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 Repealed.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6 SDR 93, effective July 1, 1980; 20 SDR 91, effective December 19, 1993; 23 SDR 91, effective December 9, 1996; repealed, 33 SDR 106, effective December 26, 2006.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