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This page lists some of the action toward parity compliance undertaken by South Dakota regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org.

Action in the Regulatory Arena

Summer 2015

SB 108 from the 2014 Legislative session required the Department of Human Services and the Department of Labor and Regulation to conduct a study about autism services and insurance coverage for autism services, including associated costs. The departments presented this slide deck (pdf | Get Adobe® Reader®) that chronicles the findings related to insurance coverage.

Spring 2015

The Division of Insurance released its seasonal newsletter (pdf | Get Adobe® Reader®) to consumers. This newsletter contained a section that informed consumers about the recently passed legislation about autism coverage (page 3 of the newsletter).

12/2014

Primary Focus: Mandated Benefit
Agency: Public Utilities Commission
Title/Description: Classifications of benefits used for applying rules
Citation: ARSD 20:06:58:12
Summary: If a plan, or health insurance coverage, provides mental health or substance use disorder benefits, mental health or substance use disorder benefits must be provided in every classification in which medical or surgical benefits are provided. A plan or health insurance issuer, must apply the same standards to medical or surgical benefits and to mental health or substance use disorder benefits.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Access to Services
Agency: Public Utilities Commission
Title/Description: Special rule for multi-tiered prescription drug benefits
Citation: ARSD 20:06:58:19
Summary: If a plan, or health insurance coverage, applies different levels of financial requirements to different tiers of prescription drug benefits, relating to requirements for nonquantitative treatment limitations, and without regard to whether a drug is generally prescribed with respect to medical or surgical benefits or with respect to mental health or substance use disorder benefits, the plan, or health insurance coverage, satisfies the parity requirements
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit
Agency: Public Utilities Commission
Title/Description: Application to out-of-network providers
Citation: ARSD 20:06:58:13
Summary: A plan, or health insurance coverage, that provides mental health or substance use disorder benefits in any classification of benefits must provide mental health or substance use disorder benefits in every classification in which medical or surgical benefits are provided, including out-of-network classifications.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Access to Services
Agency: Public Utilities Commission
Title/Description: Special rule for multiple network tiers
Citation: ARSD 20:06:58:20
Summary:  If a plan, or health insurance coverage, provides benefits through multiple tiers of in-network providers, the plan may divide its benefits furnished on an in-network basis into sub-classifications that reflect network tiers, without regard to whether a provider provides services with respect to medical or surgical benefits or mental health or substance use disorder benefits. The plan or issuer may not impose any financial requirement or treatment limitation on mental health or substance use disorder benefits in any sub-classification that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical or surgical benefits.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit
Agency: Public Utilities Commission
Title/Description: Plan with a limit on at least two-thirds of all medical or surgical benefits
Citation: ARSD 20:06:58:04
Summary: A plan or health insurance coverage that includes an aggregate lifetime or annual dollar limit on at least two-thirds of all medical or surgical benefits, must either: apply the aggregate lifetime or annual dollar limit both to the medical or surgical benefits to which the limit would otherwise apply and to mental health or substance use disorder benefits, or not include an aggregate lifetime or annual dollar limit on mental health or substance use disorder benefits that is less than the aggregate lifetime or annual dollar limit, respectively, on medical or surgical benefits.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit
Agency: Public Utilities Commission
Title/Description: General parity requirement
Citation: ARSD 20:06:58:11
Summary: A group health plan, or health insurance coverage offered by an issuer in connection with a group health plan, that provides both medical or surgical benefits and mental health or substance use disorder benefits may not apply any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification this is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all, medical or surgical benefits, in the same classification.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit
Agency: Public Utilities Commission
Title/Description: Nonquantitative treatment limitations
Citation: ARSD 20:06:58:23
Summary: A group health plan, or health insurance coverage, may not impose a nonquantitative treatment limitation with respect to mental health or substance use disorder benefits in any classification unless, under the terms of the plan, or health insurance coverage, any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical or surgical benefits in the classification.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit and Access to Services
Agency: Public Utilities Commission
Title/Description: Plan with no limit or limits on less than one-third of all medical or surgical benefits
Citation: ARSD 20:06:58:03
Summary: If a plan, or health insurance coverage, does not include an aggregate lifetime or annual dollar limit on any medical or surgical benefits or includes an aggregate lifetime or annual dollar limit that applies to less than one-third of all medical or surgical benefits, it may not impose an aggregate lifetime or annual dollar limit, respectively, on mental health or substance use disorder benefits.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit and Access to Services
Agency: Public Utilities Commission
Title/Description: Plan not described in sections 20:06:58:03 or 20:06:58:04 of this chapter
Citation: ARSD 20:06:58:06
Summary: A group health plan, or health insurance coverage, with respect to aggregate lifetime or annual dollar limits on medical or surgical benefits must either: impose no aggregate lifetime or annual dollar limit, as appropriate, on mental health or substance use disorder benefits; or 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
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit and Access to Services
Agency: Public Utilities Commission
Title/Description: No separate cumulative financial requirements or cumulative quantitative treatment limitations
Citation: ARSD 20:06:58:22
Summary: A group health plan, or health insurance coverage, offered in connection with a group health plan, may not apply any cumulative financial requirement or cumulative quantitative treatment limitation for mental health or substance use disorder benefits in a classification that accumulates separately from any established for medical or surgical benefits in the same classification.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit
Agency: Public Utilities Commission
Title/Description: Financial requirements and quantitative treatment limitations — Determining substantially all
Citation: ARSD 20:06:58:14
Summary:  If a type of financial requirement or quantitative treatment limitation does not apply to at least two-thirds of all medical or surgical benefits in a classification, then that type cannot be applied to mental health or substance use disorder benefits in that classification.
Effective Date: December 3, 2014
Notes: 41 SDR 93

Primary Focus: Mandated Benefit and Access to Services
Agency: Public Utilities Commission
Title/Description: Special rule for sub-classifications permitted for office visits, separate from other outpatient services
Citation: ARSD 20:06:58:21
Summary: A 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
Effective Date: December 3, 2014
Notes: 41 SDR 93

9/2010

Primary Focus: Mandated Benefit and Access to Services
Agency: Public Utilities Commission
Title/Description: Individual plans — Lifetime limits          
Citation: ARSD 20:06:55:21
Summary: No individual policy of insurance may establish a lifetime limit on the dollar value of essential benefits for any covered person or an unreasonable annual limit on the dollar value of essential benefits for any covered person. Essential benefits include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care.
Effective Date: September 23, 2010
Notes: 37 SDR 63 (September 23, 2010), 37 SDR 111 (effective December 7, 2010)

Primary Focus: Mandated Benefit and Access to Services
Agency: Public Utilities Commission
Title/Description: Group plans — Lifetime limits
Citation: ARSD 20:06:55:15
Summary: A group health plan may not establish any lifetime limit or any annual limit on the dollar amount of essential benefits for any individual. Essential benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.
Effective Date: September 23, 2010
Notes: 37 SDR 63 (September 23, 2010), 37 SDR 111 (effective December 7, 2010)

South Dakota Parity Law

There are several sections of the law addressing behavioral health coverage and autism coverage:

Mental Health Coverage

Individual plans, small employer fully-insured plans, and large employer fully-insured plans are required to cover services for the following conditions:

  • Schizophrenia and other psychotic disorders
  • Bipolar disorder
  • Major depression
  • Obsessive compulsive disorder

This coverage must have the same annual maximums, lifetime maximums, deductibles, coinsurance, and “restrictions” as what are in place for other medical services.

Substance Use Disorder Coverage

Individual plans, small employer fully-insured plans, and large employer fully-insured plans are required to offer optional coverage for “treatment of alcoholism.” If a plan enrollee chooses a plan with this coverage, the plan must cover at least 30 days of inpatient care during any 6-month time period and have a lifetime limit of at least 90 days of inpatient care.

There is also a condition in the state insurance law forbidding insurance plans from excluding coverage of injuries sustained while a person was under the influence of drugs and alcohol. For example, a plan may not refuse to cover treatment for a broken arm because the person was under the influence of drugs or alcohol when the injury occurred. However, plans can exclude coverage for any “sickness or injury caused in the commission of a felony.”

Autism Coverage

Large employer fully-insured plans, self-insured non-federal governmental plans (except for South Dakota’s state employee plan), some individual plans, and some small employer fully-insured plans are required to cover applied behavior analysis as follows:

  • $36,000 annual maximum through age 6
  • $25,000 annual maximum for age 7 through age 13
  • $12,000 annual maximum age 14 through age 18

Individual plans and small employer fully-insured plans that provide essential health benefits under the Affordable Care Act do not have to comply with this section of the insurance law.

Autism spectrum disorder is defined as “a complex neurodevelopmental medical disorder characterized by social impairment, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior.” There is no mention of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or any other officially recognized diagnostic guide.

Treatment for autism is listed as:

  • Behavioral health care
  • Pharmacy care
  • Therapeutic care

Insurance plans are allowed to review a child’s treatment plan once every 3 months.

Get Support

South Dakota Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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