South Dakota Administrative Code

67:44:03:04. Individual support plan -- Review. Each eligible individual applying for HOPE waiver services must have an individual support plan that is signed by the individual or the individual's legal representative. The individual support plan must include: (1) The individual'…

67:44:03:05. Redetermination of level of care. The redetermination of level of care must be done in accordance with § 67:45:01:08. Source: 15 SDR 191, effective June 11, 1989; 18 SDR 67, effective October 13, 1991; 51 SDR 36, effective September 30, 2024. General Authority: SDCL …

67:44:03:06. Services covered. Services available through the HOPE waiver as identified in the participant's individual support plan and based on assessed need may include: (1) Adult companion services; (2) Adult day services; (3) Assisted living; (4) Chore services; (5) Communit…

Rule 67:44:03:07 Repealed. 67:44:03:07. Adult day care services. Repealed. Source: 15 SDR 191, effective June 11, 1989; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:44:03:08 Repealed. 67:44:03:08. Homemaker services. Repealed. Source: 15 SDR 191, effective June 11, 1989; 28 SDR 96, effective December 30, 2001; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:44:03:09 Repealed. 67:44:03:09. Private duty nursing. Repealed. Source: 15 SDR 191, effective June 11, 1989; repealed, 38 SDR 123, effective January 23, 2012. Rule 67:44:03:09.01 Repealed. 67:44:03:09.01. Administration of medications. Repealed. Source: 23 SDR 92, effecti…

Rule 67:44:03:09.01 Repealed. 67:44:03:09.01. Administration of medications. Repealed. Source: 23 SDR 92, effective December 10, 1996; 27 SDR 32, effective October 11, 2000; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:44:03:09.02 Repealed. 67:44:03:09.02. Meals and nutritional supplements. Repealed. Source: 23 SDR 92, effective December 10, 1996; repealed, 38 SDR 123, effective January 23, 2012.

67:44:03:10. Eligible participants to participate in cost of HOPE waiver services. A participant eligible for and receiving HOPE waiver services is required to pay any remaining income of the participant after allowable deductions toward the cost of services. The department will …

67:44:03:11. Payment limits. The rate of payment for HOPE waiver services is limited to the lesser of the provider's usual and customary fee or the fee contained on the department's website, located at https://dhs.sd.gov. Source: 15 SDR 191, effective June 11, 1989; 16 SDR 161, e…

67:44:03:12. Provider requirements. Repealed. Source: 15 SDR 191, effective June 11, 1989; 38 SDR 123, effective January 23, 2012; 51 SDR 36, effective September 30, 2024.

Rule 67:44:03:13 Repealed. 67:44:03:13. Conditions for terminating provider agreement. Repealed. Source: 15 SDR 191, effective June 11, 1989; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:44:03:14 Repealed. 67:44:03:14. Submission of claims. Repealed. Source: 15 SDR 191, effective June 11, 1989; repealed, 38 SDR 123, effective January 23, 2012.

67:44:03:15. Discontinuance or denial of services. The department may discontinue or deny services provided under this chapter if: (1) The participant does not meet eligibility requirements; (2) The participant failed to participate in completing any review required by § 67:44:03…

67:44:03:16. Exceptions process. The total amount the department will authorize for all HOPE waiver services for a participant is based on assessed need as identified in the individual support plan, with a maximum threshold equal to the average cost of nursing facility care. Serv…

67:45:01:01. Definitions. Terms used in this chapter mean: (1) "Activities of daily living," tasks performed routinely by a person to maintain physical functioning and personal care; (2) "Adult foster care," as defined in chapter 67:46:03; (3) "Alternative services," services pro…

67:45:01:02. Department to determine level of care. If an assessment of the individual indicates waiver services are applicable, the department must determine if the individual requesting long-term care assistance under article 67:46 is in need of care. The need for care is estab…

67:45:01:03. Nursing facility level of care classification. The department may assign an individual to a nursing facility level of care classification if the individual requires any of the following services: (1) Continuing direct care services that have been ordered by a physici…

67:45:01:04. Intermediate level of care classification. The department may assign an individual to an intermediate level of care classification if the individual: (1) Resides, or is anticipated to reside, in an assisted living center and requires assistance available twenty-four …

67:45:01:04.01. Adult foster care classification. Repealed. Source: 23 SDR 92, effective December 10, 1996; 27 SDR 32, effective October 11, 2000; 51 SDR 13, effective August 12, 2024.

Rule 67:45:01:04.02 Repealed. 67:45:01:04.02. Assisted living/cognitively impaired. Repealed. Source: 27 SDR 32, effective October 11, 2000; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:45:01:04.03 Repealed. 67:45:01:04.03. Assisted living/physically impaired. Repealed. Source: 27 SDR 32, effective October 11, 2000; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:45:01:04.04 Repealed. 67:45:01:04.04. Assisted living/supplemental oxygen. Repealed. Source: 27 SDR 32, effective October 11, 2000; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:45:01:04.05 Repealed. 67:45:01:04.05. Assisted living/special diet. Repealed. Source: 27 SDR 32, effective October 11, 2000; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:45:01:04.06 Repealed. 67:45:01:04.06. Assisted living facility ineligible to receive reimbursement for certain individuals if not properly licensed. Repealed. Source: 27 SDR 32, effective October 11, 2000; repealed, 38 SDR 123, effective January 23, 2012.

67:45:01:05. Self-care level of care classification. For individuals who do not meet the criteria for a nursing facility level of care classification or an intermediate level of care classification, the department must assign a self-care level of care classification. Individuals …

67:45:01:05.01. Settings and services for level of care classifications. Individuals are eligible for certain settings and services, depending on their level of care classification: (1) For a nursing facility level of care classification: (a) Swing bed; (b) Nursing facility; and …

67:45:01:06. Swing-bed hospital services. Repealed. Source: 11 SDR 26, effective August 21, 1984; transferred from § 67:16:04:20.02, 18 SDR 67, effective October 13, 1991; 51 SDR 13, effective August 12, 2024.

Rule 67:45:01:07 Repealed. 67:45:01:07. Factors not considered when determining individual's level of care classification. Repealed. Source: SL 1975, ch 16, § 1; 2 SDR 71, effective April 29, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 11 SDR 26, effective August 21, 1984; …

67:45:01:08. Redetermination of level of care classification. The department shall annually redetermine an individual's level of care classification assignment. A redetermination may be made at more frequent intervals if a redetermination is warranted due to a change in the indiv…

Rule 67:45:01:09 Repealed. 67:45:01:09. Utilization review. Repealed. Source: 18 SDR 67, effective October 13, 1991; 22 SDR 16, effective August 17, 1995; repealed, 38 SDR 123, effective January 23, 2012.

Rule 67:45:02:01 Reserved. 67:45:02:01. Reserved.

Rule 67:45:02:02 Payment limits -- Level of care classification. 67:45:02:02. Payment limits -- Level of care classification. Payment to a nursing facility for services provided to an eligible individual may not be made until the following requirements are met: (1) The individual…

Rule 67:45:02:03 Repealed. 67:45:02:03. Payment limits when husband and wife both require nursing facility care. Repealed. Source: SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 2 SDR 71, effective April 29, 1976; 4 SDR 10, effective August 28, 1977; 7 SDR 66, 7 SDR 8…

Rule 67:45:02:04 Payment for reserved bed days. 67:45:02:04. Payment for reserved bed days. The department shall pay a nursing facility to reserve a bed during an eligible individual's temporary absence from the nursing facility. Payment is limited to a maximum of five days if th…

Rule 67:45:02:05 Repealed. 67:45:02:05. Documentation required for oxygen add-on payment. Repealed. Source: 15 SDR 68, effective November 7, 1988; documentation requirements transferred from § 67:16:04:08.02, 18 SDR 67, effective October 13, 1991; repealed, 22 SDR 16, effective A…

Rule 67:45:02:06 Repealed. 67:45:02:06. Documentation required for nutritional therapy add-on payment. Repealed. Source: 15 SDR 68, effective November 7, 1988; documentation requirements transferred from § 67:16:04:08.02, 18 SDR 67, effective October 13, 1991; repealed, 22 SDR 16…

Rule 67:45:02:07 Documentation required for ventilator add-on payment. 67:45:02:07. Documentation required for ventilator add-on payment. When an add-on payment for a ventilator is made under the provisions of § 67:16:04:08.04, the individual's record must contain the physician's…

Rule 67:45:02:08 Assistance when nursing facility unable to meet individual's need -- Individual assigned to self-care -- Payment limits. 67:45:02:08. Assistance when nursing facility unable to meet individual's need -- Individual assigned to self-care -- Payment limits. When a n…

Rule 67:45:02:09 Assistance when need is intermediate care for individuals with intellectual disabilities or intermediate care for the mentally disabled -- Payment limits. 67:45:02:09. Assistance when need is intermediate care for individuals with intellectual disabilities or int…

Rule 67:45:02:10 Payment limited to resident days. 67:45:02:10. Payment limited to resident days. Payments to nursing facilities are made in behalf of an individual for resident days only. Resident days include the day of admission but exclude the day of discharge. For purposes o…

Rule 67:45:02:11 Utilization review. 67:45:02:11. Utilization review. Claims and payments for nursing facility care, adult foster care, or assisted living are subject to review on the following levels: (1) At the time of admission; (2) Computerized claims review and audit; and (3…

Rule 67:45:02:12 Claim requirements. 67:45:02:12. Claim requirements. A claim for services provided under this chapter must be submitted on the CMS 1450 (UB-04) form or in an electronic format that contains the following: (1) The recipient's full name; (2) The recipient's medical…

Rule 67:45:02:13 Repealed. 67:45:02:13. Claim requirements -- New residents. Repealed. Source: 17 SDR 4, effective July 16, 1990; transferred from § 67:16:04:32, 18 SDR 67, effective October 13, 1991; repealed, 40 SDR 122, effective January 7, 2014.

67:45:03:01. Definitions. Terms used in this chapter mean: (1) "Case mix," the mixture of residents of different classifications within a nursing facility; (2) "Classification," a system of mutually exclusive categories that relate a resident's needs to the resident's cost of car…

67:45:03:02. Nursing facility to submit assessments to department. A nursing facility participating in the Medicaid program shall submit completed assessments to the department according to § 44:73:06:10. The nursing facility shall ensure that the documentation maintained in the …

67:45:03:03. Correction to previously submitted resident assessment. If a facility finds that it submitted an inaccurate or incomplete assessment, the facility shall submit a new, corrected assessment. The new assessment must: (1) Indicate it is a correction document; (2) Be date…

67:45:03:04. Review to validate resident classifications. Every fifteen months, at a minimum, a nurse consultant shall conduct a facility review to validate assessments and classifications. The nurse consultant shall notify the nursing facility of a pending review at least forty-…

67:45:03:05. Attempt to reconcile differences. In completing the review of the resident, the nurse consultant and a facility staff member shall attempt to reconcile any differences between the assessments completed by the facility and the validations completed by the nurse consul…

67:45:03:06. Conference. The nurse consultant shall conduct a conference with the administrator of the facility or the facility's director of nursing to present any finding of the review conducted pursuant to § 67:45:03:04. The conference must address the following items, as appl…