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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 following:

          (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 certificates;

          (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 providers;

          (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 grievance procedure.

          Source: 22 SDR 107, effective February 18, 1996; 31 SDR 214, effective July 6, 2005.

          General Authority: SDCL 58-17A-2(11), 58-17A-2(14), 58-17A-6, 58-17A-7.

          Law Implemented: SDCL 58-17A-2, 58-17A-5.


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