20:06:13:17.  Applicability of benefit standards. The following benefit standards described in §§ 20:06:13:17.02 and 20:06:13:17.03 are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state after July 16, 1992, and prior to June 1, 2010, and no policy or certificate may be advertised, solicited, delivered, or issued for delivery in this state as a Medicare supplement policy or certificate unless it complies with these benefit standards.

 

          Source: 8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 15 SDR 143, effective March 29, 1989; 16 SDR 174, effective May 2, 1990; standards transferred to § 20:06:13:17.02, 18 SDR 225, effective July 17, 1992; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.01.  Benefits restored. Repealed.

 

          Source: 16 SDR 174, effective May 2, 1990; repealed, 35 SDR 183, effective February 2, 2009.

 

          20:06:13:17.02.  General standards for 1990 standardized Medicare supplement benefit plans. The following standards apply to Medicare supplement policies issued for delivery after July 16, 1992, and prior to June 1, 2010, and certificates and are in addition to all other requirements of this chapter:

 

          (1)  Indemnity for losses resulting from sickness must be on the same basis as losses resulting from an accident;

 

          (2)  Benefits designed to cover cost-sharing amounts under Medicare must be changed to coincide with changes in applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may be modified to correspond with such changes.

 

          Source: 8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 15 SDR 143, effective March 29, 1989; 16 SDR 174, effective May 2, 1990; transferred from § 20:16:13:17, 18 SDR 225, effective July 17, 1992; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.03.  Standards for basic core benefits for 1990 standardized Medicare supplement benefit plans. Each insurer shall make available a policy or certificate including only the following basic core package of benefits to each prospective insured. In addition to the basic core package, an issuer may make available to prospective insureds any of the other Medicare supplement insurance plans as provided in §§ 20:06:13:17.05 and 20:06:13:17.06. The additional plans may not be offered in lieu of the basic core plan. The basic core benefits required for all benefit plans issued for delivery after July 16, 1992, and prior to June 1, 2010, are as follows:

 

          (1)  Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day to the 90th day, inclusive, 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 3 pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, 42 C.F.R. § 409.87(a)(1) (October 1, 1991), 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, 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999.

 

          Source: 18 SDR 225, effective July 17, 1992; 26 SDR 26, effective September 1, 1999; 28 SDR 157, effective May 19, 2002; 31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.04.  Standards for additional benefits for 1990 standardized Medicare supplement benefit plans. The following additional benefits must be included in Medicare supplement benefit Plans B to J, inclusive, as described in § 20:06:13:17.06, issued for delivery after July 16, 1992, and prior to June 1, 2010:

 

          (1)  Medicare Part A deductible: Coverage for all of the Medicare Part A inpatient hospital deductible amount for each benefit period;

 

          (2)  Skilled nursing facility care: Coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for posthospital skilled nursing facility care eligible under Medicare Part A;

 

          (3)  Medicare Part B deductible: Coverage for all of the Medicare Part B deductible amount for each calendar year regardless of hospital confinement;

 

          (4)  Eighty percent of the Medicare Part B excess charges: Coverage for 80 percent of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program, 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999, and the Medicare-approved Part B charge, 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999;

 

          (5)  One hundred percent of the Medicare Part B excess charges: Coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program, 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999, and the Medicare-approved Part B charge, 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999;

 

          (6)  Basic outpatient prescription drug benefit: Coverage for 50 percent of outpatient prescription drug charges, after a deductible for each calendar year of $250, to a maximum of $1,250 in benefits received by the insured for each calendar year to the extent not covered by Medicare. The basic outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006;

 

          (7)  Extended outpatient prescription drug benefit: Coverage for 50 percent of outpatient prescription drug charges, after a deductible for each calendar year of $250, to a maximum of $3,000 in benefits received by the insured for each calendar year to the extent not covered by Medicare. The extended outpatient prescription drug benefit may be included for sale or issuance in a Medicare supplement policy until January 1, 2006;

 

          (8)  Medically necessary emergency care in a foreign country: Coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, if the care would have been covered by Medicare if provided in the United States and if the care began during the first 60 consecutive days of each trip outside the United States, subject to a deductible for each calendar year of $250 and a lifetime maximum benefit of $50,000. For purposes of this benefit, the term, emergency care, means care needed immediately because of an injury or an illness of sudden and unexpected onset;

 

          (9)  Preventive medical care benefit: Coverage for the following preventive health services not covered by Medicare:

 

               (a)  An annual clinical preventive medical history and physical examination that may include tests and services from subdivision (9)(b) of this section and patient education to address preventive health care measures;

 

               (b)  Preventive screening tests or preventive services, the selection and frequency of which is considered medically appropriate by the attending physician.

 

          Reimbursement shall be for the actual charges to 100 percent of the Medicare-approved amount for each service, as if Medicare were to cover the service as identified in Current Procedural Coding Expert, 2008, as published by the American Medical Association, to a maximum of $120 annually under this benefit. This benefit may not include payment for any procedure covered by Medicare;

 

          (10)  At-home recovery benefit: Coverage for services to provide short-term, at-home assistance with activities of daily living for those recovering from an illness, injury, or surgery. Requirements for this benefit are as follows:

 

               (a)  For purposes of this benefit, the following definitions apply:

 

                      (i)    "Activities of daily living," including bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with drugs that are normally self-administered, and changing bandages or other dressings;

 

                      (ii)   "Care provider," qualified or licensed home health aide/homemaker, personal care aide, or nurse provided through a licensed home health care agency or referred by a licensed referral agency or licensed nurses registry. A home health aide/homemaker, personal care aide, or nurse provided through a licensed home health care agency, referral agency, or nurses' registry is considered licensed pursuant to this section if qualified for Medicare reimbursement pursuant to 42 U.S.C. § 1395 et seq, as in effect on July 1, 1999;

 

                      (iii)  "Home," any place used by the insured as a place of residence, if that place would qualify as a residence for home health care services covered by Medicare. A hospital or skilled nursing facility is not considered the insured's place of residence, 42 U.S.C. § 1395, et seq, as in effect on July 1, 1999;

 

                      (iv)   "At-home recovery visit," the period of a visit required to provide at-home recovery care, without limit on the duration of the visit, except that each consecutive four hours in a 24-hour period of services provided by a care provider is one visit;

 

               (b)  Coverage requirements for this benefit are as follows:

 

                      (i)    At-home recovery services provided must be primarily services which assist in activities of daily living;

 

                      (ii)   The insured's attending physician must certify that the specific type and frequency of at-home recovery services are necessary because of a condition for which a home care plan of treatment was approved by Medicare;

 

               (c)  Coverage limits for this benefit are as follows:

 

                      (i)     No more than the number and type of at-home recovery visits certified as necessary by the insured's attending physician. The total number of at-home recovery visits may not exceed the number of Medicare-approved home health care visits under a Medicare-approved home care plan of treatment;

 

                      (ii)     The actual charges for each visit up to a maximum reimbursement of $40 a visit;

 

                      (iii)    One thousand six hundred dollars for each calendar year;

 

                      (iv)    Seven visits in any one week;

 

                      (v)     Care furnished on a visiting basis in the insured's home;

 

                      (vi)    Services provided by a care provider as defined in this section;

         

                      (vii)   At-home recovery visits while the insured is covered under the policy or certificate and not otherwise excluded; and

 

                      (viii)  At-home recovery visits received during the period the insured is receiving Medicare-approved home care services or no more than eight weeks after the service date of the last Medicare-approved home health care visit;

 

               (d)  Coverage is excluded for the following:

 

                      (i)    Home care visits paid for by Medicare or other government programs; and

 

                      (ii)   Care provided by family members, unpaid volunteers, or providers who are not care providers;

 

          (11)  New or innovative benefits: An issuer may, with the prior approval of the director, offer policies or certificates with new or innovative benefits in addition to the benefits provided in a policy or certificate that otherwise complies with the applicable standards. Such new or innovative benefits may include benefits that are applicable to Medicare supplement insurance, new or innovative, not otherwise available, cost-effective, and offered in a manner which is consistent with the goal of simplification of Medicare supplement policies. After December 31, 2005, the innovative benefit may not include an outpatient prescription drug benefit.

 

          Source: 18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993; 22 SDR 107, effective February 18, 1996; 26 SDR 26, effective September 1, 1999; 27 SDR 53, 27 SDR 54, effective December 4, 2000; 30 SDR 39, effective September 28, 2003; 31 SDR 214, effective July 6, 2005; 33 SDR 59, effective October 5, 2006; 34 SDR 271, effective May 6, 2008; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          Reference: Current Procedural Coding Expert, 2008, American Medical Association. Copies may be obtained from Medicode, 5225 Wiley Post Way, Suite 500, Salt Lake City, UT 84116-2889; 1-800-999-4600; www.ingenixonline.com. Cost: $97.95.

 

          20:06:13:17.05.  Requirements for standard Medicare supplement benefit plans. An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic core benefits, as defined in § 20:06:13:17.03.

 

          No groups, packages, or combinations of Medicare supplement benefits other than those listed in § 20:06:13:17.06 may be offered for sale in this state, except as permitted in §§ 20:06:13:17.02 to 20:06:13:17.04, inclusive, and §§ 20:06:13:63 to 20:06:13:76, inclusive.

 

          Benefit plans must be uniform in structure, language, designation, and format to the standard benefit Plans A to L, inclusive, listed in § 20:06:13:17.06 and must conform to the definitions in SDCL chapter 58-17A and §§ 20:06:13:17.02 to 20:06:13:17.04, inclusive. Each benefit must be structured in accordance with the format provided in §§ 20:06:13:17.02 to 20:06:13:17.04, inclusive, and must list the benefits in the order shown in § 20:06:13:17.06. For purposes of this section, the phrase, structure, language, and format, means style, arrangement, and overall content of a benefit.

 

          An issuer may use, in addition to the benefit plan designations required in this section, other designations to the extent permitted by this chapter.

 

          Source: 18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          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.

 

          Source: 18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993; 25 SDR 44, effective September 30, 1998; 31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009; 36 SDR 209, effective July 1, 2010.

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

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

 

          20:06:13:17.07.  Suspension of coverage during period of eligibility for Medicaid. A Medicare supplement policy or certificate must provide that benefits and premiums under the policy be suspended at the request of the policyholder or certificateholder for not more than 24 months if the policyholder or certificateholder applies for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act (Medicaid) and if the policyholder or certificateholder notifies the issuer of the policy or certificate within 90 days after the date the individual becomes entitled to Medicaid assistance. Upon receipt of timely notice, the issuer shall return to the policyholder or certificateholder that portion of the premium attributable to the period of Medicaid eligibility, subject to adjustment for paid claims. This section applies to 1990 standardized Medicare supplement benefit plans as well as 2010 standardized Medicare supplement benefit plans.

 

          Source: 18 SDR 225, effective July 17, 1992; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          Cross-Reference: Medicaid eligibility, art 67:16.

 

          20:06:13:17.08.  Reinstitution of coverage following loss of eligibility for Medicaid. If suspension of Medicare supplement coverage occurs for a period of eligibility for Medicaid and if the policyholder or certificateholder loses entitlement to Medicaid, the policy or certificate shall be automatically reinstituted effective as of the date of termination of entitlement if the policyholder or certificateholder provides notice of loss of entitlement to Medicaid within 90 days after the date of the loss and pays the premium attributable to the period, effective as of the date of termination of entitlement.

 

          Reinstitution of Medicare supplement coverage must comply with the following requirements:

 

          (1)  The coverage may not provide for any waiting period for treatment of preexisting conditions;

 

          (2)  The coverage must be substantially equivalent to coverage in effect before the date of suspension. If the suspended policy or certificate provided coverage for outpatient prescription drugs, reinstitution of the policy or certificate for Medicare part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and

 

          (3)  The coverage must provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended. This section applies to 1990 standardized Medicare supplement benefit plans as well as 2010 standardized Medicare supplement benefit plans.

 

          Source: 18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.09.  Suspension requested by policyholder. Each Medicare supplement policy shall provide that benefits and premiums under the policy shall be suspended for a period at the request of the policyholder if the policyholder is entitled to benefits under § 226(b) of the Social Security Act and is covered under a group health plan as defined in § 1862(b)(1)(a)(v) of the Social Security Act. The period of suspension shall be for a period as prescribed by the director. The director shall consider any pertinent federal regulations in determining the time period. If suspension occurs and then the policyholder or certificateholder loses coverage under the group health plan, the policy shall be automatically reinstituted, effective as of the date of loss of coverage. However, the policyholder must, in order to have the policy automatically reinstituted, provide to the issuer of the suspended coverage notice of loss of coverage within 90 days after the date of such loss of coverage and pay the premium attributable to the period, effective as of the date of termination of enrollment in the group health plan. If the suspended policy provided coverage for outpatient prescription drugs, reinstitution of the policy or certificate for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension.

 

          Reinstitution of Medicare supplement coverage must comply with the following requirements:

 

          (1)  The coverage may not provide for any waiting period for treatment of preexisting conditions;

 

          (2)  The coverage must be substantially equivalent to coverage in effect before the date of suspension. If the suspended policy or certificate provided coverage for outpatient prescription drugs, reinstitution of the policy or certificate for Medicare Part D enrollees shall be without coverage for outpatient prescription drugs and shall otherwise provide substantially equivalent coverage to the coverage in effect before the date of suspension; and

 

          (3)  The coverage must provide for classification of premiums on terms at least as favorable to the policyholder or certificateholder as the premium classification terms that would have applied to the policyholder or certificateholder had the coverage not been suspended.

 

          This section applies to 1990 standardized Medicare supplement benefit plans as well as 2010 standardized Medicare supplement benefit plans.

 

          Source: 27 SDR 53, effective December 4, 2000; 28 SDR 157, effective May 19, 2002; 31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2(18).

          Law Implemented: SDCL 58-17A-2(18).

 

          20:06:13:17.10.  Prescription drug benefits under Medicare supplement plans. The following provisions apply to Medicare supplement plans:

 

          (1)  A Medicare supplement plan with benefits for outpatient prescription drugs in existence prior to January 1, 2006, shall be renewed for current policyholders who do not enroll in Medicare Part D at the option of the insured subject to §§ 20:06:13:19, 20:06:13:56, 20:06:13:60 and 20:06:13:60.01;

 

          (2)  A Medicare supplement plan with benefits for outpatient prescription drugs may not be issued after December 31, 2005;

 

          (3)  After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:

 

               (a)  The policy is modified to eliminate outpatient prescription drug coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Medicare Part D plan; and

 

               (b)  Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.

 

          This section applies to 1990 standardized Medicare supplement benefit plans.

 

          Source: 31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.11.  General standards for standardized Medicare supplement benefit plan -- Issued for delivery after May 31, 2010. The following standards apply to Medicare supplement policies and certificates issued for delivery after May 31, 2010, and are in addition to all other requirements of this chapter:

 

          (1)  A Medicare supplement policy or certificate may not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents;

 

          (2)  A Medicare supplement policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may be modified to correspond with such changes;

 

          (3)  No Medicare supplement policy or certificate may provide for termination of coverage of a spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than the nonpayment of premium;

 

          (4)  Each Medicare supplement policy shall be guaranteed renewable:

 

               (a)  The issuer may not cancel or nonrenew the policy solely on the ground of health status of the individual;

 

               (b)  The issuer may not cancel or nonrenew the policy for any reason other than nonpayment of premium or material misrepresentation;

 

               (c)  If the Medicare supplement policy is terminated by the group policyholder and is not replaced as provided in subsection e, the issuer shall offer certificateholders an individual Medicare supplement policy which at the option of the certificateholder:

 

                      (i)   Provides for continuation of the benefits contained in the group policy; or

                      (ii)  Provides for benefits that otherwise meet the requirements of this subsection;

 

               (d)  If an individual is a certificateholder in a group Medicare supplement policy and the individual terminates membership in the group, the issuer shall:

 

                      (i)   Offer the certificateholder the conversion opportunity described in § 20:06:13:56; or

                      (ii)  At the option of the group policyholder, offer the certificateholder continuation of coverage under the group policy;

 

               (e)  If a group Medicare supplement policy is replaced by another group Medicare supplement policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to all persons covered under the old group policy on its date of termination. Coverage under the new policy does not result in any exclusion for preexisting conditions that would have been covered under the group policy being replaced;

 

          (5)  Termination of a Medicare supplement policy or certificate shall be without prejudice to any continuous loss which commenced while the policy was in force, but the extension of benefits beyond the period during which the policy was in force may be conditioned upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits. Receipt of Medicare Part D benefits will not be considered in determining a continuous loss.

 

          Source: 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          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.

 

          Source: 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.13.  Standards for additional benefits. The following additional benefits shall be included in Medicare supplement benefit Plans B, C, D, F, F with High Deductible, G, M, and N as described in § 20:06:13:17.11:

 

          (1)  Medicare Part A Deductible: Coverage for 100 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;

 

          (2)  Medicare Part A Deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital deductible amount per benefit period;

 

          (3)  Skilled Nursing Facility Care: Coverage for the actual billed charges up to the coinsurance amount 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;

 

          (4)  Medicare Part B Deductible: Coverage for 100 percent of the Medicare Part B deductible amount per calendar year regardless of hospital confinement;

 

          (5)  One Hundred Percent of the Medicare Part B excess charges: Coverage for all of the difference between the actual Medicare Part B charges as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare-approved Part B charge;

 

          (6)  Medically Necessary Emergency Care in a Foreign Country: Coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, the term, emergency care, means care needed immediately because of an injury or an illness of sudden and unexpected onset.

 

          Source: 35 SDR 183, effective February 2, 2009.

          General Authority: SDCL 58-17A-2.

          Law Implemented: SDCL 58-17A-2.

 

          20:06:13:17.14.  Requirements for standard Medicare supplement benefit plans -- Plans issued after May 31, 2010. An issuer shall make available to each prospective policyholder and certificateholder a policy form or certificate form containing only the basic core benefits, as defined in § 20:06:13:17.12.

 

          If an issuer makes available any of the additional benefits described in § 20:06:13:17.13, or offers standardized benefit Plans K or L, then the issuer shall make available to each prospective policyholder and certificateholder, in addition to a policy form or certificate form with only the core benefits, a policy form or certificate containing either standardized benefit Plan C or standardized benefit Plan F.

 

          No groups, packages, or combinations of Medicare supplement benefits other than those listed in this chapter shall be offered for sale in this state.

 

          Benefit plans shall be uniform in structure, language, designation, and format to the standard benefit plans listed in this section and conform to the definitions in § 20:06:13:02. Each benefit shall be structured in accordance with the format provided in §§ 20:06:13:17.12 and 20:06:13:17.13. For purposes of this section, structure, language, and format means style, arrangement, and overall content of a benefit.

 

          In addition to the benefit plan designations required in this section, an issuer may use other designations to the extent permitted by law.

 

          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.