Words and phrases defined in SDCL 3-6C-1 have the same meaning when used in this article. As used in this article:

1. (1) "Adverse determination" means a determination by the South Dakota State Employee Health Plan or its designee utilization review organization that an admission, availability of care, continued stay, or other health-care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the South Dakota State Employee Health Plan's requirements for medical necessity, appropriateness, health-care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated;
2. (2) "Claim" means the request of coverage of an eligible employee or any other person under the South Dakota State Employee Health Plan;
3. (3) "Contract period" or "plan year" means that period beginning on July 1 of one year and ending on June 30 of the following year;
4. (4) "Contribution or premium" means the sum paid by or on behalf of an employee as consideration for a life, health, or flexible benefits;
5. (5) "Eligible employee" means a permanent full-time employee, permanent part-time employee, or an employee employed by a participating unit who has worked an average of 30 hours or more per week during a 12 month period, as defined by the Patient Protection and Affordable Care Act of 2010, as amended;
6. (6) "Flexible benefits plan" means a benefits plan that allows members to select from a list of benefits options, some or all of which may be tax-advantaged, and which may vary depending on the status of a member as either an employee or retiree. The options may include dental, vision, medical spending accounts, dependent care, and others as determined by the bureau;
7. (7) "Participating unit" means any department, bureau, campus, institution, board, or commission of the state that has employees who are eligible for participation; and
8. (8) "Proof of insurability" means evidence of a person's medical condition based upon a medical examination, a person's medical history, or a doctor's statement regarding a person's health.

Source: 38 SDR 213, effective July 1, 2012; 41 SDR 58, effective October 14, 2014; 42 SDR 97, effective January 4, 2016 ; 47 SDR 142, effective July 1, 2021 .

General Authority: SDCL 3-6E-13 .

Law Implemented: SDCL 3-6E-1 .

Prior versions effective: 2016-01-04, 2014-10-14, 2012-07-01.