58-18-12. Blanket health insurance defined.

Blanket health insurance is hereby declared to be that form of health insurance covering groups of persons as enumerated in one of §§ 58-18-13 to 58-18-19, inclusive.

Source: SL 1966, ch 111, ch 26, § 4.

58-18-13. Blanket health insurance for passengers on common carrier.

Blanket health insurance may be under a policy or contract issued to any common carrier or to any operator, owner, or lessee of a means of transportation, who or which shall be deemed the policyholder, covering a group defined as all persons or all persons of a class who may become passengers on such common carrier or such means of transportation.

Source: SL 1966, ch 111, ch 26, § 4 (1).

58-18-14. Blanket health insurance for employees, dependents, or guests with reference to hazardous activities.

Blanket health insurance may be under a policy or contract issued to an employer, who shall be deemed the policyholder, covering all employees, dependents, or guests, defined by reference to specified hazards incident to the activities or operations of the employer or any class of employees, dependents, or guests similarly defined.

Source: SL 1966, ch 111, ch 26, § 4 (2).

58-18-15. Blanket health insurance for institutions of learning, camps, or sponsors.

Blanket health insurance may be under a policy or contract issued to a school, or other institution of learning, camp or sponsor thereof; or to the head or principal thereof, who or which shall be deemed the policyholder, covering students or campers. Supervisors and employees may be included.

Source: SL 1966, ch 111, ch 26, § 4 (3).

58-18-16. Blanket health insurance for religious, charitable, recreational, educational, or civic organizations.

Blanket health insurance may be under a policy or contract issued in the name of any religious, charitable, recreational, educational, or civic organization, which shall be deemed the policyholder, covering participants in activities sponsored by the organization.

Source: SL 1966, ch 111, ch 26, § 4 (4).

58-18-17. Blanket health insurance for sports team or sponsors.

Blanket health insurance may be under a policy or contract issued to a sports team or sponsors thereof which shall be deemed the policyholder, covering members, officials, and supervisors.

Source: SL 1966, ch 111, ch 26, § 4 (5).

58-18-18. Blanket health insurance for volunteer group or agency.

Blanket health insurance may be under a policy or contract issued in the name of any volunteer fire department, first aid, or other such volunteer group, or agency having jurisdiction thereof, which shall be deemed the policyholder, covering all of the members of such fire department or group.

Source: SL 1966, ch 111, ch 26, § 4 (6).

58-18-19. Blanket health insurance for other risks approved by director.

Blanket health insurance may be under a policy or contract issued to cover any other risk or class of risks which, in the discretion of the director may be properly eligible for blanket health insurance. The discretion of the director may be exercised on an individual risk basis or class of risks, or both.

Source: SL 1966, ch 111, ch 26, § 4 (7).

58-18-20. Authority to issue blanket health insurance--Filing of copy of form--Required provisions.

Any insurer authorized to write health insurance in this state may issue blanket health insurance. No such blanket policy or certificate may be issued or delivered, or coverage solicited, in this state unless a copy of the form thereof has been filed in accordance with § 58-11-12. Every such blanket policy or certificate shall contain provisions, which in the opinion of the director, are at least as favorable to the policyholder and the individual insured as those set forth in §§ 58-18-21 to 58-18-27, inclusive.

Source: SL 1966, ch 111, ch 26, § 5; SL 2005, ch 269, § 5.

58-18-21. Policy and application constitute entire contract--Statements by policyholder not warranties--Written statement required for use in defense of claim.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that the policy and the application shall constitute the entire contract between the parties, and that all statements made by the policyholder shall, in absence of fraud, be deemed representations and not warranties, and that no such statements shall be used in defense to a claim under the policy, unless it is contained in a written application.

Source: SL 1966, ch 111, ch 26, § 5 (1).

58-18-22. Sickness or injury--Provision for notice to insurer.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that written notice of sickness or of injury must be given to the insurer within thirty days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

Source: SL 1966, ch 111, ch 26, § 5 (2).

58-18-23. Forms for filing proof of loss--Failure of insurer to furnish, submission of written proof.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that the insurer will furnish to the policyholder such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished before the expiration of fifteen days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made.

Source: SL 1966, ch 111, ch 26, § 5 (3).

58-18-24. Claim for loss of time--Time for furnishing proof of loss--Notice of continuance of disability.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within thirty days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within ninety days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.

Source: SL 1966, ch 111, ch 26, § 5 (4).

58-18-25. Time for payment of benefits.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that all benefits payable under the policy other than benefits for loss of time will be payable immediately upon receipt of due written proof of such loss, and that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of thirty days during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.

Source: SL 1966, ch 111, ch 26, § 5 (5).

58-18-26. Physical examination of insured--Autopsy in death claims.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that the insurer at its own expense, shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law.

Source: SL 1966, ch 111, ch 26, § 5 (6).

58-18-27. Time for commencement of action to recover under policy.

Subject to § 58-18-20, every blanket health insurance policy shall contain a provision that no action at law or in equity shall be brought to recover under the policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of the policy and that no such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.

Source: SL 1966, ch 111, ch 26, § 5 (7).

58-18-28. Individual application and certificate not required under blanket policy.

An individual application shall not be required from a person covered under a blanket health policy or contract, nor shall it be necessary for the insurer to furnish each person a certificate.

Source: SL 1966, ch 111, ch 26, § 6.

58-18-29. Persons to whom benefits payable under blanket health policy.

All benefits under any blanket health policy shall be payable to the person insured, or to his designated beneficiary or beneficiaries, or to his estate; except, that if the person insured be a minor or mentally incompetent, such benefits may be made payable to his parents, guardian, conservator, or other person actually supporting him, or if the entire cost of the insurance has been borne by the employer such benefits may be made payable to the employer. The policy may provide that all or any portion of any indemnities provided by such policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option, be paid directly to the hospital or person rendering such services; but the policy may not require that the service be rendered by a particular hospital or person. Payment so made shall discharge the insurer's obligation with respect to the amount of insurance so paid.

Source: SL 1966, ch 111, ch 26, § 7; SL 1993, ch 213, § 260.

58-18-30. Chapter inapplicable to prior policies.

The provisions of this chapter shall not apply to any contracts or policies entered into or issued prior to February 8, 1966, nor to any extensions, renewals, or modifications thereof or amendments thereto whenever made.

Source: SL 1966, ch 111, ch 26, § 8.

58-18-31. Continuation of coverage for child with intellectual or physical disability--Proof of dependency.

A group or blanket health insurance policy, which is delivered or issued for delivery in this state and which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy, shall also provide that attainment of such limiting age shall not operate to terminate the coverage of such child while the child is and continues to be both (a) incapable of self-sustaining employment by reason of intellectual disability or physical disability and (b) chiefly dependent upon the policyholder for support and maintenance, provided proof of such incapacity and dependency is furnished to the insurer by the policyholder within thirty-one days of the child's attainment of the limiting age and subsequently as may be required by the insurer but not more frequently than annually after the two-year period following the child's attainment of the limiting age.

Source: SL 1969, ch 140; SDCL Supp, § 58-17-30.1; SL 2013, ch 125, § 19.

58-18-31.1. Dependent coverage termination--Age--Full-time student.

No insurer or health carrier issuing health insurance coverage, other than excepted benefits, that provides dependent coverage for any qualifying child, as defined by rules promulgated pursuant to § 58-18-79, may terminate coverage due to attainment of a limiting age below age twenty-six. If the dependent remains a full-time student upon attaining the age of twenty-six but not exceeding the age of twenty-nine, the insurer shall provide for the continuation of coverage for that dependent at the insured's option. Nothing in this section requires the employer to contribute any portion of the premium for dependents that are full-time students and have attained the age of twenty-six. However, the provisions of this section do not apply to any qualifying relative, as defined by rules promulgated pursuant to § 58-18-79, whose gross income is less than the exemption amount as prescribed by the director by rules promulgated pursuant to chapter 1-26. Continuation of coverage for full-time students attaining the age of twenty-four is not required if the dependent has other creditable coverage in force nor required for any full-time students who attained the age of twenty-four prior to July 1, 2007. (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.")

Source: SL 2005, ch 265, § 2; SL 2007, ch 288, § 2; SL 2011, ch 216, § 8.

58-18-32. Family coverage to include newborn and newly adopted children.

Any group health insurance policy and group service or indemnity type contract issued by a nonprofit corporation which offers coverage for a family member of an insured or subscriber shall provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth or to a newly adopted child of the insured or subscriber from the beginning of the six-month adoption bonding period. The newly born or newly adopted child shall be added to the policy without underwriting and without the imposition of any preexisting waiting period. Any policy or contract issued before July 1, 1984, shall, upon its next anniversary date, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth or to a newly adopted child of the insured or subscriber from the beginning of the six-month adoption bonding period.

Source: SL 1974, ch 322; SDCL Supp, § 58-17-30.2; SL 1976, ch 313, § 1; SL 1977, ch 408; SL 1984, ch 327, § 1; SL 1994, ch 387, § 7.

58-18-33. Premature birth, congenital defects, and birth abnormalities covered--Applicability.

The coverage for a newly born child from the moment of birth or for a newly adopted child, from the beginning of the six-month adoption bonding period, shall consist of coverage of injury or sickness including the necessary care and treatment of premature birth and medically diagnosed congenital defects and birth abnormalities. The coverage required by this section applies to any subsequent health benefit plan that is purchased providing coverage for that newly born or newly adopted child. If there is a break in coverage that exceeds sixty-three days, the health benefit plan may apply preexisting exclusion limitations as permitted by § 58-18-45. The provisions of §§  58-18-32 to 58-18-34, inclusive, apply to any group health benefit plan issued or renewed by any health insurer, health carrier, health maintenance organization, fraternal benefit society, nonprofit medical and surgical plan, nonprofit hospital service plan, or other entity providing coverage through a health benefit plan subject to the provisions of this title.

Source: SL 1974, ch 322; SDCL Supp, § 58-17-30.3; SL 1976, ch 313, § 2; SL 1984, ch 327, § 2; SL 2001, ch 274, § 2; SL 2006, ch 258, § 1.

58-18-34. Notice of birth or adoption required for continued coverage.

An insurer may require notice that a newly born or newly adopted child is to be added to the policy or that coverage is to be changed from single or spousal coverage to family coverage. However, the insurer may not require notification sooner than the birth of the child or the start of the adoption bonding period. If the child is added or coverage changed to family coverage before the birth of the child or the start of the adoption bonding period, no additional premium may be charged by the insurer until the birth of the child or the start of the adoption bonding period. The insurer shall take reasonable steps to provide adequate notice to insureds of the need to alter coverage to ensure newborn or adopted children are covered and of the lack of premium adjustment until the birth of the child or the start of the adoption bonding period. An insurer is considered to have taken reasonable steps if prominent disclosure of the requirements of this section are included in a certificate, subscriber contract, evidence of coverage, or employee handbook if such are provided to all insureds.

If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child or notification of the start of the six-month adoption bonding period for an adopted child or start of the bonding period and payment of the required premium or fees be furnished to the insurer or nonprofit service or indemnity corporation within thirty-one days after the date of birth or notification of the start of the six-month adoption bonding period for an adopted child or start of the bonding period in order to have the coverage continued beyond the thirty-one day period.

Source: SL 1974, ch 322; SDCL Supp, § 58-17-30.4; SL 1984, ch 327, § 3; SL 1994, ch 387, § 8.

58-18-35. Notice required for rate increase by group health insurance company.

Forty-five days before a premium rate increase is effective, the group health insurance company shall notify the policy holder in writing that the premium rate for the group health insurance will be increased.

Source: SL 1989, ch 434, § 1.

58-18-36. Grandfathered plans required to cover low-dose mammography--Extent of coverage.

Each group health insurance policy that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a policy 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. (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.")

Source: SL 1990, ch 397, §§ 1, 4; SL 1991, ch 400, § 4; SL 2011, ch 216, § 9.

58-18-36.1. Policies required to cover occult breast cancer screening.

Each group health insurance policy that covers a female and that is delivered, issued for delivery, or renewed in this state, except for a policy 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. (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.")

Source: SL 2011, ch 216, § 15.

58-18-37. Freedom of choice for pharmacy services.

No policy of group health insurance providing benefits for hospital and medical expenses delivered in this state that is offered by a commercial health insurance company, by a nonprofit medical and surgical plan corporation, by a nonprofit hospital service plan corporation, by a health maintenance organization, by a preferred provider organization, by an individual practice association or by a similar mechanism may:

(1)    Deny any licensed pharmacy or licensed pharmacist as defined in § 36-11-2 the right to participate as a participating provider for any policy or plan on the same terms and conditions as are offered to any other provider of pharmacy services under the policy or plan;

(2)    Prevent any person who is a party to or beneficiary of any health insurance policy from selecting a licensed pharmacy of his choice to furnish the pharmaceutical services offered under any policy or plan, provided that the pharmacy is a participating provider under the same terms and conditions of the policy or plan as those offered to any other provider of pharmacy services; or

(3)    Permit or mandate any difference in coverage for or impose any different conditions, including copayment fees, whether the prescription benefits are provided through direct contact with a pharmacy or by use of an out-of-state mail order service so long as the provider selected is a participant in the plan involved.

Source: SL 1990, ch 395, § 1.

58-18-38. Annual period of enrollment for licensed pharmacies--Actual notice of enrollment period not required.

All health benefit programs, as defined in § 58-18-37, shall provide an annual period of enrollment of at least thirty days during which period any pharmacy licensed under chapter 36-11 may elect to participate in the plan under the terms and conditions then offered unless the pharmacy has lost its status as a participating provider due to its failure to comply with the terms and conditions of its participating provider agreement. Health benefit programs are not required to provide actual notice of the period of open enrollment to the pharmacy.

Source: SL 1990, ch 395, § 2.

58-18-39. Provisions denying choice for pharmacy services as void.

Any provision in a health insurance policy offered in this state which violates the provisions in § 58-18-37 is void.

Source: SL 1990, ch 395, § 3.

58-18-40. Enforcement of provisions permitting choice for pharmacy services.

The Division of Insurance shall enforce the provisions of §§ 58-18-37 to 58-18-39, inclusive.

Source: SL 1990, ch 395, § 4.

58-18-41. Coverage for phenylketonuria.

Every group health insurance policy that is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for specified disease or other limited benefit coverage, shall offer coverage for testing, diagnosis and treatment of phenylketonuria including dietary management, formulas, case management, intake and screening, assessment, comprehensive care planning and service referral.

Source: SL 1992, ch 348, § 3.

58-18-42. Health benefit plan defined.

For the purposes of this chapter, a health benefit plan is any hospital or medical expense incurred policy or certificate, hospital or medical service plan, contract, or health maintenance organization subscriber contract. The term does not include specified disease, hospital indemnity, fixed indemnity, accident-only, credit, dental, vision, medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical payment insurance.

Source: SL 1994, ch 383, § 1.

58-18-43. Late enrollee determined.

For the purposes of this chapter, a late enrollee is an eligible employee or dependent who requests enrollment in a health benefit plan of an employer following the initial enrollment period during which the individual is entitled to enroll under the terms of the health benefit plan, if the initial enrollment period is a period of at least thirty days. However, no eligible employee or dependent may be considered a late enrollee if:

(1)    The individual:

(a)    Was covered under creditable coverage at the time of the initial enrollment;

(b)    Lost coverage under creditable coverage as a result of termination of employment or eligibility, reduction of hours, the involuntary termination of the creditable coverage, death of a spouse, legal separation, or divorce; and

(c)    Requests enrollment within sixty-three days after termination of the creditable coverage;

(2)    The individual is employed by an employer that offers multiple health benefit plans and the individual elects a different plan during an open enrollment period;

(3)    A court has ordered coverage be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and request for enrollment is made within thirty days after issuance of the court order; or

(4)    Child custody has changed by agreement of the parties to a child custody agreement or to a child custody order which agreement has not yet been included in a court order.

Source: SL 1994, ch 383, § 2; SL 1997, ch 289, § 7.

58-18-44. Creditable coverage determined.

For the purposes of this chapter, creditable coverage are benefits or coverage provided under:

(1)    Medicare or medicaid;

(2)    An employer-based health insurance plan or health benefit arrangement that provides benefits similar to or exceeding benefits provided under a health benefit plan;

(3)    An individual health insurance policy including coverage issued by a health maintenance organization, a fraternal benefit society, a nonprofit medical and surgical plan, a nonprofit hospital service plan that provides benefits similar to or exceeding the benefits provided under the basic plan pursuant to chapter 58-18B, or an employee welfare benefit plan as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 as adopted by the director pursuant to chapter 1-26, to the extent that the plan provides directly or through insurance, reimbursement or otherwise to employees or their dependents medical care for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body and amounts paid for the transportation primarily for and essential to medical care;

(4)    Chapter 55 of Title 10, United States Code;

(5)    A medical care program of the Indian Health Service or of a tribal organization;

(6)    A state health benefits risk pool;

(7)    A health plan offered under Chapter 89 of Title 5, United States Code;

(8)    A public health plan;

(9)    A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e));

(10)    A short-term limited-duration policy; or

(11)    A college plan.

Source: SL 1994, ch 383, § 3; SL 1997, ch 289, § 8; SL 1998, ch 289, § 5.

58-18-45. Preexisting conditions--Limitation of waiting periods.

Any health carrier providing group coverage, other than excepted benefits, shall comply with the following provisions:

(1)    No policy may deny, exclude, or limit benefits for a covered individual for claims incurred more than twelve months following the effective date of the individual's coverage due to a preexisting condition. No policy may define a preexisting condition more restrictively than a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six months immediately preceding the effective date of coverage;

(2)    A policy shall waive any time period applicable to a preexisting condition exclusion or limitation period for the aggregate period of time an individual was previously covered by creditable coverage that provided benefits with respect to such services, if the creditable coverage was continuous to a date not more than sixty-three days prior to the effective date of the new coverage. The waiver for prior creditable coverage also applies to late enrollees. A period of time a person was previously covered may not be aggregated if there was a break in coverage of sixty-three days or more. The policy shall count a period of creditable coverage, without regard to the specific benefits covered under the policy, unless the policy elects to credit it based on coverage of benefits within several classes or categories of benefits specified in rules adopted by the director. A condition may not be defined or considered as preexisting if the condition arose after a person began creditable coverage and if there was not a break in coverage which exceeded sixty-three days;

(3)    A policy may exclude coverage for late enrollees for the greater of eighteen months or for an eighteen-month preexisting condition exclusion. However, if both a period of exclusion from coverage and a preexisting condition exclusion are applicable to a late enrollee, the combined period may not exceed eighteen months from the date the individual enrolls for coverage under the policy;

(4)    Genetic information may not be treated as a condition for which a preexisting condition exclusion may be imposed in the absence of a diagnosis of the condition related to such information;

(5)    A health maintenance organization which does not utilize a preexisting waiting period may use an affiliation period in lieu of a preexisting waiting period. No affiliation period may exceed two months in length. No premium may be charged for any portion of the affiliation period. If the health maintenance organization utilizes neither a preexisting waiting period nor an affiliation period, the health maintenance organization may use other criteria designed to avoid adverse selection provided that those criteria are approved by the director. In the case of a late enrollee who is subject to an affiliation period, the affiliation period may not exceed three months.

For purposes of this section, the effective date of coverage is the first day the person became covered for either accidents or sicknesses. No covered person under the age of nineteen is subject to a preexisting condition limitation or exclusion for any plan year beginning on or after September 23, 2010. (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.")

Source: SL 1994, ch 383, § 4; SL 1997, ch 289, § 9; SL 1998, ch 289, § 6; SL 2001, ch 275, § 7; SL 2003, ch 248, § 3; SL 2011, ch 216, § 10.

58-18-45.1. (Text of section effective until the first plan year, policy year, or renewal date on or after January 1, 2019) Anesthesia and hospitalization for dental care to be provided certain covered persons.

Any health benefit plan as defined by § 58-18-42 shall cover anesthesia and hospital charges for dental care provided to a covered person who:

(1)    Is a child under age five; or

(2)    Is severely disabled or otherwise suffers from a developmental disability as determined by a licensed physician which places such person at serious risk.

Such coverage applies regardless of whether the services are provided in a hospital or a dental office. A health carrier may require prior authorization of hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.

(Text of section effective the first plan year, policy year, or renewal date on or after January 1, 2019) Anesthesia and hospital or ambulatory surgery center charges for dental care to be covered for certain persons. Any health benefit plan as defined by § 58-18-42 shall cover anesthesia and hospital or ambulatory surgery center charges for dental care provided to a covered person who:

(1)    Is a child under age five; or

(2)    If determined by a licensed physician, is severely disabled, has a developmental disability, or otherwise has a medical condition that places the person at serious medical risk.

The coverage applies regardless of whether the services are provided in a hospital, ambulatory surgery center, or a dental office. A health carrier may require prior authorization in the same manner that prior authorization is required for other covered diseases or conditions.

Source: SL 1999, ch 248, § 3; SL 2018, ch 279, § 2, eff. Jan. 1, 2019.

58-18-46. Renewability of health benefit plans--Employer's election--Exceptions.

Except as provided in §§ 58-18-42 to 58-18-49, inclusive, a health benefit plan subject to this chapter is renewable to all eligible employees and dependents at the option of the employer, except for the following reasons:

(1)    The employer has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the insurer has not received timely premium payments;

(2)    Fraud or intentional misrepresentation of material fact by the employer;

(3)    Noncompliance with the carrier's employer contribution or participation requirements;

(4)    The number of individuals covered under the plan is less than the number or percentage of eligible individuals required under the plan;

(5)    In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, there is no longer any enrollees in connection with the plan who live, reside, or work in the service area of the issuer or in the area for which the issuer is authorized to do business and the issuer would deny enrollment with respect to the plan as provided for in § 58-18B-37;

(6)    The employer carrier elects to nonrenew all of its health benefit plans delivered or issued for delivery to employers in this state;

(7)    In the case of health insurance coverage that is made available only through one or more bona fide associations, the membership of an employer in the association (on the basis of which the coverage is provided) ceases but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual; or

(8)    If the issuer decides to discontinue offering a particular type of group health insurance offered in the group market, coverage of such type may be discontinued if:

(a)    The issuer provides notice to each employer provided coverage of this type in such market (and any participant and beneficiary covered under such coverage) of the discontinuation at least ninety days prior to the date of the discontinuation of the coverage;

(b)    The issuer offers to each employer provided coverage of this type in such market, the option to purchase all other health insurance coverage currently being offered by the issuer to a group health plan in such market;

(c)    In exercising the option to discontinue coverage of this type and in offering the option of coverage under subsection (b), the issuer acts uniformly without regard to the claims experience of those employers or any health status-related factor relating to any participant or beneficiary covered or any new participant or beneficiary who may become eligible for such coverage.

If a carrier nonrenews a health benefit plan pursuant to this section, the director shall assist affected employers in finding replacement coverage.

Source: SL 1994, ch 383, § 5; SL 1997, ch 289, § 10; SL 2001, ch 275, § 5.

58-18-47. Nonrenewal of health benefit plans by an employer carrier.

If an employer carrier elects not to renew all of its health benefit plans delivered or issued for delivery to employers in this state, the carrier shall:

(1)    Be prohibited from writing new business in the employer market in this state for a period of five years from the date of notice to the director;

(2)    Provide advance notice of the decision not to renew to the director in each state in which it is licensed; and

(3)    Provide notice of the decision not to renew coverage to all affected employers and to the director in each state in which an affected insured individual is known to reside at least one hundred eighty days prior to the nonrenewal of any health benefit plans by the carrier.

Notice to the director under this section shall be provided at least three working days prior to the notice to the affected employers. In the case of an employer carrier doing business in one established geographic service area of the state, this section applies only to the carrier's operations in that service area.

Source: SL 1994, ch 383, § 6.

58-18-48. Acceptance of new employees for coverage under employer's existing health benefit plan.

If an employer has an existing health benefit plan, the carrier shall accept for coverage under the health benefit plan new employees and the dependents of new employees, if the new employee had creditable coverage within the prior sixty-three days from the date the new employee is eligible for coverage. The coverage shall be issued without exclusionary riders. The carrier is not required to provide coverage for new employees or dependents who are late enrollees or who have not had creditable coverage within sixty-three days before applying for coverage. The exception allowing late enrollees to be excluded is limited to the time frames required by subdivisions 58-18-45(3) and (5). Policies may not exclude children, as set forth in subdivision 58-18-43(4), from the definition of eligible dependents. No person may be excluded from coverage based upon discriminatory criteria as defined by the director in rules promulgated pursuant to chapter 1-26.

Source: SL 1994, ch 383, § 8; SL 1996, ch 295; SL 1997, ch 289, § 11; SL 1998, ch 289, § 7.

58-18-49. Carrier's offer of coverage to employer--Coverage of all eligible employees.

If an employer carrier offers coverage to an employer, the employer carrier shall offer coverage to all of the eligible employees of an employer and their dependents. An employer carrier may not offer coverage to only certain individuals in an employer group or to only part of the group, except in the case of late enrollees.

Source: SL 1994, ch 383, § 9; SL 1995, ch 281, § 21.