S.D. Admin. R. 20:06:40:82

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

Section 20:06:40:82 - Nonrenew or discontinuance of coverage

A health insurance issuer offering health insurance coverage in the group market is required to renew or continue in force the coverage at the option of the plan sponsor or the employer, as applicable. An issuer may nonrenew or discontinue health insurance coverage offered in the group market based only on one or more of the following:

(1) Nonpayment of premiums. The plan sponsor or employer, as applicable, fails to pay premiums or contributions in accordance with the terms of the health insurance coverage, including any timeliness requirements;

(2) Fraud. The plan sponsor or employer, as applicable, performs an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact in connection with the coverage;

(3) Violation of participation or contribution rules. In the case of group health insurance coverage, the plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules;

(4) Termination of plan. The issuer ceases to offer coverage in the market;

(5) Enrollees' movement outside service area. For network plans, there is no longer any enrollee under the plan who lives, resides, or works in the service area of the issuer or in the area for which the issuer is authorized to do business; and in the case of the small group market, the issuer applies the same criteria it would apply in denying enrollment in the plan under 45 CFR § 147.104(c)(1)(i);

(6) Association membership ceases. For coverage made available in the small or large group market only through one or more bona fide associations, if the employer's membership in the bona fide association ceases, but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual.

S.D. Admin. R. 20:06:40:82

39 SDR 203, effective 6/10/2013.

General Authority: SDCL 58-18-79.

Law Implemented: SDCL 58-18-79, 58-18-80.