S.D. Admin. R. 20:06:56:21

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

Section 20:06:56:21 - Exception for uniform modification of coverage

Only at the time of coverage renewal may issuers modify the health insurance coverage for a product offered to a group health plan or an individual, as applicable, in the large group market, the individual market, and the small group market if, for coverage available in this market, other than only through one or more bona fide associations.

Modifications made uniformly and solely pursuant to applicable federal or state requirements are considered a uniform modification of coverage in the small group and individual market if:

(1) The modification is made within a reasonable time period after the imposition or modification of the federal or state requirement;

(2) The modification is directly related to the imposition or modification of the federal or state requirement;

(3) Other types of modifications made uniformly are considered a uniform modification of coverage if the health insurance coverage for the product in the individual or small group market meets all of the following criteria:

(i) The product is offered by the same health insurance issuer;

(ii) The product is offered as the same product network type;

(iii) The product continues to cover at least a majority of the same service area;

(iv) Within the product, each plan has the same cost-sharing structure as before the modification, except for any variation in cost sharing solely related to changes in cost and utilization of medical care, or to maintain the same metal tier level described in sections 1302(d) and (e) of the Affordable Care Act (December 3, 2014); and

(v) The product provides the same covered benefits, except for any changes in benefits that cumulatively impact the plan-adjusted index rate for any plan within the product within an allowable variation of +/- two percentage points.

The director may broaden the standards in subsection 3(iii) and (iv) of this section after consideration of the impact on the insurance-buying public.

If an issuer in the individual market is renewing non-grandfathered coverage or uniformly modifying non-grandfathered coverage the issuer must provide to each individual written notice of the renewal before the date of the first day of the next annual open enrollment period.

If an issuer in the small group market is renewing coverage or uniformly modifying coverage the issuer must provide to each plan sponsor or individual written notice of the renewal at least 60 calendar days before the date of the coverage will be renewed.

S.D. Admin. R. 20:06:56:21

41 SDR 93, effective 12/3/2014.

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

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