S.D. Admin. R. 20:06:56:19

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

Section 20:06:56:19 - Catastrophic plan

A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if:

(1) The only individuals who are eligible to enroll in the plan are individuals described in 1302 (e); and

(2) The plan provides except as provided in clause 1302 (e), the essential health benefits determined under section 1302 of the ACA, except that the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) of section 1302 for the plan year except as provided for in section 2713; and coverage for at least three primary care visits. An individual is described in this paragraph for any plan year if the individual has not attained the age of 30 before the beginning of the plan year; or has a certification in effect for any plan year under this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of section 5000A(e)(1) of such Code relating to individuals without affordable coverage; or section 5000A(e)(5) of such Code relating to individuals with hardships.

If a health insurance issuer offers a health plan described in this section, the issuer may only offer the plan in the individual market.

The cost-sharing incurred under a health plan described in this section with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2014 shall not exceed the dollar amounts in effect under section 223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, for taxable years beginning in 2014.

In the case of any plan year beginning in a calendar year after December 31, 2014, the limitation under this section shall in the case of self-only coverage, be equal to the dollar amount under described above for self-only coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage for the calendar year; and in the case of other coverage, twice the amount in effect. If the amount of any increase is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.

S.D. Admin. R. 20:06:56:19

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.