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Numerous state and federal laws make it easier for people with pre-existing conditions to get or keep health insurance, or to change from one health plan to another. A federal law, known as the Health Insurance Portability and Accountability Act (HIPAA) sets national standards for all health plans. In addition, states can pass different reforms for the health plans they regulate (fully insured group health plans and individual health plans), so your protections may vary if you leave South Dakota. Neither federal nor state laws protect your access to health insurance in all circumstances. So please read this guide carefully.

The following information summarizes how federal and state laws do – or do not – protect you as a South Dakota resident.

How am I protected?
In South Dakota, as in many other states, your health insurance options are somewhat dependent on your health status. Even if you are sick, however, the laws protect you in the following ways.

‡ Coverage under your group health plan (if your employer offers one) cannot be denied or limited, nor can you be required to pay more, because of your health status. This is called nondiscrimination.

‡ All group health plans in South Dakota must limit exclusion of pre-existing conditions. There are rules concerning what counts as a pre-existing condition and how long you must wait before a new group health plan will begin to pay for care for that condition. Generally, if you join a new group health plan, your old coverage will be credited toward the pre-existing condition exclusion period, provided you did not have a long break in coverage.

‡ Your health insurance cannot be canceled because you get sick. Most health coverage is guaranteed renewable.

‡ If you leave your job, you may be able to remain in your old group health plan for a certain length of time. This is called COBRA or state continuation coverage. It can help when you are between jobs, or when you retire early and are not yet eligible for Medicare. There are limits on what you can be charged for this coverage.

‡ If you are a small employer buying a small group health plan, you cannot be turned down because of the health status, age, or any factor that might predict the use of health services of those in your group. All fully insured health plans for small employers must be sold on a guaranteed issue basis. However, the insurance carrier can turn down the small employer if the small employer does not meet the participation requirements.

‡ If you are a small employer buying a group health plan, there are limits on how much your premiums can vary due to the health status, age, and other characteristics of those in your group. Even so, you can be charged significantly higher premiums due to these factors.

‡ If you are buying individual health insurance, there are limits on how much your premiums can vary due to your health status, age, and other characteristics. Even so, you can be charged significantly higher premiums due to these factors.

‡ If you have had at least 12 months of creditable coverage and then lose it, you may be guaranteed the right to buy a policy from the South Dakota Risk Pool. You will not face a new pre-existing condition exclusion period. There are limits on what you can be charged for a high risk pool policy.

‡ If you have low or modest household income, you may be eligible for free or subsidized health coverage for yourself or members of your family. The South Dakota Medicaid program offers free health coverage for pregnant women, families with children, elderly and disabled individuals with very low incomes.

‡ If your children are 18 years old or younger, do not have health insurance and meet other qualifications, you may be able to buy insurance for them through the Children’s Health Insurance Program (CHIP).

‡ If you have lost your health insurance and are receiving benefits from the Trade Adjustment Assistance (TAA) Program then you may be eligible for a federal income tax credit to help pay for new health coverage. This credit is called the Health Coverage Tax Credit (HCTC), and it is equal to 65% of the cost of qualified health coverage.

‡ If you are a retiree aged 55-65 and receiving pension benefits from Pension Benefit Guarantee Corporation (PBGC), then you may also be eligible for the HCTC.