22:02:01:01.  Definitions. Terms used in this article mean:

          (1)  "CCPR," the catastrophic county poor relief program established by SDCL 28-13A;

          (2)  "Board," the Board of Catastrophic County Poor Relief;

          (3)  "Association," the South Dakota Association of County Commissioners;

          (4)  "Annual assessment," the assessment made by the board in January of each year against a participating county;

          (5)  "Supplemental assessment," an assessment made by the board against each participating county when it anticipates that the CCPR funds remaining in a given calendar year will be insufficient to meet predicted obligations for the remainder of the current calendar year; and

          (6)  "Final assessment," for a withdrawing county, the assessment made by the board against the county which is used to reimburse that county's share of the CCPR fund from the previous calendar year; for a county participating at the time the program ends, the assessment made by the board against each of the remaining participating counties which will bring the fund balance back to the $500,000 level.

          Source: 11 SDR 144, effective May 2, 1985; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:01:01, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-5.

          Cross-Reference: CCPR appropriation, SL 1984, ch 204, § 6.

          22:02:01:02.  County request to participate -- Beginning date of participation. A county wishing to participate in the CCPR program must notify the board, in writing, by July 31. If approved as a participating county, the county may not begin participation before January 1 of the following year.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; transferred from § 67:19:01:02, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          Cross-Reference: Reasons for denial of request to participate, § 22:02:01:04.

          22:02:01:03.  Notice of approval to participate. The board and association shall review the requests submitted under § 22:02:01:02 and shall notify the requesting county, in writing, of its approval status by September 1.

          If the county's request for participation is denied, the notice shall contain the reason for the denial.

          Counties which have been denied participation have until October 1 to correct the deficiencies contained in the notice of denial.

          Source: 11 SDR 144, effective May 2, 1985; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:01:03, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          Cross-Reference: Review procedure, § 22:02:01:08

          22:02:01:04.  Reasons for denial of request to participate. The board may deny a county's request to participate in the CCPR program for any of the following reasons:

          (1)  The county has failed to pay any portion of a previous CCPR annual assessment;

          (2)  The county has failed to pay any portion of a previous CCPR supplemental assessment;

          (3)  The county has withdrawn from the program but failed to pay its final assessment;

          (4)  The county's request to participate did not meet the deadline requirements of § 22:02:01:02; or

          (5)  The county did not correct the deficiencies cited in its notice of denial.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; transferred from § 67:19:01:04, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          Cross-References: Notice of approval to participate, § 22:02:01:03; Assessments, ch 22:02:03.

          22:02:01:05.  Automatic renewal of participation. Once approved as a participating county, the county is a participating county for successive calendar years until the January 1 after the county submits a withdrawal request according to § 22:02:01:06 or until the county fails to pay a CCPR assessment.

          Source: 11 SDR 144, effective May 2, 1985; 19 SDR 76, effective November 23, 1992; transferred from § 67:19:01:05, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          Cross-Reference: Failure to pay assessment, § 22:02:03:05.

          22:02:01:06.  Request for withdrawal -- Effective date of withdrawal. A participating county wishing to withdraw from the CCPR program shall submit a withdrawal request to the board by July 31. Counties submitting withdrawal requests shall be removed from participation effective January 1 of the following year.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; transferred from § 67:19:01:06, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-6, 28-13A-7.

          Cross-Reference: Final assessments, § 22:02:03:04.

          22:02:01:07.  Reapplications. A county which has withdrawn from participation in the CCPR program and wishes to again participate shall comply with § 22:02:01:02. To receive board approval, the county may not have any arrearages due the CCPR fund from previous years of participation.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; transferred from § 67:19:01:07, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          Cross-Reference: Reasons for denial of request to participate, § 22:02:01:04.

          22:02:01:08.  Review procedure. When the board renders an adverse decision under this article, it shall notify the county concerned within 10 working days after the decision is rendered. Notification shall be by certified mail. A county wishing to contest an adverse decision may request the board to review the decision. A review is held under the provisions of SDCL 1-26. A request for a review must be sent to the association within 30 days after receiving the notice of the decision. The association shall schedule the review before the board and shall notify the county. At the time of the review, the county shall present its arguments in support of the claim. Based on the review, the board shall enter its final decision. The board shall send written notice of its final decision to the county within 30 days after the review.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; 22 SDR 2, effective July 17, 1995; transferred from § 67:19:01:08, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:01.  Board meetings. Board meetings are subject to call. Interested individuals must contact the association or a CCPR board member to request a meeting with the board.

          Source: 11 SDR 144, effective May 2, 1985; 19 SDR 76, effective November 23, 1992; transferred from § 67:19:02:01, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:02.  Board member conflict of interest. If a claim for reimbursement is submitted from a board member's county, that board member may participate in the discussions concerning the claim but may not participate in the board's final vote of approval or disapproval.

          Source: 11 SDR 144, effective May 2, 1985; transferred from § 67:19:02:02, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:03.  Notice of imminent claim -- Deadline for notifying board of amount of delayed claim. A county shall notify the association in writing as soon as possible if a claim appears to be imminent. If the county's application for CCPR fund reimbursement for the claim is going to be delayed, the county shall provide written notification to the association of the amount of the claim no later than the end of the calendar year following the year the county is billed for the medical expenses.

          Source: 11 SDR 144, effective May 2, 1985; transferred from § 67:19:02:03, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:04.  Determination of 12-month period. A 12-month period begins the first day an eligible individual incurs hospital or other medical expenses used in establishing or computing a CCPR payment. A 12-month period ends at 12:01 a.m. on the anniversary of the first date the expenses were incurred.

          Source: 11 SDR 144, adopted May 2, 1985, effective July 1, 1985; 19 SDR 76, effective November 23, 1992; transferred from § 67:19:02:04, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:05.  Application for reimbursement -- Evidence of payment. A county requesting reimbursement from the CCPR fund must submit an application for reimbursement to the association on a form available from the association.

          In addition to the application, a county must provide the following information to the association:

          (1)  A copy of the provider's invoice showing dates of service;

          (2)  Evidence, such as a copy of the approved county voucher, that payment was made by the county, including the amount paid;

          (3)  If the request for reimbursement is for a hospital claim incurred after June 30, 1997, documentation which establishes both the individual's and the county's share of the hospital bill;

          (4)  If county payment to a hospital was based on the Medicaid rate, a copy of the documentation from Medicaid which calculates the Department of Social Services payment rate; and

          (5)  A voucher signed by the county board of commissioners chair or vice-chair.

          If the claim being submitted is the first reimbursement request covering a particular individual, the county must also submit evidence which shows that the county has met its $20,000 share of the expenses for that individual for the 12-month period in which the services were rendered.

          If the claim is for an organ transplant, the county must submit evidence of compliance with SDCL 28-13A-13.

          Source: 11 SDR 144, effective May 2, 1985, amended effective July 1, 1985; 13 SDR 134, effective March 30, 1987; 19 SDR 76, effective November 23, 1992; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:05, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-6.

          22:02:02:06.  Claim approval process. The association shall return an application for reimbursement containing insufficient information or evidence to the county for completion and resubmission.

          After receipt of the county's application, supporting documentation, and the association's recommendations, the board shall review the claim and approve, deny, or adjust the payment.

          The board shall notify the county in writing if the claim is denied. The notice shall contain the reasons for the denial and shall be sent by certified mail within 10 working days after the decision is rendered.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; 22 SDR 2, effective July 17, 1995; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:06, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-6, 28-13A-7.

          Cross-Reference: Review procedure, § 22:02:01:08.

          22:02:02:07.  Reasons for claim denial. The board shall deny a county's claim for reimbursement for any of the following reasons:

          (1)  The county has not paid its CCPR annual assessment;

          (2)  The county has not paid its supplemental CCPR fund assessment;

          (3)  The county has not paid the first $20,000 for the individual for the 12-month period;

          (4)  The county has not provided the evidence required under § 22:02:02:05;

          (5)  The service was provided before January 1, 1985;

          (6)  The service was provided before the date of county participation;

          (7)  The county has not been approved as a participating county;

          (8)  The request for reimbursement has been delayed and the county failed to notify the department according to § 22:02:02:03;

          (9)  The claim is for an organ transplant for which the county has failed to meet the requirements of SDCL 28-13A-13;

          (10)  The county failed to follow its guidelines when determining eligibility;

          (11)  The county failed to pursue other third-party payment sources;

          (12)  The individual was not eligible for county poor relief; or

          (13)  The claim exceeds the payment limits established in § 22:02:02:08.

          Source: 11 SDR 144, effective May 2, 1985, amended effective July 1, 1985; 19 SDR 76, effective November 23, 1992; 22 SDR 2, effective July 17, 1995; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:07, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:08.  Payment limits. If a county has negotiated final payment with a provider, the CCPR fund shall reimburse 90 percent of the negotiated amount, less the county's $20,000 share, if applicable.

          The rate of reimbursement from the CCPR fund for a hospital expense may not exceed the limits established in SDCL 28-13-29.

          If a county carries an individual over into a new 12-month period, the individual's medical expenses for the new 12-month period must exceed $20,000 before the individual's medical expenses are again eligible for reimbursement from the CCPR fund.

          Source: 11 SDR 144, effective May 2, 1985, and July 1, 1985; 25 SDR 69, effective November 12, 1998; transferred from § 67:19:02:08, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-7.

          22:02:02:09.  Repayment to CCPR fund if county collects on claims. If a county receives a CCPR reimbursement to cover an individual's medical claims and the county subsequently collects all or part of the claims from either the individual or a third-party source, the county shall repay a percentage of the collection to the CCPR fund. The percentage of the collection to be repaid equals the percentage of the claims that the CCPR reimbursement represents.

          Source: 13 SDR 134, effective March 30, 1987; transferred from § 67:19:02:09, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:02:10.  County to pursue third-party payment sources. Because the county is the payor of last resort, a county must pursue the availability of a third-party payment source before accepting responsibility for a catastrophic claim. A third-party payment source is the obligation of an entity other than the county for either partial or full payment of the medical cost of injury, disease, or disability. Third-party payment sources include coverage such as Medicare, Medicaid, private health insurance, workers' compensation, supplemental security income, disability insurance, and automobile insurance.

          The county must be able to document pursuit of the availability of a third-party payment source. The documentation must be maintained in the individual's record. When the claim is subsequently submitted to the CCPR program for payment, evidence of the third-party payment or rejection must accompany the claim.

          Source: 22 SDR 2, effective July 17, 1995; transferred from § 67:19:02:10, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.

          22:02:03:01.  Annual report to board. The association's annual report to the board shall contain the following information:

          (1)  Beginning balance of the CCPR fund;

          (2)  County annual assessment receipts;

          (3)  County supplementary assessment receipts;

          (4)  Disbursements;

          (5)  Year-end balance;

          (6)  Anticipated influences which could affect the new year's disbursements;

          (7)  A list of each participating county's annual assessment;

          (8)  A list of final assessments for withdrawing counties; and

          (9)  An estimate of the probable need for supplemental assessments in the new year.

          Source: 11 SDR 144, effective May 2, 1985; transferred from § 67:19:03:01, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-8.

          22:02:03:02.  Annual assessments. Annual assessments shall take into consideration the unencumbered balance remaining in the CCPR fund from the previous calendar year. A county is not subject to an annual assessment until after its first year of participation.

          Source: 11 SDR 144, effective May 2, 1985; transferred from § 67:19:03:02, 36 SDR 27, effective Augusts 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-9.

          22:02:03:03.  Supplemental assessments. The amount of the supplemental assessment shall insure the availability of funds. If the board and the association agree that a supplemental assessment is necessary, the board shall send written notice to each participating county. The notice shall contain the amount of the county's supplemental assessment. The county must pay its supplemental assessment to the association within 30 days after the county's next scheduled commission meeting following its receipt of the notice.

          A withdrawing county remains liable for the payment of any supplemental assessments which the board may levy through the remainder of the calendar year.

          A county which has just joined the CCPR fund and has yet to be assessed an annual assessment is liable for the payment of any supplemental assessments levied during the first year of its participation.

          Source: 11 SDR 144, effective May 2, 1985; 25 SDR 69, effective November 12, 1998; transferred form § 67:19:03:03, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-10.

          22:02:03:04.  Final assessments. The board shall levy a final assessment against a withdrawing county which is payable to the association before March 16 of the county's first calendar year of nonparticipation.

          If the fund is discontinued because of circumstances contained in SDCL 28-13A-5, the board shall levy a final assessment against the counties which were participating during the final year of the program. This final assessment is payable to the association within one year after the final assessment is levied against the remaining participating counties.

          Source: 11 SDR 144, effective May 2, 1985; 13 SDR 134, effective March 30, 1987; transferred from § 67:19:03:04, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4, 28-13A-5.

          22:02:03:05.  Failure to pay assessment. If a county fails to pay an assessment, the association shall send a written notice to the county. The notice shall inform the county that failure to pay the assessment within the time specified in the notice will result in ineligibility and that interest on the delinquent assessment will be applied according to SDCL 4-3-14.

          A county is not eligible for readmission to the fund until its arrearages are paid. Claims from the county are not reimbursable until the county's arrearages are paid.

          Source: 19 SDR 76, effective November 23, 1992; transferred from § 67:19:03:05, 36 SDR 27, effective August 26, 2009.

          General Authority: SDCL 28-13A-4.

          Law Implemented: SDCL 28-13A-4.