S.D. Admin. R. 20:06:58:06

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

Section 20:06:58:06 - Plan not described in sections 20:06:58:03 or 20:06:58:04 of this chapter

A group health plan, or health insurance coverage, that is not described in § 20:06:58:03 or 20:06:58:04 with respect to aggregate lifetime or annual dollar limits on medical or surgical benefits must either:

(1) Impose no aggregate lifetime or annual dollar limit, as appropriate, on mental health or substance use disorder benefits; or

(2) Impose an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is no less than an average limit calculated for medical or surgical benefits in the following manner. The average limit is calculated by taking into account the weighted average of the aggregate lifetime or annual dollar limits, as appropriate, that are applicable to the categories of medical or surgical benefits. Limits based on delivery systems, such as inpatient, outpatient treatment or normal treatment of common, low-cost conditions such as treatment of normal births, do not constitute categories for purposes of subdivision 20:06:58:06(2). In addition, for purposes of determining weighted averages, any benefits that are not within a category that is subject to a separately-designated dollar limit under the plan are taken into account as a single separate category by using an estimate of the upper limit on the dollar amount that a plan may reasonably expect to incur with respect to such benefits, taking into account any other applicable restrictions under the plan.

For purposes of this section, the weighting applicable to any category of medical or surgical benefits is determined in the manner set forth in § 20:06:58:05 for determining one-third or two-thirds of all medical or surgical benefits.

S.D. Admin. R. 20:06:58:06

41 SDR 93, effective 12/3/2014.

General Authority: SDCL 58-17-87, 58-18-79, 58-18-79(15).

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