20:06:13:17.06. Make-up
of standardized benefit plans. The requirements for the make-up of
standardized Medicare supplement benefit plans issued for delivery after July
16, 1992, and prior to June 1, 2010, A to L, inclusive, are as follows:
(1) Standardized Medicare
supplement benefit Plan A is limited to the basic core benefits common to all
benefit plans, as defined in § 20:06:13:17.03;
(2) Standardized Medicare
supplement benefit Plan B may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible as
defined in § 20:06:13:17.04;
(3) Standardized Medicare
supplement benefit Plan C may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, Medicare Part B deductible, and medically necessary
emergency care in a foreign country as defined in § 20:06:13:17.04;
(4) Standardized Medicare
supplement benefit Plan D may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, medically necessary emergency care in a foreign country,
and the at-home recovery benefit as defined in § 20:06:13:17.04;
(5) Standardized Medicare supplement
benefit Plan E may include only the following: The core benefit as defined in
§ 20:06:13:17.03, plus the Medicare Part A deductible, skilled nursing
facility care, medically necessary emergency care in a foreign country, and
preventive medical care as defined in § 20:06:13:17.04;
(6) Standardized Medicare
supplement benefit Plan F may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, the
skilled nursing facility care, the Medicare Part B deductible, 100 percent of
the Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in § 20:06:13:17.04;
(7) Standardized Medicare
supplement benefit high deductible Plan F may include only the following: One
hundred percent of covered expenses following the payment of the annual high
deductible Plan F deductible. The covered expenses include the core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, the Medicare Part B deductible, 100 percent of the
Medicare Part B excess charges, and medically necessary emergency care in a
foreign country as defined in § 20:06:13:17.04. The annual high deductible
Plan F deductible consists of out-of-pocket expenses, other than premiums, for
services covered by the Medicare supplement Plan F policy, and are in addition
to any other specific benefit deductibles. The annual high deductible Plan F
deductible is $1500 for 1998 and 1999, and is based on the calendar year. It is
adjusted annually by the secretary to reflect the change in the Consumer Price
Index for all urban consumers for the twelve-month period ending with August of
the preceding year, and rounded to the nearest multiple of ten dollars.
(8) Standardized Medicare
supplement benefit Plan G may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, 80 percent of the Medicare Part B excess charges, medically
necessary emergency care in a foreign country, and that at-home recovery
benefit as defined in § 20:06:13:17.04;
(9) Standardized Medicare
supplement benefit Plan H may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, basic prescription drug benefit, and medically necessary
emergency care in a foreign country as defined § 20:06:13:17.04. The
outpatient prescription drug benefit may not be included in a Medicare
supplement policy sold after December 31, 2005;
(10) Standardized Medicare
supplement benefit Plan I may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, 100 percent of the Medicare Part B excess charges, basic
prescription drug benefit, medically necessary emergency care in a foreign
country, and at-home recovery benefit as defined in § 20:06:13:17.04. The
outpatient prescription drug benefit may not be included in a Medicare
supplement policy sold after December 31, 2005;
(11) Standardized Medicare
supplement benefit Plan J may include only the following: The core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, Medicare Part B deductible, 100 percent of the Medicare
Part B excess charges, extended prescription drug benefit, medically necessary
emergency care in a foreign country, preventive medical care, and at-home
recovery benefit as defined in § 20:06:13:17.04. The outpatient
prescription drug benefit may not be included in a Medicare supplement policy
sold after December 31, 2005;
(12) Standardized Medicare
supplement benefit high deductible Plan J consists of only the following: One
hundred percent of covered expenses following the payment of the annual high
deductible Plan J deductible. The covered expenses include the core benefit as
defined in § 20:06:13:17.03, plus the Medicare Part A deductible, skilled
nursing facility care, Medicare Part B deductible, 100 percent of the Medicare
Part B excess charges, extended outpatient prescription drug benefit, medically
necessary emergency care in a foreign country, preventive medical care benefit,
and at-home recovery benefit as defined in § 20:06:13:17.04. The annual
high deductible Plan J deductible consists of out-of-pocket expenses, other
than premiums, for services covered by the Medicare supplement Plan J policy,
and is in addition to any other specific benefit deductibles. The annual deductible
is $1500 for 1998 and 1999, and shall be based on a calendar year. It is
adjusted annually by the Secretary of Health and Human Services to reflect the
change in the Consumer Price Index for all urban consumers for the twelve-month
period ending with August of the preceding year, and rounded to the nearest
multiple of ten dollars. The outpatient prescription drug benefit may not be
included in a Medicare supplement policy sold after December 31, 2005;
(13) Standardized Medicare
supplement benefit Plan K shall consist of the following:
(a) Coverage of 100
percent of the Part A hospital coinsurance amount for each day used from the 61st
through the 90th day in any Medicare benefit period;
(b) Coverage of 100
percent of the Part A hospital coinsurance amount for each Medicare lifetime
inpatient reserve day used from the 91st through the 150th
day in any Medicare benefit period;
(c) Upon exhaustion of
the Medicare hospital inpatient coverage, including the lifetime reserve days,
coverage of 100 percent of the Medicare Part A eligible expenses for
hospitalization paid at the applicable prospective payment system (PPS) rate,
or other appropriate Medicare standard of payment, subject to a lifetime
maximum benefit of an additional 365 days. The provider shall accept the
issuer's payment as payment in full and may not bill the insured for any
balance;
(d) Medicare Part A
deductible: Coverage for 50 percent of the Medicare Part A inpatient hospital
deductible amount per benefit period until the out-of-pocket limitation is met
as described in subdivision (j);
(e) Skilled nursing
facility care: Coverage for 50 percent of the coinsurance amount for each day
used from the 21st day through the 100th day in a
Medicare benefit period for post-hospital skilled nursing facility care
eligible under Medicare Part A until the out-of-pocket limitation is met as
described in subdivision (j);
(f) Hospice care:
Coverage for 50 percent of cost sharing for all Part A Medicare eligible
expenses and respite care until the out-of-pocket limitation is met as
described in subdivision (j);
(g) Coverage for 50
percent, under Medicare Part A or B, or the reasonable cost of the first three
pints of blood, or equivalent quantities of packed red blood cells, unless replaced
in accordance with federal regulations until the out-of-pocket limitation is
met as described in subdivision (j);
(h) Except for
coverage provided in subdivision (i) below, coverage for 50 percent of the cost
sharing otherwise applicable under Medicare Part B after the policyholder pays
the Part B deductible until the out-of-pocket limitation is met as described in
subdivision (j);
(i) Coverage of 100
percent of the cost sharing for Medicare Part B preventative services after the
policyholder pays the Part B deductible; and
(j) Coverage of 100
percent of all cost sharing under Medicare Parts A and B for the balance of the
calendar year after the individual has reached the out-of-pocket limitation on
annual expenditures under Medicare Parts A and B of $4000 in 2006, indexed each
year by the appropriate inflation adjustment specified by the secretary;
(14) Standardized Medicare
supplement benefit Plan L shall consist of the following:
(a) The benefits
described in subdivisions 20:06:13:17.06(13)(a), (13)(b), (13)(c), and (13)(i);
(b) The benefits
described in subdivisions 20:06:13:17.06(13)(d), (13)(e), (13)(f), (13)(g), and
(13)(h), with 75 percent substituted for 50 percent; and
(c) The benefit
described in subdivision 20:06:13:17.06(13)(j), with $2000 substituted for
$4000.
Source:
18 SDR 225, effective July 17, 1992; 19 SDR 160, effective April 27, 1993; 25
SDR 44, effective September 30, 1998; 31 SDR 214, effective July 6, 2005; 35
SDR 183, effective February 2, 2009; 36 SDR 209, effective July 1, 2010.
General
Authority: SDCL 58-17A-2(9).
Law
Implemented: SDCL 58-17A-2(9).
