Rule 20:06:13:70 Disclosure and outline of coverage requirements.
20:06:13:70. Disclosure and outline of coverage requirements.
A Medicare select issuer shall make full disclosure in writing of the
provisions, restrictions, and limitations of the Medicare select policy or
certificate to each applicant. This disclosure must include at least the
(1) An outline of coverage
sufficient to permit the applicant to compare the coverage and premiums of the
Medicare select policy or certificate with other Medicare supplement policies
or certificates offered by the issuer and other Medicare select policies or
(2) A description of the
network providers, including primary care physicians, specialty physicians,
hospitals, and other providers. At a minimum, the description must include each
provider's address, telephone number, and hours of operation;
(3) A description of the
restricted network provisions, including payments for coinsurance and
deductibles when providers other than network providers are utilized. Except to
the extent specified in the policy or certificate, expenses incurred when using
out-of-network providers do not count toward the out-of-pocket annual limit
contained in plans K and L;
(4) A description of
coverage for emergency and urgently needed care and other out-of-service area coverage;
(5) A description of
limitations on referrals to restricted network providers and to other
(6) A description of the
policyholders' rights to purchase any other Medicare supplement policy or
certificate otherwise offered by the issuer; and
(7) A description of the
Medicare select issuer's quality assurance program and
22 SDR 107, effective February 18, 1996; 31 SDR 214, effective July 6, 2005.
Authority: SDCL 58-17A-2(11), 58-17A-2(14), 58-17A-6, 58-17A-7.
Implemented: SDCL 58-17A-2, 58-17A-5.
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