State Law

South Dakota Codified Laws-Title 58-Chapter. 17H. Utilization Review and Benefit Determinations

07/30/2020 South Dakota Section 58-17H-8

Cost-sharing requirements for covered persons–Payments to out-of-network providers

OON-Payment Issues

Notwithstanding § 58-17H-7, a covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount the health carrier is required to pay pursuant to this section.

A health carrier complies with the requirements of this section if it provides payment of emergency services provided by an out-of-network provider in an amount not less than the greatest of the following:

(1) The amount negotiated with in-network providers for emergency services, excluding any in-network copayment or coinsurance imposed with respect to the covered person;

(2) The amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services, but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or

(3) The amount that would be paid under Medicare for the emergency services, excluding any in-network copayment or coinsurance requirements. (SL 2012, ch 239, § 1 provides: “The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.”)