S.D. Admin. R. 20:06:13:17.06

Current through Register Vol. 51, page 57, November 12, 2024

Section 20:06:13:17.06 - Make-up of standardized benefit plans

The requirements for the make-up of standardized Medicare supplement benefit plans issued for delivery after July 16, 1992, and prior to June 1, 2010, A to L, inclusive, are as follows:

(1) Standardized Medicare supplement benefit Plan A is limited to the basic core benefits common to all benefit plans, as defined in § 20:06:13:17.03;

(2) Standardized Medicare supplement benefit Plan B may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible as defined in § 20:06:13:17.04;

(3) Standardized Medicare supplement benefit Plan C may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.04;

(4) Standardized Medicare supplement benefit Plan D may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country, and the at-home recovery benefit as defined in § 20:06:13:17.04;

(5) Standardized Medicare supplement benefit Plan E may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, medically necessary emergency care in a foreign country, and preventive medical care as defined in § 20:06:13:17.04;

(6) Standardized Medicare supplement benefit Plan F may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, the skilled nursing facility care, the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.04;

(7) Standardized Medicare supplement benefit high deductible Plan F may include only the following: One hundred percent of covered expenses following the payment of the annual high deductible Plan F deductible. The covered expenses include the core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, the Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.04. The annual high deductible Plan F deductible consists of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement Plan F policy, and are in addition to any other specific benefit deductibles. The annual high deductible Plan F deductible is $1500 for 1998 and 1999, and is based on the calendar year. It is adjusted annually by the secretary to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars.

(8) Standardized Medicare supplement benefit Plan G may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, 80 percent of the Medicare Part B excess charges, medically necessary emergency care in a foreign country, and that at-home recovery benefit as defined in § 20:06:13:17.04;

(9) Standardized Medicare supplement benefit Plan H may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, basic prescription drug benefit, and medically necessary emergency care in a foreign country as defined § 20:06:13:17.04. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005;

(10) Standardized Medicare supplement benefit Plan I may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, 100 percent of the Medicare Part B excess charges, basic prescription drug benefit, medically necessary emergency care in a foreign country, and at-home recovery benefit as defined in § 20:06:13:17.04. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005;

(11) Standardized Medicare supplement benefit Plan J may include only the following: The core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, extended prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care, and at-home recovery benefit as defined in § 20:06:13:17.04. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005;

(12) Standardized Medicare supplement benefit high deductible Plan J consists of only the following: One hundred percent of covered expenses following the payment of the annual high deductible Plan J deductible. The covered expenses include the core benefit as defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing facility care, Medicare Part B deductible, 100 percent of the Medicare Part B excess charges, extended outpatient prescription drug benefit, medically necessary emergency care in a foreign country, preventive medical care benefit, and at-home recovery benefit as defined in § 20:06:13:17.04. The annual high deductible Plan J deductible consists of out-of-pocket expenses, other than premiums, for services covered by the Medicare supplement Plan J policy, and is in addition to any other specific benefit deductibles. The annual deductible is $1500 for 1998 and 1999, and shall be based on a calendar year. It is adjusted annually by the Secretary of Health and Human Services to reflect the change in the Consumer Price Index for all urban consumers for the twelve-month period ending with August of the preceding year, and rounded to the nearest multiple of ten dollars. The outpatient prescription drug benefit may not be included in a Medicare supplement policy sold after December 31, 2005;

(13) Standardized Medicare supplement benefit Plan K shall consist of the following:

(a) Coverage of 100 percent of the Part A hospital coinsurance amount for each day used from the 61^st through the 90^th day in any Medicare benefit period;

(b) Coverage of 100 percent of the Part A hospital coinsurance amount for each Medicare lifetime inpatient reserve day used from the 91^st through the 150^th day in any Medicare benefit period;

(c) 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;

(d) Medicare Part A deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period until the out-of-pocket limitation is met as described in subdivision (j);

(e) Skilled nursing facility care: Coverage for 50 percent of the coinsurance amount for each day used from the 21^st day through the 100^th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A until the out-of-pocket limitation is met as described in subdivision (j);

(f) Hospice care: Coverage for 50 percent of cost sharing for all Part A Medicare eligible expenses and respite care until the out-of-pocket limitation is met as described in subdivision (j);

(g) Coverage for 50 percent, under Medicare Part A or B, or the reasonable cost of the first three pints of blood, or equivalent quantities of packed red blood cells, unless replaced in accordance with federal regulations until the out-of-pocket limitation is met as described in subdivision (j);

(h) Except for coverage provided in subdivision (i) below, coverage for 50 percent of the cost sharing otherwise applicable under Medicare Part B after the policyholder pays the Part B deductible until the out-of-pocket limitation is met as described in subdivision (j);

(i) Coverage of 100 percent of the cost sharing for Medicare Part B preventative services after the policyholder pays the Part B deductible; and

(j) Coverage of 100 percent of all cost sharing under Medicare Parts A and B for the balance of the calendar year after the individual has reached the out-of-pocket limitation on annual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the secretary;

(14) Standardized Medicare supplement benefit Plan L shall consist of the following:

(a) The benefits described in subdivisions 20:06:13:17.06(13)(a), (13)(b), (13)(c), and (13)(i);

(b) The benefits described in subdivisions 20:06:13:17.06(13)(d), (13)(e), (13)(f), (13)(g), and (13)(h), with 75 percent substituted for 50 percent; and

(c) The benefit described in subdivision 20:06:13:17.06(13)(j), with $2000 substituted for $4000.

S.D. Admin. R. 20:06:13:17.06

18 SDR 225, effective 7/17/1992; 19 SDR 160, effective 4/27/1993; 25 SDR 44, effective 9/30/1998; 31 SDR 214, effective 7/6/2005; 35 SDR 183, effective 2/2/2009; 36 SDR 209, effective 7/1/2010.

General Authority: SDCL 58-17A-2(9).

Law Implemented: SDCL 58-17A-2(9).