CHAPTER 67:46:09
\r\n\r\n\r\nDISABLED CHILDREN
\r\n\r\n\r\n\r\nSection
\r\n\r\n67:46:09:01 Definitions.
\r\n\r\n67:46:09:02 Repealed.
\r\n\r\n67:46:09:03 Repealed.
\r\n\r\n67:46:09:04 Eligibility requirements.
\r\n\r\n67:46:09:05 Physician's orders required.
\r\n\r\n67:46:09:06 Team to determine level of care.
\r\n\r\n67:46:09:07 Level of care -- Acute care hospital.
\r\n\r\n67:46:09:08 Level of care -- Specialized hospital.
\r\n\r\n67:46:09:09 Level of care -- Nursing facility.
\r\n\r\n67:46:09:10 Level of care -- ICF-IID.
\r\n\r\n67:46:09:11 Determination of intellectual disability.
\r\n\r\n67:46:09:12 Cost not to exceed cost of medical\r\ninstitutional care.
\r\n\r\n67:46:09:13 Reviews for continued eligibility.
\r\n\r\n67:46:09:14 Notice when case closed.
\r\n\r\n\r\n\r\n67:46:09:01. Definitions. Terms\r\nused in this chapter mean:
\r\n\r\n\r\n\r\n
(1) "Active treatment," a\r\ncontinuous program of specialized training, treatment, health services, and\r\nrelated services provided to help an individual achieve the highest functioning\r\nlevel possible, but not services required to maintain generally independent\r\nindividuals who are able to function with little supervision or in the absence\r\nof the continuous active treatment program;
\r\n\r\n\r\n\r\n
(2) "Activities of daily\r\nliving" or "ADL," physical functions which allow a person to\r\nlive independently, including bathing, dressing, eating, toileting, and\r\nmobility according to an age appropriate assessment;
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(3) "Developmental\r\nmilestones," significant behavior that marks and delineates normal\r\nsequences of human development;
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(4) "Disabled child program,"\r\na program for certain medically fragile and severely disabled children whose\r\nmedical care needs would otherwise require the level of care provided in a\r\nmedical institution;
\r\n\r\n\r\n\r\n
(5) "ICF-IID," an\r\nintermediate care facility for individuals with intellectual disabilities as\r\ndefined in § 67:54:03:01;
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(6) "Medical institution," a\r\nhospital as defined under § 67:16:03:01; a facility licensed by the\r\ndepartment of health under SDCL 34-12 as a specialized hospital with services limited to rehabilitation; a nursing facility as defined in ยง 67:45:01:01; or an intermediate care facility for individuals with intellectual disabilities;
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(7) "Professional nursing\r\nservices," nursing services which are provided by a professional nurse\r\nunder the provisions of SDCL chapter 36-9 and §§ 20:48:04:01,\r\n20:48:04:01.07, 20:48:04:01.11, 20:48:04:01.12; and
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(8) "Team," a group which\r\ndetermines eligibility for the disabled child program under the provisions of\r\nthis chapter and consists of a nurse and may include a representative of the\r\ndepartment and may include a physician.
\r\n\r\n\r\n\r\n
Source: 19 SDR 26, effective August 23,\r\n1992; 40 SDR 122, effective January 8, 2014; 41 SDR 93, effective December 3,\r\n2014.
\r\n\r\nGeneral Authority: SDCL 28-6-1.
\r\n\r\nLaw Implemented: SDCL 28-6-1.
\r\n\r\n\r\n\r\n
67:46:09:02. Application required --\r\nTime for determining eligibility -- Notice. Repealed.
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Source: 19 SDR 26, effective August 23,\r\n1992; repealed, 41 SDR 93, effective December 3, 2014.
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67:46:09:03. Prerequisites for\r\neligibility. Repealed.
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Source: 19 SDR 26, effective August 23,\r\n1992; repealed, 41 SDR 93, effective December 3, 2014.
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67:46:09:04. Eligibility\r\nrequirements. To be eligible, all of the following requirements must be\r\nmet:
\r\n\r\n\r\n\r\n
(1) The child is under the age of 19;
\r\n\r\n\r\n\r\n
(2) A physician designated by the\r\ndepartment has determined that the child is disabled according to 20 C.F.R.\r\n§§ 416.924 to 416.924b, inclusive, or determined disabled by the Social Security\r\nAdministration within the last year. The Social Security Administration's\r\ndisability determination is binding on eligibility or continued eligibility for\r\nservices. If supplemental security income or social security disability is\r\ndenied because the Social Security Administration determined that the child was\r\nnot disabled, the child is not eligible for assistance;
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(3) The child would be eligible for\r\nMedicaid if the child was in a medical institution;
\r\n\r\n\r\n\r\n
(4) The child requires one of the\r\nlevels of care listed in § 67:46:09:06;
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(5) The estimated cost of monthly\r\nhealth care outside the medical institution does not exceed the medical\r\ninstitution's cost of care according to § 67:46:09:12; and
\r\n\r\n\r\n\r\n
(6) The child meets the income and\r\nresource requirements contained in chapters 67:46:04 and 67:46:05.
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Source: 19 SDR 26, effective August 23,\r\n1992; 41 SDR 93, effective December 3, 2014; 44 SDR 94, effective December 4,\r\n2017.
\r\n\r\nGeneral Authority: SDCL 28-6-1(1)(4)(6).
\r\n\r\nLaw Implemented: SDCL 28-6-1(1)(4)(6).
\r\n\r\n\r\n\r\n
Cross-Reference: How we determine\r\ndisability for children, 20 C.F.R. § 416.924 (July 15, 2011);\r\nConsiderations in determining disability for children, 20 C.F.R.\r\n§ 416.924a (September 11, 2000); Age as a factor of evaluation in the\r\nsequential evaluation process for children, 20 C.F.R. § 416.924b (October\r\n19, 2007).
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67:46:09:05. Physician's orders required. The child's\r\nattending physician must order the services for the child and must determine\r\nthat home services are appropriate. Documentation verifying these findings must\r\nbe available to the department on request.
\r\n\r\n\r\nSource:\r\n19 SDR 26, effective August 23, 1992.
\r\n\r\nGeneral\r\nAuthority: SDCL 28-6-1.
\r\n\r\nLaw\r\nImplemented: SDCL 28-6-1.
\r\n\r\n\r\n67:46:09:06. Team to determine level\r\nof care. The team shall determine whether the child requesting assistance\r\nunder this chapter needs one of the following levels of care:
\r\n\r\n\r\n\r\n
(1) Acute care hospital;
\r\n\r\n(2) Specialized hospital;
\r\n\r\n(3) Nursing facility; or
\r\n\r\n(4) ICF-IID.
\r\n\r\n\r\n\r\n
A child who is medically stable, even though\r\ndisabled, is not considered in need of a level of care. A child is medically\r\nstable if the child's health care and medical needs do not require care in a\r\nmedical institution.
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Source: 19 SDR 26, effective August 23,\r\n1992; 40 SDR 122, effective January 8, 2014.
\r\n\r\nGeneral Authority: SDCL 28-6-1.
\r\n\r\nLaw Implemented: SDCL 28-6-1.
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67:46:09:07. Level of care -- Acute care hospital. A\r\nchild may qualify for an acute care hospital level of care if the child meets\r\nthe following requirements:
\r\n\r\n\r\n(1) The child has a medical\r\ncondition which requires nursing services 24 hours a day and the services can\r\nonly be provided by a professional nurse, or the child requires the use of\r\nsophisticated equipment designed to alert caregivers to potential problems;
\r\n\r\n\r\n(2) The child is at risk of\r\nrapid deterioration in health status;
\r\n\r\n\r\n(3) The child requires the\r\ncontinued use of medical technology, complex medical equipment, or invasive\r\ntechniques to sustain life; and
\r\n\r\n\r\n(4) Without the support of\r\nprofessional nursing services, the child would require hospitalization for an\r\nindefinite time because of the complexity or intensity of the child's long-term\r\nmedical needs.
\r\n\r\n\r\nSource:\r\n19 SDR 26, effective August 23, 1992.
\r\n\r\nGeneral\r\nAuthority: SDCL 28-6-1.
\r\n\r\nLaw\r\nImplemented: SDCL 28-6-1.
\r\n\r\n\r\n67:46:09:08. Level of care -- Specialized hospital. A\r\nchild may qualify for a specialized hospital level of care if the child\r\nrequires direct professional nursing services seven days a week and one of the\r\nfollowing conditions exist:
\r\n\r\n\r\n(1) The child requires\r\ncontinued use of medical technology or invasive techniques to sustain life; or
\r\n\r\n\r\n(2) The child requires\r\nassistance in at least three of the five activities of daily living and the\r\nchild requires regularly scheduled skilled therapeutic services, including\r\nphysical therapy, occupational therapy, or speech/language therapy in any\r\ncombination not less than once a week.
\r\n\r\n\r\nSource:\r\n19 SDR 26, effective August 23, 1992.
\r\n\r\nGeneral\r\nAuthority: SDCL 28-6-1.
\r\n\r\nLaw\r\nImplemented: SDCL 28-6-1.
\r\n\r\n\r\n67:46:09:09. Level of care --\r\nNursing facility. A child may qualify for a nursing facility level of care\r\nwhen all of the following conditions are met:
\r\n\r\n\r\n\r\n
(1) The child requires continuing\r\nprofessional nursing services which have been ordered by a physician and can\r\nonly be provided by or under the supervision of a professional nurse as defined\r\nin chapter 20:48:04.01. These services include daily management, direct\r\nobservation, monitoring, or performance of complex nursing procedures.\r\nContinuing care is repeated application of the procedures or services at least\r\nonce each 24 hours, frequent monitoring, and documentation of the child's\r\ncondition and response to the procedures or services;
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(2) The child requires the assistance\r\nof another person for the performance of at least three of the five activities\r\nof daily living according to an age appropriate assessment. The ADL dependency\r\nrequires the assistance and presence of another person during the entire\r\nactivity; and
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(3) The child requires skilled therapeutic\r\nservices including physical therapy, occupational therapy, and speech/language\r\ntherapy in any combination scheduled regularly, but not less than once a week\r\nunless limited by the child's medical condition or age.
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Source: 19 SDR 26, effective August 23,\r\n1992; 41 SDR 93, effective December 3, 2014.
\r\n\r\nGeneral Authority: SDCL 28-6-1.
\r\n\r\nLaw Implemented: SDCL 28-6-1.
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67:46:09:10. Level of care --\r\nICF-IID. The team may assign an individual to an ICF-IID level of care when\r\nall of the following conditions are met:
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(1) The child requires a continuous\r\nactive treatment program;
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(2) The child requires direct assistance\r\nfrom professionals for special rehabilitative or developmental intervention for\r\nconditions which significantly interfere with mental age-appropriate\r\nactivities;
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(3) The child requires the assistance\r\nof another person for the performance of at least three of the five activities\r\nof daily living according to an age appropriate assessment. The ADL dependency\r\nrequires the assistance and presence of another person during the entire\r\nactivity;
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(4) The child requires continuing\r\nprofessional nursing services which have been ordered by a physician and can\r\nonly be provided by or under the supervision of a professional nurse as defined\r\nin chapter 20:48:04.01. The services include daily management, direct\r\nobservation, monitoring, or performance of complex nursing procedures.\r\nContinuing care is repeated application of the procedures or services at least\r\nonce each 24 hours, frequent monitoring, and documentation of the child's\r\ncondition and response to the procedures or services; and
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(5) A clinical psychologist has\r\ndetermined that the child has an intellectual disability according to the\r\nprovisions of § 67:46:09:11, or a physician or a psychologist has\r\ndetermined that the child is developmentally disabled according to\r\n§ 67:54:04:05.
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Source: 19 SDR 26, effective August 23,\r\n1992; 40 SDR 122, effective January 8, 2014; 41 SDR 93, effective December 3,\r\n2014.
\r\n\r\nGeneral Authority: SDCL 28-6-1.
\r\n\r\nLaw Implemented: SDCL 28-6-1.
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67:46:09:11. Determination of\r\nintellectual disability. A clinical psychologist may determine that a child\r\nhas an intellectually disability for the purposes of subdivision 67:46:09:10(5)\r\nif the child meets one of the following conditions:
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(1) The child has achieved only those\r\ndevelopmental milestones generally acquired by children no more than half the\r\nchild's chronological age; or
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(2) The child has an intelligence\r\nrating of 69 or below as determined by a standardized intelligence test such as\r\nthe Wechsler Intelligence Scale for Children (WISC-R) or the Stanford-Binet.
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Source: 19 SDR 26, effective August 23,\r\n1992; 40 SDR 122, effective January 8, 2014.
\r\n\r\nGeneral Authority: SDCL 28-6-1.
\r\n\r\nLaw Implemented: SDCL 28-6-1.
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67:46:09:12. Cost not to exceed cost\r\nof medical institutional care. Based on the level of care determination,\r\nthe actual itemized cost of all Medicaid covered services provided in the home\r\nmay not exceed 100 percent of the Medicaid-allowable cost of care in a medical\r\ninstitution. Medicaid allowable cost is the amount payable when cost share,\r\ninsurance, or Medicare deductible or coinsurance has been applied.
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The costs of all services that would be included\r\nin a medical institution's reimbursement shall be used to determine the monthly\r\nhome care cost. When determining the monthly home care cost, the cost of\r\npurchased medical equipment shall be prorated on an annual basis.
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When the cost of care in the home exceeds the cost\r\nof institutional care, the department shall issue a notice of intent to\r\ndiscontinue or deny further service. The department may reconsider its decision\r\nto discontinue or deny further service if, within 30 days from the date of the\r\nnotice, the parent provides documentation to the department that future costs\r\nwill decline and be within 100 percent of the cost.
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The Medicaid allowable cost of care for the\r\nvarious medical institutions are as follows:
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(1) Acute hospital care for a child who\r\nmeets the requirements of § 67:46:09:07, $22,600 a month;
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(2) Specialized hospital care for a\r\ntechnology-dependent child who meets the requirements of subdivision 67:46:09:08(1), $13,800 a month;
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(3) Specialized hospital care for a\r\nchild who is not technology-dependent who meets the requirements of subdivision\r\n67:46:09:08(2), $6,350 a month;
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(4) Nursing facility care cost for a\r\nchild who meets the requirements of § 67:46:09:09, $2,054 a month plus any add-on allowances for ventilator assistance; and
\r\n\r\n\r\n\r\n
(5) Intermediate care facility for\r\nindividuals with intellectual disabilities for a child who meets the\r\nrequirements of § 67:46:09:10, $5,200 a month.
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Source: 19 SDR 26, effective August 23,\r\n1992; 20 SDR 144, effective March 10, 1994; 21 SDR 162, effective March 23,\r\n1995; 40 SDR 122, effective January 8, 2014.
\r\n\r\nGeneral Authority: SDCL 28-6-1.
\r\n\r\nLaw Implemented: SDCL 28-6-1.
\r\n\r\n\r\n\r\n
Cross-References: Add-on payment --\r\nVentilator, § 67:16:04:08.04; Documentation required for ventilator add-on\r\npayment, § 67:45:02:07.
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67:46:09:13. Reviews for continued eligibility. The team\r\nshall review a child's case at least annually to determine if the child\r\ncontinues to meet the eligibility requirements of this chapter.
\r\n\r\n\r\nIf the team determines that the child\r\nno longer meets the eligibility requirements, the case shall be closed and the\r\nchild may no longer receive services under this chapter.
\r\n\r\n\r\nFailure to provide the department with\r\nrequired documentation concerning medical or financial information is cause for\r\nterminating eligibility.
\r\n\r\n\r\nSource:\r\n19 SDR 26, effective August 23, 1992.
\r\n\r\nGeneral\r\nAuthority: SDCL 28-6-1.
\r\n\r\nLaw\r\nImplemented: SDCL 28-6-1.
\r\n\r\n\r\n67:46:09:14. Notice when case closed. If the department\r\ndetermines that the individual is no longer eligible for services under this\r\nchapter, it shall send a written notice to the child's parent, guardian, or\r\nother authorized representative at least 10 days before the case is closed.
\r\n\r\n\r\nSource:\r\n19 SDR 26, effective August 23, 1992.
\r\n\r\nGeneral\r\nAuthority: SDCL 28-6-1.
\r\n\r\nLaw\r\nImplemented: SDCL 28-6-1.
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