Marcia Hultman

Cabinet Secretary

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Division of Insurance - Health Insurance


Topics of Frequent Inquiry

 

Agent Identification
Billing
Cancer Insurance
Claims Process
Creditable Coverage
Deductibles
"Free Look" Period/Return of an Individual Health Insurance Policy
Group Health Insurance
Having a Child
Health Insurance Carrier vs. Automobile Insurance
Health Insurance Policies
Licensed Major Medical Companies
Mandated Benefits by State Law
Options for Health Insurance
Options for Terminated Employees or Those Who Lose Other Coverage
Preauthorization/Precertification of a Medical Procedure
Requirements for Self-funded or ERISA Plans
Short-term Limited Duration Plans
Small Employers' Options for Guaranteed Health Insurance
Who Pays First - Coordination of Benefits Among Multiple Plans for Dependents

 

 

Agent Identification

Administrative Rule of South Dakota (ARSD) 20:06:10:14 mandates that when soliciting insurance, life or health, agents must inform the prospective purchaser that they are acting as an agent before beginning a sales presentation. The agent must identify themselves in writing, along with the name of the insurer they represent; presenting a business card is a common way to comply with this requirement.

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Billing

If the service is covered under the policy and your provider is contracted with the network, then only deductibles, coinsurance and co-payments could be charged to you by the medical provider.

The law does not allow what are sometimes referred to as excess charges or those charges above the usual customary or reasonable amount to be charged back to the patient in a participating managed care setting.

If your provider is not part of your insurance plan's contracted network, you may be balanced billed for the amount the provider charges that is above the amount your insurance considers allowable for the services performed.

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Cancer Insurance

Your major medical policy will generally provide benefits regardless of the type of sickness or injury you have including cancer. Typically a major medical policy will meet most of your health insurance needs.

However, there are usually deductibles and co-insurance provisions with a major medical policy and there are non-medical costs associated with the treatment of cancer that a supplemental policy could provide some assistance for.

One should always carefully analyze his/her overall insurance needs prior to making any decision on additional insurance purchases.

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Claims Process

See webpage here.

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Creditable Coverage

See webpage here.

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Deductibles

An insurance deductible is generally defined as the amount you have to pay out-of-pocket for expenses before the insurance company begins covering costs.

There are different types of deductibles depending on your insurance policy. Most insurance policies have an annual deductible but it is important to note that not all policies begin on January 1st and end on December 31st. Under some circumstances there is a 'plan year'. Plan years may begin and end on the anniversary date that you obtained your policy or your employer purchased their policy, or in other cases, the year may be in the employer's fiscal year or business year.

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"Free Look" Period/Return of an Individual Health Insurance Policy

According to South Dakota law, you have the right to return an individual health insurance policy within ten (10) days of its delivery if you are not satisfied for any reason. If you choose to do so, the premium you paid will be refunded in full.

With regard to Medicare Supplement policies and long-term care, the policy holder has thirty (30) days instead of ten (10) to examine the policy and return it if he or she chooses to do so.

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Having a Child

To ensure a newborn is covered from the moment of birth, it is strongly recommended that you immediately notify your health insurance company after your child was born and request to add the child to the policy.

If your coverage is a group health plan sponsored by your employer, you must notify your employer of the child's birth. Group plans must provide a 31-day period from the birth date to add the child. You also qualify for a special enrollment period in the Federal Marketplace or for an individual policy that begins on the date of the birth and lasts 60 days.

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Health Insurance Carrier vs. Automobile Insurance

If you are in an auto accident and your health insurance company says your auto insurance company should cover the medical expenses incurred associated with the accident, contact your automobile insurance agent to verify if you have medical payments coverage. If you do, you should submit the applicable medical expenses to your agent for payment by your automobile insurance company.

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Health Insurance Policies

There can be substantial differences in benefits offered between health insurance policies.

If the premiums are significantly different there is a strong likelihood that the less expensive policy provides much less coverage. When comparing the price of insurance policies, it is important to carefully analyze the benefits between all policies.

Assistance in reviewing and interpreting the differences in benefits is available from your local insurance agent or a navigator.

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Licensed Major Medical Companies

See webpage here.

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Mandated Benefits by State Law

See webpage here.

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Options for Health Insurance

The best place to obtain health insurance is by contacting your local area health insurance agents. You can also shop plans at the federally facilitated Marketplace.

View a list of licensed major medical carriers.

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Options for Terminated Employees or Those Who Lose Other Coverage

An employee who is terminated can choose to have coverage continued under the group plan for 18 months or 36 months in special circumstances. See COBRA for additional information.

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Preauthorization/Precertification of a Medical Procedure

Precertification is a requirement found in many health insurance policies; it requires certain medical services to be okayed by the insurance company in advance. If prior approval for a treatment is not sought, many policies have significant monetary penalties.

The precertification process ensures you are getting the maximum benefits from your plan and helps to protect you from unnecessary hospital confinements or medical treatment.

When a preauthorization is denied, there are some options available to you. You or your medical provider can contact the insurance company and request an appeal reconsideration or grievance of the decision.

Each insurance company who conducts preauthorization reviews must have a grievance or appeal procedure that must be disclosed with all denials. Sometimes informal contacts to discuss the decision can be effective as well.

In addition, you can contact the Division of Insurance for assistance. Learn how to file a complaint with the Division here.

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Requirements for Self-funded or ERISA Plans

Although state law does not impose any requirements directly on private employer self-funded plans, these plans are subject to the federal law and therefore must obey the portability, nondiscrimination and other Health Insurance Portability and Accountability Act (HIPAA) requirements that fully insured plans do.

Public self-funded plans are subject to state HIPAA requirements affecting employer plans such as portability and nondiscrimination.

Your individual situation may influence the availability and terms of any coverage covered by Employee Retirement Income Security Act (ERISA) laws.

Federal law preempts state jurisdiction over self-insured plans through a law referred to as ERISA. You may contact the United States Department of Labor at:

  • United States Department of Labor
    Kansas City Regional Office
    2300 Main Street, Suite 1100
    Kansas City, MO 64108
    Telephone: 816.285.1800
    Fax: 816.285.1888

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Short-term Limited Duration Plans

Short-term limited duration coverage is health care coverage issued for a short period of time. Because short-term limited duration plans are designed to fill only very short coverage gaps, this coverage is not subject to any of the key rules governing the federal Affordable Care Act's single risk pool. They can be priced based on health status (medically underwritten), can discriminate against consumers with preexisting conditions, and do not have to cover essential health benefits.

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Small Employer Options for Guaranteed Health Insurance

Small employers, those with two to 50 employees, must be offered coverage without medical underwriting. Coverage must be extended to all eligible employees and their dependents. An eligible employee is defined as a permanent employee who works a minimum of 30 hours per week.

The plans must be actively marketed to all employers whether the employer would ordinarily qualify for underwriting or not. It is still the employer's choice whether to purchase a health plan and which plan to purchase.

Additional small employer health insurance information is available here.

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Who Pays First - Coordination of Benefits Among Multiple Plans for Dependents

When multiple policies are involved where dependents are concerned, generally benefits are determined in accordance with South Dakota Codified Law (SDCL) 58-18A.

However, if there is a court decree designating one of the parents as responsible for the health care expenses, and this parent is aware of the stipulation, the coordination of benefits follows the decree first.

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Contact the Division of Insurance