S.D. Admin. R. 20:06:58:01

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

Section 20:06:58:01 - Definitions

Unless otherwise provided, terms used in this chapter mean:

(1) "Aggregate lifetime dollar limit," a dollar limitation on the total amount of specified benefits that may be paid under a group health plan, or health insurance coverage offered in connection with such a plan, for any coverage unit;

(2) "Annual dollar limit," a dollar limitation on the total amount of specified benefits that may be paid in a 12-month period under a group health plan, or health insurance coverage offered in connection with such a plan, for any coverage unit;

(3) "Cumulative financial requirements," financial requirements that determine whether or to what extent benefits are provided based on accumulated amounts and include deductibles and out-of-pocket maximums. The term does not include aggregate lifetime or annual dollar limits because these two terms are excluded from the meaning of financial requirements;

(4) "Cumulative quantitative treatment limitations," treatment limitations that determine whether or to what extent benefits are provided based on accumulated amounts, such as annual or lifetime day or visit limits;

(5) "Financial requirements," include deductibles, co-payments, coinsurance, or out-of-pocket maximums. The term does not include aggregate lifetime or annual dollar limits;

(6) "Medical or surgical benefits," benefits with respect to items or services for medical conditions or surgical procedures, as defined under the terms of the plan, or health insurance coverage and in accordance with applicable federal and state law, but does not include mental health or substance use disorder benefits. Any condition defined by the plan as being or as not being a medical or surgical condition must be defined to be consistent with generally recognized independent standards of current medical practice;

(7) "Mental health benefits," benefits with respect to services for mental health conditions, as defined under the terms of the plan and in accordance with applicable federal and state law. Any condition defined by the plan as being or as not being a mental health condition must be defined to be consistent with generally recognized independent standards of current medical practice;

(8) "Substance use disorder benefits," benefits with respect to items or services for substance use disorders, as defined under the terms of the plan and in accordance with applicable federal and state law. Any disorder defined by the plan as being or as not being a substance use disorder must be defined to be consistent with generally recognized independent standards of current medical practice;

(9) "Treatment limitations," include limits on benefits based on the frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration of treatment. Treatment limitations include both quantitative treatment limitations, which are expressed numerically, such as 50 outpatient visits per year, and nonquantitative treatment limitations, which otherwise limit the scope or duration for treatment under a plan. A permanent exclusion of all benefits for a particular condition or disorder is not a treatment limitation for purposes of this definition.

S.D. Admin. R. 20:06:58:01

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, 58-18-79(1), 58-18-79(15), 58-18-80.

Illustrative list of nonquantitative limitations, § 20:06:58:24.