S.D. Admin. R. 20:06:55:12

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

Section 20:06:55:12 - Choice of primary care providers

If a health carrier offering group or individual health insurance coverage requires or provides for the designation by a covered person of a participating primary care health care professional, the health carrier shall permit each covered person to:

(1) Designate any participating primary care health care professional who is available to accept the covered person; and

(2) For a child, designate any participating physician who specializes in pediatrics as the child's primary care health care professional and is available to accept the child.

This section does not waive any exclusions of coverage under the terms and conditions of the policy with respect to pediatric care. If the health carrier provides coverage for obstetrical or gynecological care and requires the designation of an in-network primary care provider, the health carrier may not require the authorization or referral by the plan for a female insured who seeks obstetrical or gynecological care from a participating in-network provider specializing in obstetrics or gynecology. The health carrier shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological items and services by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care health care professional. The health carrier may require the health care professional to agree to otherwise adhere to the health carrier's policies and procedures, including procedures for obtaining prior authorization and provider services in accordance with a treatment plan, if any, approved by the health carrier. This section does not waive any exclusions of coverage under the terms and conditions of the policy with respect to coverage of obstetrical or gynecological care or preclude the health carrier involved from requiring the participating health care professional providing obstetrical or gynecological care to notify the primary health care professional or the health carrier of treatment decisions.

A health carrier shall provide notice to covered persons of the terms and conditions of the plan related to the designation of a participating health care professional provided in this section and of a covered person's rights. A group health insurance carrier shall include the notice with the summary plan description or other similar description of benefits under the group health insurance coverage. An individual health insurance carrier shall include the notice whenever the individual carrier provides a primary subscriber with a policy, certificate, or contract of health insurance. A carrier may use Appendix A to satisfy the notice requirements of this section.

Nothing in this section applies to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified at 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147 . Except for those coverages that are excepted benefits pursuant to SDCL subdivision 58-17-69(13), this section applies to any plan of individual health insurance coverage and to any health benefit plan subject to the provisions of SDCL 58-17-66 to 58-17-87, inclusive, and also applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL 58-18-42.

S.D. Admin. R. 20:06:55:12

37 SDR 63, effective 9/23/2010; 37 SDR 111, effective 12/7/2010.

General Authority: SDCL 58-17-87, 58-18-79.

Law Implemented: SDCL 58-17-87, 58-18-51.1, 58-18-79.