South Dakota Small Business
Health Insurance Plans 2023

The average price of a standard South Dakota small business health insurance policy ranges from around $583 to over $1706 per employee per month based on; single or family, location, coverages offered, deductibles and more.

More health insurance regulations are imposed in South Dakota than in other states. As such, it is very important that, if you are a small business owner, that you are aware of these regulations so that you can ensure you are offering policies that are compliant with the state, and that also meet your needs and the needs of your employees.

In the State of South Dakota, all qualifying small business owners that apply for coverage with a health insurance company must be offered a policy. Additionally, they must be offered the same policies that other business owners are offered.

The state also requires that all small group health insurance policies include guaranteed renewability provisions, which states that, so long as premiums have been paid, continued overage cannot be denied. The regulations also allow policies to offer exclusion periods for pre-existing conditions; however, the period can be no longer than 12 months.

During the exclusion period, a health insurance company does not have to pay for any medical care that an insured receives for a pre-existing health condition. South Dakota law defines "pre-existing conditions" as health conditions that are diagnose 12 months before the start of a health insurance plan.

If you are changing South Dakota small business health insurance plans and you have continuous coverage, your old plan can be used to credit the pre-existing condition period on your new small group health insurance plan in South Dakota. Additionally, health insurance companies can implement elimination riders that permanently exclude coverage for certain types of medical conditions.

According to South Dakota Department of Labor & Regulation, with the introduction of federal health care reform, the South Dakota Department of Labor and Regulation, Division of Insurance adopted rules designed to update state rules to the federal minimum standards as defined in the Patient Protection and Affordable Care Act (PPACA).

These rules are applicable to health insurance policies established in 2014 or after. These rules do not impact those health insurance plans deemed "grandfathered plans" - meaning plans that existed prior to March 23, 2010 and have not significantly changed since then, maintaining their grandfathered status.

In 2010, the Affordable Care Act (ACA or "ObamaCare") was passed by the United States Congress and was signed into law by Obama. Following its passage, provisions of the law have continued to be phased in, and as of January 1, 2014, the majority of American citizens and legal residents of the United States are required, by law, to have qualifying health care coverage.

If they fail to have coverage, they are responsible for paying an annual tax penalty for each month they aren't insured, which is known as the "individual mandate".

The cost of the penalty for failure to have qualifying coverage is $95 per adult and $47.50 per child, or 1% of your total taxable income; whichever amount is higher - as much as $285 per family. In 2017, the penalty increased, and has continued to increase thereafter.

Qualifying Exemptions For The Individual Mandate

Individuals who meet one of the following are exempt from the individual mandate and the associated tax penalties in SD:

• Illegal aliens
• Jailed individuals
• Religious objections
• The cost of health insurance coverage is higher than 8% of your household income
• Those who aren't covered for less than three months during the calendar year
• Those who have hardship waivers
• Your income level is blow the 100% poverty level

If you're a small business owner in South Dakota, you must provide your employees with insurance. This is a requirement that was put into place by the Affordable Care Act.

Referred to as the Employer Shared Responsibility provision, all employers must offer their employees at least one of the ACA-compliant South Dakota small business health insurance plans, otherwise then can face fines of up to $2,000 per employee.

South Dakota small business owners can purchase coverage for their employees through the state's Small Health Option Program (SHOP) exchange, or from a private insurance agent or broker.

Affordable Care Act Standardized Essential Health Benefits

As per the ACA, all qualifying health insurance plans must offer 10 standardized essential benefits.

Depending on the state, additional benefits may also be required. The 10 ACA standardized essential benefits are as follows:

1. Ambulatory patient services (medical care that is offered without being admitted to a hospital)
2. Emergency services
3. Hospitalizations, such as overnight stays and surgical procedures
4. Lab services
5. Mental health and substance abuse disorder services, including behavioral health treatments, such as psychotherapy and counseling
6. Pediatric health care services, including vision and oral care; however, adult vision and dental coverage aren't essential health benefits under ACA
7. Pregnancy, maternity, and newborn care, including before and after birth
8. Prescription pharmaceuticals
9. Preventative and wellness services, as well as management for chronic diseases
10. Rehabilitative and habilitative services and devices, including services and devices for injuries, disabilities, and chronic health conditions

Additional Health Benefits Mandated In South Dakota

Not only do South Dakota health insurance policies have to offer coverage for the ACA essential benefits, but they must also include the additional benefits that have been mandated by the state. These additional benefits exceed ACA requirements and include the following:

• Diabetes care management supplies
• Off-label prescription pharmaceutical drugs
• Reconstructive surgery following mastectomy

Standardized South Dakota Small Business Health Insurance Plans

In order to make it easier to compare costs and benefits, the Affordable Care Act has designated all qualifying South Dakota small business health insurance plans to be one of four metal colors, including Bronze, Silver, Gold, and Platinum.

Each of these designations is based on the average amount of health care costs that the plan will cover, which is illustrates at percentages of how much the insurance company will cover for health care, as well as the amount the insured will have to pay out-of-pocket.

All insurance companies that are participating in the federal or state health care exchange program must offer at least the Silver and Gold South Dakota small business health insurance plans.

All four of the metal plans have a shared maximum out-of-pocked amount that the insured can be charged during any calendar year. The following table illustrates this information:

Guaranteed Issue

As per the ACA, individuals cannot be denied coverage or charged higher premiums because of their past health history, or their gender.

Additionally, look-back and waiting periods cannot be imposed. Additionally, policies are effective when they are issued and all coverage is renewable if the individual chooses to renew the policy.

However, plans can be canceled if the individual fails to pay their premiums or commits fraud.

A premium is the amount the insured must pay out-of-pocket in order to maintain their health insurance policy. The premiums that are charged for any of the qualifying metal plans can be based on the following:

• Age of the individual
• Whether or not the individual uses tobacco
• Where the individual lives, based on a rating area
• The number of family members who will be enrolling

While there are several types of health insurance plans to choose from, the following plans are the most popular among SD small business owners:

Health Maintenance Organization - Simply known as an "HMO", this type of plan offers a variety of health-related services via a network of health care providers and hospitals that exclusively contract with the HMO, or who agree to offer their services to members of the HMO. Employees who participate in this type of plan usually have to choose a primary care physician (PCP), and receive most of their care from this physician. If a specialist is needed, the PCP will recommend one that is affiliated with the HMO.

Preferred Provider Organization - More commonly referred to simply as "PPO", this type of health insurance plan is the most common among South Dakota small business owners. The insurance company provides a preferred list of health care providers, and employees must receive their medical care from the doctors and hospitals on that list for their claims to be paid at the highest level possible - but they also have the flexibility to see any other provider anywhere in or out of state.

Point-of-Service Plan - Known as a (POS), this type of health insurance plan provides access to health care services at a lower overall cost, but with fewer choices. Members can access care from in-network or out-of-network providers and facilities, but coverage is better when you stay in-network. POS plans may vary, but generally, plans are considered a blend of HMO and PPO plans - offering more flexibility than HMOs, but less than PPOs.

Health Savings Account - A health savings account (HSA) is a special type of bank account that allows participants in the insurance plan to save money that can be used specifically for the medical care they require in the future. HSA-qualified health insurance plans are usually PPO plans that are specifically designed to be used with an HSA.

Indemnity Health Insurance - This type of health insurance plan allows members to control their own health care and to visit any doctor or hospital they choose. The insurance company would then pay a pre-determined percentage of the total charges for the services that were rendered. Employees may have to pay for some types of services up-front and then they can submit a request for reimbursement with the insurance company.