Federal & State Regulations | Health plans - South Dakota

State Info

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. State laws include the following provisions:

Unless the plan provides coverage for specified disease or other limited benefit coverage, it must cover equipment, supplies, and self-management training and education, including medical nutrition therapy, for treatment of persons diagnosed with diabetes if prescribed by a physician or other licensed health care provider legally authorized to prescribe such treatment. (§58-17-1.2, §58-18-83)
The plan may cover spouses, as well as children under 19 years of age. (§58-17-2)
The coverage for a newly born child from the moment of birth or for a newly adopted child, from the beginning of the six-month adoption bonding period, must consist of coverage of injury or sickness including the necessary care and treatment of premature birth and medically diagnosed congenital defects and birth abnormalities. (§58-17-30.3, §58-18-33))
If the plan covers family members, it must cover newly born children of the insured or subscriber from the moment of birth or to newly adopted children of the insured or subscriber from the beginning of the six-month adoption bonding period. (§58-18-32)
If the plan provides for reimbursement for optometric services, it must reimburse for the services whether the services were provided by a licensed physician or by a licensed optometrist. (§58-17-53)
If the plan provides for reimbursement for any service which may be legally performed by a person licensed in this state for the practice of medicine, surgery, anesthesia by a certified registered nurse anesthetist licensed, psychology, dentistry, osteopathy, social work by an independent social worker, optometry, chiropractic, or podiatry, the reimbursement under that policy or contract may not be denied if the service is rendered by a person so licensed. (§58-17-54)
If the plan provides for reimbursement for any service which may be legally performed by a hospital licensed in this state which has an organized medical staff with permanent facilities including inpatient beds and which is primarily engaged in providing diagnostic or therapeutic services for medical diagnosis, treatment, or care of injured and disabled, rehabilitation services for the physical rehabilitation of the injured and disabled, either on its premises or in facilities under the supervision of physicians on a pre-arranged basis to inpatients, reimbursement for coverage provided under such policy or contracts shall not be denied. (§58-17-55)
If the plan provides coverage on an expense incurred basis, it must offer optional coverage for the inpatient treatment of alcoholism. (§58-17-30.5, §58-18-7.1))
Unless the plan provides coverage for specified disease or other limited benefit coverage, it must offer optional coverage for testing, diagnosis, and treatment of phenylketonuria. (§58-17-62, §58-18-41)
The plan must cover anesthesia and hospital charges for dental care provided to a covered person who is a child under age five; or is severely disabled or otherwise suffers from a developmental disability as determined by a licensed physician which places such person at serious risk. (§58-17-84.1, §58-18-45.1)
Unless the plan provides coverage for specified disease or other limited benefit coverage, it must provide, in writing, coverage for the treatment and diagnosis of biologically-based mental illnesses with the same dollar limits, deductibles, coinsurance factors, and restrictions as for other covered illnesses. (§58-17-98, §58-18-80)
If the plan covers prescriptions, it cannot exclude coverage of any drug used for the treatment of cancer or life threatening conditions on the grounds that the drug has not been approved by the FDA for that indication if that drug is recognized for treatment of such indication in one of the standard reference compendia or in the medical literature. (§58-17-101)
Unless the plan provides coverage for specified disease or other limited benefit coverage, it must cover annual diagnostic screening for prostate cancer for asymptomatic men aged 50 and over; and for men aged 45 and over at high risk for prostate cancer; and for males of any age who have a prior history of prostate cancer. (§58-17-107, §58-18-85)
For managed care plans, health carriers must cover emergency services necessary to screen and stabilize a covered person and may not require prior authorization of such services if a prudent layperson would have reasonably believed that an emergency medical condition existed. (§58-17C-27)
For managed care plans, covered persons must have access to emergency services 24 hours a day, seven days a week to treat emergency medical conditions that require immediate medical attention. (§58-17C-31)
Plans that cover dependent children that terminate upon attainment of the limiting age for dependent children, must not terminate the coverage of such children while the children are and continue to be both (a) incapable of self-sustaining employment by reason of mental retardation or physical handicap and (b) chiefly dependent upon the policyholder for support and maintenance. (§58-18-31)
Plans that cover dependent children must not terminate coverage due to attainment of a limiting age below age 19, or if a full-time student as of the close of the calendar year, below age 24. If the dependent remains a full-time student upon reaching 24 and up to age 19, the insurer must provide for optional continuation of coverage. (§58-18-31.1)
The plan may not prevent plan participants from selecting a licensed pharmacy of their choice, and not require use of mail order pharmacies. (§58-18-37)
No person may make or permit any unfair discrimination between individuals of the same class and of essentially the same hazard in the amount of premium, policy fees, or rates charged for any policy or contract of health insurance or in the benefits payable, or in any of the terms or conditions of such contract, or in any other manner whatever. (§58-33-13)
Plans must not deny enrollment of a dependent child under the health insurance coverage of either the child's natural, adoptive, or stepparents because the child was born out of wedlock, the child is not claimed as a dependent on the parent's federal income tax return, or the child does not reside with the parent or in the insurer's service area. (§58-33-85)
Plans may not discriminate based on domestic violence, effective July 1, 2010. (HB 1189)
Effective September 23, 2010, the state adopted rules implementing the requirements of the federal Patient Protection and Affordable Care Act, including internal and external reviews, preventive services, and patient protections. Regulations (§20:06:22) implementing the provisions include, but are not limited to, the following:
Insurers are prohibited from discouraging applications for health insurance during open enrollment.
The standards for internal appeals of health insurance claim determinations are revised.
Standards for the coverage of preventive services in health insurance are established.
Plans must extend coverage for children who have not reached the age of 26.
Plans must allow access to certain health care specialists.
Standards for health insurance compensation with respect to emergency care are set.
Insurers are restricted in rescinding coverage.
Plans are prohibited from applying annual and lifetime limits in certain situations.
Plans must provide for open enrollment for those that have not reached the age of 19.
Plans may not discriminate on the basis of genetics.