S.D. Admin. R. 20:06:58:12

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

Section 20:06:58:12 - Classifications of benefits used for applying rules

If a plan, or health insurance coverage, provides mental health or substance use disorder benefits in any classification of benefits described in §§ 20:06:58:12 and 20:06:58:13, mental health or substance use disorder benefits must be provided in every classification in which medical or surgical benefits are provided. In determining the classification in which a particular benefit belongs, a plan, or health insurance issuer, must apply the same standards to medical or surgical benefits and to mental health or substance use disorder benefits. To the extent that a plan, or health insurance coverage, provides benefits in a classification and imposes any separate financial requirement or treatment limitation, or separate level of a financial requirement or treatment limitation, for benefits in the classification, the rules of §§ 20:06:58:07 to 20:06:58:25, inclusive, apply separately with respect to that classification for all financial requirement or treatment limitations.

The following classifications of benefits are the only classifications used in applying the rules of §§ 20:06:58:07 to 20:06:58:25, inclusive:

(1) "Inpatient, in-network," benefits furnished on an inpatient basis and within a network of providers established or recognized under a plan or health insurance coverage;

(2) "Inpatient, out-of-network," benefits furnished on an inpatient basis and outside any network of providers established or recognized under a plan or health insurance coverage. This classification includes inpatient benefits under a plan, or health insurance coverage, that has no network or providers;

(3) "Outpatient, in-network," benefits furnished on an outpatient basis and within a network of providers established or recognized under a plan or health insurance coverage;

(4) "Outpatient, out-of-network," benefits furnished on an outpatient basis and outside any network of providers established or recognized under a plan or health insurance coverage. This classification includes outpatient benefits under a plan, or health insurance coverage, that has no network of providers;

(5) "Emergency care," benefits for emergency care;

(6) "Prescription drugs," benefits for prescription drugs.

If a plan, or health insurance coverage, provides benefits only to the extent required under the PHS Act, 29 CFR 2713 (December 3, 2014), this section is not intended to require the plan, or health insurance coverage, to provide additional mental health or substance use disorder benefits in any classification.

S.D. Admin. R. 20:06:58:12

41 SDR 93, effective 12/3/2014.

General Authority: SDCL 58-17-87, 58-18-79, 58-18-79(15).

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

Special rule for multi-tiered prescription drug benefits, § 20:06:58:19.