<html> <head> <title>Rule 20:06:40:79 Denial of coverage.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:40:79"> <META NAME="Description" Content="Administrative Rules 20:06:40:79 Denial of coverage."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>20:06:40:79.&nbsp;&nbsp;Denial of coverage.</span></b> A health insurance issuer may deny health insurance coverage in the group market if the issuer demonstrates to the director&nbsp; the following:</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The health insurance issuer does not have the financial reserves necessary to underwrite additional coverage; and</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The health insurance issuer is applying the denial uniformly to all employers or individuals in the group or individual market, as applicable, in this state without regard to the claims experience of those individuals, employers, and their employees and their employees' dependents or any health status-related factor relating to such individuals, employees, and dependents.</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; An issuer that denies group health insurance coverage to any employer may not offer coverage in the group market in this state before the later of the following dates:</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The 181<sup>st</sup> day after the date the issuer denies coverage, or</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The date the issuer demonstrates to the applicable state authority that the issue has sufficient financial reserves to underwrite additional coverage.</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Nothing in this section limits the 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 &#167;&nbsp;20:06:55:42. The ability to offer or renew coverage as specified by this section and &#167;&nbsp;20:06:55:42 is subject to all applicable service area requirements and restrictions.</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 39 SDR 203, effective June 10, 2013.</span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>General Authority:</span></b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Law Implemented:</span></b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-80">58-18-80.</A></span></font></p> <p class=MsoNormal style='margin-left:-.7pt'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </div> </body> </html>