S.D. Admin. R. 20:06:55:35

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

Section 20:06:55:35 - Qualified health plan defined

A qualified health plan is a health plan that has been certified by the division that such plan meets the following criteria:

(1) Provides the essential health benefits package described in § 20:06:56:03;

(2) Meets actuarial value standards as described in § 20:06:56:11;

(3) Is licensed by and in good standing with the director;

(4) Includes a network that is compliant with SDCL chapter 58-17 F, § 20:06:55:36 and § 20:06:55:37;

(5) Complies with marketing laws;

(6) Is accredited based on local performance by an accrediting entity recognized by HHS as described in § 20:06:56:12;

(7) The rates comply with chapter 20:06:22 and § 20:06:55:45;

(8) Is non-discrimination compliant with chapter 20:06:45;

(9) Includes plan variations for individuals eligible for cost-sharing reductions and for American Indian and Alaska Native populations;

(10) Complies with the benefit design standards, as defined in § 20:06:56:08;

(11) Implements and reports on a quality improvement strategy or strategies to disclose and report information on health care quality and outcomes;

(12) Complies with the standards related to the risk adjustment program under 45 CFR part 153 (March 12, 2012).

Stand-alone dental plans are not required to comply with subdivisions (1),(2),(6),(7),(9),(10),(11), and (12). Stand-alone dental plans must meet the plan criteria identified in § 20:06:56:06.

S.D. Admin. R. 20:06:55:35

39 SDR 203, adopted June 10, 2013, effective 1/1/2014.

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

Law Implemented: SDCL 58-17-87, 58-18-79, 58-18-80.