S.D. Admin. R. 55:08:01:01

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

Section 55:08:01:01 - Definition of terms

Terms defined in SDCL 3-6C-1 have the same meaning when used in this article. In addition, terms used in this article mean:

(1) "Adverse determination," a determination by the South Dakota State Employee Health Plan or its designee utilization review organization that an admission, availability of care, continued stay, or other health-care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the South Dakota State Employee Health Plan's requirements for medical necessity, appropriateness, health-care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated;

(2) "Claim," the request of coverage of an eligible employee or any other person under the South Dakota State Employee Health Plan;

(3) "Contract period" or "plan year," that period beginning on July 1 of one year and ending on June 30 of the following year;

(4) "Contribution or premium," the sum paid by or on behalf of an employee as consideration for a life, health, or flexible benefits;

(5) "Eligible employee," a permanent full-time employee, permanent part-time employee, or an employee employed by a participating unit who has worked an average of 30 hours or more per week during a 12 month period, as defined by the Patient Protection and Affordable Care Act of 2010, as amended;

(6) "Flexible benefits plan," a benefits plan that allows members to select from a list of benefits options, some or all of which may be tax-advantaged, and which may vary depending on the status of a member as either an employee or retiree. The options may include dental, vision, medical spending accounts, dependent care and others as determined by the bureau;

(7) "Participating unit," any department, bureau, campus, institution, board, or commission of the state that has employees who are eligible for participation;

(8) "Proof of insurability," evidence of a person's medical condition based upon a medical examination, a person's medical history, or a doctor's statement regarding a person's health;

S.D. Admin. R. 55:08:01:01

38 SDR 213, effective 7/1/2012; 42 SDR 97, effective 1/4/2016; 47 SDR 142, effective 7/1/2021

General Authority: SDCL 3-6E-13.

Law Implemented: SDCL 3-6E-1, 26 U.S.C. § 4980H, 45 C.F.R. § 147.36.