reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:06.11 - Required use of tamper-resistant prescriptions

Current through Register Vol. 51, page 10, July 15, 2024
For written prescriptions, the cost of the prescribed drug or
	 over-the-counter item is not covered unless the prescription was written on a
	 tamper-resistant prescription drug pad. To be considered tamper resistant, a
	 prescription pad must contain the following three characteristics:
(1) One or more industry-recognized features
  designed to prevent unauthorized copying of a completed or blank prescription
  form, such as a high security watermark;
(2) One or more industry-recognized features
  designed to prevent the erasure or modification of information written on the
  prescription by the prescriber, such as tamper-resistant background ink that
  shows erasures or attempts to change written information; or
(3) One or more industry-recognized features
  designed to prevent the use of counterfeit prescription forms, such as
  sequentially numbered blanks and duplicate or triplicate blanks.
If the prescription fails to meet the requirements of this section and
	 an emergency exists, the pharmacy may fill the prescription and receive
	 reimbursement if the pharmacist obtains a written prescription that complies
	 with this section or obtains the prescription by telephone, fax, or
	 electronically within 72 hours after the fill date.
Prescriptions transmitted electronically to the pharmacy, prescriptions
	 transmitted to the pharmacy by facsimile, prescriptions communicated to the
	 pharmacy by telephone, and refills of a prescription that was originally filled
	 before April 1, 2008, are exempt from the previous section.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq
		Accountability Appropriations Act of 2007, § 7002(b).
Requirement for use of tamper-resistant prescription pads under the
		Medicaid program, 42 U.S.C.
		§
												1396
		b(i)(23).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:08 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Utilization review for prescription drug services may be conducted on
	 three levels:
(1) Computerized claims
  processing;
(2) Postpayment review;
  and
(3) Peer review.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Drug use review program and electronic claims management system for
		outpatient drug claims, 42
		C.F.R. §
												456.700.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:10

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 67:16:14 - Prescription drugs › Section 67:16:14:13 - Billing requirements

Current through Register Vol. 51, page 10, July 15, 2024
Except for items dispensed under the provisions of subdivision
	 67:16:14:06.06(2) or §
									67:16:14:06.09, claims for items
	 provided under this chapter must be submitted at the provider's usual and
	 customary charge.
A claim for items dispensed under subdivision 67:16:14:06.06(2) or
	 §
									67:16:14:06.09 must be submitted
	 at the provider's cost. To verify the charges, the provider must maintain a
	 copy of the supplier's invoice showing the actual cost of the item to the
	 provider and all discounts applied to the invoiced item. At the department's
	 request, a provider must furnish information to substantiate a claim.
A provider may not submit a claim for items that have not been
	 provided.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Third-party liability, ch
		67:16:26.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:14 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for items provided under this chapter must be submitted on a
	 claim form or in an electronic format that contains the following
	 information:
(1) The recipient's full
  name;
(2) The recipient's medical
  assistance identification number from the recipient's medical assistance
  identification card;
(3) The number
  of days for which the item is supplied;
(4) The name of the drug;
(5) The multiple-source drug override
  indicator if the brand name is medically necessary;
(6) Third-party liability information
  required under chapter 67:16:26;
(7) Date of service;
(8) The provider's usual and customary charge
  or cost, as applicable. The provider may not subtract other third-party or
  cost-sharing payments from this charge;
(9) Units of service furnished;
(10) The provider's name and National
  Provider Number (NPI), or the provider's PHS medical assistance identification
  number if the claim is for a drug covered under a PHS provider
  agreement;
(11) The prescription
  number assigned;
(12) The national
  drug code (NDC) number taken from the package or container used in dispensing
  the prescription. If the drug dispensed does not have an NDC number or is a
  compounded product, enter " 0999-2000-00 " on the claim form and further
  identify the item as a "special attention" item;
(13) The metric quantity of the drug
  dispensed;
(14) An indication if
  the prescription was a refilled prescription or was dispensed as a unit
  dose;
(15) The name or the South
  Dakota medical assistance provider number of the person prescribing the
  drug;
(16) The provider's National
  Council of Prescription Drug Providers (NCPDP) number; and
(17) The prescribing physician or other
  licensed practitioner's Drug Enforcement Agency (DEA) number.
A claim for a PHS-covered drug must be submitted on a separate claim
	 and may not be combined with a claim for other drugs covered under this chapter
	 even if the provider is the same.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(2)(4).
Claims, ch 67:16:35; Case management -- Primary care provider, ch
		67:16:39.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:15 - 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, 67:16:35, and 67:16:39, if applicable.
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 67:16:14 - Prescription drugs › Section 67:16:14:16 - Over-the-counter items covered

Current through Register Vol. 51, page 10, July 15, 2024
Over-the-counter items covered under this chapter are limited to drugs
	 which meet the following requirements:
The department has approved coverage of the drug based on the P and T
	 committee's recommendation;
(1) There
  is a prescription for the required medication; and
(2) There is not a lower cost drug of similar
  composition available.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Note:
A list of the OTC items covered may be obtained
		from the department or viewed online on the department's pharmacy
		website.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:17 - Drug review by P and T committee

Current through Register Vol. 51, page 10, July 15, 2024
When reviewing OTC drugs for coverage by the department, the P and T
	 committee shall consider the drug's clinical efficacy, safety, and
	 cost-effectiveness. Following the committee's review, it shall make its
	 recommendations for coverage to the department. The department shall make the
	 final determination as to whether an OTC drug is covered. The department shall
	 base its final determination on the committee's recommendation.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Note:
A list of the OTC items covered may be obtained
		from the department or viewed online on the departments pharmacy
		website.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:14 - Prescription drugs › Section 67:16:14:18 - Prior authorization for certain prescription drugs

Current through Register Vol. 51, page 10, July 15, 2024
The department requires prior approval of certain prescription drugs.
	 Based on recommendations made by the department's P and T committee, the
	 department shall determine which drugs are subject to prior authorization. The
	 provider must obtain approval from the department before supplying drugs
	 subject to prior authorization.
Drugs subject to prior authorization are listed on the department's
	 website:
http://www.hidsdmedicaid.com/
.
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 67:16:14 - Prescription drugs › Section 67:16:14:19 - P and T committee to make recommendations to department

Current through Register Vol. 51, page 10, July 15, 2024
The P and T committee's recommendations to the department for those
	 drugs requiring prior authorization from the department must include the
	 following information:
(1) A list of
  the recommended drugs that the department may consider to be appropriate for
  placement on or removal from the list of drugs that require prior approval by
  the department;
(2) For each drug
  listed, a preferred list of covered prescription drugs within the appropriate
  therapeutic classes for a particular disease or condition; and
(3) The prior authorization criteria.
When developing its preferred list of covered prescription drugs, the
	 committee must consider the clinical efficacy, safety, and cost-effectiveness
	 of the product.
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 67:16:14 - Prescription drugs › Section 67:16:14:20 - Notice to interested parties before drug placed on list - Opportunity for interested parties to present data, opinions, and arguments

Current through Register Vol. 51, page 10, July 15, 2024
Before the Division of Medical Services places a drug on its list of
	 drugs that require prior authorization, the division shall provide an
	 opportunity for interested parties to present data, opinions, and arguments
	 concerning the placement of the drug on the list. The division shall notify
	 interested parties of this opportunity. The notice shall be in writing and
	 shall state where and when an interested party can present data, opinions, and
	 arguments concerning the proposal.
When taking final action on the proposals, the division may accept or
	 reject the P and T committee's recommendations and may consider any information
	 provided to the department by an interested party.
When the division places a drug on the list, an interested party may
	 request that the department secretary review the division's decision. The
	 request for the review must be in writing, made to the department secretary,
	 and made within 30 days following the placement of the drug on the list. The
	 request must contain the following information:
(1) The drug's brand name;
(2) A summary, limited to two pages, of the
  clinical and/or economic reasons why the product should not be included on the
  list; and
(3) New information on
  the drug that has become available since the P and T committee's hearing on the
  drug.
The department secretary shall review the required information and
	 determine whether to override the division's decision. The secretary shall
	 provide a written notice of the final action to the interested party requesting
	 the 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 67:16:14 - Prescription drugs › Section 67:16:14:21 - Notice to providers when drug is to be placed on list

Current through Register Vol. 51, page 10, July 15, 2024
At least 30 days before the department implements the prior
	 authorization requirements for a particular drug, the department shall provide
	 a written notice to providers. The notice shall contain the following
	 information:
(1) The date on which the
  department intends to begin requiring prior authorization for the
  drug;
(2) The name or names of
  alternative, therapeutically equivalent drugs that do not require prior
  authorization and which may be substituted;
(3) A statement that the pharmacist or
  prescribing medical professional must seek prior approval from the department
  if the medical professional chooses not to use one of the alternative drugs
  available; and
(4) A statement that
  the recipient is responsible for the cost of the drug if prior approval is not
  obtained or a therapeutically equivalent drug is not substituted.
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 67:16:14 - Prescription drugs › Section 67:16:14:22 - Cost of drug not covered if substitution not made or prior authorization obtained

Current through Register Vol. 51, page 10, July 15, 2024
If the department informs a pharmacist that a requested drug requires
	 prior authorization and the recipient indicates to the pharmacist that the
	 recipient wishes to proceed, the pharmacist must contact the medical
	 professional who wrote the prescription and request permission to substitute a
	 therapeutically-equivalent drug.
If the request to substitute is not successful, the pharmacist must
	 inform the medical professional that the medical assistance program will not
	 cover the cost unless the medical professional can justify the use of the drug
	 and ultimately receives approval from the department to dispense the drug as
	 written.
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 67:16:14 - Prescription drugs › Section 67:16:14:23 - Emergency supplies

Current through Register Vol. 51, page 10, July 15, 2024
If an emergency situation exists and a prior authorization requirement
	 cannot be submitted and a response received within 24 hours, the pharmacy may
	 dispense and receive reimbursement from the department for a five day supply of
	 the drug. An emergency situation includes the need to dispense a drug after
	 regular working hours or over a weekend or holiday or a situation in which a
	 response to a prior authorization request is unavailable or under
	 appeal.
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 67:16:14 - Prescription drugs › Section 67:16:14:24 - Appeal process

Current through Register Vol. 51, page 10, July 15, 2024
If the department denies the prior authorization request, the medical
	 professional may appeal the decision. At the time of the denial, the department
	 shall advise the medical professional of the procedures to follow to appeal the
	 denial and that the appeal must be made within 24 hours following the
	 denial
The medical professional will receive a final decision within 24 hours
	 after the additional information is received.
If the request is approved, the pharmacist may fill the prescription as
	 written.
If the original decision to deny the claim is confirmed, the medical
	 professional will be notified.
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 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Facility," a public or private
  institution licensed by an agency of the state of South Dakota or owned and
  operated by the state of South Dakota and certified by the department as a
  provider of care under the medical assistance program for eligible individuals
  with intellectual disabilities, persons with a related condition, or
  individuals who are mentally or emotionally impaired;
(2) "Monthly care cost," the total monthly
  dollar amount payable by or in behalf of an eligible individual;
(3) "Review team," a team consisting of a
  physician, a registered nurse, a social worker, and other professionals as
  required which conducts on-site reviews and inspections of facilities for
  individuals with intellectual disabilities or emotional impairments;
  and
(4) "Utilization review," the
  assessment of the necessity for initial medical care or services and the
  periodic reassessment of the continued need for medical care or services by the
  review team.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Title XIX of the Social Security Act,
		42 U.S.C. §
												1396
		d.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:03 - Determination of need for care

Current through Register Vol. 51, page 10, July 15, 2024
An eligible recipient's need for services provided by a facility shall
	 be determined by the review team using their professional judgment of
	 information from other professional sources before payment for services
	 provided is authorized.
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 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:04 - On-site review and inspection

Current through Register Vol. 51, page 10, July 15, 2024
The review team shall conduct an on-site review and inspection of each
	 facility at least annually.
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 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:05 - Required financial reports

Current through Register Vol. 51, page 10, July 15, 2024
Facilities shall submit financial and statistical data to the
	 department for the state's or facility's fiscal accounting period on forms
	 supplied by the department. At the department's request, the facility shall
	 also submit a copy of the depreciation schedule used in determining the
	 operating expenses claimed.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Provider cost reports, 42 C.F.R. § 447.274 ; Dates of cost
		reporting, 42 C.F.R. § 447.275.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:06 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment to a participating provider for services provided by a facility
	 shall be determined by the department based on reasonable
	 costs.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Basis of reimbursement -- Inpatient services -- Hospitals with more
		than 30 Medicaid discharges, §
											67:16:03:06.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:07 - Other resources of a resident

Current through Register Vol. 51, page 10, July 15, 2024
All income received by or in behalf of a resident shall be applied
	 first against the recognized personal maintenance allowance for the individual
	 and the balance shall be credited to the monthly care cost.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Budgeting for long-term care, ch
		67:16:21.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:08 - Extent of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment to facilities shall be made in behalf of a recipient for
	 resident days only. Resident days include the day of admission but exclude the
	 day of discharge.
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 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:09 - Payments for reserved bed days

Current through Register Vol. 51, page 10, July 15, 2024
Payment shall be made in behalf of an eligible individual when it is
	 necessary to reserve a recipient's bed during temporary absence from a skilled
	 nursing or intermediate care facility for persons with mental disease or an
	 intermediate care facility for individuals with intellectual disabilities.
	 Payment is limited to a maximum of five days when the absence is due to
	 admission to an acute care general hospital for an acute condition and
	 therapeutic home visits when the absence has been provided for in the patient's
	 plan of care.
No payment may be made to a state-owned institution for reserving a bed
	 during a resident'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 67:16 - Covered medical services › Chapter 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:10 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
Services provided by facilities are subject to utilization review on
	 three levels:
(1) At the time of
  admission;
(2) Computerized claims
  processing; and
(3) Annual
  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 67:16 - Covered medical services › Chapter 67:16:16 - Facilities for the mentally impaired › Section 67:16:16:11 - 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 67:16:24 - Personal care services › Section 67:16:24:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Activities of daily living," tasks
  performed routinely by a person to maintain physical functioning and personal
  care, including transferring, moving about, dressing, grooming, toileting, and
  eating;
(2) "Economic resources,"
  the recipient's own resources together with other types of assistance,
  financial or otherwise, which are available to a recipient and would help
  maintain the recipient in the recipient's own home;
(3) "Maintenance nursing," periodic
  evaluation and counseling by a licensed nurse to promote and maintain the
  individual's optimal health. Maintenance nursing may include injections,
  monitoring and setting up medications, physical assessments, monitoring patient
  status, foot care, drawing blood, changing dressing, and health
  education;
(4) "Personal
  adjustment," the mental or emotional state of well-being of a recipient on a
  continuum from good to poor. Poor personal adjustment may include problems with
  sleeping, difficulty in expressing feelings, unhappiness, or
  depression;
(5) "Personal care
  provider," an agency incorporated in South Dakota which has a contract with the
  department to provide personal care services in the recipient's place of
  residence;
(6) "Personal care
  services," medically necessary services in the recipient's case service plan
  that are provided by an individual who is qualified to provide the services and
  is not a member of the recipient's family;
(7) "Physical environment," the recipient's
  dwelling unit, building, or house and its furnishings and the neighborhood in
  which the recipient resides;
(8)
  "Physical health," the medical state of well-being which may be on a continuum
  from good to poor. Poor health is the presence of one or more illnesses or
  physical disabilities which are either painful or inhibit a person's ability to
  perform daily tasks; and
(9)
  "Social resources," support or assistance available to a recipient from the
  recipient's family, friends, neighbors, or community organizations such as
  churches, civic groups, or senior centers or other agencies providing services
  to residents of the community.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(4).
Covered services must be medically necessary, §
											67:16:01:06.02.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:24 - Personal care services › Section 67:16:24:02.01 - Eligibility

Current through Register Vol. 51, page 10, July 15, 2024
To be eligible for services under this chapter, the individual must be
	 eligible for Medicaid under the provisions of article 67:46 and the assessment
	 prepared under the provisions of §
									67:16:24:03.02 must indicate a
	 need for 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 67:16:24 - Personal care services › Section 67:16:24:03 - Services covered

Current through Register Vol. 51, page 10, July 15, 2024
Personal care services are limited to medically necessary services
	 contained in the recipient's case service plan and provided in the recipient's
	 residence. Personal care services covered are limited to the following:
(1) Basic personal care and grooming,
  including bathing, shaving, dressing, and assisting the recipient with hair and
  teeth care;
(2) Assistance with
  bladder or bowel requirements, which does not include administration of a bowel
  program;
(3) Assisting the patient
  with medications which are ordinarily self-administered;
(4) Assistance with food, nutrition, and diet
  activities if they are incidental to a medical need;
(5) Performing those household services, if
  related to a medical need, that are essential to the patient's health and
  comfort in the patient's residence; or
(6) Maintenance nursing prescribed by a
  physician.
A personal care provider shall use SDCL chapter 36-9 to determine when
	 the needed covered services must be delivered by a licensed nurse.
For purposes of this rule, a recipient's residence does not include a
	 hospital, penal institution, detention center, school, nursing facility,
	 assisted living center, congregate facility where services are available, other
	 types of group settings, intermediate care facility for individuals with
	 intellectual disabilities, or an institution which treats individuals for
	 mental diseases.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1.
Covered services must be medically necessary, §
											67:16:01:06.02; Practices not
		prohibited by chapter, SDCL
		36-9-28.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:24 - Personal care services › Section 67:16:24:03.01 - Limitation on hours of services

Current through Register Vol. 51, page 10, July 15, 2024
An individual qualifying for services under this chapter is limited to
	 no more than 500 hours of services annually.
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).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:24 - Personal care services › Section 67:16:24:03.02 - Needs assessment

Current through Register Vol. 51, page 10, July 15, 2024
After an individual has been determined eligible for services under
	 this chapter, the department shall assess the individual's personal care
	 service needs. The needs assessment must be completed at least once every
	 twelve months. The needs assessment is based on information provided by the
	 individual in the following areas:
(1)
  Social resources;
(2) Physical
  environment;
(3) Physical health;
  and
(4) Activities of daily
  living.
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 67:16:24 - Personal care services › Section 67:16:24:03.03 - Case service plan

Current through Register Vol. 51, page 10, July 15, 2024
The department shall develop a case service plan for each individual
	 eligible for personal care services. The plan shall be based on the
	 individual's needs assessment and shall contain items such as the
	 following:
(1) The reason for the
  service request;
(2) The number of
  personal care service hours assigned to the individual;
(3) The personal care services needed;
  and
(4) The individual's
  responsibilities.
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 67:16:24 - Personal care services › Section 67:16:24:04 - Rate of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for personal care services is limited to the lesser of the
	 provider's usual and customary charge or the fee contained on the department's
	 fee schedule website.
General Authority:
SDCL
		28-6-1(1)(2).
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:24 - Personal care services › Section 67:16:24:05 - Utilization review

Current through Register Vol. 51, page 10, July 15, 2024
The department may provide utilization review of personal care services
	 through computerized claims processing and postpayment
	 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 67:16:24 - Personal care services › Section 67:16:24:06 - Claim requirements

Current through Register Vol. 51, page 10, July 15, 2024
A claim for services provided under this chapter must be submitted on a
	 form available from the department or the claim may be electronically
	 transmitted through a system approved by the department. The claim must contain
	 the following information:
(1) The
  recipient's full name;
(2) The
  recipient's medical assistance identification number from the recipient's
  medical assistance identification card;
(3) Date of service;
(4) As specified in the provider's contract
  with the department, the provider's rate of payment for the service
  provided;
(5) The units of service
  furnished, if more than one; and
(6) The provider's name and medical
  assistance identification number.
A separate claim form must be used for each recipient.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Claims, ch 67:16:35.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:24 - Personal care services › Section 67:16:24:07 - Discontinuance or denial of services

Current through Register Vol. 51, page 10, July 15, 2024
The department may discontinue or deny services provided under this
	 chapter when the department exhausts its resources for providing the services,
	 the participant can no longer benefit from the services provided, or the
	 participant's or the provider's health or safety would be jeopardized if the
	 services were continued. Specific reasons for discontinuing or denying services
	 include the following:
(1) The
  participant does not meet eligibility requirements;
(2) The participant failed to cooperate with
  the needs assessment;
(3) The
  participant is sexually harassing, verbally abusive, threatening, or
  combative;
(4) The participant's
  personal care service needs exceed the service limits of the program;
(5) The participant's physical environment
  presents health and fire hazards or unsafe conditions;
(6) The participant is not in compliance with
  the case service plan;
(7) The
  participant's health and safety risk factors are unable to be mitigated;
  or
(8) The participant refuses to
  cooperate with department staff or the service provider.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Air ambulance," an aircraft, fixed-wing
  or helicopter, that is designed or can be quickly modified to provide emergency
  transportation of wounded, injured, sick, invalid, or incapacitated human
  beings or expectant mothers to or from a place where medical care is provided
  and is licensed by the Department of Health under the provisions of chapter
  44:05:05;
(2) "Air mile," a unit of
  distance equal to one nautical mile;
(3) "Ambulance provider," a company, firm, or
  individual licensed by the Department of Health under the provisions of article
  44:05 to provide ambulance services or, if based out of state, a company, firm,
  or individual which provides ambulance services and is a participating Medicaid
  provider in the state where it is located;
(4) "Ambulance service," the service defined
  in SDCL 34-11-2(3);
(5) "Attendant," a physician, other licensed
  practitioner, registered nurse, licensed practical nurse, paramedic, qualified
  emergency medical technician, or other medical professional, other than the
  driver of an ambulance or the pilot of an air ambulance, who provides necessary
  medical care to or supervision of a person being transported;
(6) "Base fee," an amount covering the use of
  the ambulance vehicle or aircraft; the driver, pilot, or pilots; one attendant;
  all medical equipment in the ambulance; nondisposable and first-aid supplies;
  applicable taxes; ground transportation of personnel and equipment; and all
  other charges not itemized for payment in this chapter;
(7) "Community transportation service," the
  nonemergency transporting of a recipient to and from medical services by a
  community transportation provider meeting the requirements of §
									67:16:25:06.01;
(8) "Confined to a wheelchair," unable to
  walk without the continuous aid of another person; unable to walk in any
  circumstances;
(9) "Ground
  ambulance," a motor vehicle licensed by the Department of Health under chapter
  44:05:04 and used to respond to medical emergencies;
(10) "Loaded mileage," mileage driven or
  flown while a patient is being transported;
(11) "Secure medical transportation
  provider," a company, firm, or individual that uses specifically designed and
  equipped vehicles to provide nonemergency transportation to and from medical
  care for recipients confined to wheelchairs or requiring transportation on a
  stretcher.
(12) "Trip," the
  transporting of a person from the person's home to a medical provider, between
  medical providers, or from a medical provider to the person's home;
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:02 - Ambulance services covered

Current through Register Vol. 51, page 10, July 15, 2024
Ambulance services are limited to medically necessary ground ambulance
	 services at the pick-up point and ground or air ambulances services
	 transporting the recipient locally or to the nearest medical provider that is
	 equipped or trained to provide the necessary service. The following services
	 are eligible for payment when provided by a participating ambulance
	 provider:
(1) Ground ambulance service
  to or from a medical provider or between medical facilities when other means of
  transportation would endanger the life or health of the patient;
(2) Air ambulance service when the
  requirements of § 67:16:25:02.01 have been met;
(3) Services of additional attendants when
  medically necessary;
(4) Oxygen
  provided during transit;
(5) Loaded
  mileage. Mileage may not be billed for more than one patient per trip;
  and
(6) The ground and air
  ambulance services payable under the provisions of §
									67:16:25:03. Ground ambulances may
  provide secure medical transportation as defined in §
									67:16:25:01. These services are
  payable under the provisions of §§
									67:16:25:05 and
  67:16:25:08.01.
At its discretion the department may pay for transportation services
	 not meeting the conditions of this section if paying for the services results
	 in an overall cost savings for the department.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:02.01 - Air ambulance restrictions

Current through Register Vol. 51, page 10, July 15, 2024
Air ambulance services must meet all of the following criteria:
(1) The transportation must be medically
  necessary because of time, distance, emergency, or other factors or when
  transportation by any other means is contraindicated;
(2) The transportation must be the result of
  a physician or other licensed practitioner's written orders requiring the
  specific level of air transportation for medical purposes; and
(3) The provider must be licensed according
  to chapter 44:05:05 or licensed as an air ambulance in the state where the
  provider is located.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:03 - Rate of payment - Ground and air ambulance services

Current through Register Vol. 51, page 10, July 15, 2024
The rate of payment for ground or air ambulance service is the base
	 fee, loaded mileage, and other medically necessary covered services.
Payment is limited to the lesser of the provider's usual and customary
	 charge or the fee contained on the department's fee schedule website.
The procedures and associated rates of payment are subject to review
	 and amendment under the provisions of §
									67:16:01:28.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1,
		28-6-1.1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04 - Secure medical transportation - Covered services

Current through Register Vol. 51, page 10, July 15, 2024
A participating secure medical transportation provider is eligible to
	 receive payment for nonemergency transportation services. Recipients being
	 transported must be confined to a wheelchair or must require transportation on
	 a stretcher. Transportation must be from the recipient's home, place of work,
	 or school to a medical provider for diagnosis or treatment, between medical
	 providers when necessary, or from a medical provider to the recipient's home,
	 place of work, or school.
At its discretion, the department may pay for transportation services
	 not meeting the conditions of this section if paying for the services results
	 in an overall cost savings for the department.
General Authority:
SDCL
		28-6-1(1)(2)(4).
Law Implemented:
SDCL
		28-6-1(1)(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.01 - Secure medical transportation - Qualifications of driver

Current through Register Vol. 51, page 10, July 15, 2024
A secure medical transportation provider must ensure that the driver
	 providing the transportation service meets the following criteria:
(1) Possesses a valid driver's license for
  the class of vehicle driven;
(2) Is
  at least 18 years old and has at least one year of experience as a licensed
  driver;
(3) During the previous
  three years, has not had a driver's license suspended under the provisions of
  SDCL chapter 32-12 or under similar laws of another state where the driver had
  a driver's license;
(4) During the
  previous three years, has not had a conviction of driving under the influence
  pursuant to SDCL chapter 32-23 or under similar laws of another state where the
  driver had a driver's license; and
(5) Does not have a hearing loss of more than
  30 decibels in the better ear with or without a hearing aid. A driver whose
  hearing meets this minimum requirement only when wearing a hearing aid must
  wear a hearing aid and have it in operation at all times while
  driving.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.02 - Secure medical transportation - Required training for driver and attendant

Current through Register Vol. 51, page 10, July 15, 2024
A secure medical transportation provider must ensure that each driver
	 and attendant is able to assist a passenger into and out of a vehicle and each
	 receives the following training:
(1)
  Before providing services, instruction in the operation of the vehicle ramp,
  wheelchair lift, and wheelchair securement devices;
(2) Before providing services, instruction in
  the procedures to follow in case of a medical emergency or an accident,
  including first aid;
(3) Before
  providing services, instruction in the use of the fire extinguisher located in
  the vehicle.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.03 - Secure medical transportation - Required vehicle equipment

Current through Register Vol. 51, page 10, July 15, 2024
Each vehicle used for secure medical transportation services must be
	 equipped with reasonable vehicle safety equipment and a first aid kit.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.04 - Secure medical transportation - Securement devices

Current through Register Vol. 51, page 10, July 15, 2024
A vehicle used for secure medical transportation must be equipped with
	 a securement device and a occupant restraint system for each occupant being
	 transported. Each securement device must be installed and used according to the
	 manufacturer's instructions. Each occupant restraint system must provide pelvic
	 and upper torso restraint and must comply with the requirements of
	 49 C.F.R. §
										571.222, S5.4.1 to S5.4.4, inclusive, as
	 amended to April 1, 2017. The driver or the attendant must ensure that the
	 occupant restraint system is fastened around the user before the driver sets
	 the vehicle in motion.
The provisions for using a occupant restraint system do not apply if
	 the occupant possesses a written statement from a physician or other licensed
	 practitioner that the individual is unable for medical reasons to wear the
	 occupant restraint system.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.06 - Secure medical transportation - Liability insurance

Current through Register Vol. 51, page 10, July 15, 2024
At a minimum, the provider shall have liability insurance coverage in
	 the amount of $1,000,000 for bodily injury to or death of any person in a
	 single accident and $1,000,000 for destruction of or damage to property in a
	 single accident. If the policy is written on a single limit basis, the policy
	 must specify that the limit is $1,000,000 for each
	 occurrence.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).
Motor vehicle insurance -- Uninsured motorist and hit-and-run
		coverage -- Amount of coverage -- Uninsured motorist coverage not required for
		government owned vehicles, SDCL
		58-11-9;
Underinsured motorist coverage to be available with liability
		policies -- Limitation of coverage -- Exception, SDCL
		58-11-9.4.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:25 - Transportation services › Section 67:16:25:04.07 - Secure medical transportation - Complaints - Inspection

Current through Register Vol. 51, page 10, July 15, 2024
If the department receives a complaint concerning the condition of a
	 vehicle used to transport recipients or the vehicle's equipment, the department
	 may inspect or provide for an inspection of the vehicle. The inspection may be
	 unannounced.
If it is determined that the vehicle is in need of repairs, the
	 department shall provide a written notice to the provider detailing the needed
	 repairs or maintenance. The vehicle may not be used to transport recipients
	 until after the repairs are made and the provider has sent written verification
	 to the department that the repairs were made.
Failure to permit an inspection results in the immediate termination of
	 the provider's contract with the department.
If a provider receives a complaint against a driver or an attendant,
	 the provider must investigate the complaint and attempt to resolve the issue.
	 The provider must prepare and maintain a written report that contains a
	 description of the complaint, the results of the investigation, and the
	 resulting action taken, if any.
General Authority:
SDCL
		28-6-1(2)(4).
Law Implemented:
SDCL
		28-6-1(2)(4).