S.D. Admin. R. 20:06:56:06

Current through Register Vol. 50, page 159, June 17, 2024

Section 20:06:56:06 - Pediatric dental

A stand-alone dental plan covering pediatric dental may be used to cover the pediatric dental component of essential health benefits required by § 20:06:56:02. A stand-alone dental plan covering the pediatric dental category under § 20:06:56:02 must demonstrate to the director that it has a reasonable annual limitation on cost-sharing. An issuer must demonstrate that the stand-alone dental plan offers the pediatric dental essential health benefit within a de minimis variation of +/-2 percentage points of the level of coverage in subsections (1) and (2) at either:

(1) A low level of coverage with an AV of 70 percent; or

(2) A high level of coverage with an AV of 85 percent.

The coverage levels described above must be certified by a member of the American Academy of Actuaries using generally accepted actuarial principles and provided to the division.

A health benefit plan offered in the small group or individual market, which does not include minimum essential pediatric dental benefits, offers the minimum essential health benefits required under law only, if:

(1) There is at least one dental benefits carrier offering the federally-required minimum pediatric dental benefits in the state;

(2) The health benefit plan makes prominent disclosure at the time that it offers the plan, in a form approved by the director, that the health benefit plan does not provide the essential pediatric dental benefits; and

(3) That the dental benefits carriers providing the federally required minimum pediatric dental benefits and other dental benefits are licensed to offer dental benefits in the state.

For health benefit plans offered outside an exchange, pediatric dental coverage may only be excluded when an issuer is reasonably assured an individual has obtained such coverage through an exchange certified stand-alone dental plan being offered outside the exchange. A carrier may use any reasonable method for obtaining reasonable assurance including an attestation on an insurance application or other documentation from the applicant or the applicant's dental insurer.

S.D. Admin. R. 20:06:56:06

39 SDR 203, effective 6/10/2013.

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

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