58-41-35. Contents required in evidence of coverage.

An evidence of coverage shall contain a clear, concise, and complete statement of:

(1)    The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan;

(2)    Any exclusions or limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;

(3)    Where and in what manner information is available as to how service, including emergency and out-of-area services, may be obtained;

(4)    The total amount of payment and copayment if any, for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or noncontributory with respect to group certificates; and

(5)    A description of the health maintenance organization's method for resolving enrollee complaints.

Source: SL 1974, ch 321, § 19 (2).



SDLRC - Codified Law 58-41-35 - Contents required in evidence of coverage.

58-41-35.1. Alcoholism coverage to be offered at time contract is negotiated.

At the time of negotiation of any health maintenance contract, the health maintenance organization shall offer, in writing, to provide the coverage prescribed by §§ 58-17-30.5 and 58-18-7.1.

Source: SL 1979, ch 344, § 12.



SDLRC - Codified Law 58-41-35 - Contents required in evidence of coverage. 58-41-35.2
     58-41-35.2 to 58-41-35.4.   Repealed by SL 2001, ch 274, §§ 10 to 12



SDLRC - Codified Law 58-41-35 - Contents required in evidence of coverage.

58-41-35.5. Grandfathered contracts required to cover low-dose mammography--Extent of coverage.

Each health maintenance contract that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening by low-dose mammography for the presence of occult breast cancer that is subject to the same dollar limits, deductibles, and coinsurance factors as for other radiological examinations. Coverage for the screening shall be provided as follows: ages thirty-five to thirty-nine, one baseline mammography; ages forty to forty-nine, a mammography every other year; and age fifty and older, a mammography every year.

As used in this section, "low-dose mammography" means the X ray examination of the breast using equipment dedicated specifically for mammography, including the X ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad midbreast, with two views for each breast and with interpretation by a qualified radiologist.

The provisions of this section apply only to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§ 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147.

Source: SL 1990, ch 397, §§ 1, 7; SL 1991, ch 400, § 7; SL 2011, ch 216, § 12.

Commission Note: SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."



SDLRC - Codified Law 58-41-35 - Contents required in evidence of coverage.

58-41-35.6. Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited--Exception for sickness or injury caused in commission of felony.

A health maintenance contract that is delivered, issued for delivery, or renewed in this state may not exclude the payment of benefits for injuries sustained by an insured person because the insured was under the influence of alcohol or drugs, as defined by § 32-23-1.

Nothing in this section precludes a health maintenance contract from excluding coverage for an insured for any sickness or injury caused in the commission of a felony.

Source: SL 1997, ch 290, §§ 6, 7.



SDLRC - Codified Law 58-41-35 - Contents required in evidence of coverage.

58-41-35.7. Contracts required to cover occult breast cancer screening.

Each health maintenance contract that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a contract that provides coverage for specified disease or other limited benefit coverage, shall provide coverage for screening for the presence of occult breast cancer.

The provisions of this section apply only to plans that are not grandfathered pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. §§ 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147.

Source: SL 2011, ch 216, § 17.

Commission Note: SL 2011, ch 216, § 19 provides: "The provisions of this Act are repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."