Rule 20:06:13:0A Medicare Supplement Refund Calculation Forms.

{"Article":"20:06:13","Agency":"","Status":"","RuleId":6064,"RuleNumber":"20:06:13","Type":"C","Catchline":"MEDICARE SUPPLEMENT INSURANCE","Path":"20/06/13/","Filename":"2006130000000c.htm","Title":20,"Parents":[{"DisplayRuleNumber":"20:06","RuleNumber":"20:06"},{"DisplayRuleNumber":"13","RuleNumber":"20:06:13"}],"Html":"

\r\n\r\n\r\nRule 20:06:13:0A Medicare Supplement Refund Calculation Forms.\r\n\r\n\r\n\r\n\r\nDEPARTMENT OF REVENUE AND REGULATION\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

DEPARTMENT\r\nOF LABOR AND REGULATION

\r\n\r\n

DIVISION\r\nOF INSURANCE

\r\n\r\n

MEDICARE\r\nSUPPLEMENT REFUND CALCULATION FORMS

\r\n\r\n

Chapter\r\n20:06:13

\r\n\r\n

APPENDIX\r\nA

\r\n\r\n

SEE:\r\n§ 20:06:13:21.01

\r\n\r\n

Source: 18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005; 39 SDR 10, effective August 1, 2012.

\r\n\r\n
\r\n\r\n\r\n

APPENDIX A

\r\n\r\n

MEDICARE\r\nSUPPLEMENT REFUND CALCULATION FORM

\r\n\r\n

FOR\r\nCALENDAR YEAR_________________

\r\n\r\n

TYPE\r\n(u) ___________________________ SMSBP (w)\r\n_________________________

\r\n\r\n

For\r\nthe State of ______________ Company Name ______________________________

\r\n\r\n

NAIC\r\nGroup Code ___________ NAIC Company Code _________________________

\r\n\r\n

Address\r\n________________________________________________________________

\r\n\r\n

Person\r\nCompleting This Exhibit _____________________________________________

\r\n\r\n

Title\r\n____________________________________ Telephone Number_______________

\r\n\r\n

	\r\n \r\n \r\n Line \r\n	\r\n \r\n \r\n \r\n \r\n	\r\n (a) \r\n Earned \r\n Premium (x) \r\n \r\n \r\n	\r\n (b) \r\n Incurred \r\n Claims (y) \r\n
	\r\n 1. \r\n	\r\n Current Year's Experience \r\n \r\n	\r\n \r\n \r\n \r\n	\r\n \r\n
\r\n \r\n		\r\n a. Total (all policy years) \r\n	\r\n \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n		\r\n b. Current year's issues (z) \r\n c. Net (for reporting purposes =\r\n 1a - 1b) \r\n \r\n	\r\n \r\n ___________ \r\n	\r\n \r\n ____________ \r\n \r\n
\r\n 2. \r\n		\r\n Past Years' Experience (all policy\r\n years) \r\n	\r\n ___________ \r\n \r\n	\r\n ____________ \r\n \r\n
\r\n 3. \r\n		\r\n Total Experience \r\n (Net Current Year + Past Year's\r\n Experience) \r\n	\r\n \r\n ___________ \r\n \r\n	\r\n \r\n ____________ \r\n \r\n
\r\n 4. \r\n		\r\n Refunds Last Year (Excluding\r\n Interest) \r\n \r\n		\r\n \r\n
\r\n 5. \r\n		\r\n Previous Since Inception (Excluding\r\n Interest) \r\n \r\n		\r\n \r\n
\r\n 6. \r\n		\r\n Refunds Since Inception (Excluding\r\n Interest) \r\n \r\n		\r\n \r\n
\r\n 7. \r\n		\r\n Benchmark Ratio Since Inception \r\n (SEE WORKSHEET FOR RATIO 1) \r\n \r\n		\r\n \r\n
\r\n 8. \r\n \r\n \r\n \r\n \r\n		\r\n Experienced Ratio Since Inception \r\n \r\n Total Actual Incurred Claims (line\r\n 3, col. b) = Ratio 2 \r\n ---------------------------------------------------- \r\n Total Earned Prem. (line 3, col. a)\r\n - Refunds Since Inception (line 6) \r\n \r\n		\r\n \r\n
\r\n 9. \r\n \r\n \r\n \r\n \r\n		\r\n Life Years Exposed Since\r\n Inception __________________ \r\n \r\n If the Experienced Ratio is less\r\n than the Benchmark Ratio, and there are more than 500 life years exposure,\r\n then proceed to calculation of refund. \r\n \r\n		\r\n \r\n
\r\n 10. \r\n		\r\n Tolerance Permitted (obtained from\r\n credibility table) __________ \r\n		\r\n \r\n

\r\n\r\n\r\n\r\n\r\n

MEDICARE\r\nSUPPLEMENT REFUND CALCULATION FORM

\r\n\r\n

FOR\r\nCALENDAR YEAR_________________

\r\n\r\n

TYPE\r\n(u) ___________________________ SMSBP (w)\r\n_________________________

\r\n\r\n

For\r\nthe State of ______________ Company Name ______________________________

\r\n\r\n

NAIC\r\nGroup Code ___________ NAIC Company Code _________________________

\r\n\r\n

Address\r\n________________________________________________________________

\r\n\r\n

Person\r\nCompleting This Exhibit _____________________________________________

\r\n\r\n

Title\r\n____________________________________ Telephone Number_______________

\r\n\r\n

\r\n\r\n\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n

\r\n

11.

\r\n

Adjustment to Incurred Claims for\r\n Credibility

\r\n

\r\n
\r\n

\r\n

Ratio 3 = Ratio 2 + Tolerance

\r\n

\r\n\r\n

If Ratio 3 is more\r\nthan Benchmark Ratio (Ratio 1), a refund or credit to premium is not required.

\r\n\r\n

If Ratio 3 is less\r\nthan the Benchmark Ratio, then proceed.

\r\n\r\n

\r\n\r\n\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n

\r\n 12. \r\n	\r\n Adjusted Incurred Claims = \r\n \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n \r\n	\r\n [Total Earned Premiums (line 3,\r\n col. a) - Refunds Since Inception \r\n (line 6)] x Ratio 3 (line 11) \r\n	\r\n \r\n
\r\n 13. \r\n	\r\n Refund = Total Earned Premiums\r\n (line 3, col. a) - \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n \r\n	\r\n Refunds Since Inception (line 6) - \r\n \r\n Adjusted Incurred Claims (line 12) \r\n ----------------------------------------- \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n	\r\n Benchmark Ratio (Ratio 1) \r\n	\r\n \r\n

\r\n\r\n

If the amount on\r\nline 13 is less than .005 times the annualized premium in force as of December\r\n31 of the reporting year, then no refund is made. Otherwise, the amount on line\r\n13 is to be refunded or credited, and a description of the refund and/or credit\r\nagainst premiums to be used must be attached to this form.

\r\n\r\n

Medicare Supplement Credibility Table

\r\n\r\n

Life Years Exposed

\r\n\r\n\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n

\r\n Since\r\n Inception \r\n \r\n	\r\n Tolerance\r\n \r\n
\r\n 10,000\r\n + \r\n	\r\n 0.0%\r\n \r\n
\r\n 5,000\r\n - 9,999 \r\n	\r\n 5.0%\r\n \r\n
\r\n 2,500\r\n - 4,999 \r\n	\r\n 7.5%\r\n \r\n
\r\n 1,000\r\n - 2,499 \r\n	\r\n 10.0%\r\n \r\n
\r\n 500\r\n - 999 \r\n	\r\n 15.0%\r\n \r\n

\r\n\r\n

If less than 500, no credibility.

\r\n\r\n\r\n\r\n\r\n

MEDICARE\r\nSUPPLEMENT REFUND CALCULATION FORM

\r\n\r\n

FOR\r\nCALENDAR YEAR_________________

\r\n\r\n

TYPE\r\n(u) ___________________________ SMSBP (w)\r\n_________________________

\r\n\r\n

For\r\nthe State of ______________ Company Name ______________________________

\r\n\r\n

NAIC\r\nGroup Code ___________ NAIC Company Code _________________________

\r\n\r\n

Address\r\n________________________________________________________________

\r\n\r\n

Person\r\nCompleting This Exhibit _____________________________________________

\r\n\r\n

Title\r\n____________________________________ Telephone Number_______________

\r\n\r\n

(u) Individual,\r\nGroup, Individual Medicare Select, or Group Medicare Select Only.

\r\n\r\n

(w) \r\n"SMSBP" = Standardized Medicare Supplement Benefit Plan - Use\r\n"P" for pre-standardized plans.

\r\n\r\n

(x) Includes Modal\r\nLoadings and Fees Charged

\r\n\r\n

(y) Excludes\r\nActive Life Reserves

\r\n\r\n

(z) \r\nThis is to be used as "Issue Year Earned Premium" for Year 1 of next\r\nyear's "Worksheet for Calculation of Benchmark Ratios."

\r\n\r\n

I certify that the\r\nabove information and calculations are true and accurate to the best of my\r\nknowledge and belief.

\r\n\r\n

____________________________________

\r\n\r\n

Signature

\r\n\r\n

____________________________________

\r\n\r\n

Name\r\n- Please Type

\r\n\r\n

____________________________________

\r\n\r\n

Title\r\n- Please Type

\r\n\r\n

____________________________________

\r\n\r\n

Date

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

REPORTING\r\nFORM FOR THE CALCULATION OF BENCHMARK

\r\n\r\n

RATIO\r\nSINCE INCEPTION FOR GROUP POLICIES

\r\n\r\n

FOR\r\nCALENDAR YEAR____________________

\r\n\r\n

TYPE\r\n(q) ____________________ SMSBP (p) _____________________

\r\n\r\n

FOR\r\nTHE STATE OF __________ Company Name _________________

\r\n\r\n

NAIC\r\nGroup Code ______________ NAIC Company Code ___________

\r\n\r\n

Address\r\n____________________________________________________

\r\n\r\n

Person\r\nCompleting This Exhibit _________________________________

\r\n\r\n

Title\r\n___________________________ Telephone Number ____________

\r\n\r\n

\r\n\r\n\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n

\r\n (a) \r\n	\r\n (b) \r\n	\r\n (c)\r\n \r\n	\r\n (d)\r\n \r\n	\r\n (e)\r\n \r\n	\r\n (f)\r\n \r\n	\r\n (g)\r\n \r\n	\r\n (h)\r\n \r\n	\r\n (i)\r\n \r\n	\r\n (j)\r\n \r\n	\r\n (o) \r\n
\r\n \r\n	\r\n Earned\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n Cumulative\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n Cumulative\r\n \r\n	\r\n \r\n	\r\n Policy\r\n Year \r\n
\r\n Year\r\n \r\n	\r\n Premium\r\n \r\n	\r\n Factor\r\n \r\n	\r\n (b)\r\n x (c) \r\n	\r\n Loss\r\n Ratio \r\n	\r\n (d)\r\n x (e) \r\n	\r\n Factor\r\n \r\n	\r\n (b)\r\n x (g) \r\n	\r\n Loss\r\n Ratio \r\n	\r\n (h)\r\n x (i) \r\n	\r\n Loss\r\n Ratio \r\n
\r\n 1\r\n \r\n	\r\n \r\n	\r\n 2.770\r\n \r\n	\r\n \r\n	\r\n 0.507\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.46\r\n \r\n
\r\n 2\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.63\r\n \r\n
\r\n 3\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 1.194\r\n \r\n	\r\n \r\n	\r\n 0.759\r\n \r\n	\r\n \r\n	\r\n 0.75\r\n \r\n
\r\n 4\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 2.245\r\n \r\n	\r\n \r\n	\r\n 0.771\r\n \r\n	\r\n \r\n	\r\n 0.77\r\n \r\n
\r\n 5\r\n \r\n	\r\n \r\n	\r\n 4.175 \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 3.170\r\n \r\n	\r\n \r\n	\r\n 0.782\r\n \r\n	\r\n \r\n	\r\n 0.80\r\n \r\n
\r\n 6\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 3.998\r\n \r\n	\r\n \r\n	\r\n 0.792\r\n \r\n	\r\n \r\n	\r\n 0.82\r\n \r\n
\r\n 7\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 4.754\r\n \r\n	\r\n \r\n	\r\n 0.802\r\n \r\n	\r\n \r\n	\r\n 0.84\r\n \r\n
\r\n 8\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 5.445\r\n \r\n	\r\n \r\n	\r\n 0.811\r\n \r\n	\r\n \r\n	\r\n 0.87\r\n \r\n
\r\n 9\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 6.075\r\n \r\n	\r\n \r\n	\r\n 0.818\r\n \r\n	\r\n \r\n	\r\n 0.88\r\n \r\n
\r\n 10\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 6.650\r\n \r\n	\r\n \r\n	\r\n 0.824\r\n \r\n	\r\n \r\n	\r\n 0.88\r\n \r\n
\r\n 11\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 7.176\r\n \r\n	\r\n \r\n	\r\n 0.828\r\n \r\n	\r\n \r\n	\r\n 0.88\r\n \r\n
\r\n 12\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 7.655\r\n \r\n	\r\n \r\n	\r\n 0.831\r\n \r\n	\r\n \r\n	\r\n 0.88\r\n \r\n
\r\n 13\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 8.093\r\n \r\n	\r\n \r\n	\r\n 0.834\r\n \r\n	\r\n \r\n	\r\n 0.89\r\n \r\n
\r\n 14\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 8.493\r\n \r\n	\r\n \r\n	\r\n 0.837\r\n \r\n	\r\n \r\n	\r\n 0.89\r\n \r\n
\r\n \r\n 15+ \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.567\r\n \r\n	\r\n \r\n	\r\n 8.684\r\n \r\n	\r\n \r\n	\r\n 0.838\r\n \r\n	\r\n \r\n	\r\n 0.89\r\n \r\n
\r\n Total:\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n (k): \r\n	\r\n \r\n	\r\n (l): \r\n	\r\n \r\n	\r\n (m): \r\n	\r\n \r\n	\r\n (n): \r\n	\r\n \r\n

\r\n\r\n

Benchmark Ratio Since Inception: (1 + n) /\r\n(k + m):

\r\n\r\n

(a): Year 1 is the current\r\ncalendar year - 1 (b): For the calendar\r\nyear on the appropriate line in column (a),

\r\n\r\n

Year 2 is the current\r\ncalendar year - 2 (etc.) the premium earned\r\nduring that year for policies issued in

\r\n\r\n

(Example: If the current\r\nyear is 1991, then: that year.

\r\n\r\n

Year 1 is 1990; Year 2 is\r\n1989, etc.).

\r\n\r\n

Year 15+ is the earned\r\npremium for all years prior

\r\n\r\n

to as well as the 15^th\r\nyear prior to the current year.

\r\n\r\n

(o): These loss ratios are not\r\nexplicitly used in computing the (p): "SMSBP" = Standardized Medicare\r\nSupplement Benefit Plan.

\r\n\r\n

benchmark loss ratios.\r\nThey are the loss ratios, on

\r\n\r\n

a policy year basis,\r\nwhich result in the cumulative (q): Individual Group,\r\nIndividual Medicare Select, or Group Medicare

\r\n\r\n

loss ratios displayed on\r\nthis worksheet. They are shown Select Only.

\r\n\r\n

here for informational\r\npurposes only.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

REPORTING\r\nFORM FOR THE CALCULATION OF BENCHMARK

\r\n\r\n

RATIO\r\nSINCE INCEPTION FOR INDIVIDUAL POLICIES

\r\n\r\n

FOR\r\nCALENDAR YEAR____________________

\r\n\r\n

TYPE\r\n(q) ____________________ SMSBP (p) _____________________

\r\n\r\n

FOR\r\nTHE STATE OF __________ Company Name _________________

\r\n\r\n

NAIC\r\nGroup Code ______________ NAIC Company Code ___________

\r\n\r\n

Address\r\n____________________________________________________

\r\n\r\n

Person\r\nCompleting This Exhibit _________________________________

\r\n\r\n

Title\r\n___________________________ Telephone Number ____________

\r\n\r\n

\r\n (a) \r\n	\r\n (b) \r\n	\r\n (c)\r\n \r\n	\r\n (d)\r\n \r\n	\r\n (e)\r\n \r\n	\r\n (f)\r\n \r\n	\r\n (g)\r\n \r\n	\r\n (h)\r\n \r\n	\r\n (i) \r\n	\r\n (j)\r\n \r\n	\r\n (o) \r\n
\r\n \r\n	\r\n Earned\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n Cumulative\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n Cumulative\r\n \r\n	\r\n \r\n	\r\n Policy\r\n Year \r\n
\r\n Year\r\n \r\n	\r\n Premium\r\n \r\n	\r\n Factor\r\n \r\n	\r\n (b)\r\n x (c) \r\n	\r\n Loss\r\n Ratio \r\n	\r\n (d)\r\n x (e) \r\n	\r\n Factor\r\n \r\n	\r\n (b)\r\n x (g) \r\n	\r\n Loss\r\n Ratio \r\n	\r\n (h)\r\n x (i) \r\n	\r\n Loss\r\n Ratio \r\n
\r\n 1\r\n \r\n	\r\n \r\n	\r\n 2.770\r\n \r\n	\r\n \r\n	\r\n 0.442\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.40\r\n \r\n
\r\n 2\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.000\r\n \r\n	\r\n \r\n	\r\n 0.55\r\n \r\n
\r\n 3\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 1.194\r\n \r\n	\r\n \r\n	\r\n 0.659\r\n \r\n	\r\n \r\n	\r\n 0.65\r\n \r\n
\r\n 4\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 2.245\r\n \r\n	\r\n \r\n	\r\n 0.669\r\n \r\n	\r\n \r\n	\r\n 0.67\r\n \r\n
\r\n 5\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 3.170\r\n \r\n	\r\n \r\n	\r\n 0.678\r\n \r\n	\r\n \r\n	\r\n 0.69\r\n \r\n
\r\n 6\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 3.998\r\n \r\n	\r\n \r\n	\r\n 0.686\r\n \r\n	\r\n \r\n	\r\n 0.71\r\n \r\n
\r\n 7\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 4.754\r\n \r\n	\r\n \r\n	\r\n 0.695\r\n \r\n	\r\n \r\n	\r\n 0.73\r\n \r\n
\r\n 8\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 5.445\r\n \r\n	\r\n \r\n	\r\n 0.702\r\n \r\n	\r\n \r\n	\r\n 0.75\r\n \r\n
\r\n 9\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 6.075\r\n \r\n	\r\n \r\n	\r\n 0.708\r\n \r\n	\r\n \r\n	\r\n 0.76\r\n \r\n
\r\n 10\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 6.650\r\n \r\n	\r\n \r\n	\r\n 0.713\r\n \r\n	\r\n \r\n	\r\n 0.76\r\n \r\n
\r\n 11\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 7.176\r\n \r\n	\r\n \r\n	\r\n 0.717\r\n \r\n	\r\n \r\n	\r\n 0.76\r\n \r\n
\r\n 12\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 7.655\r\n \r\n	\r\n \r\n	\r\n 0.720\r\n \r\n	\r\n \r\n	\r\n 0.77\r\n \r\n
\r\n 13\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 8.093\r\n \r\n	\r\n \r\n	\r\n 0.723\r\n \r\n	\r\n \r\n	\r\n 0.77\r\n \r\n
\r\n 14\r\n \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 8.493\r\n \r\n	\r\n \r\n	\r\n 0.725\r\n \r\n	\r\n \r\n	\r\n 0.77\r\n \r\n
\r\n \r\n 15+ \r\n	\r\n \r\n	\r\n 4.175\r\n \r\n	\r\n \r\n	\r\n 0.493\r\n \r\n	\r\n \r\n	\r\n 8.684\r\n \r\n	\r\n \r\n	\r\n 0.725\r\n \r\n	\r\n \r\n	\r\n 0.77\r\n \r\n
\r\n Total:\r\n \r\n	\r\n \r\n	\r\n \r\n	\r\n (k): \r\n	\r\n \r\n	\r\n (l): \r\n	\r\n \r\n	\r\n (m): \r\n	\r\n \r\n	\r\n (n): \r\n	\r\n \r\n

\r\n\r\n

Benchmark Ratio Since Inception: (l + n) /\r\n(k + m):

\r\n\r\n

(a): Year 1 is the current\r\ncalendar year - 1 (b): For the calendar\r\nyear on the appropriate line in column (a),

\r\n\r\n

Year 2 is the current\r\ncalendar year - 2 (etc.) the premium\r\nearned during that year for policies issued in that

\r\n\r\n

(Example: If the current\r\nyear is 1991, then: year.

\r\n\r\n

Year 1 is 1990; Year 2 is\r\n1989, etc.).

\r\n\r\n

Year 15+ is the earned\r\npremium for all years prior

\r\n\r\n

to as well as the 15^th\r\nyear prior to the current year.

\r\n\r\n

(o): These loss ratios are not\r\nexplicitly used in computing the ( p): "SMSBP" = Standardized\r\nMedicare Supplement Benefit Plan.

\r\n\r\n

benchmark loss ratios.\r\nThey are the loss ratios, on

\r\n\r\n

a policy year basis,\r\nwhich result in the cumulative (q): Individual Group,\r\nIndividual Medicare Select, or Group Medicare

\r\n\r\n

loss ratios displayed on\r\nthis worksheet. They are shown Select Only.

\r\n\r\n

here for informational\r\npurposes only.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:0B Form for Reporting Medicare Supplement Policies.\r\n\r\n\r\n\r\n\r\nDEPARTMENT OF REVENUE AND REGULATION\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

DEPARTMENT\r\nOF LABOR AND REGULATION

\r\n\r\n

DIVISION\r\nOF INSURANCE

\r\n\r\n

FORM\r\nFOR REPORTING

\r\n\r\n

MEDICARE\r\nSUPPLEMENT POLICIES

\r\n\r\n

Chapter\r\n20:06:13

\r\n\r\n

APPENDIX\r\nB

\r\n\r\n

SEE:\r\n§ 20:06:13:53

\r\n\r\n

Source: 18 SDR 225, effective July 17, 1992;\r\n39 SDR 10, effective August 1, 2012.

\r\n\r\n
\r\n\r\n\r\n

APPENDIX B

\r\n\r\n

FORM FOR REPORTING

\r\n\r\n

MEDICARE SUPPLEMENT POLICIES

\r\n\r\n

Company Name: ______________________________

\r\n\r\n

Address: ______________________________

\r\n\r\n

______________________________

\r\n\r\n

Phone Number: ______________________________

\r\n\r\n

Due\r\nMarch 1, annually

\r\n\r\n

The purpose of this\r\nform is to report the following information on each resident of this state who\r\nhas in force more than one Medicare supplement policy or certificate. The\r\ninformation is to be grouped by individual policyholder.

\r\n\r\n

Policy\r\nand Date of

\r\n\r\n

Certificate\r\n# Issuance

\r\n\r\n\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n

\r\n \r\n \r\n \r\n \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n \r\n	\r\n \r\n
\r\n \r\n \r\n \r\n \r\n	\r\n \r\n

\r\n\r\n

___________________________________

\r\n\r\n

Signature

\r\n\r\n

___________________________________

\r\n\r\n

Name\r\nand Title (please type)

\r\n\r\n

___________________________________

\r\n\r\n

Date

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:0C Notice to Applicant Regarding Replacement of Medicare Supplement Insurance.\r\n\r\n\r\n\r\n\r\nDEPARTMENT OF REVENUE AND REGULATION\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

DEPARTMENT\r\nOF LABOR AND REGULATION

\r\n\r\n

DIVISION\r\nOF INSURANCE

\r\n\r\n

NOTICE\r\nTO APPLICANT REGARDING REPLACEMENT

\r\n\r\n

OF\r\nMEDICARE SUPPLEMENT INSURANCE

\r\n\r\n

Chapter\r\n20:06:13

\r\n\r\n

APPENDIX\r\nC

\r\n\r\n

SEE:\r\n§ 20:06:13:35

\r\n\r\n

Source: 18 SDR 225, effective July 17, 1992; 22 SDR 107, effective February 18, 1996; 31 SDR 214, effective July 6, 2005;\r\n39 SDR 10, effective August 1, 2012.

\r\n\r\n
\r\n\r\n\r\n

APPENDIX C

\r\n\r\n

NOTICE\r\nTO APPLICANT REGARDING REPLACEMENT

\r\n\r\n

OF\r\nMEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE

\r\n\r\n

[insurance\r\ncompany's name and address]

\r\n\r\n

SAVE\r\nTHIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE

\r\n\r\n

According\r\nto [your application] [information you have furnished], you intend to terminate\r\nexisting Medicare supplement or Medicare Advantage insurance and replace it\r\nwith a policy to be issued by [Company Name] Insurance Company. Your new policy\r\nwill provide thirty (30) days within which you may decide without cost whether\r\nyou desire to keep the policy.

\r\n\r\n

You\r\nshould review this new coverage carefully. Compare it with all accident and\r\nsickness coverage you now have. If, after due consideration, you find that\r\npurchase of this Medicare supplement coverage is a wise decision, you should\r\nterminate your present Medicare supplement or Medicare Advantage coverage. You\r\nshould evaluate the need for other accident and sickness coverage you have that\r\nmay duplicate this policy.

\r\n\r\n

STATEMENT\r\nTO APPLICANT BY ISSUER, AGENT [BROKER OR OTHER REPRESENTATIVE]

\r\n\r\n

I\r\nhave reviewed your current medical or health insurance coverage. To the best of\r\nmy knowledge, this Medicare supplement policy will not duplicate your existing\r\nMedicare supplement or, if applicable, Medicare Advantage coverage because you\r\nintend to terminate your existing Medicare supplement coverage or leave your\r\nMedicare Advantage plan. The replacement policy is being purchased for the\r\nfollowing reason (check one):

\r\n\r\n

_______\r\nAdditional benefits.

\r\n\r\n

_______\r\nNo change in benefits, but lower premiums.

\r\n\r\n

_______\r\nFewer benefits and lower premiums.

\r\n\r\n

_______\r\nMy plan has outpatient prescription drug coverage and I am enrolling in part D.

\r\n\r\n

_______\r\nDisenrollment from a Medicare Advantage plan. Please explain reason for\r\ndisenrollment. [optional only for direct mailers.]

\r\n\r\n

______________________________________________________________________________________________________________________________________________________________

\r\n\r\n

_______\r\nOther. (please specify)

\r\n\r\n

______________________________________________________________________________________________________________________________________________________________

\r\n\r\n

1. Note: If the issuer of the Medicare supplement policy being\r\napplied for does not, or is otherwise prohibited from imposing preexisting\r\ncondition limitations, please skip to statement 2 below. Health conditions\r\nwhich you may presently have (preexisting conditions) may not be immediately or\r\nfully covered under the new policy. This could result in denial or delay of a\r\nclaim for benefits under the new policy, whereas a similar claim might have\r\nbeen payable under your present policy.

\r\n\r\n

2. State law provides that\r\nyour replacement policy or certificate may not contain new preexisting\r\nconditions, waiting periods, elimination periods or probationary periods. The\r\ninsurer will waive any time periods applicable to preexisting conditions,\r\nwaiting periods, elimination periods, or probationary periods in the new policy\r\n(or coverage) for similar benefits to the extent such time was spent (depleted)\r\nunder the original policy.

\r\n\r\n

3. If you still wish to\r\nterminate your present policy and replace it with new coverage, be certain to\r\ntruthfully and completely answer all questions on the application concerning\r\nyour medical and health history. Failure to include all material medical\r\ninformation on an application may provide a basis for the company to deny any\r\nfuture claims and to refund your premium as though your policy had never been\r\nin force. After the application has been completed and before you sign it,\r\nreview it carefully to be certain that all information has been properly\r\nrecorded. [If the policy or certificate is guaranteed issue, this paragraph\r\nneed not appear.]

\r\n\r\n

Do\r\nnot cancel your present policy until you have received your new policy and are\r\nsure that you want to keep it.

\r\n\r\n

_______________________________________________________________________________

\r\n\r\n

(Signature\r\nof Agent, Broker, or Other Representative)*

\r\n\r\n

[Typed Name and Address of\r\nIssuer, Agent, or Broker]

\r\n\r\n

_______________________________________________________________________________

\r\n\r\n

(Applicant's Signature)

\r\n\r\n

_______________________________________________________________________________

\r\n\r\n

(Date)

\r\n\r\n

* Signature not required for\r\ndirect response sales.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE POLICIES

PLANS A THROUGH N

Chapter 20:06:13

APPENDIX D

SEE: § 20:06:13:36

Source: 18 SDR 225, effective July 17, 1992; 23 SDR 236, effective July 13, 1997; 25 SDR 44, effective September 30, 1998; 26 SDR 26, effective September 1, 1999; 27 SDR 53, effective December 4, 2000; 31 SDR 214, effective July 6, 2005; 35 SDR 83, effective February 2, 2009; 36 SDR 209, effective July 1, 2010; 37 SDR 241, effective July 1, 2011; 39 SDR 10, effective August 1, 2012; 41 SDR 41, effective September 17, 2014; 42 SDR 52, effective October 13, 2015; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 184, effective June 25, 2018; 46 SDR 147, effective July 2, 2020; 47 SDR 137, effective June 28, 2021; 48 SDR 115, effective May 24, 2022; 49 SDR 130, effective July 4, 2023; 50 SDR 135, effective May 20, 2024; 51 SDR 127, effective June 5, 2025; 52 SDR 125, effective July 1, 2026.

‎APPENDIX D

[COMPANY NAME]

Outline of Medicare Supplement Coverage-Cover Page:

Benefit Plan(s)________[insert letter(s) of plan(s) being offered]

These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state.

See Outlines of Coverage sections for details about ALL plans.

Basic Benefits:

Hospitalization -- Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses -- Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments.

Blood -- First three pints of blood each year.

Hospice -- Part A coinsurance.

Basic, including 100% Part B

coinsurance

Basic,

including 100% Part

B coinsurance

Basic, including 100% Part

B coinsurance

Basic, including 100% Part

B coinsurance

Basic, including 100% Part

B coinsurance*

Basic, including 100% Part

B coinsurance

Part A

Deductible

Skilled Nursing Facility coinsurance Part A

Deductible Part B

Deductible

Foreign Travel Emergency

Skilled Nursing Facility coinsurance Part A

Deductible

Foreign Travel Emergency

Skilled Nursing Facility coinsurance Part A

Deductible Part B

Excess (100%) Foreign Travel Emergency

Skilled Nursing Facility coinsurance Part A

Deductible

Part B

Excess (100%) Foreign Travel Emergency

‎

K	L	M	N
Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%	Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%	Basic, including 100% Part B coinsurance	Basic, including 100% Part B coinsurance except up to $20 copayment for office visit, and up to $50 copayment for ER
50% Skilled Nursing Facility coinsurance 50% Part A Deductible	75% Skilled Nursing Facility coinsurance 75% Part A Deductible	Skilled Nursing Facility coinsurance 50% Part A Deductible	Skilled Nursing Facility coinsurance Part A Deductible


		Foreign Travel Emergency	Foreign Travel Emergency

Out-of-pocket limit $[8,000]; paid at 100% after limit reached	Out-of-pocket limit $[4,000]; paid at 100% after limit reached

*Plan F also has an option called a high-deductible Plan F. This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,950 deductible. Benefits from high-deductible Plan F will not begin until out-of-pocket expenses exceed $2,950. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

‎PREMIUM INFORMATION [Boldface Type]

We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this state. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]

READ YOUR POLICY VERY CAREFULLY [Boldface Type]

This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

RIGHT TO RETURN POLICY [Boldface Type]

If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

POLICY REPLACEMENT [Boldface Type]

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE [Boldface Type]

This policy may not fully cover all of your medical costs.

[for agents:]

Neither [insert company's name] nor its agents are connected with Medicare.

[for direct response:]

[insert company's name] is not connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult \"Medicare & You\" for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type]

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this chapter. An issuer may use additional benefit plan designations on these charts pursuant to § 20:06:13:17.05.]

[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]

‎Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020

This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high-deductible F.

Note: A ü means 100% of the benefit is paid.

Benefits	Plans Available to All Applicants	Medicare first eligible before 2020 only
A	B	D	G¹	K	L	M	N	C	F¹
Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)	ü	ü	ü	ü	ü	ü	ü	ü	ü	ü
Medicare Part B coinsurance or copayment	ü	ü	ü	ü	50%	75%	ü	ü copays apply³	ü	ü
Blood (first three pints)	ü	ü	ü	ü	50%	75%	ü	ü	ü	ü
Part A hospice care coinsurance or copayment	ü	ü	ü	ü	50%	75%	ü	ü	ü	ü
Skilled nursing facility coinsurance			ü	ü	50%	75%	ü	ü	ü	ü
Medicare Part A deductible		ü	ü	ü	50%	75%	50%	ü	ü	ü
Medicare Part B deductible									ü	ü
Medicare Part B excess charges				ü						ü
Foreign travel emergency (up to plan limits)			80%	80%			80%	80%	80%	80%
Out-of-pocket limit in [2026]²		[$8,000]²	[$4,000]²

¹Plans F and G also have a high-deductible option which require first paying a plan deductible of [$2,950] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High-deductible plan G does not cover the Medicare Part B deductible. However, high-deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

²Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

³Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.
‎PLAN A

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

‎
‎
‎

All but $[1,736]
‎All but $[434] a day
‎
‎All but $[868] a day
‎

‎
‎
‎

$0
‎$[434] a day
‎

$[868] a day

‎100% of Medicare-eligible expenses

$[1,736] (Part A deductible)

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^st day and after

‎
‎
‎
‎
‎
‎

All approved amounts

All but $[217] a day

‎
‎
‎
‎

$0
‎$0
‎$0

Up to $[217] a day

All costs

BLOOD

First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare

copayment/coinsurance

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days, as provided in the policy's Core Benefits. During this time, the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.

‎PLAN A

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 80%	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 20%	$[283] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎$0 ‎$0 ‎ ‎80%	‎All costs ‎$0 ‎ ‎20%	$0 $[283] (Part B deductible) $0
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES	‎100%	‎$0	$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES
‎---Medically necessary skilled care
‎services and medical supplies

---Durable medical equipment

First $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

100%

80%

20%

$[283] (Part B deductible)

‎PLAN B

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

‎
‎
‎
‎All but $[1,736]

All but $[434] a day

‎All but $[868] a day
‎
‎$0

‎
‎
‎
‎$[1,736](Part A deductible)

$[434] a day

‎$[868] a day

100% of Medicare-eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^st day and after

‎
‎
‎
‎
‎
‎

All approved amounts
‎All but $[217] a day

‎
‎
‎
‎
‎
‎

$0
‎$0

Up to $[217] a day

All costs

BLOOD

First 3 pints

Additional amounts

‎$0

100%

‎3 pints

HOSPICE CARE

You must meet Medicare's requirements including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

‎PLAN B

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 80% ‎	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 20% ‎	$[283] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts	$0	$0	All costs
BLOOD First 3 pints Next $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎$0 ‎$0 ‎ ‎80%	‎All costs ‎$0 ‎ ‎20%	$0 $[283] (Part B deductible) $0
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES	‎100%	‎$0	$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES
‎---Medically necessary skilled care
‎ services and medical supplies

---Durable medical equipment

First $[283] of Medicare-approved

amounts*
‎ Remainder of Medicare-approved amounts

100%

80%

20%

$[283] (Part B deductible)

‎PLAN C

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

‎
‎
‎
‎All but $[1,736]

All but $[434] a day

‎All but $[868] a day
‎
‎$0

‎
‎
‎
‎$[1,736](Part A deductible)

$[434] a day
‎
‎$[868] a day

100% of Medicare-eligible expenses
‎$0

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^st day and after

‎
‎
‎
‎
‎

‎All approved amounts
‎All but $[217] a day

‎
‎
‎
‎
‎
‎
‎$0
‎Up to $ [217] a day

All costs

BLOOD

First 3 pints

Additional amounts

‎$0

100%

‎3 pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

‎PLAN C

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 80%	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$[283] (Part B deductible) ‎Generally 20%	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎$0 ‎$0 ‎ ‎80%	‎All costs ‎$[283] (Part B deductible) 20%	$0 $0 $0
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES	‎100%	‎$0	$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES
‎---Medically necessary skilled care services and medical supplies

---Durable medical equipment

First $[283] of Medicare-approved

amounts*

Remainder of Medicare-approved
‎ amounts

100%

80%

$[283] (Part B deductible)

20%

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL -

NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year
‎ Remainder of charges

‎
‎
‎
‎
‎$0
‎$0

‎
‎
‎
‎
‎$0

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum benefit

‎PLAN D

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

‎
‎
‎
‎All but $[1,736]

All but $[434] a day
‎

All but $[868] a day
‎

‎$0

‎
‎
‎
‎$[1,736](Part A deductible)

$[434] a day
‎
‎$[868] a day

‎100% of Medicare-eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21^st thru 100^th day

101^st day and after

‎
‎
‎
‎
‎
‎
‎All approved amounts

All but $[217] a day

‎
‎
‎
‎
‎
‎
‎$0

Up to $ [217] a day

All costs

BLOOD

First 3 pints

Additional amounts

‎$0

100%

‎3 pints

HOSPICE CARE

You must meet Medicare's requirements including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

‎Medicare copayment/coinsurance

‎PLAN D

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 80%	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 20%	$[283] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	$0	All costs
BLOOD First 3 pints Next $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎$0 ‎$0 ‎ ‎80%	‎All costs ‎$0 ‎ ‎20%	$0 $[283] (Part B deductible) $0
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES	‎100%	‎$0	$0

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES

---Medically necessary skilled care services and medical supplies

---Durable medical equipment

First $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

‎100%
‎

‎80%
‎

‎$0
‎
‎
‎$0
‎

20%

$[283] (Part B deductible)

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

FOREIGN TRAVEL -

NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year
‎ Remainder of charges

‎
‎
‎
‎
‎$0
‎$0

‎
‎
‎
‎
‎$0

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum benefit

‎PLAN F or HIGH-DEDUCTIBLE PLAN F

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

**This high-deductible plan pays the same benefits as Plan F after you have paid a calendar year $[2,950] deductible. Benefits from the high-deductible Plan F will not begin until out-of-pocket expenses are $[2,950]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the plan's separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

[AFTER YOU PAY

$[2,950]

DEDUCTIBLE,**

PLAN PAYS]

[IN ADDITION TO

$[2,950]

DEDUCTIBLE,**

YOU PAY]

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

‎
‎
‎
‎All but $[1,736]

All but $[434] a day
‎
‎All but $[868] a day

‎$0

‎
‎
‎
‎$[1,736](Part A deductible) $[434] a day
‎
‎$[868] a day

‎100% of Medicare-eligible expenses
‎$0

$0***

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital

First 20 days

21^st thru 100^th day

101^st day and after

‎
‎
‎
‎
‎
‎
‎All approved amounts
‎All but $[217] a day

‎
‎
‎
‎
‎
‎
‎$0
‎Up to $[217] a day

All costs

BLOOD

First 3 pints

Additional amounts

‎$0

100%

‎3 pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

‎Medicare copayment/coinsurance

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days, as provided in the policy's Core Benefits. During this time, the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.

‎PLAN F or HIGH-DEDUCTIBLE PLAN F

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

**This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $[2,950] deductible. Benefits from the high-deductible Plan F will not begin until out-of-pocket expenses are $[2,950]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	[AFTER YOU PAY $[2,950] DEDUCTIBLE,** PLAN PAYS]	[IN ADDITION TO $[2,950] DEDUCTIBLE,** YOU PAY]
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎ ‎Generally 80% ‎	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$[283] (Part B deductible) ‎ ‎Generally 20% ‎	$0 $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	$0
BLOOD First 3 pints Next $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎$0 ‎$0 ‎ ‎80%	‎All costs ‎$[283] (Part B deductible) ‎ ‎20%	$0 $0 $0
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES	‎100%	‎$0	$0

PARTS A & B

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2,950] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2,950]

DEDUCTIBLE,**] YOU PAY'

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES
‎ --Medically necessary skilled care
‎services and medical supplies

---Durable medical equipment

---First $[283] of Medicare-approved amounts*
‎ Remainder of Medicare-approved amounts

100%
‎
‎
‎$0
‎
‎80%

‎
‎$0
‎
‎
‎$[283] (Part B deductible)
‎

20%

(continued)

‎PLAN F or HIGH-DEDUCTIBLE PLAN F (continued)

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

[AFTER YOU PAY

$[2,950]

DEDUCTIBLE,**]

PLAN PAYS

[IN ADDITION TO

$[2,950]

DEDUCTIBLE,**]

YOU PAY

FOREIGN TRAVEL -

NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year
‎ Remainder of charges

‎
‎
‎
‎
‎$0
‎$0

‎
‎
‎
‎
‎$0

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum benefit

‎PLAN G or HIGH-DEDUCTIBLE PLAN G

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

**This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,950] deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are [$2,950]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2,950] DEDUCTIBLE,**]

PLAN PAYS

[IN ADDITION TO $[2,950]

DEDUCTIBLE,**]

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

‎
‎
‎
‎All but $[1,736]

All but $[434] a day
‎
‎All but $[868] a day
‎
‎$0

‎$0

‎
‎
‎
‎$[1,736](Part A deductible) $[434] a day
‎
‎$[868] a day

‎100% of Medicare-eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^th day and after

‎
‎
‎
‎
‎
‎
‎All approved amounts
‎All but $[217] a day

‎
‎
‎
‎
‎
‎
‎$0
‎Up to $[217] a day

All costs

BLOOD

First 3 pints

Additional amounts

‎$0

100%

‎3 pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

‎Medicare copayment/coinsurance

‎PLAN G or HIGH-DEDUCTIBLE PLAN G

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

**This high-deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,950] deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are [$2,950]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.

SERVICES	MEDICARE PAYS	[AFTER YOU PAY $[2,950] DEDUCTIBLE,**] PLAN PAYS	[IN ADDITION TO $[2,950] DEDUCTIBLE,**] YOU PAY
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎Generally 80%	‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎$0 ‎Generally 20%	$[283] (Unless Part B deductible has been met) $0
Part B Excess Charges (Above Medicare-approved amounts)	$0	100%	0%
BLOOD First 3 pints Next $[283] of Medicare-approved amounts* Remainder of Medicare-approved amounts	‎$0 ‎$0 ‎ ‎80%	‎All costs ‎$0 ‎ ‎20%	$0 $[283] (Unless Part B deductible has been met) $0
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES	‎100%	‎$0	$0

PARTS A & B

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2,950] DEDUCTIBLE,**]

PLAN PAYS

[IN ADDITION TO $[2,950] DEDUCTIBLE,**]

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES

---Medically necessary skilled care services and medical supplies

---Durable medical equipment

First $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

‎
‎
‎100%
‎
‎$0
‎
‎80%

‎
‎
‎$0
‎
‎$0
‎
‎20%

$[283] (Unless Part B deductible has been met)

‎

OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

[AFTER YOU PAY $[2,950] DEDUCTIBLE,**] PLAN PAYS

[IN ADDITION TO $[2,950] DEDUCTIBLE,**]

YOU PAY

FOREIGN TRAVEL -

NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year
‎ Remainder of charges

‎
‎
‎
‎
‎$0
‎$0

‎
‎
‎
‎
‎$0

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum benefit

‎PLAN K

*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[8,000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts. These are called \"excess charges,\" and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for that item or service.

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

**A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOSPITALIZATION**

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

All but $[1,736]

All but $[434] a day

All but $[868] a day

$[868] (50% of Part A deductible)

$[434] a day

$[868] a day

100% of Medicare-eligible expenses

$[868] (50% of Part A deductible)♦

$0***

All costs

SKILLED NURSING FACILITY CARE**

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^st day and after

All approved amounts

All but $[217] a day

Up to $[108.50] a day (50% of Part A coinsurance)

Up to $[108.50] a day (50% of Part A coinsurance)♦

All costs

BLOOD

First 3 pints

Additional amounts

100%

50%

50%♦

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

50% of Medicare coinsurance/copayment

50% of Medicare copayment/coinsurance♦

‎PLAN K

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

MEDICAL EXPENSES -

IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $[283] of Medicare-approved amounts****

Preventative Benefits for Medicare-covered services

Remainder of Medicare-approved amounts

Generally 80% or more of Medicare-approved amounts

Generally 80%

Remainder of Medicare-approved amounts

Generally 10%

$[283] (Part B deductible)****♦

All costs above Medicare-approved amounts

Generally 10%

Part B Excess Charges (Above Medicare-approved amounts)

All costs (and they do not count toward annual out-of-pocket limit of $[8,000])*

BLOOD

First 3 pints

Next $[283] of Medicare-approved amounts****

Remainder of Medicare-approved amounts

Generally 80%

50%

Generally 10%

$50%♦

$[283] (Part B deductible)****♦

Generally 10%♦

CLINICAL LABORATORY SERVICES

--TESTS FOR DIAGNOSTIC SERVICES

100%

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[8,000] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts. These are called \"excess charges,\" and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES

--Medically necessary skilled care services and medical supplies

--Durable medical equipment

First $[283] of Medicare-approved amounts *****

Remainder of Medicare-approved amounts

100%

80%

10%

$[283] (Part B deductible)♦

10%♦

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

‎PLAN L

*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4,000] each calendar year. The amounts that count toward your annual limit are noted with diamonds (♦) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts. These are called \"excess charges,\" and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for that item or service.

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

HOSPITALIZATION**

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

All but $[1,736]

All but $[434] a day

All but $[868] a day

$[1,302] (75% of Part A deductible)

$[434] a day

$[868] a day

100% of Medicare-eligible expenses

$[434] (25% of Part A deductible)♦

$0***

All costs

SKILLED NURSING FACILITY CARE**

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^st day and after

All approved amounts

All but $[217] a day

Up to $[162.75] a day (75% of Part A coinsurance)

Up to $[54.25] a day (25% of Part A coinsurance)♦

All costs

BLOOD

First 3 pints

Additional amounts

100%

75%

25%♦

HOSPICE CARE

You must meet Medicare's requirements including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

75% of Medicare copayment/coinsurance

25% of Medicare copayment/coinsurance ♦

‎PLAN L

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

****Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY*

MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $[283] of Medicare-approved amounts****

Preventative Benefits for Medicare-covered services

Remainder of Medicare-approved amounts

Generally 80% or more of Medicare-approved amounts

Generally 80%

Remainder of Medicare-approved amounts

Generally 15%

$[283] (Part B deductible)****♦

All costs above Medicare-approved amounts

Generally 5%♦

Part B Excess Charges (Above Medicare-approved amounts)

All costs (and they do not count toward annual out-of-pocket limit of $[4,000])*

BLOOD

First 3 pints

Next $[283] of Medicare-approved amounts****

Remainder of Medicare-approved amounts

Generally 80%

75%

Generally 15%

$25%

$[283] (Part B deductible)****♦

Generally 5%♦

CLINICAL LABORATORY SERVICES

--TESTS FOR DIAGNOSTIC SERVICES

100%

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4,000] per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts. These are called \"excess charges,\" and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES

--Medically necessary skilled care services and medical supplies

--Durable medical equipment

First $[283] of Medicare-approved amounts *****

Remainder of Medicare-approved amounts

100%

80%

15%

$[283] (Part B deductible)♦

5%♦

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

‎PLAN M

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

All but $[1,736]

All but $[434] a day

All but $[868] a day

$[868] (50% of Part A deductible)

$[434] a day

$[868] a day

100% of Medicare-eligible expenses

$[868] (50% of Part A deductible)

$0***

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days

21^st thru 100^th day

101^st day and after

All approved amounts

All but $[217] a day

Up to $[217] a day

All costs

BLOOD

First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days, as provided in the policy's Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

‎PLAN M

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

First $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Generally 20%

$[283] (Part B deductible)

Part B Excess Charges

(Above Medicare-approved amounts)

All costs

BLOOD

First 3 pints

Next $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

All costs

20%

$0%

$[283] (Part B deductible)

CLINICAL LABORATORY SERVICES

--TESTS FOR DIAGNOSTIC SERVICES

100%

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE APPROVED SERVICES

--Medically necessary skilled care services and medical supplies

--Durable medical equipment

First $[283] of Medicare-approved amounts *

Remainder of Medicare-approved amounts

100%

80%

20%

$[283] (Part B deductible)

OTHER BENEFITS -- NOT COVERED BY MEDICARE

FOREIGN TRAVEL

NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum benefit

‎PLAN N

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days

61^st thru 90^th day

91^st day and after:

--While using 60 lifetime reserve days

--Once lifetime reserve days are used:

--Additional 365 days

--Beyond the additional 365 days

All but $[1,736]

All but $[434] a day

All but $[868] a day

$[1,736] (Part A deductible)

$[434] a day

$[868] a day

100% of Medicare-eligible expenses

$0**

All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days

21^st thru 100^th day

101^st day and after

All approved amounts

All but $[217] a day

Up to $[217] a day

All costs

BLOOD

First 3 pints

Additional amounts

100%

3 pints

HOSPICE CARE

You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days, as provided in the policy's Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

‎PLAN N

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $[283] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

First $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The copayment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

$[283] (Part B deductible)

Up to [$20] per office visit and up to [$50] per emergency room visit. The copayment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges

(Above Medicare-approved amounts)

All costs

BLOOD

First 3 pints

Next $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

All costs

20%

$0%

$[283] (Part B deductible)

CLINICAL LABORATORY SERVICES

--TESTS FOR DIAGNOSTIC SERVICES

100%

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN PAYS

YOU PAY

HOME HEALTH CARE

MEDICARE-APPROVED SERVICES

--Medically necessary skilled care services and medical supplies

--Durable medical equipment

First $[283] of Medicare-approved amounts*

Remainder of Medicare-approved amounts

100%

80%

20%

$[283] (Part B deductible)

‎OTHER BENEFITS -- NOT COVERED BY MEDICARE

FOREIGN TRAVEL

NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year

Remainder of charges

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum benefit

\r\n\r\n\r\nRule 20:06:13:0E Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

DEPARTMENT OF\r\nLABOR AND REGULATION

\r\n\r\n

DIVISION OF\r\nINSURANCE

\r\n\r\n

INSTRUCTIONS FOR\r\nUSE OF THE DISCLOSURE STATEMENTS

\r\n\r\n

FOR HEALTH\r\nINSURANCE POLICIES SOLD TO

\r\n\r\n

MEDICARE\r\nBENEFICIARIES THAT DUPLICATE MEDICARE

\r\n\r\n

Chapter 20:06:13

\r\n\r\n

APPENDIX E

\r\n\r\n

SEE: § 20:06:13:31

\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13, 1997;\r\n25 SDR 44, effective September 30, 1998; 31 SDR 214, effective July 6, 2005; 36\r\nSDR 209, effective July 1, 2010; 39 SDR 10, effective August 1, 2012.

\r\n\r\n
\r\n\r\n\r\n

APPENDIX E

\r\n\r\n

DISCLOSURE\r\nSTATEMENTS

\r\n\r\n

Instructions for\r\nUse of the Disclosure Statements for

\r\n\r\n

Health Insurance\r\nPolicies Sold to Medicare Beneficiaries

\r\n\r\n

that Duplicate\r\nMedicare

\r\n\r\n

1. Section\r\n1882 (d) of the federal Social Security Act [42 U.S.C. 1395ss] prohibits the\r\nsale of a health insurance policy (the term policy or policies includes\r\ncertificates) that duplicate Medicare benefits unless it will pay benefits\r\nwithout regard to other health coverage and it includes the prescribed\r\ndisclosure statement on or together with the application for the policy

\r\n\r\n

2. All\r\ntypes of health insurance policies that duplicate Medicare shall include one of\r\nthe attached disclosure statements, according to the particular policy type\r\ninvolved, on the application or together with the application. The disclosure\r\nstatement must be in substantially the same form and in no less than\r\ntwelve-point type. For purposes of this section, "form" means the\r\nlanguage, format, type size, type proportional spacing, bold character, line\r\nspacing, and usage of boxes around text.

\r\n\r\n

3. State\r\nand federal law prohibits insurers from selling a Medicare supplement policy to\r\na person that already has a Medicare supplement policy except as a replacement.

\r\n\r\n

4. Property/casualty\r\nand life insurance policies are not considered health insurance.

\r\n\r\n

5. Disability\r\nincome policies are not considered to provide benefits that duplicate Medicare.

\r\n\r\n

6. Long-term\r\ncare insurance policies that coordinate with Medicare and other health\r\ninsurance are not considered to provide benefits that duplicate Medicare.

\r\n\r\n

7. The\r\nfederal law does not pre-empt state laws that are more stringent than the\r\nfederal requirements.

\r\n\r\n

8. The\r\nfederal law does not pre-empt existing state form filing requirements.

\r\n\r\n

9. Section\r\n1882 of the federal Social Security Act was amended in subsection (d)(3)(A) to\r\nallow for alternative disclosure statements. The disclosure statements already\r\nin Appendix C remain. Carriers may use either disclosure statement with the\r\nrequisite insurance product. However, carriers should use either the original\r\ndisclosure statements or the alternative disclosure statements and not use both\r\nsimultaneously.

\r\n\r\n\r\n\r\n\r\n

[For policies that\r\nprovide benefits for expenses incurred for an accidental injury only.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\nprovides limited benefits, if you meet the policy conditions, for hospital or\r\nmedical expenses that result from accidental injury. It does not pay your\r\nMedicare deductibles or coinsurance and is not a substitute for Medicare\r\nSupplement insurance.

\r\n\r\n

This insurance\r\nduplicates Medicare benefits when it pays:

\r\n\r\n

· \r\nhospital\r\nor medical expenses up to the maximum stated in the policy

\r\n\r\n

Medicare generally\r\npays for most or all of these expenses.

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items and services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n\r\n\r\n\r\n

[For\r\npolicies that provide benefits for specified limited services.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\nprovides limited benefits, if you meet the policy conditions, for expenses\r\nrelating to the specific services listed in the policy. It does not pay your\r\nMedicare deductibles or coinsurance and is not a substitute for Medicare\r\nSupplement insurance.

\r\n\r\n

This insurance\r\nduplicates Medicare benefits when:

\r\n\r\n

· \r\nany\r\nof the services covered by the policy are also covered by Medicare

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items and services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n\r\n\r\n\r\n

[For policies that\r\nreimburse expenses incurred for specified disease(s) or other specified\r\nimpairment(s). This includes expense-incurred cancer, specified disease and\r\nother types of health insurance policies that limit reimbursement to named\r\nmedical conditions.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\nprovides limited benefits, if you meet the policy conditions, for hospital or\r\nmedical expenses only when you are treated for one of the specific diseases or\r\nhealth conditions listed in the policy. It does not pay your Medicare\r\ndeductibles or coinsurance and is not a substitute for Medicare Supplement\r\ninsurance.

\r\n\r\n

This insurance\r\nduplicates Medicare benefits when it pays:

\r\n\r\n

· \r\nhospital\r\nor medical expenses up to the maximum stated in the policy

\r\n\r\n

Medicare generally\r\npays for most or all of these expenses.

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\nhospice

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items and services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n\r\n\r\n\r\n

[For policies that\r\npay fixed dollar amounts for specified disease(s) or other specified\r\nimpairment(s). This includes cancer, specified disease, and other health\r\ninsurance policies that pay a scheduled benefit or specific payment based on\r\ndiagnosis of the conditions named in the policy.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\npays a fixed amount, regardless of your expenses, if you meet the policy\r\nconditions, for one of the specific diseases or health conditions named in the\r\npolicy. It does not pay your Medicare deductibles or coinsurance and is not a\r\nsubstitute for Medicare Supplement insurance.

\r\n\r\n

This insurance\r\nduplicates Medicare benefits because Medicare generally pays for most of the\r\nexpenses for the diagnosis and treatment of the specific conditions or\r\ndiagnoses named in the policy.

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\nhospice

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items and services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n\r\n\r\n\r\n

[For indemnity\r\npolicies and other policies that pay a fixed dollar amount per day, excluding\r\nlong-term care policies.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\npays a fixed dollar amount, regardless of your expenses, for each day you meet\r\nthe policy conditions. It does not pay your Medicare deductibles or\r\ncoinsurance and is not a substitute for Medicare Supplement insurance.

\r\n\r\n

This insurance duplicates\r\nMedicare benefits when:

\r\n\r\n

· \r\nany\r\nexpenses or services covered by the policy are also covered by Medicare

\r\n\r\n

Medicare generally\r\npays for most or all of these expenses.

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\nhospice

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items and services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n\r\n\r\n\r\n

[For policies that\r\nprovide benefits for both an expense-incurred and fixed indemnity basis.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\npays limited reimbursement for expenses if you meet the conditions listed in\r\nthe policy. It also pays a fixed amount, regardless of your expenses, if you\r\nmeet other policy conditions. It does not pay your Medicare deductibles or\r\ncoinsurance and is not a substitute for Medicare Supplement insurance.

\r\n\r\n

This\r\ninsurance duplicates Medicare benefits when:

\r\n\r\n

· \r\nany\r\nexpenses or services covered by the policy are also covered by Medicare; or

\r\n\r\n

· \r\nit\r\npays the fixed dollar amount stated in the policy and Medicare covers the same\r\nevent

\r\n\r\n

Medicare generally\r\npays for most or all of these expenses.

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\nhospice\r\ncare

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items & services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n\r\n\r\n\r\n

[For other health\r\ninsurance policies not specifically identified in the previous statements.]

\r\n\r\n

IMPORTANT\r\nNOTICE TO PERSONS ON MEDICARE

\r\n\r\n

THIS\r\nINSURANCE DUPLICATES SOME MEDICARE BENEFITS

\r\n\r\n

This is not\r\nMedicare Supplement Insurance

\r\n\r\n

This insurance\r\nprovides limited benefits if you meet the conditions listed in the policy. It\r\ndoes not pay your Medicare deductibles or coinsurance and is not a substitute\r\nfor Medicare Supplement insurance.

\r\n\r\n

This insurance\r\nduplicates Medicare benefits when it pays:

\r\n\r\n

· \r\nthe\r\nbenefits stated in the policy and coverage for the same event is provided by\r\nMedicare

\r\n\r\n

Medicare generally\r\npays for most or all of these expenses.

\r\n\r\n

Medicare pays\r\nextensive benefits for medically necessary services regardless of the reason\r\nyou need them. These include:

\r\n\r\n

· \r\nhospitalization

\r\n\r\n

· \r\nphysician\r\nservices

\r\n\r\n

· \r\nhospice

\r\n\r\n

· \r\n[outpatient\r\nprescription drugs if you are enrolled in Medicare Part D]

\r\n\r\n

· \r\nother\r\napproved items and services

\r\n\r\n

Before\r\nYou Buy This Insurance

\r\n\r\n

l Check the\r\ncoverage in all health insurance policies you already have.

\r\n\r\n

l For more\r\ninformation about Medicare and Medicare Supplement insurance, review the Guide\r\nto Health Insurance for People with Medicare, available from the insurance\r\ncompany.

\r\n\r\n

l For help in\r\nunderstanding your health insurance, contact your state insurance department or\r\nstate [health] insurance [assistance] program [SHIP].

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

CHAPTER 20:06:13

\r\n\r\n\r\n

MEDICARE\r\nSUPPLEMENT INSURANCE

\r\n\r\n\r\n\r\n

Section

\r\n\r\n

20:06:13:01 Repealed.

\r\n\r\n

20:06:13:02 Definitions.

\r\n\r\n

20:06:13:02.01 Requirements\r\nfor definition of "accident" and similar words in policies.

\r\n\r\n

20:06:13:02.02 Requirements for definitions in policies.

\r\n\r\n

20:06:13:03 Applicability.

\r\n\r\n

20:06:13:04 Repealed.

\r\n\r\n

20:06:13:05 Repealed.

\r\n\r\n

20:06:13:06 Repealed.

\r\n\r\n

20:06:13:07 Repealed.

\r\n\r\n

20:06:13:08 Repealed.

\r\n\r\n

20:06:13:09 Repealed.

\r\n\r\n

20:06:13:10 Repealed.

\r\n\r\n

20:06:13:11 Repealed.

\r\n\r\n

20:06:13:12 Repealed.

\r\n\r\n

20:06:13:13 Repealed.

\r\n\r\n

20:06:13:14 Eligible expenses under Medicare.

\r\n\r\n

20:06:13:14.01 Repealed.

\r\n\r\n

20:06:13:15 Repealed.

\r\n\r\n

20:06:13:16 Waiver of coverage not allowed.

\r\n\r\n

20:06:13:17 Applicability of benefit standards.

\r\n\r\n

20:06:13:17.01 Repealed.

\r\n\r\n

20:06:13:17.02 General\r\nstandards for 1990 standardized Medicare supplement benefit plans.

\r\n\r\n

20:06:13:17.03 Standards\r\nfor basic core benefits for 1990 standardized Medicare supplement benefit\r\nplans.

\r\n\r\n

20:06:13:17.04 Standards\r\nfor additional benefits for 1990 standardized Medicare supplement benefit\r\nplans.

\r\n\r\n

20:06:13:17.05 Requirements for standard Medicare\r\nsupplement benefit plans.

\r\n\r\n

20:06:13:17.06 Make-up of standardized benefit plans.

\r\n\r\n

20:06:13:17.07 Suspension\r\nof coverage during period of eligibility for Medicaid.

\r\n\r\n

20:06:13:17.08 Reinstitution\r\nof coverage following loss of eligibility for Medicaid.

\r\n\r\n

20:06:13:17.09 Suspension requested by policyholder.

\r\n\r\n

20:06:13:17.10 Prescription drug benefits under Medicare\r\nsupplement plans.

\r\n\r\n

20:06:13:17.11 General\r\nstandards for standardized Medicare supplement benefit plan -- Issued for\r\ndelivery after May 31, 2010.

\r\n\r\n

20:06:13:17.12 Standards\r\nfor basic core benefits common to Medicare supplement insurance benefit Plans\r\nA, B, C, D, F, F with High Deductible, G, M, and N.

\r\n\r\n

20:06:13:17.13 Standards for additional benefits.

\r\n\r\n

20:06:13:17.14 Requirements\r\nfor standard Medicare supplement benefit plans -- Plans issued after May 31,\r\n2010.

\r\n\r\n

20:06:13:17.15 Make-up\r\nof standardized benefit plans -- Issued after May 31, 2010.

\r\n\r\n

20:06:13:17.16 Standard\r\nMedicare supplement benefit plans for 2020 standardized Medicare supplement\r\nbenefit plan policies or certificates issued for delivery to individuals newly\r\neligible for Medicare after December 31, 2019.

\r\n\r\n

20:06:13:18 Premium adjustments to match Medicare\r\nbenefit adjustments.

\r\n\r\n

20:06:13:19 Renewability.

\r\n\r\n

20:06:13:20 Extended benefits on termination of\r\ninsurance.

\r\n\r\n

20:06:13:21 Loss ratio standards.

\r\n\r\n

20:06:13:21.01 Refund or credit calculation.

\r\n\r\n

20:06:13:22 Annual filing of premium rates.

\r\n\r\n

20:06:13:22.01 Filing of premium adjustments after\r\nMedicare benefit change.

\r\n\r\n

20:06:13:22.02 Public hearings.

\r\n\r\n

20:06:13:22.03 Filing\r\nand approval of policies and certificates and of premium rates required.

\r\n\r\n

20:06:13:22.04 One policy or certificate form allowed --\r\nExceptions.

\r\n\r\n

20:06:13:22.05 Discontinuance of availability.

\r\n\r\n

20:06:13:22.06 Combination of experience for calculation\r\nof refund or credit.

\r\n\r\n

20:06:13:22.07 New\r\nor innovative benefits -- Policy or certificate form allowed -- Exceptions --\r\nissued after May 31, 2010.

\r\n\r\n

20:06:13:23 Repealed.

\r\n\r\n

20:06:13:24 Disclosure of preexisting conditions.

\r\n\r\n

20:06:13:25 Increased benefits after issue.

\r\n\r\n

20:06:13:26 Separate additional premium disclosure.

\r\n\r\n

20:06:13:27 Buyer's guide.

\r\n\r\n

20:06:13:28 Delivery of buyer's guide.

\r\n\r\n

20:06:13:29 Use of term "Medicare\r\nsupplement."

\r\n\r\n

20:06:13:30 Disclosure\r\nrequirements for policies or subscriber contracts that are not Medicare\r\nsupplement policies.

\r\n\r\n

20:06:13:31 Notice\r\nrequirements for policies or certificates that are not Medicare supplement\r\npolicies.

\r\n\r\n

20:06:13:31.01 Disclosure\r\nrequirements for Medicare supplement policies -- Riders and endorsements.

\r\n\r\n

20:06:13:31.02 "Usual,"\r\n"customary," and "reasonable" requirements prohibited.

\r\n\r\n

20:06:13:31.03 Right of return.

\r\n\r\n

20:06:13:32 Requirements\r\nconcerning application forms and replacement coverage.

\r\n\r\n

20:06:13:32.01 Transferred.

\r\n\r\n

20:06:13:32.02 Disclosure by agent.

\r\n\r\n

20:06:13:33 Repealed.

\r\n\r\n

20:06:13:34 Replacement requirements for direct\r\nresponse insurers.

\r\n\r\n

20:06:13:35 Notice of replacement.

\r\n\r\n

20:06:13:36 Outline of coverage requirements.

\r\n\r\n

20:06:13:37 Delivery of outline of coverage.

\r\n\r\n

20:06:13:38 Revisions of outline of coverage.

\r\n\r\n

20:06:13:39 Repealed.

\r\n\r\n

20:06:13:40 Style and arrangement for outline of\r\ncoverage.

\r\n\r\n

20:06:13:41 Repealed.

\r\n\r\n

20:06:13:42 Repealed.

\r\n\r\n

20:06:13:43 Overinsurance.

\r\n\r\n

20:06:13:43.01 Misrepresentation -- Unfair or deceptive\r\ntrade practices.

\r\n\r\n

20:06:13:43.02 Determination of suitability.

\r\n\r\n

20:06:13:43.03 Medicare\r\nsupplement and Medicare Part C (Medicare Advantage) or Medicare Cost\r\nduplication.

\r\n\r\n

20:06:13:44 Failure to provide required forms.

\r\n\r\n

20:06:13:45 Refund in replacement situations.

\r\n\r\n

20:06:13:46 Coverage replaced within the same\r\ncompany.

\r\n\r\n

20:06:13:47 Insurance replaced by the same agent.

\r\n\r\n

20:06:13:48 Repealed.

\r\n\r\n

20:06:13:49 Requirements for claims payment.

\r\n\r\n

20:06:13:50 Policy classification -- Requirements and\r\nlimitations.

\r\n\r\n

20:06:13:51 Notice of benefit change.

\r\n\r\n

20:06:13:52 Repealed.

\r\n\r\n

20:06:13:53 Duplication of coverage prohibited.

\r\n\r\n

20:06:13:54 Repealed.

\r\n\r\n

20:06:13:55 Exception to reinstitution of coverage.

\r\n\r\n

20:06:13:56 Continuation and conversion rights.

\r\n\r\n

20:06:13:57 Standards for marketing.

\r\n\r\n

20:06:13:58 Marketing practices prohibited.

\r\n\r\n

20:06:13:58.01 Health insurance advertisement rate\r\ndisclosures

\r\n\r\n

20:06:13:58.02 Health insurance advertisement disclosure\r\nstatements.

\r\n\r\n

20:06:13:59 Reporting of multiple policies.

\r\n\r\n

20:06:13:60 Cancellation or nonrenewal of policies.

\r\n\r\n

20:06:13:60.01 Guaranteed renewable with benefit changes.

\r\n\r\n

20:06:13:61 Agent compensation limited.

\r\n\r\n

20:06:13:62 Repealed.

\r\n\r\n

20:06:13:63 Medicare select policies and\r\ncertificates.

\r\n\r\n

20:06:13:64 Medicare select authorization.

\r\n\r\n

20:06:13:65 Approval required for issuance.

\r\n\r\n

20:06:13:66 Filing plan of operation.

\r\n\r\n

20:06:13:67 Filing of changes.

\r\n\r\n

20:06:13:68 Network restrictions.

\r\n\r\n

20:06:13:69 Coverage for unavailable services.

\r\n\r\n

20:06:13:70 Disclosure and outline of coverage\r\nrequirements.

\r\n\r\n

20:06:13:71 Applicant signature required.

\r\n\r\n

20:06:13:72 Complaints and grievances.

\r\n\r\n

20:06:13:73 Required offer of other Medicare\r\nsupplement coverage.

\r\n\r\n

20:06:13:74 Required\r\noffer of replacement coverage without a restricted network provision.

\r\n\r\n

20:06:13:75 Continuation.

\r\n\r\n

20:06:13:76 Compliance with data requests.

\r\n\r\n

20:06:13:77 Creditable coverage.

\r\n\r\n

20:06:13:78 Medicare Advantage plan.

\r\n\r\n

20:06:13:79 Guaranteed issue.

\r\n\r\n

20:06:13:80 Guaranteed issue -- Eligible persons.

\r\n\r\n

20:06:13:80.01 Guaranteed issue time periods.

\r\n\r\n

20:06:13:80.02 Extended medigap access for interrupted\r\ntrial periods.

\r\n\r\n

20:06:13:81 Guaranteed\r\nissue -- Products to which eligible persons are entitled.

\r\n\r\n

20:06:13:82 Guaranteed issue -- Notification provisions.

\r\n\r\n

20:06:13:83 Open enrollment.

\r\n\r\n

20:06:13:84 Open\r\nenrollment required for Medicare eligible individuals regardless of age.

\r\n\r\n

20:06:13:85 Notice requirements.

\r\n\r\n

20:06:13:86 Exchanging of standardized plan.

\r\n\r\n

20:06:13:86.01 Exchanging of standardized plan -- Age rate\r\nschedule.

\r\n\r\n

20:06:13:86.02 Exchanging of standardized plan -- Rating\r\nclass.

\r\n\r\n

20:06:13:86.03 Exchanging\r\nof standardized plan -- Preexisting conditions and incontestability period.

\r\n\r\n

20:06:13:86.04 Exchanging of standardized plan --\r\nOffering.

\r\n\r\n

20:06:13:87 Applicability of genetic information.

\r\n\r\n

20:06:13:88 Definitions applicable to genetic\r\ninformation.

\r\n\r\n

20:06:13:89 Use of genetic information.

\r\n\r\n

20:06:13:90 Request of genetic testing.

\r\n\r\n

20:06:13:91 Requirement of genetic testing.

\r\n\r\n

20:06:13:92 Genetic information -- Underwriting\r\npurposes and enrollment.

\r\n\r\n

Appendix A Medicare Supplement Refund Calculation Forms.

\r\n\r\n

Appendix B Form for Reporting Medicare Supplement Policies.

\r\n\r\n

Appendix C Notice to Applicant Regarding Replacement of Medicare Supplement Insurance.

\r\n\r\n

Appendix D Outline of Medicare Supplement Coverage Policies Plans A through N.

\r\n\r\n

Appendix E Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare.

\r\n\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:01 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:01. Disclosure form required.Repealed.

\r\n\r\n\r\n

Source:\r\n5 SDR 108, effective June 27, 1979; repealed, 8 SDR 174, effective July 1,\r\n1982.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:02 Definitions.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:02. Definitions. Terms defined in SDCL 58-17A-1 have the same meaning when used in this chapter. In addition, terms used in this chapter mean:

\r\n\r\n

(1) "1990 Standardized\r\nMedicare supplement benefit plan," a group or individual policy of\r\nMedicare supplement insurance issued after July 16, 1992, and prior to June 1,\r\n2010, and includes Medicare supplement insurance policies and certificates\r\nrenewed during that period which are not replaced by the issuer at the request\r\nof the insured;

\r\n\r\n

(2) "2010 Standardized\r\nMedicare supplement benefit plan," a group or individual policy of\r\nMedicare supplement insurance issued after May 31, 2010;

\r\n\r\n

(3) "Bankruptcy,"\r\nwhen a Medicare Advantage organization that is not an issuer has filed, or has\r\nhad filed against it, a petition for declaration of bankruptcy and has ceased\r\ndoing business in the state;

\r\n\r\n

(4) "Benefit\r\nperiod" or "Medicare benefit period," as defined in the Medicare\r\nprogram, 42 U.S.C. § 1395 et seq, as in effect on\r\nJuly 1, 1992;

\r\n\r\n

(5) "Buyer's\r\nguide," the informational brochure as approved by the director;

\r\n\r\n

(6) "Complaint,"\r\ndissatisfaction expressed by an individual concerning a Medicare select issuer\r\nor its network providers;

\r\n\r\n

(7) "Continuous period\r\nof creditable coverage," the period during which an individual was covered\r\nby creditable coverage, if during the period of the coverage the individual had\r\nno breaks in coverage greater than 63 days;

\r\n\r\n

(8) "Convalescent\r\nnursing home," "extended care facility," or "skilled\r\nnursing facility," as defined in the Medicare program, 42 U.S.C.\r\n§ 1395 et seq, as in effect on July 1, 1992;

\r\n\r\n

(9) "Employee welfare\r\nbenefit plan," a plan, fund, or program of employee benefits as defined in\r\n29 U.S.C. § 1002 (Employee Retirement Income Security Act), as in effect\r\non September 1, 1998;

\r\n\r\n

(10) "Grievance,"\r\ndissatisfaction with the administration, claims practices, or provision of\r\nservices by a Medicare select issuer or its network providers that is expressed\r\nin writing by an individual insured under a Medicare select policy or\r\ncertificate;

\r\n\r\n

(11) "Health care\r\nexpenses," expenses of a health maintenance organization associated with\r\nthe delivery of health care services, and which are analogous to the incurred\r\nlosses of insurers;

\r\n\r\n

(12) "Hospital,"\r\nas defined in the Medicare program, 42 U.S.C. § 1395 et\r\nseq, as in effect on July 1, 1992;

\r\n\r\n

(13) "Insolvency,"\r\nwhen an issuer, licensed to transact the business of insurance in this state,\r\nhas had a final order of liquidation entered against it with a finding of\r\ninsolvency by a court of competent jurisdiction in the issuer's state of\r\ndomicile;

\r\n\r\n

(14) "Medicare\r\nAdvantage plan," a plan of coverage for health benefits under Medicare Part C\r\nas defined in the Medicare program, 42 U.S.C. § 1395 et seq and includes:

\r\n\r\n

(a) Coordinated care\r\nplans that provide health care services, including health maintenance\r\norganization plans, plans offered by provider-sponsored organizations, and\r\npreferred provider organization plans;

\r\n\r\n

(b) Medical savings\r\naccount plans coupled with a contribution into a Medicare Advantage plan\r\nmedical savings account; and

\r\n\r\n

(15) "Medicare select\r\nissuer," an issuer offering or seeking to offer a Medicare select policy or certificate;

\r\n\r\n

(16) "Medicare select policy"\r\nor "Medicare select certificate," a Medicare supplement\r\npolicy or a Medicare supplement certificate that contains restricted network\r\nprovisions;

\r\n\r\n

(17) "NAIC,"\r\nNational Association of Insurance Commissioners;

\r\n\r\n

(18) "Network\r\nprovider," a provider of health care or a group of providers of health\r\ncare which has entered into a written agreement with the issuer to provide\r\nbenefits insured under a Medicare select policy;

\r\n\r\n

(19) "Physician,"\r\nmay not be defined more restrictively than as defined in the Medicare program;

\r\n\r\n

(20) "Pre-standardized\r\nMedicare supplement benefit plan," a group or individual policy of\r\nMedicare supplement insurance issued prior to July 17, 1992;

\r\n\r\n

(21) "Restricted\r\nnetwork provision," any provision which conditions the payment of\r\nbenefits, in whole or in part, on the use of network providers;

\r\n\r\n

(22) "Secretary of\r\nHealth and Human Services," the secretary of the United States Department\r\nof Health and Human Services;

\r\n\r\n

(23) "Service\r\narea," the geographic area within which an issuer is authorized to offer a\r\nMedicare select policy;

\r\n\r\n

(24) "Sickness,"\r\nillness or disease of an insured person which first manifests\r\nitself after the effective date of insurance and while the insurance is\r\nin force;

\r\n\r\n

(25) "Type," an\r\nindividual policy or a group policy;

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 16 SDR 174, effective May 2, 1990;\r\n18 SDR 225, effective July 17, 1992; 22 SDR 107, effective February 18, 1996;\r\n23 SDR 236, effective July 13, 1997; 25 SDR 44, effective September 30, 1998;\r\n26 SDR 26, effective September 1, 1999; 27 SDR 53, 27 SDR 54, effective\r\nDecember 4, 2000; 28 SDR 157, effective May 19, 2002; 31 SDR 214, effective\r\nJuly 6, 2005; 35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(9).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(9).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:02.01 Requirements for definition of \"accident\" and similar words in policies.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:02.01. Requirements for definition of\r\n"accident" and similar words in policies. "Accidental\r\ninjury" or "accidental means" shall be defined in a Medicare\r\nsupplement policy by employing results language and may not include words which\r\nestablish an accidental means test or use words such as "external,"\r\n"violent," or "visible wounds" or similar words of\r\ndescription or characterization.

\r\n\r\n\r\n

The definition may not be more\r\nrestrictive than the following "Injury or injuries for which benefits are\r\nprovided" means accidental bodily injury sustained by the insured person\r\nwhich is the direct result of an accident, which is independent of disease or\r\nbodily infirmity or any other cause, and which occurs while insurance coverage\r\nis in force.

\r\n\r\n\r\n

The definition may provide that\r\ninjuries do not include injuries for which benefits are provided or available\r\nunder any workers' compensation, employer's liability, or similar law or any\r\nmotor vehicle no-fault plan, unless prohibited by law.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:02.02 Requirements for definitions in policies.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:02.02. Requirements for definitions in policies. No\r\npolicy or certificate may be advertised, solicited, or issued for delivery in\r\nthis state as a Medicare supplement policy or certificate unless the policy or\r\ncertificate contains definitions or terms which conform to SDCL chapter 58-17A and this chapter.

\r\n\r\n\r\n

A hospital may be defined in relation\r\nto its status, facilities, and available services or to reflect its\r\naccreditation by the Joint Commission on Accreditation of Hospitals, but not\r\nmore restrictively than as in the Medicare program, 42 U.S.C. § 1395 et\r\nseq, as in effect on July 1, 1992.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:03 Applicability.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:03. Applicability. This chapter applies to all\r\nMedicare supplement policies advertised, solicited, delivered, or issued in\r\nthis state, to all Medicare supplement certificates issued under group Medicare\r\nsupplement policies, contracts issued for delivery in this state, nonprofit\r\nMedicare supplement plans, health maintenance organization contracts, and\r\nMedicare supplement coverage sold by fraternals. This chapter also applies to\r\npolicies and certificates which are not Medicare supplements but are sold to\r\npeople eligible for Medicare. This chapter does not apply to any policy\r\nexempted by SDCL 58-17A-1.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 23 SDR 236, effective July 13, 1997; 31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:04 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:04. Allowed restrictions on coverage of accidents.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; repealed, 18 SDR 225, effective\r\nJuly 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:05 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:05. Effects of other insurance and coverage of\r\naccidents.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 18 SDR 225, effective July 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:06 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:06. Restrictions for accidents while employed.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 16 SDR 174, effective May 2, 1990.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:07 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:07. Denial of benefits to persons in skilled nursing\r\nfacilities prohibited.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; repealed, 18 SDR 225, effective\r\nJuly 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:08 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:08. Skilled nursing facility -- Exclusions.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 18 SDR 225, effective July 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:09 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:09. Hospital reimbursement by nonprofit plans.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 18 SDR 225, effective July 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:10 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:10. Mental or emotional disorders -- Limitations and\r\nexclusions.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; repealed, 18 SDR 225, effective\r\nJuly 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:11 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:11. Nurse -- Description of classes.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 18 SDR 225, effective July 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:12 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:12. Coverage of sickness -- Allowed restrictions.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 15 SDR 143, effective March 29, 1989.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:13 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:13. Coverage\r\nof sickness -- Other insurance. Repealed.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 36 SDR 209, effective July 1, 2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:14 Eligible expenses under Medicare.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:14. Eligible expenses under Medicare. Eligible\r\nexpenses under Medicare means medical expenses that are covered by Medicare to\r\nthe extent recognized as reasonable and customary by Medicare. Payments,\r\nbenefits, benefit periods, medical necessity, policy limitations, or exclusions\r\nmay not be more restrictive than as used by Medicare.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 16 SDR 174, effective May 2, 1990.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:14.01 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:14.01. Health care expenses defined -- Exclusions.Repealed.

\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989; repealed, 31 SDR 214, effective July 6,\r\n2005.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:15 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:15. Permitted\r\npolicy limitations and exclusions. Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 18 SDR 225, effective July 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:16 Waiver of coverage not allowed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:16. Waiver\r\nof coverage not allowed. No Medicare supplement policy may use a waiver to\r\nexclude, limit, or reduce benefits for a specifically named or described\r\npreexisting sickness or physical condition.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17 Applicability of benefit standards.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17. Applicability of benefit standards. The\r\nfollowing benefit standards described in §§ 20:06:13:17.02 and\r\n20:06:13:17.03 are applicable to all Medicare supplement policies or\r\ncertificates delivered or issued for delivery in this state after July 16,\r\n1992, and prior to June 1, 2010, and no policy or certificate may be\r\nadvertised, solicited, delivered, or issued for delivery in this state as a\r\nMedicare supplement policy or certificate unless it complies with these benefit\r\nstandards.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 16 SDR 174, effective May 2, 1990;\r\nstandards transferred to § 20:06:13:17.02, 18 SDR 225, effective July 17,\r\n1992; 35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.01 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990; repealed, 35 SDR 183, effective February 2,\r\n2009.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.02 General standards for 1990 standardized Medicare supplement benefit plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.02. General standards for 1990 standardized Medicare\r\nsupplement benefit plans. The following standards apply to Medicare\r\nsupplement policies issued for delivery after July 16, 1992, and prior to June\r\n1, 2010, and certificates and are in addition to all\r\nother requirements of this chapter:

\r\n\r\n

(1) Indemnity for losses\r\nresulting from sickness must be on the same basis as losses resulting from an\r\naccident;

\r\n\r\n

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

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 16 SDR 174, effective May 2, 1990;\r\ntransferred from §\r\n20:16:13:17, 18 SDR 225, effective July 17, 1992; 35 SDR\r\n183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.03 Standards for basic core benefits for 1990 standardized Medicare supplemen plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.03. Standards for basic core benefits for 1990\r\nstandardized Medicare supplement benefit plans. Each insurer shall make\r\navailable a policy or certificate including only the following basic core\r\npackage of benefits to each prospective insured. In addition to the basic core\r\npackage, an issuer may make available to prospective insureds any of the other\r\nMedicare supplement insurance plans as provided in §§ 20:06:13:17.05 and\r\n20:06:13:17.06. The additional plans may not be offered in lieu of the basic\r\ncore plan. The basic core benefits required for all benefit plans issued for\r\ndelivery after July 16, 1992, and prior to June 1, 2010, are as follows:

\r\n\r\n

(1) Coverage of Part A\r\nMedicare eligible expenses for hospitalization to the extent not covered by Medicare\r\nfrom the 61st day to the 90th day, inclusive, in any Medicare benefit period;

\r\n\r\n

(2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to\r\nthe extent not covered by Medicare for each Medicare lifetime inpatient reserve\r\nday used;

\r\n\r\n

(3) Upon exhaustion of the\r\nMedicare hospital inpatient coverage, including the lifetime reserve days,\r\ncoverage of 100 percent of the Medicare Part A eligible expenses for\r\nhospitalization paid at the applicable prospective payment system (PPS) rate,\r\nor other appropriate Medicare standard of payment, subject to a lifetime\r\nmaximum benefit of an additional 365 days. The provider shall accept the\r\nissuer's payment as payment in full and may not bill the insured for any\r\nbalance;

\r\n\r\n

(4) Coverage under Medicare\r\nParts A and B for the reasonable cost of the first 3 pints of blood, or\r\nequivalent quantities of packed red blood cells, as defined under federal\r\nregulations, 42 C.F.R. § 409.87(a)(1) (October 1, 1991), unless replaced\r\nin accordance with federal regulations, 42 C.F.R. § 409.87(d);

\r\n\r\n

(5) Coverage for the\r\ncoinsurance amount, or in the case of hospital outpatient department services\r\npaid under a prospective payment system, the copayment amount, of\r\nMedicare-eligible expenses under Part B regardless of hospital confinement,\r\nsubject to the Medicare Part B deductible, 42 U.S.C. § 1395 et seq, as in\r\neffect on July 1, 1999.

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 26 SDR 26, effective September 1, 1999; 28\r\nSDR 157, effective May 19, 2002; 31 SDR 214, effective July 6, 2005; 35 SDR\r\n183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.04 Standards for additional benefits for 1990 standardized Medicare supplement plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(9) Preventive medical care\r\nbenefit: Coverage for the following preventive health services not covered by\r\nMedicare:

\r\n\r\n

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

\r\n\r\n

(b) Preventive\r\nscreening tests or preventive services, the selection and frequency of which is\r\nconsidered medically appropriate by the attending physician.

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(a) For purposes of\r\nthis benefit, the following definitions apply:

\r\n\r\n

(i) "Activities\r\nof daily living," including bathing, dressing, personal hygiene,\r\ntransferring, eating, ambulating, assistance with drugs that are normally\r\nself-administered, and changing bandages or other dressings;

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(b) Coverage\r\nrequirements for this benefit are as follows:

\r\n\r\n

(i) At-home\r\nrecovery services provided must be primarily services which assist in\r\nactivities of daily living;

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(iii) One\r\nthousand six hundred dollars for each calendar year;

\r\n\r\n

(iv) Seven\r\nvisits in any one week;

\r\n\r\n

(v) Care\r\nfurnished on a visiting basis in the insured's home;

\r\n\r\n

(vi) Services\r\nprovided by a care provider as defined in this section;

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(d) Coverage is\r\nexcluded for the following:

\r\n\r\n

(i) Home\r\ncare visits paid for by Medicare or other government programs; and

\r\n\r\n

(ii) Care\r\nprovided by family members, unpaid volunteers, or providers who are not care\r\nproviders;

\r\n\r\n

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

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993; 22\r\nSDR 107, effective February 18, 1996; 26 SDR 26, effective September 1, 1999;\r\n27 SDR 53, 27 SDR 54, effective December 4, 2000; 30 SDR 39, effective\r\nSeptember 28, 2003; 31 SDR 214, effective July 6, 2005; 33 SDR 59, effective\r\nOctober 5, 2006; 34 SDR 271, effective May 6, 2008; 35 SDR 183, effective\r\nFebruary 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

Reference:\r\nCurrent Procedural Coding Expert, 2008, American\r\nMedical Association. Copies may be obtained from Medicode, 5225 Wiley Post Way,\r\nSuite 500, Salt Lake City, UT 84116-2889; 1-800-999-4600; www.ingenixonline.com.\r\nCost: $97.95.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.05 Requirements for standard Medicare supplement benefit plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

Benefit plans must be uniform in\r\nstructure, language, designation, and format to the standard benefit Plans A to\r\nL, inclusive, listed in § 20:06:13:17.06 and must conform to the\r\ndefinitions 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.

\r\n\r\n

An issuer may use, in addition to the\r\nbenefit plan designations required in this section, other designations to the\r\nextent permitted by this chapter.

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005; 35 SDR\r\n183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.06 Make-up of standardized benefit plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.06. Make-up\r\nof standardized benefit plans. The requirements for the make-up of\r\nstandardized Medicare supplement benefit plans issued for delivery after July\r\n16, 1992, and prior to June 1, 2010, A to L, inclusive, are as follows:

\r\n\r\n

(1) Standardized Medicare\r\nsupplement benefit Plan A is limited to the basic core benefits common to all\r\nbenefit plans, as defined in § 20:06:13:17.03;

\r\n\r\n

(2) Standardized Medicare\r\nsupplement benefit Plan B may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible as\r\ndefined in § 20:06:13:17.04;

\r\n\r\n

(3) Standardized Medicare\r\nsupplement benefit Plan C may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, Medicare Part B deductible, and medically necessary\r\nemergency care in a foreign country as defined in § 20:06:13:17.04;

\r\n\r\n

(4) Standardized Medicare\r\nsupplement benefit Plan D may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, medically necessary emergency care in a foreign country,\r\nand the at-home recovery benefit as defined in § 20:06:13:17.04;

\r\n\r\n

(5) Standardized Medicare supplement\r\nbenefit Plan E may include only the following: The core benefit as defined in\r\n§ 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing\r\nfacility care, medically necessary emergency care in a foreign country, and\r\npreventive medical care as defined in § 20:06:13:17.04;

\r\n\r\n

(6) Standardized Medicare\r\nsupplement benefit Plan F may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, the\r\nskilled nursing facility care, the Medicare Part B deductible, 100 percent of\r\nthe Medicare Part B excess charges, and medically necessary emergency care in a\r\nforeign country as defined in § 20:06:13:17.04;

\r\n\r\n

(7) Standardized Medicare\r\nsupplement benefit high deductible Plan F may include only the following: One\r\nhundred percent of covered expenses following the payment of the annual high\r\ndeductible Plan F deductible. The covered expenses include the core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, the Medicare Part B deductible, 100 percent of the\r\nMedicare Part B excess charges, and medically necessary emergency care in a\r\nforeign country as defined in § 20:06:13:17.04. The annual high deductible\r\nPlan F deductible consists of out-of-pocket expenses, other than premiums, for\r\nservices covered by the Medicare supplement Plan F policy, and are in addition\r\nto any other specific benefit deductibles. The annual high deductible Plan F\r\ndeductible is $1500 for 1998 and 1999, and is based on the calendar year. It is\r\nadjusted annually by the secretary to reflect the change in the Consumer Price\r\nIndex for all urban consumers for the twelve-month period ending with August of\r\nthe preceding year, and rounded to the nearest multiple of ten dollars.

\r\n\r\n

(8) Standardized Medicare\r\nsupplement benefit Plan G may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, 80 percent of the Medicare Part B excess charges, medically\r\nnecessary emergency care in a foreign country, and that at-home recovery\r\nbenefit as defined in § 20:06:13:17.04;

\r\n\r\n

(9) Standardized Medicare\r\nsupplement benefit Plan H may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, basic prescription drug benefit, and medically necessary\r\nemergency care in a foreign country as defined § 20:06:13:17.04. The\r\noutpatient prescription drug benefit may not be included in a Medicare\r\nsupplement policy sold after December 31, 2005;

\r\n\r\n

(10) Standardized Medicare\r\nsupplement benefit Plan I may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, 100 percent of the Medicare Part B excess charges, basic\r\nprescription drug benefit, medically necessary emergency care in a foreign\r\ncountry, and at-home recovery benefit as defined in § 20:06:13:17.04. The\r\noutpatient prescription drug benefit may not be included in a Medicare\r\nsupplement policy sold after December 31, 2005;

\r\n\r\n

(11) Standardized Medicare\r\nsupplement benefit Plan J may include only the following: The core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, Medicare Part B deductible, 100 percent of the Medicare\r\nPart B excess charges, extended prescription drug benefit, medically necessary\r\nemergency care in a foreign country, preventive medical care, and at-home\r\nrecovery benefit as defined in § 20:06:13:17.04. The outpatient\r\nprescription drug benefit may not be included in a Medicare supplement policy\r\nsold after December 31, 2005;

\r\n\r\n

(12) Standardized Medicare\r\nsupplement benefit high deductible Plan J consists of only the following: One\r\nhundred percent of covered expenses following the payment of the annual high\r\ndeductible Plan J deductible. The covered expenses include the core benefit as\r\ndefined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled\r\nnursing facility care, Medicare Part B deductible, 100 percent of the Medicare\r\nPart B excess charges, extended outpatient prescription drug benefit, medically\r\nnecessary emergency care in a foreign country, preventive medical care benefit,\r\nand at-home recovery benefit as defined in § 20:06:13:17.04. The annual\r\nhigh deductible Plan J deductible consists of out-of-pocket expenses, other\r\nthan premiums, for services covered by the Medicare supplement Plan J policy,\r\nand is in addition to any other specific benefit deductibles. The annual deductible\r\nis $1500 for 1998 and 1999, and shall be based on a calendar year. It is\r\nadjusted annually by the Secretary of Health and Human Services to reflect the\r\nchange in the Consumer Price Index for all urban consumers for the twelve-month\r\nperiod ending with August of the preceding year, and rounded to the nearest\r\nmultiple of ten dollars. The outpatient prescription drug benefit may not be\r\nincluded in a Medicare supplement policy sold after December 31, 2005;

\r\n\r\n

(13) Standardized Medicare\r\nsupplement benefit Plan K shall consist of the following:

\r\n\r\n

(a) Coverage of 100\r\npercent of the Part A hospital coinsurance amount for each day used from the 61^st\r\nthrough the 90^th day in any Medicare benefit period;

\r\n\r\n

(b) Coverage of 100\r\npercent of the Part A hospital coinsurance amount for each Medicare lifetime\r\ninpatient reserve day used from the 91^st through the 150^th\r\nday in any Medicare benefit period;

\r\n\r\n

(c) Upon exhaustion of\r\nthe Medicare hospital inpatient coverage, including the lifetime reserve days,\r\ncoverage of 100 percent of the Medicare Part A eligible expenses for\r\nhospitalization paid at the applicable prospective payment system (PPS) rate,\r\nor other appropriate Medicare standard of payment, subject to a lifetime\r\nmaximum benefit of an additional 365 days. The provider shall accept the\r\nissuer's payment as payment in full and may not bill the insured for any\r\nbalance;

\r\n\r\n

(d) Medicare Part A\r\ndeductible: Coverage for 50 percent of the Medicare Part A inpatient hospital\r\ndeductible amount per benefit period until the out-of-pocket limitation is met\r\nas described in subdivision (j);

\r\n\r\n

(e) Skilled nursing\r\nfacility care: Coverage for 50 percent of the coinsurance amount for each day\r\nused from the 21^st day through the 100^th day in a\r\nMedicare benefit period for post-hospital skilled nursing facility care\r\neligible under Medicare Part A until the out-of-pocket limitation is met as\r\ndescribed in subdivision (j);

\r\n\r\n

(f) Hospice care:\r\nCoverage for 50 percent of cost sharing for all Part A Medicare eligible\r\nexpenses and respite care until the out-of-pocket limitation is met as\r\ndescribed in subdivision (j);

\r\n\r\n

(g) Coverage for 50\r\npercent, under Medicare Part A or B, or the reasonable cost of the first three\r\npints of blood, or equivalent quantities of packed red blood cells, unless replaced\r\nin accordance with federal regulations until the out-of-pocket limitation is\r\nmet as described in subdivision (j);

\r\n\r\n

(h) Except for\r\ncoverage provided in subdivision (i) below, coverage for 50 percent of the cost\r\nsharing otherwise applicable under Medicare Part B after the policyholder pays\r\nthe Part B deductible until the out-of-pocket limitation is met as described in\r\nsubdivision (j);

\r\n\r\n

(i) Coverage of 100\r\npercent of the cost sharing for Medicare Part B preventative services after the\r\npolicyholder pays the Part B deductible; and

\r\n\r\n

(j) Coverage of 100\r\npercent of all cost sharing under Medicare Parts A and B for the balance of the\r\ncalendar year after the individual has reached the out-of-pocket limitation on\r\nannual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each\r\nyear by the appropriate inflation adjustment specified by the secretary;

\r\n\r\n

(14) Standardized Medicare\r\nsupplement benefit Plan L shall consist of the following:

\r\n\r\n

(a) The benefits\r\ndescribed in subdivisions 20:06:13:17.06(13)(a), (13)(b), (13)(c), and (13)(i);

\r\n\r\n

(b) The benefits\r\ndescribed in subdivisions 20:06:13:17.06(13)(d), (13)(e), (13)(f), (13)(g), and\r\n(13)(h), with 75 percent substituted for 50 percent; and

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993; 25\r\nSDR 44, effective September 30, 1998; 31 SDR 214, effective July 6, 2005; 35\r\nSDR 183, effective February 2, 2009; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(9).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(9).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.07 Suspension of coverage during period of eligibility for Medicaid.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

Cross-Reference:\r\nMedicaid eligibility, art 67:16.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.08 Reinstitution of coverage following loss of eligibility for Medicaid.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

Reinstitution of Medicare supplement\r\ncoverage must comply with the following requirements:

\r\n\r\n

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

\r\n\r\n

(2) The coverage must be\r\nsubstantially equivalent to coverage in effect before the date of suspension.\r\nIf the suspended policy or certificate provided coverage for outpatient\r\nprescription drugs, reinstitution of the policy or certificate for Medicare\r\npart D enrollees shall be without coverage for outpatient prescription drugs\r\nand shall otherwise provide substantially equivalent coverage to the coverage\r\nin effect before the date of suspension; and

\r\n\r\n

(3) The coverage must\r\nprovide for classification of premiums on terms at least as favorable to the\r\npolicyholder or certificateholder as the premium classification terms that\r\nwould have applied to the policyholder or certificateholder had the coverage\r\nnot been suspended. This section applies to 1990 standardized Medicare\r\nsupplement benefit plans as well as 2010 standardized Medicare supplement\r\nbenefit plans.

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005; 35 SDR\r\n183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.09 Suspension requested by policyholder.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

Reinstitution of Medicare supplement\r\ncoverage must comply with the following requirements:

\r\n\r\n

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

\r\n\r\n

(2) The coverage must be\r\nsubstantially equivalent to coverage in effect before the date of suspension.\r\nIf the suspended policy or certificate provided coverage for outpatient\r\nprescription drugs, reinstitution of the policy or certificate for Medicare\r\nPart D enrollees shall be without coverage for outpatient prescription drugs\r\nand shall otherwise provide substantially equivalent coverage to the coverage\r\nin effect before the date of suspension; and

\r\n\r\n

This section applies to 1990\r\nstandardized Medicare supplement benefit plans as well as 2010 standardized\r\nMedicare supplement benefit plans.

\r\n\r\n

Source:\r\n27 SDR 53, effective December 4, 2000; 28 SDR 157, effective May 19, 2002; 31\r\nSDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(18).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(18).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.10 Prescription drug benefits under Medicare supplement plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

(1) A Medicare supplement\r\nplan with benefits for outpatient prescription drugs in existence prior to\r\nJanuary 1, 2006, shall be renewed for current policyholders who do not enroll\r\nin Medicare Part D at the option of the insured subject to §§ 20:06:13:19,\r\n20:06:13:56, 20:06:13:60 and 20:06:13:60.01;

\r\n\r\n

(2) A Medicare supplement\r\nplan with benefits for outpatient prescription drugs may not be issued after\r\nDecember 31, 2005;

\r\n\r\n

(3) After December 31,\r\n2005, a Medicare supplement policy with benefits for outpatient prescription\r\ndrugs may not be renewed after the policyholder enrolls in Medicare Part D\r\nunless:

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

This section applies to 1990\r\nstandardized Medicare supplement benefit plans.

\r\n\r\n

Source:\r\n31 SDR 214, effective July 6, 2005; 35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.11 General standards for standardized Medicare supplement benefit plan -- Issued for delivery after May 31, 2010.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

(1) A Medicare supplement\r\npolicy or certificate may not indemnify against losses resulting from sickness\r\non a different basis than losses resulting from accidents;

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(4) Each Medicare\r\nsupplement policy shall be guaranteed renewable:

\r\n\r\n

(a) The issuer may not\r\ncancel or nonrenew the policy solely on the ground of health status of the\r\nindividual;

\r\n\r\n

(b) The issuer may not\r\ncancel or nonrenew the policy for any reason other than nonpayment of premium\r\nor material misrepresentation;

\r\n\r\n

(c) If the Medicare\r\nsupplement policy is terminated by the group policyholder and is not replaced\r\nas provided in subsection e, the issuer shall offer certificateholders an\r\nindividual Medicare supplement policy which at the option of the\r\ncertificateholder:

\r\n\r\n

(i) Provides\r\nfor continuation of the benefits contained in the group policy; or

\r\n\r\n

(ii) Provides\r\nfor benefits that otherwise meet the requirements of this subsection;

\r\n\r\n

(d) If an individual\r\nis a certificateholder in a group Medicare supplement policy and the individual\r\nterminates membership in the group, the issuer shall:

\r\n\r\n

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

\r\n\r\n

(ii) At the\r\noption of the group policyholder, offer the certificateholder continuation of\r\ncoverage under the group policy;

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 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.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.12. Standards\r\nfor basic core benefits common to Medicare supplement insurance benefit Plans\r\nA, B, C, D, F, F with High Deductible, G, M, and N. Every issuer of\r\nMedicare supplement insurance benefit plans shall make available a policy or\r\ncertificate including only the following basic core package of benefits to each\r\nprospective insured. An issuer may make available to prospective insureds any\r\nof the other Medicare Supplement Insurance Benefit Plans in addition to the\r\nbasic core package, but not in lieu of it. The following benefits must be\r\nincluded in policies or certificates issued for delivery after May 31, 2010:

\r\n\r\n

(1) Coverage of Part A Medicare eligible expenses for hospitalization to the\r\nextent not covered by Medicare from the 61^st day through the 90^th\r\nday in any Medicare benefit period;

\r\n\r\n

(2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to\r\nthe extent not covered by Medicare for each Medicare lifetime inpatient reserve\r\nday used;

\r\n\r\n

(4) Coverage under Medicare\r\nParts A and B for the reasonable cost of the first three pints of blood or\r\nequivalent quantities of packed red blood cells, federal regulations 42 C.F.R\r\n409.87(a)(1) unless replaced in accordance with federal regulations 42 C.F.R.\r\n§ 409.87(d);

\r\n\r\n

(5) Coverage for the\r\ncoinsurance amount, or in the case of hospital outpatient department services\r\npaid under a prospective payment system, the copayment amount, of Medicare\r\neligible expenses under Part B regardless of hospital confinement, subject to\r\nthe Medicare Part B deductible;

\r\n\r\n

(6) Coverage of cost\r\nsharing for all Part A Medicare eligible hospice care\r\nand respite care expenses.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.13 Standards for additional benefits.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

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

\r\n\r\n

(1) Medicare Part A\r\nDeductible: Coverage for 100 percent of the Medicare Part A\r\ninpatient hospital deductible amount per benefit period;

\r\n\r\n

(2) Medicare Part A\r\nDeductible: Coverage for 50 percent of the Medicare Part A\r\ninpatient hospital deductible amount per benefit period;

\r\n\r\n

(3) Skilled Nursing\r\nFacility Care: Coverage for the actual billed charges up to the coinsurance\r\namount from the 21^st day through the 100^th day in a\r\nMedicare benefit period for post-hospital skilled nursing facility care\r\neligible under Medicare Part A;

\r\n\r\n

(4) Medicare Part B\r\nDeductible: Coverage for 100 percent of the Medicare Part B deductible amount\r\nper calendar year regardless of hospital confinement;

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.14 Requirements for standard Medicare supplement benefit plans -- Plans issued after May 31, 2010.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.14. Requirements\r\nfor standard Medicare supplement benefit plans -- Plans issued after May 31,\r\n2010. An issuer shall make available to each prospective policyholder and\r\ncertificateholder a policy form or certificate form containing only the basic\r\ncore benefits, as defined in § 20:06:13:17.12.

\r\n\r\n

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

\r\n\r\n

No groups, packages, or combinations\r\nof Medicare supplement benefits other than those listed in this chapter shall\r\nbe offered for sale in this state.

\r\n\r\n

Benefit plans shall be uniform in\r\nstructure, language, designation, and format to the standard benefit plans\r\nlisted in this section and conform to the definitions in § 20:06:13:02.\r\nEach benefit shall be structured in accordance with the format provided in\r\n§§ 20:06:13:17.12 and 20:06:13:17.13. For purposes of this section,\r\nstructure, language, and format means style, arrangement, and overall content of\r\na benefit.

\r\n\r\n

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

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.15 Make-up of standardized benefit plans -- Issued after May 31, 2010.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.15. Make-up\r\nof standardized benefit plans -- Issued after May 31, 2010. The\r\nrequirements for the make-up of standardized Medicare supplement benefit Plans\r\nA to L, inclusive, are as follows:

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(5) Standardized Medicare\r\nsupplement regular Plan F shall include only the following: The core benefit as\r\ndefined in § 20:06:13:17.12, plus 100 percent of the Medicare Part A\r\ndeductible, the skilled nursing facility care, one hundred percent of the\r\nMedicare Part B deductible, 100 percent of the Medicare Part B excess charges,\r\nand medically necessary emergency care in a foreign country as defined in\r\n§ 20:06:13:17.13;

\r\n\r\n

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

\r\n\r\n

(a) The basic\r\ncore benefit as defined in § 20:06:13:17.12, plus 100 percent of the\r\nMedicare Part A deductible, skilled nursing facility care, 100 percent of the\r\nMedicare Part B deductible, 100 percent of the Medicare Part B excess charges,\r\nand medically necessary emergency care in a foreign country as defined in\r\n§ 20:06:13:17.12(1),(3),(4),(5), and (6);

\r\n\r\n

(b) The annual\r\ndeductible in Plan F with High Deductible shall consist of out-of-pocket\r\nexpenses, other than premiums, for services covered by regular Plan F, and\r\nshall be in addition to any other specific benefit deductibles. The basis for\r\nthe deductible shall be $1,500 and shall be adjusted annually from 1999 by the\r\nSecretary of the U.S. Department of Health and Human Services to reflect the\r\nchange in the Consumer Price Index for all urban consumers for the twelve-month\r\nperiod ending with August of the preceding year, and rounded to the nearest\r\nmultiple of ten dollars;

\r\n\r\n

(7) Standardized\r\nMedicare supplement benefit Plan G shall include only the following: The core\r\nbenefit as defined in § 20:06:13:17.12, plus 100 percent of the Medicare\r\nPart A deductible, skilled nursing facility care, one hundred percent of the\r\nMedicare Part B excess charges, and medically necessary emergency care in a\r\nforeign country as defined in § 20:06:13:17.13. After December\r\n31, 2019, the standardized benefit plans described in § 20:06:13:17.16(4)\r\n(redesignated Plan G High Deductible) may be offered to any individual who was\r\neligible for Medicare after December 31, 2019;

\r\n\r\n

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

\r\n\r\n

(a) Part A\r\nHospital Coinsurance 61^st through 90^th days: Coverage of\r\n100 percent of the Part A hospital coinsurance amount for each day used from\r\nthe 61^st to the 90^th day, inclusive, in any Medicare\r\nbenefit period;

\r\n\r\n

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

\r\n\r\n

(c) Part A Hospitalization\r\nafter Lifetime Reserve Days are exhausted: Upon exhaustion of the Medicare\r\nhospital inpatient coverage, including the lifetime reserve days, coverage of\r\n100 percent of the Medicare Part A eligible expenses for hospitalization paid\r\nat the applicable prospective payment system (PPS) rate, or other appropriate\r\nMedicare standard of payment, subject to a lifetime maximum benefit of an\r\nadditional 365 days. The provider shall accept the issuer's payment as payment\r\nin full and may not bill the insured for any balance;

\r\n\r\n

(d) Medicare\r\nPart A Deductible: Coverage for 50 percent of the Medicare Part A inpatient\r\nhospital deductible amount per benefit period until the out-of-pocket\r\nlimitation is met as described in subsection (j);

\r\n\r\n

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

\r\n\r\n

(f) Hospice\r\nCare: Coverage for 50 percent of cost sharing for all Part A Medicare eligible\r\nexpenses and respite care until the out-of-pocket limitation is met as\r\ndescribed in subsection (j);

\r\n\r\n

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

\r\n\r\n

(h) Part B Cost\r\nSharing: Except for coverage provided in subsection (i), coverage for 50\r\npercent of the cost sharing otherwise applicable under Medicare Part B after\r\nthe policyholder pays the Part B deductible until the out-of-pocket limitation\r\nis met as described in subsection (j);

\r\n\r\n

(i) Part B\r\nPreventive Services: Coverage of 100 percent of the cost sharing for Medicare\r\nPart B preventive services after the policyholder pays the Part B deductible;\r\nand

\r\n\r\n

(j) Cost Sharing\r\nafter Out-of-Pocket Limits: Coverage of 100 percent of all cost sharing under\r\nMedicare Parts A and B for the balance of the calendar year after the individual\r\nhas reached the out-of-pocket limitation on annual expenditures under Medicare\r\nParts A and B or $4000 in 2006, indexed each year by the appropriate inflation\r\nadjustment specified by the Secretary of the U.S. Department of Health and\r\nHuman Services;

\r\n\r\n

(9) Standardized\r\nMedicare supplement Plan L, which mandated by The Medicare Prescription Drug\r\nImprovement and Modernization Act of 2003, and shall include only the\r\nfollowing:

\r\n\r\n

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

\r\n\r\n

(b) The benefit\r\ndescribed in § 20:06:13:17.15(8)(d),(e),(f),(g), and (h), but substituting\r\n75 percent for 50 percent; and

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

(a) The lesser\r\nof $20 or the Medicare Part B coinsurance or copayment for each covered health\r\ncare provider office visit, including visits to medical specialists; and (b)\r\nthe lesser of fifty dollars or the Medicare Part B coinsurance or copayment for\r\neach covered emergency room visit. However, this copayment shall be waived if\r\nthe insured is admitted to any hospital and the emergency visit is subsequently\r\ncovered as a Medicare Part A expense.

\r\n\r\n

Source: 35 SDR 183,\r\neffective February 2, 2009; 36 SDR 209, effective July 1, 2010; 44 SDR 184,\r\neffective June 25, 2018.

\r\n\r\n

General Authority: SDCL 58-17A-2.

\r\n\r\n

Law Implemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:17.16 Standard Medicare supplement benefit plans for 2020 standardized Medicare supplement benefit plan policies or certificates issued for delivery to individuals newly eligible for Medicare after December 31, 2019.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:17.16. Standard\r\nMedicare supplement benefit plans for 2020 standardized\r\nMedicare supplement benefit plan policies or certificates issued for delivery\r\nto individuals newly eligible for Medicare after December 31, 2019. No policy or\r\ncertificate that provides coverage for the Medicare Part B deductible may\r\nbe advertised, solicited, delivered or issued for delivery in this state as a\r\nMedicare\r\nsupplement\r\npolicy or certificate to individuals newly eligible for Medicare after December\r\n31, 2019.

\r\n\r\n

An individual who,\r\nafter December 31, 2019, becomes newly eligible for Medicare upon reaching the\r\nage of 65, becomes newly entitled to benefits under Medicare Part A pursuant to\r\nsection 226(b) or 226A of the Social Security Act, or becomes newly eligible\r\nfor benefits under section 226(a) of the Social Security Act may only be\r\noffered, delivered, or issued for delivery in this state a Medicare supplement\r\npolicy or certificate that complies with the standards and requirements of §§ 20:06:13:17.14 and\r\n20:06:13:17.15, with the following exceptions:

\r\n\r\n

(1) Standardized\r\nMedicare supplement benefit Plan C is redesignated as Plan D and must provide\r\nthe benefits contained in subdivision 20:06:13:17:15(3) except coverage for any\r\nportion of the Medicare Part B deductible;

\r\n\r\n

(2) Standardized\r\nMedicare supplement benefit Plan F is redesignated as Plan G and must provide\r\nthe benefits contained in subdivision 20:06:13:17:15(5) except coverage for any\r\nportion of the Medicare Part B deductible;

\r\n\r\n

(3) Standardized\r\nMedicare supplement benefit plans C, F, and F with High Deductible may not be\r\noffered to individuals newly eligible for Medicare after December 31, 2019;

\r\n\r\n

(4) Standardized\r\nMedicare supplement benefit Plan F With High Deductible is redesignated as Plan\r\nG With High Deductible and must provide the benefits contained in subdivision\r\n20:06:13:17:15(6), except coverage for the Medicare Part B deductible, and the\r\nMedicare Part B deductible paid by the beneficiary must be considered an\r\nout-of-pocket expense in meeting the annual high deductible; and

\r\n\r\n

(5) The reference to\r\nPlans C or F contained in § 20:06:13:17.14 is a reference to Plans D or G.

\r\n\r\n

After\r\nDecember 31, 2019, the standardized benefit plans described above may be\r\noffered to any individual who was eligible for Medicare on or prior to January\r\n1, 2020, in addition to the standardized plans described in\r\n§ 20:06:13:17.15.

\r\n\r\n

Source:\r\n44\r\nSDR 184, effective June 25, 2018; 46 SDR 147, effective July 2, 2020.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:18 Premium adjustments to match Medicare benefit adjustments.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:18. Premium adjustments to match Medicare benefit\r\nadjustments. Premiums may be adjusted to correspond to changes in Medicare\r\ndeductible and copayment percentage factors. Before a rate adjustment can be\r\nimplemented, the rate adjustment must have prior approval from the division.\r\nApproval will be based on the percentage of increase requested, prior\r\nexperience, and an explanation of how the percentage of increase was derived.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:19 Renewability.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:19. Renewability. An insurer may not reserve the\r\nright not to renew a policy. A noncancellable, guaranteed renewable, or\r\nnoncancellable and guaranteed renewable policy may not:

\r\n\r\n

(1) Terminate coverage of a\r\nspouse solely because of the occurrence of an event specified for termination\r\nof coverage of the insured, other than the nonpayment of premium; or

\r\n\r\n

(2) Be cancelled or\r\nnonrenewed by the insurer solely on the grounds of deterioration of health.

\r\n\r\n

If a Medicare supplement policy\r\neliminates an outpatient prescription drug benefit as a result of requirements\r\nimposed by the Medicare Prescription Drug, Improvement, and Modernization Act\r\nof 2003, the modified policy shall be deemed to satisfy the guaranteed renewal\r\nrequirements of this section. This section applies to 1990 standardized\r\nMedicare supplement benefit plans as well as 2010 standardized Medicare\r\nsupplement benefit plans.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 17 SDR 58, effective October 29, 1990; 31 SDR 214, effective July 6,\r\n2005; 35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:20 Extended benefits on termination of insurance.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:20. Extended benefits on termination of insurance.\r\nThe payment of benefits shall be continued beyond the termination of insurance\r\nif a loss began while the policy was in force and continues past termination.\r\nThe extension of benefits beyond termination may be predicated on continuous\r\ntotal disability of the insured. Limits on the duration of the policy benefit\r\nperiod or maximum benefit amounts, if any, may be applied to coverage past\r\ntermination. Receipt of Medicare part D benefits may not be considered in\r\ndetermining a continuous loss.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 17 SDR 58, effective October 29, 1990; 31 SDR 214, effective July 6,\r\n2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:21 Loss ratio standards.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:21. Loss\r\nratio standards. A Medicare supplement policy form or certificate form may\r\nnot be delivered or issued for delivery in this state unless the policy form or\r\ncertificate form can be expected, as estimated for the entire period for which\r\nrates are computed to provide coverage, to return the following to\r\npolicyholders and certificateholders in the form of aggregate benefits provided\r\nunder the policy form or certificate form, not including anticipated refunds or\r\ncredits, at least 75 percent of the aggregate amount of premiums earned in the\r\ncase of group policies or at least 65 percent of the aggregate amount of\r\npremiums earned in the case of individual policies.

\r\n\r\n

The ratios in this section shall be\r\nbased on incurred claims experience or incurred health care expenses if\r\ncoverage is provided by a health maintenance organization on a service rather\r\nthan reimbursement basis and on earned premiums for the period in accordance\r\nwith accepted actuarial principles and practices. Incurred health care expenses\r\nwhere coverage is provided by a health maintenance organization may not include\r\nhome office and overhead costs; advertising costs; commissions and other\r\nacquisition costs; taxes; capital costs; administrative costs; and claim\r\nprocessing costs.

\r\n\r\n

All filings of rates and rating\r\nschedules must demonstrate that expected claims in relation to premiums comply\r\nwith the requirements of this section when combined with actual experience to\r\ndate. Filings of rate revisions must also demonstrate that the anticipated loss\r\nratio over the entire future period for which the revised rates are computed to\r\nprovide coverage can be expected to meet the applicable loss ratio standards.\r\nPolicies issued as a result of solicitations of individuals through the mail or\r\nby mass media advertising, including both print and broadcast advertising,\r\nshall be deemed to be individual policies.

\r\n\r\n

For policies issued before July 17,\r\n1992, expected claims in relation to premiums must meet the following\r\nrequirements:

\r\n\r\n

(1) The originally filed\r\nanticipated loss ratio when combined with the actual experience since\r\ninception;

\r\n\r\n

(2) The applicable loss\r\nratio requirement from the first paragraph of this section, when combined with\r\nactual experience to date, beginning with the effective date of this amendment;\r\nand

\r\n\r\n

(3) The applicable loss\r\nratio requirement from the first paragraph of this section over the entire\r\nfuture period for which the rates are computed to provide coverage.

\r\n\r\n

In meeting these requirements and for\r\nthe purpose of attaining credibility, an insurer may combine experience under\r\npolicy forms which provide substantially similar coverage. Once a combined form\r\nis adopted, the insurer may not separate the experience except with the\r\napproval of the director.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27,\r\n1993; 22 SDR 107, effective February 18, 1996; 25 SDR 13, effective August 9,\r\n1998; 26 SDR 26, effective September 1, 1999; 27 SDR 53, 27 SDR 54, effective\r\nDecember 4, 2000; 30 SDR 39, effective September 28, 2003; 31 SDR 214,\r\neffective July 6, 2005; 33 SDR 59, effective October 5, 2006; 36 SDR 209,\r\neffective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:21.01 Refund or credit calculation.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:21.01. Refund or\r\ncredit calculation. An issuer shall collect and file with the director by\r\nMay 31 of each year the data required on the forms in Appendix A at the end of\r\nthis chapter for each type in a standard Medicare supplement benefit plan.

\r\n\r\n

If,\r\non the basis of the experience as reported, the benchmark ratio since inception\r\n(ratio 1) exceeds the adjusted experience ratio since inception (ratio 3), a\r\nrefund or credit calculation is required. The refund or credit calculation\r\nshall be done on a statewide basis for each type in a standard Medicare\r\nsupplement benefit plan. For purposes of the refund or credit calculation,\r\nexperience on policies issued with the reporting year shall be excluded.

\r\n\r\n

For\r\npurposes of this section, for policies or certificates issued before July 17,\r\n1992, the issuer shall make the refund or credit calculation separately for all\r\nindividual policies combined, including all group policies subject to an\r\nindividual loss ratio standard when issued, and all other group policies combined\r\nfor experience after the effective date of this amendment. The first such\r\nreport affected by this paragraph is due May 31, 1998.

\r\n\r\n

The\r\nissuer may refund or credit only when the benchmark loss ratio exceeds the\r\nadjusted experience loss ratio and the amount to be refunded or credited\r\nexceeds the sum of $5. The refund shall include interest from the end of the\r\ncalendar year to the date of the refund or credit at a rate specified by the\r\nsecretary of health and human services, but it may not be less than the average\r\nrate of interest for 13-week treasury notes on the date of refund or credit\r\ncalculation as established by the federal reserve board and published in the\r\nWall Street Journal. The issuer shall make a refund or credit against premiums\r\ndue by September 30 following the experience year upon which the refund or\r\ncredit is based.

\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 22 SDR 107, effective February 18, 1996;\r\n42 SDR 52, effective October 13, 2015.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n

Cross-Reference:\r\nCombination of experience for calculation of refund or credit,\r\n§ 20:06:13:22.06.

\r\n\r\n

Notes:\r\nAs of the effective date of this rule, the secretary of the U.S. Department of\r\nHealth and Human Services had not specified an interest rate.

\r\n\r\n

Forms\r\nmay be obtained from the South Dakota Division of Insurance, 124 South Euclid\r\nAvenue, 2^nd Floor, Pierre, SD 57501, (605) 773-3563, free of charge.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22 Annual filing of premium rates.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22. Annual filing of premium rates. An issuer of\r\nMedicare supplement policies and certificates issued either before or after the\r\neffective date of this rule must file its rates, rating schedule, and\r\nsupporting documentation annually, including ratios of incurred losses to\r\nearned premiums by policy duration, for approval by the director in accordance\r\nwith SDCL 58-17A-4, 58-17-4.1, 58-17-4.2, ARSD chapter 20:06:22, and this chapter. The supporting documentation must also demonstrate in accordance with actuarial standards of practice using reasonable assumptions that the applicable loss ratio standards can be expected to be met over the entire period for which rates are computed. The demonstration shall exclude active life reserves. An expected third-year loss ratio which is greater than or equal to the applicable percentage must be demonstrated for policies or certificates in force less than 3 years.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 18 SDR 225, effective July 17,\r\n1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.01 Filing of premium adjustments after Medicare benefit change.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.01. Filing of premium adjustments after Medicare\r\nbenefit change. As soon as practicable, but prior to the effective date of\r\nenhancements in Medicare benefits, each issuer of Medicare supplement policies\r\nor certificates in this state shall file the following with the director, in\r\naccordance with the applicable provisions of SDCL 58-17A-4, 58-17-4.1, 58-17-4.2, ARSD chapter 20:06:22, and this chapter:

\r\n\r\n\r\n

(1) The premium adjustments\r\nnecessary to produce loss ratios as anticipated for the current premium for the\r\napplicable policies or certificates. Supporting documents necessary to justify\r\nthe adjustment must accompany the filing.

\r\n\r\n\r\n

An issuer shall make the premium\r\nadjustments necessary to produce an expected loss ratio under the policy or\r\ncertificate that will conform with minimum loss ratio standards for Medicare\r\nsupplement policies in § 20:06:13:21 and which are expected to result in a\r\nloss ratio at least as great as that originally anticipated in the rates used\r\nto produce current premiums by the issuer for the Medicare supplement policies\r\nor certificates. No premium adjustment which would modify the loss ratio\r\nexperience under the policy other than the adjustments described in this\r\nsection may be made to a policy at any time other than upon its renewal date or\r\nanniversary date.

\r\n\r\n\r\n

If an issuer fails to make premium\r\nadjustments acceptable to the director, the director may order premium\r\nadjustments, refunds, or premium credits considered necessary to achieve the\r\nloss ratio required by this section;

\r\n\r\n\r\n

(2) Any riders,\r\nendorsements, or policy forms needed to accomplish the Medicare supplement\r\npolicy or certificate modifications necessary to eliminate benefit duplications\r\nwith Medicare. The riders, endorsements, or policy forms must provide a clear\r\ndescription of the Medicare supplement benefits provided by the policy or\r\ncertificate.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989; 16 SDR 174, effective May 2, 1990; 18 SDR\r\n225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.02 Public hearings.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.02. Public hearings. The director may conduct a\r\npublic hearing to gather information concerning a request by an issuer for an\r\nincrease in a rate for a policy form or certificate form issued either before\r\nor after the effective date of this rule if the experience of the form for the\r\nprevious reporting period is not in compliance with the applicable loss ratio\r\nstandard. The determination of compliance is made without consideration of any\r\nrefund or credit for the reporting period. Public notices of the hearing shall\r\nbe furnished by the director in compliance with SDCL 1-26-16.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.03 Filing and approval of policies and certificates and of premium rates required.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.03. Filing and approval of policies and certificates\r\nand of premium rates required. An issuer may not deliver or issue for\r\ndelivery a policy or certificate to a resident of this state unless the policy\r\nform or certificate form has been filed with and approved by the director in\r\naccordance with SDCL 58-17A-4, 58-17-4.1, 58-17-4.2, ARSD chapter 20:06:22 and this chapter.

\r\n\r\n\r\n

An issuer may not use or change\r\npremium rates for a Medicare supplement policy or certificate unless the rates,\r\nrating schedule, and supporting documentation have been filed with and approved\r\nby the director in accordance with the applicable provisions of SDCL 58-17A-4, 58-17-4.1, 58-17-4.2, ARSD chapter 20:06:22, and this chapter.

\r\n\r\n\r\n

An issuer shall not present for filing\r\nor approval a rate structure for its Medicare supplement policies or\r\ncertificates issued after January 1, 2006, based upon a structure or\r\nmethodology with any groupings of attained ages greater than one year. The\r\nratio between rates for successive ages shall increase smoothly as age\r\nincreases.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.04 One policy or certificate form allowed -- Exceptions.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.04. One policy or certificate form allowed --\r\nExceptions. An issuer may not file for approval more than one form of a\r\npolicy or certificate of each type for each standard Medicare supplement\r\nbenefit plan except as provided in this section.

\r\n\r\n\r\n

An issuer may offer, with the approval\r\nof the director, up to four additional policy forms or certificate forms of the\r\nsame type for the same standard Medicare supplement benefit plan, one for each\r\nof the following cases:

\r\n\r\n\r\n

(1) The inclusion of new or\r\ninnovative benefits;

\r\n\r\n

(2) The addition of either\r\ndirect response or agent marketing methods;

\r\n\r\n

(3) The addition of either\r\nguaranteed issue or underwritten coverage; and

\r\n\r\n

(4) The offering of\r\ncoverage to individuals eligible for Medicare by reasons of disability.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.05 Discontinuance of availability.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.05. Discontinuance of availability. An issuer\r\nshall continue to make available for purchase any policy form or certificate\r\nform issued after the effective date of this rule that has been approved by the\r\ndirector, unless the issuer notifies the director of its discontinuance in\r\naccordance with this section. A policy form or certificate form is not\r\nconsidered to be available for purchase unless the issuer has actively offered\r\nit for sale in the previous 12 months.

\r\n\r\n\r\n

An issuer may discontinue the\r\navailability of a policy form or certificate form if the issuer provides notice\r\nof its decision to do so to the director in writing at least 30 days prior to\r\ndiscontinuance. After receipt of the notice by the director, the issuer may no\r\nlonger offer for sale the policy form or certificate form in this state.

\r\n\r\n\r\n

An issuer that discontinues the\r\navailability of a policy form or certificate form pursuant to the notice\r\nprocedure in this section may not file for approval a new policy form or\r\ncertificate form of the same type for the same standard Medicare supplement\r\nbenefit plan as the discontinued form for five years after the issuer provides\r\nnotice to the director of the discontinuance. The period of discontinuance may\r\nbe reduced by the director at the director's discretion.

\r\n\r\n\r\n

The sale or other transfer of Medicare\r\nsupplement business to another issuer is considered a\r\ndiscontinuance for the purposes of this section.

\r\n\r\n\r\n

A change in the rating structure or\r\nmethodology is considered a discontinuance under the first paragraph of this\r\nsection unless the issuer provides an actuarial memorandum describing the\r\nmanner in which the revised rating methodology and resultant rates differ from\r\nthe existing rating methodology and existing rates; and the issuer does not\r\nsubsequently put into effect a change of rates or rating factors that would\r\ncause a change in the percentage differential between the discontinued and\r\nsubsequent rates as described in the actuarial memorandum. The director may\r\napprove a change to the differential which is in the public interest.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.06 Combination of experience for calculation of refund or credit.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.06. Combination of experience for calculation of\r\nrefund or credit. The experience of all policy forms or certificate forms\r\nof the same type in a standard Medicare supplement benefit plan shall be\r\ncombined for purposes of the refund or credit calculation prescribed in\r\n§ 20:06:13:21.01. Forms assumed under an assumption reinsurance agreement\r\nmay not be combined with the experience of other forms for purposes of the\r\nrefund or credit calculation.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:22.07 New or innovative benefits -- Policy or certificate form allowed -- Exceptions -- Issued after May 31, 2010.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:22.07. New or innovative benefits -- Policy or\r\ncertificate form allowed -- Exceptions -- Issued after May 31, 2010. An\r\nissuer may, with the prior approval of the director, offer policies or\r\ncertificates with new or innovative benefits in addition to the standardized\r\nbenefits provided in a policy or certificate that otherwise complies with the\r\napplicable standards. Such new or innovative benefits shall include only\r\nbenefits that are applicable to Medicare supplement insurance, are new or\r\ninnovative, are not otherwise available, and are cost-effective. Approval of\r\nnew or innovative benefits shall not adversely impact the goal of Medicare\r\nsupplement simplification. New or innovative benefits shall not include an\r\noutpatient prescription drug benefit. New or innovative benefits shall not be\r\nused to change or reduce benefits, including a change of any cost-sharing\r\nprovision, in any standardized plan.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:23 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:23. Rate increases.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; repealed, 18 SDR 225, effective July 17, 1992.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:24 Disclosure of preexisting conditions.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:24. Disclosure of preexisting conditions. A\r\npolicy containing a preexisting condition limitation shall display the\r\npreexisting condition limitation as a separate paragraph labeled\r\n"Preexisting Condition Limitations."

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 16 SDR 174, effective May 2, 1990.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:25 Increased benefits after issue.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:25. Increased benefits after issue. A rider\r\nattached to a policy after issue which increases benefits with an increase in\r\npremium shall be agreed to in writing and signed by the insured. This section\r\ndoes not apply to increases in benefits required by law, increases to meet\r\nchanges in Medicare deductibles or copayments, or increases in benefits\r\nrequested by the insured in writing.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:26 Separate additional premium disclosure.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:26. Separate additional premium disclosure. A\r\nrider or endorsement requiring an additional premium shall display its premium\r\nprominently in the policy. The premium may not be displayed as part of an\r\naggregate premium.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:27 Buyer's guide.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:27. Buyer's guide. Issuers of accident and\r\nsickness policies or certificates which provide hospital or medical expense\r\ncoverage on an expense-incurred or indemnity basis to persons eligible for\r\nMedicare shall provide to applicants a copy of the most recent guide as\r\napproved by the director in a type size no smaller than 12-point type.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993;\r\n22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13, 1997;\r\n26 SDR 26, effective September 1, 1999; 27 SDR 53, 27 SDR 54, effective\r\nDecember 4, 2000; 28 SDR 157, effective May 19, 2002.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-6.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-6.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:28 Delivery of buyer's guide.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:28. Delivery\r\nof buyer's guide. A policy sold through an agent shall include a buyer's\r\nguide at the time of application. The agent shall obtain a signed\r\nacknowledgment of receipt from the applicant. The insurer shall maintain the\r\nacknowledgment of receipt on file for five years. The insurer shall make the\r\nfile, in whole or part, accessible to the division on request.

\r\n\r\n

Direct response insurers shall deliver\r\na buyer's guide to the applicant upon request. The offer to provide a buyer's\r\nguide to the applicant shall be in writing on the application unless a buyer's\r\nguide is delivered to all insured. A requested buyer's guide may not be\r\ndelivered later than the time of delivery of the policy.

\r\n\r\n

Delivery of the buyer's guide shall be\r\nmade whether or not such policies or certificates are advertised, solicited, or\r\nissued as Medicare supplement policies or certificates as defined in this\r\nchapter. Except for direct response issuers, delivery of the buyer's guide\r\nshall be made to the applicant at the time of application and acknowledgment of\r\nreceipt of the buyer's guide shall be obtained by the issuer. Direct response\r\nissuers shall deliver the buyer's guide to the applicant upon request, but not\r\nlater than at the time the policy is delivered.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 18 SDR 225, effective July 17, 1992; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-6.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-6.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:29 Use of term \"Medicare supplement.\"\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:29. Use of term "Medicare supplement."\r\nA policy or insurance contract not in compliance with this chapter may not use\r\nthe terms "Medicare supplement," "medigap,"\r\n"Medicare wrap-around," or words of similar meaning and may not be\r\nadvertised, solicited, or issued for delivery in this state as a Medicare\r\nsupplement policy. "Medicare" must be defined in the policy.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 18 SDR 225, effective July 17,\r\n1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:30 Disclosure requirements for policies or subscriber contracts that are not Medicare supplement policies.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:30. Disclosure requirements for policies or\r\nsubscriber contracts that are not Medicare supplement policies. Any issuer\r\nselling an accident and sickness insurance policy or subscriber contract, other\r\nthan a Medicare supplement policy or a risk-sharing contract or reasonable cost\r\nreimbursement contract; a Medicare Advantage policy; disability income policy;\r\nor certificates issued under group Medicare supplement policies or subscriber\r\ncontracts which have been delivered or issued for delivery in this state to\r\npersons eligible for Medicare shall notify insureds that the policy,\r\ncertificate, or subscriber contract is not a Medicare supplement policy.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 17 SDR 58, effective October 29,\r\n1990; 18 SDR 225, effective July 17, 1992; 23 SDR 236, effective July 13, 1997;\r\n27 SDR 53, effective December 4, 2000; 31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-7.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:31 Notice requirements for policies or certificates that are not Medicare supplement policies.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:31. Notice requirements for policies or certificates\r\nthat are not Medicare supplement policies. The disclosure notice required\r\nby § 20:06:13:30 must be in at least twelve-point type. The notice must be\r\nprinted on or attached to the first page of the policy, subscriber contract, or\r\ncertificate or the first page of an outline of coverage under a policy,\r\nsubscriber contract, or certificate if an outline is provided at the time of\r\napplication. The notice must contain the following language:

\r\n\r\n\r\n

"THIS (POLICY OR CERTIFICATE) IS\r\nNOT A MEDICARE SUPPLEMENT (POLICY OR CONTRACT). If you are eligible for\r\nMedicare, review the [insert the most recent guide as approved by the director]\r\navailable from the company."

\r\n\r\n\r\n

Applications provided to persons\r\neligible for Medicare for the health insurance policies or certificates\r\ndescribed in § 20:06:13:30 must disclose, using the applicable statement\r\nin Appendix E at the end of this chapter, the extent to which the policy\r\nduplicates Medicare. Disclosure used by an issuer must be in substantially the\r\nsame form and in no less than twelve-point type. For purposes of this section,\r\n"form" means the language, format, type size, type proportional\r\nspacing, bold character, line spacing, and usage of boxes around text. The\r\nissuer shall provide the disclosure statement as a part of, or together with,\r\nthe application for the policy or certificate.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 17 SDR 58, effective October 29,\r\n1990; 18 SDR 225, effective July 17, 1992; 22 SDR 107, effective February 18,\r\n1996; 23 SDR 236, effective July 13, 1997; 26 SDR 26, effective September 1,\r\n1999; 27 SDR 53, 27 SDR 54, effective December 4, 2000; 28 SDR 157, effective May\r\n19, 2002.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-7.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:31.01 Disclosure requirements for Medicare supplement policies -- Riders and endorsements.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:31.01. Disclosure requirements for Medicare supplement\r\npolicies -- Riders and endorsements. Medicare supplement policies shall\r\ninclude a renewal, continuation, or nonrenewal\r\nprovision. The language or specifications of the provision must be consistent\r\nwith the type of contract to be issued. The provision must be captioned as\r\napplicable, must appear on the cover page of the policy, and must clearly state\r\nthe duration, limitations, or terms of renewal, continuation, or nonrenewal of the policy, any reservation by the issuer of\r\nthe right to change premiums, and any automatic renewal premium increases based\r\non the policyholder's age.

\r\n\r\n\r\n

Except for riders or endorsements by\r\nwhich the issuer effectuates a request made in writing by the insured or\r\nexercises a specifically reserved right under a Medicare supplement policy, or\r\nis required to reduce or eliminate benefits to avoid duplication of Medicare\r\nbenefits, all riders or endorsements added to a Medicare supplement policy\r\nafter date of issue or at reinstatement or renewal which reduce or eliminate\r\nbenefits or coverage in the policy shall require a signed acceptance by the\r\ninsured. After the date of policy issue, any rider or endorsement which\r\nincreases benefits or coverage with a concomitant increase in premium during\r\nthe policy term must be agreed to in writing signed by the insured, unless the\r\nincreased benefits or coverage is required by changes to the minimum benefit\r\nstandards in § 20:06:13:17 or required by law. If a separate additional\r\npremium is charged for benefits provided in connection with riders or\r\nendorsements, the premium must be set forth in the policy.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989; 18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-7.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:31.02 \"Usual,\" \"customary,\" and \"reasonable\" requirements prohibited.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:31.02. "Usual," "customary," and\r\n"reasonable" requirements prohibited. Medicare supplement\r\npolicies or certificates may not provide for the payment of benefits based on\r\nstandards described as "usual and customary," "reasonable and\r\ncustomary," or words of similar import.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-7.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:31.03 Right of return.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:31.03. Right of return. Medicare supplement\r\npolicies and certificates shall have a notice prominently printed on the first\r\npage of the policy or certificate, or attached thereto, stating in substance\r\nthat the policyholder or certificateholder has the right to return the policy\r\nor certificate within 30 days after its delivery and to have the premium\r\nrefunded if, after examination of the policy or certificate, the insured person\r\nis not satisfied for any reason.

\r\n\r\n\r\n

Source:\r\n18 SDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:32 Requirements concerning application forms and replacement coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:32. Requirements\r\nconcerning application forms and replacement coverage. Application forms\r\nmust include the following statements and questions which are designed to\r\nelicit information as to whether, as of the date of the application, the\r\napplicant currently has Medicare supplement, Medicare Advantage, Medicaid\r\ncoverage, or another health insurance policy or certificate in force, or\r\nwhether a Medicare supplement policy or certificate is intended to replace any\r\nother accident and sickness policy or certificate presently in force. A\r\nsupplementary application or other form to be signed by the applicant and agent\r\ncontaining such questions and statements may be used. Unless coverage is direct\r\nmarketed, the agent must ask and record the answers to all questions on the\r\nforms. In the case of a direct response issuer, a copy of the application or\r\nsupplemental form, signed by the applicant and acknowledged by the issuer, must\r\nbe returned to the applicant by the issuer upon delivery of the policy.

\r\n\r\n

In lieu of the agent's recording all\r\nof the applicant's responses, an insurer may record or make contractual\r\narrangements for persons other than agents to record the applicant's responses.\r\nPrior to issuance of coverage, the insurer, agent, or contractor involved in the\r\napplication process must ask all remaining application questions and such\r\npersons must accurately record the applicant's responses to each of the\r\napplicable questions in the application. The insurer is responsible for any\r\nfailure to ask and accurately record the applicant's responses to each\r\napplicable question. The privacy requirements outlined in chapter 20:06:45 and\r\nthe Medicare Supplement marketing restrictions outlined in § 20:06:13:58\r\napply to such arrangements.

\r\n\r\n

Nothing in this section may be construed\r\nto prohibit the insurer from denying an incomplete application or to require\r\nthat further questions be asked of the applicant once the response to a\r\nquestion clearly indicates the applicant is ineligible for coverage.

\r\n\r\n

Nothing in this section in any way\r\nmodifies the requirement for a person to hold an insurance agent license if\r\nthat person sells, solicits, or negotiates Medicare Supplement insurance or any\r\nother kind of insurance.

\r\n\r\n

While assisting the applicant, a\r\nnon-licensed person is prohibited from attempting to sell or to interest the\r\napplicant in purchasing any product, insurance related or otherwise.

\r\n\r\n

The required statements and questions\r\nare as follows:

\r\n\r\n

STATEMENTS

\r\n\r\n

(1) You do not need more\r\nthan one Medicare supplement policy.

\r\n\r\n

(2) If you purchase this\r\npolicy or certificate, you may want to evaluate your existing health coverage\r\nand decide if you need multiple coverages.

\r\n\r\n

(3) You may be eligible for\r\nbenefits under Medicaid and may not need a Medicare supplement policy.

\r\n\r\n

(4) If, after purchasing\r\nthis policy, you become eligible for Medicaid, the benefits and premiums under\r\nyour Medicare supplement policy can be suspended, if requested, during your\r\nentitlement to benefits under Medicaid for 24 months. You must request this\r\nsuspension within 90 days after becoming eligible for Medicaid. If you are no\r\nlonger entitled to Medicaid, your suspended Medicare supplement policy (or, if\r\nthat is no longer available, a substantially equivalent policy) will be\r\nreinstituted if requested within 90 days after losing Medicaid eligibility. If\r\nthe Medicare supplement policy provided coverage for outpatient prescription\r\ndrugs and you enrolled in Medicare Part D while your policy was suspended, the\r\nreinstituted policy will not have outpatient prescription drug coverage, but\r\nwill otherwise be substantially equivalent to your coverage before the date of\r\nthe suspension;

\r\n\r\n

(5) If you are eligible\r\nfor, and have enrolled in a Medicare supplement policy by reason of disability\r\nand you later become covered by an employer or union-based group health plan,\r\nthe benefits and premiums under your Medicare supplement policy can be\r\nsuspended, if requested, while you are covered under the employer or\r\nunion-based group health plan. If you suspend your Medicare supplement policy\r\nunder these circumstances, and later lose your employer or union-based group\r\nhealth plan, your suspended Medicare supplement policy or if that is no longer\r\navailable, a substantially equivalent policy will be reinstituted if requested\r\nwithin 90 days of losing your employer or union-based group health plan. If the\r\nMedicare supplement policy provided coverage for outpatient prescription drugs\r\nand you enrolled in Medicare Part D while your policy was suspended, the\r\nreinstituted policy will not have outpatient prescription drug coverage, but\r\nwill otherwise be substantially equivalent to your coverage before the date of\r\nthe suspension.

\r\n\r\n

(6) Counseling services may\r\nbe available in your state to provide advice concerning your purchase of\r\nMedicare supplement insurance and concerning medical assistance through the\r\nstate Medicaid program, including benefits as a qualified Medicare beneficiary\r\n(QMB) and a specified low-income Medicare beneficiary (SLMB).

\r\n\r\n

QUESTIONS

\r\n\r\n

If you lost or are losing other health\r\ninsurance coverage and received a notice from your previous insurer stating\r\nthat you were eligible for guaranteed issue of a Medicare supplement insurance\r\npolicy, or that you had certain rights to buy such a policy, you may be\r\nguaranteed acceptance in one or more of our Medicare supplement plans. Please\r\ninclude a copy of the notice from your previous insurer with your application.\r\nPLEASE ANSWER ALL QUESTIONS.

\r\n\r\n

[Please mark YES or NO below with an\r\n"X"]

\r\n\r\n

To the best of your knowledge,

\r\n\r\n

(1) (a) Did you\r\nturn age 65 in the last 6 months?

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(b) Did\r\nyou enroll in Medicare Part B in the last 6 months?

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(2) Are you covered for\r\nmedical assistance through the state Medicaid program? [NOTE TO APPLICANT: If\r\nyou are participating in a "spend-down program" and have not met your\r\n"share of cost," please answer NO to this question.]

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

If yes,

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(d) Do you\r\nreceive any benefits from Medicaid OTHER THAN payments toward your Medicare\r\npart B premium?

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(3) (a) If you\r\nhad coverage from any Medicare plan other than original Medicare within the\r\npast 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or\r\nPPO), fill in your start and end dates below. If you are still covered under\r\nthis plan, leave "END" blank.

\r\n\r\n

START ___/___/___ END ___/___/___

\r\n\r\n

(b) If you are still\r\ncovered under the Medicare plan, do you intend to replace your current coverage\r\nwith this new Medicare supplement policy?

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(d) Did you drop a\r\nMedicare supplement policy to enroll in the Medicare plan?

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(4) (a) Do you\r\nhave another Medicare supplement policy in force?

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(b) If so, with what\r\ncompany, and what plan do you have [optional for direct mailers]?

\r\n\r\n

____________________________________________________________________

\r\n\r\n

Yes\r\n______ No ______

\r\n\r\n

(d) If so, what is\r\nthe paid-to or expiration date of your policy: ___/___/___

\r\n\r\n

(5) Have you had coverage\r\nunder any other health insurance within the past 63 days? (For example, an\r\nemployer, union, or individual plan?)

\r\n\r\n

(a) If so,\r\nwith what company and what kind of policy?

\r\n\r\n

___________________________________________________________________

\r\n\r\n

___________________________________________________________________

\r\n\r\n

___________________________________________________________________

\r\n\r\n

___________________________________________________________________

\r\n\r\n

(b) What\r\nare your dates of coverage under the other policy?

\r\n\r\n

START\r\n___/___/___ END ___/___/___

\r\n\r\n

(If you are still\r\ncovered under the other policy, leave "END" blank.)

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 16 SDR 174, effective May 2, 1990; transferred from\r\n§ 20:06:13:32.01, 18 SDR 225, effective July 17, 1992; 22 SDR 107, effective\r\nFebruary 18, 1996; 23 SDR 236, effective July 13, 1997; 28 SDR 157, effective\r\nMay 19, 2002; 31 SDR 214, effective July 6, 2005; 36 SDR 209, effective July 1,\r\n2010; 37 SDR 215, effective May 31, 2011; 39 SDR 10, effective August 1, 2012.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(3)(7).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(3)(7).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:32.01 Transferred.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:32.01. Transferred to § 20:06:13:32.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:32.02 Disclosure by agent.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:32.02. Disclosure by agent. On the application or\r\nthe supplementary application or form, agents shall list any health insurance\r\npolicies they have sold to the applicant. The list shall contain policies still\r\nin force and policies sold in the past five years which are no longer in force.

\r\n\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:33 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:33. Replacement\r\nrequirements for agents. Repealed.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 16 SDR 174, effective May 2, 1990; repealed, 35 SDR 306, effective July\r\n1, 2009.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:34 Replacement requirements for direct response insurers.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:34. Replacement requirements for direct response\r\ninsurers. Direct response insurers shall deliver a notice regarding\r\nreplacement of coverage to the applicant at the time the policy is issued.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 16 SDR 174, effective May 2, 1990.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:35 Notice of replacement.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:35. Notice\r\nof replacement. Upon determining that a sale will involve replacement of\r\nMedicare supplement coverage, any issuer, other than a direct response issuer,\r\nor its agent, shall furnish the applicant, prior to issuance or delivery of the\r\nMedicare supplement policy or certificate, a notice regarding replacement of\r\nMedicare supplement coverage. One copy of the notice signed by the applicant\r\nand the agent, unless the coverage is sold without an agent, must be provided\r\nto the applicant and an additional signed copy must be retained by the issuer.\r\nA direct response issuer shall deliver to the applicant at the time of the\r\nissuance of the policy the notice regarding replacement of Medicare supplement\r\ncoverage.

\r\n\r\n

The notice required by this\r\nsection is in Appendix C at the end of this chapter. Notice used by an issuer\r\nmust be in substantially the same form and in no less than twelve-point type.\r\nFor purposes of this section, "form" means the language, format, type\r\nsize, type proportional spacing, bold character, and line spacing.

\r\n\r\n

Unless the coverage is direct\r\nmarketed, the agent must ask and record the answers to all questions on the\r\nforms.

\r\n\r\n

Source: 8 SDR 174,\r\neffective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 15 SDR\r\n143, effective March 29, 1989; 18 SDR 225, effective July 17, 1992; 23 SDR 236,\r\neffective July 13, 1997; 37 SDR 215, effective May 31, 2011; 42 SDR 52,\r\neffective October 13, 2015.

\r\n\r\n

General Authority: SDCL 58-17A-2.

\r\n\r\n

Law Implemented: SDCL 58-17A-2.

\r\n\r\n

Note: A copy of the\r\nnotice that meets the requirements of this section may be obtained by writing\r\nor calling the Division of Insurance, 124 South Euclid Avenue, 2^nd\r\nFloor, Pierre, SD 57501 (605-773-3563) or writing NAIC, P.O. Box 38, Kansas\r\nCity, MO 64183-0108.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:36 Outline of coverage requirements.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:36. Outline\r\nof coverage requirements. An outline of coverage for Medicare supplement\r\npolicies, as found in Appendix D at the end of this chapter, must be provided.\r\nThe outline of coverage provided to applicants pursuant to this section\r\nconsists of four parts: a cover page, premium information, disclosure pages,\r\nand charts displaying the features of each benefit plan offered by the issuer.\r\nThe outline of coverage shall be printed in no less than 12-point type. All\r\nplans shall be shown on the cover page, and the plan or plans that are offered\r\nby the issuer shall be prominently identified. Premium information for plans\r\nthat are offered shall be shown on the cover page or immediately following the\r\ncover page and shall be prominently displayed. The premium and mode shall be\r\nstated for all plans that are offered to the prospective applicant. All\r\npossible premiums for the prospective applicant shall be illustrated.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 18 SDR 225, effective July 17,\r\n1992; 19 SDR 160, effective April 27, 1993; 31 SDR 214, effective July 6, 2005;\r\n36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-5.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:37 Delivery of outline of coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:37. Delivery\r\nof outline of coverage. Issuers issuing Medicare supplement policies for\r\ndelivery in this state shall provide the outline of coverage at the time the\r\napplication is taken. Except for direct response policies, the issuer shall\r\nobtain a written acknowledgment of receipt from the applicant. The issuer shall\r\nretain written acknowledgments of receipt for at least four years.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 18 SDR 225, effective July 17, 1992; 22 SDR 107, effective February 18,\r\n1996; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-5.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:38 Revisions of outline of coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:38. Revisions of outline of coverage. If the\r\ncoverage actually provided is different from the coverage outlined at the time\r\nof application, a substitute outline of coverage showing the coverage actually\r\nissued shall accompany the policy or certificate at the time of delivery. The\r\nsubstitute outline of coverage must have the following statement: "Notice:\r\nRead this outline of coverage carefully. It is not identical to the outline of\r\ncoverage provided upon application and the coverage originally applied for has\r\nnot been issued." The required statement must appear immediately above the\r\ncompany name and must be in at least twelve-point type.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:39 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:39. Outline\r\nof coverage requirements for "usual and customary" benefits.\r\nRepealed

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 22 SDR 107, effective February 18, 1996; repealed, 36 SDR 209, effective\r\nJuly 1, 2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:40 Style and arrangement for outline of coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:40. Style and arrangement for outline of coverage.\r\nThe style, arrangement, and overall appearance of a policy may not give undue\r\nprominence to any portion of the text. Every portion of the text must be\r\nclearly printed in medium-faced type. The size of the type must be uniform. All\r\nprint must be twelve-point at a minimum. This section does not apply to any\r\npolicy required to comply with SDCL 58-17-6.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13,\r\n1997.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:41 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:41. Supplemental disclosure form.Repealed.

\r\n\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; 22 SDR 107, effective February 18,\r\n1996; repealed, 25 SDR 13, effective August 9, 1998.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:42 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:42. Variable\r\ninformation for supplemental disclosure form. Repealed.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 15 SDR 143, effective March 29, 1989; repealed, 36 SDR 209, effective\r\nJuly 1, 2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:43 Overinsurance.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:43. Overinsurance. A health insurance policy\r\nissued to a Medicaid recipient or to a person who already possesses insurance\r\nsubstantially covering the same risk and paying for the same coverage is\r\noverinsurance. If the director determines after investigation that\r\noverinsurance exists and provides notice, the duplicating insurer must offer a\r\nfull refund less benefits paid. Any sale of a Medicare supplement policy or\r\ncertificate that will provide an individual more than one Medicare supplement\r\npolicy or certificate is prohibited.

\r\n\r\n

Duplication of Medicare supplement\r\ninsurance, as prohibited by § 58-17A-15, exists whenever an insured has\r\nmore than one Medicare supplement policy or certificate in force, regardless of\r\nthe number of days in which multiple policies or certificates are in force,\r\nincluding any duplication of coverage that is 30 days or less. Any overlap of\r\ncoverage requires the replacing or subsequent issuer, upon notice from the\r\npolicyholder, to adjust the dates of coverage and provide credit for premiums\r\npaid during the period of duplication. Any such refund or credit shall be\r\nreduced by the amount of any claims paid by the replacing or subsequent issuer\r\nduring the period of duplication. The replacing or subsequent issuer is not in\r\nviolation of this rule if the effective date of the policy or contract does not\r\nprecede the paid to or expiration date of the prior policy as shown on the\r\napplication, provided that upon notice to the issuer of overinsurance, refunds\r\nare made or offered pursuant to this section.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-15, 58-33-5, 58-33-6, 58-33-8.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:43.01 Misrepresentation -- Unfair or deceptive trade practices.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:43.01. Misrepresentation -- Unfair or deceptive trade\r\npractices. An agent is presumed to have violated SDCL 58-33-5 when the agent knowingly solicits, procures, or sells to any prospective insured who has an existing policy in force a Medicare supplement policy, long term care policy, or other type of health insurance policy designed specifically to be marketed to individuals who qualify for Medicare because of their age unless the agent informs the insured in writing either separately or on the face of the application that the new policy is intended to replace the existing policy. The agent must ensure that the prospective insured understands that the policy is a replacement of an existing policy.

\r\n\r\n\r\n

An agent who engages in the sale or\r\nsolicitation of such policies when the purchase is not reasonable or prudent or\r\nis otherwise not in the prospective insured's best interest has engaged in an\r\nunfair or deceptive trade practice in violation of SDCL 58-33-2.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-33-2, 58-33-5, 58-33-6, 58-33-8.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:43.02 Determination of suitability.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:43.02. Determination of suitability. To determine\r\nwhether the sale or solicitation of policies described in § 20:06:13:43.01\r\nis reasonable, prudent, or in the prospective insured's best interest, the\r\nagent, if any, shall examine the totality of the prospective insured's\r\ncircumstances, including the following:

\r\n\r\n\r\n

(1) The prospective\r\ninsured's financial condition, i.e., is the person on a fixed income, premium\r\ncost;

\r\n\r\n\r\n

(2) The prospective\r\ninsured's need for insurance at the time of sale, i.e., existing policies,\r\ninsured's finances; and

\r\n\r\n\r\n

(3) The values, benefits,\r\nand costs of the prospective insured's existing insurance program, if any, when\r\ncompared to the values, benefits, and costs of the recommended policy or\r\npolicies.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:43.03 Medicare supplement and Medicare Part C (Medicare Advantage) or Medicare Cost duplication.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:43.03. Medicare\r\nsupplement and Medicare Part C (Medicare Advantage) or Medicare Cost duplication.\r\nDuplication of coverage between Medicare supplement insurance and coverage\r\nissued pursuant to Medicare Part C or Medicare Cost requires adjustment of the\r\ncoverage dates by the Medicare supplement issuer regardless of whether the\r\nMedicare supplement coverage is replacing Medicare Part C coverage or Medicare\r\nCost or is being replaced by Medicare Part C or Medicare Cost coverage. If the\r\nissuer's Medicare supplement coverage is being replaced by Medicare Part C or\r\nMedicare Cost, the issuer must, upon receipt of written notice from the\r\npolicyholder that he or she desires to terminate the policy and of\r\ndocumentation substantiating the Medicare Part C coverage or Medicare Cost,\r\nadjust the coverage dates so as to terminate coverage on the date that\r\ncoincides with the effective date of the Medicare Part C or Medicare Cost\r\ncoverage and must refund any unearned premium based upon that revised\r\ntermination date to the insured. The issuer may deduct claims paid from the\r\nrefund amount for any claims incurred during the adjusted coverage time frame.\r\nNothing in this section requires a refund of premium for any time frame in\r\nexcess of five years prior to the date of written notice. If the Medicare\r\nsupplement plan is replacing a Medicare Part C or Medicare Cost plan then the\r\nprocedures for replacing issuer pursuant to § 20:06:13:43 apply.

\r\n\r\n

Source:\r\n35 SDR 48, effective September 8, 2008; 38 SDR 116, effective January 10, 2012.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(3).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(3).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:44 Failure to provide required forms.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:44. Failure\r\nto provide required forms. Failure of an insurance agent to provide\r\nany forms required by this chapter is a violation of this state's Unfair Trade\r\nPractices Act. Failure of a direct response insurer to provide any forms or\r\nfailure to maintain any files required by this chapter shall be viewed by the\r\ndivision as contrary to the public interest.

\r\n\r\n

Source: 8 SDR\r\n174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 39\r\nSDR 219, effective June 26, 2013.

\r\n\r\n

General Authority:\r\nSDCL 58-17A-2.

\r\n\r\n

Law Implemented:\r\nSDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:45 Refund in replacement situations.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:45. Refund\r\nin replacement situations. An insurer issuing a Medicare supplement\r\npolicy replacing a Medicare supplement policy shall allow for a full refund of\r\npremium if the refund is requested within 30 days after the insured receives\r\nthe policy.

\r\n\r\n

Source:\r\n8 SDR 174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1,\r\n1986; 39 SDR 219, effective June 26, 2013.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:46 Coverage replaced within the same company.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:46. Coverage\r\nreplaced within the same company. An insurer issuing new insurance\r\nreplacing insurance with the same insurer shall allow the insured 30 days to\r\nreinstate the replaced coverage without evidence of insurability if the new\r\ninsurance is not accepted by the insurer or the insured. The 30-day period\r\nshall begin on the date the replaced coverage lapses or the date the insurer\r\nrefuses to insure, whichever is more beneficial to the insured.

\r\n\r\n

Source: 8 SDR\r\n174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 39\r\nSDR 219, effective June 26, 2013.

\r\n\r\n

General Authority:\r\nSDCL 58-17A-2.

\r\n\r\n

Law Implemented:\r\nSDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:47 Insurance replaced by the same agent.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:47. Insurance\r\nreplaced by the same agent. If an agent replaces insurance\r\noriginally placed by that agent, the insured shall be allowed to reinstate the\r\nreplaced coverage if application is made within 30 days after the replaced\r\npolicy lapses. The right to reinstate shall be made without evidence of\r\ninsurability. The reinstated coverage may exclude payment for any injury or\r\nsickness starting after the policy lapsed and prior to reinstatement or for\r\nsickness starting within 10 days after reinstatement.

\r\n\r\n

Source: 8 SDR\r\n174, effective July 1, 1982; 12 SDR 151, 12 SDR 155, effective July 1, 1986; 39\r\nSDR 219, effective June 26, 2013.

\r\n\r\n

General Authority:\r\nSDCL 58-17A-2.

\r\n\r\n

Law Implemented:\r\nSDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:48 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:48. Payment\r\nand recognition of physicians. Repealed.

\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989; 18 SDR 225, effective July 17, 1992;\r\nrepealed, 36 SDR 209, effective July 1, 2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:49 Requirements for claims payment.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:49. Requirements for claims payment. An issuer\r\nshall comply with § 1882(c)(3) of the Social\r\nSecurity Act {as enacted by § 4081(b)(2)(C) of the Omnibus Budget\r\nReconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203}, 42 U.S.C.\r\n§ 1395 etseq, as in\r\neffect on July 1, 1992, by:

\r\n\r\n\r\n

(1) Accepting a notice from\r\na Medicare carrier on dually assigned claims submitted by participating\r\nphysicians and suppliers as a claim for benefits in place of any other claim\r\nform otherwise required and making a payment determination on the basis of the\r\ninformation contained in that notice;

\r\n\r\n\r\n

(2) Notifying the\r\nparticipating physician or supplier and the beneficiary of the payment\r\ndetermination;

\r\n\r\n\r\n

(3) Paying the\r\nparticipating physicians or supplier directly;

\r\n\r\n\r\n

(4) Furnishing each\r\nenrollee at the time of enrollment with a card listing the policy name and\r\nnumber and a central mailing address to which notices from a Medicare carrier\r\nmay be sent;

\r\n\r\n\r\n

(5) Paying user fees for\r\nclaim notices that are transmitted electronically or otherwise; and

\r\n\r\n\r\n

(6) Providing to the\r\nsecretary of health and human services, at least annually, a central mailing\r\naddress to which all claims may be sent by Medicare carriers.

\r\n\r\n\r\n

The issuer shall certify compliance\r\nwith the requirements set forth in this section on the Medicare supplement\r\ninsurance experience reporting form.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989; 17 SDR 58, effective October 29, 1990; 18\r\nSDR 225, effective July 17, 1992.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:50 Policy classification -- Requirements and limitations.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:50. Policy classification -- Requirements and\r\nlimitations. No agent or insurer may classify a Medicare supplement policy\r\nas a 100 percent policy or describe any benefit as paying 100 percent unless\r\nthe policy, without exception, pays 100 percent of the difference between the\r\nmedical charges incurred and the amount Medicare pays.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:51 Notice of benefit change.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:51. Notice\r\nof benefit change. At least 30 days before the annual effective date of\r\nMedicare benefit changes each issuer, health care service plan, or other entity\r\nproviding Medicare supplement insurance or benefits to a resident of this state\r\nshall notify its policyholders and certificateholders of modifications it has\r\nmade to Medicare supplement insurance policies or certificates in a format\r\nacceptable to the director or adopted by the NAIC. The notice must contain the\r\nfollowing information:

\r\n\r\n

(1) A description\r\nof revisions to the Medicare program and a description of each modification\r\nmade to the coverage provided under the Medicare supplement insurance policy or\r\ncertificate;

\r\n\r\n

(2) Information for\r\neach covered person about when any premium adjustment due to changes in\r\nMedicare benefits will be made; and

\r\n\r\n

(3) Benefit\r\nmodifications and any premium adjustments in outline form stated in clear and\r\nsimple terms.

\r\n\r\n

The notice may not contain or\r\nbe accompanied by a solicitation.

\r\n\r\n

Source: 15 SDR 143,\r\neffective March 29, 1989; 16 SDR 174, effective May 2, 1990; 18 SDR 225,\r\neffective July 17, 1992; 27 SDR 53, effective December 4, 2000; 42 SDR 52,\r\neffective October 13, 2015.

\r\n\r\n

General Authority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law Implemented: SDCL 58-17A-2.

\r\n\r\n

Cross-Reference: Policy\r\nforms -- Filing with and approved by the director, SDCL 58-11-12.

\r\n\r\n

Note: A copy of a\r\nnotice that meets the requirements of this section may be obtained from the\r\nDivision of Insurance, 124 South Euclid Avenue, 3nd Floor, Pierre, SD 57501\r\n(605-773-3563), free of charge.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:52 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:52. Filing\r\nof policies to comply with Medicare changes. Repealed.

\r\n\r\n

Source:\r\n15 SDR 143, effective March 29, 1989; repealed, 36 SDR 209, effective July 1,\r\n2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:53 Duplication of coverage prohibited.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:53. Duplication of coverage prohibited. No\r\nMedicare supplement insurance policy, contract, or certificate may be issued or\r\nissued for delivery in this state which provides benefits which duplicate\r\nbenefits provided by Medicare.

\r\n\r\n\r\n

An issuer may not issue a Medicare\r\nsupplement policy or certificate to an individual enrolled in Medicare part C\r\nunless the effective date of the coverage is after the termination date of the\r\nindividual's part C coverage.

\r\n\r\n\r\n

In addition, issuers must comply with\r\nthe requirements of § 20:06:13:59 and this section by the annual filing of\r\nthe form in Appendix B at the end of this chapter each March 1.

\r\n\r\n\r\n

Source:\r\n15 SDR 143, adopted March 29, 1989, retroactively\r\neffective January 1, 1989; 18 SDR 225, effective July 17, 1992; 31 SDR 214,\r\neffective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:54 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:54. Reinstitution\r\nof coverage. Repealed.

\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990; repealed, 36 SDR 209, effective July 1,\r\n2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:55 Exception to reinstitution of coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:55. Exception to reinstitution of coverage. An\r\ninsurer is not required to make the offer under § 20:06:13:54 to an\r\nindividual who is a policyholder or certificateholder in another Medicare\r\nsupplement policy as of January 1, 1990, if the individual is not subject to a\r\nwaiting period for treatment of a preexisting condition under the other policy.

\r\n\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:56 Continuation and conversion rights.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:56. Continuation\r\nand conversion rights. Group members of a group Medicare supplement\r\ninsurance policy may continue or convert their rights under the following\r\nconditions:

\r\n\r\n

(1) If a group Medicare\r\nsupplement insurance policy is terminated by the group policyholder and not\r\nreplaced as provided in subdivision (3) of this section, the issuer shall offer\r\ncertificateholders an individual Medicare supplement policy. The issuer shall\r\noffer certificateholders at least the following choices:

\r\n\r\n

(a) Continuation of\r\nbenefits contained in the group policy; or

\r\n\r\n

(b) An individual\r\npolicy which provides for benefits which otherwise meets the requirements of\r\nthis section;

\r\n\r\n

(2) If membership in a\r\ngroup is terminated, the issuer shall:

\r\n\r\n

(a) Offer the certificateholder\r\nthe conversion opportunities described in subdivision (1) of this section; or

\r\n\r\n

(b) At the option of\r\nthe group policyholder, offer the certificateholder continuation of coverage\r\nunder the group policy;

\r\n\r\n

(3) If a group Medicare\r\nsupplement policy is replaced by another group Medicare supplement policy\r\npurchased by the same policyholder, the succeeding issuer shall offer coverage\r\nto all persons covered under the old group policy on its date of termination.\r\nCoverage under the new group policy may not result in any exclusion for\r\npreexisting conditions that would have been covered under the group policy\r\nbeing replaced.

\r\n\r\n

This section applies to 1990\r\nstandardized Medicare supplement benefit plans as well as 2010 standardized\r\nMedicare supplement benefit plans.

\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990; 18 SDR 225, effective July 17, 1992; 35 SDR\r\n183, effective February 2, 2009; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-3.1.

\r\n\r\n

Cross-Reference:\r\nMinimum benefit standards, § 20:06:13:17.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:57 Standards for marketing.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:57. Standards for marketing. Every issuer,\r\nhealth care service plan, or other entity marketing Medicare supplement\r\ninsurance coverage in this state, directly or through its agents or\r\nrepresentatives, shall:

\r\n\r\n\r\n

(1) Establish marketing\r\nprocedures to assure that any comparison of policies or certificates by its\r\nagents or other representatives will be fair and accurate;

\r\n\r\n\r\n

(2) Establish marketing\r\nprocedures to assure that excessive insurance is not sold or issued;

\r\n\r\n\r\n

(3) Display prominently by\r\ntype, stamp, or other means on the first page of the outline of coverage and\r\npolicy or certificate the following:

\r\n\r\n\r\n

"Notice to buyer: This policy may not cover all of your medical\r\nexpenses";

\r\n\r\n\r\n

(4) Inquire and otherwise\r\nmake every effort to identify whether a prospective applicant, certificate\r\nholder, or enrollee for Medicare supplement insurance already has accident and\r\nsickness insurance and the types and amounts; and

\r\n\r\n\r\n

(5) Establish auditable\r\nprocedures for verifying compliance with this section.

\r\n\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990; 17 SDR 58, effective October 29, 1990; 18\r\nSDR 225, effective July 17, 1992; 22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:58 Marketing practices prohibited.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:58. Marketing\r\npractices prohibited. No person may employ any method of marketing to\r\ninduce the purchase of insurance through force, fright, or threat whether\r\nexplicit or implied or apply undue pressure to purchase insurance. No person\r\nmay directly or indirectly use any method of marketing that fails to disclose\r\nin a conspicuous manner that a purpose of the method of marketing is\r\nsolicitation of insurance and that contact will be made by an insurance agent\r\nor insurance company.

\r\n\r\n

The following acts and practices are\r\nspecifically prohibited in marketing:

\r\n\r\n

(1) "Twisting,"\r\nknowingly making any misleading representation or incomplete or fraudulent\r\ncomparison of any insurance policies or insurers for the purposes of inducing\r\nor tending to induce, any person to lapse, forfeit, surrender, terminate,\r\nretain, pledge, assign, borrow on, or convert an insurance policy or to take\r\nout a policy of insurance with another insurer;

\r\n\r\n

(2) ''High pressure\r\ntactics," employing any method of marketing having the effect of or\r\ntending to induce the purchase of insurance through force, fright, threat,\r\nwhether explicit or implied, or undue pressure to purchase or recommend the\r\npurchase of insurance;

\r\n\r\n

(3) "Cold lead\r\nadvertising," making use directly or indirectly of any method of marketing\r\nwhich fails to disclose in a conspicuous manner that a purpose of the method of\r\nmarketing is solicitation of insurance and that contact will be made by an\r\ninsurance agent or insurance company.

\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990; 36 SDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-7.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:58.01 Health insurance advertisement rate disclosures.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:58.01. Health insurance advertisement rate disclosures.\r\nUnless the disclosure made as required by § 20:06:13:58.02 is provided, no\r\nindividual or group health insurance policy or certificate may in its\r\nadvertisements include statements that directly or indirectly indicate that:

\r\n\r\n

(1) Premiums or rates do\r\nnot increase with age;

\r\n\r\n

(2) Premiums or rates do\r\nnot increase because of health conditions; or

\r\n\r\n

(3) An insured will not be\r\nsingled out for a rate or premium increase.

\r\n\r\n

Policies for which no rate increase\r\nmay be applied for any reason are exempt from the provisions of this section.

\r\n\r\n

Source:\r\n32 SDR 128, effective January 29, 2006.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(11).

\r\n\r\n

Law\r\nImplemented: SDCL 58-33-5, 58-33-6.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:58.02 Health insurance advertisement disclosure statements.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:58.02. Health insurance advertisement disclosure\r\nstatements. Any health insurance advertisement that includes a statement\r\nfor which disclosure is required pursuant to § 20:06:13:58.01 must contain\r\nin close proximity to any such statement and in an at least as conspicuous a\r\nform as the statement itself, the following disclosure or an alternative as may\r\nbe approved by the director:

\r\n\r\n

Premiums or rates may increase for\r\nother reasons such as an increase applicable to all persons covered under this\r\ntype of policy or certificate in this state.

\r\n\r\n

Source:\r\n32 SDR 128, effective January 29, 2006.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(11).

\r\n\r\n

Law\r\nImplemented: SDCL 58-33-5, 58-33-6.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:59 Reporting of multiple policies.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:59. Reporting of multiple policies. For each\r\nindividual resident of this state for whom the insurer or entity has in force\r\nmore than one Medicare supplement insurance policy or certificate, each insurer\r\nor other entity providing Medicare supplement insurance coverage in this state\r\nshall report to the director by March 1 the policy and certificate numbers and\r\nthe dates of issuance, grouped by individual policyholder.

\r\n\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:60 Cancellation or nonrenewal of policies.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:60. Cancellation\r\nor nonrenewal of policies. Except as authorized by the director, an issuer\r\nmay not cancel or refuse to renew a Medicare supplement policy or certificate\r\nfor any reason other than nonpayment of premium or material misrepresentation.\r\nEach Medicare supplement policy must be guaranteed renewable.

\r\n\r\n

Source:\r\n16 SDR 174, effective May 2, 1990; 18 SDR 225, effective July 17, 1992; 36 SDR\r\n209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:60.01 Guaranteed renewable with benefit changes.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:60.01. Guaranteed renewable with benefit changes.\r\nAn issuer that eliminates an outpatient prescription drug benefit as a result\r\nof requirements imposed by the Medicare Prescription Drug, Improvement and\r\nModernization Act of 2003 shall be deemed to satisfy the guaranteed renewable\r\nprovision of § 20:06:13:60.

\r\n\r\n

Source:\r\n31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:61 Agent compensation limited.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:61. Agent\r\ncompensation limited. An issuer or other entity may provide a commission or\r\nother compensation to an agent or other representative for the sale of a\r\nMedicare supplement policy or certificate only if the commission or\r\ncompensation for the first year is no more than 200 percent of the commission\r\nor compensation paid for selling or servicing the policy or certificate in the\r\nsecond year or period.

\r\n\r\n

The commission or other compensation\r\nprovided in subsequent or renewal years must be the same as that provided in\r\nthe second year or period and must be provided for at least five renewal years.

\r\n\r\n

An issuer or other entity may not\r\nprovide compensation to its agents or other producers and an agent or producer\r\nmay not receive compensation greater than the renewal compensation payable by\r\nthe replacing issuer on renewal policies or certificates if an existing policy\r\nor certificate is replaced.

\r\n\r\n

For purposes of this section, the\r\nterm, compensation, includes pecuniary and nonpecuniary remuneration of any\r\nkind relating to the sale or renewal of the policy or certificate, including\r\nbonuses, gifts, prizes, awards, and finder's fees.

\r\n\r\n

Any commission advance or commission\r\nloan or other compensation by whatever named called, whether measured alone or\r\nin conjunction with other commissions, provided by an issuer or other entity,\r\nmay not exceed the monetary threshold for a first year commission as required\r\nby this section. The fact that a commission loan or commission advance may be\r\nrequired to be repaid later or reduced if the insurance is terminated does not\r\nallow for compensation at any time to be in excess of the first year\r\nlimitations required by this section.

\r\n\r\n

Source:\r\n17 SDR 58, effective October 29, 1990; 18 SDR 225, effective July 17, 1992; 22\r\nSDR 107, effective February 18, 1996; 31 SDR 214, effective July 6, 2005; 36\r\nSDR 209, effective July 1, 2010.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:62 Repealed.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:62. Requirements\r\nof insurers. Repealed.

\r\n\r\n

Source:\r\n17 SDR 58, effective October 29, 1990; repealed, 36 SDR 209, effective July 1,\r\n2010.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:63 Medicare select policies and certificates.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:63. Medicare select policies and certificates.\r\nSections 20:06:13:63 to 20:06:13:76, inclusive, apply to Medicare select\r\npolicies and certificates, as defined in § 20:06:13:02.

\r\n\r\n\r\n

A policy or certificate may not be\r\nadvertised as a Medicare select policy or certificate unless it meets the\r\nrequirements of § 20:06:13:63 to 20:06:13:76, inclusive.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(11).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:64 Medicare select authorization.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:64. Medicare select authorization. The director\r\nmay authorize an issuer to offer a Medicare select policy or certificate\r\npursuant to § 20:06:13:63 to 20:06:13:76, inclusive, and § 4358 of\r\nthe Omnibus Budget Reconciliation Act (OBRA) of 1990 if the director finds that\r\nthe issuer has satisfied all of the requirements of these sections.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(10), 58-17A-2(12).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:65 Approval required for issuance.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:65. Approval required for issuance. A Medicare\r\nselect issuer may not issue a Medicare select policy or certificate in this\r\nstate until its plan of operation has been approved by the director, pursuant\r\nto SDCL 58-17A-2.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(10), 58-17A-2(12).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:66 Filing plan of operation.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:66. Filing plan of operation. A Medicare select\r\nissuer shall file a proposed plan of operation with the director in a format\r\nprescribed by the director. The plan of operation must contain at least the\r\nfollowing information:

\r\n\r\n\r\n

(1) Evidence that all\r\ncovered services that are subject to restricted network provisions are\r\navailable and accessible through network providers, including a demonstration\r\nthat:

\r\n\r\n\r\n

(a) Such services can\r\nbe provided by network providers with reasonable promptness regarding geographic\r\nlocation, hours of operation, and after-hour care. The hours of operation and\r\navailability of after-hour care must reflect the usual practice in the local\r\narea. Geographic availability must reflect the usual travel times within the\r\ncommunity;

\r\n\r\n\r\n

(b) The number of\r\nnetwork providers in the service area is sufficient for current and expected\r\npolicyholders either to deliver adequately all services that are subject to a\r\nrestricted network provision or to make appropriate referrals.

\r\n\r\n\r\n

(d) Emergency care is\r\navailable 24 hours a day and 7 days a week;

\r\n\r\n\r\n

(e) In the case of\r\ncovered services that are subject to a restricted network provision and are\r\nprovided on a prepaid basis, there are written agreements with network\r\nproviders prohibiting such providers from billing or otherwise seeking\r\nreimbursement from or recourse against any individual insured under a Medicare\r\nselect policy or certificate. This subsection does not apply to supplemental\r\ncharges or coinsurance amounts as stated in the Medicare select policy or\r\ncertificate;

\r\n\r\n\r\n

(2) A statement or map\r\nproviding a clear description of the service area;

\r\n\r\n

(3) A description of the\r\ngrievance procedure to be used;

\r\n\r\n

(4) A description of the\r\nquality assurance program, including:

\r\n\r\n\r\n

(a) The formal\r\norganizational structure;

\r\n\r\n

(b) The written\r\ncriteria for selection, retention, and removal of network providers; and

\r\n\r\n

(c) The procedures for\r\nevaluating quality of care provided by network providers and the process to\r\ninitiate corrective action when warranted;

\r\n\r\n\r\n

(5) A list and description,\r\nby specialty, of the network providers;

\r\n\r\n

(6) Copies of the written\r\ninformation proposed to be used by the issuer to comply with § 20:06:13:70;\r\nand

\r\n\r\n

(7) Any other information\r\nrequested by the director.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13, 1997.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(12), 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:67 Filing of changes.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:67. Filing of changes. A Medicare select issuer\r\nshall file any proposed changes to the plan of operation, except for changes to\r\nthe list of network providers, with the director before implementing the\r\nchanges. The changes are considered to be approved by the director after 30\r\ndays unless they are specifically disapproved.

\r\n\r\n\r\n

An updated list of network providers\r\nmust be filed with the director at least quarterly.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(12), 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:68 Network restrictions.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:68. Network restrictions. A Medicare select\r\npolicy or certificate may not restrict payment for covered services provided by\r\nproviders outside the network if:

\r\n\r\n\r\n

(1) The services are for\r\nsymptoms requiring emergency care or are immediately required for an unforeseen\r\nillness, injury, or a condition; and

\r\n\r\n\r\n

(2) It is not appropriate\r\ngiven specific circumstances, such as time or distance, to obtain such services\r\nthrough a network provider.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996; 23 SDR 236, effective July 13, 1997.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(5), 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:69 Coverage for unavailable services.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:69. Coverage for unavailable services. A\r\nMedicare select policy or certificate shall provide payment for full coverage\r\nunder the policy for covered services that are not available through network\r\nproviders.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(5), 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:70 Disclosure and outline of coverage requirements.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:70. Disclosure and outline of coverage requirements.\r\nA Medicare select issuer shall make full disclosure in writing of the\r\nprovisions, restrictions, and limitations of the Medicare select policy or\r\ncertificate to each applicant. This disclosure must include at least the\r\nfollowing:

\r\n\r\n\r\n

(1) An outline of coverage\r\nsufficient to permit the applicant to compare the coverage and premiums of the\r\nMedicare select policy or certificate with other Medicare supplement policies\r\nor certificates offered by the issuer and other Medicare select policies or\r\ncertificates;

\r\n\r\n\r\n

(2) A description of the\r\nnetwork providers, including primary care physicians, specialty physicians,\r\nhospitals, and other providers. At a minimum, the description must include each\r\nprovider's address, telephone number, and hours of operation;

\r\n\r\n\r\n

(3) A description of the\r\nrestricted network provisions, including payments for coinsurance and\r\ndeductibles when providers other than network providers are utilized. Except to\r\nthe extent specified in the policy or certificate, expenses incurred when using\r\nout-of-network providers do not count toward the out-of-pocket annual limit\r\ncontained in plans K and L;

\r\n\r\n\r\n

(4) A description of\r\ncoverage for emergency and urgently needed care and other out-of-service area coverage;

\r\n\r\n\r\n

(5) A description of\r\nlimitations on referrals to restricted network providers and to other\r\nproviders;

\r\n\r\n\r\n

(6) A description of the\r\npolicyholders' rights to purchase any other Medicare supplement policy or\r\ncertificate otherwise offered by the issuer; and

\r\n\r\n\r\n

(7) A description of the\r\nMedicare select issuer's quality assurance program and\r\ngrievance procedure.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996; 31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(11), 58-17A-2(14), 58-17A-6, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2, 58-17A-5.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:71 Applicant signature required.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:71. Applicant signature required. Prior to the\r\nsale of a Medicare select policy or certificate, a Medicare select issuer must\r\nobtain from the applicant a signed and dated form stating that the applicant\r\nhas received the information provided, pursuant to § 20:06:13:70, and that\r\nthe applicant understands the restrictions of the Medicare select policy or\r\ncertificate.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(11), 58-17A-2(14), 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:72 Complaints and grievances.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:72. Complaints and grievances. A Medicare select\r\nissuer must have and use procedures for hearing complaints and resolving\r\nwritten grievances from subscribers. Such procedures must be aimed at mutual\r\nagreement for settlement and may include arbitration procedures. Grievance\r\nprocedures must meet the following requirements:

\r\n\r\n\r\n

(1) The grievance procedure\r\nmust be described in the policy and certificate and in the outline of coverage;

\r\n\r\n\r\n

(2) At the time the policy\r\nor certificate is issued, the issuer must provide detailed information to the\r\npolicyholder describing how a grievance may be registered with the issuer;

\r\n\r\n\r\n

(3) The issuer must\r\nconsider grievances in a timely manner and transmit them to decision-makers who\r\nhave authority to investigate the issue fully and take corrective action;

\r\n\r\n\r\n

(4) If a grievance is found\r\nto be valid, the issuer must take corrective action promptly;

\r\n\r\n\r\n

(5) The issuer must notify\r\nall concerned parties about the results of a grievance;

\r\n\r\n\r\n

(6) The issuer must report\r\nno later than March 31 each year to the director regarding its grievance\r\nprocedure in a format provided by the director. The report must contain the\r\nnumber of grievances filed in the past year and a summary of the subject,\r\nnature, and resolution of the grievances.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(5), 58-17A-2(12), 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:73 Required offer of other Medicare supplement coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:73. Required offer of other Medicare supplement\r\ncoverage. At the time of initial purchase, a Medicare select issuer must\r\nmake available to each applicant for a Medicare select policy or certificate\r\nthe opportunity to purchase any Medicare supplement policy or certificate\r\notherwise offered by the issuer.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2), 58-17A-2(11), 58-17A-2(14).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:74 Required offer of replacement coverage without a restricted network provision.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:74. Required offer of replacement coverage without a\r\nrestricted network provision. At the request of an individual insured under\r\na Medicare select policy or certificate, a Medicare select issuer must make\r\navailable to the individual insured the opportunity to purchase a Medicare\r\nsupplement policy or certificate offered by the issuer which has comparable or\r\nlesser benefits and which does not contain a restricted network provision. The\r\nissuer must make such policies or certificates available without requiring\r\nevidence of insurability after the Medicare select policy or certificate has\r\nbeen in force for six months.

\r\n\r\n\r\n

For the purpose of this section, a\r\nMedicare supplement policy or certificate is considered to have comparable or\r\nlesser benefits unless it contains one or more significant benefits not\r\nincluded in the Medicare select policy or certificate being replaced. For the\r\npurpose of this paragraph, a significant benefit means coverage for the\r\nMedicare Part A deductible, coverage for prescription drugs, coverage for\r\nat-home recovery services, or coverage for Part B excess charges.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2), 58-17A-2(11), 58-17A-2(14).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:75 Continuation.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:75. Continuation. Medicare select policies and\r\ncertificates must provide for continuation coverage if the secretary of health\r\nand human services determines that Medicare select policies and certificates\r\nissued pursuant to §§ 20:06:13:63 to 20:06:13:76, inclusive, should be\r\ndiscontinued because the Medicare select program was not reauthorized under law\r\nor it was substantially amended.

\r\n\r\n\r\n

Each Medicare select issuer must make\r\navailable to each individual insured under a Medicare select policy or certificate\r\nthe opportunity to purchase any Medicare supplement policy or certificate\r\noffered by the issuer which has comparable or lesser benefits and which does\r\nnot contain a restricted network provision. The issuer must make such policies\r\nand certificates available without requiring evidence of insurability.

\r\n\r\n\r\n

For the purpose of this section, a\r\nMedicare supplement policy or certificate is considered to have comparable or\r\nlesser benefits unless it contains one or more significant benefits not\r\nincluded in the Medicare select policy or certificate being replaced. For the\r\npurposes of this paragraph, a significant benefit means coverage for the\r\nMedicare Part A deductible, coverage for prescription drugs, coverage for\r\nat-home recovery services, or coverage for Part B excess charges.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2), 58-17A-2(7), 58-17A-2(16).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:76 Compliance with data requests.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:76. Compliance with data requests. A Medicare\r\nselect issuer must comply with requests for data made by state or federal\r\nagencies, including the United States Department of Health and Human Services,\r\nfor the purpose of evaluating the Medicare select program.

\r\n\r\n\r\n

Source:\r\n22 SDR 107, effective February 18, 1996.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(12).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:77 Creditable coverage.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:77. Creditable\r\ncoverage.\r\nFor purposes of this chapter, creditable coverage is defined as follows:

\r\n\r\n

(1) "Creditable\r\ncoverage," with respect to an individual, coverage of the individual\r\nprovided under any of the following:

\r\n\r\n

(a) A group health plan;

\r\n\r\n

(b) Health insurance\r\ncoverage;

\r\n\r\n

(d) Title XIX of the\r\nSocial Security Act (Medicaid), other than coverage consisting solely of\r\nbenefits under § 1928;

\r\n\r\n

(e) Chapter\r\n55 of Title, 10 United States Code (CHAMPUS);

\r\n\r\n

(f) A medical care\r\nprogram of the Indian Health Service or of a tribal organization;

\r\n\r\n

(g) A state health\r\nbenefits risk pool;

\r\n\r\n

(h) A health plan offered\r\nunder chapter 89 of Title 5, United States Code (Federal Employees Health\r\nBenefits Program);

\r\n\r\n

(i) A public health plan\r\nas defined in federal regulation; and

\r\n\r\n

(j) A health benefit\r\nplan under § 5(e) of the Peace Corps Act (22 U.S.C. § 2504(e));

\r\n\r\n

(2) "Creditable\r\ncoverage” may not include one or more, or any combination, of the following:

\r\n\r\n

(a) Coverage only for\r\naccident or disability income insurance, or any combination;

\r\n\r\n

(b) Coverage issued as a\r\nsupplement to liability insurance;

\r\n\r\n

(d) Workers' compensation\r\nor similar insurance;

\r\n\r\n

(e) Automobile medical\r\npayment insurance;

\r\n\r\n

(f) Credit-only\r\ninsurance;

\r\n\r\n

(g) Coverage for on-site\r\nmedical clinics; and

\r\n\r\n

(h) Other similar\r\ninsurance coverage, specified in federal regulations, under which benefits for\r\nmedical care are secondary or incidental to other insurance benefits;

\r\n\r\n

(3) "Creditable\r\ncoverage," may not include the following benefits if they are provided\r\nunder a separate policy, certificate, or contract of insurance or are otherwise\r\nnot an integral part of the plan:

\r\n\r\n

(a) Limited scope dental\r\nor vision benefits;

\r\n\r\n

(b) Benefits for\r\nlong-term care, nursing home care, home health care, community-based care, or\r\nany combination thereof; and

\r\n\r\n

(4) "Creditable\r\ncoverage," may not include the following benefits if offered as\r\nindependent, noncoordinated benefits:

\r\n\r\n

(a) Coverage only for a\r\nspecified disease or illness; and

\r\n\r\n

(b) Hospital indemnity or\r\nother fixed indemnity insurance;

\r\n\r\n

(5) "Creditable\r\ncoverage" may not include the following if it is offered as a separate\r\npolicy, certificate, or contract of insurance:

\r\n\r\n

(a) Medicare supplemental\r\nhealth insurance as defined under § 1882(g)(1) of the Social Security Act;

\r\n\r\n

(b) Coverage supplemental\r\nto the coverage provided under Chapter 55 of Title 10, United States Code; and

\r\n\r\n

Source: 25 SDR 44,\r\neffective September 30, 1998.

\r\n\r\n

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

\r\n\r\n

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

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:78 Medicare Advantage plan.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:78. Medicare Advantage plan.\r\nFor purposes of this chapter, Medicare Advantage plan means a plan of coverage\r\nfor health benefits under Medicare Part C as defined in 42 U.S.C.\r\n1395w-28(b)(1), as in effect on January 1, 2004, and includes:

\r\n\r\n\r\n

(1) Coordinated care plans\r\nwhich provide health care services, including health maintenance organization\r\nplans, with or without a point-of-service option, plans offered by\r\nprovider-sponsored organizations, and preferred provider organization plans;

\r\n\r\n\r\n

(2) Medicare medical\r\nsavings account plans coupled with a contribution into a Medicare Advantage\r\nmedical savings account; and

\r\n\r\n\r\n

(3) Medicare Advantage\r\nprivate fee-for-service plans.

\r\n\r\n\r\n

Source:\r\n25 SDR 44, effective September 30, 1998; 26 SDR 26, effective September 1,\r\n1999; 31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(9).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(9).

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:79 Guaranteed issue.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:79. Guaranteed issue.\r\nWith respect to an eligible person, an issuer may not deny or condition the\r\nissuance or effectiveness of a Medicare supplement policy described in\r\n§ 20:06:13:81 that is offered and is available for issuance to a new\r\nenrollee by the issuer, may not discriminate in the pricing of a Medicare\r\nsupplement policy because of the eligible person's health status, claims\r\nexperience, receipt of health care, or medical condition, and may not impose an\r\nexclusion of benefits based on a preexisting condition under a Medicare\r\nsupplement policy.

\r\n\r\n\r\n

Source:\r\n25 SDR 44, effective September 30, 1998.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2)(5)(11).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(2)(5)(11), 58-17A-17.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:80 Guaranteed issue -- Eligible persons.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:80. Guaranteed issue -- Eligible persons. An\r\neligible person is one who seeks to enroll under the policy during the period\r\nspecified in § 20:06:13:80.01 and who submits evidence of the date of\r\ntermination, disenrollment, or Medicare part D enrollment with the application\r\nfor a Medicare supplement policy, and who is described in any of the following\r\nparagraphs:

\r\n\r\n

(1) The person is enrolled\r\nunder an employee welfare benefit plan or an employer-based health insurance\r\nplan that provides health benefits, and coverage under the plan terminates for\r\nthat person;

\r\n\r\n

(2) The\r\nperson is 65 years of age or older and is enrolled with a Program of\r\nAll-Inclusive Care for the Elderly (PACE) provider under § 1894 of the\r\nSocial Security Act, and there are circumstances similar to those described\r\nbelow that would permit discontinuance of the person's enrollment with such\r\nprovider if the person were enrolled in a Medicare Advantage plan, or the\r\nperson is enrolled with a Medicare Advantage organization under a Medicare\r\nAdvantage plan under part C of Medicare, and any of the following circumstances\r\napply:

\r\n\r\n

(a) The certification of the organization or plan\r\nunder this part has been terminated;

\r\n\r\n

(b) The organization has terminated or otherwise\r\ndiscontinued providing the plan in the area in which the person resides;

\r\n\r\n

(c) The person is no longer eligible to elect the\r\nplan because of a change in the person's place of residence or other change in\r\ncircumstances specified by the secretary, but not including termination of the\r\nperson's enrollment on the basis described in § 1851(g)(3)(B) of the\r\nfederal Social Security Act, if the person has not paid premiums on a timely\r\nbasis or has engaged in disruptive behavior as specified in standards under\r\n§ 1856, or the plan is terminated for all individuals within a residence\r\narea;

\r\n\r\n

(d) The person demonstrates, in accordance with\r\nguidelines established by the secretary, that:

\r\n\r\n

(i) The\r\norganization offering the plan substantially violated a material provision of\r\nthe organization's contract under part C of Medicare in relation to the person,\r\nincluding the failure to provide an enrollee on a timely basis medically\r\nnecessary care for which benefits are available under the plan or the failure\r\nto provide the covered care in accordance with applicable quality standards; or

\r\n\r\n

(ii) The\r\norganization, or agent or other entity acting on the organization's behalf,\r\nmaterially misrepresented the plan's provisions in marketing the plan to the\r\nperson; or

\r\n\r\n

(e) The person meets any other exceptional\r\nconditions as the secretary may provide;

\r\n\r\n

(3)(a) The person is\r\nenrolled with:

\r\n\r\n

(i) An\r\neligible organization under a contract under § 1876 of the Social Security\r\nAct, Medicare cost;

\r\n\r\n

(ii) A similar\r\norganization operating under demonstration project authority, effective for\r\nperiods before April 1, 1999;

\r\n\r\n

(iii) An\r\norganization under an agreement under § 1833(a)(1)(A)\r\nof the Social Security Act, health care prepayment plan; or

\r\n\r\n

(iv) An\r\norganization under a Medicare select policy; and

\r\n\r\n

(b) The enrollment\r\nceases under the same circumstances that would permit discontinuance of a\r\nperson's election of coverage under subdivision 2;

\r\n\r\n

(4)(a) The person is\r\nenrolled under a Medicare supplement policy and the enrollment ceases because:

\r\n\r\n

(i) Of\r\nthe insolvency of the issuer or bankruptcy of the nonissuer organization; or

\r\n\r\n

(ii) Of other\r\ninvoluntary termination of coverage or enrollment under the policy;

\r\n\r\n

(b) The issuer of the\r\npolicy substantially violated a material provision of the policy; or

\r\n\r\n

(c) The issuer, or an\r\nagent or other entity acting on the issuer's behalf, materially misrepresented\r\nthe policy's provisions in marketing the policy to the person;

\r\n\r\n

(5)(a) The\r\nperson was enrolled under a Medicare supplement policy and terminates\r\nenrollment and subsequently enrolls, for the first time, with any Medicare\r\nAdvantage organization under a Medicare Advantage plan under part C of\r\nMedicare, any eligible organization under a contract under § 1876 of the\r\nSocial Security Act (Medicare cost), any similar organization operating under\r\ndemonstration project authority, any PACE provider under § 1894 of the\r\nSocial Security Act or a Medicare Select policy;

\r\n\r\n

(b) The subsequent\r\nenrollment under subparagraph (a) is terminated by the enrollee during any\r\nperiod within the first 12 months of the subsequent enrollment, during which\r\nthe enrollee is permitted to terminate the subsequent enrollment under\r\n§ 1851(e) of the federal Social Security Act;

\r\n\r\n

(6) The person, upon first\r\nbecoming eligible for benefits under part A of Medicare at age 65, enrolls in a\r\nMedicare Advantage plan under part C of Medicare, or with a PACE provider under\r\n§ 1894 of the Social Security Act, and disenrolls from the plan by not\r\nlater than 12 months after the effective date of enrollment; or

\r\n\r\n

(7) The person enrolls in a\r\nMedicare part D plan during the initial enrollment period and, at the time of\r\nenrollment in part D, was enrolled under a Medicare supplement policy that\r\ncovers outpatient prescription drugs and the individual terminates enrollment\r\nin the Medicare supplement policy and submits evidence of enrollment in\r\nMedicare part D along with the application for a policy described in\r\nsubdivision 20:06:13:81(4).

\r\n\r\n

Source:\r\n25 SDR 44, effective September 30, 1998; 25 SDR 90, effective January 3, 1999;\r\n27 SDR 53, effective December 4, 2000; 28 SDR 157, effective May 19, 2002; 31\r\nSDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2)(9)(16).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(2)(9)(16).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:80.01 Guaranteed issue time periods.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:80.01. Guaranteed issue time periods.

\r\n\r\n\r\n

(1) In the case of an\r\nindividual described in subdivision 20:06:13:80(1), the guaranteed issue period\r\nbegins on the later of:

\r\n\r\n\r\n

(a) the\r\ndate the individual receives a notice of termination or cessation of all\r\nsupplemental health benefits (or, if a notice is not received, notice that a\r\nclaim has been denied because of such a termination or cessation);

\r\n\r\n\r\n

(b) or\r\nthe date that the applicable coverage terminates or ceases and ends 63 days\r\nthereafter;

\r\n\r\n\r\n

(2) In the case of an\r\nindividual described in subdivision 20:06:13:80(2), (3), (5), or (6) whose\r\nenrollment is terminated involuntarily, the guaranteed issue period begins on\r\nthe date that the individual receives a notice of termination and ends 63 days\r\nafter the date the applicable coverage is terminated;

\r\n\r\n\r\n

(3) In the case of an\r\nindividual described in subdivision 20:06:13:80(4)(a),\r\nthe guaranteed issue period begins on the earlier of the date that the\r\nindividual receives a notice of termination, a notice of the issuer's\r\nbankruptcy or insolvency, or other such similar notice if any, and the date\r\nthat the applicable coverage is terminated, and ends on the date that is 63\r\ndays after the date the coverage is terminated;

\r\n\r\n\r\n

(4) In the case of an\r\nindividual described in subdivision 20:06:13:80(2), (4)(b), (4)(c), (5), or (6)\r\nwho disenrolls voluntarily, the guaranteed issue period begins on the date that\r\nis 60 days before the effective date of the disenrollment and ends on the date\r\nthat is 63 days after the effective date;

\r\n\r\n\r\n

(5) In the case of an\r\nindividual described in subdivision 20:06:13:80(7), the guaranteed issue period\r\nbegins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the Social Security Act from the Medicare\r\nsupplement issuer during the 60-day period immediately preceding the initial\r\npart D enrollment period and ends on the date that is 63 days after the\r\neffective date of the individual's coverage under Medicare part D; and

\r\n\r\n\r\n

(6) In the case of an\r\nindividual described in § 20:06:13:80 but not described in the preceding\r\nprovisions of this section, the guaranteed issue period begins on the effective\r\ndate of disenrollment and ends on the date that is 63 days after the effective\r\ndate.

\r\n\r\n\r\n

Source:\r\n28 SDR 157, effective May 19, 2002; 31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2)(9)(16).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(2)(9)(16).

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:80.02 Extended medigap access for interrupted trial periods.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:80.02. Extended medigap access for interrupted trial\r\nperiods.

\r\n\r\n\r\n

(1) In the case of an\r\nindividual described in subdivision 20:06:13:80(5) (or deemed to be so\r\ndescribed, pursuant to this subsection) whose enrollment with an organization\r\nor provider described in subdivision 20:06:13:80(5)(a) is involuntarily\r\nterminated within the first twelve (12) months of enrollment, and who, without\r\nan intervening enrollment, enrolls with another such organization or provider,\r\nthe subsequent enrollment shall be deemed to be an initial enrollment described\r\nin subdivision 20:06:13:80(5);

\r\n\r\n\r\n

(2) In the case of an\r\nindividual described in subdivision 20:06:13:80(6) (or deemed to be so\r\ndescribed, pursuant to this subsection) whose enrollment with a plan or in a\r\nprogram described in subdivision 20:06:13:80(6) is involuntarily terminated\r\nwithin the first twelve (12) months of enrollment, and who, without an\r\nintervening enrollment, enrolls in another such plan or program, the subsequent\r\nenrollment shall be deemed to be an initial enrollment described in subdivision\r\n20:06:13:80(6); and

\r\n\r\n\r\n

(3) For purposes of\r\nsubdivisions 20:06:13:80(5) and (6), no enrollment of an individual with an\r\norganization or provider described in subdivision 20:06:13:80(5)(a), or with a\r\nplan or in a program described in subdivision 20:06:13:80(6), may be deemed to\r\nbe an initial enrollment under this subsection after the two-year period\r\nbeginning on the date on which the individual first enrolled with such an\r\norganization, provider, plan, or program.

\r\n\r\n\r\n

Source:\r\n28 SDR 157, effective May 19, 2002.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2)(9)(16).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(2)(9)(16).

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:81 Guaranteed issue -- Products to which eligible persons are entitled.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:81. Guaranteed\r\nissue -- Products to which eligible persons are entitled. The Medicare\r\nsupplement policies to which an eligible person is entitled are as follows:

\r\n\r\n

(1) A person eligible\r\nunder subdivisions 20:06:13:80(1), (2), (3), or (4) is entitled to a Plan A, B,\r\nC, F, F with high deductible, K, or L Medicare supplement policy offered by an\r\nissuer;

\r\n\r\n

(2) A person eligible\r\nunder subdivision 20:06:13:80(5) is entitled to the same Medicare supplement\r\npolicy in which the individual was most recently enrolled, if available from\r\nthe same issuer, or, if not available, a policy described in subdivision (1) of\r\nthis section. After December 31, 2005, if the individual was most recently\r\nenrolled in a Medicare supplement policy with an outpatient prescription drug\r\nbenefit, a Medicare supplement policy described in this subdivision is:

\r\n\r\n

(a) The policy\r\navailable from the same issuer but modified to remove outpatient prescription\r\ndrug coverage; or

\r\n\r\n

(b) At the\r\nelection of the policyholder, an A, B, C, F, F with high deductible, K, or L\r\npolicy that is offered by any issuer;

\r\n\r\n

(3) A person eligible\r\nunder subdivision 20:06:13:80(6) is entitled to any Medicare supplement policy\r\noffered by an issuer;

\r\n\r\n

(4) A person eligible\r\nunder subdivision 20:06:13:80(7) is entitled to a Plan A, B, C, F, F with high\r\ndeductible, K, or L that is offered and available for issuance to new enrollees\r\nby the same issuer that issued the individual's Medicare supplement policy with\r\noutpatient prescription drug coverage.

\r\n\r\n

For purposes of\r\n§ 20:06:13:81, in the case of any individual newly eligible for Medicare\r\nafter December 31, 2019, any reference to a Medicare supplement policy C or F,\r\nincluding F With High Deductible, shall be deemed to be a reference to Medicare\r\nsupplement policy D or G, including G With High Deductible.

\r\n\r\n

Source: 25 SDR 44,\r\neffective September 30, 1998; 31 SDR 214, effective July 6, 2005; 36 SDR 209,\r\neffective July 1, 2010; 46 SDR 147, effective July 2, 2020.

\r\n\r\n

General Authority: SDCL 58-17A-2(2)(16).

\r\n\r\n

Law Implemented: SDCL 58-17A-2(2)(16).

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:82 Guaranteed issue -- Notification provisions.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:82. Guaranteed issue -- Notification provisions.

\r\n\r\n\r\n

(1) At the time of an event\r\ndescribed in § 20:06:13:80 because of which a person loses coverage or\r\nbenefits due to the termination of a contract or agreement, policy, or plan,\r\nthe organization that terminates the contract or agreement, the issuer\r\nterminating the policy, or the administrator of the plan being terminated,\r\nrespectively, shall notify the person of that person's rights under this\r\nsection, and of the obligations of issuers of Medicare supplement policies\r\nunder § 20:06:13:79. The notice shall be communicated along with the\r\nnotice of termination.

\r\n\r\n\r\n

(2) At the time of an event\r\ndescribed in § 20:06:13:80 because of which a person ceases enrollment\r\nunder a contract or agreement, policy, or plan, the organization that offers\r\nthe contract or agreement, regardless of the basis for the cessation of\r\nenrollment, the issuer offering the policy, or the administrator of the plan,\r\nrespectively, shall notify the person of that person's rights under this\r\nsection, and of the obligations of issuers of Medicare supplement policies\r\nunder § 20:06:13:79. The notice shall be communicated within 10 working\r\ndays of the issuer receiving notification of disenrollment.

\r\n\r\n\r\n

Source:\r\n25 SDR 44, effective September 30, 1998.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(1)(2)(12)(16)(18).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(1)(2)(12)(16)(18).

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:83 Open enrollment.`\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:83. Open enrollment. If an applicant qualifies\r\nunder SDCL 58-17A-17 and submits an application during the time period referenced in SDCL 58-17A-17 and, as of the date of application, has had a continuous period of creditable coverage of at least six months, the issuer may not exclude benefits based on a preexisting condition. If the applicant qualifies under SDCL 58-17A-17 and submits an application during the time period referenced in SDCL 58-17A-17 and, as of the date of application, has had a continuous period of creditable coverage that is less than six months, the issuer shall reduce the period of any preexisting condition exclusion by the aggregate of the period of creditable coverage applicable to the applicant as of the enrollment date. The secretary shall specify the manner of the reduction under this section.

\r\n\r\n\r\n

Source:\r\n25 SDR 44, effective September 30, 1998.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2)(5).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(2)(5), 58-17A-17.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:84 Open enrollment required for Medicare eligible individuals regardless of age.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:84. Open enrollment required for Medicare eligible\r\nindividuals regardless of age. Any individual, regardless of age, who\r\nbecomes eligible for Medicare by reason of age or disability, is entitled to\r\nopen enrollment into any Medicare supplement policy if application is made\r\nwithin six months of enrollment in Part B of Medicare. This rule applies only\r\nto individuals who become eligible for Medicare on or after July 1, 1999.\r\nNothing in this rule prohibits a carrier from using rating methodologies on a\r\nclass basis for those that qualify for Medicare by reason of disability if:

\r\n\r\n

(1) The rate is an\r\nactuarially justified rate; and

\r\n\r\n

(2) The rate does not\r\nexceed the rate that the carrier has for an individual who qualifies for\r\nMedicare by reason of age and is 75 years of age.

\r\n\r\n

Source:\r\n26 SDR 55, effective October 21, 1999; 32 SDR 53, effective October 10, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2(2), 58-17A-2(5).

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2(2), 58-17A-2(5), 58-17A-17.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:85 Notice requirement.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:85. Notice requirement. Any issuer shall comply\r\nwith any notice requirement of the Medicare Prescription Drug, Improvement, and\r\nModernization Act of 2003.

\r\n\r\n\r\n

Source:\r\n31 SDR 214, effective July 6, 2005.

\r\n\r\n

General\r\nAuthority: SDCL 58-4-1, 58-17A-2, 58-17A-7.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:86 Exchanging of standardized plan.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:86. Exchanging of standardized plan. An issuer\r\nmay make a written offer to a policyholder or certificateholder to exchange\r\nduring a specified period from a 1990 standardized plan to a 2010 standardized\r\nplan.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:86.01 Exchanging of standardized plan -- Age rate schedule.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:86.01. Exchanging of standardized plan -- Age rate\r\nschedule. An issuer need not provide justification to the director if the\r\ninsured replaces a 1990 Standardized policy or certificate with an issue age\r\nrated 2010 Standardized policy or certificate at the insured's original issue\r\nage. If an insured's policy or certificate to be replaced is priced on an issue\r\nage rate schedule at the time of such offer, the rate charged to the insured\r\nfor the new exchanged policy shall recognize the policy reserve buildup, due to\r\nthe pre-funding inherent in the use of an issue age rate basis, for the benefit\r\nof the insured. The method proposed to be used by an issuer must be submitted\r\nwith the director through the System for Electronic Rate and Form filing,\r\nSERFF.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

Reference:\r\nSystem for Electronic Rate and Form Filing, SERFF. Copies of industry manuals\r\nmay be obtained from National Association of Insurance Commissioners, 2301\r\nMcGee Street, Suite 800, Kansas City, Missouri, 64108-2604, http://www.serff.org/index.htm.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:86.02 Excahnging of standardized plan -- Rating class.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:86.02. Exchanging of standardized plan -- Rating class.\r\nThe rating class of the new policy or certificate is the class closest to the\r\ninsured's class of the replaced coverage.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:86.03 Exchanging of standardized plan -- Preexisting conditions and incontestability period.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:86.03. Exchanging of standardized plan -- Preexisting\r\nconditions and incontestability period. An issuer may not apply new\r\npre-existing condition limitations or a new incontestability period to the new\r\npolicy for those benefits contained in the exchanged 1990 standardized policy\r\nor certificate of the insured. Pre-existing condition limitations may be\r\napplied of no more than six months to any added benefits contained in the new\r\n2010 standardized policy or certificate not contained in the exchanged policy.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:86.04 Exchanging of standardized plan -- Offering.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:86.04. Exchanging of standardized plan -- Offering.\r\nThe new policy or certificate shall be offered to all policyholders or\r\ncertificateholders within a given plan, except where the offer or issue would\r\nbe in violation of state or federal law.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:87 Applicability of genetic information.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:87. Applicability of genetic information.\r\nSections 20:06:13:88 to 20:06:13:92, inclusive, apply to all policies with\r\npolicy years beginning after May 20, 2009.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:88 Definitions applicable to genetic information.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:88. Definitions applicable to genetic information.\r\nThe following terms are defined for purposes of §§ 20:06:13:88 to\r\n20:06:13:92, inclusive:

\r\n\r\n

(1) "Family\r\nmember," with respect to an individual, any other individual who is a\r\nfirst-degree, second-degree, third-degree, or fourth-degree relative of such\r\nindividual;

\r\n\r\n

(2) "Genetic\r\ninformation," with respect to any individual, information about such\r\nindividual's genetic tests, the genetic tests of family members of such\r\nindividual, and the manifestation of a disease or disorder in family members of\r\nsuch individual. Such term includes, with respect to any individual, any\r\nrequest for, or receipt of, genetic services, or participation in clinical\r\nresearch which includes genetic services, by such individual or any family\r\nmember of such individual. Any reference to genetic information concerning an\r\nindividual or family member of an individual who is a pregnant woman includes\r\ngenetic information of any fetus carried by such pregnant woman, or with\r\nrespect to an individual or family member utilizing reproductive technology,\r\nincludes genetic information of any embryo legally held by an individual or\r\nfamily member. The term genetic information does not include information about\r\nthe sex or age of any individual;

\r\n\r\n

(3) "Genetic\r\nservices," a genetic test, genetic education, or genetic counseling.\r\nGenetic counseling includes obtaining, interpreting, or assessing genetic\r\ninformation;

\r\n\r\n

(4) "Genetic\r\ntest," an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detect genotypes, mutations, or\r\nchromosomal changes. The term, genetic test, does not mean an analysis of\r\nproteins or metabolites that does not detect genotypes, mutations, or\r\nchromosomal changes; or an analysis of proteins or metabolites that is directly\r\nrelated to a manifested disease, disorder, or pathological condition that could\r\nreasonably be detected by a health care professional with appropriate training\r\nand expertise in the field of medicine involved;

\r\n\r\n

(5) "Issuer of a\r\nMedicare supplement policy or certificate," includes any insurance\r\ncompany, fraternal benefit society, health care service plan, health\r\nmaintenance organization, third party administrator, or other person acting for\r\nor on behalf of such issuer, and any other entity delivering or issuing for\r\ndelivery in this state Medicare supplement policies or certificates;

\r\n\r\n

(6) "Underwriting\r\npurposes:"

\r\n\r\n

(a) Rules for, or\r\ndetermination of, eligibility, including enrollment and continued eligibility,\r\nfor benefits under the policy;

\r\n\r\n

(b) The computation of\r\npremium or contribution amounts under the policy;

\r\n\r\n

(d) Other activities\r\nrelated to the creation, renewal, or replacement of a contract of health\r\ninsurance or health benefits.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:89 Use of genetic information.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:89. Use of genetic information. An issuer of a\r\nMedicare supplement policy or certificate may not deny or condition the\r\nissuance or effectiveness of the policy or certificate, including the\r\nimposition of any exclusion of benefits under the policy based on a\r\npre-existing condition on the basis of the genetic information with respect to\r\nsuch individual. The issuer may not discriminate in the pricing of the policy\r\nor certificate including the adjustment of premium rates of an individual on\r\nthe basis of the genetic information with respect to such individual. Nothing\r\nin this section may be construed to limit the ability of an issuer, to the\r\nextent otherwise permitted by law, from denying or conditioning the issuance or\r\neffectiveness of the policy or certificate or increasing the premium for a\r\ngroup based on the manifestation of a disease or disorder of an insured or\r\napplicant or increasing the premium for any policy issued to an individual\r\nbased on the manifestation of a disease or disorder of an individual who is\r\ncovered under the policy. In such case, the manifestation of a disease or\r\ndisorder in one individual may not also be used as genetic information about\r\nother group members and to further increase the premium for the group.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:90 Request of genetic testing.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:90. Request of genetic testing. Except as\r\nprovided under § 20:06:13:91 an issuer of a\r\nMedicare supplement policy or certificate may not request or require an\r\nindividual or a family member of such individual to undergo a genetic test.\r\nThis section may not be construed to preclude an issuer of a Medicare\r\nsupplement policy or certificate from obtaining and using the results of a\r\ngenetic test in making a determination regarding payment as defined for the\r\npurposes of applying the regulations promulgated under Part C of Title XI and\r\nsection 264 of the Health Insurance Portability and Accountability Act of 1996,\r\nand consistent with § 20:06:13:88. An issuer of a Medicare supplement\r\npolicy or certificate may request only the minimum amount of information necessary\r\nto accomplish the intended purpose.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:91 Requirement of genetic testing.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:91. Requirement of genetic testing. An issuer of\r\na Medicare supplement policy may request, but not require, that an individual\r\nor a family member of such individual undergo a genetic test if each of the\r\nfollowing conditions is met:

\r\n\r\n

(1) The request is made\r\npursuant to research that complies with Part 46 of Title 45, Code of Federal\r\nRegulations, or equivalent federal regulations, and any applicable state or\r\nlocal law or regulations for the protection of human subjects in research;

\r\n\r\n

(2) The issuer clearly\r\nindicates to each individual, or in the case of a minor child, to the legal\r\nguardian of such child, to whom the request is made that:

\r\n\r\n

(a) Compliance with\r\nthe request is voluntary; and

\r\n\r\n

(b) Non-compliance\r\nwill have no effect on enrollment status or premium or contribution amounts;

\r\n\r\n

(3) The issuer notifies the\r\nSecretary of Health and Human Services in writing that the issuer is conducting\r\nactivities pursuant to the exception provided for under this section, including\r\na description of the activities conducted;

\r\n\r\n

(4) The issuer complies\r\nwith such other conditions as the Secretary of Health and Human Services may by\r\nregulation require for activities conducted under this section and the\r\nregulation has been adopted through the issuance of a bulletin by the director.

\r\n\r\n

No genetic information collected or\r\nacquired under this section may be used for underwriting, determination of\r\neligibility to enroll or maintain enrollment status, premium rates, or the\r\nissuance, renewal, or replacement of a policy or certificate.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

\r\n\r\n\r\nRule 20:06:13:92 Genetic information -- Underwriting purposes and enrollment.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

\r\n\r\n

20:06:13:92. Genetic information -- Underwriting purposes and\r\nenrollment. An issuer of a Medicare supplement policy or certificate may\r\nnot request, require, or purchase genetic information for underwriting\r\npurposes. An issuer of a Medicare supplement policy or certificate may not\r\nrequest, require, or purchase genetic information for underwriting purposes\r\nwith respect to any individual prior to such individual's enrollment under the\r\npolicy in connection with such enrollment.

\r\n\r\n

If genetic information is obtained\r\nincidental to the requesting, requiring, or purchasing of other information\r\nconcerning any individual, such request, requirement, or purchase may not be\r\nconsidered a violation of this section.

\r\n\r\n

Source:\r\n35 SDR 183, effective February 2, 2009.

\r\n\r\n

General\r\nAuthority: SDCL 58-17A-2.

\r\n\r\n

Law\r\nImplemented: SDCL 58-17A-2.

\r\n\r\n

\r\n\r\n\r\n\r\n\r\n

","Archived":[],"Next":"20:06:13:0A","Previous":"20:06:12:09"}