South Dakota maintains a high-risk pool, called the South Dakota Risk Pool.  The South Dakota Risk Pool provides health insurance coverage only to HIPAA eligible persons and those with 12 months of prior creditable coverage who have lost access to their prior coverage involuntarily.  There are limits on how much you can be charged.  There are also limits on pre-existing exclusion periods that can be imposed.

When can I get health insurance from the South Dakota Risk Pool?

• There are two ways that you may be eligible to buy health insurance from the South Dakota Risk Pool.

First, if you are HIPAA eligible, you can buy health insurance from the South Dakota Risk Pool. 

To be HIPAA eligible, you must meet certain criteria:

No matter where you live in the U.S., if you are HIPAA eligible you are guaranteed the right to buy individual coverage of some kind with no pre-existing condition exclusion periods.  In South Dakota, you are guaranteed the right to buy coverage only from the South Dakota Risk Pool.  To be HIPAA eligible, you must meet all of the following:

• You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.

• You also must have used up any COBRA or state continuation coverage for which you were eligible.

• You must not be eligible for Medicare, Medicaid, or a group health plan.

• You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)

• You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.

Federal eligibility ends when you enroll in an individual plan, because the last day of your continuous health coverage must have been in a group plan.  You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

Second, if you have 12 months of prior creditable coverage and then lose access to that prior creditable coverage involuntarily or receive notice that your coverage will be ending, you can buy health insurance from the South Dakota Risk Pool. 

Although conversion coverage and temporary health insurance counts as creditable coverage, neither of these can be your last coverage prior to applying for health insurance from the South Dakota Risk Pool.  In addition, your prior creditable coverage must not have been terminated due to nonpayment of premiums or fraud.   

What will the South Dakota Risk Pool cover?

• South Dakota Risk Pool offers three plan options. Each plan offers similar benefits including daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care including pharmaceuticals.
• Each plan has similar benefits but different cost sharing options.

Under Plan A, after a $1,000 deductible has been met, the plan will pay 75% of eligible expenses and you are responsible for the balance of charges.  After you have paid an annual out-of-pocket maximum of $3,250, the plan will pay the rest.   There is a separate $1,500 annual out-of-pocket maximum for pharmacy benefits.

Under Plan B, after a $3,000 deductible has been met, the plan will pay 75% of eligible expenses and you are responsible for the balance of charges.  After you have paid an annual out-of-pocket maximum of $5,250, the plan will pay the rest.  There is a separate $1,500 annual out-of-pocket maximum for pharmacy benefits

Under Plan C, after a $10,000 deductible has been met, the plan will pay 75% of eligible expenses and you are responsible for the balance of charges.  After you have paid an annual out-of-pocket maximum of $12,250, the plan will pay the rest.  There is a separate $1,500 annual out-of-pocket maximum for pharmacy benefits

What about coverage for my pre-existing condition?

• The South Dakota Risk Pool does not impose pre-existing condition exclusion periods.

What can I be charged for health insurance from the risk pool?

• Premiums can vary based on age, the plan option you choose, and whether or not you use tobacco products.

For example, a 25-year-old man who doesn’t use tobacco products would pay $196.59 per month under Plan A, $162.51 under Plan B, and $120.50 under the Plan C. By contrast, a 60-year-old woman who doesn’t use tobacco products would pay $774.310 under Plan A, $640.07 under Plan B, and $474.65 under Plan C. Please note that premiums may have changed since this guide was written, so contact the South Dakota Risk Pool for the most current information.

How long does health pool coverage last?

Coverage under the South Dakota Risk Pool is renewable as long as you pay your premiums, continue to reside in South Dakota, and meet other eligibility requirements.