S.D. Admin. R. 20:06:39:43

Current through Register Vol. 51, page 67, December 16, 2024

Section 20:06:39:43 - Definitions

Unless otherwise provided, the following terms are defined for purposes of §§ 20:06:39:43 to 20:06:39:56, inclusive:

(1) "Collect," with respect to information, to request, require, or purchase such information;

(2) "Family member," with respect to an individual, a dependent of the individual or any other person who is a first-degree, second-degree, third-degree, or fourth-degree relative of the individual or of a dependent of the individual. Relatives by affinity such as by marriage or adoption are treated the same as relatives by consanguinity that is, relatives who share a common biological ancestor. In determining the degree of the relationship, relatives by less than full consanguinity such as half-siblings, who share only one parent are treated the same as relatives by full consanguinity such as siblings who share both parents;

(3) "First-degree relatives," parents, spouses, siblings, and children;

(4) "Fourth-degree relatives," great-great grandparents, great-great grandchildren, and children of first cousins;

(5) "Genetic information:"

(a) The individual's genetic tests;

(b) The genetic tests of family members of the individual;

(c) The manifestation of a disease or disorder in family members of the individual; or

(d) Any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by the individual or any family member of the individual.

With respect to a pregnant woman or a family member of the pregnant woman, the term includes genetic information of any fetus carried by the pregnant woman. With respect to an individual or a family member of the individual who is utilizing an assisted reproductive technology, the term includes genetic information of any embryo legally held by the individual or family member. However, the term does not include information about sex or age of any individual;

(6) "Genetic services," genetic test; genetic counseling including obtaining, interpreting, or assessing genetic information; or genetic education;

(7) "Genetic test," an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. However, a genetic test does not include an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition. Therefore, a test to determine whether an individual has a BRCA1 or BRCA2 variant is a genetic test. Similarly, a test to determine whether an individual has a genetic variant associated with hereditary nonpolyposis colorectal cancer is a genetic test. However, an HIV test, complete blood count, cholesterol test, liver function test, or test for the presence of alcohol or drugs is not a genetic test;

(8) "Manifestation or manifested," with respect to a disease, disorder, or pathological condition, that an individual has been or could reasonably be diagnosed with the disease, disorder, or pathological condition by a health care professional with appropriate training and expertise in the field of medicine involved. A disease, disorder, or pathological condition is not manifested if a diagnosis is based principally on genetic information;

(9) "Payment," with respect to the activities undertaken by a health plan, to obtain premiums or to determine or fulfill its responsibility for coverage and the provision of benefits under the health plan, or by a health care provider or health plan, to obtain or provide reimbursement for the provision of health care. However, these activities include:

(a) Determinations of eligibility or coverage including coordination of benefits or the determination of cost sharing amounts, and adjudication or subrogation of health benefit claims;

(b) Risk adjusting amounts due based on enrollee health status and demographic characteristics;

(c) Billing, claims management, collection activities, obtaining payment under a contract for reinsurance including stop-loss insurance and excess of loss insurance, and related health care data processing;

(d) Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges;

(e) Utilization review activities, including precertification and preauthorization of services, and concurrent and retrospective review of services; and

(f) Disclosure to consumer reporting agencies of the name and address, date of birth, social security number, payment history, account number or name and address of the health care provider or health plan, or both, relating to collection of premiums or reimbursement;

(10) "Second-degree relatives," grandparents, grandchildren, aunts, uncles, nephews, and nieces;

(11) "Third-degree relatives," great-grandparents, great-grandchildren, great aunts, great uncles, and first cousins;

(12) "Underwriting purposes," with respect to an issuer offering health insurance coverage in the individual market:

(a) Rules for or determination of eligibility, including enrollment and continued eligibility for benefits under the plan or coverage, including changes in deductibles or other cost-sharing mechanisms in return for activities such as completing a health risk assessment or participating in a wellness program;

(b) The computation of premium or contribution amounts under the plan or coverage, including discounts, rebates, payments in kind, or other premium differential mechanisms in return for activities such as completing a health risk assessment or participation in a wellness program;

(c) The application of any preexisting condition exclusion under the plan or coverage; and

(d) Other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

S.D. Admin. R. 20:06:39:43

37 SDR 47, effective 9/20/2010.

General Authority: SDCL 58-17-87, 58-17-87(4).

Law Implemented: SDCL 58-17-87, 58-33-13.