S.D. Admin. R. 20:06:13:17.15

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

Section 20:06:13:17.15 - Make-up of standardized benefit plans - Issued after May 31, 2010

The requirements for the make-up of standardized Medicare supplement benefit Plans A to L, inclusive, are as follows:

(1) Standardized Medicare supplement benefit Plan A shall include only the following: The core benefits as defined in § 20:06:13:17.12;

(2) Standardized Medicare supplement benefit Plan B shall include the following: The basic core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible as defined in § 20:06:13:17.13;

(3) Standardized Medicare supplement benefit Plan C shall include only the following: The basic core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, one hundred percent of the Medicare Part B deductible, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.13;

(4) Standardized Medicare supplement benefit Part D shall include only the following: The core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.13;

(5) Standardized Medicare supplement regular Plan F shall include only the following: The core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible, the skilled nursing facility care, one hundred percent of 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 § 20:06:13:17.13;

(6) Standardized Medicare supplement Plan F with High Deductible shall include only the following: 100 percent of covered expenses following the payment of the annual deductible set forth in subsection (b):

(a) The basic core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, 100 percent of 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 § 20:06:13:17.12(1),(3),(4),(5), and (6);

(b) The annual deductible in Plan F with High Deductible shall consist of out-of-pocket expenses, other than premiums, for services covered by regular Plan F, and shall be in addition to any other specific benefit deductibles. The basis for the deductible shall be $1,500 and shall be adjusted annually from 1999 by the Secretary of the U.S. Department 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;

(7) Standardized Medicare supplement benefit Plan G shall include only the following: The core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, one hundred percent of the Medicare Part B excess charges, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.13. After December 31, 2019, the standardized benefit plans described in 20:06: 13:17.15 may be offered to any individual who was eligible for Medicare after December 31, 2019;

(8) Standardized Medicare supplement Plan K, which is mandated by The Medicare Prescription Drug Improvement and Modernization Act of 2003, shall include only the following:

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

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

(c) Part A Hospitalization after Lifetime Reserve Days are exhausted: 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 subsection (j);

(e) Skilled Nursing Facility Care: Coverage for 50 percent of the coinsurance amount for each day used from the 21^st day to the 100^th day, inclusive, in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A, until the out-of-pocket limitation is met as described in subsection (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 subsection (j);

(g) Blood: Coverage for 50 percent, under Medicare Part A or B, of the reasonable cost of the first three pints of blood or equivalent quantities of packed red blood cells, as defined under federal regulations 42 C.F.R. § 409.87(a) unless replaced in accordance with federal regulations 42 C.F.R. § 409.87(d) until the out-of-pocket limitation is met as described in subsection (j);

(h) Part B Cost Sharing: Except for coverage provided in subsection (i), 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 subsection (j);

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

(j) Cost Sharing after Out-of-Pocket Limits: 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 or $4000 in 2006, indexed each year by the appropriate inflation adjustment specified by the Secretary of the U.S. Department of Health and Human Services;

(9) Standardized Medicare supplement Plan L, which mandated by The Medicare Prescription Drug Improvement and Modernization Act of 2003, and shall include only the following:

(a) The benefits described in § 20:06:13:17.15(8)(a),(b),(c), and (i);

(b) The benefit described in § 20:06:13:17.15(8)(d),(e),(f),(g), and (h), but substituting 75 percent for 50 percent; and

(c) The benefit described in § 20:06:13:17.15(8)(j), but substituting $2000 for $4000;

(10) Standardized Medicare supplement Plan M shall include only the following: The core benefit as defined in § 20:06:13:17.12, plus 50 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.13;

(11) Standardized Medicare supplement Plan N shall include only the following: The basic core benefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A deductible, skilled nursing facility care, and medically necessary emergency care in a foreign country as defined in § 20:06:13:17.13, with copayments in the following amounts:

(a) The lesser of $20 or the Medicare Part B coinsurance or copayment for each covered health care provider office visit, including visits to medical specialists; and

(b) the lesser of fifty dollars or the Medicare Part B coinsurance or copayment for each covered emergency room visit. However, this copayment shall be waived if the insured is admitted to any hospital and the emergency visit is subsequently covered as a Medicare Part A expense.

S.D. Admin. R. 20:06:13:17.15

35 SDR 183, effective 2/2/2009; 36 SDR 209, effective 7/1/2010; 44 SDR 184, effective 6/25/2018

General Authority: SDCL 58-17A-2.

Law Implemented: SDCL 58-17A-2.