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.