55:08:01:01. Definition of terms. Words and phrases defined in SDCL 3-6C-1 have the same meaning when used in this article. As used in this article:
(1) "Adverse determination" means a determination by the South Dakota State Employee Health Plan or its designee utilization review organization that an admission, availability of care, continued stay, or other health-care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the South Dakota State Employee Health Plan's requirements for medical necessity, appropriateness, health-care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated;
(2) "Claim" means the request of coverage of an eligible employee or any other person under the South Dakota State Employee Health Plan;
(3) "Contract period" or "plan year" means that period beginning on July 1 of one year and ending on June 30 of the following year;
(4) "Contribution or premium" means the sum paid by or on behalf of an employee as consideration for a life, health, or flexible benefits;
(5) "Eligible employee" means a permanent full-time employee, permanent part-time employee, or an employee employed by a participating unit who has worked an average of 30 hours or more per week during a 12 month period, as defined by the Patient Protection and Affordable Care Act of 2010, as amended;
(6) "Flexible benefits plan" means a benefits plan that allows members to select from a list of benefits options, some or all of which may be tax-advantaged, and which may vary depending on the status of a member as either an employee or retiree. The options may include dental, vision, medical spending accounts, dependent care, and others as determined by the bureau;
(7) "Participating unit" means any department, bureau, campus, institution, board, or commission of the state that has employees who are eligible for participation; and
(8) "Proof of insurability" means evidence of a person's medical condition based upon a medical examination, a person's medical history, or a doctor's statement regarding a person's health.
Source: 38 SDR 213, effective July 1, 2012; 41 SDR 58, effective October 14, 2014; 42 SDR 97, effective January 4, 2016; 47 SDR 142, effective July 1, 2021.
General Authority: SDCL 3-6E-13.
Law Implemented: SDCL 3-6E-1.
CHAPTER 55:08:02
HEALTH BENEFIT
Section
55:08:02:01 Election of coverage.
55:08:02:02 Provision of coverage.
55:08:02:03 Effective date of dependent coverage.
55:08:02:04 Application for dependent coverage.
55:08:02:05 Reduction in or termination of dependent coverage.
55:08:02:06 Notice of ability to continue coverage.
55:08:02:01. Election of coverage. An eligible employee has 30 days from the date eligibility is determined to apply for coverage of any dependents without showing proof of insurability.
Source: 38 SDR 213, effective July 1, 2012; 42 SDR 97, effective January 4, 2016.
General Authority: SDCL 3-6E-13(3)(9).
Law Implemented: SDCL 3-6E-1, 3-6E-4, 26 U.S.C. § 4980H.
55:08:02:02. Provision of coverage. The commissioner shall make health coverage available to eligible employees, Consolidated Omnibus Budget Reconciliation Act participants, and their dependents.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(2).
Law Implemented: SDCL 3-6E-1, 3-6E-6.
55:08:02:03. Effective date of dependent coverage. Dependent coverage is effective on the first day of the month following the employee's hire date. Dependent coverage may not become effective before the effective date of the employee’s coverage.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
General Authority: SDCL 3-6E-13(4).
Law Implemented: SDCL 3-6E-1, 3-6E-5, 3-6E-6.
Editor's Note: The Legislative Research Council struck the extra "the" in front of the phrase "the first day of the month" to correct an apparent error.
55:08:02:04. Application for dependent coverage. An eligible employee may apply for dependent coverage within 30 days after the employee’s marriage or the birth or adoption of a child. A child may be covered from birth by notification of the commissioner by the employee. Payment shall be made by payroll deduction unless otherwise authorized by the commissioner.
Source: 38 SDR 213, effective July 1, 2012; 44 SDR 99, effective December 11, 2017.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1.
55:08:02:05. Reduction in or termination of dependent coverage. An eligible employee enrolled for dependent coverage may reduce the number of dependents covered following a death, divorce, or marriage and if a dependent child becomes ineligible because of age. Dependent coverage terminates in the month following the last month in which contributions were paid. An employee shall notify the commissioner and the participating unit of any dependent who becomes ineligible for participation in the plan. Any contribution previously paid may not be refunded if coverage has been provided.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(6).
Law Implemented: SDCL 3-6E-11.
55:08:02:06. Notice of ability to continue coverage. If an eligible employee dies, is divorced or legally separated, terminates employment, has hours of employment reduced, or has a dependent who no longer qualifies as a dependent, the participating unit shall provide written notice, as applicable, to the eligible employee and the employee’s affected dependent that the employee or the dependent, or both, may elect to continue health coverage.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1.
CHAPTER 55:08:03
LIFE BENEFIT
Section
55:08:03:01 Election of employee and dependent coverage.
55:08:03:02 Beginning of coverage.
55:08:03:03 Election of coverage after initial eligibility period.
55:08:03:04 Termination of coverage.
55:08:03:05 Repealed.
55:08:03:06 Basic life benefit defined.
55:08:03:01. Election of employee and dependent coverage. An eligible employee has 30 days from the date eligibility is determined to elect the life benefit plan to cover the employee and the employee’s dependents without showing proof of insurability.
An eligible employee may elect dependent coverage within 30 days after marriage. If an employee elects dependent coverage, future children are automatically covered at birth.
Source: 38 SDR 213, effective July 1, 2012; 42 SDR 97, effective January 4, 2016; 44 SDR 99, effective December 11, 2017.
General Authority: SDCL 3-6E-13(1).
Law Implemented: SDCL 3-6E-1.
55:08:03:02. Beginning of coverage. Coverage begins the first day of the month following the employee’s hire date.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
General Authority: SDCL 3-6E-13(4).
Law Implemented: SDCL 3-6E-1, 3-6E-5.
55:08:03:03. Election of coverage after initial eligibility period. An eligible employee may elect coverage for the employee and the employee’s dependents after the initial eligibility period upon showing proof of insurability for each person to be insured and may increase the employee’s coverage after the initial eligibility period upon showing proof of insurability.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1.
55:08:03:04. Termination of coverage. An employee enrolled for life coverage may elect, at any time, to terminate enrollment and deductions. Coverage continues through the last day of the month for which contributions were paid.
Source: 38 SDR 213, effective July 1, 2012; 41 SDR 58, effective October 14, 2014; 47 SDR 142, effective July 1, 2021.
General Authority: SDCL 3-6E-13(5).
Law Implemented: SDCL 3-6E-1.
55:08:03:05. Continuation of coverage. Repealed.
Source: 38 SDR 213, effective July 1, 2012; repealed, 41 SDR 58, effective October 14, 2014.
55:08:03:06. Basic life benefit defined. The basic life benefit payable under the life benefit program is $25,000.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(1).
Law Implemented: SDCL 3-6E-1.
55:08:04:01. Eligibility of retiree and dependents. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
55:08:04:02. Election of coverage by retiree. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
55:08:04:03. Election of coverage by retiree after expiration of initial eligibility period. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 41 SDR 58, effective October 14, 2014; 47 SDR 142, effective July 1, 2021.
55:08:04:04. Beginning of coverage. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
55:08:04:05. Payment of contributions. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
55:08:04:06. Termination of coverage. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
55:08:04:07. Continuation of coverage of dependents of deceased retiree. Repealed.
Source: 38 SDR 213, effective July 1, 2012; 47 SDR 142, effective July 1, 2021.
CHAPTER 55:08:05
FLEXIBLE BENEFITS PLAN
Section
55:08:05:01 Eligibility.
55:08:05:02 Election to participate.
55:08:05:03 Changes in election.
55:08:05:04 Notice of ability to continue participation.
55:08:05:01. Eligibility. Any eligible employee may participate in the flexible benefits plan. If an eligible employee retires, the retiree may apply to participate in the flexible benefits plan for 18 months after the eligible employee retires.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(2).
Law Implemented: SDCL 3-6E-1.
55:08:05:02. Election to participate. An eligible employee may file an election to participate in the flexible benefits plan for the employee or the employee’s dependents in the office of the commissioner. Once made, an election shall remain in effect for the entire plan year.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1.
55:08:05:03. Changes in election. An eligible employee may change the employee’s election when there has been a marriage, birth or adoption, divorce, change in school status or jobs, or death. The change shall be made within 30 days after the change in family status and shall be consistent with the change in family status. A new employee may make the election at the time the employee is initially hired or within 30 days thereafter. An election or change in election shall be in writing on a form provided by the commissioner. A new election may be made for each plan year during annual enrollment.
If a former employee is rehired within a plan year, the employee’s election at the time of the employee’s previous employment continues unless there has been a change in family status during the break in service. If applicable, changes shall be consistent with the change in family status.
Source: 38 SDR 213, effective July 1, 2012; 44 SDR 99, effective December 11, 2017.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1.
55:08:05:04. Notice of ability to continue participation. If an eligible employee dies, is divorced or legally separated, is terminated from employment, has the hours of employment reduced, or has a dependent who no longer qualifies as a dependent, the participating unit shall provide written notice, as applicable, to the eligible employee and the employee’s affected dependent that the employee or the dependent, or both, may elect to continue to participate in flexible benefits.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1.
CHAPTER 55:08:06
CLAIMS REVIEW PROCEDURE
Section
55:08:06:01 Notice of denial of claim.
55:08:06:02 Appeal from denial of claim.
55:08:06:03 Appeal procedure.
55:08:06:04 Repealed.
55:08:06:05 Failure to comply with time limits.
55:08:06:06 Delivery requirements for written notice.
55:08:06:01. Notice of denial of claim. The benefits manager shall provide written notice to an eligible employee whose claim for benefits is denied. The notice shall include the specific reason for denial, including reference to the plan provision upon which denial is based, and a description of additional material or information necessary for the eligible employee to complete the employee’s claim, including an explanation of the claims review procedure.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13.
Law Implemented: SDCL 3-6E-1.
55:08:06:02. Appeal from denial of claim. An eligible employee or any other person whose claim for benefits under chapter 55:08:02 is denied may appeal to the benefits manager within 30 days after receipt of the notice of adverse determination. The benefits manager shall investigate and make a decision within 30 days after receipt of the complaint. If the benefits manager upholds an adverse determination, the eligible employee or any other person will be notified of their right to an external review. The eligible employee or any other person has four months after receipt of notice of an adverse determination to request an external review.
Source: 38 SDR 213, effective July 1, 2012; 42 SDR 97, effective January 4, 2016.
General Authority: SDCL 3-6E-13.
Law Implemented: SDCL 3-6E-1, 45 C.F.R. § 147.136.
55:08:06:03. Appeal procedure. An eligible employee or any other person whose claim has been denied and desires to appeal the adverse determination of the benefits manager may request an external review by filing a request for external review with an independent review organization through the Department of Labor and Regulation, Division of Insurance under ARSD 20:06:53 within four months after receipt of notice of an adverse determination.
An independent review organization's external review decision is binding on the South Dakota State Employee Health Plan except to the extent the South Dakota State Employee Health Plan has other remedies available under applicable state law. An independent review organization's external review decision is binding on the eligible employee or any other person except to the extent the eligible employee or any other person has other remedies available under applicable federal or state law.
Source: 38 SDR 213, effective July 1, 2012; 42 SDR 97, effective January 4, 2016.
General Authority: SDCL 3-6E-13.
Law Implemented: SDCL 3-6E-1, 45 C.F.R. § 147.136.
55:08:06:05. Failure to comply with time limits. Failure by an eligible employee or any other person whose claim has been denied to comply with time limits in this chapter constitutes a withdrawal of the claim. Failure of the benefits manager to comply with the time limits allows the claimant to initiate the next successive step of the procedure. A party may agree to a time extension requested in writing by the other party.
Source: 38 SDR 213, effective July 1, 2012; 42 SDR 97, effective January 4, 2016.
General Authority: SDCL 3-6E-13.
Law Implemented: SDCL 3-6E-1.
CHAPTER 55:08:07
OPT-OUT PROCEDURE
Section
55:08:07:01 Election not to participate.
55:08:07:02 Conditions for rescinding election not to participate.
55:08:07:03 Costs incurred during period of nonparticipation not covered.
55:08:07:04 Repealed.
55:08:07:01. Election not to participate. A new employee may elect not to participate in the state employee health benefit plan pursuant to SDCL 3-6E-4, upon the new employee’s initial opportunity to enroll. An employee may elect not to participate in the state employee health benefit plan pursuant to SDCL 3-6E-4 during the annual enrollment period. Each plan year, the employee shall provide documentation to the benefit plan administrator that the employee is covered by another group health insurance plan as either a spouse or dependent. The documentation of other coverage shall identify the effective dates for the coverage and the family members that are covered. If an employee elects not to participate in the state employee health benefit plan, the employee’s family members are not eligible to participate in the state’s plan.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1, 3-6E-4.
55:08:07:02. Conditions for rescinding election not to participate. An employee may rescind the election not to participate in the state employee health benefit plan at any time outside the annual enrollment period if the employee loses the other group health insurance coverage because the employee is divorced or legally separated, the spouse is terminated, the spouse’s hours of employment are reduced, or the employee no longer qualifies as a dependent. The employee shall provide proof of the loss of other group coverage to the benefit plan administrator.
If the election not to participate is rescinded by the member within the current plan year for any of the reasons listed in this section, the employee may enroll for coverage under the terms of the current state employee health benefit plan. An employee may rescind the election not to participate in the state employee health benefit plan for any reason during the annual health benefit enrollment period.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(3).
Law Implemented: SDCL 3-6E-1, 3-6E-5.
55:08:07:03. Costs incurred during period of nonparticipation not covered. Costs that were incurred by an employee or the employee’s dependents while the employee was not participating in the state employee health benefit plan are not covered expenses under the state employee health benefit plan.
Source: 38 SDR 213, effective July 1, 2012.
General Authority: SDCL 3-6E-13(1).
Law Implemented: SDCL 3-6E-1.
