reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:01 - Level of care › Section 67:45:01:03 - Nursing facility care classification

Current through Register Vol. 51, page 10, July 15, 2024
The Department of Human Services may assign an individual to a nursing
	 facility level of care classification if the individual requires any of the
	 following services:
(1) Continuing
  direct care services which have been ordered by a physician and can only be
  provided by or under the supervision of a licensed nurse. These services
  include daily management, direct observation, monitoring, or performance of
  complex nursing procedures. For purposes of this rule, continuing direct care
  is repeated application of the procedures or services at least once every 24
  hours, frequent monitoring, and documentation of the individual's condition and
  response to the procedures or services;
(2) The assistance of another person for the
  performance of any activity of daily living according to an assessment of the
  individual's needs; or
(3) Skilled
  therapeutic services, including physical therapy, occupational therapy, or
  speech/language therapy in any combination that is provided at least once a
  week, or continuing mental health services provided through the comprehensive
  assistance with recovery and empowerment program according to chapter 67:62:12,
  or the individualized and mobile program of assertive community treatment
  program according to chapter 67:62:13, and a need for waiver services to
  prevent nursing facility placement as documented by a mental health
  professional.
The Department of Human Services must have completed a level of care
	 determination for an eligible individual before payment is made for services
	 provided.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Redetermination of level of care classification, §
											67:45:01:08.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:01 - Level of care › Section 67:45:01:04 - Intermediate level of care classification

Current through Register Vol. 51, page 10, July 15, 2024
The Department of Human Services may assign an individual to an
	 intermediate level of care classification when the individual:
(1) Resides, or is anticipated to reside, in
  an assisted living center and needs to have assistance available twenty-four
  hours a day to enable the individual to carry out those tasks associated with
  the activities of daily living and the instrumental activities of daily living;
  or
(2) Resides, or is anticipated
  to reside, in adult foster care and needs supervision, minimal assistance, or
  monitoring in:
(a) The activities of daily
  living or instrumental activities of daily living;
(b) The self-administration of
  medications;
(c) The self-treatment
  of a physical disorder; and
(d)
  Self-preservation in emergencies when capable of taking action with direction.
The Department of Human Services must have completed a level of care
	 determination for an eligible individual before payment is made for services
	 provided.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:01 - Level of care › Section 67:45:01:05 - Self-care level of care classification

Current through Register Vol. 51, page 10, July 15, 2024
Individuals who do not meet the criteria for nursing facility or
	 intermediate level of care classification, shall be assigned the self-care
	 level of care classification. Individuals in the self-care level of care
	 classification are not eligible for waiver services but may be eligible for
	 services under other programs.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:01 - Level of care › Section 67:45:01:05.01 - Settings or services for level of care classifications

Current through Register Vol. 51, page 10, July 15, 2024
Individuals are eligible for certain settings or services, depending on
	 their level of care classification.
(1) Setting or service options for the
  nursing facility level of care classification include:
(a) Swing bed;
(b) Nursing facility;
(c) Home and community based waiver service
  settings including:
(i) In-home;
(ii) Assisted living;
(iii) Community living home; and
(iv) Structured family caregiving;
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:01 - Level of care › Section 67:45:01:08 - Redetermination of level of care classification

Current through Register Vol. 51, page 10, July 15, 2024
The Department of Human Services must annually redetermine an
	 individual's level of care classification.
A redetermination may be made at more frequent intervals if a
	 redetermination is warranted due to a change in the resident's mental or
	 physical condition.
If it is determined that the individual does not need nursing facility
	 level of care or intermediate level of care, the department shall notify the
	 individual and the facility, if applicable. The facility must document this
	 notice in the individual's record.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Assistance when nursing facility unable to meet individual's need --
		Individual assigned to self-care -- Payment limits, §
											67:45:02:08.
Assistance when need is intermediate care for individuals with
		intellectual disabilities or intermediate care for the mentally disabled --
		Payment limits, §
											67:45:02:09.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:02 - Payment limits - Level of care classification

Current through Register Vol. 51, page 10, July 15, 2024
Payment to a nursing facility for services provided to an eligible
	 individual may not be made until the following requirements are met:
(1) The individual is eligible under article
  67:46;
(2) The medical review team
  has determined that the individual requires the level of care for which payment
  is being requested;
(3) The
  redetermination of the level of care classification required in §
									67:45:01:08 is current;
  and
(4) The facility is able to
  meet the needs of the individual.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:04 - Payment for reserved bed days

Current through Register Vol. 51, page 10, July 15, 2024
The department shall pay a nursing facility to reserve a bed during an
	 eligible individual's temporary absence from the nursing facility. Payment is
	 limited to a maximum of five days if the absence is due to admission to an
	 acute care general hospital and a maximum of 15 consecutive days if the absence
	 is for therapeutic home visits and the absence has been provided for in the
	 individual's plan of care. After 15 days of therapeutic home visiting, the
	 individual shall be considered a new admission on return to the
	 facility.
Payment is limited to 100 percent of the allowable per diem rate for
	 the facility as established under the provisions of chapter 67:16:04.
No payment may be made to a state-owned institution for reserving a bed
	 during an individual's absence.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:05 and 67:45:02:06 - Documentation required for oxygen add-on payment. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:07 - Documentation required for ventilator add-on payment

Current through Register Vol. 51, page 10, July 15, 2024
When an add-on payment for a ventilator is made under the provisions of
	 §
									67:16:04:08.04, the individual's
	 record must contain the physician's orders documenting dependency on a
	 ventilator.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:08 - Assistance when nursing facility unable to meet individual's need - Individual assigned to self-care - Payment limits

Current through Register Vol. 51, page 10, July 15, 2024
When a nursing facility is unable to meet the needs of the individual,
	 the department may assist the facility or the individual in finding an
	 appropriate placement. Payment to the facility will continue for a maximum of
	 30 days or until the date of transfer to the new facility, whichever occurs
	 first.
When an individual no longer needs nursing facility services and is
	 given a self-care level of care, the burden of finding a place to live rests
	 with the individual. The department may assist the individual if so requested.
	 Payment to the facility will continue for a maximum of 60 days or until the
	 date of transfer to the community, whichever occurs first.
No payment is allowed for self-care.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:09 - Assistance when need is intermediate care for the individuals with intellectual disabilities or intermediate care for the mentally disabled - Payment limits

Current through Register Vol. 51, page 10, July 15, 2024
When a nursing facility is unable to meet the needs of the individual
	 because the need is for intermediate care for an individual with an
	 intellectual disability or intermediate care for the mentally disabled, the
	 department shall refer the individual to the Department of Human Services for
	 assistance in finding an appropriate facility.
Payment to the facility will continue for a maximum of 60 days or until
	 the date of transfer to an intermediate care facility for individuals with
	 intellectual disabilities or to an intermediate care facility for the mentally
	 disabled, whichever occurs first.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:10 - Payment limited to resident days

Current through Register Vol. 51, page 10, July 15, 2024
Payments to nursing facilities are made in behalf of an individual for
	 resident days only. Resident days include the day of admission but exclude the
	 day of discharge. For purposes of this section, a resident day is when the
	 individual is physically present in the facility at midnight or when a bed is
	 being reserved for the individual at midnight. It is not a resident day if the
	 individual is discharged or dies prior to midnight.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:11 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Claims and payments for nursing facility care, adult foster care, or
	 assisted living are subject to review on the following levels:
(1) At the time of admission;
(2) Computerized claims review and audit;
  and
(3) Annual care classification
  review.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:02 - Nursing facility claims and payments limits › Section 67:45:02:12 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted on
	 the CMS 1450 (UB-04) form or in an electronic format that contains the
	 following:
(1) The recipient's full
  name;
(2) The recipient's medical
  assistance identification number from the recipient's medical assistance
  identification card;
(3)
  Third-party liability information as required under chapter 67:16:26;
(4) Beginning and end dates of service. A
  provider may only bill for one month at a time;
(5) The number of covered days;
(6) The total charges;
(7) The type of bill;
(8) The provider's name, address, telephone
  number, and National Provider Identification (NPI) number;
(9) The applicable diagnosis codes adopted in
  §
									67:16:01:26;
(10) The patient status code indicating the
  patient's status on the final day of service of the billing period;
  and
(11) The revenue code
  identifying the specific accommodation, ancillary service, or billing
  calculation.
A separate claim form must be submitted for each
	 recipient.
General Authority:
SDCL
		28-6-1. Law Implemented: SDCL
		28-6-1.
Note:
The CMS 1450 (UB-04) forms are available for
		direct purchase through the Superintendent of Documents, U.S. Government
		Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing
		desk.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Case mix," the mixture of residents of
  different classifications within a nursing facility;
(2) "Classification," a system of mutually
  exclusive categories that relate a resident's needs to the resident's cost of
  care;
(3) "Nurse consultant," a
  registered nurse employed by the department to validate resident
  classifications used to establish payment levels for the facility;
(4) "Nursing facility," a facility licensed
  as a nursing facility by the Department of Health and maintained and operated
  for the express or implied purpose of providing care to one or more persons,
  whether for consideration or not, who are not acutely ill but require nursing
  care and related medical services of such complexity as to require professional
  nursing care under the direction of a physician twenty-four hours a day;
  and
(5) "Assessment," a
  comprehensive assessment of the functional, medical, mental, nursing, and
  psychosocial needs of a resident of a nursing facility and includes admission,
  readmission, and discharge information as applicable.
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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:02 - Nursing facility to submit assessments to department

Current through Register Vol. 51, page 10, July 15, 2024
A nursing facility participating in the Medicaid program shall submit
	 completed resident assessments to the department according to §
									44:73:06:10.
The nursing facility shall ensure that the documentation maintained in
	 the resident's file replicates exactly the assessment submitted to the
	 department.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Resident assessments, §
											44:73:06:10.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:03 - Correction to previously submitted resident assessment

Current through Register Vol. 51, page 10, July 15, 2024
If a facility finds that it submitted an inaccurate or incomplete
	 resident assessment, the facility shall submit a new assessment to correct the
	 previous assessment. The new assessment shall:
1) Indicate it is a correction document
  ;
2) Be dated with the date the new
  assessment is prepared; and
3)
  Reflect the resident's status of that date.
Corrections are restricted to the most recently submitted resident
	 assessment.
The schedule for submitting subsequent resident assessments is reset
	 according to the date the corrected document is submitted.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Resident assessments, §
											44:73:06:10
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:04 - Review to validate resident classifications

Current through Register Vol. 51, page 10, July 15, 2024
At least every fifteen months, a nurse consultant shall conduct a
	 facility review to validate resident assessments and classifications. The nurse
	 consultant shall notify the nursing facility of a pending review at least
	 forty-eight hours before the review is conducted. The review may encompass any
	 resident of the nursing facility, regardless of payment source, whose
	 assessment was completed in the last forty-five to ninety days.
Validation of resident assessments and classifications is accomplished
	 by reviewing the resident's clinical record, interviewing staff from the
	 nursing facility, and comparing the nurse consultant's findings with the
	 resident assessment completed by the facility. If a resident to be reviewed no
	 longer lives in the facility or is temporarily absent, the nurse consultant may
	 review another resident of the same classification. The nurse consultant may
	 conduct the review onsite at the facility and may observe or interview the
	 resident.
If the nurse consultant finds an error or- inconsistency on the
	 resident assessment being reviewed, the nurse consultant may review that
	 resident's assessments completed during the prior- twelve months.
If the nurse consultant identifies errors or irregularities in any one
	 classification, the nurse consultant may expand the review to include resident
	 assessments completed for residents of the same classification. This expanded
	 review may include residents who have since died or been discharged from the
	 facility.
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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:05 - Attempt to reconcile differences

Current through Register Vol. 51, page 10, July 15, 2024
In completing the review of the resident, the nurse consultant and a
	 facility staff member shall attempt to reconcile any differences between the
	 assessments completed by the facility and the validations completed by the
	 nurse consultant. The nurse consultant's decision prevails if a difference
	 cannot be resolved.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Fair hearing, §
											67:45:03:12.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:06 - Review conference

Current through Register Vol. 51, page 10, July 15, 2024
The nurse consultant shall conduct a review conference with the
	 administrator of the facility or the facility's director of nursing to present
	 the finding of the review. The review conference shall address the following
	 items, as applicable:
(1) Areas which
  need improvement;
(2) Assessments
  requiring classification and payment changes;
(3) Error patterns; and
(4) Staff education and training needs.
Before the review conference is concluded, the department shall give
	 the facility staff the opportunity to provide additional information or
	 explanations about discrepancies in the coding or documentation of the resident
	 assessment. If the facility staff cannot provide evidence that supports its
	 coding of the resident assessment, the decision of the nurse consultant
	 stands.
Staff from the nursing facility who attend the review conference must
	 sign the review conference attendance sheet as an indication that the
	 conference was held and that they attended.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:07 - Written report of on-site review

Current through Register Vol. 51, page 10, July 15, 2024
Within fifteen calendar days following the review conference, the nurse
	 consultant shall send to the facility a written report detailing the results of
	 the review. The written report is the department's final
	 decision.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Payment adjustment due to review of resident assessment, §
											67:45:03:08.
Fair hearing, §
											67:45:03:12.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:08 - Payment adjustment due to review of resident assessment

Current through Register Vol. 51, page 10, July 15, 2024
The department shall adjust a facility's payment if a review of a
	 resident results in either an increase or a decrease in the payment amount the
	 nursing facility should have received on behalf of a resident. The payment
	 adjustment is limited to the most recent resident assessment submitted. The
	 department shall adjust the nursing facility's next available payment.
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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:09 - Nursing facility to provide resident's clinical record

Current through Register Vol. 51, page 10, July 15, 2024
The nursing facility shall provide the nurse consultant with the
	 clinical record of each resident being reviewed. The resident's clinical record
	 must include clear, concise, descriptive, and dated documentation that
	 accurately described the resident's condition. The facility must make a
	 resident's clinical record available to the department in a format acceptable
	 to the department and must provide the department with copies of needed
	 documentation from the resident's clinical record on request.
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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:10 - Record retention

Current through Register Vol. 51, page 10, July 15, 2024
The facility shall retain the documentation necessary to support each
	 resident's assessment for a minimum of six years.
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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:11 - Cases of suspected fraud - Investigation - Restitution

Current through Register Vol. 51, page 10, July 15, 2024
If the department receives a report that suggests fraud or abuse has
	 occurred or is occurring, it shall immediately investigate to determine the
	 validity of the report.
Nothing contained in this chapter restricts the department's ability to
	 collect payments made to a facility as a result of fraud committed by the
	 facility.
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 67:45 - Nursing facility level of care and claims › Chapter 67:45:03 - Case mix validation process › Section 67:45:03:12 - Fair hearing

Current through Register Vol. 51, page 10, July 15, 2024
A facility may appeal an adverse decision made under the provisions of
	 this chapter. A request for a fair hearing must be made within ten calendar
	 days after the nursing facility receives the written notice of the department's
	 final decision.
A facility shall request a fair hearing in writing. A fair hearing is
	 conducted under the provisions of chapter 67:17:02.
A decision affecting the nursing facility's payment level is applied
	 retroactively to the assessment start date.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2).
Hearing requests, §
											67:17:02:03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this article mean:
(1) "AFDC," the aid to families with
  dependent children program as it existed on July 16, 1996, under the provisions
  of article 67:12;
(2) "Applicant,"
  an individual who has filed an application for participation in the medical
  assistance program;
(3)
  "Department," the Department of Social Services;
(4) "Medicaid," the program authorized by
  Title XIX of the Social Security Act,
  42 U.S.C. §
										1396 d, as amended to July 1, 2014, which
  covers the allowable medical expenses of eligible individuals;
(5) "Medical assistance," "medical services,"
  or "medical assistance program," the Medicaid program authorized by Title XIX
  of the Social Security Act, 42 U.S.C. §
										1396 d, as
  amended to July 1, 2014, and SDCL 28-6, which provides medical assistance to
  eligible individuals but does not necessarily include long-term care;
  assistance provided to children who qualify for the nonmedicaid children's
  health insurance program covered under the provisions of chapter
  67:46:14;
(6) "Qualified alien," a
  legal alien who arrived in the United States after August 21, 1996, who meets
  either the requirements of 8
  U.S.C. §
										1641 (b) or
  8 U.S.C. §
										1613 (b)(2), as amended to
  July 1, 2014;
(7) "Qualified
  developmental disabilities professional," any person with at least one year of
  experience working directly with individuals with intellectual disabilities or
  other developmental disabilities and is either a doctor of medicine or
  osteopathy, a registered nurse, or a person who holds at least a bachelor's
  degree in a professional category;
(8) "Recipient," a person who is determined
  by the department to be eligible for services under this article; and
(9) "SSI," supplemental security
  income.
General Authority:
SDCL 28-6-1,
		42 U.S.C. §
												1396 d.
Law Implemented:
SDCL 28-6-1,
		42 U.S.C. §
												1396 d.
Definition of "qualified developmental disabilities professional,"
		SDCL 27B-1-17(14), 42 C.F.R.
		§
												483.430.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:03 - Eligibility starting date

Current through Register Vol. 51, page 10, July 15, 2024
Unless otherwise specified, eligibility for medical assistance begins
	 with the first day of the month the department receives the application if the
	 applicant meets all the requirements for assistance. Unless otherwise
	 specified, medical assistance may also begin as early as the first day of the
	 third month immediately before the month the department received the
	 application if the individual received Medicaid services during this period and
	 would have been eligible to receive medical assistance if the individual had
	 applied at the time the services were received.
General Authority:
SDCL
		28-6-1(6).
Law Implemented:
SDCL
		28-6-1(6).
Long-term care residency requirement and beginning of eligibility,
		§
											67:46:03:03.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:04 - Choosing a provider. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:05 - Payment of Medicare buy-in premiums. Repealed

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Qualified Medicare beneficiary, ch 67:46:11.
Definition of special low-income Medicare beneficiary, §
											67:46:11:01.
Special status as an SSI recipient for Title XIX, Social Security
		Act, Title XVI, § 1619(b).
Individuals who become ineligible for cash assistance as a result of
		OASDI cost-of-living increases received after April 1977,
		42 C.F.R. §
												435.135.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:06 - Confidential information

Current through Register Vol. 51, page 10, July 15, 2024
Information in the department's possession that concerns an applicant
	 or recipient is considered confidential and its use is limited to purposes
	 directly related to the administration of the medical services program. The
	 following uses or purposes are considered to be directly related to the
	 administration of the medical services program:
(1) Establishing eligibility for the medical
  services program;
(2) Determining
  the amount of medical assistance;
(3) Providing services to or on behalf of an
  eligible individual; or
(4)
  Conducting or assisting in an investigation, prosecution, or civil or criminal
  proceeding relating to the administration of the medical assistance
  program.
General Authority:
SDCL
		28-1-32.
Law Implemented:
SDCL
		28-1-29,
		28-1-32.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:06.01 - Release of confidential information

Current through Register Vol. 51, page 10, July 15, 2024
An individual or entity outside the department requesting confidential
	 information about an applicant or recipient must make the request in writing.
	 The information being requested must be for one of the purposes listed in
	 §
									67:46:01:06.
Before the department releases the requested information, the applicant
	 or recipient or the applicant's or recipient's parent or guardian, as
	 applicable, must complete and sign the department's form authorizing the
	 release of the requested information. The department must have the original,
	 completed, and signed form in its possession before it releases the information
	 to the requesting individual or entity.
Information the department receives from a source other than the
	 applicant or recipient or the applicant's or recipient's parent or guardian, as
	 applicable, may not be disclosed even if a signed authorization for the
	 requested information is provided to the department.
Federal agencies that oversee the department's medical assistance
	 program, other federally-funded, state-administered public assistance programs,
	 and other state-administered programs that have a data use agreement with the
	 department that allows the exchange of information for purposes of
	 administering the medical assistance program or for verifying income,
	 eligibility, and the amount of assistance for its applicants and recipients are
	 exempt from the provisions of this rule.
General Authority:
SDCL
		28-1-32.
Law Implemented:
SDCL
		28-1-32.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:07 - 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
	 service.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:08 - 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 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:09 - Medical assistance for refugees

Current through Register Vol. 51, page 10, July 15, 2024
Medical assistance shall be provided to refugees who are eligible for
	 assistance under the provisions of chapter 67:46:15.
General Authority:
SDCL
		28-6-1(1)(4)(6).
Law Implemented:
SDCL
		28-6-1(1)(4)(6).
Refugee Act of 1980, Pub. L. No. 96-212, 94 Stat.
		115.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:10 - Medical assistance for qualified alien

Current through Register Vol. 51, page 10, July 15, 2024
A qualified alien is ineligible for assistance under this article for
	 five years unless the alien meets the requirements contained in Pub. L. No. 104-193, § 402 (b)(2) (110 Stat. 2264) (August 22, 1996). The
	 five-year period begins with the date the alien entered the United
	 States.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Limited eligibility for designated federal programs, Pub. L. No. 104-93, § 402 (b) (110 Stat. 2264) (August 22,
		1996).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:11 - Application for assistance

Current through Register Vol. 51, page 10, July 15, 2024
Except for those individuals covered under subdivisions 67:46:01:02(2),
	 (3), (8), (12), (22), or (24), an individual desiring medical assistance under
	 this article or someone acting on the individual's behalf, must submit a
	 completed and signed application for assistance to the
	 department.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Written application,
		42 C.F.R.
		435.907 (September 23,
		1994).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:12 - Social security numbers

Current through Register Vol. 51, page 10, July 15, 2024
As a condition of eligibility, each applicant for assistance must
	 furnish the department with the applicant's social security
	 number.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:13 - Individual to supply required information

Current through Register Vol. 51, page 10, July 15, 2024
As a condition of eligibility, an individual applying for or receiving
	 assistance under this article must provide the department with the necessary
	 verification to establish initial or continuing eligibility or information
	 necessary for quality control efforts. The individual must also cooperate with
	 the department in establishing the paternity of an applicant or recipient child
	 and in obtaining medical support and medical payments unless the individual
	 establishes good cause for not cooperating. Failure or refusal to cooperate or
	 supply the necessary information results in the denial of an application or the
	 termination of current benefits.
A pregnant woman is exempt from this section with regard to
	 establishing paternity for a child conceived out of wedlock who has yet to be
	 born.
Good cause is established following the provisions of §§
									67:10:01:26 through
	 67:10:01:34,
	 inclusive.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Acceptance of assistance as assignment and subrogation of support
		rights and insurance proceeds -- Liability of insurer or attorney, SDCL
		28-6-7.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:14 - Availability of income and resources

Current through Register Vol. 51, page 10, July 15, 2024
An individual applying for or receiving medical assistance must take
	 advantage of all income and resources to which the individual is entitled,
	 including items such as social security, SSI, unemployment compensation, income
	 and resources available under the terms of a trust, veterans' benefits,
	 insurance policies, and contractual agreements. Failure or refusal by the
	 individual to take the necessary action to take advantage of the income and
	 resources makes the individual ineligible for medical
	 assistance.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:15 - Recovery of overpayments

Current through Register Vol. 51, page 10, July 15, 2024
If medical assistance is paid on behalf of an individual and the
	 department subsequently finds that the individual was ineligible for the
	 medical assistance benefits paid, the department considers that the medical
	 benefit was paid in error. A benefit paid in error constitutes a debt to and is
	 subject to recovery from the individual by the department according to the
	 limits of chapter 67:48:01.
General Authority:
SDCL
		28-6-1(4).
Law Implemented:
SDCL
		28-6-1(4).
Recoveries and investigations, art
		67:48.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:16 - Declaration and documentation of citizenship required

Current through Register Vol. 51, page 10, July 15, 2024
An applicant or recipient must declare his or her citizenship or alien
	 status. An applicant or recipient who declares that he or she is a citizen or
	 national of the United States must present to the department documentary
	 evidence of citizenship or nationality as specified in
	 42 U.S.C. §
										1396 b(x), as amended to July 1,
	 2014.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:17 - State residency determinations - General provisions

Current through Register Vol. 51, page 10, July 15, 2024
An applicant or recipient must be a resident of the state of South
	 Dakota to be eligible for long-term care assistance. An individual's state of
	 residence shall be determined according to the following:
(1) If the individual has been placed by a
  state agency into an out-of-state institution, the state arranging or actually
  making the placement is the individual's state of residence;
(2) If the individual is competent and leaves
  the facility into which the individual had been placed by a state, that
  individual's state of residence is the state in which the individual is
  physically located;
(3) If a
  placement is initiated by a state because that state lacks a sufficient number
  of appropriate facilities to provide services to its residents, the state
  making the placement is the individual's state of residence;
(4) If the individual is receiving a state
  supplementary payment, the state making the supplementary payment is the
  individual's state of residence;
(5) If the individual is receiving federal
  payments for foster care and adoption assistance under Title IV-E of the Social
  Security Act, the state making the payment is the individual's state of
  residence.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Incapability of indicating intent, §
											67:46:01:20.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:18 - Residency - Placement by states in an out-of-state long-term care facility

Current through Register Vol. 51, page 10, July 15, 2024
If a state arranges for an individual to be placed in a long-term care
	 facility located in another state, the state making the placement is the
	 individual's state of residence, regardless of the individual's intent or
	 ability to indicate intent.
If an individual capable of indicating intent leaves the facility into
	 which the individual has been placed by a state, the individual's state of
	 residence is the state where the individual is physically located.
Any action beyond providing information to the individual and the
	 individual's family constitutes arranging or making a state placement.
	 Providing basic information about facilities available in another state or
	 assisting an individual to locate an institution in another state, provided the
	 individual is capable of indicating intent and independently decides to move,
	 is not considered state placement.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Placement by a State in an out-of-State institution,
		42 C.F.R. §
												435.403 (e) (July 12,
		2006).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:19 - No specified period of residence required

Current through Register Vol. 51, page 10, July 15, 2024
The department shall not deny long-term care assistance to an eligible
	 individual in a long-term care facility who has not resided in South Dakota for
	 a specified period or who did not establish residence in South Dakota before
	 entering the long-term care facility.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:20 - Incapability of indicating intent

Current through Register Vol. 51, page 10, July 15, 2024
The department shall consider an individual incapable of indicating
	 intent if the individual meets one of the following:
(1) The individual has been judged legally
  incompetent by a court;
(2) A
  physician, psychologist, or a qualified developmental disability professional
  has found the individual to be incapable of indicating intent and has based
  this finding on medical evidence; or
(3) A psychologist has determined that the
  individual has an IQ of 49 or less or a mental age of 7 or less and has based
  this determination on tests appropriate for the individual being
  tested.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
State residence -- Individual considered incapable of indicating
		intent, 42 C.F.R. §
												435.403 (c) (July 12,
		2006).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:21 - Residency determinations - Individuals under age 21 residing in long-term care facilities

Current through Register Vol. 51, page 10, July 15, 2024
The state of residence for an individual under age 21 who is residing
	 in a long-term care facility shall be determined according to the
	 following:
(1) If the individual is
  emancipated from the individual's parents or if the individual is married and
  capable of indicating intent, the state where the individual is living with the
  intention to remain permanently or for an indefinite period is the individual's
  state of residence;
(2) If the
  individual is neither married nor emancipated, the state of residence may be
  determined by one of the following:
(a) The
  state of residence is that of the parent's state of residence at the time of
  placement;
(b) The state of
  residence is that of the parent who filed the application provided the
  individual is institutionalized in the parent's state of residence;
(c) If parental rights have been terminated
  and a legal guardian has been appointed, the state of residence is that of the
  guardian's state of residence at the time of placement; or
(d) If parental rights have been terminated
  and a legal guardian has been appointed, the state of residence is that of the
  guardian who files the application provided the individual is institutionalized
  in the guardian's state of residence.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:22 - Residency determinations - Individuals under age 21 not residing in a long-term care facility

Current through Register Vol. 51, page 10, July 15, 2024
The state of residence for individuals under age 21 who are not
	 residing in a long-term care facility is one of the following:
(1) For an individual who is emancipated from
  the individual's parents or married and who is capable of indicating intent,
  the state of residence is the state where the individual is living and
(a) Intends to reside, including without a
  fixed address; or
(b) Has entered
  the state with a job commitment or seeking employment, whether or not currently
  employed;
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:01 - General provisions › Section 67:46:01:23 - Residency determinations - Individuals aged 21 and over residing in long term care facilities - Capable of indicating intent

Current through Register Vol. 51, page 10, July 15, 2024
For a long-term care applicant or recipient aged 21 or over capable of
	 indicating intent, the state of residence is the state where the individual is
	 living with the intention to remain there permanently or for an indefinite
	 period.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
State residence -- Individuals age 21 and over,
		42 C.F.R. §
												435.403 (i) (July 12,
		2006).