South Dakota Administrative Code

Rule 67:54:04:11 Parent's income and resources. 67:54:04:11. Parent's income and resources. The income and resources of the parents or guardians of children receiving assistance from school districts or the state section for special education may not be considered when determinin…

Rule 67:54:04:12 Determining amount of HCBS assistance. 67:54:04:12. Determining amount of HCBS assistance. Payment for HCBS is based on the difference between the participant's income, minus allowable deductions, and the participant's monthly care costs. If the participant meets…

Rule 67:54:04:13 Repealed. 67:54:04:13. Living arrangements -- Payment limitation -- Documentation required. Repealed. Source: 10 SDR 79, effective February 1, 1984; 15 SDR 154, effective April 9, 1989; 17 SDR 127, effective March 3, 1991; transferred from § 67:16:27:13, effectiv…

Rule 67:54:04:14 Covered services. 67:54:04:14. Covered services. Home and community-based services covered and payable under this chapter consist of the following only if they are not otherwise payable under article 67:16: (1) Day habilitation; (2) Prevocational services; (3) Se…

Rule 67:54:04:15 Repealed. 67:54:04:15. Administration and agency support. Repealed. Source: 15 SDR 154, effective April 9, 1989; transferred from § 67:16:27:14.01, effective August 23, 1992; repealed, SL 2013, ch 128, § 11, effective July 1, 2013

Rule 67:54:04:16 Repealed. 67:54:04:16. Case management and consumer support. Repealed. Source: 15 SDR 154, effective April 9, 1989; transferred from § 67:16:27:14.02, effective August 23, 1992; 26 SDR 150, effective May 21, 2000; repealed, SL 2013, ch 128, § 12, effective July 1…

Rule 67:54:04:17 Repealed. 67:54:04:17. Habilitation and training. Repealed. Source: 15 SDR 154, effective April 9, 1989; transferred from § 67:16:27:14.03, effective August 23, 1992; 26 SDR 150, effective May 21, 2000; repealed, SL 2013, ch 128, § 13, effective July 1, 2013.

Rule 67:54:04:18 Initial level of care. 67:54:04:18. Initial level of care. The following documentation is required to determine the initial level of care: (1) A completed ICAP that indicates a minimum of three substantial functional limitations; (2) A copy of the psychological e…

Rule 67:54:04:18.01 Redetermination of level of care. 67:54:04:18.01. Redetermination of level of care. The level of care shall be reviewed and completed annually for each participant receiving waiver services. The HCBS provider shall update the ICAP data as changes occur and eve…

Rule 67:54:04:19 Conditions of provider participation -- Certification -- Agreement. 67:54:04:19. Conditions of provider participation -- Certification -- Agreement. To participate in the delivery of HCBS, providers shall be approved by the Department of Human Services according …

Rule 67:54:04:20 Repealed. 67:54:04:20. Agreement to provide services -- Limit on number of clients. Repealed. Source: 10 SDR 79, effective February 1, 1984; repealed, 12 SDR 151, March 16, 1986; readopted, 15 SDR 154, effective April 9, 1989; transferred from § 67:16:27:17, effe…

Rule 67:54:04:21 Repealed. 67:54:04:21. Required financial reports. Repealed. Source: 10 SDR 79, effective February 1, 1984; transferred from § 67:16:27:18, effective August 23, 1992; repealed, 26 SDR 150, effective May 21, 2000.

Rule 67:54:04:22 Extent of payment. 67:54:04:22. Extent of payment. The department shall pay a facility for the days a participant is enrolled with the provider. Enrolled days include the day of admission but exclude the day of discharge. Source: 10 SDR 79, effective February 1, …

Rule 67:54:04:23 Payments during temporary absences. 67:54:04:23. Payments during temporary absences. Payment shall be made on behalf of an eligible participant when it is necessary to reserve that participant's HCBS position during temporary absences. Payment shall be made for a…

Rule 67:54:04:24 Basis of payment. 67:54:04:24. Basis of payment. Payment to a participating provider for services provided shall be determined by the Department of Human Services. Source: 10 SDR 79, effective February 1, 1984; transferred from § 67:16:27:21, effective August 23,…

Rule 67:54:04:25 Utilization review. 67:54:04:25. Utilization review. Services provided under this chapter are subject to the following utilization reviews: (1) At the time of eligibility determination; (2) During claim processing; (3) During postpayment reviews; and (4) At the t…

Rule 67:54:04:26 Application of other chapters. 67:54:04:26. 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 67:54:04:27 Right to request a fair hearing. 67:54:04:27. Right to request a fair hearing. A participant or a participant's parent or guardian who is dissatisfied with a determination regarding services under this chapter may request a fair hearing in accordance with chapter…

Rule 67:54:05:01 Definitions. 67:54:05:01. Definitions. Terms used in this chapter mean: (1) "Interdisciplinary team," a team under the auspices of a nursing home or the Department of Human Services which consists of a physician who is either a psychiatrist or is supervised by a …

Rule 67:54:05:02 Eligibility for medical assistance. 67:54:05:02. Eligibility for medical assistance. An individual with a mental disease is eligible for medical assistance if the following criteria are met: (1) The individual is eligible for Medicaid under article 67:46; (2) The…

Rule 67:54:05:03 Criteria used to determine existence of mental disease. 67:54:05:03. Criteria used to determine existence of mental disease. The utilization control team shall determine an individual's need for specialized psychiatric services based on a psychiatric evaluation t…

Rule 67:54:05:04 Determination of need for nursing facility care. 67:54:05:04. Determination of need for nursing facility care. The utilization control team shall establish an individual's need for nursing facility care by reviewing the individual's medical, nursing, social, and …

Rule 67:54:05:05 Determination of need for specialized psychiatric services. 67:54:05:05. Determination of need for specialized psychiatric services. The utilization control team shall determine the individual's need for specialized psychiatric services. The determination must be…

Rule 67:54:05:06 Services not covered in nursing facility for individual with mental disease. 67:54:05:06. Services not covered in nursing facility for individual with mental disease. The following services are not covered in a nursing facility for an individual with a mental dis…

Rule 67:54:05:07 Utilization review. 67:54:05:07. Utilization review. Services provided under this chapter are subject to utilization review on the following four levels: (1) At the time of the admission; (2) During claims processing; (3) At the annual redetermination review; and…

Rule 67:54:05:08 Payment limits. 67:54:05:08. Payment limits. Payment to a facility is made for resident days only. Resident days include the day of admission but exclude the day of discharge. No payment may be made to a facility owned by the state for reserving a bed during a re…

Rule 67:54:05:09 Application of other rules. 67:54:05:09. Application of other rules. Unless otherwise specified, the following chapters apply to this chapter: (1) Chapter 67:16:01 -- General provisions; (2) Chapter 67:16:26 -- Third-party liability; (3) Chapter 67:16:33 -- Provi…

Rule 67:54:05:10 Claim requirements. 67:54:05:10. Claim requirements. Each month the Department of Social Services shall send a two-part claim form (nursing home request for payment) to the provider. The first part contains a list of the recipients who were present at the provide…

Rule 67:54:06:01 Definitions. 67:54:06:01. Definitions. Terms used in this chapter mean: (1) "Ancillary services," services or equipment that supplement the direct care services provided under this chapter; (2) "Assistive daily living services," services of a personal attendant, …

Rule 67:54:06:02 Eligibility -- Individual. 67:54:06:02. Eligibility -- Individual. An individual must meet the following requirements to be eligible to receive services under this chapter: (1) Must be receiving personal attendant, case management, consumer preparation, or ancill…

Rule 67:54:06:03 Individual to select provider agency. 67:54:06:03. Individual to select provider agency. The Department of Human Services shall provide an individual desiring assistive daily living services with a list of provider agencies. The individual must select a service p…

Rule 67:54:06:04 Eligibility -- Provider agency. 67:54:06:04. Eligibility -- Provider agency. To be eligible to receive reimbursements for services provided under this chapter, a provider agency must meet the following requirements: (1) Must have experience in delivering services…

Rule 67:54:06:05 Provider agency to assign case manager -- Preparation of assessment and case service plan. 67:54:06:05. Provider agency to assign case manager -- Preparation of assessment and case service plan. Within 10 days after the individual requests services from a provide…

Rule 67:54:06:06 Qualifications of case manager. 67:54:06:06. Qualifications of case manager. A provider agency's case manager must meet the following qualifications: (1) Must be employed by a provider agency; (2) Must have a minimum of one year experience working with individual…

Rule 67:54:06:07 Covered services -- Case management. 67:54:06:07. Covered services -- Case management. Covered case management services include the following: (1) Determining the consumer's level of functioning, including an assessment of the consumer's knowledge of service need…

Rule 67:54:06:08 Qualifications of personal attendant. 67:54:06:08. Qualifications of personal attendant. A personal attendant must have completed a basic nurse aide or home health aide training course, as evidenced by a certificate of completion signed by the director of the tra…

Rule 67:54:06:09 Covered services -- Personal attendant. 67:54:06:09. Covered services -- Personal attendant. Covered services of a personal attendant are those services listed in the case service plan which include services such as the following: (1) Practicing infection control…

Rule 67:54:06:09.01 Services not covered. 67:54:06:09.01. Services not covered. The following services are not covered under the provisions of this chapter, and a provider agency may not submit a bill if it provides any of these services on behalf of an eligible individual: (1) W…

Rule 67:54:06:10 Qualifications and duties of consumer preparation specialist. 67:54:06:10. Qualifications and duties of consumer preparation specialist. A provider agency's consumer preparation specialist must meet the following qualifications: (1) Must be employed by a provider…

Rule 67:54:06:11 Covered services -- Consumer preparation specialist. 67:54:06:11. Covered services -- Consumer preparation specialist. Covered consumer preparation specialist services include the following: (1) Instructing clients in the methods of identifying personal needs and…

Rule 67:54:06:11.01 Ancillary services. 67:54:06:11.01. Ancillary services. Ancillary services provided under this chapter are limited to emergency response devices and private duty nursing services. The need for ancillary services must be determined by the client's case manager …

Rule 67:54:06:11.02 Ancillary services -- Private duty nursing -- Limits. 67:54:06:11.02. Ancillary services -- Private duty nursing -- Limits. Private duty nursing services are limited to nursing services provided under the direction of the consumer's physician that cannot be pr…

Rule 67:54:06:12 Department of Human Services to determine level of care. 67:54:06:12. Department of Human Services to determine level of care. Within 30 days after receiving the completed client assessment and service plan, the Department of Human Services' utilization review te…

Rule 67:54:06:13 Payment, procedure codes, and limits for covered services. 67:54:06:13. Payment, procedure codes, and limits for covered services. Payment for assistive daily living services is limited to the following procedure codes: PROCEDURE CODE PROCEDURE T1019 Services of …

Rule 67:54:06:14 Basis of payment. 67:54:06:14. Basis of payment. Payment for assistive daily living services is based on the difference between the consumer's income, minus allowable deductions, and the consumer's monthly care costs. If the consumer meets the requirements of sub…

Rule 67:54:06:15 Billing requirements. 67:54:06:15. 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 and units being billed. Source: 21 S…

Rule 67:54:06:16 Claim requirements. 67:54:06:16. Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information: (1) The recipient's full name; (2) The recipient's medical assistance identification number…

Rule 67:54:06:17 Cost of service not to exceed cost of institutional care. 67:54:06:17. Cost of service not to exceed cost of institutional care. The cost of services provided under this chapter may not exceed the cost of caring for the client in an institutional setting. The cos…

Rule 67:54:06:18 Provider agency may terminate services. 67:54:06:18. Provider agency may terminate services. If a provider agency terminates services to a consumer, the termination must be for cause. Specific reasons for terminating services include circumstances such as the fol…

Rule 67:54:06:18.01 Provider agency may terminate services -- Notice -- Exception. 67:54:06:18.01. Provider agency may terminate services -- Notice -- Exception. If a provider agency intends to terminate services to a consumer, the provider agency must notify the consumer in writ…