S.D. Admin. R. 20:06:46:06

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

Section 20:06:46:06 - Benefit restrictions must be uniformly applied to all similarly situated individuals

Except as required by this section, § 20:06:46:03 does not require a carrier subject to this chapter to provide coverage for any particular benefit to any group of similarly situated individuals.

(1) A carrier subject to this chapter shall make the benefits provided under a plan available uniformly to all similarly situated individuals, as those groups are determined under §§ 20:06:46:09 to 20:06:46:12, inclusive.

(2) For any restriction on a benefit or benefits provided under a plan, a carrier subject to this chapter shall apply the restriction uniformly to all similarly situated individuals and may not direct the restriction, as determined based on all of the relevant facts and circumstances, at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.

(3) A carrier subject to this chapter may impose annual, lifetime, or other limits on benefits and may require a deductible, copayment, coinsurance, or other cost-sharing requirement in order to obtain a benefit under the plan if the limit or cost-sharing requirement applies uniformly to all similarly situated individuals and is not directed at individual participants or beneficiaries based on any health factor of the participants or beneficiaries.

(4) For purpose of this section, a plan amendment applicable to all individuals in one or more groups of similarly situated individuals under the plan and made effective no earlier than the first day of the first plan year after the amendment is adopted is not considered per se to be directed at any individual participants or beneficiaries.

S.D. Admin. R. 20:06:46:06

29 SDR 48, effective 10/10/2002.

General Authority: SDCL 58-18-79.

Law Implemented: SDCL 58-18-79.