S.D. Admin. R. 20:06:13:17.03

Current through Register Vol. 50, page 159, June 17, 2024

Section 20:06:13:17.03 - Standards for basic core benefits for 1990 standardized Medicare supplement benefit plans

Each insurer shall make available a policy or certificate including only the following basic core package of benefits to each prospective insured. In addition to the basic core package, an issuer may make available to prospective insureds any of the other Medicare supplement insurance plans as provided in §§ 20:06:13:17.05 and 20:06:13:17.06. The additional plans may not be offered in lieu of the basic core plan. The basic core benefits required for all benefit plans issued for delivery after July 16, 1992, and prior to June 1, 2010, are as follows:

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day to the 90th day, inclusive, in any Medicare benefit period;

(2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used;

(3) Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate, or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer's payment as payment in full and may not bill the insured for any balance;

(4) Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, 42 C.F.R. § 409.87(a)(1) (October 1, 1991), unless replaced in accordance with federal regulations, 42 C.F.R. § 409.87(d);

(5) Coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount, of Medicare-eligible expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible, 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999.

S.D. Admin. R. 20:06:13:17.03

18 SDR 225, effective 7/17/1992; 26 SDR 26, effective 9/1/1999; 28 SDR 157, effective 5/19/2002; 31 SDR 214, effective 7/6/2005; 35 SDR 183, effective 2/2/2009.

General Authority: SDCL 58-17A-2.

Law Implemented: SDCL 58-17A-2.