<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000002 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0-000004 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.01in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } </style></head><body><div><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=55:08:01:01"><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000000">55:08:01:01</span></a><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000001">.  Definition of terms.</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">Words and phrases</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> defined in SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=3-6C-1"><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000002">3-6C-1</span></a><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> have the same meaning when used in this article. </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">As</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> used in this article:</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0-000004"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (1)  "Adverse determination" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">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;</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0-000004"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0-000004"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (2)  "Claim" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">the request of coverage of an eligible employee or any other person under the South Dakota State Employee Health Plan;</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (3)  "Contract period" or "plan year" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">that period beginning on July 1 of one year and ending on June 30 of the following year;</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (4)  "Contribution or premium" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">the sum paid by or on behalf of an employee as consideration for a life, health, or flexible benefits;</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (5)  "Eligible employee" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">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;</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (6)  "Flexible benefits plan" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">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</span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">,</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> and others as determined by the bureau;</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (7)  "Participating unit" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">any department, bureau, campus, institution, board, or commission of the state that has employees who are eligible for participation;</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> and</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    (8)  "Proof of insurability" </span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">means </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">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</span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">.</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000001">Source:</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> 38 SDR 213, effective July 1, 2012; 41 SDR 58, effective October 14, 2014; 42 SDR 97, effective January 4, 2016</span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">; 47 SDR 142, effective July 1, 2021</span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">.</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000001">General Authority:</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=3-6E-13"><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000002">3-6E-13</span></a><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">.</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">    </span><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000001">Law Implemented:</span><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=3-6E-1"><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0-000002">3-6E-1</span></a><span class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10C0">.</span></p><p dir="ltr" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10P0"><span xml:space="preserve" class="sd0978ff1-a2b8-441e-80c1-b4dad1be9b10000003"> </span></p></div></body></html>