28-13-27. Hospitalization of poor persons--Definition of terms.

Terms used in this chapter mean:

(1)    "Actual cost of hospitalization," the actual cost to a hospital of providing hospital services to a medically indigent person, determined by applying the ratios of costs to charges appearing on the statement of costs required in § 28-13-28 to charges at the hospital in effect at the time the hospital services are provided;

(2)    "Emergency hospital services," treatment in the most appropriate hospital available to meet the emergency need. The physician, physician assistant, or certified nurse practitioner on duty or on call at the hospital must determine whether the individual requires emergency hospital care. The need for emergency hospital care is established if the absence of emergency care is expected to result in death, additional serious jeopardy to the individual's health, serious impairment to the individual's bodily functions, or serious dysfunction of any bodily organ or part. The term does not include care for which treatment is available and routinely provided in a clinic or physician's office;

(3)    "Hospital," any hospital licensed as such by the state in which it is located;

(4)    "Household," the patient, minor children of the patient living with the patient, and anyone else living with the patient to whom the patient has the legal right to look for support;

(5)    "Nonemergency care," hospitalization which is medically necessary and recommended by a physician licensed under chapter 36-4 but does not require immediate care or attention;

(6)    "Indigent by design," an individual who meets any one of the following criteria:

(a)    Is able to work but has chosen not to work;

(b)    Is a student at a postsecondary institution who has chosen not to purchase health insurance;

(c)    Has failed to purchase or elect major medical health insurance or health benefits made available through an employer-based health benefit plan although the person was financially able, pursuant to § 28-13-32.11, to purchase or elect the insurance or health benefits;

(d)    Has failed to purchase available major medical health insurance although the individual was insurable and was financially able, pursuant to § 28-13-32.11, to purchase the insurance. For purposes of this subdivision, an individual is presumed insurable unless the individual can produce sufficient evidence to show that the individual was declined major medical insurance by an insurance company and the individual did not qualify for any guarantees of major medical insurance available through any legal or contractual right that was not exercised; or

(e)    Has transferred resources for purposes of establishing eligibility for medical assistance available under the provisions of this chapter. The lookback period for making this determination includes the thirty-six month period immediately prior to the onset of the individual's illness and continues through the period of time for which the individual is requesting services.

Source: SL 1953, ch 131, § 1; SDC Supp 1960, § 27.12B01; SL 1980, ch 202, § 4; SL 1984, ch 203, § 3; SL 1988, ch 225, § 1; SL 1991, ch 227, § 1; SL 1997, ch 170, § 3; SL 2000, ch 134, § 1; SL 2017, ch 171, § 50.

28-13-27.1. Medically necessary hospital services.

Medically necessary hospital services are services provided in a hospital which meet the following criteria:

(1)    Are consistent with the person's symptoms, diagnosis, condition, or injury;

(2)    Are recognized as the prevailing standard and are consistent with generally accepted professional medical standards of the provider's peer group;

(3)    Are provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition which would result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing standards for the diagnosis or condition;

(4)    Are not furnished primarily for the convenience of the person or the provider; and

(5)    There is no other equally effective course of treatment available or suitable for the person needing the services which is more conservative or substantially less costly.

A county shall rely on the attending physician's determination as to medical necessity of hospital services unless evidence exists to the contrary.

Source: SL 1997, ch 170, § 5.

28-13-27.2. Cost guidelines for medical and remedial services.

Except for the costs of emergency hospital services, a county may adopt guidelines which define the amount, scope, and duration of medical and remedial services available to eligible persons and the basis for and extent of payments made to providers by counties on behalf of eligible persons.

Source: SL 1997, ch 170, § 6.