loading…
loading…
loading…
CHAPTER 67:46:09
DISABLED CHILDREN
Section
67:46:09:01 Definitions.
67:46:09:02 Repealed.
67:46:09:03 Repealed.
67:46:09:04 Eligibility requirements.
67:46:09:05 Physician's orders required.
67:46:09:06 Team to determine level of care.
67:46:09:07 Level of care -- Acute care hospital.
67:46:09:08 Level of care -- Specialized hospital.
67:46:09:09 Level of care -- Nursing facility.
67:46:09:10 Level of care -- ICF-IID.
67:46:09:11 Determination of intellectual disability.
67:46:09:12 Cost not to exceed cost of medical institutional care.
67:46:09:13 Reviews for continued eligibility.
67:46:09:14 Notice when case closed.
67:46:09:01. Definitions. Terms used in this chapter mean:
(1) "Active treatment," a continuous program of specialized training, treatment, health services, and related services provided to help an individual achieve the highest functioning level possible, but not services required to maintain generally independent individuals who are able to function with little supervision or in the absence of the continuous active treatment program;
(2) "Activities of daily living" or "ADL," physical functions which allow a person to live independently, including bathing, dressing, eating, toileting, and mobility according to an age appropriate assessment;
(3) "Developmental milestones," significant behavior that marks and delineates normal sequences of human development;
(4) "Disabled child program," a program for certain medically fragile and severely disabled children whose medical care needs would otherwise require the level of care provided in a medical institution;
(5) "ICF-IID," an intermediate care facility for individuals with intellectual disabilities as defined in § 67:54:03:01;
(6) "Medical institution," a hospital as defined under § 67:16:03:01; a facility licensed by the department of health under SDCL 34-12 as a specialized hospital with services limited to rehabilitation; a nursing facility as defined in § 67:45:01:01; or an intermediate care facility for individuals with intellectual disabilities;
(7) "Professional nursing services," nursing services which are provided by a professional nurse under the provisions of SDCL chapter 36-9 and §§ 20:48:04:01, 20:48:04:01.07, 20:48:04:01.11, 20:48:04:01.12; and
(8) "Team," a group which determines eligibility for the disabled child program under the provisions of this chapter and consists of a nurse and may include a representative of the department and may include a physician.
Source: 19 SDR 26, effective August 23, 1992; 40 SDR 122, effective January 8, 2014; 41 SDR 93, effective December 3, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:02. Application required -- Time for determining eligibility -- Notice. Repealed.
Source: 19 SDR 26, effective August 23, 1992; repealed, 41 SDR 93, effective December 3, 2014.
67:46:09:03. Prerequisites for eligibility. Repealed.
Source: 19 SDR 26, effective August 23, 1992; repealed, 41 SDR 93, effective December 3, 2014.
67:46:09:04. Eligibility requirements. To be eligible, all of the following requirements must be met:
(1) The child is under the age of 19;
(2) A physician designated by the department has determined that the child is disabled according to 20 C.F.R. §§ 416.924 to 416.924b, inclusive, or determined disabled by the Social Security Administration within the last year. The Social Security Administration's disability determination is binding on eligibility or continued eligibility for services. If supplemental security income or social security disability is denied because the Social Security Administration determined that the child was not disabled, the child is not eligible for assistance;
(3) The child would be eligible for Medicaid if the child was in a medical institution;
(4) The child requires one of the levels of care listed in § 67:46:09:06;
(5) The estimated cost of monthly health care outside the medical institution does not exceed the medical institution's cost of care according to § 67:46:09:12; and
(6) The child meets the income and resource requirements contained in chapters 67:46:04 and 67:46:05.
Source: 19 SDR 26, effective August 23, 1992; 41 SDR 93, effective December 3, 2014; 44 SDR 94, effective December 4, 2017.
General Authority: SDCL 28-6-1(1)(4)(6).
Law Implemented: SDCL 28-6-1(1)(4)(6).
Cross-Reference: How we determine disability for children, 20 C.F.R. § 416.924 (July 15, 2011); Considerations in determining disability for children, 20 C.F.R. § 416.924a (September 11, 2000); Age as a factor of evaluation in the sequential evaluation process for children, 20 C.F.R. § 416.924b (October 19, 2007).
67:46:09:05. Physician's orders required. The child's attending physician must order the services for the child and must determine that home services are appropriate. Documentation verifying these findings must be available to the department on request.
Source: 19 SDR 26, effective August 23, 1992.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:06. Team to determine level of care. The team shall determine whether the child requesting assistance under this chapter needs one of the following levels of care:
(1) Acute care hospital;
(2) Specialized hospital;
(3) Nursing facility; or
(4) ICF-IID.
A child who is medically stable, even though disabled, is not considered in need of a level of care. A child is medically stable if the child's health care and medical needs do not require care in a medical institution.
Source: 19 SDR 26, effective August 23, 1992; 40 SDR 122, effective January 8, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:07. Level of care -- Acute care hospital. A child may qualify for an acute care hospital level of care if the child meets the following requirements:
(1) The child has a medical condition which requires nursing services 24 hours a day and the services can only be provided by a professional nurse, or the child requires the use of sophisticated equipment designed to alert caregivers to potential problems;
(2) The child is at risk of rapid deterioration in health status;
(3) The child requires the continued use of medical technology, complex medical equipment, or invasive techniques to sustain life; and
(4) Without the support of professional nursing services, the child would require hospitalization for an indefinite time because of the complexity or intensity of the child's long-term medical needs.
Source: 19 SDR 26, effective August 23, 1992.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:08. Level of care -- Specialized hospital. A child may qualify for a specialized hospital level of care if the child requires direct professional nursing services seven days a week and one of the following conditions exist:
(1) The child requires continued use of medical technology or invasive techniques to sustain life; or
(2) The child requires assistance in at least three of the five activities of daily living and the child requires regularly scheduled skilled therapeutic services, including physical therapy, occupational therapy, or speech/language therapy in any combination not less than once a week.
Source: 19 SDR 26, effective August 23, 1992.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:09. Level of care -- Nursing facility. A child may qualify for a nursing facility level of care when all of the following conditions are met:
(1) The child requires continuing professional nursing services which have been ordered by a physician and can only be provided by or under the supervision of a professional nurse as defined in chapter 20:48:04.01. These services include daily management, direct observation, monitoring, or performance of complex nursing procedures. Continuing care is repeated application of the procedures or services at least once each 24 hours, frequent monitoring, and documentation of the child's condition and response to the procedures or services;
(2) The child requires the assistance of another person for the performance of at least three of the five activities of daily living according to an age appropriate assessment. The ADL dependency requires the assistance and presence of another person during the entire activity; and
(3) The child requires skilled therapeutic services including physical therapy, occupational therapy, and speech/language therapy in any combination scheduled regularly, but not less than once a week unless limited by the child's medical condition or age.
Source: 19 SDR 26, effective August 23, 1992; 41 SDR 93, effective December 3, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:10. Level of care -- ICF-IID. The team may assign an individual to an ICF-IID level of care when all of the following conditions are met:
(1) The child requires a continuous active treatment program;
(2) The child requires direct assistance from professionals for special rehabilitative or developmental intervention for conditions which significantly interfere with mental age-appropriate activities;
(3) The child requires the assistance of another person for the performance of at least three of the five activities of daily living according to an age appropriate assessment. The ADL dependency requires the assistance and presence of another person during the entire activity;
(4) The child requires continuing professional nursing services which have been ordered by a physician and can only be provided by or under the supervision of a professional nurse as defined in chapter 20:48:04.01. The services include daily management, direct observation, monitoring, or performance of complex nursing procedures. Continuing care is repeated application of the procedures or services at least once each 24 hours, frequent monitoring, and documentation of the child's condition and response to the procedures or services; and
(5) A clinical psychologist has determined that the child has an intellectual disability according to the provisions of § 67:46:09:11, or a physician or a psychologist has determined that the child is developmentally disabled according to § 67:54:04:05.
Source: 19 SDR 26, effective August 23, 1992; 40 SDR 122, effective January 8, 2014; 41 SDR 93, effective December 3, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:11. Determination of intellectual disability. A clinical psychologist may determine that a child has an intellectually disability for the purposes of subdivision 67:46:09:10(5) if the child meets one of the following conditions:
(1) The child has achieved only those developmental milestones generally acquired by children no more than half the child's chronological age; or
(2) The child has an intelligence rating of 69 or below as determined by a standardized intelligence test such as the Wechsler Intelligence Scale for Children (WISC-R) or the Stanford-Binet.
Source: 19 SDR 26, effective August 23, 1992; 40 SDR 122, effective January 8, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:12. Cost not to exceed cost of medical institutional care. Based on the level of care determination, the actual itemized cost of all Medicaid covered services provided in the home may not exceed 100 percent of the Medicaid-allowable cost of care in a medical institution. Medicaid allowable cost is the amount payable when cost share, insurance, or Medicare deductible or coinsurance has been applied.
The costs of all services that would be included in a medical institution's reimbursement shall be used to determine the monthly home care cost. When determining the monthly home care cost, the cost of purchased medical equipment shall be prorated on an annual basis.
When the cost of care in the home exceeds the cost of institutional care, the department shall issue a notice of intent to discontinue or deny further service. The department may reconsider its decision to discontinue or deny further service if, within 30 days from the date of the notice, the parent provides documentation to the department that future costs will decline and be within 100 percent of the cost.
The Medicaid allowable cost of care for the various medical institutions are as follows:
(1) Acute hospital care for a child who meets the requirements of § 67:46:09:07, $22,600 a month;
(2) Specialized hospital care for a technology-dependent child who meets the requirements of subdivision 67:46:09:08(1), $13,800 a month;
(3) Specialized hospital care for a child who is not technology-dependent who meets the requirements of subdivision 67:46:09:08(2), $6,350 a month;
(4) Nursing facility care cost for a child who meets the requirements of § 67:46:09:09, $2,054 a month plus any add-on allowances for ventilator assistance; and
(5) Intermediate care facility for individuals with intellectual disabilities for a child who meets the requirements of § 67:46:09:10, $5,200 a month.
Source: 19 SDR 26, effective August 23, 1992; 20 SDR 144, effective March 10, 1994; 21 SDR 162, effective March 23, 1995; 40 SDR 122, effective January 8, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-References: Add-on payment -- Ventilator, § 67:16:04:08.04; Documentation required for ventilator add-on payment, § 67:45:02:07.
67:46:09:13. Reviews for continued eligibility. The team shall review a child's case at least annually to determine if the child continues to meet the eligibility requirements of this chapter.
If the team determines that the child no longer meets the eligibility requirements, the case shall be closed and the child may no longer receive services under this chapter.
Failure to provide the department with required documentation concerning medical or financial information is cause for terminating eligibility.
Source: 19 SDR 26, effective August 23, 1992.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
67:46:09:14. Notice when case closed. If the department determines that the individual is no longer eligible for services under this chapter, it shall send a written notice to the child's parent, guardian, or other authorized representative at least 10 days before the case is closed.
Source: 19 SDR 26, effective August 23, 1992.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.