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;
(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 61st through 90th days: Coverage of 100
percent of the Part A hospital coinsurance amount for each day used from the 61st
to the 90th day, inclusive, in any Medicare benefit period;
(b) Part A Hospital
Coinsurance, 91st through 150th days: Coverage of 100
percent of the Part A hospital coinsurance amount for each Medicare lifetime
inpatient reserve day used from the 91st to the 150th
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 21st day to the 100th 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.
Source:
35 SDR 183, effective February 2, 2009; 36 SDR 209, effective July 1, 2010.
General
Authority: SDCL 58-17A-2.
Law
Implemented: SDCL 58-17A-2.