reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:41.01 - Agreement required if rent includes cost of heat

Current through Register Vol. 51, page 10, July 15, 2024
If the household's rent includes the cost of heat, the landlord must
	 sign the agreement specified in §
									67:15:01:41. Failure of the
	 landlord to sign the agreement will result in the household's
	 ineligibility.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:41.02 - Amount of payment if rent includes cost of heat

Current through Register Vol. 51, page 10, July 15, 2024
If the household's rent includes the cost of heat, the LIEAP payment
	 may be up to 30 percent of the household's monthly rent.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:43 - Payment date

Current through Register Vol. 51, page 10, July 15, 2024
If a household is eligible for direct payments, the department shall
	 pay the household within 21 days after the department notifies the household of
	 its eligibility.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:43.01 - Payment limits

Current through Register Vol. 51, page 10, July 15, 2024
Monthly LIEAP payment will continue to be made to the energy supplier
	 or landlord until one of the following has occurred:
(1) The household has reached its maximum
  LIEAP benefit level;
(2) The
  household no longer has a heating expense;
(3) The LIEAP program year has ended;
  or
(4) The funds available for
  LIEAP payments have been exhausted.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:44 - No changes to benefit level allowed

Current through Register Vol. 51, page 10, July 15, 2024
After a LIEAP benefit is paid, no adjustments may be made to the
	 benefit level due to changes in income, household size, fuel type, or
	 region.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:45 - Household's responsibility for charges beyond amount of assistance

Current through Register Vol. 51, page 10, July 15, 2024
If a household's energy bill exceeds the amount of energy assistance
	 for which the household is eligible, the household is responsible to the
	 supplier for the excess charges.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:46 - Duplicate payments

Current through Register Vol. 51, page 10, July 15, 2024
Households may only be determined eligible for LIEAP assistance once
	 during the program year. The department shall consider it a duplicate payment
	 if a member of a household previously received LIEAP assistance leaves that
	 household and later applies for energy assistance either as a separate
	 household or as part of another household.
The department shall consider it a duplicate payment if the household
	 has received LIEAP assistance from another state or tribal entity during the
	 current program year.
The provisions of this rule do not apply to children under the age of
	 19 if legal custody has changed from one parent to the other or if a joint
	 custody arrangement requires that the child resides in both parents' separate
	 households.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:46.01 - Recovery of overpayments

Current through Register Vol. 51, page 10, July 15, 2024
LIEAP payments made as a result of an agency error or a client error
	 are considered overpayments and are subject to recovery by the
	 department.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:47 - Change in energy supplier

Current through Register Vol. 51, page 10, July 15, 2024
A household may change energy suppliers if the household notifies the
	 department and obtains approval from the department and the current energy
	 supplier. When a change is requested, the household may not have a balance
	 owing for the current program year with the household's current energy
	 supplier.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
Requirements for energy suppliers, ch
		67:15:02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:48 - Notice to household of exhaustion of energy assistance funds

Current through Register Vol. 51, page 10, July 15, 2024
After the supplier or landlord has billed the department for the total
	 amount of energy assistance for which a household is eligible, the department
	 shall notify the household that all funds available to the household have been
	 spent and that the household is no longer eligible to receive further energy
	 assistance during the current energy assistance program year.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
Requirements for energy suppliers, ch
		67:15:02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:01 - General eligibility requirements › Section 67:15:01:49 - Request for fair hearing

Current through Register Vol. 51, page 10, July 15, 2024
An applicant or recipient requesting a fair hearing shall do so within
	 60 days of the action or inaction. Fair hearings shall be conducted according
	 to chapter 67:17:02.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
Fair hearings, ch
		67:17:02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:01 - Agreements required for direct payments

Current through Register Vol. 51, page 10, July 15, 2024
For an energy supplier or landlord to receive direct energy payments in
	 behalf of eligible households, the energy supplier or landlord shall have a
	 signed agreement with the department.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:02 - Limitation on payment

Current through Register Vol. 51, page 10, July 15, 2024
The energy supplier may use the energy assistance funds only for those
	 energy supply bills that are incurred by a household between July 1 and April
	 30 of the current program year and are unpaid at the time the claim is
	 submitted to the department for payment. Utility companies which bill their
	 customers monthly and which base their billings on their meter readings may
	 submit bills for energy assistance funds only for those meter readings
	 occurring between October 1 and May 15 of the current program
	 year.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:03 - Submission of claim forms for reimbursement

Current through Register Vol. 51, page 10, July 15, 2024
To obtain reimbursement for home energy supplies, an energy supplier or
	 landlord shall submit a signed claim to the department. The claim shall be
	 submitted on forms provided by the department. The energy supplier may not
	 request reimbursement until the energy supply has been delivered to the
	 household.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:04 - Deadline for submission of claims

Current through Register Vol. 51, page 10, July 15, 2024
Energy claims submitted by energy suppliers or landlords in behalf of
	 eligible households must be postmarked on or before May 15. After that date,
	 the department shall revert any unused benefits to the LIEAP
	 fund.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:05 - Notice to energy supplier or landlord

Current through Register Vol. 51, page 10, July 15, 2024
At least once a month the department shall send to the participating
	 energy supplier or landlord notice of the following:
(1) Which of the supplier's customers or the
  landlord's tenants have been determined eligible for LIEAP;
(2) The total amount of energy assistance
  available to the household; and
(3)
  Balances remaining, if any, on the accounts after a LIEAP payment.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:06 - Time frame for payments to energy suppliers or landlords

Current through Register Vol. 51, page 10, July 15, 2024
The department shall make payments to participating energy suppliers or
	 landlords in behalf of eligible households within 21 days after receipt of the
	 supplier's or landlord's claim by the department.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:07 - Energy supplier to bill household for overages

Current through Register Vol. 51, page 10, July 15, 2024
If the actual cost of home energy exceeds the payment made under LIEAP
	 or ECIP, the energy supplier shall bill the household and collect the excess
	 charges.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:02 - Requirements for energy suppliers › Section 67:15:02:08 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department shall conduct energy supplier and landlord utilization
	 reviews to determine whether or not energy suppliers and landlords meet the
	 requirements of the energy supply agreement and this article.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:01 - ECIP application

Current through Register Vol. 51, page 10, July 15, 2024
An individual desiring ECIP assistance may apply by contacting the
	 department's Office of Energy Assistance.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:02 - Deadline for application

Current through Register Vol. 51, page 10, July 15, 2024
ECIP applications will be taken beginning the first working day in
	 October and ending on March 31.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:03 - ECIP funds available for emergencies

Current through Register Vol. 51, page 10, July 15, 2024
ECIP funds are available in an emergency to a LIEAP-eligible household
	 that meets one of the following conditions:
(1) For a household whose heat is included in
  the rent or who pays rent plus heat, the household must provide the department
  with a copy of the eviction notice from the landlord for nonpayment of rent or
  heating costs;
(2) For a household
  whose primary source of heat is natural gas or electricity, the household must
  provide the department with a copy of its disconnect notice from the
  supplier;
(3) For a household whose
  primary source of heat is fuel oil or propane, its fuel tank must be at least
  80 percent empty and the fuel supplier must be requiring that a cash payment be
  made at the time the fuel is delivered.
The department must approve expenditures made under the provisions of
	 this chapter before the household incurs the expenses.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:03.01 - Income limits

Current through Register Vol. 51, page 10, July 15, 2024
To determine whether a household is income eligible for ECIP, the
	 department shall compute the household's income according to §
									67:15:01:10.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:04 - Limits for ECIP payments

Current through Register Vol. 51, page 10, July 15, 2024
Maximum ECIP payment levels for the fuel or electricity used for a
	 household's heating source shall be based on the ECIP income limits established
	 in §
									67:15:01:11. The maximum payments
	 for the heating season are established in §
									67:15:01:20.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:05 - Notice to eligible households

Current through Register Vol. 51, page 10, July 15, 2024
If a household is determined to be eligible for ECIP assistance, the
	 department shall notify the household of the amount of ECIP assistance for
	 which the household is eligible. Notification must be made within 48 hours
	 after the application is filed or within 18 hours after the application is
	 filed if a life-threatening situation exists for the
	 household.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:06 - Notice to ineligible households

Current through Register Vol. 51, page 10, July 15, 2024
If a household is determined to be ineligible for ECIP assistance, the
	 department shall inform the household of the reason for ineligibility within
	 three working days after the date of application.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:15 - Low income energy assistance › Chapter 67:15:04 - Energy crisis intervention › Section 67:15:04:07 - Fair hearings

Current through Register Vol. 51, page 10, July 15, 2024
A request for a fair hearing shall be made within 60 days from the date
	 of notice or inaction. Fair hearings shall be conducted according to chapter
	 67:17:02.
General Authority:
SDCL
		28-1-50.
Law Implemented:
SDCL
		28-1-46.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:03 - Eligibility starting date. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Long-term care residency requirement and beginning of eligibility,
		§
											67:46:03:03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:04 - Choosing a provider

Current through Register Vol. 51, page 10, July 15, 2024
An eligible individual is free to choose a provider from among those
	 willing to participate under the medical assistance program.
If the eligible individual is required to participate in the primary
	 care case management program, the individual must chose a provider according to
	 §
									67:16:39:06.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:06 - Payment of Medicare buy-in premiums

Current through Register Vol. 51, page 10, July 15, 2024
Payment of Medicare buy-in premiums shall be made for individuals who
	 are eligible under the federal Medicare program and are receiving SSI or who
	 are receiving benefits as a qualified Medicare beneficiary.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Qualified Medicare beneficiaries (QMB), ch
		67:46:11.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:06.01 - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
Covered services are those medically necessary health care services or
	 items that are within the service limits and meet the prior authorization
	 requirements specified in this article or article 67:54. The department will
	 pay for a medically necessary covered service furnished to a recipient or to a
	 person who is found to be eligible on the date of service.
Prior authorization is based on a review of required documentation to
	 determine if the conditions for Medicaid payment have been met. The review is
	 not considered a medical consultation.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Case management -- Primary care provider, ch 67:16:39; Covered
		services must be medically necessary, §
											67:16:01:06.02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:06.02 - Covered services must be medically necessary

Current through Register Vol. 51, page 10, July 15, 2024
Services covered under this article must be medically necessary. To be
	 medically necessary, the covered service must meet the following
	 conditions:
(1) It is consistent with
  the recipient's symptoms, diagnosis, condition, or injury;
(2) It is recognized as the prevailing
  standard and is consistent with generally accepted professional medical
  standards of the provider's peer group;
(3) It is provided in response to a
  life-threatening condition; to treat pain, injury, illness, or infection; to
  treat a condition that could result in physical or mental disability; or to
  achieve a level of physical or mental function consistent with prevailing
  community standards for diagnosis or condition;
(4) It is not furnished primarily for the
  convenience of the recipient or the provider; and
(5) There is no other equally effective
  course of treatment available or suitable for the recipient requesting the
  service which is more conservative or substantially less costly.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:06.03 - Covered services requiring prior authorization

Current through Register Vol. 51, page 10, July 15, 2024
The department requires prior authorization for certain services. The
	 provider shall obtain approval from the department before supplying services
	 subject to prior authorization. Services subject to prior authorization are
	 listed on the department's prior authorization website.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:07 - State payment as payment in full - Individual responsible for payment of noncovered services

Current through Register Vol. 51, page 10, July 15, 2024
Payments under this article made on behalf of an eligible individual
	 together with the individual's cost-sharing amount, if cost sharing is
	 required, are considered payment in full for medical services covered under the
	 provisions of this article. No additional charges may be made to family,
	 friends, political subdivisions, or the eligible individual unless the service
	 provided was a noncovered medical service. The eligible individual is
	 responsible for the payment of any noncovered service.
A claim submitted to the department under the provisions of §
									67:16:03:06.15 is considered to be
	 paid in full even if no additional payment is made by the
	 department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Services not covered, §
											67:16:01:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:08.01 - Sterilization services

Current through Register Vol. 51, page 10, July 15, 2024
Payment for sterilization services is limited to those services
	 provided after the conditions contained in §
									67:16:02:09 have been
	 met.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:09 - Amount of payment

Current through Register Vol. 51, page 10, July 15, 2024
The amount of payment for services under the medical assistance program
	 shall not exceed the provider's usual and customary charge.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:10 - Payment of mileage to provider

Current through Register Vol. 51, page 10, July 15, 2024
A provider is not entitled to payment of mileage unless authorized
	 under the provisions of chapter 67:16:25 or 67:16:49.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:11 - Payment made to provider

Current through Register Vol. 51, page 10, July 15, 2024
Payments on behalf of an eligible individual shall be made directly to
	 the provider.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:12 - Confidential information

Current through Register Vol. 51, page 10, July 15, 2024
All information concerning applicants and recipients of medical
	 assistance is limited to purposes directly connected with the administration of
	 the medical assistance program and shall be treated as confidential.
	 Information may only be released upon the approval of the patient. No list of
	 names of applicants or recipients shall be published. No materials sent or
	 distributed to applicants, recipients, fiscal agents, or medical providers
	 directly related to the administration of the medical assistance program shall
	 be used for political or commercial purposes.
General Authority:
SDCL
		28-1-32.
Law Implemented:
SDCL
		28-1-32.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:13 - Identification card

Current through Register Vol. 51, page 10, July 15, 2024
The department shall issue an identification card to an individual
	 eligible for medical services under this article. The individual must show this
	 identification card to the medical provider when requesting
	 services.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:16 - Uniformity of services

Current through Register Vol. 51, page 10, July 15, 2024
The amount, duration, and scope of medical care and services available
	 under the medical assistance program must be uniform for all eligible
	 individuals, except the early and periodic screening, diagnosis, and treatment
	 services provided for eligible individuals under 21 years of
	 age.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Early and periodic screening, ch 67:16:11; Case management Primary
		care provider, ch 67:16:39.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:17 - Fair hearings

Current through Register Vol. 51, page 10, July 15, 2024
Providers, applicants, and recipients shall be entitled to fair
	 hearings in accordance with the provisions of SDCL
	 28-6-6 and chapter
	 67:17:02.
General Authority:
SDCL
		28-6-6.
Law Implemented:
SDCL
		28-6-6.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:18 - Civil rights

Current through Register Vol. 51, page 10, July 15, 2024
A provider may not withhold services to any eligible individual because
	 of race, color, creed, religion, sex, ancestry, handicap, political belief,
	 marital or economic status, or national origin. A statement of compliance with
	 the Civil Rights Act of 1964 shall be submitted to the department upon
	 request.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:19 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review of services provided under the medical assistance
	 program shall be conducted by the department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:22 - Cost-sharing participants

Current through Register Vol. 51, page 10, July 15, 2024
All individuals are required to participate in cost sharing.
	 Individuals exempt from cost sharing include:
(1) Individuals under age 21;
(2) Individuals receiving hospice
  care;
(3) Individuals residing in a
  long-term care facility or receiving home and community-based
  services;
(4) American Indians who
  have ever received an item or service furnished by an Indian Health Services
  (IHS) provider or through referral under contract health services;
  and
(5) Individuals eligible
  through the Breast and Cervical Cancer program. Cost sharing is required for
  the services designated in chapters 67:16:02, 67:16:03, 67:16:06, 67:16:07,
  67:16:08, 67:16:09, 67:16:13, 67:16:14, 67:16:28, 67:16:29, 67:16:41, 67:16:42,
  67:16:44, and 67:16:46. Cost sharing is limited to the amount specified on the
  departments cost sharing website.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Cost sharing: Basis and purpose,
		42 C.F.R. §
												447.50.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:22.01 - Services exempt from cost sharing

Current through Register Vol. 51, page 10, July 15, 2024
Services exempt from cost sharing include:
1. Emergency services;
2. Family planning services;
3. Services relating to a pregnancy,
  post-partum condition, a condition caused by the pregnancy, or a condition that
  may complicate the pregnancy;
4.
  Provider-preventable services;
5.
  Laboratory services;
6. Psychiatric
  inpatient and rehabilitation services;
7. Radiological services;
8. Chemical dependency treatment;
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:23 - Cost sharing deducted from allowable reimbursement before payment

Current through Register Vol. 51, page 10, July 15, 2024
The department shall deduct the recipient's cost-sharing amount from
	 the provider's allowable reimbursement before paying the
	 provider.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:24 - Application of chapter

Current through Register Vol. 51, page 10, July 15, 2024
The rules in this chapter apply to all enrolled providers and
	 recipients.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:25 - Use of Current Procedural Terminology

Current through Register Vol. 51, page 10, July 15, 2024
The guidelines contained in CPT®2023: Current Procedural
	 Terminology apply to claims submitted under the provisions of chapters
	 67:16:02, 67:16:03, 67:16:05, 67:16:07, 67:16:08, 67:16:09, 67:16:11, 67:16:12,
	 67:16:13, 67:16:24, 67:16:25, 67:16:28, 67:16:29, 67:16:37, 67:16:41, 67:16:44,
	 and 67:16:48, unless otherwise specified.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
CPT®2023: Current Procedural Terminology
, American
		Medical Association, October 28, 2022. Copies may be obtained from the American
		Medical Association,
https://commerce.ama-assn.org/store/ui;$121.45
.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:26 - Use of International Classification of Diseases

Current through Register Vol. 51, page 10, July 15, 2024
Claims submitted under the provisions of chapters 67:16:02, 67:16:03,
	 67:16:05, 67:16:07, 67:16:09, 67:16:11, 67:16:13, 67:16:25, 67:16:41, 67:16:43,
	 67:16:44, 67:16:46, 67:16:47, and 67:16:48 must contain the applicable
	 diagnosis codes contained in the International Classification of Diseases, 10th
	 Revision, Clinical Modification, 2023.
Claims submitted under chapter 67:16:03 must also contain the
	 applicable procedure codes contained in the International Classification of
	 Diseases, 10th Revision, Procedure Coding System, 2023.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
International Classification of Diseases, 10th Revision,
		Clinical Modification
, American Medical Association, October 1, 2022.
		Copies may be obtained from the American Medical Association,
https://commerce.ama-assn.org/store/ui
;
		$88.83;
International Classification of Diseases, 10th Revision,
		Procedure Coding System,
American Medical Association, August 8, 2022.
		Copies may be obtained from the American Medical Association,
https://commerce.ama-assn.org/store/ui
;
		$89.12.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:27 - Use of Health Care Common Procedure Coding System

Current through Register Vol. 51, page 10, July 15, 2024
The guidelines contained in the Health Care Common Procedure Coding
	 System 2023 Level II apply to claims submitted under the provisions of chapters
	 67:16:02, 67:16:13, 67:16:28, 67:16:29, 67:16:44, 67:16:46, 67:16:47, 67:16:48,
	 and 67:54:09.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Health Care Common Procedure Coding System 2023 Level
		II
, American Medical Association, January 15, 2023. Copies may be
		obtained from the American Medical Association,
https://commerce.ama-assn.org/store/ui
;
		$89.23.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:01 - General provisions › Section 67:16:01:28 - Rates and procedures subject to review and amendment - Provider may request review

Current through Register Vol. 51, page 10, July 15, 2024
Rates paid under the provisions of article 67:16 and posted on the
	 department's website located
HERE
are subject to review and amendment by the department.
A provider may request that the department review a particular
	 reimbursement rate for possible adjustment or request the inclusion or
	 exclusion of a particular procedure code, item, or service for payment
	 purposes. The request must be in writing. When reviewing a request, the
	 department shall review paid claims information, Medicare fee schedules,
	 national coding lists, and documentation submitted by the provider or the
	 associated medical professional organization to determine whether a change is
	 warranted. When the review is complete, the department shall notify the
	 provider in writing of the results of the department's
	 review.
General Authority:
SDCL
		28-6-1,
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1,
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Clinical nurse specialist," an
  individual who is licensed under SDCL
  36-9-85 to perform the functions
  contained in SDCL
  36-9-87, or an individual licensed
  or certified in another state to perform those functions;
(2) "Medical and other health services," any
  of the items or services covered in this chapter under the sections on
  physician's and other health services;
(3) "Nurse anesthetist," an individual who is
  qualified under SDCL
  36-9-30.1 to perform the functions
  contained in SDCL
  36-9-3.1, or an individual
  licensed or certified in another state to perform those functions;
(4) "Nurse midwife," an individual who is
  qualified under SDCL chapter 36-9 A to perform the functions contained in SDCL
  36-9A-13, or an individual
  licensed or certified in another state to perform those functions;
(5) "Nurse practitioner," an individual who
  is qualified under SDCL chapter 36-9A to perform the functions contained in
  SDCL 36-9A-12, or an individual
  licensed or certified in another state to perform those functions;
(6) "Physician," a person licensed as a
  physician in accordance with the provisions of SDCL chapter 36-4 and qualified
  to provide medical and other health services under this chapter, or an
  individual licensed or certified in another state to perform those
  functions;
(7) "Physician
  assistant," an individual qualified and certified under the provisions of SDCL
  chapter 36-4 A, or an individual licensed or certified in another state to
  perform those functions;
(8)
  "Postoperative management only," performance of postoperative management by one
  physician or other licensed practitioner after another physician or other
  licensed practitioner has performed the surgical procedure;
(9) "Preoperative management only,"
  performance of preoperative care and evaluation by one physician or other
  licensed practitioner before another physician or other licensed practitioner
  performs the surgical procedure;
(10) "Procedure codes," identifying numbers
  used in the submission of claims for medical, surgical, and diagnostic
  services;
(11) "Reduced services,"
  those instances in which a service or procedure is partially reduced or
  eliminated at the physician or other licensed practitioners request;
  and
(12) "Unusual services," the
  situation under which the service provided is greater than that usually
  required for the procedure.
General Authority:
SDCL
		28-6-1(1).
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:01.01 - Fee schedules for physician services

Current through Register Vol. 51, page 10, July 15, 2024
Fee schedules for services provided under this chapter are available
	 on the department's fee schedule website. When computing the rate of
	 reimbursement for physician services, the department uses the following fee
	 schedules:
(1) Nonlaboratory fee
  schedule; and
(2) Laboratory fee
  schedule.
The fee schedules are subject to review and amendment by the
	 department. A provider may request that the department review a particular
	 reimbursement rate for possible adjustment or request the inclusion or
	 exclusion of a particular code from the list. When reviewing the requests, the
	 department shall review paid claims information, Medicare fee schedules,
	 national coding lists, and documentation submitted by the provider or the
	 associated medical professional organization to determine whether a change is
	 warranted.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:03 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
When computing the rate of reimbursement, the department uses the fee
	 schedules established under the provisions of §
									67:16:02:01.01. A claim submitted
	 under this chapter must be submitted at the provider's usual and customary
	 charge. Payment is limited to the lesser of the provider's usual and customary
	 charge or the payment established under the following provisions:
(1) For nonlaboratory procedures listed in
  the applicable fee schedule, the amount specified in the fee
  schedule;
(2) If no fee is
  specified for nonlaboratory procedures, payment is limited to forty percent of
  the usual and customary charge;
(3)
  For laboratory procedures listed in the applicable fee schedule, the amount
  specified in the fee schedule;
(4)
  If no fee is specified for laboratory procedures, payment is limited to sixty
  percent of the provider's usual and customary charge;
(5) For anesthesia services furnished by a
  physician, the fee established in the fee schedule on the department's fee
  schedule website. Time must be reported in fifteen minute units beginning from
  the time the physician begins to prepare the patient for induction and ending
  when the patient is placed under postoperative supervision and the physician is
  no longer in personal attendance;
(6) For anesthesia services furnished by a
  nurse anesthetist, the fee established in the fee schedule on the department's
  fee schedule website, computed according to subdivision (5) of this section as
  long as the anesthetist is assisting the physician in the care of the
  patient;
(7) For medical supplies
  incidental to the professional service provided, the fee established in the
  nonlaboratory fee schedule. If no fee is specified, payment is limited to
  ninety percent of the lesser of the provider's usual and customary charge or
  the manufacturer's suggested retail price;
(8) For injection and immunization
  procedures, the amount established in the nonlaboratory fee schedule. If no fee
  is specified, payment is limited to forty percent of the provider's usual and
  customary charge; and
(9) For
  prosthetic or orthotic devices or medical equipment provided by a physician,
  the fee established in the nonlaboratory fee schedule. If no fee is specified,
  payment is limited to seventy-five percent of the lesser of the provider's
  usual and customary charge or the manufacturer's suggested retail
  price.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2),
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:03.01 - Reimbursement for multiple surgeries

Current through Register Vol. 51, page 10, July 15, 2024
The department shall apply the provisions of this section and the fee
	 schedules established under the provisions of §
									67:16:02:01.01 to calculate the
	 rate of reimbursement if multiple surgical procedures are performed. Payment
	 for multiple surgical procedures performed during the same operating session is
	 limited to the lesser of the provider's usual and customary charge or the
	 amount specified in the following:
(1)
  Full allowable reimbursement for the primary surgical procedure and for a
  surgical procedure which cannot stand alone but which is performed as a part of
  a primary surgical procedure. All other procedures, except for bilateral
  procedures, performed during the same operating session require the use of the
  modifier 51 and are payable under the provisions of subdivision (3) of this
  section;
(2) For surgical
  procedures using the modifier 50 (bilateral procedure), 150 percent of the fee
  specified in the applicable fee schedule or, if no fee is listed, 40 percent of
  the provider's usual and customary charge;
(3) For secondary surgical procedures using
  the modifier 51 (multiple procedures performed on the same day), 50 percent of
  fee specified in the applicable fee schedule or, if no fee is listed, 30
  percent of the provider's usual and customary charge; and
(4) No reimbursement for surgical procedures
  that are incidental to the primary procedure, as determined by the
  department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:03.03 - Required modifier codes

Current through Register Vol. 51, page 10, July 15, 2024
A modifier provides the means by which the reporting provider
	 indicates on the claim form that a service or procedure that was performed was
	 altered by some specific circumstance but not changed in its definition or
	 code. If applicable, modifier codes must be included on the provider's claim
	 for services. A list of authorized modifier codes is available on the
	 department's modifier website.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:04 - Physician's services covered

Current through Register Vol. 51, page 10, July 15, 2024
Physician's services covered are limited to the following professional
	 services, which must be medically necessary and provided by a physician or
	 other licensed practitioner to a recipient:
(1) Medical and surgical services;
(2) Services and supplies furnished
  incidental to the professional services of a physician or other licensed
  practitioner;
(3) Psychiatric
  services;
(4) Drugs and biologicals
  administered which cannot be self-administered;
(5) Routine physical examinations;
(6) Routine visits to a nursing facility, a
  home and community-based service provider, an intermediate care facility for
  individuals with intellectual disabilities, or a home and community-based
  waiver service provider;
(7)
  Cosmetic surgery when incidental to prompt repair following an accidental
  injury or for the improvement of the functioning of a malformed body
  member;
(8) Family planning
  services;
(9) Pap smears;
(10) Dialysis treatments;
(11) Hysterectomies as authorized under
  42 C.F.R. §§
										441.250 to
  441.259, inclusive, as amended to
  April 1, 2017; and
(12) Hyperbaric
  oxygen therapy if the requirements listed on the department's prior
  authorization website are met.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Home and community-based services, ch 67:54:04.
HCBS waiver operated by the Division of Adult Services and Aging, ch
		67:44:03.
Covered services must be medically necessary, §
											67:16:01:06.02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:02 - Physician and other health services › Section 67:16:02:05 - Other health services covered

Current through Register Vol. 51, page 10, July 15, 2024
The other medically necessary health services and supplies covered
	 under the program are limited to the following:
(1) X rays for diagnostic and treatment
  purposes;
(2) Laboratory tests for
  diagnostic and treatment purposes;
(3) Prosthetic devices, except dental,
  including braces, artificial limbs, artificial eyes, augmentative communication
  devices, items to replace all or part of an internal body organ, and the
  replacement of such devices required by a change in the patient's condition. An
  augmentative communication device is covered under the provisions of chapter
  67:16:29;
(4) X-ray, radium, and
  radioactive isotope therapy, including materials and services of
  technicians;
(5) Surgical dressings
  following surgery;
(6) Splints,
  casts, and similar devices;
(7)
  Supplies necessary for the use of prosthetic devices or medical equipment
  payable under the provisions of chapter 67:16:29; and
(8) Hearing aids, subject to the limits and
  payment provisions established in chapter 67:16:29.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Medical equipment payable, §
											67:16:29:02.
Covered services must be medically necessary, §
											67:16:01:06.02.