South Dakota Administrative Code

Rule 67:16:04:47 Costs not allowed. 67:16:04:47. Costs not allowed. The following costs are not allowed: (1) Income tax; (2) Compensation paid to owners or employees who serve on a facility's board of directors. Compensation paid to other board members is limited to $75 a day for…

Rule 67:16:04:48 Repealed. 67:16:04:48. Department to assign facility to a group. Repealed. Source: 16 SDR 26, effective August 13, 1989; transferred from § 67:16:04:07.04, 21 SDR 8, effective July 25, 1994; 26 SDR 5, effective July 1, 1999; 26 SDR 21, effective August 24, 1999; …

67:16:04:49. Occupancy. To determine the nondirect care per diem rate of a facility, the department shall use the facility's actual occupancy, or three percent less than the statewide average of all nursing facilities, whichever is greater. The department shall waive this provisi…

Rule 67:16:04:50 Return on net equity. 67:16:04:50. Return on net equity. A return on net equity is an allowable cost for proprietary facilities. The allowable rate of return is the sum of the average midpoint of the prime interest rate and the average rate of 180-day United Stat…

67:16:04:51. Ceilings. Ceilings are established using allowable costs as follows: (1) To determine the case mix adjusted direct care costs of a facility, the department shall use two ceiling calculations. The first ceiling is one hundred and fifteen percent of the median cost of …

67:16:04:52. Maximum capital cost for leased facility. The maximum capital cost for leased facilities is limited to the lower of actual costs or the total capital costs per resident day established in § 67:16:04:51. The capital cost items for computing the above limit consist of …

Rule 67:16:04:53 Repealed. 67:16:04:53. Change of ownership. Repealed. Source: 15 SDR 68, effective November 7, 1988; 16 SDR 26, effective August 13, 1989; transferred from § 67:16:04:06.05, 21 SDR 8, effective July 25, 1994; 21 SDR 172, effective April 3, 1995; repealed, 35 SDR …

67:16:04:54. Method of establishing per diem rates. The department shall establish a case mix adjusted direct care per diem rate and a nondirect care per diem rate for each facility prior to July first of each year. These rates are based on the facility's allowable costs, the fac…

Rule 67:16:04:54.01 Method of establishing per diem rates -- Case mix adjusted direct care costs. 67:16:04:54.01. Method of establishing per diem rates -- Case mix adjusted direct care costs. When calculating the allowable payment for the case mix adjusted direct care costs for t…

Rule 67:16:04:54.02 Method of establishing per diem rates -- Nondirect care costs of health and subsistence, plant/operational, and other operating costs. 67:16:04:54.02. Method of establishing per diem rates -- Nondirect care costs of health and subsistence, plant/operational, a…

Rule 67:16:04:54.03 Method of establishing per diem rates -- Nondirect care costs of administration. 67:16:04:54.03. Method of establishing per diem rates -- Nondirect care costs of administration. When calculating the allowable payment for the nondirect care costs of administrat…

Rule 67:16:04:55 Provisional per diem rates. 67:16:04:55. Provisional per diem rates. The department shall establish provisional per diem rates for newly constructed facilities and for facilities experiencing major expansion. The department shall calculate provisional per diem ra…

Rule 67:16:04:56 Per diem rates as payment in full. 67:16:04:56. Per diem rates as payment in full. The per diem rates established by the department are applied to every resident in the facility who is eligible for Medicaid, excluding those classified as assisted living, and paym…

Rule 67:16:04:56.01 Per diem rate -- Existing facility experiencing new operational ownership. 67:16:04:56.01. Per diem rate -- Existing facility experiencing new operational ownership. For a facility acquired through purchase or a capital lease, the daily rate of reimbursement i…

Rule 67:16:04:57 Repealed. 67:16:04:57. Effective dates of per diem rates -- Interim rate adjustment. Repealed. Source: 16 SDR 26, effective August 13, 1989; 17 SDR 50, effective October 7, 1990; 18 SDR 67, effective October 13, 1991; transferred from § 67:16:04:07.05, 21 SDR 8, …

Rule 67:16:04:58 Facility's average per diem charge. 67:16:04:58. Facility's average per diem charge. A nursing facility which elects to participate in the Medicaid program must notify the department of its average per diem charge to individuals who are not presently receiving nu…

Rule 67:16:04:59 Repealed. 67:16:04:59. Add-on payment -- Ventilator. Repealed. Source: 16 SDR 26, effective August 13, 1989; 18 SDR 67, effective October 13, 1991; transferred from § 67:16:04:08.04, 21 SDR 8, effective July 25, 1994; 44 SDR 94, effective December 4, 2017.

67:16:04:60. Basis of payment. Payment to participating providers of nursing facility services is made on the following basis: (1) Payment to an in-state facility is calculated using the per diem rates according to § 67:16:04:54, multiplying the case mix adjusted direct care per …

Rule 67:16:04:61 Preadmission screening. 67:16:04:61. Preadmission screening. No payment may be made in behalf of a resident of a nursing facility who is mentally ill or intellectually or developmentally disabled and who was admitted to the facility after December 31, 1988, and d…

67:16:04:62. Medicare Provider Reimbursement Manual. Provider reimbursement under the provisions of this chapter and chapter 67:16:44 is made by the department according to the Medicare Provider Reimbursement Manual (CMS Pub 15-1), (December 2021) available at https://www.cms.gov…

Rule 67:16:04:63 Repealed. 67:16:04:63. Add-on payment – Specialty bed. Repealed. Source: 24 SDR 185, effective July 6, 1998; 35 SDR 312, effective July 6, 2009; 42 SDR 51, effective October 13, 2015; 44 SDR 94, effective December 4, 2017.

Rule 67:16:05:01 Definition of terms. 67:16:05:01. Definition of terms. Terms as used in this chapter: (1) "Attending physician or other licensed practitioner" means the individual's personal private physician or other licensed practitioner or a physician or other licensed practi…

Rule 67:16:05:02 Repealed. 67:16:05:02. Provider agreement. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981; cross-reference added, 16 SDR 233, effective July 1, 1990. Cross-Reference: Provider agre…

Rule 67:16:05:03 Individuals eligible for home health services. 67:16:05:03. Individuals eligible for home health services. Home health services are available to an individual in the individual's place of residence. The individual must be eligible for medical assistance and the r…

Rule 67:16:05:04 Repealed. 67:16:05:04. Payments for home health services for individuals eligible for Medicare and Medicaid. Repealed. Source: 1 SDR 30, effective October 13, 1974; 4 SDR 35, effective December 22, 1977; 5 SDR 109, effective July 1, 1979; 7 SDR 66, 7 SDR 89, effe…

Rule 67:16:05:05 Covered services -- Limits. 67:16:05:05. Covered services -- Limits. Home health services are limited to: (1) Skilled nursing services; (2) Medical social services provided by a licensed social worker who is not an employee of the department; (3) Medical supplies…

Rule 67:16:05:05.01 Service restrictions. 67:16:05:05.01. Service restrictions. Home health services must: (1) Be provided by a home health agency employee who is qualified to perform the required service; (2) Be prescribed by the attending physician or other licensed practitione…

Rule 67:16:05:05.02 Prescription for services required before services begin -- Plan of care -- Certification and recertification. 67:16:05:05.02. Prescription for services required before services begin -- Plan of care -- Certification and recertification. Before a home health a…

Rule 67:16:05:05.03 Supervisory visit required when home health aide services provided. 67:16:05:05.03. Supervisory visit required when home health aide services provided. Supervisory visits when home health aide services are being provided must follow the criteria established in…

Rule 67:16:05:05.04 Repealed. 67:16:05:05.04. Extended services -- Prior authorization required. Repealed. Source: 16 SDR 111, effective January 7, 1990; repealed, 18 SDR 203, effective July 1, 1992.

Rule 67:16:05:05.05 Respiratory therapy -- Limitations. 67:16:05:05.05. Respiratory therapy -- Limitations. An individual receiving home respiratory therapy must meet the following requirements: (1) Be medically dependent on a ventilator for life support at least six hours a day …

Rule 67:16:05:05.06 Postpartum services -- Limitations. 67:16:05:05.06. Postpartum services -- Limitations. Postpartum services are limited to one visit each day, may not be provided for more than four consecutive weeks following the child's birth, and are subject to this chapter…

Rule 67:16:05:06 Services not covered. 67:16:05:06. Services not covered. In addition to the other services not specifically listed in § 67:16:05:05, the following services are not covered under this chapter: (1) Physician or other licensed practitioner's medical or surgical serv…

Rule 67:16:05:06.01 Medical records. 67:16:05:06.01. Medical records. A home health agency must maintain a medical record for each individual receiving services. The medical record must contain documentation verifying that the claimed service was performed and was authorized by t…

Rule 67:16:05:07 Covered services -- Rate of payment. 67:16:05:07. Covered services -- Rate of payment. Covered home health services are limited to the procedures listed on the department's fee schedule website. Payment is limited to the home health agency's usual and customary c…

Rule 67:16:05:07.01 Billing requirements. 67:16:05:07.01. Billing requirements. A claim submitted for services provided under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes contained on the department's …

Rule 67:16:05:07.02 Cost not to exceed institutional care. 67:16:05:07.02. Cost not to exceed institutional care. If the actual or projected cost of all home health services over a period of three months exceeds 135 percent of the cost of care if the individual was institutionali…

Rule 67:16:05:07.03 Services provided outside South Dakota. 67:16:05:07.03. Services provided outside South Dakota. Services provided outside South Dakota shall be covered if all of the following criteria are met: (1) The services provided are covered under this chapter; (2) The …

Rule 67:16:05:08 Utilization review. 67:16:05:08. Utilization review. Home health services may be reviewed on the following levels: (1) Computerized claims processing; (2) Cost comparison to institutional care; and (3) Postpayment review. Source: 1 SDR 30, effective October 13, 1…

Rule 67:16:05:09 Claim requirements. 67:16:05:09. Claim requirements. A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following information: (1) The recipient's full name; (2) The recipient's medical assist…

Rule 67:16:05:10 Application of other chapters. 67:16:05:10. Application of other chapters. 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. Source: 17 SDR 184…

Rule 67:16:06:01 Definitions. 67:16:06:01. Definitions. Terms used in this chapter mean: (1) "Contractor," a vendor that has a contract with the department to adjudicate claims for dental services and goods provided to eligible recipients of the medical assistance program; and (2…

Rule 67:16:06:02 Repealed. 67:16:06:02. Provider agreement. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 66, effective April 6, 1975; repealed, 7 SDR 66, 7 SDR 89, effective July 1, 1981; cross-reference added, 16 SDR 234, effective July 1, 1990. Cross-Reference: Participating pr…

Rule 67:16:06:03 Repealed. 67:16:06:03. Payment limits. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 66, effective April 6, 1975; 15 SDR 167, effective May 11, 1989; 16 SDR 64, effective October 8, 1989; 16 SDR 234, effective July 1, 1990; repealed, 23 SDR 197, effective May 26, …

Rule 67:16:06:03.01 Contractor to provide certain services. 67:16:06:03.01. Contractor to provide certain services. A contractor must provide the following services: (1) At a minimum, the dental services contained in this chapter; (2) An automated claims processing and payment sy…

67:16:06:04. Covered services -- Limits -- Rate of payment. Covered dental services include those procedures and limitations listed on the department's fee schedule website. The rate of payment is limited to the lesser of the provider's usual and customary fee or the fee listed o…

Rule 67:16:06:05 Repealed. 67:16:06:05. Services not provided. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 66, effective April 6, 1975; 4 SDR 10, effective August 28, 1977; 4 SDR 35, effective December 22, 1977; 7 SDR 66, 7 SDR 89, effective July 1, 1981; repealed, 16 SDR 234, e…

Rule 67:16:06:06 Repealed. 67:16:06:06. Utilization review. Repealed. Source: 1 SDR 66, effective April 6, 1975; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 15 SDR 167, effective May 11, 1989; 16 SDR 234, effective July 1, 1990; repealed, 23 SDR 197, effective May 26, 1997.

Rule 67:16:06:07 Repealed. 67:16:06:07. Cost sharing. Repealed. Source: 9 SDR 164, effective June 30, 1983; 11 SDR 26, effective August 21, 1984; 15 SDR 167, effective May 11, 1989; 17 SDR 200, effective July 1, 1991; 31 SDR 191, effective June 8, 2005; 35 SDR 88, effective Octob…

Rule 67:16:06:08 Billing requirements. 67:16:06:08. Billing requirements. A provider submitting a claim under this chapter must submit the claim to the contractor. Source: 16 SDR 234, effective July 1, 1990; 23 SDR 197, effective May 26, 1997. General Authority: SDCL 28-6-1. Law …