Bill > HB1292

This bill establishes new rules for health carriers, which are insurance companies that provide health coverage, regarding their ability to take back money they've already paid out for medical claims. Generally, a health carrier can only try to recoup, recover, or retroactively deny a previously paid claim within eighteen months of when the payment was made, and they must provide written notice to the healthcare provider explaining why. However, this eighteen-month limit does not apply in several situations, including if the claim was submitted fraudulently or involved waste or abuse, if the services are covered by other types of insurance like casualty insurance, self-insured health plans governed by ERISA (a federal law protecting employee benefits), Medicare, Medicaid, or workers' compensation, or if the provider or patient was already paid for those same services. The bill also clarifies that "medical services" in this context does not include dental or pharmaceutical services, and that recouping payments means requiring repayment, reducing future payments, or withholding funds. If a provider has to repay a health carrier, the amount repaid cannot include extra fees, penalties, or interest. These new provisions will apply to medical services provided on or after July 1, 2026.

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https://sdlegislature.gov/#/Session/Bill/26466