Free Medical Plans Study Guide
South Dakota Life, Accident & Health exam — Medical Plans.
The national Medical Plans guide covers plan types, cost sharing and the ACA. This guide covers the South Dakota mandates and consumer rules that attach to health policies. They come from SDCL 58-17 (individual health), 58-18 (group health) and 58-33. Group continuation and small-employer rules are in the South Dakota Group Health guide.
Dependent children
- Limiting age: a policy can't end a qualifying child's coverage because of an age limit below 26 (SDCL 58-17-2.3, 58-18-31.1).
- Full-time students: at the insured's option, coverage continues for a dependent who stays a full-time student past 26, up to age 29 (58-17-2.3).
- Disabled children: coverage continues past the limiting age while the child can't hold self-sustaining employment and is chiefly dependent on the insured (58-17-30.1).
- Proof is due within 31 days of reaching the limiting age.
- Enrollment: a child can't be refused enrollment because the child (58-33-85):
- was born out of wedlock
- isn't claimed on the parent's tax return
- doesn't live with the parent or in the service area
Newborns and adopted children
- A newborn is covered from the moment of birth (58-17-30.2, 58-18-32).
- An adopted child is covered from the start of the six-month adoption bonding period.
- Coverage must include premature birth and medically diagnosed congenital defects and birth abnormalities (58-17-30.3).
- The policy may require notice of birth and the premium within 31 days to continue the child's coverage past that period (58-17-30.4).
Required benefits and offers
| Topic | South Dakota rule |
|---|---|
| Maternity stay | At least 48 hours inpatient after a vaginal delivery and 96 hours after a cesarean (58-17-88) |
| Diabetes | Every health policy except specified-disease and limited-benefit policies covers diabetes equipment, supplies and self-management education (58-17-1.2) |
| Alcoholism | Group expense-incurred insurers must offer inpatient alcoholism treatment in writing (58-18-7.1). Benefits may be limited to 30 days in 6 months and 90 days over the life of the contract (58-17-30.6, 58-18-7.2). Accident-only and specified-disease policies are exempt (58-17-30.7). |
| Chiropractors and other licensed providers | A covered service can't be denied just because a listed licensee, such as a chiropractor, provided it (58-17-54) |
| Therapy copays | Copays or coinsurance for chiropractic, physical therapy or occupational therapy can't exceed the primary-care physician charge for the same condition (58-17-54.1) |
| Telehealth | A service can't be excluded only because it's delivered by telehealth (58-17-168) |
Disclosure
- When a producer sells a health policy, the outline of coverage is delivered at the time of application (58-33A-5).
- Individual health policies have a 10-day free look from delivery (58-17-11). See the South Dakota Individual A&H Provisions guide.
Provider waiver of cost sharing
A provider who knowingly waives deductibles or copays as a regular business practice commits abuse of health insurance, a Class 1 misdemeanor (58-17-57).
Common exam traps
- Dependent coverage runs to 26. A full-time student can stay on to 29 at the insured's option.
- Disabled-child proof is due within 31 days of the limiting age.
- A newborn is covered from birth. Notice and premium may be required within 31 days.
- Maternity minimums are 48 / 96 hours.
- Alcoholism coverage is an offer. Its limits are 30 days per 6 months and 90 days over the life of the contract.
- Routinely waiving copays is a crime in South Dakota, not a discount.
Practice Medical Plans questions All Life, Accident & Health topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
