Department of Labor and Regulation

Title - Division of Insurance email the Division of Insurance

Individual Major Medical
Health Rate & Form Filing Requirements

South Dakota Codified Laws
21-25A-3 Arbitration not permitted.
58-9-3 "Health insurance" defined.
58-11-1 "Premium" defined.
58-11-2 Contents of policy.
58-11-3 Statement of basis and rates for determination of premium included in policy.
58-11-5 Standard or uniform provisions of insurance contracts.
58-11-7 Substitute provisions required by law of domicile of foreign or alien insurer, approval by director.
58-11-8 Assessable policies.
58-11-10 Additional policy provisions.
58-11-11 Charter and bylaws, inclusion as part of contract of insurance.
58-11-12  Policy forms must be submitted for approval.
58-11-21 Discretionary clause not permitted.
58-11-22 Identification of contracts issued and forms filed with director.
58-11-23 Execution of policy by authorized representative of insurer.
58-11-26 Jointly issued policies.
58-11-27 Combination policy.
58-11-36 Assignment of policies.
58-11-39 Modification by rider, endorsement, or application made part of policy.
58-11-62 Notice of intent to cease marketing block of business.
58-11A-1 Definitions.
58-11A-2 Policies subject to chapter.
58-11A-3 Reading ease.
58-11A-4 Alternate reading ease tests.
58-11A-5 Certificate concerning reading ease.
58-11A-6 Variation of reading ease requirement.
58-11A-9 Law permitting issuance of policies after form on file for specified period.
58-17-1 Requirements for all health insurance policies delivered in state.
58-17-1.1 Policies to cover low-dose mammography.
58-17-1.2 Policies to provide coverage for diabetes supplies, equipment and education.
58-17-1.3 Diabetes coverage not required of certain plans and policies.
58-17-2 Persons covered by policy.
58-17-2.1 Health insurance on a franchise plan.
58-17-2.2 Conversion privileges of insured's spouse upon divorce.
58-17-2.3 Full time student coverage through age 29.
58-17-3 Time of commencement and termination to be set out in policy.
58-17-4 Consideration for policy to be stated.
58-17-4.1 Filing and prior approval of individual premium rates by director.
58-17-4.2 Premium rates required to be reasonable.
58-17-5 Identification of forms, riders and endorsements--Form number, location.
58-17-6 Style and arrangement of policy provisions--Printing, size of type.
58-17-7 Documents forming part of policy--Setting forth in full, rates and classifications excepted.
58-17-8 Exceptions and reductions of coverage to be clearly set out.
58-17-9 Renewal of policy at option of insurer--Statement in policy so informing the policyholder.
58-17-10.2 Individual policy for insured's spouse required in policies covering spouse.
58-17-11 Free look period.
58-17-12 Required provisions.
58-17-13 Omission from policy of inapplicable provision.
58-17-14 Insured signature required for contract changes.
58-17-15 Incontestability clause.
58-17-16 Incontestability clause--Optional provisions.
58-17-17 Grace period on premiums required in policy.
58-17-18 Renewal of policy.
58-17-19 Reinstatement when premium not paid within grace period.
58-17-20 Omission of provision as to application of premiums accepted in connection with reinstatement.
58-17-21 Notice of claim.
58-17-22 Notice of claim--Optional provision.
58-17-23 Claim forms--Furnishing by insurer.
58-17-24 Proofs of loss--Provision required in policy.
58-17-25 Time of payment of claims.
58-17-26 Payment of claims.
58-17-27 Payment of claims--Optional provisions.
58-17-28 Physical examination and autopsy in case of death.
58-17-29 Time limits for legal action.
58-17-30 Beneficiary.
58-17-30.1 Continuation of coverage for physically handicapped or mentally retarded child
58-17-30.2 Family coverage to include newborn or newly adopted children.
58-17-30.3 Premature birth and congenital defects covered.
58-17-30.4 Notice of birth or adoption required for continued coverage.
58-17-30.5 Coverage for inpatient alcoholism treatment required.
58-17-30.6 Alcoholism benefits provided.
58-17-30.8 Exclusion of benefits for injury while under the influence of alcohol or drugs prohibited.
58-17-30.9 Notice that dependent is no longer eligible for coverage--Premium adjustment.
58-17-31 Optional policy provisions.
58-17-32 Occupational change.
58-17-33 Misstatement of age.
58-17-37 Unpaid premiums--Deduction from benefits.
58-17-38 Conformity with state statutes of insured.
58-17-39 Illegal occupation of insured.
58-17-41 Order of policy provisions.
58-17-42 Age limit in policy.
58-17-44 Foreign or alien insurer--Policy provision required by home state.
58-17-45 Policy of domestic insurer delivered in other state.
58-17-46 Policy provisions not subject to chapter.
58-17-47 Nonconforming and conflicting provisions construed in conformity with statute.
58-17-53 Optometric services.
58-17-54 Reimbursement provisions applicable to all healing arts licensees.
58-17-55 Reimbursement provisions applicable to licensed hospitals.
58-17-56 Reimbursement for service rendered or supervised by qualified mental health professional.
58-17-62 Coverage for phenylketonuria.
58-17-63 "Health benefit plan" defined.
58-17-64 Minimum loss ratio for individual health benefit plans.
58-17-65 Individual health insurance plan used in conjunction with managed care plan or URO.
58-17-66 Definitions for 58-17-66 to 58-17-87.
58-17-67 "Professional association" defined.
58-17-68 "Professional association plan" defined.
58-17-69 "Creditable coverage" defined.
58-17-70 Application of 58-17-66 to 58-17-87, inclusive.
58-17-71 Separate classes of individual business.
58-17-72 Transitional period when additional class of business acquired.
58-17-73 Director approval required to establish additional classes of business.
58-17-74 Provisions for premium rates for individual health benefit plans.
58-17-74.1 Premium rate limitations.
58-17-78 Required disclosure when offering individual health benefit plan.
58-17-80 Filing of actuarial certification by carrier of individual health benefit plans.
58-17-82 Renewal of individual health benefit plans.
58-17-84 Provisions of compliance for any individual health benefit plan.
58-17-84.1 Anesthesia and hospitalization for dental care to be provided certain covered persons.
58-17-85.1 Health carrier to offer additional deductible options.
58-17-88 Minimum inpatient care coverage following delivery.
58-17-89 Shorter hospital stay permitted.
58-17-98 Health insurance policies to provide coverage for biologically-based mental illnesses.
58-17-100 Definitions.
58-17-101 Insurer may not exclude certain off-label uses of prescription drugs.
58-17-102 Exceptions.
58-17-103 Provisions limited to cancer or life threatening diseases.
58-17-104 Deductibles, copayments, and managed care review not affected.
58-17-105 Drugs used in research trials not covered.
58-17-106 No reduction or limitation of coverage otherwise required by law.
58-17-107 Health insurance policies to provide coverage for prostate cancer screening.
58-17C-27 Emergency services defined.
58-17C-29 Emergency services coverage subject to limitations.
Chapter 58-18A Coordination of benefits.
58-33-13 Unfair discrimination as misdemeanor.
58-33-13.1 Sex or marital status discrimination prohibited.
58-33-13.2 Definition of sex or marital status discrimination terms.
58-33-85 Health insurers prohibited from denying enrollment of dependent child on certain grounds.
62-1-1.3 In regard to exclusions for workers' compensation the word “paid” must be used instead of “payable” or “entitled to” or similar language.
Administrative Rules of South Dakota
20:06:22:01 Types of renewal clauses.
20:06:22:02 Anticipated loss ratio requirements.
20:06:22:03 Rate filing required,
 20:06:22:04 Filings of rate revisions.
20:06:22:05 Requirements for history of experience.
20:06:28:01 Filing fees.
20:06:28:03 Filings by third parties.
20:06:28:08 Electronic filings.
20:06:39:01 Dual eligibility.
20:06:39:02 Creditable coverage and preexisting waiting periods for newborn and adopted children.
20:06:39:03 Permissible rating factors.
20:06:39:04 Certificates required upon loss of coverage.
20:06:39:05 Standards for determinations on length of preexisting waiting periods.
20:06:39:06 College plans -- Bona fide association plans.
20:06:39:07 Requirements for breaks in coverage when applying for a new policy.
20:06:39:21 Definition of ordinarily prudent person in preexisting condition clauses.
20:06:39:23 20:06:40:17 and 20:06:40:17.02 applicability to individual market.
20:06:39:27 Requirements for basic plan -- Schedule of benefits.
20:06:39:28 Requirements for basic plan -- Eligible expenses.
20:06:39:29 Requirements for basic plan -- Allowable exceptions and limitations.
20:06:39:32 Contract of more than six months -- Defined.
20:06:39:34 Disclosure requirements.
20:06:39:70 Special enrollment periods for marriage, birth, and adoption.
20:06:39:71 Special enrollment triggers.
20:06:40:17 Breast reconstruction options after covered mastectomy.
20:06:40:17.02 Prohibited practices.
20:06:50 Model coordination of benefits contract provisions.
20:06:52 Discretionary clause not permitted
Bulletins
Bulletin 07-01 SERFF required for all form and rate filings
Bulletin 08-04  
  • For policies or certificates that provide coverage for hospital stays, benefits may not be restricted in a way that is based upon the number of hours that the insured stays in the hospital.
  • ' Policies or certificates may not contain an exclusion that excludes all services or charges not specifically covered in the policy or certificate.
  • o policy or certificate may limit coverage to natural or sound teeth.
  • An application or a policy form may not include a statement that indicates that the agent cannot bind the company. An application or a policy form may contain language that indicates that agents or others have no authority to modify or waive any provisions of the policy or certificate.
  • For long term care insurance advertisements, including those that contain invitations to attend a meeting at which no solicitations will take place, the term "seminar" may not be used.
  • For any policy or certificate exclusions for doctors that are family members must permit coverage for treatment by family members if it is the only doctor in the area provided that the doctor is acting within the scope of practice.
  • Any policy or certificate that contains a precertification or preauthorization provision that must be instituted within a specific time frame must contain an exception that also allows notification as soon as reasonably possible.
  • No policy or certificate may contain a provision that allows for the decision of a insurer selected medical provider to be binding for purposes of determining medical appropriateness or medical necessity of any claimed benefit.
  • A provision of a policy or certificate which has the effect of making the insurance excess or secondary is a coordination of benefits provision and must only be included in compliance with Chapter 58-18A.
  • No health policy or certificate amendment or endorsement filing may contain blank provisions that may be completed upon issuance by the insurer.
  • No policy or certificate may exclude covered sicknesses or injuries caused by alcohol or drug use unless it is in the commission of a felony.

 


Division of Insurance
445 E. Capitol Avenue
Pierre, SD 57501
Tel. 605.773.3563
Fax. 605.773.5369