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Summary of differences between federal and state regulations
Federal HIPAA portability provisions limit exclusions for preexisting conditions; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances.
States are allowed to go beyond the federal requirements. South Dakota has laws that govern HIPAA, and they include the following provisions:
A “late enrollee” is an eligible employee or dependent who requests enrollment in a health plan after the initial enrollment period to which they are entitled if that period is at least 30 days in length. A person may not be considered a late enrollee if he/she
- was covered under creditable coverage at the time of initial enrollment, lost coverage as a result of termination of employment or eligibility, death of spouse, legal separation or divorce, and requests coverage within 63 days after loss of coverage;
- The employer offers multiple health plans and the employee switches to a different plan;
- enrollment is requested pursuant to court order or child custody agreement. §58-18-43
“Creditable coverage” includes benefits provided under Medicare/Medicaid; an employer-based health insurance plan or similar health benefit arrangement; an individual health insurance policy or employee welfare benefit plan subject to ERISA. §58-18-44
Preexisting Conditions:
- No health benefit plan may deny, exclude, or limit benefits for a covered individual for claims incurred more than twelve months following the effective date of the individual's coverage due to a preexisting condition. A preexisting condition is defined as a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six months immediately preceding the effective date of coverage. The preexisting condition exclusion will be waived if the individual had creditable coverage 63 days prior to the effective date of the new coverage with no break in coverage during that time.
- A health benefit plan may exclude coverage for late enrollees for the greater of eighteen months or for up to an eighteen-month preexisting condition exclusion.
- A health maintenance organization which does not utilize a preexisting waiting period may use an affiliation period in lieu of a preexisting waiting period. No affiliation period may exceed two months in length. No premium may be charged for any portion of the affiliation period. §58-18-45
New Enrollees: The health insurance carrier shall accept new employees and dependents of new employees for coverage under the health plan if the new employee had creditable coverage within the prior sixty-three days from the date the new employee is eligible for coverage. The coverage shall be issued without exclusionary riders. The carrier is not required to provide coverage to late enrollees or to those who have not had creditable coverage within sixty-three days before applying for coverage. The exception allowing late enrollees to be excluded is limited to the time frames required by §58-18-45. §58-18-48
State
Contact
South Dakota Department of Revenue and Regulation Division of Insurance
Regulations
South Dakota Statutes
Title 58 Insurance
Chapter 58-18 Group and Blanket Health Insurance Policies
§58-18-43 "Late enrollee" defined
§58-18-44 "Creditable coverage" defined
§58-18-45 Preexisting conditions — Portability of health insurance — Limitation of waiting periods
§58-18-48 Acceptance of new employees for coverage under employer's existing health benefit plan