Division of Insurance - Date Certain and Medicare Supplement Coverage Amounts

1 20:06:12:07. Guidelines for examination reports. The insurer's examination report must be
prepared in accordance with standards adopted by the National Association of Insurance
Commissioners in the Financial Condition Examiners Handbook, 2025 2026 edition.
Source: 21 SDR 144, effective February 19, 1995; 23 SDR 43, effective October 1, 1996; 23
SDR 202, effective June 1, 1997; 25 SDR 13, effective August 9, 1998; 26 SDR 26, effective
September 1, 1999; 27 SDR 54, effective December 4, 2000; 29 SDR 84, effective December 15,
2002; 31 SDR 21, effective August 23, 2004; 33 SDR 59, effective October 5, 2006; 34 SDR 271,
effective May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR 209, effective July 1,
2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25, 2012; 39 SDR 219,
effective June 26, 2013; 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; 45 SDR 10,
effective August 2, 2018; 46 SDR 26, effective September 4, 2019; 46 SDR 147, effective July 2,
2020; 47 SDR 137, effective June 28, 2021; 49 SDR 9, effective August 9, 2022; 50 SDR 13,
effective August 10, 2023; 50 SDR 157, effective July 1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-3-11, 58-3-26.
Law Implemented: SDCL 58-3-11.
Reference: Financial Condition Examiners Handbook, 2025 2026 edition, National
Association of Insurance Commissioners (NAIC). Copies may be obtained from the NAIC, 1100
Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-8300; http://www.naic.org.
Cost: $0.
2 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. 3 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.
A B C D F F* G
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 Deductible Part B Excess (100%) Foreign Travel Emergency Skilled Nursing Facility coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency 4 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 $[7,2208,000]; paid at 100% after limit reached Out-of-pocket limit $[3,6104,000]; 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 $2,870 $2,950 deductible. Benefits from high-deductible Plan F will not begin until out-of-pocket expenses exceed $2,870 $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. 5 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 6 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.] 7 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 ✓ 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) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Medicare Part B coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ copays apply3 ✓ ✓
Blood (first three pints) ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓
Part A hospice care coinsurance or copayment ✓ ✓ ✓ ✓ 50% 75% ✓ ✓ ✓ ✓
Skilled nursing facility coinsurance ✓ ✓ 50% 75% ✓ ✓ ✓ ✓
Medicare Part A deductible ✓ ✓ ✓ 50% 75% 50% ✓ ✓ ✓
Medicare Part B deductible ✓ ✓
Medicare Part B excess charges ✓ ✓
Foreign travel emergency (up to plan limits) 80% 80% 80% 80% 80% 80%
Out-of-pocket limit in [20252026]2 [$7,220$
8,000]2 [$3,610$4,
000]2
1Plans F and G also have a high-deductible option which require first paying a plan deductible of [$2,870$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. 8 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. 9 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $0 $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $[1,6761,736] (Part A deductible) $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 $0 $0 $0 Up to $[209.50217] a day All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
**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. 10 PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $0 Generally 20% $[257283] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $0 20% $0 $[257283] (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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $0 20% $0 $[257283] (Part B deductible) $0
11 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,6761,736](Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $0 $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 $0 $0 $0 Up to $[209.50217] a day All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
** 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. 12 PLAN B MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $0 Generally 20% $[257283] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts $0 $0 All costs
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $0 20% $0 $[257283] (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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $0 20% $0 $[257283] (Part B deductible) $0
13 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,6761,736](Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $0 $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $ [209.50217] a day $0 $0 $0 All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
**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. 14 PLAN C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $[257283] (Part B deductible) Generally 20% $0 $0
Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $[257283] (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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $[257283] (Part B deductible) 20% $0 $0 $0
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
15 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,6761,736](Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $0 $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $ [209.50217] a day $0 $0 $0 All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
**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. 16 PLAN D MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $0 Generally 20% $[257283] (Part B deductible) $0
Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $0 20% $0 $[257283] (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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $0 20% $0 $[257283] (Part B deductible) $0
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
17 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 $[2,8702,950] deductible. Benefits from the high-deductible Plan F will not begin until out-of-pocket expenses are $[2,8702,950]. 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 $[2,8702,950] DEDUCTIBLE,** PLAN PAYS] [IN ADDITION TO $[2,8702,950] DEDUCTIBLE,** YOU PAY] HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,6761,736](Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $0 $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $[209.50217] a day $0 $0 $0 All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
***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. 18 PLAN F or HIGH-DEDUCTIBLE PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[2,8702,950] deductible. Benefits from the high-deductible Plan F will not begin until out-of-pocket expenses are $[2,8702,950]. 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 $[2,8702,950] DEDUCTIBLE,** PLAN PAYS] [IN ADDITION TO $[2,8702,950] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $[257283] (Part B deductible) Generally 20% $0 $0
Part B Excess Charges (Above Medicare-approved amounts) $0 100% $0
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $[257283] (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 $[2,8702,950] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2,8702,950] DEDUCTIBLE,**] YOU PAY' HOME HEALTH CARE MEDICARE-APPROVED SERVICES --Medically necessary skilled care services and medical supplies ---Durable medical equipment ---First $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $[257283] (Part B deductible) 20% $0 $0 $0
(continued) 19 PLAN F or HIGH-DEDUCTIBLE PLAN F (continued) OTHER BENEFITS - NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [AFTER YOU PAY $[2,8702,950] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2,8702,950] 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
20 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 [$2,870$2,950] deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are [$2,870$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 $[2,8702,950] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2,8702,950] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,6761,736](Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $0 $0 $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 21st thru 100th day 101th day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $[209.50217] a day $0 $0 $0 All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
***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. 21 PLAN G or HIGH-DEDUCTIBLE PLAN G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 [$2,870$2,950] deductible. Benefits from the high-deductible Plan G will not begin until out-of-pocket expenses are [$2,870$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 $[2,8702,950] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2,8702,950] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $0 Generally 20% $[257283] (Unless Part B deductible has been met) $0
Part B Excess Charges (Above Medicare-approved amounts) $0 100% 0%
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $0 20% $0 $[257283] (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 $[2,8702,950] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2,8702,950] DEDUCTIBLE,**] YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES ---Medically necessary skilled care services and medical supplies ---Durable medical equipment First $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $0 20% $0 $[257283] (Unless Part B deductible has been met) $0
22 OTHER BENEFITS - NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [AFTER YOU PAY $[2,8702,950] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2,8702,950] 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 23 PLAN K *You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[7,2208,000] 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[838868] (50% of Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $[838868] (50% of Part A deductible)♦ $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $[104.75108.50] a day (50% of Part A coinsurance) $0 $0 Up to $[104.75108.50] a day (50% of Part A coinsurance)♦ All costs
BLOOD First 3 pints Additional amounts $0 100% 50% $0 50%♦ $0
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♦
***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. 24 PLAN K MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR ****Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts**** Preventative Benefits for Medicare-covered services Remainder of Medicare-approved amounts $0 Generally 80% or more of Medicare-approved amounts Generally 80% $0 Remainder of Medicare-approved amounts Generally 10% $[257283] (Part B deductible)****♦ All costs above Medicare-approved amounts Generally 10% Part B Excess Charges (Above Medicare-approved amounts) $0 0% All costs (and they do not count toward annual out-of-pocket limit of $[7,2208,000])*
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts**** Remainder of Medicare-approved amounts $0 $0 Generally 80% 50% $0 Generally 10% $50%♦ $[257283] (Part B deductible)****♦ Generally 10%♦
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[7,2208,000] 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 $[257283] of Medicare-approved amounts ***** Remainder of Medicare-approved amounts 100% $0 80% $0 $0 10% $0 $[257283] (Part B deductible)♦ 10%♦
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 25 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 $[3,6104,000] 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,2571,302] (75% of Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $[419434] (25% of Part A deductible)♦ $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $[157.13162.75] a day (75% of Part A coinsurance) $0 $0 Up to $[52.3854.25] a day (25% of Part A coinsurance)♦ All costs
BLOOD First 3 pints Additional amounts $0 100% 75% $0 25%♦ $0
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 ♦
***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. 26 PLAN L MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR ****Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts**** Preventative Benefits for Medicare-covered services Remainder of Medicare-approved amounts $0 Generally 80% or more of Medicare-approved amounts Generally 80% $0 Remainder of Medicare-approved amounts Generally 15% $[257283] (Part B deductible)****♦ All costs above Medicare-approved amounts Generally 5%♦
Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs (and they do not count toward annual out-of-pocket limit of $[3,6104,000])* BLOOD First 3 pints Next $[257283] of Medicare-approved amounts**** Remainder of Medicare-approved amounts $0 $0 Generally 80% 75% $0 Generally 15% $25% $[257283] (Part B deductible)****♦ Generally 5%♦
CLINICAL LABORATORY SERVICES --TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[3,5304,000] 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 $[257283] of Medicare-approved amounts ***** Remainder of Medicare-approved amounts 100% $0 80% $0 $0 15% $0 $[257283] (Part B deductible)♦ 5%♦
*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 27 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[838868] (50% of Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $[838868] (50% of Part A deductible) $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $[209.50217] a day $0 $0 $0 All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
***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. 28 PLAN M MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $0 Generally 20% $[257283] (Part B deductible) $0 Part B Excess Charges (Above Medicare-approved amounts) $0 $0 All costs BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $0 20% $0% $[257283] (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 $[257283] of Medicare-approved amounts * Remainder of Medicare-approved amounts 100% $0 80% $0 $0 20% $0 $[257283] (Part B deductible) $0
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 $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum benefit
29 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 61st thru 90th day 91st 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 $[1,6761,736] All but $[419434] a day All but $[838868] a day $0 $0 $[1,6761,736] (Part A deductible) $[419434] a day $[838868] a day 100% of Medicare-eligible expenses $0 $0 $0 $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 21st thru 100th day 101st day and after All approved amounts All but $[209.50217] a day $0 $0 Up to $[209.50217] a day $0 $0 $0 All costs
BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0
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 $0
**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. 30 PLAN N MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[257283] 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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 Generally 80% $0 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. $[257283] (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) $0 $0 All costs
BLOOD First 3 pints Next $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts $0 $0 80% All costs $0 20% $0% $[257283] (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 $[257283] of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $0 80% $0 $0 20% $0 $[257283] (Part B deductible) $0
31 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 $0 $0 $0 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum benefit
32 20:06:19:04. Accounting standards for transactions in exchange-traded call and put
options. An insurance company that buys or sells exchange-traded call and put options shall record
the details of the transactions in a manner consistent with National Association of Insurance
Commissioners (NAIC) rules and procedures contained in the 2024 2025 edition of the Annual
Statement Instructions - Life, Accident, and Health/Fraternal, the 2024 2025 edition of the Annual
Statement Instructions - Property and Casualty, the 2025 2026 edition of the Financial Condition
Examiners Handbook, the 2025 2026 edition of the Accounting Practices and Procedures Manual,
and the 2024 2025 edition of the Purposes and Procedures Manual of the NAIC Investment Analysis
Office.
Source: 13 SDR 75, effective December 21, 1986; 22 SDR 110, effective March 1, 1996; 23
SDR 43, effective October 1, 1996; 25 SDR 13, effective August 9, 1998; 26 SDR 26, effective
September 1, 1999; 27 SDR 54, effective December 4, 2000; 27 SDR 111, effective May 7, 2001;
30 SDR 39, effective September 28, 2003; 33 SDR 59, effective October 5, 2006; 34 SDR 271,
effective May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR 209, effective July 1,
2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25, 2012; 39 SDR 219,
effective June 26, 2013; 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; 45 SDR 10,
effective August 2, 2018; 46 SDR 26, effective September 4, 2019; 46 SDR 147, effective July 2,
2020; 47 SDR 137, effective June 28, 2021; 49 SDR 9, effective August 9, 2022; 50 SDR 13,
effective August 10, 2023; 50 SDR 157, effective July 1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-6-75, 58-27-7.
Law Implemented: SDCL 58-6-75.
References:
1. Annual Statement Instructions - Life, Accident and Health/Fraternal, 2024 2025
edition, National Association of Insurance Commissioners. Cost: $0. 33 2. Annual Statement Instructions - Property and Casualty, 2024 2025 edition, National
Association of Insurance Commissioners. Cost: $0.
3. Accounting Practices and Procedures Manual, 2025 2026 edition, National Association
of Insurance Commissioners. Cost: $0.
4. Financial Condition Examiners Handbook, 2025 2026 edition, National Association of
Insurance Commissioners. Cost: $0.
5. Purposes and Procedures Manual of the NAIC Investment Analysis Office, 2024 2025
edition, National Association of Insurance Commissioners. Cost: $0.
Copies of references 1 through 5 may be obtained from the National Association of Insurance
Commissioners, 1100 Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-8300;
http://www.naic.org.

34 20:06:25:01. Annual statements. An insurer shall file an annual statement in accordance
with the standards adopted by the National Association of Insurance Commissioners in the 2025
2026 edition of the Accounting Practices and Procedures Manual, and the 2024 2025 editions of the
following Annual Statement Instructions manuals: Life, Accident, and Health/Fraternal;
Property/Casualty; Health; and Title.
Source: 21 SDR 144, effective February 19, 1995; 22 SDR 110, effective March 1, 1996; 23
SDR 202, effective June 1, 1997; 25 SDR 13, effective August 9, 1998; 26 SDR 26, effective
September 1, 1999; 27 SDR 54, effective December 4, 2000; 27 SDR 111, effective May 7, 2001;
30 SDR 39, effective September 28, 2003; 31 SDR 21, effective August 23, 2004; 33 SDR 59,
effective October 5, 2006; 34 SDR 271, effective May 6, 2008; 35 SDR 165, effective December
22, 2008; 36 SDR 209, effective July 1, 2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219,
effective June 25, 2012; 39 SDR 219, effective June 26, 2013; 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; 45 SDR 10, effective August 2, 2018; 46 SDR 26, effective September 4,
2019; 46 SDR 147, effective July 2, 2020; 47 SDR 137, effective June 28, 2021; 49 SDR 9, effective
August 9, 2022; 50 SDR 13, effective August 10, 2023; 50 SDR 157, effective July 1, 2024; 51 SDR
142, effective July 3, 2025.
General Authority: SDCL 58-6-75.
Law Implemented: SDCL 58-6-75.
References:
1. Annual Statement Instructions - Life, Accident, and Health/Fraternal, 2024 2025
edition. Cost: $0.
2. Annual Statement Instructions - Property/Casualty, 2024 2025 edition. Cost: $0.
3. Annual Statement Instructions - Health, 2024 2025 edition. Cost: $0.
4. Annual Statement Instructions - Title, 2024 2025 edition. Cost: $0. 35 5. Accounting Practices and Procedures Manual, 2025 2026 edition. Cost: $0.
Copies of references 1 through 5 may be obtained from the National Association of Insurance
Commissioners, 1100 Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-8300;
http://www.naic.org.

36 20:06:25:01.01. Accounting methods for certain surety bonds. An insurer writing surety
bonds guaranteeing to lending institutions the repayment of student loans made by lending
institutions may, in lieu of compliance with SSAP No. 60 of the Accounting Practices and
Procedures Manual, 2025 2026 edition, develop premium earning patterns that are representative of
the insurer's claims and expense patterns by loan and program, and compute unearned premium
reserves according to those premium earning patterns. In lieu of compliance with SSAP No. 3 of the
Accounting Practices and Procedures Manual, 2025 2026 edition, changes in accounting estimates,
for this method of accounting only, may be amortized over the remaining life of the student loans
utilizing pro-rated current premium earning patterns. In lieu of compliance with SSAP No. 53 of the
Accounting Practices and Procedures Manual, 2025 2026 edition, the insurer may recognize written
premiums when due.
Source: 27 SDR 111, effective May 7, 2001; 29 SDR 5, effective July 10, 2002; 30 SDR 39,
effective September 28, 2003; 31 SDR 21, effective August 23, 2004; 33 SDR 59, effective October
5, 2006; 34 SDR 271, effective May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR
209, effective July 1, 2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25,
2012; 39 SDR 219, effective June 26, 2013; 41 SDR 41, effective September 17, 2014; 42 SDR 52,
effective October 13, 2015; 42 SDR 177, effective June 28, 2016; 45 SDR 10, effective August 2,
2018; 46 SDR 26, effective September 4, 2019; 46 SDR 147, effective July 2, 2020; 47 SDR 137,
effective June 28, 2021; 49 SDR 9, effective August 9, 2022; 50 SDR 13, effective August 10, 2023;
50 SDR 157, effective July 1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-6-75.
Law Implemented: SDCL 58-6-75.
Reference: Accounting Practices and Procedures Manual, 2025 2026 edition. Copies may
be obtained from the National Association of Insurance Commissioners, 1100 Walnut Street, Ste.
1500, Kansas City, MO 64106-2197,; (816) 783-8300; http://www.naic.org. Cost: $0. 37 20:06:25:01.02. Accounting methods for bail bonds. An insurer writing bail bonds may, in
lieu of compliance with SSAP No. 53 of the Accounting Practices and Procedures Manual, 2025
2026 edition, report bail bond written premiums less agent commissions and may recognize total
premiums as earned on the effective date of the bonds. An insurer reporting premiums on this method
shall file a supplemental Schedule T with the annual statement setting forth the gross premiums by
state for premium tax purposes.
Source: 29 SDR 5, effective July 10, 2002; 30 SDR 39, effective September 28, 2003; 31
SDR 21, effective August 23, 2004; 33 SDR 59, effective October 5, 2006; 34 SDR 271, effective
May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR 209, effective July 1, 2010; 37
SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25, 2012; 39 SDR 219, effective June
26, 2013; 41 SDR 41, effective September 17, 2014; 42 SDR 52, effective October 13, 2015; 42
SDR 177, effective June 28, 2016; 45 SDR 10, effective August 2, 2018; 46 SDR 26, effective
September 4, 2019; 46 SDR 147, effective July 2, 2020; 47 SDR 137, effective June 28, 2021; 49
SDR 9, effective August 9, 2022; 50 SDR 13, effective August 10, 2023; 50 SDR 157, effective July
1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-6-75.
Law Implemented: SDCL 58-6-75.
Reference: Accounting Practices and Procedures Manual, 2025 2026 edition. Copies may
be obtained from the National Association of Insurance Commissioners, 1100 Walnut Street, Ste.
1500, Kansas City, MO 64106-2197,; (816) 783-8300; http://www.naic.org. Cost: $0.
38 20:06:25:02. Actuarial opinions. Actuarial opinions must be filed in accordance with
standards adopted by the National Association of Insurance Commissioners in the manuals on
Annual Statement Instructions - Life, Accident, and Health/Fraternal, 2024 2025 edition, and Annual
Statement Instructions - Property/Casualty, 2024 2025 edition.
Source: 21 SDR 144, effective February 19, 1995; 22 SDR 110, effective March 1, 1996; 23
SDR 202, effective June 1, 1997; 25 SDR 13, effective August 9, 1998; 26 SDR 26, effective
September 1, 1999; 27 SDR 54, effective December 4, 2000; 30 SDR 39, effective September 28,
2003; 31 SDR 21, effective August 23, 2004; 33 SDR 59, effective October 5, 2006; 34 SDR 271,
effective May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR 209, effective July 1,
2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25, 2012; 39 SDR 219,
effective June 26, 2013; 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; 45 SDR 10,
effective August 2, 2018; 46 SDR 26, effective September 4, 2019; 46 SDR 147, effective July 2,
2020; 47 SDR 137, effective June 28, 2021; 49 SDR 9, effective August 9, 2022; 50 SDR 13,
effective August 10, 2023; 50 SDR 157, effective July 1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-26-13.1, 58-26-46.
Law Implemented: SDCL 58-26-13.1, 58-26-46.
References:
1. Annual Statement Instructions - Life, Accident, and Health/Fraternal, 2024 2025
edition. Cost: $0.
2. Annual Statement Instructions - Property/Casualty, 2024 2025 edition. Cost: $0.
Copies of references 1 and 2 may be obtained from the National Association of Insurance
Commissioners, 1100 Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-8300;
http://www.naic.org. 39 20:06:26:01. Standards for rating and valuation of investments. The division's standards
for rating and valuing investments are set forth in the Purposes and Procedures Manual of the NAIC
Investment Analysis Office, 2024 2025 edition.
Source: 21 SDR 144, effective February 19, 1995; 22 SDR 110, effective March 1, 1996; 23
SDR 202, effective June 1, 1997; 25 SDR 13, effective August 9, 1998; 26 SDR 26, effective
September 1, 1999; 27 SDR 54, effective December 4, 2000; 30 SDR 39, effective September 28,
2003; 31 SDR 21, effective August 23, 2004; 33 SDR 59, effective October 5, 2006; 34 SDR 271,
effective May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR 209, effective July 1,
2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25, 2012; 39 SDR 219,
effective June 26, 2013; 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; 45 SDR 10,
effective August 2, 2018; 46 SDR 26, effective September 4, 2019; 46 SDR 147, effective July 2,
2020; 47 SDR 137, effective June 28, 2021; 49 SDR 9, effective August 9, 2022; 50 SDR 13,
effective August 10, 2023; 50 SDR 157, effective July 1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-27-108.
Law Implemented: SDCL 58-27-108.
Reference: Purposes and Procedures Manual of the NAIC Investment Analysis Office,
2024 2025 edition, National Association of Insurance Commissioners (NAIC). Copies may be
obtained from the NAIC, 1100 Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-
8300; http://www.naic.org. Cost: $0.
40 20:06:36:01. Definitions. Terms used in this chapter mean:
(1) "Adjusted RBC report," a RBC report that has been adjusted by the director in accordance
with § 20:06:36:06;
(2) "Corrective order," an order that has been issued by the director and which specifies the
corrective actions;
(3) "Domestic health organization," any health organization domiciled in this state;
(3)(4) "Domestic insurer," any insurance company domiciled in this state or any entity
required to comply with RBC pursuant to SDCL 58-4-48;
(4) "Domestic health organization," any health organization domiciled in this state;
(5) "Foreign health organization," any health organization that is licensed to do business in
this state but not domiciled in this state;
(5)(6) "Foreign insurer," any insurance company that is licensed to do business in this state
but not domiciled in this state;
(6) "Foreign health organization," any health organization that is licensed to do business in
this state but not domiciled in this state;
(7) "Health organization," any health maintenance organization,; limited health service
organization,; dental or vision plan,; hospital, medical, and dental indemnity or service corporation,;
or other managed care organization licensed under SDCL title 58, except an organization that is:
(a) Licensed as a life or health insurer or property and casualty insurer; and
(b) Subject to either life or property and casualty RBC requirements;
(8) "NAIC," the National Association of Insurance Commissioners;
(9)(8) "Life or health insurer," any:
(a) Insurance company licensed under SDCL title 58 to write life or health insurance; or
(b) Property and casualty insurer licensed to do business in this state writing only accident
and health insurance; 41 (9) "NAIC," the National Association of Insurance Commissioners;
(10) "Negative trend," a negative trend in the level of RBC over a period of time;
(10)(11) "Property and casualty insurer," any insurance company licensed under SDCL title
58 to do business in this state, excluding monoline mortgage guaranty insurers, financial guaranty
insurers, or and title insurers;
(11) "Negative trend," a negative trend in the level of RBC over a period of time;
(12) "RBC," risk-based capital;
(13) "RBC instructions," the 2024 NAIC RBC Forecasting and Instructions-Life/Fraternal,
the 2024 2025 NAIC RBC Forecasting and Instructions-Property/Casualty, and the 2024 2025
NAIC RBC Forecasting and Instructions-Health 2025 editions of the NAIC RBC Forecasting and
Instructions-Life/Fraternal, NAIC RBC Forecasting and Instructions-Property/Casualty, and NAIC
RBC Forecasting and Instructions-Health;
(14) "RBC plan," a comprehensive financial plan containing the elements specified in
§ 20:06:36:08;
(15) "RBC report," the report required in §§ 20:06:36:03 to 20:06:36:06, inclusive;
(16) "Revised RBC plan," a RBC plan rejected by the director that, which is revised by the
insurer or health organization, with or without the director's recommendation; and
(17) "Total adjusted capital," the sum of an insurer's or health organization's statutory capital
and surplus as determined in accordance with the statutory accounting applicable to the annual
financial statements required to be filed under SDCL 58-6-75, and any other items required by the
RBC instructions.
Source: 23 SDR 228, effective July 3, 1997; 25 SDR 13, effective August 9, 1998; 26 SDR
26, effective September 1, 1999; 27 SDR 54, effective December 4, 2000; 30 SDR 39, effective
September 28, 2003; 31 SDR 21, effective August 23, 2004; 33 SDR 59, effective October 5, 2006;
34 SDR 271, effective May 6, 2008; 35 SDR 165, effective December 22, 2008; 36 SDR 209, 42 effective July 1, 2010; 37 SDR 241, effective July 1, 2011; 38 SDR 219, effective June 25, 2012; 39
SDR 219, effective June 26, 2013; 41 SDR 41, effective September 17, 2014; 41 SDR 93, effective
December 3, 2014; 42 SDR 52, effective October 13, 2015; 42 SDR 177, effective June 28, 2016;
43 SDR 181, effective July 7, 2017; 45 SDR 10, effective August 2, 2018; 46 SDR 26, effective
September 4, 2019; 46 SDR 147, effective July 2, 2020; 47 SDR 137, effective June 28, 2021; 49
SDR 9, effective August 9, 2022; 50 SDR 13, effective August 10, 2023; 50 SDR 157, effective July
1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-4-48.
Law Implemented: SDCL 58-4-48.
References:
1. 2024 NAIC RBC Forecasting and Instructions-Life/Fraternal.,2025 edition. Cost: $0.
2. 2024 NAIC RBC Forecasting and Instructions-Property/Casualty., 2025 edition. Cost:
$0.
3. 2024 NAIC RBC Forecasting and Instructions-Health., 2025 edition Cost: $0.
Copies of references 1 through 3 may be obtained from the National Association of Insurance
Commissioners, 1100 Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-8300;
http://www.naic.org.
43 20:06:59:01. Valuation manual -- Operative date. The valuation of reserve liabilities for
life insurance contracts, annuity and pure endowment contracts, accident and health contracts, and
deposit-type contracts must be calculated in accordance with the standards in the Valuation Manual
of the National Association of Insurance Commissioners, 2025 2026 edition. The operative date for
the valuation manual is January 1, 2025 January 1, 2026.
Source: 43 SDR 80, effective December 5, 2016; 45 SDR 10, effective August 2, 2018; 46
SDR 26, effective September 4, 2019; 46 SDR 147, effective July 2, 2020; 47 SDR 137, effective
June 28, 2021; 49 SDR 9, effective August 9, 2022; 50 SDR 13, effective August 10, 2023; 50 SDR
157, effective July 1, 2024; 51 SDR 142, effective July 3, 2025.
General Authority: SDCL 58-26-45.1.
Law Implemented: SDCL 58-26-44.1(11), 58-26-45.1.
Reference: Valuation Manual of the National Association of Insurance Commissioners,
2025 2026 edition, National Association of Insurance Commissioners (NAIC). Copies may be
obtained from the NAIC, 1100 Walnut Street, Ste. 1500, Kansas City, MO 64106-2197,; (816) 783-
8300; http://www.naic.org. Cost: $0.