<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s536cefe8-d920-40e3-895b-4afebbfcff87P0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.s536cefe8-d920-40e3-895b-4afebbfcff87C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s536cefe8-d920-40e3-895b-4afebbfcff87C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s536cefe8-d920-40e3-895b-4afebbfcff87C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s536cefe8-d920-40e3-895b-4afebbfcff87000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:04:60"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000000">67:16:04:60</span></a><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000001">.  Basis of payment.</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> Payment to participating providers of nursing facility services is made on the following basis:</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    (1)  Payment to </span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">an </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">in-state facilit</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">y</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> is calculated using the per diem rates according to § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:04:54"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003">67:16:04:54</span></a><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">, multiplying the case mix adjusted direct care per diem rate by the resident's </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">Patient Driven Payment Model</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> weight established by the resident assessment, and adding the nondirect care rate for each day the Medicaid resident is an inpatient resident;</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    (2)  Payment to </span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">an </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">out-of-state facilit</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">y</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> providing nursing </span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">facility </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">services to residents of South Dakota is the lesser of the Medicaid rate established by the state in which the facility is located or the South Dakota statewide average Medicaid rate for all in</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">-</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">state facilities. Payment to </span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">an </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">out-of-state facilit</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">y</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> for care not available at </span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">an </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">in</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">-</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">state facilit</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">y</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> is the rate recognized for the facility by the Medicaid agency in the state in which the facility is located;</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    (3)  Payment for reserved bed days is governed by the provisions of § </span><a href="https://sdlegislature.gov/Rules?Rule=67:45:02:04"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003">67:45:02:04</span></a><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> and is based on the resident's latest resident assessment and </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">Patient Driven Payment Model nursing case mix group</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> at the time of the resident's absence;</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    (4)  </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">A s</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">wing-bed hospital</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> is</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> reimbursed at a daily rate established by the department. The daily rates are located on the department's fee schedule website; and</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    (5)  Coinsurance under the Medicare program is payable at the Medicare coinsurance rate.</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000001">Source:</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> SL 1975, ch 16, § 1; 2 SDR 16, effective September 4, 1975; 2 SDR 88, effective July 1, 1976; 7 SDR 23, effective September 18, 1980; 7 SDR 76, effective February 11, 1981; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 8 SDR 11, effective August 13, 1981; 11 SDR 26, effective August 21, 1984; 15 SDR 68, effective November 7, 1988; 16 SDR 26, effective August 13, 1989; 18 SDR 67, effective October 13, 1991; transferred from § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:04:08"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003">67:16:04:08</span></a><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">, 21 SDR 8, effective July 25, 1994; 24 SDR 185, effective July 6, 1998; 26 SDR 21, effective August 24, 1999; 38 SDR 224, effective July 1, 2012; 42 SDR 51, effective October 13, 2015</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">; 50 SDR 11, effective August 7, 2023</span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">.</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000001">General Authority:</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003">28-6-1</span></a><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">.</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000001">Law Implemented:</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003">28-6-1</span></a><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">(2).</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">    </span><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000001">Cross-Reference:</span><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87C0"> Payment adjustment due to review of resident assessment, § </span><a href="https://sdlegislature.gov/Rules?Rule=67:45:03:08"><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0-000003">67:45:03:08</span></a><span class="s536cefe8-d920-40e3-895b-4afebbfcff87C0">.</span></p><p dir="ltr" class="s536cefe8-d920-40e3-895b-4afebbfcff87P0"><span xml:space="preserve" class="s536cefe8-d920-40e3-895b-4afebbfcff87000002"> </span></p></div></body></html>