S.D. Admin. R. 20:06:13:17.12

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

Section 20:06:13:17.12 - Standards for basic core benefits common to Medicare supplement insurance benefit Plans A, B, C, D, F, F with High Deductible, G, M, and N

Every issuer of Medicare supplement insurance benefit plans shall make available a policy or certificate including only the following basic core package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare Supplement Insurance Benefit Plans in addition to the basic core package, but not in lieu of it. The following benefits must be included in policies or certificates issued for delivery after May 31, 2010:

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61^st day through the 90^th day 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 three pints of blood or equivalent quantities of packed red blood cells, federal regulations 42 C.F.R 409.87(a)(1) 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;

(6) Coverage of cost sharing for all Part A Medicare eligible hospice care and respite care expenses.

S.D. Admin. R. 20:06:13:17.12

35 SDR 183, effective 2/2/2009.

General Authority: SDCL 58-17A-2.

Law Implemented: SDCL 58-17A-2.