20:06:39:28. Requirements for basic plan -- Eligible
expenses. The eligible expenses for the basic plan are as follows:
(1) Accidental injury services;
(2) Anesthetics and their administration.
Payment for anesthesia given by the operating physician or the surgical
assistant is limited to 50 percent of the allowable charge or usual, customary,
and reasonable (UCR) amount, whichever is applicable;
(3) Assisting surgeon services;
(4) Treatment and diagnosis of
biologically-based mental illnesses with the same dollar limits, deductibles,
coinsurance factors, and restrictions as for other covered illnesses;
(5) Chemotherapy services for treatment of
malignancy;
(6) Concurrent care for the treatment of more
than one medical condition, but not for two or more practitioners to treat the
same condition, unless medically necessary;
(7) Consultation services of a medical,
surgical, obstetrical, pathological, or radiological consultant when requested
by the attending practitioner. The consultation must include an actual physical
examination, and any services ordered or performed must be documented in the
patient's medical record and communicated to the requesting practitioner;
(8) Dental services, limited to accidental
injuries which occur while the person is covered under this policy and which
are treated within six months of the injury. Injuries associated with or
resulting from the act of chewing are never covered. Anesthesia and
hospitalization for dental care for persons who are under age five or are
severely disabled will also be covered;
(9) Diabetes supplies, equipment, and education,
as required by SDCL 58-17-1.2;
(10) Emergency air or ground ambulance to the
nearest hospital capable of handling the emergency;
(11) Hemodialysis services
when provided to an inpatient of a hospital or an outpatient in a Medicare
approved dialysis center;
(12) Maternity services for the covered person
or the covered person's spouse for complications of pregnancy only;
(13) Medical services (other than surgical or
obstetrical) provided by a practitioner to an inpatient or an outpatient. Home
and office calls are covered;
(14) Medical supplies including oxygen, rental
of durable medical equipment up to the purchase price, surgical dressings, casts,
splints, braces, and crutches;
(15) Occupational and physical therapy;
(16) Physicians services, including surgery;
(17) Prosthetic appliances used to replace a
missing, natural part of the body and braces used to support or restrict
movement of weakened or deformed body parts;
(18) Radiation therapy;
(19) Room, board, and general nursing care
during hospital inpatient confinement, but not to exceed the average
semi-private room charge of the hospital;
(20) Miscellaneous hospital services including
outpatient services;
(21) Surgical services which include operative
and cutting procedures, major endoscopic procedures
and preoperative and postoperative care. Payment for multiple surgical
procedures, not including the primary surgical procedure, performed at the same
time may be reduced to 50 percent of the allowable charge or usual, customary,
and reasonable (UCR) amount, whichever is applicable. If the multiple surgical procedure is determined incidental, benefits will be denied;
(22) X-ray and laboratory services for the
diagnosis and treatment of an illness or injury. Coverage would include routine
mammography x-ray as required by SDCL 58-17-1.1;
(23) Breast reconstruction in connection with
mastectomy, which includes:
(a) Reconstruction of the breast on which
the mastectomy was performed;
(b) Surgery and reconstruction of the other
breast to produce a symmetrical appearance; and
(c) Prostheses and physical complications
at all stages of a mastectomy, including lymphedemas;
and
(24) Hospice.
Source: 27 SDR
69, effective January 15, 2001.
General Authority:
SDCL 58-17-87.
Law Implemented:
SDCL 58-17-85.