
20:06:55:10 Special rule for grandfathered group health plans.
20:06:55:11 Applicability.
20:06:55:12 Choice of primary care providers.
20:06:55:13 Emergency services.
20:06:55:14 Rescissions.
20:06:55:15 Group plans -- Lifetime limits.
20:06:55:16 Group plans -- Annual limits.
20:06:55:17 Group plans -- Eligibility.
20:06:55:18 Group plans -- Notices and enrollment.
20:06:55:19 Group plans -- Special enrollment.
20:06:55:20 Group plans -- Applicability.
20:06:55:21 Individual plans -- Lifetime limits.
20:06:55:22 Individual plans -- Annual limits.
20:06:55:23 Reinstatement of coverage.
20:06:55:24 Individual plans -- Applicability.
20:06:55:25 Repealed.
20:06:55:25.01 Individual plans -- No preexisting condition.
20:06:55:26 Group plans -- No preexisting condition.
20:06:55:27 Excepted benefits -- Defined.
20:06:55:28 Repealed.
20:06:55:29 Repealed.
20:06:55:30 Repealed.
20:06:55:31 Repealed.
20:06:55:32 Definitions.
20:06:55:33 Certifying qualified health plans.
20:06:55:34 Issuer standards and certification criteria.
20:06:55:35 Qualified health plan defined.
20:06:55:36 Exchange network adequacy standards.
20:06:55:37 Network adequacy standards.
20:06:55:38 Essential community providers defined.
20:06:55:39 Essential community providers.
20:06:55:40 Payment of federally-qualified health centers.
20:06:55:41 Treatment of direct primary care medical homes.
20:06:55:42 Recertification of qualified health plans.
20:06:55:43 Decertification of qualified health plan.
20:06:55:44 Non-renewal and decertification of qualified health plans.
20:06:55:45 Rates.
20:06:55:46 Health plan applications and notices.
20:06:55:47 Accreditation of qualified health plan issuers.
20:06:55:48 Repealed.
20:06:55:49 Annual open enrollment period.
20:06:55:50 Changing qualified health plans.
20:06:55:50.01 Loss of coverage.
20:06:55:50.02 Special enrollment period effective dates.
20:06:55:51 Compensation.
20:06:55:52 Plan offerings in the exchange.
20:06:55:53 Applicability and effective dates.
Appendix A Model Choice of Health Care Professional Notice Language.
20:06:55:01. Eligibility of
children up to age 26. A group health plan, or a health insurance issuer
offering group or individual health insurance coverage, that makes available
dependent coverage of children must make such coverage available for children
until attainment of 26 years of age. The provisions of §§ 20:06:55:01 to
20:06:55:10, inclusive, apply for plan years, in the individual market policy
years, beginning after September 22, 2010. Nothing in this section alters the
requirements of SDCL 58-17-2.3 or 58-18-31.1 as it relates to any dependent who is over the age of 25 but has not reached the age of 30.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:02. Restrictions on
plan definition of dependent. With respect to a child who has not attained
age 26, a plan or issuer may not define dependent for purposes of eligibility
for dependent coverage of children other than in terms of a relationship
between a child and the participant, and in the individual market, the primary
subscriber. A plan or issuer may not deny or restrict coverage for a child who
has not attained age 26 based on the presence or absence of the child's
financial dependency upon the participant, primary subscriber, or with any
other person; residency with the participant and in the individual market the
primary subscriber, or any other person; student status; marital status;
employment; or any combination of those factors. In addition, a plan or issuer
may not deny or restrict coverage of a child based on eligibility for other
coverage, except as provided in § 20:06:55:10.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:03. Coverage of
grandchildren not required. Nothing in §§ 20:06:55:01 to 20:06:55:10,
inclusive, requires a plan or issuer to make coverage available for the child
of a child receiving dependent coverage, unless the grandparent becomes the
legal guardian or adoptive parent of that grandchild.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:04. Uniformity
irrespective of age. The terms of the plan or health insurance coverage
providing dependent coverage of children may not vary based on age except for
children who are age 26 or older. Nothing in this section applies to premium
rates.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:05. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Applicability. Sections 20:06:55:05 to 20:06:55:09, inclusive, apply to any child whose coverage ended, or who was denied coverage or was not eligible for coverage under a group health plan or group or individual health insurance coverage because, under the terms of the plan or coverage, the availability of dependent coverage of children ended before the attainment of age 26 and who becomes eligible or is required to become eligible for coverage under a group health plan or group or individual health insurance coverage on the first day of the first plan year and in the individual market the first day of the first policy year, beginning after September 22, 2010.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:06. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Opportunity to enroll required. If a group health plan, or group or individual health insurance coverage, in which a child described in § 20:06:55:05 is eligible to enroll or is required to become eligible to enroll in the plan, or coverage in which the child's coverage ended or did not begin for the reasons described in § 20:06:55:05, and if the plan, or the issuer of such coverage, is subject to the requirements of §§ 20:06:55:05 to 20:06:55:09, inclusive, the plan and the issuer are required to give the child an opportunity to enroll that continues for at least 30 days including written notice of the opportunity to enroll as described in § 20:06:55:10. The opportunity to enroll must be provided beginning not later than the first day of the first plan year and in the individual market the first day of the first policy year, beginning after September 22, 2010.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:07. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Written notice. For purposes of §§ 20:06:55:05 to 20:06:55:09, inclusive, the written notice must include a statement that children whose coverage ended, who were denied coverage or were not eligible for coverage, because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in the plan or coverage. The notice may be provided to an employee on behalf of the employee's child and in the individual market, to the primary subscriber on behalf of the primary subscriber's child. In addition, for a group health plan or group health insurance coverage, the notice may be included with other enrollment materials that a plan distributes to employees, provided the statement is prominent. For a group health plan or group health insurance coverage, if a notice satisfying the requirements of this section is provided to an employee whose child is entitled to an enrollment opportunity pursuant to § 20:06:55:05, the obligation to provide the notice of enrollment opportunity pursuant to § 20:06:55:05 with respect to that child is satisfied for both the plan and the issuer. The written notice must be provided beginning not later than the first day of the first plan year and in the individual market the first day of the first policy year, beginning after September 22, 2010.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:08. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Effective date. In the case of an individual who enrolls pursuant to § 20:06:55:05, coverage must take effect in the group market not later than the first day of the first plan year and in the individual market, the first day of the first policy year, beginning after September 22, 2010.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:09. Individuals whose coverage ended by reason of reaching a dependent eligibility threshold -- Group health plan special enrollee. Any child enrolling in a group health plan pursuant to § 20:06:55:05 must be treated as if the child were a special enrollee, as provided under the rules of 45 C.F.R. § 146.117(d). Accordingly, the child and, if the child would not be a participant once enrolled in the plan, the participant through whom the child is otherwise eligible for coverage under the plan, must be offered all the benefit packages available to similarly situated individuals who did not lose coverage by reason of cessation of dependent status. For this purpose, any difference in benefits or cost-sharing requirements constitutes a different benefit package. The child also cannot be required to pay more for coverage than similarly situated individuals who did not lose coverage by reason of cessation of dependent status.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:10. Special rule for grandfathered group health plans. For plan years beginning before January 1, 2014, a group health plan that qualifies as a grandfathered health plan pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147, and that makes available dependent coverage of children may exclude an adult child who has not attained age 26 from coverage only if the adult child is eligible to enroll in an eligible employer-sponsored health plan, as defined in section 5000A(f)(2) of the Internal Revenue Code, other than a group health plan of a parent.
For plan years beginning after December 31, 2013, a group health plan that qualifies as a grandfathered health plan pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147 must comply with the requirements of §§ 20:06:55:01 to 20:06:55:04, inclusive.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
20:06:55:11. Applicability. Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), §§ 20:06:55:01 to 20:06:55:08, inclusive, apply to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive.
Sections 20:06:55:01 to 20:06:55:10, inclusive, apply to any employer based health plan, including any health benefit plan subject to the provisions of SDCL 58-18-42. This chapter does not apply to self funded plans preempted from state regulation pursuant to the Employee Retirement Income Security Act of 1974.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-51.1, 58-18-79.
20:06:55:12. Choice of primary care providers. If a health carrier offering group or individual health insurance coverage requires or provides for the designation by a covered person of a participating primary care health care professional, the health carrier shall permit each covered person to:
(1) Designate any participating primary care health care professional who is available to accept the covered person; and
(2) For a child, designate any participating physician who specializes in pediatrics as the child's primary care health care professional and is available to accept the child.
This section does not waive any exclusions of coverage under the terms and conditions of the policy with respect to pediatric care. If the health carrier provides coverage for obstetrical or gynecological care and requires the designation of an in-network primary care provider, the health carrier may not require the authorization or referral by the plan for a female insured who seeks obstetrical or gynecological care from a participating in-network provider specializing in obstetrics or gynecology. The health carrier shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care health care professional. The health carrier may require the health care professional to agree to otherwise adhere to the health carrier's policies and procedures, including procedures for obtaining prior authorization and provider services in accordance with a treatment plan, if any, approved by the health carrier. This section does not waive any exclusions of coverage under the terms and conditions of the policy with respect to coverage of obstetrical or gynecological care or preclude the health carrier involved from requiring the participating health care professional providing obstetrical or gynecological care to notify the primary health care professional or the health carrier of treatment decisions.
A health carrier shall provide notice to covered persons of the terms and conditions of the plan related to the designation of a participating health care professional provided in this section and of a covered person's rights. A group health insurance carrier shall include the notice with the summary plan description or other similar description of benefits under the group health insurance coverage. An individual health insurance carrier shall include the notice whenever the individual carrier provides a primary subscriber with a policy, certificate, or contract of health insurance. A carrier may use Appendix A to satisfy the notice requirements of this section.
Nothing in this section applies to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147. Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), this section applies to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive, and also applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL 58-18-42.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-51.1, 58-18-79.
20:06:55:13. Emergency services. No prior authorization of emergency services may be required by a health carrier either for in-network or out-of-network emergency services. A plan must provide for the payment of emergency services by an out-of-network provider in an amount not less than the greatest of the following:
(1) The amount negotiated with in-network providers for emergency services excluding any in-network co-payment on coinsurance imposed with respect to the covered person;
(2) The amount for the emergency service calculated and excluding any in-network co-payment or coinsurance, using the same method the plan uses to determine payments for out-of-network services but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or
(3) The amount that would be paid under Medicare part A or part B for the emergency service and excluding any in-network co-payment or coinsurance.
For capitated and other plans that do not have a negotiated per-service amount for in-network providers, subdivision (1) does not apply. If a plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount of subdivision (1) is the median of these negotiated amounts. Nothing in this section applies to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147. Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), this section applies to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive, and applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL 58-18-42.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-51.1, 58-18-79.
20:06:55:14. Rescissions. A
policy, certificate, or contract of insurance may not be rescinded unless the
individual performs an act, practice, or omission that constitutes fraud or
unless the individual makes an intentional misrepresentation of a material
fact. A rescission is any cancellation or discontinuance of coverage under any
individual or group health insurance policy or certificate, other than a plan
of excepted benefits, that has a retroactive effect. Rescission does not
include a cancellation or discontinuance of coverage under a health policy or
certificate if:
(1) The
cancellation or discontinuance of coverage has only a prospective effect;
(2) The
cancellation or discontinuance of coverage is effective retroactively to the
extent it is attributable to a failure to timely pay required premiums or
contributions towards the cost of coverage; or
(3) The
health benefit plan covers only active employees and, if applicable, dependents
and those covered under continuation coverage provisions, the employee pays no
premiums for coverage after termination of employment and the cancellation or
discontinuance of coverage is effective retroactively back to the date of
termination of employment due to a delay in administrative record-keeping.
A
health carrier shall provide at least thirty days advance notice to each plan
enrollee or covered person who would be affected by the proposed rescission of
coverage before coverage under the plan may be rescinded. If the proposed
rescission is with respect to a group plan, the notice is required regardless
of whether the rescission applies only to an individual within the group or to
the entire group.
Except
for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), this section applies to any plan of individual or group health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive, and also applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL 58-18-42.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-51.1, 58-18-79.
20:06:55:15. Group plans --
Lifetime limits. A group health plan may not establish any lifetime limit
or any annual limit on the dollar amount of essential benefits for any
individual except as permitted in § 20:06:55:16. However, a flexible
spending arrangement may have an annual limit on the dollar amount of benefits.
Nothing in this section prohibits a group health plan from placing annual or
lifetime limits on specific covered benefits that are not essential benefits.
Essential benefits include ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and substance use
disorder services including behavioral health treatment, prescription drugs,
rehabilitative and habilitative services and devices, laboratory services,
preventive and wellness services and chronic disease management, and pediatric
services including oral and vision care. Nothing in this section prohibits a
group health plan from excluding all benefits for a given condition.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:55:16. Group plans -- Annual limits. With respect to plan years beginning prior to January 1, 2014, a group health plan may establish, for any individual, an annual limit on the dollar amount of benefits that are essential health benefits if the limit is no less than the following:
(1) For a plan year beginning after September 22, 2010, but before September 23, 2011, $750,000;
(2) For a plan year beginning after September 22, 2011, but before September 23, 2012, $1,250,000;
(3) For plan years beginning after September 22, 2012, but before January 1, 2014, $2,000,000.
In determining whether an individual has received benefits that meet or exceed the allowable annual limits as required by this section the plan or issuer may only take into account essential health benefits.
For plan years beginning after December 31, 2013, no annual dollar limit is permitted for essential health benefits.
Source: 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010; 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:55:17. Group plans --
Eligibility. An individual who meets the requirements of this section is
eligible for benefits under a group health plan as described in
§ 20:06:55:18. This section applies to any individual:
(1) Whose
coverage or benefits under a group health plan ended by reason of reaching a
lifetime limit on the dollar value of all benefits for any individual; and
(2) Who
becomes eligible, or is required to become eligible, for benefits not subject
to a lifetime limit on the dollar value of all benefits under the group health
plan on the first day of the first plan year beginning after September 22,
2010, by reason of the application of this section.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:55:18. Group plans --
Notices and enrollment. If an individual described in § 20:06:55:17 is
eligible for benefits or is required to become eligible for benefits under the
group health plan, the group health plan is required to give the individual written
notice that the lifetime limit on the dollar value of all benefits no longer
applies and that the individual, if covered, is once again eligible for
benefits under the plan. If the individual is not enrolled in the plan or if an
enrolled individual is eligible for but not enrolled in any benefit package
under the plan, then the plan must also give such individual an opportunity to
enroll that continues for at least thirty days. The notices and enrollment
opportunity required under this section must be provided beginning no later
than the first day of the first plan year beginning after September 22, 2010.
In the case of an individual who enrolls pursuant to this section, coverage
must take effect no later than the first day of the first plan year beginning
after September 22, 2010.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:55:19. Group plans --
Special enrollment. An individual enrolling in a group health plan pursuant
to § 20:06:55:18 must be treated as if the individual were a special
enrollee pursuant to §§ 20:06:40:05 and 20:06:40:05.01. The individual
eligible for special enrollment must be offered all the benefit packages
available to similarly situated individuals who did not lose coverage by reason
of reaching a lifetime limit on the dollar value of all benefits. Any
difference in benefits or cost-sharing constitutes a different benefit package.
The individual may not be required to pay more for coverage than similarly
situated individuals who did not lose coverage by reason of reaching a lifetime
limit on the dollar value of all benefits.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-79.
20:06:55:20. Group plans --
Applicability. Sections 20:06:55:15 to 20:06:55:19, inclusive, apply for
plan years beginning after September 22, 2010, and apply to any employer based
health plan, including health benefit plans subject to the provisions of SDCL 58-18-42 but do not apply to excepted benefits.
For
plan or policy years beginning prior to January 1, 2014, a group health
insurance policy is exempt from the annual limit requirements if the policy is
approved for a waiver from such requirements by the U.S. Department of Health
and Human Services but such exemption only applies for the specified period of
time that the waiver from the U.S. Department of Health and Human Services is
applicable.
At
the time a policy receives a waiver from the U.S. Department of Health and
Human Services, the health carrier shall notify prospective applicants and
affected policyholders and the commissioner in each state where prospective
applicants and any affected insured are known to reside.
At
the time the waiver expires or is otherwise no longer in effect, the health
carrier shall notify affected policyholders and the commissioner in each state
where any affected insured is known to reside.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-43, 58-18-44, 58-18-45, 58-18-48, 58-18-51.1, 58-18-79.
20:06:55:21. Individual plans --
Lifetime limits. No individual policy of insurance may establish a lifetime
limit on the dollar value of essential benefits for any covered person or an
unreasonable annual limit on the dollar value of essential benefits for any
covered person. Nothing in this section prohibits a health plan from placing
annual or lifetime limits on specific covered benefits that are not essential
benefits. Essential benefits include ambulatory patient services; emergency
services; hospitalization; maternity and newborn care; mental health and
substance use disorder services including behavioral health treatment;
prescription drugs; rehabilitative and habilitative services and devices;
laboratory services; preventive and wellness services and chronic disease
management; and pediatric services including oral and vision care. Nothing in
this section prohibits a health plan from excluding all benefits for a given
condition. The written notice requirements described in § 20:06:55:18
apply to individual plans of insurance.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:55:22. Individual plans -- Annual limits. With respect to policy years beginning prior to January 1, 2014, a health plan may establish, for any individual, an annual limit on the dollar amount of benefits that are essential health benefits provided the limit is no less than the following:
(1) For a plan year beginning after September 22, 2010, but before September 23, 2011, $750,000;
(2) For a plan year beginning after September 22, 2011, but before September 23, 2012, $1,250,000;
(3) For plan years beginning after September 22, 2012, but before January 1, 2014, $2,000,000.
In determining whether an individual has received benefits that meet or exceed the allowable annual limits as required by this section the plan or issuer may only take into account essential health benefits.
For plan years beginning after December 31, 2013, no annual dollar limit is permitted for essential health benefits.
Source: 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010; 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:55:23. Reinstatement of coverage. An individual whose coverage or benefits under a health plan ended by reason of reaching a lifetime limit on the dollar value of all benefits for the individual must be provided an opportunity for reinstatement of coverage provided that the individual policy or the group health plan remains in force.
Source: 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:55:24. Individual plans --
Applicability. Except for those coverages that are excepted benefits
pursuant to SDCL subdivision 58-17-69(13), §§ 20:06:55:21 to 20:06:55:23, inclusive, apply to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive.
Sections
20:06:55:21 to 20:06:55:23, inclusive, do not apply to individual plans with
respect to annual limits if the plans are grandfathered plans pursuant to 75 Fed.
Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R.
§ 2590, and 45 C.F.R. § 147.
For
plan or policy years beginning prior to January 1, 2014, an individual health
insurance policy is exempt from the annual limit requirements if the policy is
approved for a waiver from such requirements by the U.S. Department of Health
and Human Services but such exemption only applies for the specified period of
time that the waiver from the U.S. Department of Health and Human Services is
applicable.
At
the time a policy receives a waiver from the U.S. Department of Health and
Human Services, the health carrier shall notify prospective applicants and
affected policyholders and the commissioner in each state where prospective
applicants and any affected insured are known to reside.
At
the time the waiver expires or is otherwise no longer in effect, the health
carrier shall notify affected policyholders and the commissioner in each state
where any affected insured is known to reside.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:55:25. Individual plans -- No preexisting condition for a person under the age of 19 -- Open enrollment. Repealed.
Source: 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010; 37 SDR 215, effective May 31, 2011; 38 SDR 40, effective September 20, 2011; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.
20:06:55:25.01. Individual plans -- No preexisting condition. No health policy, certificate, or plan may limit or exclude coverage based upon a preexisting condition for a person. For policies issued after March 23, 2010, but before September 23, 2010, any remaining preexisting condition waiting period must be removed beginning on the first day of the policy year following September 22, 2010. For individual policies issued after September 22, 2010, no preexisting waiting period for persons under the age of 19 may be applied. For persons who are age 19 or over no preexisting condition may apply after December 31, 2013. This section does not apply to grandfathered plans.
If a health insurance issuer offers health insurance coverage in any level of coverage other than excepted benefits, the issuer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21.
This section does not apply to a plan that is stand-alone dental.
Except for those coverages that are excepted benefits pursuant to § 20:06:55:27, this section applies to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-84, 58-17-87, 58-17-97.
20:06:55:26. Group plans -- No
preexisting condition for a person under the age of 19. No health policy,
certificate, or plan may limit or exclude coverage based upon a preexisting
condition for a person under the age of 19. Any prexisting condition waiting
period for a covered person under the age of 19 must be removed no later than
the first day of the plan year following September 22, 2010.
This
section applies to any employer based health plan, including health benefit
plans subject to the provisions of SDCL 58-18-42 and plans that are either grandfathered or not grandfathered.
Source: 37 SDR 63, effective September
23, 2010; 37 SDR 111, effective December 7, 2010.
General Authority: SDCL 58-18-79.
Law Implemented: SDCL 58-18-48, 58-18-51.1, 58-18-79, 58-18-86.
20:06:55:27. Excepted benefits -- Defined. For any health insurance policy or certificate subject to the provisions of Title 58 the term excepted benefits are those benefits as defined in section 2791 (c) of the Public Health Service Act.
Source: 37 SDR 215, effective May 31, 2011.
General Authority: SDCL 58-11-63, 58-17-87, 58-18-79.
Law Implemented: SDCL 58-11-44, 58-17-69, 58-17-87, 58-18-31, 58-18-45, 58-18-79.
20:06:55:28. Disproportionate share reporting. Repealed.
Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.
20:06:55:29. Disproportionate share based on loss ratio. Repealed.
Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed, January 1, 2014.
20:06:55:30. Disproportionate share based upon earned premium. Repealed.
Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed, January 1, 2014.
20:06:55:31. Length of disproportionate share approval. Repealed.
Source: 37 SDR 215, effective May 31, 2011; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.
20:06:55:32. Definitions.
(1) "Exchange," individual and SHOP Exchange;
(2) "HHS," United States Department of Health and Human Services;
(3) "Health insurance issuer," any person that provides health insurance in this state including an insurance company, a prepaid hospital, or similar plan, a health maintenance organization, a multiple employer welfare arrangement, or any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. A health insurance issuer does not include a person providing only excepted benefits;
(4) "Individual Exchange," an Exchange as provided for by section 1311 of PPACA to provide coverage to individuals;
(5) "PPACA," means the Patient Protection and Affordable Care Act (P.L. 111-148, 2010), as amended by the Health Care and Education Reconciliation Act (P.L. 111-152, 2010);
(6) "SHOP Exchange," an Exchange provided for by section 1311 of PPACA to provide coverage to small employers.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:33. Certifying qualified health plans. A health insurance issuer selling plans in an Exchange may offer only health plans which have in effect a certification issued by the director as a qualified health plan, unless specifically provided for otherwise. A stand-alone dental plan must be certified by the director to participate in an Exchange.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:34. Issuer standards and certification criteria. In order to participate in an Exchange, a health insurance issuer must have in effect a certification issued or recognized by the director to demonstrate that each health plan it offers in an Exchange is a qualified health plan. The director may certify a health plan as a qualified health plan if the requirements of § 20:06:55:35 are met or the director determines that making the health plan available is in the interest of the qualified individuals and qualified employers. The director may not exclude a health plan on the following basis:
(1) Such plan is a fee-for-service plan;
(2) Through the imposition of premium price controls; or
(3) That the health plan provides treatments necessary to prevent patients' deaths in circumstances determined to be inappropriate or too costly.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:35. Qualified health plan defined. A qualified health plan is a health plan that has been certified by the division that such plan meets the following criteria:
(1) Provides the essential health benefits package described in § 20:06:56:03;
(2) Meets actuarial value standards as described in § 20:06:56:11;
(3) Is licensed by and in good standing with the director;
(4) Includes a network that is compliant with SDCL chapter 58-17F, § 20:06:55:36 and § 20:06:55:37;
(5) Complies with marketing laws;
(6) Is accredited based on local performance by an accrediting entity recognized by HHS as described in § 20:06:56:12;
(7) The rates comply with chapter 20:06:22 and § 20:06:55:45;
(8) Is non-discrimination compliant with chapter 20:06:45;
(9) Includes plan variations for individuals eligible for cost-sharing reductions and for American Indian and Alaska Native populations;
(10) Complies with the benefit design standards, as defined in § 20:06:56:08;
(11) Implements and reports on a quality improvement strategy or strategies to disclose and report information on health care quality and outcomes;
(12) Complies with the standards related to the risk adjustment program under 45 CFR part 153 (March 12, 2012).
Stand-alone dental plans are not required to comply with subdivisions (1),(2),(6),(7),(9),(10),(11), and (12). Stand-alone dental plans must meet the plan criteria identified in § 20:06:56:06.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:36. Exchange network adequacy standards. A qualified health plan issuer must ensure that the provider network of each qualified health plan meets the standards specified in SDCL chapter 58-17F. A qualified health plan in an Exchange may contract with any essential community provider. The service area of a qualified health plan is subject to the approval of the director and must cover a minimum geographical area that is at least the entire geographic area of a county, or a group of counties defined by the director. The service area of a qualified health plan must be established without regard to racial, ethnic, language, health status-related factors or other factors that exclude specific high utilizing, high cost or medically-underserved populations.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:37. Network adequacy standards. A qualified health plan issuer must ensure that the provider network of each of its qualified health plans meets the following standards:
(1) Includes essential community providers in accordance with §§ 20:06:55:38 and 20:06:55:39;
(2) Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance abuse services, to assure that all services are accessible without unreasonable delay; and
(3) Is consistent with the network adequacy provisions of SDCL chapter 58-17F.
A qualified health plan issuer must make its provider directory for a qualified health plan available for publication online to potential enrollees in hard copy upon request. In the provider directory, a qualified health plan issuer must identify providers that are not accepting new patients.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:38. Essential community providers defined. Essential community providers are providers that serve predominantly low-income, medically underserved individuals, unless the provider lost its status as a result of a violation of Federal law:
(1) Health care providers defined in section 340B(a)(4) of the Public Health Service Act (Pub. L. 102-585), as amended by PPACA, Health Care and Education Reconciliation Act (Pub. L. 111-152), and Medicare and Medicaid Extenders Act of 2010 (Pub. L. 111-309); and
(2) Providers described in section 1927(c)(1)(D)(i)(IV) of the Public Health Service Act as set forth by section 221 of Pub. L. 111-8 (March 11, 2009).
Nothing in this section shall be construed to require a qualified health plan issuer to contract with an essential community provider if such provider refuses to accept the generally applicable payment rates of such issuer.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:39. Essential community providers. A qualified health plan issuer must have a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the qualified health plan's service area.
A qualified health plan issuer that provides a majority of covered professional services through physicians employed by the issuer or through a single contracted medical group may, with approval from the director, as an alternative to the standard set forth above comply as follows:
A qualified health plan issuer must have a sufficient number and geographic distribution of employed providers and hospital facilities, or providers of its contracted medical group and hospital facilities to ensure reasonable and timely access for low-income, medically underserved individuals in the qualified health plans service area.
Nothing in this section shall be construed to require any qualified health plan to provide coverage for any specific medical procedure provided by the essential community provider.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:40. Payment of federally-qualified health centers. If an item or service covered by a qualified health plan is provided by a federally-qualified health center to an enrollee of a qualified health plan, the qualified health plan issuer must pay the federally-qualified health center for the item or service an amount that is not less than the amount of payment that would be required to be paid to the center under section 1902(bb) of PPACA for such item or service. Nothing in this section would preclude a qualified health plan issuer and federally-qualified health center from mutually agreeing upon payment rates other than those that would be paid to the center under section 1902(bb) of PPACA, as long as such mutually agreed upon rates are at least equal to the generally applicable payment rates of the issuer.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:41. Treatment of direct primary care medical homes. A qualified health plan issuer may provide coverage through a direct primary care medical home that meets the criteria established by HHS, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the direct primary care medical home are coordinated with the qualified health plan issuer.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:42. Recertification of qualified health plans. Each qualified health plan offered in an Exchange must obtain annual recertification from the director in accordance with the criteria as outlined in § 20:06:55:35 each year. Upon determining the recertification status of a qualified health plan the director shall notify qualified health plan issuers.
If a qualified health plan issuer elects not to seek recertification with an Exchange for its qualified health plan, the qualified health plan issuer must provide written notice of the election to each enrollee.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 45 SDR 45, effective October 10, 2018.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:43. Decertification of qualified health plan. If an issuer offering a qualified health plan is no longer in compliance with the general certification criteria as outlined in § 20:06:55:35 the issuer may not offer coverage through an Exchange.
If a qualified health plan is decertified or otherwise not approved to offer coverage through an Exchange the qualified health plan issuer must terminate coverage for enrollees only after:
(1) The plan provides notification as described in § 20:06:55:46; and
(2) Enrollees have an opportunity to enroll in other coverage.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:44. Non-renewal and decertification of qualified health plans. If a qualified health plan issuer elects not to seek recertification with the director, the qualified health plan issuer must:
(1) Notify the director of its decision prior to the beginning of the recertification process;
(2) Fulfill its obligation to cover benefits for each enrollee through the end of the plan or benefit year;
(3) Fulfill data reporting obligations from the last plan or benefit year of the certification;
(4) Provide notice to enrollee in writing; and
(5) Terminate coverage for enrollees in the qualified health plan once enrollees have an opportunity to enroll in other coverage.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:45. Rates. A qualified health plan issuer must set rates for an entire benefit year, or for the SHOP Exchange, plan year. An issuer must submit rate and benefit information to the director. A qualified health plan issuer must submit to the director a justification for a rate increase prior to the implementation of the increase. A qualified health plan issuer must prominently post the justification for a rate increase on its website. A qualified health plan issuer may vary premiums by the geographic rating area described in § 20:06:22:29.
Stand-alone dental plans are not subject to § 20:06:22:29. Stand-alone dental must file rates in accordance with SDCL 58-17-4.1 and SDCL 58-39-8. Any stand-alone dental plan that is not subject to rate approval pursuant to SDCL 58-17-4.1 or SDCL 58-39-8 must file rates with the director for informational purposes only.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:46. Health plan applications and notices. A qualified health plan issuer must provide all applications and notices to enrollees in plain language and in a manner that is accessible and timely to individuals living with disabilities including accessible websites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act, Pub. L. No. 101-336 (1990), as amended, and section 504 of the Rehabilitation Act, Pub. L. No. 93-112 (1973), as amended. Individuals who are limited English proficient through the provision of language services at no cost to the individual.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:47. Accreditation of qualified health plan issuers. A qualified health plan issuer must be accredited on the basis of local performance of a qualified health plan in accordance with § 20:06:56:12.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:48. Initial open enrollment period. Repealed.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 45 SDR 45, effective October 10, 2018.
20:06:55:49. Annual open enrollment period. All health insurance issuers must provide for an annual open enrollment period for the individual market inside the Exchange.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 41 SDR 93, effective December 3, 2014; 45 SDR 45, effective October 10, 2018.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:50. Changing qualified health plans. A health insurance issuer must allow a qualified individual or enrollee in an Exchange to enroll in or change from one qualified health plan (QHP) to another as a result of the following triggering events:
(1) The qualified individual or his or her dependent either:
(i) Loses minimum essential coverage except for in the case of nonpayment of premium. The date of the loss of coverage is the last day the consumer would have coverage under their previous plan or coverage;
(ii) Is enrolled in any non-calendar year health insurance policy, even if the qualified individual or their dependent has the option to renew such coverage. The date of the loss of coverage is the last day of the plan or policy year;
(iii) Loses pregnancy-related coverage described under section 1902(a)(10)(A)(i)(IV) and (a)(10)(A)(ii)(IX) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(i)(IV), (a)(10)(A)(ii)(IX) (July 1, 2018). The date of the loss of coverage is the last day the consumer would have pregnancy-related coverage; or
(iv) Loses medically needy coverage as described under section 1902(a)(10)(C) of the Social Security Act only once per calendar year. The date of the loss of coverage is the last day the consumer would have medically needy coverage;
(2) The qualified individual:
(i) Gains a dependent or becomes a dependent through marriage, birth, adoption, placement for adoption, placement in foster care, or through a child support order or other court order;
(a) In the case of marriage, at least one spouse must demonstrate having minimum essential coverage for 1 or more days during the 60 days preceding the date of marriage;
(ii) Loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee, or his or her dependent, dies;
(3) An individual, who was not previously a citizen, national, or lawfully present individual gains such status;
(4) A qualified individual's enrollment or non-enrollment in a qualified health plan is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the health insurance issuer. In such cases, the health insurance issuer may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction;
(5) An enrollee adequately demonstrates to the director that the qualified health plan in which the individual is enrolled substantially violated a material provision of its contract in relation to the individual;
(6) A qualified individual or enrollee gains access to new qualified health plans as a result of a permanent move and had minimum essential coverage as described in 26 CFR 1.5000A-l(b) for one or more days during the 60 days preceding the date of the permanent move;
(7) A qualified individual or enrollee meets other exceptional circumstances as the director may provide;
(8) An Indian, as defined by section 4 of the Indian Health Care Improvement Act, Pub. L. No. 94-437 (1976), as amended, may enroll in a qualified health plan or change from one qualified health plan to another one time per month and is not subject to any qualifying event;
(9) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions:
(i) The enrollee is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions;
(ii) The enrollee's dependent enrolled in the same QHP is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; or
(iii) A qualified individual or his or her dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for advance payments of the premium tax credit based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3) (April 15, 2016), including as a result of their employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage;
(iv) A qualified individual in a non-Medicaid expansion state who was previously ineligible for advance payments of the premium tax credit solely because of a household income below 100 percent of the FPL, who was ineligible for Medicaid during that same timeframe, and who has experienced a change in household income that makes the qualified individual newly eligible for advance payments of the premium tax credit;
(10) Is a victim of domestic abuse or spousal abandonment, as defined by 26 CFR 1.36B-2T, as amended, including a dependent or unmarried victim within a household, is enrolled in minimum essential coverage and seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment; or is a dependent of a victim of domestic abuse or spousal abandonment, on the same application as the victim, may enroll in coverage at the same time as the victim;
(11) Applies for coverage on the Exchange during the annual open enrollment period or due to a qualifying event, is assessed by the Exchange as potentially eligible for Medicaid or the Children's Health Insurance Program (CHIP), and is determined ineligible for Medicaid or CHIP by the State Medicaid or CHIP agency either after open enrollment has ended or more than 60 days after the qualifying event or applies for coverage at the State Medicaid or CHIP agency during the annual open enrollment period, and is determined ineligible for Medicaid or CHIP after open enrollment has ended;
(12) The qualified individual or enrollee, or his or her dependent, adequately demonstrates to the Exchange that a material error related to plan benefits, service area, or premium influenced the qualified individual's or enrollee's decision to purchase a QHP through the Exchange; or
(13) At the option of the Exchange, the qualified individual provides satisfactory documentary evidence to verify his or her eligibility for an insurance affordability program or enrollment in a QHP through the Exchange following termination of Exchange enrollment due to a failure to verify such status within the time period specified in § 155.315 or is under 100 percent of the FPL and did not enroll in coverage while waiting for HHS to verify his or her citizenship, status as a national, or lawful presence.
A qualified individual or enrollee has 60 days from the date of a triggering event to select a QHP. A qualified individual or the individual's dependent who is described in subsection 1 of this section has 60 days before and after the loss of coverage to select a QHP. A qualified individual or the individual's dependent who is described in subsection 9 of this section has 60 days before and after the loss of eligibility for qualifying coverage in an eligible employer-sponsored plan to select a QHP.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 41 SDR 93, effective December 3, 2014; 45 SDR 45, effective October 10, 2018.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:50.01. Loss of coverage. Loss of coverage does not include termination or loss due to:
(1) Failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or
(2) Situations allowing for a rescission.
If the triggering event is loss of qualified health plan a qualified individual or enrollee may only move to a different plan at the same level of coverage as the enrollees current plan.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:50.02. Special enrollment period effective dates. After December 31, 2013, a health insurance issuer must provide special enrollment periods consistent with this section inside the Exchange, during which qualified individuals and enrollees may enroll in nongrandfathered health plans or change enrollment from one plan to another. Once a qualified individual is determined eligible for a special enrollment period, the health insurance issuer must ensure that the qualified individual's date of coverage is:
(1) Between the first and the fifteenth day of any month, the plan must ensure a coverage effective date of the first day of the following month;
(2) Between the sixteenth and the last day of any month, the plan must ensure a coverage effective date of the first day of the second following month;
(3) In the case of birth, adoption or placement for adoption, or placement in foster care, the plan must ensure that coverage is effective on the date of birth, adoption, placement for adoption, or placement in foster care. If the Exchange permits the qualified individual or enrollee to elect a coverage effective date of the first day of the month following the date of birth, adoption, placement for adoption, or placement in foster care, the Exchange must ensure coverage is effective on such date elected by the qualified individual or enrollee;
(4) In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, the plan must ensure coverage is effective on the first day of the month following plan selection;
(5) In the case of a qualified individual or enrollee eligible for a special enrollment period as described in §§ 20:06:55:50(4), 20:06:55:50(5), or 20:06:55:50(7) the plan must ensure coverage is effective on an appropriate date based on the circumstances of the special enrollment period;
(6) In a case where an individual loses coverage as described in subdivision 20:06:55:50(1) if the plan selection is made before or on the day of the loss of coverage, the Exchange must ensure that the coverage effective date is on the first day of the month following the loss of coverage. If the plan selection is made after the loss of coverage, the Exchange must ensure that coverage is effective in accordance with subsection (1) and (2) of this section or on the first day of the month following plan selection in accordance with subsection (3) and (4) of this section;
(7) In the case of a court order the plan must ensure that coverage is effective for a qualified individual or enrollee on the date the court order is effective, or it may permit the qualified individual or enrollee to elect a coverage effective date in accordance with subdivision (1). If the Exchange permits the qualified individual or enrollee to elect a coverage effective date in accordance with subdivision (1) of this section, the Exchange must ensure coverage is effective on the date duly selected by the qualified individual or enrollee; and
(8) If an enrollee or his or her dependent dies, the plan must ensure that coverage is effective on the first day of the month following the plan selection, or it may permit the enrollee or his or her dependent to elect a coverage effective date in accordance with subdivision (1). If the Exchange permits the enrollee or his or her dependent to elect a coverage effective date in accordance with subdivision (1) of this rule, the Exchange must ensure coverage is effective on the date duly selected by the enrollee or his or her dependent.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 41 SDR 93, effective December 3, 2014; 45 SDR 45, effective October 10, 2018.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:51. Compensation. A qualified health plan issuer must pay the same broker compensation for a qualified health plan offered through an Exchange that the qualified health plan issuer pays for a similar health plan offered outside an Exchange.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:52. Plan offerings in the exchange. A qualified health plan issuer must offer at least one qualified health plan in the silver level and at least one plan in the gold level to participate in an Exchange.
Sections 20:06:55:25, 20:06:55:28, 20:06:55:29, 20:06:55:30, and 20:06:55:31 are repealed effective January 1, 2014.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
20:06:55:53. Applicability and effective dates. The open enrollment provisions of §§ 20:06:55:48 and 20:06:55:49 do not apply to any coverage issued to an employer that covers at least two individuals.
Sections 20:06:55:25, 20:06:55:28, 20:06:55:29, 20:06:55:30, and 20:06:55:31 are repealed effective January 1, 2014.
Sections 20:06:55:33 to 20:06:55:52, inclusive, are effective January 1, 2014.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.
