Department of Labor and Regulation

Title - Division of Insurance email the Division of Insurance

PPACA Standard Contract Clauses

Sample Contract Language for PPACA

The following sample language is available for insurers to use in their health insurance form filings in order to comply with the applicable provisions of PPACA. These sample provisions are not mandatory but rather represent sample language that will be approved by the Division. Variations from the sample language will be reviewed for compliance with PPACA and applicable state law.

Rescissions
Emergency Treatment
Preventive Services
Lifetime Dollar Amounts
Extension of Coverage to Dependents
Preexisting Conditions
Appeals
Internal Appeals
Group Health Insurance
Individual Health Insurance
External Review

Rescissions

Replace existing incontestability language and insert:

"Only an act, practice, or omission that constitutes fraud or intentional misrepresentations of material fact, made by an applicant for health insurance coverage may be used to void this application or policy [and deny claims]."

Emergency Treatment

No standard language has been developed as policies/contracts should already have standards in place that comply with current South Dakota law that meets PPACA standards. The exception is the reimbursement for nonparticipating providers which is not required to be addressed in policies/contracts.

Preventive Services

The following services received from a network provider are covered without regard to any deductible, copayment, or coinsurance requirement that would otherwise apply:

  1. Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
  2. Iimmunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved;
  3. With respect to Covered Persons who are infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration;
  4. With respect to Covered Persons who are women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

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Lifetime Dollar Limits

Essential Health Benefits provided within your policy/contract are not subject to any lifetime dollar limit. "Essential health benefits" include the following categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care.

Extension of Coverage to Dependents

Notwithstanding the eligibility requirements described in (insert relevant reference in policy/contract), a child is eligible to become a covered person if the child is under age 26 and is related to you as a child. The child's marital status, financial dependency, residency, student status or employment status will not be considered in determining eligibility for initial or continued coverage. [ If the plan is grandfathered and if the child is eligible for other employer sponsored coverage, the child is not eligible for this extension of coverage.]

Preexisting Conditions

The (insert applicable portion(s) of policy/contract) does not apply to a covered person that has not attained the age of nineteen.

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Appeals

Internal Appeals

Group Health Insurance

The following is inserted and amends the section in your certificate entitled (insert appropriate reference in certificate).

You have the right to appeal an adverse benefit determination made by your health insurance carrier through your health plan's internal process. An adverse benefit determination includes a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit including any denial, reduction, termination, or failure to provide or make a payment (for pre-service or post service claims) that is based on;

  1. A determination that a benefit is not a covered benefit.
  2. The imposition of a preexisting condition exclusion, source-of-injury exclusion, network exclusion, or other limitation on otherwise covered benefits; or
  3. A determination that a benefit is experimental, investigational, or not medically necessary or appropriate.

A rescission is an adverse benefit determination.

Once an appeal is filed you will be provided free of charge a copy of "new evidence" that may apply and a rationale sufficiently in advance of the adverse determination so that you the policy holder have time to respond. The claim or appeal decision maker assignment will be made so as to avoid conflict of interests in a manner designed to ensure the independence and impartiality of the persons involved in making a decision. We will respond to your request for appeal no later then 72 hours if it is an urgent care situation. You have the right to contact the South Dakota Division of Insurance for additional information or assistance with your claim. We will provide you a copy of the complete appeals procedure upon request. If it is a concurrent review you will have continued coverage pending the outcome of an internal appeal.

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Individual Health Insurance

The following is inserted and amend the section of your policy entitle (insert appropriate policy reference).

You have the right to appeal an adverse benefit determination made by your health insurance carrier through your health plan's internal process. An adverse benefit determination includes a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit including any denial, reduction, termination, or failure to provide or make a payment (for pre-service or post service claims) that is based on:

  1. A determination of an individual's eligibility to participate in a plan or health insurance coverage.
  2. A determination that a benefit is not a covered benefit.
  3. The imposition of a preexisting condition exclusion, source-of-injury exclusion, network exclusion, or other limitation on otherwise covered benefits; or
  4. A determination that a benefit is experimental, investigational, or not medically necessary or appropriate.

A rescission is an adverse benefit determination.

Once an appeal is filed you will be provided free of charge a copy of "new evidence" that may apply and a rationale sufficiently in advance of the adverse determination so that you the policy holder have time to respond. The Claim or appeal decision maker assignment will be made so as to avoid conflict of interests in a manner designed to ensure the independence and impartiality of the persons involved in making a decision. We will respond to your request for appeal no later then 72 hours if it is an urgent care situation. You have the right to seek either an external review or judicial review immediately after an adverse benefit determination is upheld in the first level of the internal appeals process. We will provide you a copy of the complete appeals procedure upon request. If it is a concurrent review you will have continued coverage pending the outcome of an internal appeal.

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External Review

The following is added to your policy/certificate/contract:

As a policyholder you have the right to an external review of an adverse benefit determination within 4 months after date of receipt of notice of an adverse determination. An adverse benefit determination is a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. A rescission of coverage is an adverse determination.

The external review will be made by an independent review organization with health care professionals that they have no conflict of interest with respect to the benefit determination. Except for approved expedited external reviews this external review is available once you the policy holder have exhausted the internal grievance process. You may request an external review by completing the request for external review which may be obtained from us or from the South Dakota Division of Insurance. The South Dakota Division of Insurance upon application and approval of the request for external review will assign the external review organization. Upon request we will provide a copy of the full external review procedure. You may also contact the Division of Insurance for assistance or if you have questions.

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