S.D. Codified Laws § 58-18B-1

Current through the 2024 Legislative Session

Section 58-18B-1 - Definition of terms

Terms used in this chapter mean:

(1) "Actuarial certification," a written statement by a member of the American Academy of Actuaries or other individual approved by the director that a small employer carrier is in compliance with the provisions of this chapter, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the carrier in establishing premium rates for applicable health benefit plans;

(2) "Base premium rate," the lowest premium rate charged or which could have been charged for each class of business for a rating period under a rating system for that class of business, by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage;

(3) "Carrier," any person who provides health insurance in this state. In this chapter, carrier includes a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization, a multiple employer welfare arrangement, or any person providing a plan of health insurance subject to state insurance regulation;

(4) "Case characteristics," demographic or other relevant characteristics of a small employer, as determined by a small employer carrier, which are considered by the carrier for the determination of premium rates. Claim experience, health status, and duration of coverage since issue are not case characteristics in this chapter;

(5) "Class of business," all or a distinct grouping of small employers as shown on the records of the small employer carrier;

(a) A distinct grouping may only be established by a small employer carrier on the basis that the applicable health benefit plans:

(i) Are marketed and sold through individuals and organizations which are not participating in the marketing or sale of other distinct groupings of small employers for such small employer carrier;

(ii) Have been acquired from another small employer carrier as a distinct grouping of plans;

(iii) Are provided through an association with membership of not less than twenty-five small employers which has been formed for purposes other than obtaining insurance; or

(iv) Are in a class of business that meets the requirements for exception to the restrictions related to premium rates provided in subsection 58-18B-3(1)(a);

(b) A small employer carrier may establish no more than two additional groupings under each of the subparagraphs in subsection (a) on the basis of underwriting criteria which are expected to produce substantial variation in the health care costs;

(c) The director may approve the establishment of additional distinct groupings upon application to, and a finding by, the director that such action would enhance the efficiency and fairness of the small employer insurance marketplace;

(6) "Director," the director of the Division of Insurance;

(7) "Division," the Division of Insurance of the Department of Labor and Regulation;

(8) "Index rate," the arithmetic average of the applicable base premium rate and the corresponding highest premium rate for each class of business for small employers with similar case characteristics;

(9) "New business premium rate," the premium rate charged or offered by a small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage for each class of business for a rating period;

(10) "Rating period," the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier;

(11) "Small employer," any person, firm, corporation, partnership, or association actively engaged in business which on an average of its working days during the preceding year, employed no more than fifty and no less than two employees and who employs at least two employees on the first day of the plan year. In determining the number of employees, companies which are affiliated companies or which are eligible to file a combined tax return for purposes of state taxation are considered to be one employer;

(12) "Small employer carrier," any carrier which offers health benefit plans covering the employees of a small employer;

(13) "Affiliate" or "affiliated," any person who, directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, any other specified person;

(14) "Dependent," except as otherwise required by this title, any spouse, any unmarried child under the age of nineteen years, any unmarried child who is a full-time student under the age of twenty-three and who is financially dependent upon the parent, and any unmarried child of any age who is medically certified as disabled and dependent upon the parent;

(15) "Eligible employee," any employee who works on a permanent basis and has a normal work week of thirty or more hours. The term includes any sole proprietor, any partner, and any independent contractor, if the sole proprietor, partner, or independent contractor is included as an employee under a health benefit plan of a small employer, but does not include any employee who works less than thirty hours or on a temporary or substitute basis;

(16) "Employee," has the meaning given such term under Section 3(6) of Title I of the Employee Retirement Income Security Act of 1974 (ERISA) as amended to January 1, 2001;

(17) "Health benefit plan," any hospital or medical policy or certificate, hospital or medical service plan, or health maintenance organization subscriber contract. The term does not include specified disease, hospital indemnity, fixed indemnity, accident-only, credit, dental, vision, prescription drug, medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance, or automobile medical payment insurance;

(18) "Restricted network provision," any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of health care providers that have entered into a contractual arrangement with the carrier to provide health care services to covered individuals.

SDCL 58-18B-1

SL 1991, ch 402, § 1; SL 1995, ch 281, § 1; SL 1997, ch 289, § 14; SL 2001, ch 279, §1; SL 2003, ch 272 (Ex. Ord. 03-1), § 27; SL 2011, ch 1 (Ex. Ord. 11-1), § 162, eff. Apr. 12, 2011.