South Dakota Health Insurance Guide
South Dakota Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
As a resident of South Dakota you can choose from a variety of private health insurance plans including plans for individuals and group plans provided by an employer. Depending on your income or employment status, you may also be eligible for South Dakota State-funded affordable health insurance for individuals and families, and federal programs such as Medicaid and COBRA.
South Dakota is not a guarantee issue state. By law, private insurance companies that sell individual policies must medically underwrite them and are required to sell you an individual health insurance policy if you do not meet their criteria. You can be turned down for any number of reasons including your past or current health and lifestyle habits. In South Dakota, insurers are permitted a 12-month exclusionary period and a 12-month look-back period for pre-existing conditions, unless you have proof of prior creditable coverage. South Dakota also permits health insurance providers to issue Elimination Riders that exclude coverage for specific health conditions. If you file a claim during the first two years that your policy is in effect, your insurer reserves the right to another look-back at your medical records to determine if you should have listed that condition as a pre-existing condition, and to deny benefits in that case. Insurers in South Dakota can base premiums for individual policies based on your health, your age and lifestyle factors. However, there is a cap that limits what you can reasonably be charged; the variance is plus or minus 30% of the state’s individual market rate. South Dakota does not require insurers to offer standardized policies for individuals.
South Dakota is a guarantee issue state for group health plans issued to small businesses. If your South Dakota health insurance is provided through your employer, your coverage cannot be denied because of your past or current health. The insurer can impose a 12-month exclusionary period and a six-month look-back period for pre-existing medical conditions, but must give credit for prior creditable coverage if there has been no more than a 63-day break in coverage. Your employer may impose a waiting period for eligibility for new hires, but it must be applied equally to all new hires. Premiums for small group health insurance may be underwritten and the insurer can charge a premium not to exceed 25% of its index rate if your group has a history of unfavorable health.
South Dakota is a guaranteed renewal state. Regardless of your health, your insurer must renew your individual health insurance policy as long as you’ve paid your premiums on time and haven’t defrauded the company, or in the case of some HMOs, as long as you haven’t moved out of the service area. However, your premiums can be increased to reflect your current health status. Your policy can be canceled if your insurer discontinues a plan or no longer sells insurance in the state.
South Dakota Mandated Health Benefits
South Dakota laws require private health insurance policies to cover several state-mandated benefits. These currently include:
- Ambulatory Surgery
- Breast Reconstruction
- Clinical Trials
- Contraceptives
- Diabetes Supplies and Self Management
- Emergency Services
- Home Health Care
- Mammography
- Maternity Stays
- Parity Mental Health
- Off Label Drug Use
- PKU/Formula
- Coverage for newborns under their guardian’s policy
- Coverage for adopted children under their guardian’s policy
- Coverage for handicapped under their guardian’s policy
- Coverage for continuation/dependents under their guardian’s policy
- Coverage for conversion to non-group
Types Health Insurance Plans Available in South Dakota
The following major medical health insurance plans are generally available in South Dakota. Major medical plans cover illness and injury, hospitalization, prescription drugs and office visits, as well as the mandated services stated above.
Indemnity plans - Typically the most flexible and therefore highest priced choice, an indemnity plan lets you select your health providers and facilities. Depending on your plan, you will have to pay a deductible or co-insurance.
Preferred provider organization plans (PPOs) - You select from a network of preferred health care providers and facilities, and receive services at an agreed-upon discounted rate. You also have the option of going outside the network, but typically at a higher cost. You do not need a referral from a primary care physician to see a specialist. Premiums may be less than an indemnity plan but more than an HMO. You will have to pay a deductible or co-insurance.
Health maintenance organizations (HMOs) - HMOs plans require you to select a primary care physician from a prescribed network of providers, who must issue a referral before you can see a specialist. Services and covered costs are typically more comprehensive than those provided by a PPO. HMOs offer the advantage of affordable premiums and low out-of-pocket costs, with an emphasis on preventive care. Non-emergency services out of network are usually not reimbursed.
Point of Service plans (POS) - Similar to a PPO in that you will receive reimbursement for out-of-network care, but with an HMO’s requirement for a primary care physician who must provide referrals to specialists. Premiums, co-pays and co-insurance are typically higher than what you’d pay with an HMO.
Alternative Health Programs in South Dakota
South Dakota Risk Pool
This is the state-sponsored high-risk pool that offers health insurance if you are a South Dakota resident who has lost your coverage involuntarily and can show proof of 12 months of prior creditable coverage. Other eligibility requirements apply. One PPO plan is offered, with three different deductable levels ranging from $1,000 to $10,000. The plan is also available as a Health Savings Account Plan. Coinsurance for most treatment in and out of network is 25%. Maximum out-of-pocket includes the deductible and varies depending on deductible level selected. Premiums are based on the plan you select, your age and tobacco use, but are capped at 150% of the average rate charged for similar coverage in South Dakota. Enrollment is open. There is no exclusionary period for pre-existing conditions.
South Dakota Children’s Health Insurance Program
SDCHIP provides comprehensive free or low-cost health care for resident children up to age 18, whose families meet income requirements and other eligibility requirements. No premiums or co-pays are charged for most covered services. There may be a waiting period but it can be waived in certain circumstances. Enrollment is open but is subject to review and renewal every 12 months.
Regulating Agency
The South Dakota Division of Insurance is responsible for regulating South Dakota’s health insurance industry.
Get access to South Dakota health insurance quotes from http://www.einsurance.com/health-insurance.
South Dakota Division of Insurance
445 E Capitol Ave
Pierre, SD 57501
(605) 773-3563
http://www.state.sd.us/drr2/reg/insurance
South Dakota Risk Pool
Capitol Building
500 E Capitol Ave
Pierre, SD 57501-5070
(605) 773-3148
http://riskpool.sd.gov
Children’s Health Insurance Program (CHIP)
(800) 305-3064
http://dss.sd.gov/medicalservices/CHIP
(NAIC) National Association of Insurance Commissioners
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
http://www.naic.org/
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
Contact info:
110 William Street
New York, NY 10038
212-346-5500
http://www.iii.org/