reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:09 - Disabled children › Section 67:46:09:04 - Eligibility requirements

Current through Register Vol. 51, page 10, July 15, 2024
To be eligible, all of the following requirements must be met:
(1) The child is under the age of
  19;
(2) A physician designated by
  the department has determined that the child is disabled according to
  20 C.F.R. §§
										416.924 to
  416.924b, inclusive, or determined
  disabled by the social security administration within the last year. The social
  security administration's disability determination is binding on eligibility or
  continued eligibility for services. If supplemental security income or social
  security disability is denied because the social security administration
  determined that the child was not disabled, the child is not eligible for
  assistance;
(3) The child would be
  eligible for Medicaid if the child was in a medical institution;
(4) The child requires one of the levels of
  care listed in §
									67:46:09:06;
(5) The estimated cost of monthly health care
  outside the medical institution does not exceed the medical institution's cost
  of care according to §
									67:46:09:12; and
(6) The child meets the income and resource
  requirements contained in chapters 67:46:04 and 67:46:05.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
How we determine disability for children,
		20 C.F.R. §
												416.924 (July 15, 2011); Considerations in
		determining disability for children,
		20 C.F.R. §
												416.924a (September 11, 2000); Age as a
		factor of evaluation in the sequential evaluation process for children,
		20 C.F.R. §
												416.924b (October 19,
		2007).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:09 - Disabled children › Section 67:46:09:05 - Physician's orders required

Current through Register Vol. 51, page 10, July 15, 2024
The child's attending physician must order the services for the child
	 and must determine that home services are appropriate. Documentation verifying
	 these findings must be available to the department on
	 request.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:09 - Disabled children › Section 67:46:09:06 - Team to determine level of care

Current through Register Vol. 51, page 10, July 15, 2024
The team shall determine whether the child requesting assistance under
	 this chapter needs one of the following levels of care:
(1) Acute care hospital;
(2) Specialized hospital;
(3) Nursing facility; or
(4) ICF-IID.
A child who is medically stable, even though disabled, is not
	 considered in need of a level of care. A child is medically stable if the
	 child's health care and medical needs do not require care in a medical
	 institution.
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 67:46:09 - Disabled children › Section 67:46:09:07 - Level of care - Acute care hospital

Current through Register Vol. 51, page 10, July 15, 2024
A child may qualify for an acute care hospital level of care if the
	 child meets the following requirements:
(1) The child has a medical condition which
  requires nursing services 24 hours a day and the services can only be provided
  by a professional nurse, or the child requires the use of sophisticated
  equipment designed to alert caregivers to potential problems;
(2) The child is at risk of rapid
  deterioration in health status;
(3)
  The child requires the continued use of medical technology, complex medical
  equipment, or invasive techniques to sustain life; and
(4) Without the support of professional
  nursing services, the child would require hospitalization for an indefinite
  time because of the complexity or intensity of the child's long-term medical
  needs.
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 67:46:09 - Disabled children › Section 67:46:09:08 - Level of care - Specialized hospital

Current through Register Vol. 51, page 10, July 15, 2024
A child may qualify for a specialized hospital level of care if the
	 child requires direct professional nursing services seven days a week and one
	 of the following conditions exist:
(1)
  The child requires continued use of medical technology or invasive techniques
  to sustain life; or
(2) The child
  requires assistance in at least three of the five activities of daily living
  and the child requires regularly scheduled skilled therapeutic services,
  including physical therapy, occupational therapy, or speech/language therapy in
  any combination not less than once a week.
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 67:46:09 - Disabled children › Section 67:46:09:09 - Level of care - Nursing facility

Current through Register Vol. 51, page 10, July 15, 2024
A child may qualify for a nursing facility level of care when all of
	 the following conditions are met:
(1)
  The child requires continuing professional nursing services which have been
  ordered by a physician and can only be provided by or under the supervision of
  a professional nurse as defined in chapter 20:48:04.01. These services include
  daily management, direct observation, monitoring, or performance of complex
  nursing procedures. Continuing care is repeated application of the procedures
  or services at least once each 24 hours, frequent monitoring, and documentation
  of the child's condition and response to the procedures or services;
(2) The child requires the assistance of
  another person for the performance of at least three of the five activities of
  daily living according to an age appropriate assessment. The ADL dependency
  requires the assistance and presence of another person during the entire
  activity; and
(3) The child
  requires skilled therapeutic services including physical therapy, occupational
  therapy, and speech/language therapy in any combination scheduled regularly,
  but not less than once a week unless limited by the child's medical condition
  or age.
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 67:46:09 - Disabled children › Section 67:46:09:10 - Level of care - ICF-IID

Current through Register Vol. 51, page 10, July 15, 2024
The team may assign an individual to an ICF-IID level of care when all
	 of the following conditions are met:
(1) The child requires a continuous active
  treatment program;
(2) The child
  requires direct assistance from professionals for special rehabilitative or
  developmental intervention for conditions which significantly interfere with
  mental age-appropriate activities;
(3) The child requires the assistance of
  another person for the performance of at least three of the five activities of
  daily living according to an age appropriate assessment. The ADL dependency
  requires the assistance and presence of another person during the entire
  activity;
(4) The child requires
  continuing direct care services which have been ordered by a physician and can
  only be provided by or under the supervision of a professional nurse. The
  services include daily management, direct observation, monitoring, or
  performance of complex nursing procedures. Continuing care is repeated
  application of the procedures or services at least once each 24 hours, frequent
  monitoring, and documentation of the child's condition and response to the
  procedures or services; and
(5) A
  clinical psychologist has determined that the child has an intellectual
  disability according to the provisions of §
									67:46:09:11, or a physician or a
  psychologist has determined that the child is developmentally disabled
  according to § 67:16:27:05.
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 67:46:09 - Disabled children › Section 67:46:09:11 - Determination of intellectual disability

Current through Register Vol. 51, page 10, July 15, 2024
A clinical psychologist may determine that a child has an
	 intellectually disability for the purposes of subdivision 67:46:09:10(5) if the
	 child meets one of the following conditions:
(1) The child has achieved only those
  developmental milestones generally acquired by children no more than half the
  child's chronological age; or
(2)
  The child has an intelligence rating of 69 or below as determined by a
  standardized intelligence test such as the Wechsler Intelligence Scale for
  Children (WISC-R) or the Stanford-Binet.
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 67:46:09 - Disabled children › Section 67:46:09:12 - Cost not to exceed cost of medical institutional care

Current through Register Vol. 51, page 10, July 15, 2024
Based on the level of care determination, the actual itemized cost of
	 all Medicaid covered services provided in the home may not exceed 100 percent
	 of the Medicaid-allowable cost of care in a medical institution. Medicaid
	 allowable cost is the amount payable when cost share, insurance, or Medicare
	 deductible or coinsurance has been applied.
The costs of all services that would be included in a medical
	 institution's reimbursement shall be used to determine the monthly home care
	 cost. When determining the monthly home care cost, the cost of purchased
	 medical equipment shall be prorated on an annual basis.
When the cost of care in the home exceeds the cost of institutional
	 care, the department shall issue a notice of intent to discontinue or deny
	 further service. The department may reconsider its decision to discontinue or
	 deny further service if, within 30 days from the date of the notice, the parent
	 provides documentation to the department that future costs will decline and be
	 within 100 percent of the cost.
The Medicaid allowable cost of care for the various medical
	 institutions are as follows:
(1) Acute
  hospital care for a child who meets the requirements of §
									67:46:09:07, $22,600 a
  month;
(2) Specialized hospital
  care for a technology-dependent child who meets the requirements of subdivision
  67:46:09:08(1), $13,800 a month;
(3) Specialized hospital care for a child who
  is not technology-dependent who meets the requirements of subdivision
  67:46:09:08(2), $6,350 a month;
(4)
  Nursing facility care cost for a child who meets the requirements of §
									67:46:09:09, $2,054 a month plus
  any add-on allowances for ventilator assistance; and
(5) Intermediate care facility for
  individuals with intellectual disabilities for a child who meets the
  requirements of §
									67:46:09:10, $5,200 a
  month.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Add-on payment -- Ventilator, §
											67:16:04:08.04; Documentation
		required for ventilator add-on payment, §
											67:45:02:07.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:09 - Disabled children › Section 67:46:09:13 - Reviews for continued eligibility

Current through Register Vol. 51, page 10, July 15, 2024
The team shall review a child's case at least annually to determine if
	 the child continues to meet the eligibility requirements of this
	 chapter.
If the team determines that the child no longer meets the eligibility
	 requirements, the case shall be closed and the child may no longer receive
	 services under this chapter.
Failure to provide the department with required documentation
	 concerning medical or financial information is cause for terminating
	 eligibility.
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 67:46:09 - Disabled children › Section 67:46:09:14 - Notice when case closed

Current through Register Vol. 51, page 10, July 15, 2024
If the department determines that the individual is no longer eligible
	 for services under this chapter, it shall send a written notice to the child's
	 parent, guardian, or other authorized representative at least 10 days before
	 the case is closed.
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 67:46:10 - Chronic renal disease program › Section 67:46:10:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Chronic renal failure," a phase of renal
  functional impairment which can no longer be favorably influenced by
  conservative management and which requires long-term, continuing dialysis or
  transplantation to maintain life and health;
(2) "Income," any money or in-kind payments
  before deductions as established in §
									67:46:10:05;
(3) "Legally responsible persons," those
  persons responsible for the support of the applicant or recipient, including
  the parents of a minor child;
(4)
  "Program," the South Dakota chronic renal disease program administered by the
  Department of Social Services;
(5)
  "Resident," a person residing in South Dakota with an intent to remain or
  absent from the state for medical purposes but with an intent to
  return;
(6) "Resource," real or
  personal property and income owned by the applicant or persons legally
  responsible for the applicant; and
(7) "Third party payer," any individual;
  firm; partnership; corporation; company; association; governmental agency,
  including Medicaid or veterans administration; local fund drive contributions;
  or any other entity responsible for or otherwise assuming an obligation to
  provide the payment of all or part of the cost of the medical care and
  treatment of a person suffering from chronic renal failure.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:02 - Application to establish initial eligibility - Refusal to comply

Current through Register Vol. 51, page 10, July 15, 2024
An individual suffering from chronic renal failure may complete and
	 submit to the department a signed application for assistance under the program
	 after the individual has been on dialysis for one month or has received a
	 transplant within the last 12 months. The applicant's refusal to complete,
	 date, and sign the application for assistance is a basis for rejecting the
	 application.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
Eligibility requirements, §
											67:46:10:04.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:03 - Application to establish continuing eligibility

Current through Register Vol. 51, page 10, July 15, 2024
A recipient of services under this chapter must submit a new, signed
	 application upon request of the department or at least annually. If the
	 recipient fails to complete, sign, date, and return the application within 10
	 days after the date the department mails the request, the recipient becomes
	 ineligible beginning the first day of the following month.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:04 - Eligibility requirements

Current through Register Vol. 51, page 10, July 15, 2024
An individual is eligible for benefits under this chapter if all of the
	 following requirements are met:
(1)
  The individual is a resident of South Dakota;
(2) The individual is either a citizen of the
  United States or an alien eligible under the provisions of §
									67:46:01:10;
(3) The individual is unable to pay the total
  cost of lifesaving care and treatment for the renal failure;
(4) The individual has not deprived himself
  or herself, directly or indirectly, of any property or assets for the purpose
  of qualifying for assistance;
(5)
  The individual does not have a third-party payer. For purposes of this rule,
  Medicare and Indian Health Services are not considered third-party payers. In
  addition, the department is not considered a third-party payer if the
  individual is determined to be a qualified Medicare beneficiary, a special
  low-income Medicare beneficiary, or a Medicare beneficiary who has income of at
  least 120 percent but less than 135 percent of the federal poverty level, and
  the individual's Medicaid benefits are limited to payment of the individual's
  part A or B premiums, deductibles, or coinsurance;
(6) The individual is a proper candidate for
  care and treatment as determined by §§
									67:46:10:02,
  67:46:10:15, and 67:46:10:16 and
  is willing to receive it;
(7) The
  individual's income, considered according to §
									67:46:10:05, is less than 150
  percent of the federal poverty level established in §
									67:11:01:03; and
(8) Excluding items listed in §
									67:46:10:06, the equity value of
  resources is less than $4,000 for a single individual and $6,000 for an
  individual with a spouse.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
Qualified Medicare beneficiaries, ch
		67:46:11.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:05 - Income considered

Current through Register Vol. 51, page 10, July 15, 2024
When determining income eligibility, the department considers the
	 household's earned and unearned income. For a salaried household member, earned
	 income includes income in cash or in kind, before deductions, such as income
	 taxes, social security taxes, insurance premiums, or savings bonds, earned
	 through the receipt of wages, salary, commissions, or fees.
For a self-employed household member, earned income is the taxable
	 income declared on the most recent tax return plus all depreciation allowances
	 claimed as a deduction on the return.
All other income is considered unearned income and is considered when
	 received.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:06 - Exclusions from resources

Current through Register Vol. 51, page 10, July 15, 2024
All resources are considered available to the household unless
	 excluded. The following resources are excluded:
(1) Personal residence and the contiguous
  land;
(2) Personal property, such
  as household furniture, life insurance policies, items essential for daily
  living, and automobiles;
(3)
  Income-producing property within the limits established in §
									67:46:10:04; and
(4) Income-producing personal property, such
  as equipment, inventory of a small business, or tools needed to produce income
  during or following rehabilitation services.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:07 - Eligibility determination

Current through Register Vol. 51, page 10, July 15, 2024
Applications shall be reviewed by the department and approval or
	 rejection shall be made to the applicant in writing within sixty days from the
	 date of application. Approval for assistance, when granted, shall be for a
	 period of one year or for a period of one year after the date of a successful
	 transplant, whichever occurs first.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:08 - Program limitations

Current through Register Vol. 51, page 10, July 15, 2024
All payments for assistance and services under the chronic renal
	 disease program shall be made within the budget limitation of the
	 program.
General Authority:
SDCL
		28-6A-2.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:09 - Scope of services and benefits

Current through Register Vol. 51, page 10, July 15, 2024
Services and benefits which may be paid under the program include the
	 following:
(1) Institutional
  dialysis;
(2) Home dialysis,
  including supplies, equipment, and special water softeners;
(3) Renal transplants;
(4) Hospitalization;
(5) Prescription drugs necessary for dialysis
  or transplants not covered by other sources; and
(6) Travel expenses for the recipient are
  reimbursed according to the provisions of chapter 67:16:49.
General Authority:
SDCL
		28-6A-12,
		28-6-1.1.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:10 - Basis of payment

Current through Register Vol. 51, page 10, July 15, 2024
Payment for services under the program shall be made to the provider.
	 All payments for services provided shall be based on the criteria used to
	 establish rates for services and benefits in chapters 67:16:02, 67:16:03,
	 67:16:14, 67:46:10, and 67:16:25.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:11 - Payment limit

Current through Register Vol. 51, page 10, July 15, 2024
Total payments made on behalf of an individual eligible under this
	 chapter may not exceed $5,000 in a fiscal year.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:12 - Claim submission limit

Current through Register Vol. 51, page 10, July 15, 2024
All claims for services provided under this chapter must be submitted
	 to the department according to the provisions of §
									67:16:35:04.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:13 - Date of eligibility

Current through Register Vol. 51, page 10, July 15, 2024
Eligibility for benefits under this chapter shall start with the first
	 day of the month in which the application is signed.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:14 - Provider limitations

Current through Register Vol. 51, page 10, July 15, 2024
Payments to medical providers under the program shall be limited to
	 providers qualified for reimbursement from the Medicare program administered by
	 the social security administration.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:15 - Medical eligibility

Current through Register Vol. 51, page 10, July 15, 2024
Medical eligibility for benefits under this chapter is limited to
	 persons who meet both of the following criteria:
(1) Presence of terminal irreversible renal
  failure of such severity that conservative management will not support life.
  The person requires peritoneal dialysis, hemodialysis, or renal transplant in
  order to sustain life; and
(2) A
  sufficient degree of understanding and motivation to assure that the person
  will participate in continuing dialysis. The person is willing to adhere to
  dietary and intake restrictions.
A report from the renal disease center or the applicant's or
	 recipient's attending physician shall confirm that the requirements in this
	 section are met before initial or continuing eligibility is
	 determined.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:16 - Acceptance for treatment

Current through Register Vol. 51, page 10, July 15, 2024
The person must be accepted for evaluation and treatment by a renal
	 disease center which has been certified as such by the Medicare program
	 administered by the social security administration.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:10 - Chronic renal disease program › Section 67:46:10:18 - Copayment

Current through Register Vol. 51, page 10, July 15, 2024
A recipient of benefits under this chapter must make a copayment to the
	 provider. The amount of the copayment is five percent of the amount allowed in
	 §
									67:46:10:10.
General Authority:
SDCL
		28-6A-12.
Law Implemented:
SDCL
		28-6A-2.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms defined in §
									67:16:01:01 have the same meaning
	 when used in this chapter. In addition, terms used in this chapter mean:
(1) "BIA," the bureau of Indian
  affairs;
(2) "Coinsurance," that
  portion of the medical costs allowable but not payable by Medicare and for
  which the individual is responsible;
(3) "Deductible," the initial amount of
  allowable Medicare costs paid by the individual before Medicare begins
  paying;
(4) "Medicare," the federal
  health insurance program available through the social security administration
  for certain disabled individuals and for individuals 65 years of age or
  older;
(5) "OCSE," the office of
  child support enforcement within the department of social services;
(6) "Part A," insurance available through the
  Medicare program to help pay for medically necessary hospice or home health
  care or care in a hospital or skilled nursing facility;
(7) "Part B," insurance available through the
  Medicare program to help pay for medically necessary physician services,
  outpatient hospital services, and medical supplies;
(8) "Qualifying Individual" or "QI," a person
  who meets the requirements of this chapter and who is not otherwise eligible
  for Medicaid benefits and for whom the state pays the Part B Medicare
  premium;
(9) "Qualified Medicare
  beneficiary" or "QMB," a person who meets the requirements of this chapter and
  for whom the state pays the Medicare Part A and Part B premiums, deductibles,
  coinsurance, and copayments;
(10)
  "SCORE," the service corps of retired executives;
(11) "Special low-income Medicare
  beneficiary" or "SLMB," a person who meets the requirements of this chapter and
  for whom the state pays the Part B Medicare premium; and
(12) "VISTA," the volunteers in service to
  America.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:02 - Long-term care requirements applicable to QI, QMB and SLMB

Current through Register Vol. 51, page 10, July 15, 2024
All provisions of chapters 67:46:02 to 67:46:05, inclusive, and
	 67:46:08 apply to QI, QMB and SLMB applicants and recipients unless otherwise
	 specified in this chapter.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:03 - Income eligibility

Current through Register Vol. 51, page 10, July 15, 2024
After the $20 disregard, income for a QMB individual may not exceed 100
	 percent of the federal poverty level established in §
									67:11:01:03. If the individual's
	 countable income is 100 percent of the federal poverty level or less and the
	 individual is married and living with a spouse, the income of the spouse must
	 be considered. If their combined countable income exceeds 100 percent of the
	 federal poverty level for two individuals, the individual is ineligible.
After the $20 disregard, the countable income for a SLMB individual
	 must exceed 100 percent of the federal poverty level and be less than 120
	 percent of the federal poverty level. If the individual's countable income is
	 less than 120 percent of the federal poverty level and the individual is
	 married and living with a spouse, the income of the spouse must be considered.
	 If their combined countable income is equal to or greater than 120 percent of
	 the federal poverty level for two individuals, the individual is
	 ineligible.
After the $20 disregard, the countable income for a QI individual must
	 be at least 120 percent of the federal poverty level and be less than 135
	 percent of the federal poverty level. If the individual's countable income is
	 less than 135 percent of the federal poverty level and the individual is
	 married and living with a spouse, the income of the spouse must be considered.
	 If their combined countable income is equal to or greater than 135 percent of
	 the federal poverty level for two individuals, the individual is
	 ineligible.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
Income disregard, §
											67:46:11:09.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:04 - Deduction from income for dependent child. 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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:05 - Deduction for court-ordered support or support enforced by OCSE

Current through Register Vol. 51, page 10, July 15, 2024
The department shall deduct from the ineligible spouse's income that
	 portion of the income paid under court order or enforced by OCSE for the
	 support of another person who is not in the household.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:06 - Items not considered income when determining QI, QMB or SLMB eligibility

Current through Register Vol. 51, page 10, July 15, 2024
In addition to those items contained in §
									67:46:04:03, the following items
	 are not considered income when determining QI, QMB or SLMB eligibility:
(1) Assistance based on need provided by a
  local government or nongovernmental agency, such as Catholic Charities, county
  assistance, or assistance from the Salvation Army;
(2) Replacement of resources in cash or in
  kind because of loss, damage, or theft of property;
(3) Home energy assistance;
(4) Home produce for personal use;
(5) Foster care payments made to a foster
  care provider;
(6) Grants or loans
  to undergraduate students for educational purposes which are insured by the
  United States secretary of education;
(7) Housing assistance from housing and urban
  development or farmer's home administration;
(8) Credit life or credit disability
  insurance payments on loans, installment purchases, and similar items in the
  event of death or disability;
(9)
  Money borrowed;
(10) Money received
  as repayment on the principal of a loan;
(11) Reimbursements for expenses of obtaining
  income such as per diem payments and mileage;
(12) United States department of agriculture
  food commodities, the value of coupon allotments from government agencies and,
  for an individual age 60 or over, the value of meals received at a center or
  the value of meals delivered to the individual's home;
(13) Any benefits received under the
  provisions of the Older Americans Act of 1965, except wages or
  salary;
(14) Payments to volunteers
  under the Domestic Volunteer Service Act of 1973, such as from SCORE, VISTA, or
  the foster grandparent program; and
(15) Indian judgment funds distributed on a
  per capita basis.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:07 - Income from self-employment

Current through Register Vol. 51, page 10, July 15, 2024
The net income from self-employment is considered earned income. Net
	 income is the taxable income declared on the individual's most recent income
	 tax return. If a tax return was not filed or was filed and indicated no
	 self-employment, the net income is as established on either a profit and loss
	 statement or on some other business record for the tax year.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:08 - Deduction from earned income

Current through Register Vol. 51, page 10, July 15, 2024
A deduction of $65 plus one-half of the remainder is deducted from the
	 total monthly earned income. If the individual is living with a spouse, the
	 earned income deduction applies to the couple's total earned
	 income.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:09 - Income disregard

Current through Register Vol. 51, page 10, July 15, 2024
The department shall disregard $20 a month from the applicant's or
	 recipient's unearned income unless the income is from a source based on need,
	 such as certain veterans' benefits, TANF, or BIA general assistance. If
	 unearned income is less than $20, the difference shall be deducted from the
	 applicant's or recipient's gross earned income before applying the earned
	 income disregard provided in §
									67:46:11:06. If the individual is
	 living with the individual's spouse, the $20 deduction applies to the couple's
	 combined income.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:10 - Resource limit (Repealed)

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Premium and cost-sharing subsidies for low-income individuals --
		Maximum resource level annual adjustment,
		42 U.S.C. §
												1395w-114(a)(3).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:11 - Disposal of resources

Current through Register Vol. 51, page 10, July 15, 2024
The value of resources disposed of and no longer owned by the
	 individual are not considered. The provisions of §§
									67:46:05:06 and
	 67:46:05:07 do not
	 apply.
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 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:12 - Date of eligibility

Current through Register Vol. 51, page 10, July 15, 2024
Benefits for individuals eligible for QMB begin with the month after
	 the month in which the individual is determined eligible. Eligibility starting
	 dates outlined in §
									67:46:01:03 do not apply.
Benefits for individuals eligible for SLMB or QI begin with the first
	 day of the month of application. Eligibility may begin as early as the first
	 day of the third month prior to the month of application if all eligibility
	 criteria are met.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:11 - Qualified Medicare beneficiaries (QMB) › Section 67:46:11:13 - Payment limits

Current through Register Vol. 51, page 10, July 15, 2024
If an individual is eligible for QMB, payment is limited to Medicare
	 premiums, deductibles, and coinsurance for Part A and Part B of
	 Medicare.
If an individual is eligible for SLMB, payment is limited to the Part B
	 Medicare premium.
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 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Caretaker relative," a relative of a
  dependent child by blood, adoption, or marriage with whom the child is living,
  who assumes primary responsibility for the child's care (as may, but is not
  required to, be indicated by claiming the child as a tax dependent for Federal
  income tax purposes), and who is one of the following:
(a) The child's father, mother, grandfather,
  grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister,
  uncle, aunt, first cousin, nephew, or niece;
(b) The spouse of such parent or relative,
  even after the marriage is terminated by death or divorce.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:02 - Medicaid eligibility - Parent/caretaker relative

Current through Register Vol. 51, page 10, July 15, 2024
If a dependent child is living with a parent/caretaker relative, the
	 parent/caretaker relative may be eligible for Medicaid if the following
	 criteria is met:
(1) They meet the
  general eligibility requirements of chapter 67:46:01;
(2) They meet the requirements contained in
  this chapter.
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 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:08 - Income limit - Parent/caretaker relative

Current through Register Vol. 51, page 10, July 15, 2024
To be eligible for assistance under this chapter a parent/caretaker
	 relative's income, based on family size determined under the provisions of
	 42 C.F.R. §
										435.603 (July 15, 2013), may not exceed the
	 following amounts plus five percent of the current year's federal poverty
	 guidelines for that family size:
FAMILY SIZE
MONTHLY GROSS INCOME LIMIT
1
$ 563
2
703
3
796
4
885
5
977
6
1,070
7
1,160
8
1,249
9
1,340
10
1,431
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Definitions and use of terms,
		42 C.F.R. §
												435.4 (March 23, 2012); Application of
		modified adjusted gross income (MAGI),
		42 C.F.R. §
												435.603 (July 15,
		2013).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:10 - Medicaid eligibility - Pregnant woman

Current through Register Vol. 51, page 10, July 15, 2024
A pregnant woman is eligible for Medicaid if the following criteria is
	 met:
(1) She meets the general
  eligibility requirements of chapter 67:46:01;
(2) She meets the requirements contained in
  this chapter.
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 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:11 - Income limit - Pregnant woman

Current through Register Vol. 51, page 10, July 15, 2024
To be eligible for assistance under this chapter, a pregnant woman, as
	 defined in subdivision 67:46:01:02(11), may not exceed income of one hundred
	 thirty-eight percent of the federal poverty guidelines based on family size for
	 the current year.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1(4)(6).
Application of modified adjusted gross income,
		42 C.F.R. §
												435.603, in effect on November 30,
		2016.
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:12 - Medicaid eligibility - Children

Current through Register Vol. 51, page 10, July 15, 2024
A child is eligible for Medicaid if the following criteria is
	 met:
(1) With the exception of §
									67:46:01:14, the child meets the
  general eligibility requirements of chapter 67:46:01;
(2) The child meets the requirements
  contained in this chapter.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Application of modified adjusted gross income (MAGI),
		42 C.F.R. §
												435.603 (July 15,
		2013).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:13 - Income limit - Children

Current through Register Vol. 51, page 10, July 15, 2024
To be eligible for assistance under this chapter a child's family
	 income, based on family size, may not exceed 182% of the current year's federal
	 poverty guidelines for that family size.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Application of modified adjusted gross income (MAGI),
		42 C.F.R. §
												435.603 (July 15,
		2013).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:14 - Medicaid eligibility - Other reasonable classifications of children

Current through Register Vol. 51, page 10, July 15, 2024
A child under age 21 is eligible for Medicaid assistance if the
	 child:
(1) Is in an adoption that is
  subsidized in full or part by a public agency;
(2) Resides in a nursing or intermediate care
  facility;
(3) Is under the custody
  of the department;
(4) Is in foster
  care and the department is assuming full or partial financial
  responsibility;
(5) Is under the
  jurisdiction of the Department of Corrections and is not an inmate of a public
  institution under the provisions of
  42 CFR
  435.1008;
(6) Is adjudicated under the guardianship of
  the South Dakota Human Services Center and is receiving inpatient psychiatric
  treatment for drug or alcohol dependency; or
(7) Is adjudicated under the guardianship of
  the South Dakota Human Services Center and is receiving inpatient psychiatric
  treatment.
The child must also meet the requirements in Chapter 67:46:01,
	 residency requirements in §§
										67:46:03:04 through
	 67:46:03:15, and have income
	 within limits specified in §
										67:46:12:15.
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Application of modified adjusted gross income (MAGI),
		42 C.F.R. §
												435.603 (July 15,
		2013).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:15 - Income limit - Other reasonable classifications of children

Current through Register Vol. 51, page 10, July 15, 2024
FAMILY SIZE
MONTHLY GROSS INCOME LIMIT
1
$ 382
2
484
3
561
4
636
5
713
6
790
7
865
8
940
9
1016
10
1092
General Authority:
SDCL 28-6-1.
Law Implemented:
SDCL
		28-6-1.
Application of modified adjusted gross income (MAGI),
		42 C.F.R. §
												435.603 (July 15,
		2013).
South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:46 - Eligibility for medical services › Chapter 67:46:12 - Modified adjusted gross income (MAGI) Medicaid eligibility standards › Section 67:46:12:16 - Medicaid eligibility - Individuals age nineteen or older and under age sixty-five at or below one hundred thirty-three percent of the federal poverty level

Current through Register Vol. 51, page 10, July 15, 2024
An individual may be eligible for Medicaid if they:
(1) Are over age nineteen or older and under
  age sixty-five;
(2) Are not
  pregnant;
(3) Are not entitled to
  or enrolled for Medicare benefits;
(4) Are not otherwise eligible for and
  enrolled for mandatory coverage under the state's Medicaid State
  Plan;
(5) Have household income
  that is at or below one hundred thirty-three percent of the federal poverty
  level for the applicable family size.
General Authority:
SDCL
		28-6-1.
Law Implemented:
SDCL
		28-6-1(4)(6).