58-41-121. Documents provided to risk bearing entity by health maintenance organization.
In entering into, amending, or renewing a contract with a risk bearing entity, a health maintenance organization shall, unless already specified in the contract, provide the following, upon request, to a risk bearing entity:
(1)At the time the contract is entered into, a written statement describing the amount or method of remuneration to be paid to the risk bearing entity. If any part of the remuneration is a calculated amount based on variable factors, the payment methodology upon which the calculated amount will be determined. The statement shall specify the services and expenses for which the risk bearing entity is financially liable in whole or part;
(2)At the time payment is made, the basis of the calculation of that payment;
(3)For health benefit plans in which the covered persons are assigned to the risk bearing entity under a capitated payment arrangement, a list of enrollees and payments due to the risk bearing entity, to be provided monthly if not already available to the risk bearing entity;
(4)At the time the contract is entered into, a copy of the health maintenance organization's most recent annual statement filed with the NAIC; and
(5)Once the contract is in effect, the quarterly or annual statement.
Source: SL 2013, ch 256, ยง36.
Structure South Dakota Codified Laws
Chapter 41 - Health Maintenance Organizations
Section 58-41-1 - Definition of terms.
Section 58-41-2 - Organizations subject to chapter.
Section 58-41-4 - Application for certificate of authority required.
Section 58-41-6 - Verification and form of application--Contents.
Section 58-41-7 - Financial statements required with application.
Section 58-41-8 - Copies of forms required with application.
Section 58-41-9 - Marketing, charges, and financial plans required with application.
Section 58-41-10 - Appointment to receive process required of foreign applicant.
Section 58-41-11 - Surety bond or deposit required--Waiver.
Section 58-41-12 - Determination of health care qualifications.
Section 58-41-13 - Coordination with federal professional standards review.
Section 58-41-15 - Health maintenance not considered practice of healing arts.
Section 58-41-17 - Issuance or denial of certificate--Fee--Conditions for issuance.
Section 58-41-18 - Factors considered in determining financial responsibility.
Section 58-41-19 - Insurance arrangements permitted.
Section 58-41-20 - Corporation operating after certification.
Section 58-41-21 - Foreign corporations qualifying--Exemption from other requirements.
Section 58-41-23 - Composition of governing body--Consumer representation.
Section 58-41-24 - Mechanisms for enrollee participation in policy and operation of governing body.
Section 58-41-25 - Fiduciary responsibilities to enrollees.
Section 58-41-25.1 - Investments.
Section 58-41-26 - Exemption from insurance laws--Exceptions--Taxation.
Section 58-41-28 - Solicitation of enrollment not deemed professional advertising.
Section 58-41-29 - Contracts and necessary activities.
Section 58-41-31 - Direct payments to enrollees prohibited.
Section 58-41-33 - Trade practice laws applicable.
Section 58-41-34 - Evidence of coverage issued to enrollees.
Section 58-41-35 - Contents required in evidence of coverage.
Section 58-41-35.1 - Alcoholism coverage to be offered at time contract is negotiated.
Section 58-41-35.7 - Contracts required to cover occult breast cancer screening.
Section 58-41-36 - Unfair and misleading information in evidence of coverage as misdemeanor.
Section 58-41-37 - Deceptive advertising or evidence of coverage as misdemeanor.
Section 58-41-38 - Statements deemed untrue.
Section 58-41-39 - Statements deemed misleading.
Section 58-41-40 - Evidence of coverage deemed deceptive.
Section 58-41-41 - Issuance to enrollees of change in evidence of coverage.
Section 58-41-42 - Evidence of coverage to be approved before use--Violation as misdemeanor.
Section 58-41-43 - Filing and approval requirements applicable.
Section 58-41-44 - Charges to enrollees--Fairness--Actuary's certificate.
Section 58-41-45 - Discrimination as misdemeanor.
Section 58-41-50 - Authorized expenses.
Section 58-41-51.2 - Conversion privileges of insured's spouse upon divorce.
Section 58-41-51.3 - Continuation and conversion coverage to be offered.
Section 58-41-52 - Contracts with providers of health care services.
Section 58-41-52.1 - Collection for covered services prohibited.
Section 58-41-52.2 - Contracts--Hold harmless provision.
Section 58-41-52.3 - Hold harmless provision--Language of provision.
Section 58-41-55 - Insurance contracts authorized--Group coverage--Benefit payments.
Section 58-41-56 - Contracts for management and administrative services authorized.
Section 58-41-57 - Payment of unreasonably high expenses as misdemeanor.
Section 58-41-63 - General annual report required--Form and contents.
Section 58-41-65 - Applications, filings and reports as public documents.
Section 58-41-66 - Annual summary for enrollees required--Contents.
Section 58-41-67 - Promulgation of rules.
Section 58-41-73 - Physician-patient privileges.
Section 58-41-74 - Confidential data--Exceptions.
Section 58-41-78 - Cease and desist orders.
Section 58-41-79 - Hearing on cease and desist order--Procedure--Judicial review.
Section 58-41-80 - Injunctive relief against violations--Venue.
Section 58-41-81 - Suspension or revocation of certificate of authority on findings by director.
Section 58-41-82 - Additional grounds for suspension or revocation.
Section 58-41-83 - Voluntary conference before commencing actions for violation.
Section 58-41-84 - Informality in voluntary conferences.
Section 58-41-85 - Money penalty in lieu of suspension or revocation.
Section 58-41-86 - Requirements for suspension or revocation.
Section 58-41-86.1 - Suspension without notice or hearing.
Section 58-41-88 - Administrative procedure and rules.
Section 58-41-90 - Action of director after hearing--Written findings.
Section 58-41-91 - Judicial review.
Section 58-41-92 - Activities prohibited during suspension of certificate.
Section 58-41-94 - Summary proceeding to reorganize organization--Grounds.
Section 58-41-95 - Rehabilitation, liquidation, or conservation under insurance company laws.
Section 58-41-96 - Severability of provisions.
Section 58-41-97 - Citation of chapter.
Section 58-41-98 - Coverage for phenylketonuria.
Section 58-41-99 - Formation of voluntary health insurance purchasing organizations.
Section 58-41-100 - Membership of voluntary health insurance purchasing organizations.
Section 58-41-101 - Purchasing organization's responsibility for negotiating terms and conditions.
Section 58-41-102 - Purchasing organization's notice of premium charge.
Section 58-41-103 - Additional chapters applicable to purchasing organization.
Section 58-41-104 - Approval of purchasing organization by Division of Insurance.
Section 58-41-105 - Premiums held in trust by purchasing organization.
Section 58-41-106 - Rates for group health insurance issued to purchasing organizations.
Section 58-41-108 - Purchasing organizations exempt from antitrust provisions.
Section 58-41-109 - Promulgation of rules for purchasing organizations.
Section 58-41-110 - Application of chapter to provider contracting with state.
Section 58-41-112 - Minimum inpatient care coverage following delivery.
Section 58-41-114 - Notice to enrollees--Disclosures.
Section 58-41-116 - Application--Exemptions.
Section 58-41-118 - Diabetes coverage not required of certain plans and policies.
Section 58-41-119 - Contracts to provide coverage for prostate cancer screening.
Section 58-41-120 - Annual report on risk bearing entities.
Section 58-41-121 - Documents provided to risk bearing entity by health maintenance organization.
Section 58-41-122 - Documents provided to health maintenance organization by risk bearing entity.
Section 58-41-123 - Notice by risk bearing entity of change in conditions--Assignment of contract.
Section 58-41-125 - Confidentiality of information.
Section 58-41-126 - Nontransferable responsibilities of health maintenance organization.
Section 58-41-127 - Coverage for treatment of hearing impairment for persons under age nineteen.