S.D. Admin. R. 20:06:58:21

Current through Register Vol. 51, page 57, November 12, 2024

Section 20:06:58:21 - Special rule for sub-classifications permitted for office visits, separate from other outpatient services

For purposes of applying the financial requirement and treatment limitation rules of §§ 20:06:58:07 to 20:06:58:25, inclusive, a plan or issuer may divide its benefits furnished on an outpatient basis into the two sub-classifications described in this section. After the sub-classifications are established, the plan or issuer may not impose any financial requirement or quantitative treatment limitation on mental health or substance use disorder benefits in any sub-classification that is more restrictive than the predominant financial requirement or quantitative treatment limitation that applies to substantially all medical or surgical benefits in the sub-classification using the methodology set forth in paragraphs §§ 20:06:58:14 to 20:06:58:17, inclusive. Sub-classifications other than these special rules, such as separate sub-classifications for generalists and specialists, are not permitted. The two sub-classifications permitted under this section are:

(1) Office visits, such as physician visits; and

(2) All other outpatient items and services, such as outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items.

S.D. Admin. R. 20:06:58:21

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.