<html> <head> <title>Rule 20:06:56:21 Exception for uniform modification of coverage.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:56:21"> <META NAME="Description" Content="Administrative Rules 20:06:56:21 Exception for uniform modification 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-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><a name="_GoBack"></a><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>20:06:56:21.&nbsp;&nbsp;Exception for uniform modification of coverage.</b> Only at the time of coverage renewal may issuers modify the health insurance coverage for a product offered to a group health plan or an individual, as applicable, in the large group market, the individual market, and the small group market if, for coverage available in this market, other than only through one or more bona fide associations.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Modifications made uniformly and solely pursuant to applicable federal or state requirements are considered a uniform modification of coverage in the small group and individual market if:</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The modification is made within a reasonable time period after the imposition or modification of the federal or state requirement;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The modification is directly related to the imposition or modification of the federal or state requirement;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;Other types of modifications made uniformly are considered a uniform modification of coverage if the health insurance coverage for the product in the individual or small group market meets all of the following criteria:</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (i)&nbsp;&nbsp;The product is offered by the same health insurance issuer;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (ii)&nbsp;&nbsp;The product is offered as the same product network type;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (iii)&nbsp;&nbsp;The product continues to cover at least a majority of the same service area;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (iv)&nbsp;&nbsp;Within the product, each plan has the same cost-sharing structure as before the modification, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in sections 1302(d) and (e) of the Affordable Care Act (December 3, 2014); and</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (v)&nbsp;&nbsp;The product provides the same covered benefits, except for any changes in benefits that cumulatively impact the plan-adjusted index rate for any plan within the product within an allowable variation of +/- two percentage points.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The director may broaden the standards in subsection 3(iii) and (iv) of this section after consideration of the impact on the insurance-buying public.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; If an issuer in the individual market is renewing non-grandfathered coverage or uniformly modifying non-grandfathered coverage the issuer must provide to each individual written notice of the renewal before the date of the first day of the next annual open enrollment period.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; If an issuer in the small group market is renewing coverage or uniformly modifying coverage the issuer must provide to each plan sponsor or individual written notice of the renewal at least 60 calendar days before the date of the coverage will be renewed.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 41 SDR 93, effective December 3, 2014.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <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></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:-.7pt;margin-bottom:.0001pt;text-align:justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html>