DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
EXAMPLE OF CERTIFICATE OF INDIVIDUAL HEALTH INSURANCE COVERAGE
Chapter 20:06:39
APPENDIX A
SEE: § 20:06:39:04
(Repealed)
Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, effective June 10, 2013; 42 SDR 83, effective December 3, 2015.
DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
NOTICE OF RESEARCH EXCEPTION
Chapter 20:06:39
APPENDIX B
SEE: § 20:06:39:47
Source: 37 SDR 47, effective September 20, 2010.
Notice of Research Exception
PART I: Entity Classification and Identification
1. Date of submission: ________________________
2. Specify whether the entity claiming the research exception is:
(A) □ A group health plan (plan); or
(B) □ A health insurance issuer (issuer).
3. If the entity is a plan (as designated in Box 2A), is the plan:
(A) □ A plan subject to Part 7 of Title I of ERISA;
(B) □ A church plan; or
(C) □ A nonfederal governmental plan.
4. If the entity is an issuer (as designated in Box 2B), is the issuer claiming the exception in connection with the provision of:
(A) □ Group health insurance coverage only;
(B) □ Individual health insurance coverage only; or
(C) □ Both group and individual health insurance coverage.
5a. Name and address of the entity claiming the exception:
__________________________________________________________
__________________________________________________________
__________________________________________________________
5b. Telephone number of entity claiming the exception:
__________________________________________________________
5c. Employer Identification Number (EIN) of the entity claiming the exception:
__________________________________________________________
5d. If the entity is a plan (as designated in Box 2A), specify plan number:
______________________________________________________
PART II: Research Project Information
6. Title of the research project:
______________________________________________________
7. Name of the principal investigator:
______________________________________________________
8. Research project number ( if available):
______________________________________________________
PART III: Attestation of Compliance with the Requirements of the Research Exception
With respect to the research project described in Part II, I attest that the following is true:
(i) The research complies with 45 CFR part 46 or equivalent federal regulations and applicable state or local law or regulations for the protection of human subjects in research; (ii) each request of a participant or beneficiary (or in the case of a minor child, the legal guardian of such beneficiary) to undergo genetic testing as part of the research will be made in writing and clearly indicate that compliance with the request is voluntary and that noncompliance will have no effect on eligibility for benefits or premium or contribution amounts; and (iii) no genetic information collected or acquired through this research will be used for underwriting purposes.
Under penalty of perjury, I declare that I have examined this notice, including any accompanying attachments, and to the best of my knowledge and belief, it is true and correct. Under penalty of perjury, I also declare that this notice is complete.
Signature: _______________________________________ Date: ________________
Type or print name, address, and telephone number:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CHAPTER 20:06:39
INDIVIDUAL PLANS
Section
20:06:39:01 Dual eligibility.
20:06:39:02 Creditable coverage and preexisting waiting periods for newborn and adopted children.
20:06:39:03 Permissible rating factors.
20:06:39:04 Repealed.
20:06:39:04.01 Certificates required upon loss of coverage.
20:06:39:05 Standards for determinations on length of preexisting waiting periods.
20:06:39:06 Repealed.
20:06:39:06.01 Student health plans -- Bona fide association plans.
20:06:39:07 Requirements for breaks in coverage when applying for a new policy.
20:06:39:08 Repealed.
20:06:39:08.01 Active marketing required.
20:06:39:09 Prohibited practices.
20:06:39:10 Prohibited compensation arrangements.
20:06:39:11 Repealed.
20:06:39:12 Repealed.
20:06:39:13 Repealed.
20:06:39:14 Repealed.
20:06:39:15 Repealed.
20:06:39:16 Repealed.
20:06:39:17 Repealed.
20:06:39:18 Repealed.
20:06:39:19 Guaranteed issue -- Effective date of coverage.
20:06:39:20 Guaranteed issue -- Tolling of 63-day time frame.
20:06:39:20.01 Repealed.
20:06:39:20.02 Repealed.
20:06:39:20.03 Repealed.
20:06:39:20.04 Repealed.
20:06:39:20.05 Effective date of guaranteed issue plan.
20:06:39:20.06 Repealed.
20:06:39:21 Definition of ordinarily prudent person in preexisting condition clauses.
20:06:39:22 Fair market standards for carriers.
20:06:39:23 Group applicability to individual market.
20:06:39:24 Repealed.
20:06:39:25 Repealed.
20:06:39:26 Repealed.
20:06:39:27 Repealed.
20:06:39:28 Repealed.
20:06:39:29 Repealed.
20:06:39:30 Usual, customary, and reasonable charges for standard and basic plans.
20:06:39:31 Repealed.
20:06:39:32 Contract of more than six months -- Defined.
20:06:39:33 Repealed.
20:06:39:34 Repealed.
20:06:39:34.01 Disclosure requirements.
20:06:39:34.02 Renewability of short term major medical plans.
20:06:39:35 Policy not subject to group requirements.
20:06:39:36 Medically necessary leave of absence defined.
20:06:39:37 Dependent coverage.
20:06:39:38 Notification.
20:06:39:39 Continued application in case of changed coverage.
20:06:39:40 Effective date.
20:06:39:41 Creditable coverage -- Children's Health Insurance Program.
20:06:39:42 Association health insurance plans subject to individual market rating requirements.
20:06:39:43 Definitions.
20:06:39:44 Prohibition on genetic information in setting premium rates.
20:06:39:45 Limitation on requesting or requiring genetic testing.
20:06:39:46 Exceptions to requiring genetic testing.
20:06:39:47 Research exception.
20:06:39:48 Prohibitions on collection of genetic information for underwriting purposes.
20:06:39:49 Medical appropriateness.
20:06:39:50 Collection of genetic information prior to or in connection with enrollment.
20:06:39:51 Incidental collection exception.
20:06:39:52 Prohibition on genetic information as a condition of eligibility.
20:06:39:53 Prohibition on genetic information as preexisting condition.
20:06:39:54 Medicare supplemental health insurance.
20:06:39:55 Applicability to excepted benefits.
20:06:39:56 Effective date.
20:06:39:57 Guaranteed availability of coverage in the individual market.
20:06:39:58 Denial of coverage.
20:06:39:59 Open enrollment.
20:06:39:60 Initial open enrollment period.
20:06:39:61 Annual open enrollment period.
20:06:39:62 Special enrollment period effective dates.
20:06:39:63 Coverage issued outside open enrollment.
20:06:39:64 Enrollment in catastrophic plans.
20:06:39:65 Student health insurance coverage.
20:06:39:66 Clinical trial.
20:06:39:67 Nonrenewal of coverage.
20:06:39:68 Discontinuing a particular product.
20:06:39:69 Discontinuing all coverage.
20:06:39:70 Special enrollment periods for marriage, birth, and adoption.
20:06:39:71 Special enrollment triggers.
20:06:39:72 Preexisting condition exclusion and waiting period prohibited.
20:06:39:73 Health insurance issuer defined.
20:06:39:74 Applicability.
Appendix A Repealed.
Appendix B Notice of Research Exception.
20:06:39:01. Dual eligibility. An individual who is otherwise eligible may not be denied coverage under SDCL 58-17-85 for the reason that the individual is also eligible for a conversion policy or other individual coverage. Individuals eligible for coverage under this section may not be required to provide proof that coverage was denied by another carrier in order to obtain coverage under SDCL 58-17-85.
Source: 24 SDR 35, effective September 29, 1997
General Authority: SDCL 58-17-87(2).
20:06:39:02. Creditable coverage and preexisting waiting periods for newborn and adopted children. A child who was covered as a dependent within 31 days after the date of birth under the policy of a parent, or within 31 days after the start of the adoption bonding period under the policy of a prospective parent in the case of a child who has been placed for adoption, is not subject to the creditable coverage requirement of 12 months and qualifies as having 12 months of creditable coverage pursuant to SDCL 58-17-85 if any creditable coverage has been in force within the preceding 63 days. Waiting periods for preexisting conditions may not be imposed on children who meet the requirements of this section.
The requirements of this section apply to any health benefit plan as defined in SDCL subdivision 58-17-66(9).
Source: 24 SDR 35, effective September 29, 1997; 29 SDR 107, effective February 5, 2003.
General Authority: SDCL 58-17-30.2, 58-17-87(2).
Law Implemented: SDCL 58-17-30.2, 58-17-84, 58-17-85, 58-17-87.
20:06:39:03. Permissible rating factors. A health benefit plan may use health status and weight in determining the rate charged for an individual when issuing a new policy or certificate. The application of rating factors based on health status or weight is limited to a 30 percent deviation from the index rate. Adjustments in the rating factors based on health status or weight may not be made after coverage is issued.
Source: 24 SDR 35, effective September 29, 1997.
General Authority: SDCL 58-17-75.
Law Implemented: SDCL 58-17-74.
Cross-Reference: Definition of index rate, SDCL 58-17-66.
20:06:39:04. Certificates required upon loss of coverage. Repealed.
Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.
20:06:39:04.01. Certificates required upon loss of coverage. A health insurance issuer must provide a certificate of creditable coverage or simply certify that the individual has creditable coverage to any individual losing coverage upon requests by or on behalf of an individual. At any time within 24 months after coverage ceases, a health insurance issuer must also provide additional certificates or certifications upon requests by or on behalf of an individual. Each certificate or certification must be provided in a reasonable and prompt fashion. A separate fee may not be charged for the provision of a certificate or certification, but the cost of this service may be factored into the policy premium.
If a health insurance issuer provides coverage in connection with another type of creditable coverage, the health insurance issuer must provide a certificate or certification as required by this section.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 42 SDR 83, effective December 3, 2015.
General Authority: SDCL 58-17-87(2).
Law Implemented: SDCL 58-11-1, 58-17-85, 58-17-87, 58-33-36.
20:06:39:05. Standards for determinations on length of preexisting waiting periods. A carrier must determine whether an individual is eligible for coverage pursuant to SDCL 58-17-85. In making that determination a carrier must use reasonable diligence. Reasonable diligence may include questions on an application for insurance designed to elicit information on the individual’s eligibility for coverage under SDCL 58-17-85. A carrier may not use the absence of a certificate as required by § 20:06:39:04 or 20:06:40:03 as the only method for determining eligibility for coverage pursuant to SDCL 58-17-85. The carrier must take into account all information presented by the individual. The carrier must consider the individual to have furnished a certificate if the individual attests to the period of creditable coverage, the individual presents relevant corroborating evidence of some creditable coverage during the period, and the individual cooperates with the carrier’s efforts to verify the individual’s coverage. The provisions of this section also apply to complete or partial waivers of preexisting condition waiting periods.
Source: 24 SDR 35, effective September 29, 1997.
General Authority: SDCL 58-17-87(2).
Law Implemented: SDCL 58-17-84, 58-17-85, 58-17-87.
20:06:39:06. College plans -- Bona fide association plans. Repealed.
Source: 24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.
20:06:39:06.01. Student health plans -- Bona fide association plans (effective January 1, 2014). A student health plan is an association plan that provides coverage to students of a college or university. A student health plan that is a bona fide association plan under SDCL 58-18B-48 is not required to renew coverage once the covered individual is no longer a student.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87(1),(2),(3),(4).
Law Implemented: SDCL 58-17-69, 58-17-70, 58-17-82, 58-17-85, 58-17-87.
20:06:39:07. Requirements for breaks in coverage when applying for a new policy. The maximum break in coverage of 63 days does not apply to the period of time after an individual applies for an individual policy if coverage is actually issued pursuant to that application.
Source: 24 SDR 35, effective September 29, 1997.
General Authority: SDCL 58-17-87(2),(3).
Law Implemented: SDCL 58-17-84, 58-17-85, 58-17-87.
20:06:39:08. Active marketing required. Repealed.
Source: 24 SDR 86, effective December 31, 1997; 37 SDR 63, effective September 23, 2010; 37 SDR 111, effective December 7, 2010; 39 SDR 203, adopted June 10, 2013, repealed January 1, 2014.
20:06:39:08.01. Active marketing required. No health insurance issuer may employ marketing practices or benefit designs that will have the effect of discouraging applicants from exercising their open enrollment rights under § 20:06:39:59. No health insurance issuer may, in any manner penalize agents for submitting applications for those qualifying for open enrollment under § 20:06:39:59. If a health insurance issuer in the individual market offers health insurance coverage in any level of coverage specified under section 1302(d)(1) of PPACA as defined in § 20:06:55:32, the issuer must offer coverage in that level to individuals who, as of the beginning of a plan year, have not attained the age of 21.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014.
General Authority: SDCL 58-17-87(6).
Law Implemented: SDCL 58-17-87(6).
20:06:39:09. Prohibited practices. No carrier or agent may, directly or indirectly, engage in the following activities:
(1) Encouraging or directing eligible individuals to refrain from filing an application for coverage with the carrier because of the health status, claims experience, industry, occupation, or geographic location of the individual; or
(2) Encouraging or directing eligible individuals to seek coverage from another carrier because of the health status, claims experience, industry, occupation, or geographic location of the individual.
Source: 24 SDR 86, effective December 31, 1997.
General Authority: SDCL 58-17-87(6).
Law Implemented: SDCL 58-17-87(6).
20:06:39:10. Prohibited compensation arrangements. Each carrier must provide reasonable compensation to an insurance producer for the sale of a basic or standard health benefit plan or those plans the carrier has chosen to offer on a guaranteed issue basis in lieu of the basic and standard plans. No carrier may, directly or indirectly, enter into any contract, agreement, or arrangement with an insurance producer which provides for or results in the compensation paid to an insurance producer for the sale of a health benefit plan to be reduced because the insured qualified for coverage pursuant to SDCL 58-17-85. A carrier may pay a commission percentage that does not vary based upon health status. A carrier may reimburse producers for insureds qualified pursuant to SDCL 58-17-85 on a basis that varies the commission percentage or that is based only upon the premium of a lesser rated risk provided that the aggregate compensation received by the producer is not less than would have been paid by the carrier for a similarly situated individual who qualified for a lower rate. No compensation is required if the insurance producer is compensated by the carrier on a noncommission basis for selling its products other than basic or standard plans.
Source: 24 SDR 86, effective December 31, 1997; 28 SDR 105, effective February 3, 2002.
General Authority: SDCL 58-17-87(8).
Law Implemented: SDCL 58-17-87(8).
20:06:39:11. Guaranteed issue -- Criteria for meeting the exception for issuing coverage to high-risk individuals. Repealed.
Source: 25 SDR 13, effective August 13, 1998; 28 SDR 105, effective February 3, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:12. Guaranteed issue -- Premiums counted toward statutory threshold. Repealed.
Source: 25 SDR 13, effective August 13, 1998; 28 SDR 105, effective February 3, 2002; repealed, 32 SDR 232, effective July 10, 2006
20:06:39:13. Guaranteed issue -- Formula for calculating percentage of premiums attributable to high-risk individuals. Repealed.
Source: 25 SDR 13, effective August 13, 1998; 28 SDR 105, effective February 3, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:14. Guaranteed issue -- High-risk individuals. Repealed.
Source: 25 SDR 13, effective August 13, 1998; 28 SDR 105, effective February 3, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:15. Guaranteed issue -- Report of meeting statutory threshold. Repealed.
Source: 25 SDR 13, effective August 13, 1998; 28 SDR 105, effective February 3, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:16. Guaranteed issue -- Application for determination of disproportionate share. Repealed.
Source: 25 SDR 13, effective August 13, 1998; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:17. Guaranteed issue -- Filing of application. Repealed.
Source: 25 SDR 13, effective August 13, 1998; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:18. Guaranteed issue -- Director’s determination. Repealed.
Source: 25 SDR 13, effective August 13, 1998; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:19. Guaranteed issue -- Effective date of coverage. Upon receipt of an application for any major medical coverage subject to SDCL 58-17-66 to 58-17-87, inclusive, from an individual eligible under SDCL 58-17-85, whether or not the product applied for is on a guaranteed issue basis, the carrier must issue the policy with an effective date corresponding to the date of the application. If an eligible person makes the application prior to the actual date of termination of existing creditable coverage, the carrier may issue the coverage with an effective date coinciding with the termination date of the creditable coverage.
Source: 25 SDR 13, effective August 13, 1998.
General Authority: SDCL 58-17-85, 58-17-87(14).
Law Implemented: SDCL 58-17-85, 58-17-87(14).
20:06:39:20. Guaranteed issue -- Tolling of 63-day time frame. Any substantially completed application, whether an underwritten application or one specifically designed for guaranteed issue products, will toll the 63-day time frame for persons eligible pursuant to SDCL 58-17-85 not only for the carrier to which the application was submitted but also for any subsequent carriers from which the individual is seeking coverage.
Source: 25 SDR 13, effective August 13, 1998.
General Authority: SDCL 58-17-87(2)(14).
Law Implemented: SDCL 58-17-85, 58-17-87(2)(14).
20:06:39:20.01. Required timeframe in which to submit subsequent applications for guaranteed issue plans if rejection was received after February 24, 2002. Repealed.
Source: 28 SDR 158, effective May 19, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:20.02. Required timeframe in which to submit subsequent applications for guaranteed issue plans if rejection was received prior to February 25, 2002. Repealed.
Source: 28 SDR 158, effective May 19, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:20.03. Subsequent rejections and timeframes. Repealed.
Source: 28 SDR 158, effective May 19, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:20.04. Exceptions for those applying during 63-day timeframe following loss of creditable coverage. Repealed.
Source: 28 SDR 158, effective May 19, 2002; repealed, 32 SDR 232, effective July 10, 2006.
20:06:39:20.05. Effective date of guaranteed issue plan. Any eligible applicant that makes timely application pursuant to SDCL 58-17-85 and §§ 20:06:39:19 to 20:06:39:20.04, inclusive, must be issued coverage with an effective date consistent with the original application regardless of which carrier the application was made with or which type of benefit plan was applied for. If the original application was made prior to the date of loss of prior creditable coverage, the effective date of the guaranteed issue plan shall coincide with the date of loss of creditable coverage. For those making an initial timely application during the 63-day timeframe following loss of creditable coverage a guaranteed issue plan must be issued with an effective date that coincides with the date of the initial application. For those making application during the 63-day timeframe following loss of creditable coverage where an initial application is rejected and where a subsequent application is made within the 63-day timeframe, but more than 30 days following the rejection of the initial application, the date of the subsequent application is the effective date of the guaranteed issue plan. If the carrier and the applicant wish to make the plan's effective date other than what is required by this section, then any mutually agreeable effective date may be used.
Source: 28 SDR 158, effective May 19, 2002.
General Authority: SDCL 58-17-85, 58-17-87(2).
Law Implemented: SDCL 58-17-85.
20:06:39:20.06. Notice requirements regarding guaranteed issue when rejecting applications. Repealed.
Source: 28 SDR 158, effective May 19, 2002; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:21. Definition of ordinarily prudent person in preexisting condition clauses. For diseases that include symptoms of denial or failure to recognize the disease or illness, a carrier shall define an ordinarily prudent person within the definition of a preexisting condition in terms of the claimant's health-related circumstances and how a similarly situated person would be expected to act in seeking medical treatment or advice for that disease or illness. Nothing in this section prohibits a carrier from investigating the existence of denial symptoms or failure to recognize such disease or illnesses on a case by case basis. This section applies to the definition of an ordinarily prudent person within the preexisting condition clauses in SDCL 58-17-84 and 58-17-97 and does not apply to the contestability clause of a contract.
Source: 25 SDR 90, effective January 3, 1999.
General Authority: SDCL 58-17-87(3)(4)(11)(15).
20:06:39:22. Fair market standards for carriers. A carrier may not terminate,
fail to renew, or limit its contract or agreement of representation with an
agent for any reason related to the health status, claims experience,
occupation, or geographic location of the individuals placed or sought to be
placed by the agent with the carrier.
Source:
25 SDR 85, effective December 23, 1998.
General
Authority: SDCL 58-17-87(6)(8).
Law
Implemented: SDCL 58-17-87(6)(8).
20:06:39:23. Group applicability to individual market. The provisions of §§ 20:06:40:17 to 20:06:40:17.02, inclusive, apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to a health insurance issuer in connection with a group health plan in small or large groups.
Source: 27 SDR 15, effective September 6, 2000.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:24. Requirements for standard plan -- Schedule of benefits. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:25. Requirements for standard plan -- Eligible expenses. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:26. Requirements for standard plan -- Allowable exceptions and limitations. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:27. Requirements for basic plan -- Schedule of benefits. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:28. Requirements for basic plan -- Eligible expenses. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:29. Requirements for basic plan -- Allowable exceptions and limitations. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:30. Usual, customary, and reasonable charges for standard and basic plans. For any claim for which the usual, customary, and reasonable policy or contract provision is used, the eligible benefits must be paid at no less than the eightieth percentile of the usual, customary, and reasonable amount for the standard and basic plans. Benefits obtained from network providers may not use the usual, customary and reasonable provisions.
Source: 27 SDR 69, effective January 15, 2001.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-85.
20:06:39:31. Network available for standard and basic plans. Repealed.
Source: 27 SDR 69, effective January 15, 2001; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:32. Contract of more than six months -- Defined. The phrase, contract of more than six months duration, means any contract that provides for renewal by the insured for a period beyond six months after the inception date. The phrase does not include short-term major medical plan that is nonrenewable.
Source: 30 SDR 39, effective September 28, 2003.
General Authority: SDCL 58-17-87(4).
Law Implemented: SDCL 58-17-66(9).
20:06:39:33. Coverages prior to August 1, 2003. Repealed.
Source: 32 SDR 232, effective July 10, 2006; repealed, 39 SDR 203, effective June 10, 2013.
20:06:39:34. Disclosure requirements. Repealed.
Source: 34 SDR 200, effective January 28, 2008; 37 SDR 215, effective May 31, 2011; 39 SDR 203, effective June 10, 2013, repealed, January 1, 2014.
20:06:39:34.01. Disclosure requirements. Any policy or certificate of specified disease, short-term hospital-surgical care having a duration of six months or less but not including short-term major medical, hospital confinement indemnity, limited benefit health insurance, or other policy or certificate that provides less than essential health benefits, must clearly and prominently disclose that the policy is a limited benefit health insurance plan. The following is an example of a disclosure for limited benefit coverages that is in compliance, provided it is prominent and otherwise meets the requirements of this section:
This limited health benefits plan does not provide comprehensive medical coverage. It is a basic or limited benefits policy and is not intended to cover all medical expenses. This plan is not designed to cover the costs of a serious or chronic illness.
For short-term major medical policies clear and prominent disclosure of the preexisting condition limitation and the short-term duration of the product must be made. The following notice is an example of a short-term major medical disclosure that is in compliance provided it is prominent and otherwise meets the requirements of this section:
This policy is a short-term medical insurance [policy/certificate] that provides coverage for less than 12 months and excludes coverage for preexisting conditions. Short-term major medical plans do not satisfy the requirement for individuals to have insurance under the Patient Protection and Affordable Care Act and individuals who have purchased short-term major medical coverage may be subject to federal penalties for not having minimum essential coverage.
The disclosures required by this section must be contained on the first page of the policy. The requirements of this section also apply to outlines of coverage. Nothing in this section applies to Medicare supplement, or to long-term care, disability, or credit health insurance coverages.
Source: 39 SDR 203, adopted June 10, 2013, effective January 1, 2014; 47 SDR 68, effective December 7, 2020.
General Authority: SDCL 58-17-87(6), 58-33A-7(13).
Law Implemented: SDCL 58-17-70.
20:06:39:34.02. Renewability of short term major medical plans. For short term major medical plans, as defined in SDCL subdivision 58-17-66(14), the policy must specify an expiration date that is less than 12 months after the original effective date of the policy and, taking into account renewals or extensions, may have a duration of no more than 36 months in total.
Source: 47 SDR 68, effective December 7, 2020.
General Authority: SDCL58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:35. Policy not subject to group requirements. If a carrier upon application for an individual health benefit plan takes reasonable steps to ensure that premiums are not paid by an employer, then a carrier, upon becoming aware of a premium payment by an employer for an individual health benefit plan, must request substitute payment from the individual insured which is not paid by an employer
A carrier which fails to either take reasonable steps to ensure premiums are not paid by an employer during the application process or fails to request substitute payment from the individual insured which is not paid by an employer must treat the policy or policies as group contracts if a payment is received from an employer unless the employer has only one employee.
Source: 34 SDR 200, effective January 28, 2008.
Law Implemented: SDCL 58-17-87.
General Authority: SDCL 58-17-70, 58-18B-2.
20:06:39:36. Medically necessary leave of absence defined. For purposes of §§ 20:06:39:37 to 20:06:39:39, inclusive, the phrase medically necessary leave of absence means a leave of absence from an accredited institution of higher learning or any other change in enrollment at such an institution that
(1) Commences while a qualifying child is suffering from a serious illness or injury;
(2) Is medically necessary; and
(3) Causes the qualifying child to lose student status for purposes of coverage under the terms of the plan.
Source: 36 SDR 96, effective December 9, 2009.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:37. Dependent coverage. Any health insurance issuer issuing a health benefit plan that provides dependent coverage for any qualifying child may not terminate coverage due to a medically necessary leave of absence for a period of twelve months after the first day of leave or the date on which such coverage would otherwise terminate under the terms of the plan, whichever is earlier. A qualifying child whose benefits are continued under this section is entitled to the same benefits as if the qualifying child continued to be a covered student and was not on a medically necessary leave of absence.
The health benefit plan must receive written certification of the medically necessary leave of absence by a treating physician of the qualifying child that states that the child is suffering from a serious illness or injury and that the leave of absence or other change of enrollment is medically necessary.
Source: 36 SDR 96, effective December 9, 2009; 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:38. Notification. Any health insurance carrier providing health insurance coverage, shall include, with any notice regarding a requirement for certification of student status for coverage under the plan, a description of the terms of § 20:06:39:37 for continued coverage during any medically necessary leave of absence. Such description shall be in language that is understandable to the typical plan participant.
Source: 36 SDR 96, effective December 9, 2009.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:39. Continued application in case of changed coverage. The provisions of §§ 20:06:39:37 and 20:06:39:38 apply if there is a change in coverage for the dependent child and if the following occur:
(1) Dependent child of a participant or beneficiary is in a period of coverage under a health benefit plan offered in connection with such a plan, pursuant to a medically necessary leave of absence of the child;
(2) The manner in which the participant or beneficiary is covered under the plan changes, whether through a change in health insurance coverage or health insurance issuer, a change between health insurance coverage and self-insured coverage, or otherwise; and
(3) The coverage as so changed continues to provide coverage of beneficiaries as dependent children.
This section applies to coverage of the child under the changed coverage for the remainder of the period of the medically necessary leave of absence of the dependent child under the plan in the same manner as it would have applied if the changed coverage had been the previous coverage.
Source: 36 SDR 96, effective December 9, 2009.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:41. Creditable coverage -- Children's Health Insurance Program. Coverage provided pursuant to a state's Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act is creditable coverage.
Source: 36 SDR 127, effective March 1, 2010.
General Authority: SDCL 58-17-87(13).
Law Implemented: SDCL 58-17-69, 58-17-85, 58-18-44.
20:06:39:42. Association health insurance plans subject to individual market rating requirements. A health insurance issuer issuing health policies or certificates to an association must file its premium rates in accordance with the requirements of SDCL 58-17-4.1 to 58-17-4.3, inclusive, and chapter 20:06:22. The requirements of this section apply to rates for any newly approved policies or certificates to be offered in this state and to any increase in premium rates for previously issued certificates that take effect after June 30, 2010. This section does not apply to any association plan exclusively issued to employers as members of an association, to any association plan that is an excepted benefit as defined by SDCL 58-17-69(13), or to any association plan which provides blanket health insurance.
Student health plans must comply with the applicable requirements of this chapter for policy years beginning after December 31, 2013. For purposes of student plans, policy year is not dependent upon the effective date of coverage of individual students or dependents.
Source: 36 SDR 209, effective July 1, 2010; 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87(5).
Law Implemented: SDCL 58-17-4.1, 58-17-4.2, 58-17-4.3.
20:06:39:43. Definitions. Unless otherwise provided, the following terms are defined for purposes of §§ 20:06:39:43 to 20:06:39:56, inclusive:
(1) "Collect," with respect to information, to request, require, or purchase such information;
(2) "Family member," with respect to an individual, a dependent of the individual or any other person who is a first-degree, second-degree, third-degree, or fourth-degree relative of the individual or of a dependent of the individual. Relatives by affinity such as by marriage or adoption are treated the same as relatives by consanguinity that is, relatives who share a common biological ancestor. In determining the degree of the relationship, relatives by less than full consanguinity such as half-siblings, who share only one parent are treated the same as relatives by full consanguinity such as siblings who share both parents;
(3) "First-degree relatives," parents, spouses, siblings, and children;
(4) "Fourth-degree relatives," great-great grandparents, great-great grandchildren, and children of first cousins;
(5) "Genetic information:"
(a) The individual's genetic tests;
(b) The genetic tests of family members of the individual;
(c) The manifestation of a disease or disorder in family members of the individual; or
(d) Any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by the individual or any family member of the individual.
With respect to a pregnant woman or a family member of the pregnant woman, the term includes genetic information of any fetus carried by the pregnant woman. With respect to an individual or a family member of the individual who is utilizing an assisted reproductive technology, the term includes genetic information of any embryo legally held by the individual or family member. However, the term does not include information about sex or age of any individual;
(6) "Genetic services," genetic test; genetic counseling including obtaining, interpreting, or assessing genetic information; or genetic education;
(7) "Genetic test," an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Therefore, a test to determine whether an individual has a BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test;
(8) "Manifestation or manifested," with respect to a disease, disorder, or pathological condition, that an individual has been or could reasonably be diagnosed with the disease, disorder, or pathological condition by a health care professional with appropriate training and expertise in the field of medicine involved. A disease, disorder, or pathological condition is not manifested if a diagnosis is based principally on genetic information;
(9) "Payment," with respect to the activities undertaken by a health plan, to obtain premiums or to determine or fulfill its responsibility for coverage and the provision of benefits under the health plan, or by a health care provider or health plan, to obtain or provide reimbursement for the provision of health care. However, these activities include:
(a) Determinations of eligibility or coverage including coordination of benefits or the determination of cost sharing amounts, and adjudication or subrogation of health benefit claims;
(b) Risk adjusting amounts due based on enrollee health status and demographic characteristics;
(c) Billing, claims management, collection activities, obtaining payment under a contract for reinsurance including stop-loss insurance and excess of loss insurance, and related health care data processing;
(d) Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges;
(e) Utilization review activities, including precertification and preauthorization of services, and concurrent and retrospective review of services; and
(f) Disclosure to consumer reporting agencies of the name and address, date of birth, social security number, payment history, account number or name and address of the health care provider or health plan, or both, relating to collection of premiums or reimbursement;
(10) "Second-degree relatives," grandparents, grandchildren, aunts, uncles, nephews, and nieces;
(11) "Third-degree relatives," great-grandparents, great-grandchildren, great aunts, great uncles, and first cousins;
(12) "Underwriting purposes," with respect to an issuer offering health insurance coverage in the individual market:
(a) Rules for or determination of eligibility, including enrollment and continued eligibility for benefits under the plan or coverage, including changes in deductibles or other cost-sharing mechanisms in return for activities such as completing a health risk assessment or participating in a wellness program;
(b) The computation of premium or contribution amounts under the plan or coverage, including discounts, rebates, payments in kind, or other premium differential mechanisms in return for activities such as completing a health risk assessment or participation in a wellness program;
(c) The application of any preexisting condition exclusion under the plan or coverage; and
(d) Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87, 58-17-87(4).
Law Implemented: SDCL 58-17-87, 58-33-13.
20:06:39:44. Prohibition on genetic information in setting premium rates. An issuer offering health insurance coverage in the individual market may not adjust premium amounts for an individual on the basis of genetic information regarding the individual or a family member of the individual.
Nothing in this section precludes an issuer from adjusting premium amounts for an individual on the basis of a manifestation of a disease or disorder in that individual, or on the basis of a manifestation of a disease or disorder in a family member of that individual if the family member is covered under the policy that covers the individual.
However, the manifestation of a disease or disorder in one individual may not also be used as genetic information about other individuals covered under the policy issued to that individual or used to further increase premium amounts.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-11-1, 58-17-4.2, 48-17-74.1, 58-17-87, 58-33-13.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
Nothing in § 20:06:39:45 precludes an issuer offering health insurance in the individual market from obtaining and using the results of a genetic test in making a determination regarding payment. Therefore, if an issuer conditions payment for an item or service based on its medical appropriateness and the medical appropriateness of the item or service depends on a covered individual's genetic makeup, the issuer is permitted to condition payment on the outcome of a genetic test and may refuse payment if the covered individual does not undergo the genetic test. An issuer in the individual market may only request the minimum amount of information necessary to make a determination regarding payment. The minimum amount of information necessary is determined in accordance with the minimum necessary standard in 45 CFR 164.502(b) of the privacy regulations issued under the Health Insurance Portability and Accountability Act.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:47. Research exception. An issuer may request, but not require, that an individual or family member covered under the same policy undergo a genetic test if all of the following conditions are met:
(1) The issuer makes the request pursuant to research, as defined in 45 CFR 46.102(d), that complies with 45 CFR Part 46 or equivalent federal regulations, and any applicable state or local law or regulations for the protection of human subjects in research; and
(2) The issuer makes the request in writing, and the request clearly indicates to each individual or, in the case of a minor child, to the legal guardian of the child that:
(a) Compliance with the request is voluntary; and
(b) Noncompliance will have no effect on eligibility for benefits or premium amounts. The issuer must complete a copy of the Notice of Research Exception form found in Appendix B and submit the form to the federal Secretary of Health and Human Services. No genetic information collected or acquired under this section may be used for underwriting purposes.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:49. Medical appropriateness. An issuer in the individual market may limit or exclude a benefit based on whether the benefit is medically appropriate. The determination of whether the benefit is medically appropriate is not within the meaning of underwriting purposes. Therefore, if an issuer conditions a benefit based on its medical appropriateness and the medical appropriateness of the benefit depends on a covered individual's genetic information, the issuer may condition the benefit on the genetic information. An issuer may only request the minimum amount of genetic information necessary to determine medical appropriateness and may deny the benefit if the covered individual does not provide the genetic information required to determine medical appropriateness.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:50. Collection of genetic information prior to or in connection with enrollment. An issuer offering health insurance coverage in the individual market may not collect genetic information with respect to any individual prior to the individual's enrollment under the coverage or in connection with that individual's enrollment. Whether or not an individual's information is collected prior to that individual's effective date of coverage is determined based upon the time of collection.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:51. Incidental collection exception. If an issuer offering health insurance coverage in the individual market obtains genetic information incidental to the collection of other information concerning any individual, the collection is not a violation of § 20:06:39:50, as long as the collection is not for underwriting purposes in violation of §§ 20:06:39:48 and 20:06:39:49. The incidental collection exception in this section does not apply to any collection where it is reasonable to anticipate that health information will be received, unless the issuer explicitly provides that genetic information should not be provided to the issuer.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:52. Prohibition on genetic information as a condition of eligibility. An issuer offering health insurance coverage in the individual market may not establish rules for the eligibility, including continued eligibility, of any individual to enroll in individual health insurance coverage based on genetic information.
Nothing in this section precludes an issuer from establishing rules for eligibility for an individual to enroll in individual health insurance coverage based on the manifestation of a disease or disorder in that individual, or in a family member of that individual when the family member is covered under the policy that covers the individual.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87, 58-17-87(2).
Law Implemented: SDCL 58-17-87.
20:06:39:53. Prohibition on genetic information as preexisting condition. An issuer offering health insurance coverage in the individual market may not, on the basis of genetic information, impose any preexisting condition exclusion with respect to that coverage.
Nothing in this section precludes an issuer from imposing any preexisting condition exclusion for an individual with respect to health insurance coverage on the basis of a manifestation of a disease or disorder in that individual.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-84(4), 58-17-87.
20:06:39:54. Medicare supplemental health insurance. The requirements of §§ 20:06:39:43 to 20:06:39:56, inclusive, do not apply to Medicare supplemental health insurance policies. However, Medicare supplemental health insurance policies are subject to §§ 20:06:13:87 to 20:06:13:92, inclusive.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:55. Applicability to excepted benefits. Sections 20:06:39:43 to 20:06:39:54, inclusive, do not apply to excepted benefits as defined by 42 USC 300gg-91(c), as of August 1, 2010.
Source: 37 SDR 47, effective September 20, 2010.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:57. Guaranteed availability of coverage in the individual market. After December 31, 2013, a health insurance issuer that offers health insurance coverage in the individual market in this state must offer to any individual in the state all products that are approved for sale in the applicable market, and must accept any individual that applies for any of those products. Nothing in this section requires an issuer to offer or provide coverage outside its approved service area.
A health insurance issuer offering health insurance coverage in the individual market, other than excepted benefits, must ensure that such coverage includes the essential health benefits package as defined in § 20:06:56:03 effective for plan or policy years beginning after December 31, 2013. Except for catastrophic plans, any plans not providing at least a bronze level of coverage or not providing essential health benefits as defined in § 20:06:56:03 must be issued as a supplement to other health insurance coverage and may not be used to replace essential health benefits coverage, a grandfathered health benefit plan or a catastrophic plan.
An issuer may but is not required to confirm residence of any applicant or insured to confirm eligibility. Nothing requires an issuer to exclude nonresidents or international students or their dependents from coverage on a student health plan.
Nothing in this section applies to long-term care, medicare supplement, short-term major medical, accident only, stand-alone dental, TRICARE, disability income, or other policies providing coverage based upon a disability trigger.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:58. Denial of coverage. After December 31, 2013, a health insurance issuer may deny health insurance coverage in the individual market outside the Exchange if the issuer has demonstrated to the director the following:
(1) The health insurance issuer does not have the financial reserves necessary to underwrite additional coverage;
(2) The health insurance issuer is applying the denial uniformly to all individuals in the individual market without regard to the claims experience of those individuals, and their dependents or any health status-related factor relating to such individuals, and dependents.
An issuer that denies coverage to any individual may not offer coverage in the individual market before the later of the following dates: the 181st day after the date the issuer denies coverage or the date the issuer demonstrates to the director that the issuer has sufficient financial reserves to underwrite additional coverage.
Nothing in this section limits an issuer's ability to renew coverage already in force or relieve the issuer of the responsibility to renew that coverage. Coverage offered after the 180-day period specified in this section is subject to the requirements of this section and § 20:06:55:42. The ability to offer or renew coverage as specified by this section and § 20:06:55:42 is subject to all applicable service area requirements and restrictions.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:59. Open enrollment. After December 31, 2013, a health insurance issuer must provide an initial open enrollment period and annual open enrollment periods outside the individual Exchange, during which qualified individuals may enroll in a non-grandfathered plan or enrollees may change plans. Except as provided by § 20:06:39:63, a health insurance issuer may restrict enrollment to a qualified individual or an enrollee to change plans during the initial open enrollment period, the annual open enrollment period, or a special enrollment period for which the qualified individual or enrollee has been determined eligible.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:60. Initial open enrollment period. The initial open enrollment period in the individual market outside the individual market Exchange begins October 1, 2013, and extends through March 31, 2014. The effective coverage dates for the initial open enrollment period are as follows:
(1) For a person enrolling on or before December 15, 2013, the issuer must make the coverage effective on January 1, 2014;
(2) For a person enrolling between the first and fifteenth day of January 1, 2014, to March 15, 2014, the issuer must make coverage effective on the first day of the following month; and
(3) For a person enrolling between the sixteenth and last day of the month for any month between December 2013 and March 31, 2014, the issuer must make coverage effective on the first day of the second following month.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:61. Annual open enrollment period. Health insurance issuers must provide an annual open enrollment period for the individual market.
Source: 39 SDR 203, effective June 10, 2013; 41 SDR 93, effective December 3, 2014; 45 SDR 45, effective October 10, 2018.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:62. Special enrollment period effective dates. After December 31, 2013, a health insurance issuer must provide special enrollment periods consistent with this section outside 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 effective 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, the plan must ensure that coverage is effective on the date of birth, adoption, or placement for adoption; and
(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 following month.
Unless specifically stated otherwise herein, a qualified individual or enrollee has 60 days from the date of a triggering event to select a nongrandfathered health plan.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:63. Coverage issued outside open enrollment. A health insurance issuer may issue a health plan to any individual applying for coverage outside of an insurance Exchange and outside of an open enrollment period. For health plans offered outside the exchange and outside an open enrollment the following apply:
(1) For those that are uninsured the issuer may require a waiting period of not more than 90 days from the date of application until coverage is effective;
(2) For uninsured applicants only a bronze level plan or, if eligible, a catastrophic plan may be issued with an effective date consistent with open enrollment standards;
(3) For those with creditable coverage within 63 days of the date of application, only coverage in the same metal level as the applicant's prior coverage may be issued. This section applies to all applications received after March 31, 2014, in the individual market outside the Exchange that are not received during an open enrollment period. For purposes of this section an uninsured does not include a person who lapsed or voluntarily terminated coverage in the past 12 months prior to applying.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:64. Enrollment in catastrophic plans. A health plan is a catastrophic plan if it meets the following conditions:
(1) Meets all applicable requirements for health insurance coverage in the individual market and is offered only in the individual market;
(2) Does not provide a bronze, silver, gold, or platinum level of coverage described in § 20:06:56:11;
(3) Provides coverage of the essential health benefits under § 20:06:56:03 once the annual limitation on cost sharing is reached;
(4) Provides coverage for at least three primary care visits per year before reaching the deductible; and
(5) Covers only individuals who meet either of the following conditions:
(a) Have not attained the age of 30 prior to the first day of the plan year;
(b) Have received a certificate of exemption for the reasons identified in section 1302(e)(2)(B)(i) or (ii) of PPACA as defined in § 20:06:55:32.
A catastrophic plan may not impose any cost-sharing requirements, such as a copayment, coinsurance, or deductible, for preventive services, in accordance with § 20:06:56:03. For other than self-only coverage, each individual enrolled must meet the requirements.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:65. Student health insurance coverage. Student health insurance coverage is considered to be available only through a bona fide association. A health insurance issuer that offers student health insurance coverage is not required to accept persons who are not students or dependents of students in such coverage.
A health insurance issuer that offers student health insurance coverage is not required to renew or continue coverage for individuals who are no longer students or dependents of students.
This section applies to any non-grandfathered student health coverage issued or renewed after December 31, 2013.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:66. Clinical trial. After December 31, 2013, a health insurance issuer that offers a health benefit plan providing health insurance coverage individual market in this state may not:
(1) Deny participation by a qualified individual in an approved clinical trial;
(2) Deny, limit or impose additional conditions on the coverage of routine patient costs for items or services furnished in connection with participation in the trial; or
(3) Discriminate against an individual on the basis of the individual's participation in an approved clinical trial.
A network plan may require a qualified individual who wishes to participate in an approved clinical trial to participate in a trial that is offered through a health care provider who is part of the network plan if the provider is participating in the trial and the provider accepts the individual as a participant in the trial.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:67. Nonrenewal of coverage. After December 31, 2013, a health insurance issuer offering health insurance coverage in the individual market is required to renew or continue in force the coverage at the option of the individual. An issuer may nonrenew or discontinue health insurance coverage offered in the individual market based only on the occurrence of one or more of the following:
(1) Nonpayment of premiums. The plan sponsor or individual, as applicable, has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage, including any timeliness requirements;
(2) Fraud. The plan sponsor or individual, as applicable, has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact in connection with the coverage;
(3) Termination of plan. The issuer is ceasing to offer coverage in the market in accordance with § 20:06:39:58;
(4) Enrollees' movement outside service area. For network plans, there is no longer any enrollee under the plan who lives, resides, or works in the service area of the issuer; and
(5) Association membership ceases. For coverage made available in the small or large group market only through one or more bona fide associations, if the employer's membership in the bona fide association ceases, but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual.
This section does not apply to grandfathered plans.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:68. Discontinuing a particular product. After December 31, 2013, in any case in which a health insurance issuer elects to discontinue offering a particular product in the individual market, that product may only be discontinued by the issuer if the following occurs:
(1) The issuer provides notice in writing to each individual provided that particular product in that market covered under such coverage of the discontinuation at least 90 calendar days before the date the coverage will be discontinued;
(2) The issuer offers to each individual provided that particular product the option, on a guaranteed issue basis, to purchase all health insurance coverage currently being offered by the issuer to an individual health insurance coverage; and
(3) In exercising the option to discontinue that product and in offering the option of coverage, the issuer acts uniformly without regard to the claims experience of those individuals, or any health status-related factor relating to any participant or beneficiary covered or new participant or beneficiary who may become eligible for such coverage.
This section does not apply to grandfathered plans.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:69. Discontinuing all coverage. After December 31, 2013, an issuer may elect to discontinue offering all health insurance coverage in the individual market, or all markets, in a state in accordance with applicable state law only if the issuer meets all of the following conditions:
(1) The issuer provides notice in writing to the director and to each individual covered under the discontinued coverage at least 180 calendar days prior to the date the coverage will be discontinued; and
(2) All health insurance policies issued or delivered for issuance by the issuer in the state in the applicable market or markets are discontinued and not renewed.
An issuer that elects to discontinue offering all health insurance coverage in a market or markets in a state may not issue coverage in the applicable market or markets in the state for a period of five years beginning on the date of discontinuation for the last coverage discontinued.
This section does not apply to grandfathered plans.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:70. Special enrollment periods for marriage, birth, and adoption. After December 31, 2013, a special enrollment period occurs for the individual, the individual's spouse, and the individual's dependents if the following conditions are met:
(1) A group health benefit plan makes coverage available with respect to a dependent of an individual;
(2) The individual is an employee; and
(3) The individual becomes married or a child becomes a new dependent as a result of marriage, birth, adoption, or placement for adoption.
The special enrollment period must be at least 60 days in length and must begin 30 days after the qualifying event. If coverage required pursuant to this section is applied for, the effective date for coverage in the case of a marriage may be no later than the first day of the first calendar month after the date the completed request is received by the plan or, in the case of a dependent, the date of birth or the start of the adoption bonding period.
This section does not apply to grandfathered plans.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:71. Special enrollment triggers. After December 31, 2013, a health insurance issuer offering health insurance coverage in the individual market outside the Exchange must allow for an individual or dependent to enroll or change from one plan to another as a result of the following qualifying events:
(1) The death of the covered individual;
(2) The termination of individual's employer coverage other than by reason of gross misconduct, or reduction of hours of the covered employee's spouse;
(3) The divorce or legal separation;
(4) Individual becoming entitled to benefits under XVII of the Social Security Act;
(5) Dependent child ceasing to be dependent child;
(6) A proceeding in a case under Title 11, United States Code, commencing on or after July 1, 1986, with respect to the employer from whose employment the covered individual retired at any time;
(7) An individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption; and
(8) A qualified individual or enrollee gains access to nongrandfathered health plan as a result of a permanent move.
A health insurance issuer in the individual market must provide, with respect to individuals enrolled in non-calendar year, a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.
This section does not apply to grandfathered plans.
Source: 39 SDR 203, effective June 10, 2013; 41 SDR 93, effective December 3, 2014.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:72. Preexisting condition exclusion and waiting period prohibited. No health insurance issuer offering an individual health benefit plan may impose any preexisting condition exclusion or preexisting condition waiting period with respect to such coverage.
Grandfathered plans are not required to remove preexisting condition waiting periods on exclusionary riders.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:73. Health insurance issuer defined. A health insurance issuer is 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, and 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.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
20:06:39:74. Applicability. Effective January 1, 2014, §§ 20:06:39:03, 20:06:39:05, 20:06:39:07, 20:06:39:10, 20:06:39:19, 20:06:39:20, 20:06:39:20.05, and 20:06:39:30, only apply to grandfathered plans.
Sections 20:06:39:04, 20:06:39:06, 20:06:39:08, and 20:06:39:34 are repealed effective January 1, 2014.
Sections 20:06:39:04.01, 20:06:39:06.01, 20:06:39:08.01, and 20:06:39:34.01 are effective January 1, 2014.
Source: 39 SDR 203, effective June 10, 2013.
General Authority: SDCL 58-17-87.
Law Implemented: SDCL 58-17-87.
