S.D. Admin. R. 20:06:55:13

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

Section 20:06:55:13 - Emergency services

No prior authorization of emergency services may be required by a health carrier either for in-network or out-of-network emergency services. A plan must provide for the payment of emergency services by an out-of-network provider in an amount not less than the greatest of the following:

(1) The amount negotiated with in-network providers for emergency services excluding any in-network co-payment on coinsurance imposed with respect to the covered person;

(2) The amount for the emergency service calculated and excluding any in-network co-payment or coinsurance, using the same method the plan uses to determine payments for out-of-network services but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or

(3) The amount that would be paid under Medicare part A or part B for the emergency service and excluding any in-network co-payment or coinsurance.

For capitated and other plans that do not have a negotiated per-service amount for in-network providers, subdivision (1) does not apply. If a plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount of subdivision (1) is the median of these negotiated amounts. 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 applies to any employer based health plan, including health benefit plans subject to the provisions of SDCL 58-18-42.

S.D. Admin. R. 20:06:55:13

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.