reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:07.02 - Maximum rate of payment - Patient transfer not medically necessary

Current through Register Vol. 51, page 10, July 15, 2024
If a patient is transferred between hospitals and the transfer is not
	 medically necessary, the total reimbursement for the combined care may not
	 exceed 100 percent of the payment the transferring hospital would have received
	 had all the needed services been provided by the transferring hospital.
The rate of reimbursement for the receiving hospital is the difference
	 between the transferring hospital's payment and the payment the transferring
	 hospital would have received had the entire episode of care been provided by
	 the transferring hospital. If the transferring hospital is eligible for 100
	 percent of the payment, no payment is made to the receiving hospital.
The cost of transporting the patient between hospitals is included in
	 the maximum DRG reimbursement and is not payable as a separate service under
	 the provisions of chapter 67:16:25.
This section does not apply if the transfer is from an out-of-state
	 hospital to a South Dakota hospital as long as the hospital care is medically
	 necessary.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:10 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department may review inpatient hospital service claims for the
	 following information:
(1) Necessity
  of admission;
(2) Length of
  stay;
(3) Coding;
(4) Computerized claims processing;
(5) Post-payment review; and
(6) Peer review.
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 67:16:03 - Hospital services › Section 67:16:03:11 - Inpatient psychiatric hospital services

Current through Register Vol. 51, page 10, July 15, 2024
Services provided by freestanding psychiatric hospitals are not
	 payable.
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 67:16:03 - Hospital services › Section 67:16:03:13

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Cost-sharing participants, §
											67:16:01:22.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:14 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted at
	 the hospital's usual and customary charge to the general public and must comply
	 with the informational requirements established in the
Official UB-04
	 Data Specifications Manual 2023.
Claims for outpatient laboratory services must contain the applicable
	 procedure codes from the
Current Procedural Terminology
adopted in
	 §
									67:16:01:25.
General Authority:
SDCL
		28-6-1(4).
Law Implemented:
SDCL
		28-6-1.
Official UB-04 Data Specifications Manual 2023
,
https://www.nubc.org/ub-04-products
;
		$165.00.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:14.01 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim submitted under this chapter must be submitted at the
	 provider's usual and customary charge.
For an outpatient laboratory test, the laboratory which actually
	 performed the test must submit the claim for the test.
For an inpatient laboratory test, the hospital must submit the claim
	 for the test on the patient's inpatient hospital claim.
If the claim is for emergency care, the claim must so
	 indicate.
General Authority:
SDCL
		28-6-1(4).
Law Implemented:
SDCL
		28-6-1(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:14.02 - Claim requirements for individuals subject to managed care who remain in psychiatric unit beyond established discharge date

Current through Register Vol. 51, page 10, July 15, 2024
A hospital must submit two separate claims for individuals who are
	 subject to care management under the provisions of chapter 67:16:40 but who
	 remained in the unit beyond the discharge date established by the care
	 manager.
The first claim must meet the requirements of §
									67:16:03:14 and must cover the
	 length of stay authorized by the care manager. The claim must contain the
	 unit's provider identification number, the provider's usual and customary
	 charge, and a patient status code of "30."
The second claim must meet the requirements of §
									67:16:03:14 and must cover the
	 length of stay that is beyond the established discharge date to the date of
	 actual discharge. The claim must contain the unit's provider identification
	 number and the appropriate discharge status code.
For purposes of this rule, the established discharge date is the date
	 set by the care manager for the individual's discharge from the unit. If the
	 care manager changes that date, the new date becomes the established discharge
	 date.
Services provided in an exempt unit that are not authorized by the care
	 manager are not reimbursable.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Rate of reimbursement if individual subject to care management
		remains in psychiatric unit beyond the established discharge date, §
											67:16:03:06.16.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:15 - Application of other chapters

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the rules contained in this chapter, providers and
	 recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33,
	 67:16:34, and 67:16:35.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:34 - Required financial reports

Current through Register Vol. 51, page 10, July 15, 2024
A nursing facility shall submit to the department a statistical and
	 cost summary report relating to the operation of the facility no later than 150
	 days following the close of the facility's fiscal year. The report must be
	 completed following generally accepted accounting procedures as defined in
	 §
									20:75:05:06 and the accrual method
	 of accounting. The report must cover the facility's most recent fiscal
	 accounting period and must be submitted on forms provided by the department or
	 by electronic media. The facility must have prior approval from the department
	 if submitting its forms electronically. The department may request additional
	 information to clarify and substantiate the facility's cost report. This
	 additional information shall serve as an attachment to the statistical and cost
	 summary report.
Failure to submit the required financial reports by the established
	 deadlines, failure to complete the report, failure to supply additional
	 information as requested by the department, or failure to comply with all
	 applicable rules within this article may result in the withholding of monthly
	 payments until the report is filed or until the facility complies with the
	 affected rules.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
Deadline extensions, §
											67:16:04:35.
Principles of reasonable cost reimbursement, 42 C.F.R. Part
		413.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:35 - Deadline extensions

Current through Register Vol. 51, page 10, July 15, 2024
The department may grant a facility an extension beyond the 150-day
	 deadline for filing its statistical and cost summary report. A facility's
	 request for an extension must be in writing and must be received by the
	 department at least 15 working days before the report's due date. The request
	 must contain a clear explanation of the need for the extension and the date
	 when the report can be submitted.
Approval of an extension request is based on the merits of the request
	 and for good cause. For purposes of this rule, good cause is one that supplies
	 a substantial reason for the delay, a legal excuse for the delay, or an
	 intervening action beyond the facility's control. Ignorance of the rule,
	 inconvenience, a cost report preparer engaged in other work, or an accountant
	 involved with income tax preparation is not good cause.
General Authority:
SDCL
		28-6-1(4).
Law Implemented:
SDCL
		28-6-1(4).
Required financial reports, §
											67:16:04:34.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:36 - Record retention

Current through Register Vol. 51, page 10, July 15, 2024
A nursing facility must retain all financial and statistical records
	 for a minimum of six years following the submission of statistical and cost
	 summary reports under §
									67:16:04:34. Records may not be
	 destroyed when an audit exception is pending, regardless of time. These records
	 must be made available on demand to representatives of the State of South
	 Dakota or the United States Department of Health and Human
	 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 67:16:04 - Nursing facility rate setting › Section 67:16:04:37 - Audits - Appeal provisions

Current through Register Vol. 51, page 10, July 15, 2024
The department shall conduct desk audits of the statistical and cost
	 reports submitted under §
									67:16:04:34. If a field audit is
	 conducted, the auditor shall hold an exit conference with representatives from
	 the facility to discuss and explain the preliminary audit findings. Following
	 the exit conference, the auditor shall prepare written audit findings and
	 comments and shall mail a copy to the facility.
The facility has 30 calendar days following receipt of a desk or field
	 audit report to contest an adjustment or a disallowed expenditure by requesting
	 an administrative hearing under the provisions of chapter 67:17:02. The
	 department may extend this time limit at the request of the provider. Such an
	 extension may not exceed 30 calendar days. The department may not accept
	 additional documentation from the provider once the time limit has expired. At
	 the hearing, the burden of proof is on the provider to demonstrate its
	 entitlement to Medicaid reimbursement by a preponderance of the
	 evidence.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Time limits for requesting hearing, §
											67:16:04:38.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:38 - Time limits for requesting hearing

Current through Register Vol. 51, page 10, July 15, 2024
A request for a fair hearing must be made within 30 days after the
	 department sends its final audit report to a nursing facility or within 60 days
	 after the department sends its final audit report to a nursing facility if the
	 department has granted the facility an extension of time to request a fair
	 hearing.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:39 - Notification of per diem rates

Current through Register Vol. 51, page 10, July 15, 2024
The department shall notify the nursing facility in writing of the
	 established per diem rates and the effective date of the rates. The date on the
	 letter is considered the date of notification.
The facility has 30 calendar days following the date of notification to
	 contest an established per diem rate by requesting an administrative hearing
	 under the provisions of chapter 67:17:02. The department may extend this time
	 limit at the request of the provider. Such an extension may not exceed 30
	 calendar days. The department may not accept additional documentation from the
	 provider once the time limit has expired. At the hearing, the burden of proof
	 is on the provider to demonstrate its entitlement to Medicaid reimbursement by
	 a preponderance of the evidence.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:40 - Absence of regulations - Allowable costs based on CMS-15

Current through Register Vol. 51, page 10, July 15, 2024
In the absence of specific regulations relating to allowable costs for
	 nursing care facilities, allowable cost decisions shall be based on the
	 criteria contained in the
Medicare Provider Reimbursement Manual
(CMS Pub 15-1), as specified in §
									67:16:04:62.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:41 - Routine services

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of cost reporting, the department considers the following
	 items and services to be routine:
(1)
  Shelter;
(2) At least three meals a
  day planned from the basic four food groups in quantity and variety to provide
  medically prescribed diets, including special oral, enteral, or parenteral
  dietary supplements used for meal or nourishment supplementation, even if
  written as a prescription item by a physician or other licensed
  practitioner;
(3) Expendable items
  used in the care and treatment of residents such as alcohol, applicators,
  cotton balls, band-aids, linen savers, colostomy supplies, catheters, catheter
  supplies, irrigation equipment, needles, syringes, IV equipment, support hose,
  hydrogen peroxide, enemas, tongue depressors, facial tissue, and
  over-the-counter medications;
(4)
  Screening tests such as Clinitest, Testape, and Ketostix;
(5) Personal hygiene items such as soap,
  lotion, powder, shampoo, deodorant, toothbrushes, toothpaste, denture cups and
  cleaner, mouthwash, and pericare products;
(6) Social services, activities, and the
  supplies necessary for each;
(7)
  Laundry services;
(8) Therapy
  services if provided by a facility employee or by a consultant who is under
  contract with the facility;
(9)
  Transportation services necessary to meet the medical and activity needs of the
  residents exclusive of ambulance services and secure medical transportation
  services. Reimbursement is limited to transportation to the nearest medical
  provider able to provide the service;
(10) Items which are used by individual
  residents but which are reusable and expected to be available, such as resident
  gowns, water pitchers, bedpans, ice bags, bed rails, canes, crutches, walkers,
  wheelchairs, traction equipment, alternating pressure pad and pump, and other
  medical equipment;
(11) General
  nursing services, including restorative nursing activities, toileting programs,
  administration of oxygen and medications, hand or tube feeding, care of
  incontinence, enemas, tray service, and personal hygiene including bathing,
  skin care, hair care, shaving, and oral hygiene;
(12) Oxygen and oxygen regulators,
  concentrators, tubing, masks, tents, and other equipment necessary for the
  administration of oxygen; and
(13)
  Respiratory services and supplies.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:42 - Nonroutine services

Current through Register Vol. 51, page 10, July 15, 2024
A facility may not include the cost of nonroutine services as an
	 allowable cost on the cost report required in §
									67:16:04:34. The provider of the
	 nonroutine service must bill the department directly. Nonroutine services
	 include the following types of services:
(1) Prescription drugs;
(2) Physician services for direct resident
  care;
(3) Laboratory and radiology
  services;
(4) Mental health
  services;
(5) Therapy services when
  provided by someone other than a facility employee or a licensed therapist who
  has a contract with the facility to provide the therapy;
(6) Prosthetic devices and prosthetic
  supplies provided for an individual resident which are prescribed by a doctor
  and cannot be altered for use by other residents; and
(7) Any other professional medical service or
  supply which may be billed directly to Medicare or Medicaid by the provider of
  the service.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:44 - Allowable costs of related-party transactions

Current through Register Vol. 51, page 10, July 15, 2024
The allowable costs associated with a related-party transaction are
	 equal to the actual cost to the related organization or the fair market value,
	 whichever is lower.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:45 - Rent paid to related-party organization not allowable - Cost of ownership used

Current through Register Vol. 51, page 10, July 15, 2024
Rent paid to a related-party organization is not an allowable cost.
	 Actual cost of ownership must be used. For purposes of this rule, cost of
	 ownership is mortgage interest, depreciation on and repairs to buildings and
	 equipment, insurance on buildings and equipment, and property
	 taxes.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:46 - Depreciation

Current through Register Vol. 51, page 10, July 15, 2024
The department calculates depreciation as follows:
(1) Masonry buildings are calculated using
  the straight-line method not to exceed three percent of the capital cost basis
  of the building. The capital cost basis for depreciation of new construction,
  major renovations, and facilities acquired through purchase is subject to a
  salvage value computation of at least fifteen percent;
(2) Frame buildings are calculated using the
  straight-line method not to exceed four percent of the capital cost basis of
  the building. The capital cost basis for depreciation of new construction,
  major renovations, and facilities acquired through purchase is subject to a
  salvage value computation of at least- fifteen percent;
(3) Fixed equipment are calculated based on
  the useful life of the item as determined according to the "Estimated Useful
  Lives of Depreciable Hospital Assets, 2018 Edition";
(4) Major movable equipment, furniture,
  automobiles, and specialized equipment are calculated using the straight-line
  method and the useful life of the item as determined according to the
  "Estimated Useful Lives of Depreciable Hospital Assets, 2018 Edition."
The department may allow a facility to deviate from a determination
	 based on the "Estimated Useful Lives of Depreciable Hospital Assets" if the
	 facility provides the department with documented historical proof of the
	 asset's useful life.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2).
Estimated Useful Lives of Depreciable Hospital Assets
,
		2018 edition, published by the American Hospital Association, 211 East Chicago
		Avenue, Chicago, Illinois 60611,
https://www.aha.org/
;
		$88.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:47 - Costs not allowed

Current through Register Vol. 51, page 10, July 15, 2024
The following costs are not allowed:
(1) Income tax;
(2) Compensation paid to owners or employees
  who serve on a facility's board of directors. Compensation paid to other board
  members is limited to $75 a day for each board meeting up to a maximum of 12
  meetings each fiscal year;
(3)
  Promotional and advertising expenses are not allowed except as provided in the
Medicare Provider Reimbursement Manual
(CMS Pub 15-1), as
  specified in §
									67:16:04:62;
(4) Travel and entertainment other than for
  professional meetings and direct operations of the facility;
(5) Costs of motor homes, boats, and other
  recreational equipment or vehicles, including operation and
  maintenance;
(6)
  Donations;
(7) Expenses of
  non-nursing facilities and operations to be calculated using allocation methods
  as outlined in the
Medicare Provider Reimbursement Manual
(CMS Pub
  15-1), as specified in §
									67:16:04:62;
(8) Bad debts, charity, and courtesy
  allowances;
(9) Carryover of costs
  lost due to any limit in this article;
(10) Costs of legal fees, accounting and
  consultant services, or other related costs incurred in connection with
  hearings, arbitration, or judicial proceedings pertaining to reimbursement
  rates. However, such costs are allowable when a facility's request for a
  reimbursement rate adjustment constitutes a valid claim;
(11) Acquisition costs, including legal fees,
  brokerage fees or commissions, accounting, administration, travel, and
  feasibility studies. This applies whether the costs are incurred as the result
  of the purchase or lease of a facility;
(12) Any cost of a sublease that exceeds the
  cost of the lease between the owner and the first lessee of the current
  lease;
(13) Any penalty or fee
  assessed by a government agency for tardy reporting, nonpayment of any other
  fee, or any other fee which could have been avoided; and
(14) Any fee paid for the preparation of the
  resident assessment after a government agency has withdrawn or suspended its
  approval for preparation of the document because of improper reporting of a
  resident's condition.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:49 - Occupancy

Current through Register Vol. 51, page 10, July 15, 2024
When determining a facility's nondirect care per diem rate, the
	 department shall use the facility's actual occupancy or three percent less than
	 the statewide average of all nursing facilities, whichever is greater.
The department shall waive this provision for the first twelve months
	 of operation of a newly constructed facility that does not replace an existing
	 facility. For the second twelve months, the occupancy factor used to establish
	 the facility's per diem rate is three percent less than the statewide average
	 of all nursing facilities or the facility's actual occupancy for the last
	 quarter of the first twelve months prorated to - twelve months, whichever is
	 greater.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:50 - Return on net equity

Current through Register Vol. 51, page 10, July 15, 2024
A return on net equity is an allowable cost for proprietary facilities.
	 The allowable rate of return is the sum of the average midpoint of the prime
	 interest rate and the average rate of 180-day United States treasury bills as
	 reported on the last business day of June, September, December, and March,
	 divided by two. The rate of return may not exceed ten
	 percent.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:52 - Maximum capital cost for leased facility

Current through Register Vol. 51, page 10, July 15, 2024
The maximum capital cost for leased facilities is limited to the lower
	 of actual costs or the total capital costs per resident day established in
	 §
									67:16:04:51.
The capital cost items for computing the above limit consist of rent,
	 building insurance, building depreciation, furniture and equipment
	 depreciation, amortization of organization and preoperating costs, capital
	 related interest, and return on net equity. The capital cost items are
	 allowable only if incurred and paid by the lessee. Capital costs incurred by
	 the lessor and passed on to the lessee will not be allowed in any other manner
	 than as outlined in this section. No reimbursement is allowed for additional
	 costs related to subleases.
The maximum allowed for the rental component of the capital cost items
	 for facilities negotiating new leases and facilities renewing, assigning,
	 selling, transferring, or otherwise changing existing leases after June 30,
	 1999, is limited to the lower of actual lease costs or seventy percent of the
	 average per diem cost of the capital cost for owner-managed facilities,
	 excluding hospital-affiliated facilities.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:54 - Method of establishing per diem rates

Current through Register Vol. 51, page 10, July 15, 2024
The department shall establish a case mix adjusted direct care per diem
	 rate and a nondirect care per diem rate for each facility prior to July 1 of
	 each year. These rates are based on the facility's allowable costs, the
	 facility's Patient Driven Payment Model case mix score, inflation factors, cost
	 ceilings, occupancy, and known future cost increases that have prior
	 departmental approval.
The case mix adjusted direct care per diem rate is established on a
	 facility-specific basis using allowable direct patient care costs and paid
	 according to the Patient Driven Payment Model index under the Patient Driven
	 Payment Model classification system on a resident-specific basis. The case mix
	 adjusted direct care per diem rate is established by calculating the average
	 Patient Driven Payment Model case mix score for the facility, determining the
	 per diem case mix component cost for the facility by dividing the allowable
	 cost by total resident days, and dividing the facility's per diem case mix
	 component cost by its Patient Driven Payment Model average case mix score. The
	 case mix adjusted direct care per diem cost is used to establish the case mix
	 adjusted direct care cost ceilings established in §
									67:16:04:51, and the case mix
	 adjusted direct care per diem rate is subject to those ceilings and the payment
	 limits established in § 67:16:04:54.01.
The nondirect care per diem rate is established on a facility-specific
	 basis using all other allowable costs. The nondirect care per diem rate is
	 based on cost components consisting of health and subsistence, general
	 administrative, other operating, plant, plant operations, and capital. The
	 nondirect care per diem rate is established by dividing the allowable nondirect
	 care costs by the occupancy as determined according to §
									67:16:04:49. The allowable
	 nondirect care costs are used to establish the ceilings contained in §
									67:16:04:51, and the nondirect
	 care per diem rate is subject to those ceilings and the payment limits
	 established in § 67:16:04:54.02. The nondirect care cost is not subject to
	 case mix adjustment.
The per diem rate for the nondirect care costs of administration is
	 subject to the payment limits established in § 67:16:04:54.03.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2).
Payment adjustment due to review of resident assessment, §
											67:45:03:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:54.01 - Method of establishing per diem rates - Case mix adjusted direct care costs

Current through Register Vol. 51, page 10, July 15, 2024
When calculating the allowable payment for the case mix adjusted direct
	 care costs for the state fiscal year 2005 and thereafter, the department shall
	 pay 80 percent of the costs between the 115 and 125 percent ceilings.
The department does not recognize any case mix adjusted direct care
	 costs which exceed 125 percent.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
Ceilings, §
											67:16:04:51.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:54.02 - Method of establishing per diem rates - Nondirect care costs of health and subsistence, plant/operational, and other operating costs

Current through Register Vol. 51, page 10, July 15, 2024
When calculating the allowable payment for the nondirect care costs of
	 health and subsistence, plant/operational, and other operating costs for the
	 state fiscal year 2005 and thereafter, the department shall pay 80 percent of
	 the costs between the 105 and 110 percent ceilings.
The department does not recognize any of the nondirect care costs of
	 health and subsistence, plant/operation, and other operating costs which exceed
	 110 percent.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
Ceilings, §
											67:16:04:51.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:54.03 - Method of establishing per diem rates - Nondirect care costs of administration

Current through Register Vol. 51, page 10, July 15, 2024
When calculating the allowable payment for the nondirect care costs of
	 administration for the state fiscal year 2005 and thereafter, the department
	 shall pay 80 percent of the costs between the 105 and 110 percent
	 ceilings.
The department does not recognize any of the nondirect care costs of
	 administration which exceed 110 percent.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
Ceilings, §
											67:16:04:51.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:55 - Provisional per diem rates

Current through Register Vol. 51, page 10, July 15, 2024
The department shall establish provisional per diem rates for newly
	 constructed facilities and for facilities experiencing major expansion. The
	 department shall calculate provisional per diem rates according to §
									67:16:04:54 and shall base the
	 rates on projected costs to be submitted to the department prior to the opening
	 date of a newly constructed facility. Provisional per diem rates are effective
	 for six months only. After six months, the department shall adjust rates
	 retroactively on the basis of actual costs.
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:56 - Per diem rates as payment in full

Current through Register Vol. 51, page 10, July 15, 2024
The per diem rates established by the department are applied to every
	 resident in the facility who is eligible for Medicaid, excluding those
	 classified as assisted living, and payment made on behalf of an eligible
	 individual is considered payment in full as provided in §
									67:16:01:07.
Additional amounts may be payable as add-on payments.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Add-on payment -- Ventilator, §
											67:16:04:59; Payment adjustment
		due to review of resident assessment, §
											67:45:03:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:56.01 - Per diem rate - Existing facility experiencing new operational ownership

Current through Register Vol. 51, page 10, July 15, 2024
For a facility acquired through purchase or a capital lease, the daily
	 rate of reimbursement is the amount paid to the facility under the previous
	 operator as determined according to §
									67:16:04:54. This rate shall be
	 adjusted by inflation or other increases as appropriated by the South Dakota
	 Legislature until the facility's new required financial reports are used to
	 calculate rates according to §
									67:16:04:54.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:58 - Facility's average per diem charge

Current through Register Vol. 51, page 10, July 15, 2024
A nursing facility which elects to participate in the Medicaid program
	 must notify the department of its average per diem charge to individuals who
	 are not presently receiving nursing facility benefits under Medicare, Medicaid,
	 or Veterans Administration programs. Notice must be made by the first day of
	 the third month after the department notifies the facility of the Medicaid per
	 diem rates set by the department.
Medicaid reimbursement is limited to the lower of the facility's
	 average private pay per diem charge, as case mix adjusted, or the facility's
	 Medicaid per diem rates for direct and nondirect care established by the
	 department by July 1 of each year. If the facility's case mix adjusted average
	 private pay per diem charge is less than the facility's case mix adjusted
	 Medicaid per diem rate, the department shall amend the facility's case mix
	 adjusted Medicaid rate to be no greater than the facility's case mix adjusted
	 private pay per diem 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 67:16:04 - Nursing facility rate setting › Section 67:16:04:59

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Documentation required for ventilator add-on payment, §
											67:45:02:07.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:60 - Basis of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment to participating providers of nursing facility services is made
	 on the following basis:
(1) Payment to
  in-state facilities is calculated using the per diem rates according to §
									67:16:04:54, multiplying the case
  mix adjusted direct care per diem rate by the resident's Patient Driven Payment
  Model weight established by the resident assessment, and adding the nondirect
  care rate for each day the Medicaid resident is an inpatient
  resident;
(2) Payment to
  out-of-state facilities providing nursing facility services to residents of
  South Dakota is the lesser of the Medicaid rate established by the state in
  which the facility is located or the South Dakota statewide average Medicaid
  rate for all in-state facilities. Payment to out-of-state facilities for care
  not available at in-state facilities is the rate recognized for the facility by
  the Medicaid agency in the state in which the facility is located;
(3) Payment for reserved bed days is governed
  by the provisions of §
									67:45:02:04 and is based on the
  resident's latest resident assessment and Patient Driven Payment Model nursing
  case mix group at the time of the resident's absence;
(4) Swing-bed hospitals are reimbursed at a
  daily rate established by the department. The daily rates are located on the
  department's fee schedule website. Swing-bed hospitals are reimbursed for
  assisted living at the current maximum rate paid for assisted living;
  and
(5) Coinsurance under the
  Medicare program is payable at the Medicare coinsurance rate.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2).
Payment adjustment due to review of resident assessment, §
											67:45:03:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:61 - Preadmission screening

Current through Register Vol. 51, page 10, July 15, 2024
No payment may be made in behalf of a resident of a nursing facility
	 who is mentally ill or intellectually or developmentally disabled and who was
	 admitted to the facility after December 31, 1988, and did not receive the
	 preadmission screening as required by § 1919(b)(3)(F) of the Social
	 Security Act as amended by § 4211 of Pub. L. No. 100-203, (101 Stat.
	 1330-183), January 1, 1989.
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 67:16:04 - Nursing facility rate setting › Section 67:16:04:62 - Medicare Provider Reimbursement Manual

Current through Register Vol. 51, page 10, July 15, 2024
Provider reimbursement under the provisions of this chapter and
	 chapter 67:16:44 is made by the department according to the
Medicare
	 Provider Reimbursement Manual
(CMS Pub 15-1), (December 2021) available
	 at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals
.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Absence of regulations -- Allowable costs based on CMS-15, §
											67:16:04:40.
Costs not allowed, §
											67:16:04:47.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:04 - Nursing facility rate setting › Section 67:16:04:63

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1(2).
Law Implemented:
SDCL
		28-6-1(2).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:05 - Home health services › Section 67:16:05:01 - Definition of terms

Current through Register Vol. 51, page 10, July 15, 2024
Terms used is this chapter mean:
(1) "Attending physician or other licensed
  practitioner," the individual's personal private physician or other licensed
  practitioner or a physician or other licensed practitioner assigned to care for
  the individual in the absence of a personal private physician or other licensed
  practitioner;
(2) "Custodial care,"
  services that do not require nursing supervision and are designed to assist an
  individual perform the activities of daily living;
(3) "Home health agency," an organization
  which is primarily engaged in providing skilled nursing, medical social
  services, or home health aide services and which meets the requirements of a
  home health agency under 42
  C.F.R. §§
										484.1 to
  484.115, inclusive (June 19,
  2020). This does not include an agency or organization whose function is
  primarily the care and treatment of mental illness;
(4) "Home health aide services," those
  nursing-related services not required to be performed by a licensed health
  professional but prescribed by a licensed physician and provided on an
  intermittent basis;
(5) "Home
  health services" or "services," skilled nursing services, medical social
  services, or home health aide services provided by a home health
  agency;
(6) "Medical social
  services," those services which contribute to the treatment of a patient's
  physical condition and are needed because social problems exist which impede
  the effective treatment of the patient's medical condition or the patient's
  rate of recovery;
(7) "Plan of
  care," the plan developed by the home health agency in response to the
  physician or other licensed practitioners written orders to the agency
  prescribing the needed services and the duration of those services;
(8) "Postpartum services," skilled nursing
  services following a child's birth;
(9) "Skilled nursing services," those nursing
  services defined in SDCL
  36-9-3 which are provided on a
  part-time or intermittent basis;
(10) "Therapy services," physical,
  respiratory, occupational, and speech therapy services provided by the home
  health agency either directly by or under contract with a qualified therapist
  acting within the therapist's scope of practice; and
(11) "Visit," one encounter with a recipient
  for the purpose of delivering home health services.
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 67:16:05 - Home health services › Section 67:16:05:03 - Individuals eligible for home health services

Current through Register Vol. 51, page 10, July 15, 2024
Home health services are available to an individual in the individual's
	 place of residence. The individual must be eligible for medical assistance and
	 the required services must meet the conditions of this
	 chapter.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Service restrictions, §
											67:16:05:05.01.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:05 - Home health services › Section 67:16:05:05 - Covered services - Limits

Current through Register Vol. 51, page 10, July 15, 2024
Home health services are limited to the following:
(1) Skilled nursing services;
(2) Medical social services provided by a
  licensed social worker who is not an employee of the department;
(3) Medical supplies used incidental to the
  visit when necessary to administer the attending physician or other licensed
  practitioners prescribed plan of care;
(4) Multiple visits of the same discipline on
  the same day if the medical necessity for the multiple visits is documented by
  the attending physician or other licensed practitioner in the individual's
  medical record;
(5) Daily visits if
  the medical necessity for the visits is documented by the attending physician
  or other licensed practitioner in the individual's medical record. The daily
  visits are limited to four weeks but may be extended beyond the four-week
  period if the attending physician or other licensed practitioner documents the
  need for the visits in the individual's medical record;
(6) Therapy services unless restricted by
  § 67:16:05:05.05; and
(7)
  Postpartum services meeting the requirements of § 67:16:05:05.06.
The covered items and services provided under this chapter for children
	 under the age of 21 are not subject to the limits contained in this
	 section.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Services not covered, §
											67:16:05:06.
Covered services must be medically necessary, §
											67:16:01:06.02.
Cost not to exceed institutional care, §
											67:16:05:07.02.
Covered services -- Limits, §
											67:16:37:04.01.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:05 - Home health services › Section 67:16:05:05.01 - Service restrictions

Current through Register Vol. 51, page 10, July 15, 2024
Home health services must meet the following criteria:
(1) They must be provided by a home health
  agency employee who is qualified to perform the required service;
(2) They must be prescribed by the attending
  physician or other licensed practitioner and contained in the home health
  agency's written plan of care;
(3)
  They must be provided at the individual's place of residence, which does not
  include a hospital, penal institution, detention center, school, nursing
  facility, intermediate care facility for individuals with intellectual
  disabilities, or an institution which treats individuals for mental diseases;
  and
(4) They must be provided
  intermittently but not more than once a day and no more frequently than five
  days a week, except as specified by subdivision 67:16:05:05(4).
If Medicare denies payment for a service because there is no medical
	 necessity, the individual is ineligible for services under this
	 chapter.
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 67:16:05 - Home health services › Section 67:16:05:05.02 - Physician's orders required before services begin - Plan of care - Certification and recertification

Current through Register Vol. 51, page 10, July 15, 2024
Before a home health agency may begin providing services to an
	 individual, it must have the physician or other licensed practitioners orders
	 prescribing the needed services.
The home health agency shall prepare a plan of care for each individual
	 served. The plan shall be based on the care services prescribed by the
	 attending physician or other licensed practitioner and the information obtained
	 by the home health agency from the individual. The attending physician or other
	 licensed practitioner must review and sign the plan.
The attending physician or other licensed practitioner must
	 periodically review the individual's plan of care and recertify the need for
	 services. For medical social work, the recertification must be completed at
	 least every 30 days following service initiation. For nursing, home health
	 aide, and therapy services, the recertification must be completed at least
	 every 60 days following service initiation. The home health agency must obtain
	 the recertification.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).