44:06:01:00.  Definitions. Terms used in this chapter mean:

 

          (1)  "Care coordination services," services to promote the effective and efficient organization and utilization of resources to ensure access to necessary comprehensive services for children with chronic medical conditions and their families;

 

          (2)  "Chronic medical condition," condition has existed or is expected to exist for two years or more, requires evaluation, consultation and medical treatment, and is a coverable condition under the CSHS program as listed in § 44:06:06:01;

 

          (3)  "Client," an individual who is determined by CSHS to be eligible for and receiving services;

 

          (4)  "Consultation," the medical examination and testing by a specialist needed to determine the cause of and possible treatment for a suspected or known chronic medical condition;

 

          (5)  "Copay," the obligation of the family or legal guardian for either partial or full payment of the medical cost after submission of the bill to a health insurance plan;

 

          (6)  "Cost share," a family's percentage of financial participation in the cost of CSHS authorized services determined by family size and income;

 

          (7)  "CSHS," children's special health services;

 

          (8)  "Deductible," the specified amount that must be met in medical costs and paid by the family or policy holder before a health insurance plan will pay;

 

          (9)  "Department," the South Dakota Department of Health;

 

          (10)  "Diagnostic services," use of scientific medical methods to establish the cause and nature of a person's illness or chronic medical condition;

 

          (11)  "Financial assistance," determined amount paid to a provider by CSHS on a client's behalf;

 

          (12)  "Individual case review," the process whereby a team of individuals from the department reviews a request to consider an individual's medical eligibility or treatment;

 

          (13)  "Participating provider," a provider who has a current, signed participating provider agreement with CSHS;

 

          (14)  "Primary care physician," the physician to whom a family or individual goes for management of care for acute illness and ongoing health needs;

 

          (15)  "Secretary," the South Dakota secretary of health or the secretary's designee;

 

          (16)  "Third-party resource," a public or private agency or entity which is or may be liable to pay all or part of the medical costs of an applicant or client, including private insurance, Civilian Health and Medical Program Uniformed Services, Medicaid, Medicare, Indian Health Services, and other sources of funds available to the applicant or client for medical care;

 

          (17)  "Treatment," medical or surgical intervention, or both, to alleviate a chronic medical condition; and

 

          (18)  "Usual and customary charge," the individual provider's normal charge to the general public for a specific service on the date the service was provided.

 

          Source: 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:01:01.  Program scope. The CSHS program, through federal and state moneys, provides care coordination services, diagnostic and consultation clinics, and financial assistance for travel reimbursement and specified procedures and treatment for those who qualify under this chapter.

 

          Source: 3 SDR 2, effective July 15, 1976; 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 34 SDR 93, effective October 17, 2007.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:01:06.  Right to administrative review and fair hearing. An applicant for or recipient of CSHS who is aggrieved by an action taken with regard to the furnishing or denial of such services may appeal under the provisions of chapter 1-26 as a contested case.

 

          Source: 3 SDR 2, effective July 15, 1976; 6 SDR 93, effective July 1, 1980; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 34 SDR 93, effective October 17, 2007.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:01:08.  Termination of eligibility. Eligibility for the CSHS program ends if any of the following conditions exists:

 

          (1)  The client reaches the twenty-first birthday;

          (2)  The client is no longer a resident of the state;

          (3)  The client does not have a chronic medical condition covered by CSHS; or

          (4)  The income of the client's family or legal guardian, responsible for the client's care, exceeds the federal poverty guidelines specified in § 44:06:04:01.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 34 SDR 322, effective June 30, 2008.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:01:08.01.  Termination of eligibility for financial assistance. Repealed.

 

          Source: 33 SDR 106, effective December 26, 2006; repealed, 34 SDR 322, effective June 30, 2008.

 

          44:06:02:02  Eligibility for the CSHS program. All of the following criteria must be met before individuals can be determined eligible for the CSHS program:

 

          (1)  The client is a resident of South Dakota;

          (2)  The client is under age 21;

          (3)  The client's chronic medical condition is coverable by CSHS; and

          (4)  The income of the client's family or legal guardian, responsible for the client's care, is below the federal poverty guidelines specified in § 44:06:04:01.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; eligibility requirements for diagnostic evaluation and consultation services transferred from § 44:06:02:01, 23 SDR 91 effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 34 SDR 93, effective October 17, 2007; 34 SDR 322, effective June 30, 2008.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:02:03.  Eligibility for individuals adopted, outside of home, or married. Repealed.

 

          Source: 6 SDR 93, effective July 1, 1980; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; repealed, 33 SDR 106, effective December 26, 2006.

 

          44:06:02:04.  Financial assistance eligibility requirements. Before any services may be authorized or financial assistance provided, a written application must be submitted to the CSHS program by the parent or legal guardian of the child seeking assistance using forms and process designated by CSHS. Specific information required to determine eligibility for financial assistance is child's chronic medical condition, proof of family income as listed on the most recent tax return or proof of current monthly income, and family size. Reapplication is required yearly or upon a change in family financial status or family size.

 

          Applicants for CSHS financial assistance must apply for benefits from other programs for which they may be eligible. The CSHS program may pay only after it has been determined the applicant is not eligible for other programs. The CSHS program shall review all applications for possible eligibility for other programs and shall make applicable referrals.

 

          Source: 3 SDR 2, effective July 15, 1976; 6 SDR 93, effective July 1, 1980; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; transferred from § 44:06:01:02, 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 34 SDR 322, effective June 30, 2008.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:02:05.  Financial assistance authorized services requirements. The CSHS program shall provide written notice to authorize financial assistance for specified procedures and treatment. All services must be preauthorized. The authorization must outline the services covered, the time period of coverage, and the family's financial responsibility toward the service authorized. In an emergency, CSHS may give an oral authorization, but the parent or legal guardian of the child must notify CSHS within five working days of the emergency services.

 

          Source: 3 SDR 2, effective July 15, 1976; 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; transferred from § 44:06:01:04, 30 SDR 198, effective June 23, 2004; 34 SDR 322, effective June 30, 2008.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          Cross-References: Eligibility for diagnostic and consultation clinics, § 44:06:02:02; Financial eligibility -- Schedule of discounts, § 44:06:04:01.

 

          44:06:02:06.  Treatment services financially covered. The department may provide financial assistance through CSHS only for preauthorized medical and surgical services for the treatment of the eligible condition and for the preservation of the benefits derived from the treatment. To receive treatment services, the child shall be medically eligible for CSHS pursuant to §§ 44:06:02:04 and 44:06:01:08 and the child's family shall meet the financial eligibility specified in § 44:06:04:01.

 

          Services covered under this article must be medically necessary. To be medically necessary, the covered services must meet the following conditions:

 

          (1)  It is consistent with the child's symptoms, diagnosis, or condition; and

          (2)  It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group.

 

          Source: 33 SDR 106, effective December 26, 2006.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

 

          44:06:03:04.  Provider reimbursement. The CSHS program shall pay providers for authorized services rendered according to the following:

 

          (1)  If CSHS is the primary payer for physician, laboratory, radiology, and pharmacy services, the reimbursement shall be at the Medicaid (Title XIX) reimbursement rates in Appendix A, B, C, or D to chapters 67:16:02 and 67:16:14;

 

          (2)  If CSHS is the primary payer for inpatient or outpatient hospitalizations, the reimbursement shall be at sixty-eight percent of allowable billed charges; or

 

          (3)  If CSHS is the secondary payer the reimbursement shall be the family copay amount; or the balance after any insurance or health plan payment is first deducted from the provider's bill.

 

          Source: 6 SDR 93, effective July 1, 1980; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 34 SDR 322, effective June 30, 2008.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:03:05.  Acceptance of payment. By the acceptance of a payment made by the CSHS program, a provider agrees to accept the CSHS amount allowable as payment in full for services rendered.

 

          Source: 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 34 SDR 322, effective June 30, 2008.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          Code Commission Note: Appendix A to § 44:06:03:04, published separately, and Appendixes B, C, and D to § 44:06:03:04 were repealed by 14 SDR 182, effective July 11, 1988.

 

          44:06:04:01.  Financial eligibility. A client is eligible to receive financial assistance from the CSHS program if the income of the client's family or legal guardian, responsible for the client's care, is below 250 percent of the federal poverty guidelines established in 74 Fed. Reg. 4199-4201 (January 23, 2009).

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 33 SDR 212, effective June 4, 2007; 34 SDR 271, effective May 5, 2008; 34 SDR 322, effective June 30, 2008; 35 SDR 253, effective May 11, 2009.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          Cross-Reference: Financial assistance authorized services requirements, § 44:06:02:05.

 

          44:06:04:02.  Financial need -- Cost-sharing. Repealed.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; repealed, 34 SDR 322, effective June 30, 2008.

 

          44:06:04:04.  Mileage reimbursement. A financially eligible family, as determined pursuant to § 44:06:04:01 is eligible to receive mileage reimbursement from the CSHS program. Mileage reimbursement is calculated based on map miles from the family's city of residence to the city where medical services were provided, at state rates determined pursuant to SDCL 3-9-1, and upon meeting the following criteria:

 

          (1)  The mileage was incurred transporting the eligible client to or from medically necessary services covered by § 44:06:02:06 or both; and

 

          (2)  The mileage was incurred at least ten miles outside the city limits of the family's residence, as listed on the family's mailing address.

 

          Source: 34 SDR 93, effective October 17, 2007.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:05:01.  Billing procedures. The CSHS program shall pay the provider for authorized services rendered after receiving pertinent billing information as follows:

 

          (1)  A completed standardized billing form received within one year from the service date; and

          (2)  An insurance deduction or rejection shown on the billing form with an attached explanation of benefits from the insurance plan, or if a prescription drug claim, a completed CSHS prescription drug claim form allowing the pharmacy to bill CSHS without an explanation of benefits form.

 

          Source: 6 SDR 93, effective July 1, 1980; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 34 SDR 93, effective October 17, 2007.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:05:03.  Maximum allowed for financial assistance. An eligible client is allowed a maximum of $20,000 each state fiscal year for preauthorized services related to the client's coverable chronic medical condition.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:06:01.  Chronic medical conditions covered. Chronic medical conditions which may be covered for an eligible individual include the following:

 

          (1)  Genetics:

 

               (a)  Multiple anomaly syndromes;

               (b)  Genetic conditions; and

               (c)  Chromosomal disorders;

 

          (2)  Cardiology:

 

               (a)  Cyanotic heart disease;

               (b)  Acyanotic heart disease;

               (c)  Cardiomyopathies and pericarditis;

               (d)  Rheumatic heart disease;

               (e)  Arrythmias;

               (f)  Systemic hypertension;

               (g)  Kawasaki disease; and

               (h)  Other cardiac conditions which are complex and chronic;

 

          (3)  Gastroenterology:

 

               (a)  Malabsorption syndrome/disorders;

               (b)  Inflammatory bowel disease/ulcerative colitis;

               (c)  Congenital abnormalities of gastrointestinal tract, excluding pyloric stenosis and umbilical or femoral/inguinal hernias;

               (d)  Esophageal reflux; and

               (e)  Other gastrointestinal conditions which are complex and chronic;

 

          (4)  Pulmonary:

 

               (a)  Cystic fibrosis;

               (b)  Asthma;

               (c)  Bronchopulmonary dysplasia;

               (d)  Pectus excovatum;

               (e)  Tracheo - esophageal Fistula (with or without reflux); and

               (f)  Other pulmonary conditions which are complex and chronic;

 

          (5)  Craniofacial anomalies:

 

               (a)  Cleft lip and palate; and

               (b)  Other congenital craniofacial anomalies that are complex and chronic;

 

          (6)  Endocrinology:

 

               (a)  Thyroid malfunction;

               (b)  Delayed adolescence;

               (c)  Parathyroid malfunction;

               (d)  Sexual precocity;

               (e)  Pituitary tumors;

               (f)  Inborn errors of metabolism;

               (g)  Diabetes mellitus or insipidus; and

               (h)  Other endocrine conditions which are complex and chronic;

 

          (7)  Hematology/hemophilia/oncology:

 

               (a)   Chronic anemia;

               (b)  Neutropenias;

               (c)  Leukemias;

               (d)  Clotting disorders;

               (e)  Solid tumors;

               (f)  Hemophilia A;

               (g)  Hemophilia B; and

               (h)  Other hematology/oncology conditions which are complex and chronic;

 

          (8)  Children's rehabilitation:

 

               (a)  Congenital hydrocephalus;

               (b)  Myelomeningocele;

               (c)  Juvenile rheumatoid arthritis;

               (d)  Scoliosis;

               (e)  Congenital dislocation of the hip;

               (f)  Slipped capital femoral epiphysis;

               (g)  Club foot; and

               (h)  Other multiple physical disabilities which are complex and chronic;

 

          (9)   Neurology:

 

               (a)  Congenital anomalies of the central nervous system;

               (b)  Seizure disorders;

               (c)  Chronic neuromuscular disorders;

               (d)  Cerebral palsy; and

               (e)  Other neurological disorders which are complex and chronic;

 

          (10)  Renal:

 

               (a)  Chronic glomerulonephritis;

               (b)  Nephrosis;

               (c)  Chronic renal tubular disease;

               (d)  Congenital anomalies of the urinary tract; and

               (e)  Chronic renal disease resulting from structural abnormalities of urinary tract;

 

          (11)  Ophthalmology:

 

               (a)  Severe myopia;

               (b)  Strabismus;

               (c)  Congenital cataracts;

               (d)  Glaucoma; and

               (e)  Amblyopia.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:06:03.  Diagnostic and consultation services covered. Diagnostic and consultation services coverable through CSHS include those scientific medical methods necessary to establish the cause and nature of a child's chronic medical condition by use of a medical examination and tests to determine a definitive diagnosis and possible treatment.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.

 

          44:06:06:04.  Treatment services covered. Repealed.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; repealed, 33 SDR 106, effective December 26, 2006.

 

          44:06:06:07.  Services and conditions not covered. Services and conditions not covered under the CSHS program include the following:

 

          (1)  Doctor visits for routine care unless recommended by the specialist in charge;

          (2)  Routine dental care, except for that requested by an orthodontist for a child with a cleft palate;

          (3)  Surgical procedures with any associated hospitalizations except upon individual case review;

          (4)  Cosmetic surgery except upon individual case review for cleft lip or palate or both;

          (5)  Acute accidents or illnesses;

          (6)  Vocational rehabilitation;

          (7)  Special education;

          (8)  Appliance repairs;

          (9)  Room and board;

          (10)  Ambulance charges;

          (11)  Supplies and appliances as follows:

 

               (a)   Artificial eyes;

               (b)   Catheters except for renal disorders;

               (c)   Contact lenses except upon individual case review for congenital cataracts;

               (d)   Crutches;

               (e)   Over-the-counter drugs and medications, except upon individual case review;

               (f)    Glasses;

               (g)   Hearing aids, except upon individual review;

               (h)   Immunizations;

               (i)    Kidney dialysis machines;

               (j)    Prosthesis, except upon individual review;

               (k)   Shoes;

               (l)    Special beds;

               (m)  Speech appliances except for obturators;

               (n)   Walkers;

               (o)   Wheelchairs; and

               (p)   Dietary supplements, except upon individual case review;

 

          (12)  Infectious diseases;

          (13)  Organ transplants;

          (14)  Fractures or other acute trauma;

          (15)  Kidney dialysis;

          (16)  Undescended testicles;

          (17)  Intestinal obstruction;

          (18)  Imperforate anus;

          (19)  Experimental procedures; and

          (20)  Psychological evaluations.

 

          Source: 6 SDR 93, effective July 1, 1980; 8 SDR 155, effective May 27, 1982; 9 SDR 162, effective June 20, 1983; 14 SDR 182, effective July 11, 1988; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; 30 SDR 198, effective June 23, 2004; 33 SDR 106, effective December 26, 2006; 34 SDR 93, effective October 17, 2007.

          General Authority: SDCL 34-1-21.

          Law Implemented: SDCL 34-1-21.