Rule 67:46:10 CHRONIC RENAL DISEASE PROGRAM

CHAPTER 67:46:10

CHRONIC RENAL DISEASE PROGRAM

Section

67:46:10:01 Definitions.

67:46:10:02 Application to establish initial eligibility -- Refusal to comply.

67:46:10:03 Application to establish continuing eligibility.

67:46:10:04 Eligibility requirements.

67:46:10:05 Income considered.

67:46:10:06 Exclusions from resources.

67:46:10:07 Eligibility determination.

67:46:10:08 Program limitations.

67:46:10:09 Scope of services and benefits.

67:46:10:10 Basis of payment.

67:46:10:11 Payment limit.

67:46:10:12 Claim submission limit.

67:46:10:13 Date of eligibility.

67:46:10:14 Provider limitations.

67:46:10:15 Medical eligibility.

67:46:10:16 Acceptance for treatment.

67:46:10:17 Repealed.

67:46:10:18 Copayment.

67:46:10:01. Definitions. Terms used in this chapter mean:

(1) "Chronic renal failure," a phase of renal functional impairment which can no longer be favorably influenced by conservative management and which requires long-term, continuing dialysis or transplantation to maintain life and health;

(2) "Income," any money or in-kind payments before deductions as established in § 67:46:10:05;

(3) "Program," the South Dakota chronic renal disease program administered by the Department of Social Services;

(4) "Resident," a person residing in South Dakota with an intent to remain or absent from the state for medical purposes but with an intent to return;

(5) "Resource," real or personal property and income owned by the applicant or persons legally responsible for the applicant; and

(6) "Third party payer," any individual; firm; partnership; corporation; company; association; governmental agency, including Medicaid or veterans administration; local fund drive contributions; or any other entity responsible for or otherwise assuming an obligation to provide the payment of all or part of the cost of the medical care and treatment of a person suffering from chronic renal failure.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:01, effective August 23, 1992; 21 SDR 86, effective December 29, 1994; 22 SDR 2, effective July 17, 1995; 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:02. Application to establish initial eligibility -- Refusal to comply. An individual suffering from chronic renal failure may complete and submit to the department a signed application for assistance under the program after the individual has been on dialysis for one month or has received a transplant within the last 12 months. The applicant's refusal to complete, date, and sign the application for assistance is a basis for rejecting the application.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:02, effective August 23, 1992; 21 SDR 86, effective December 29, 1994; 30 SDR 193, effective June 13, 2004.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

Cross-Reference: Eligibility requirements, § 67:46:10:04.

67:46:10:03. Application to establish continuing eligibility. A recipient of services under this chapter must submit a new, signed application upon request of the department or at least annually. If the recipient fails to complete, sign, date, and return the application within 10 days after the date the department mails the request, the recipient becomes ineligible beginning the first day of the following month.

Source: 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:02.01, effective August 23, 1992; 21 SDR 86, effective December 29, 1944.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:04. Eligibility requirements. An individual is eligible for benefits under this chapter if all of the following requirements are met:

(1) The individual is a resident of South Dakota;

(2) The individual is either a citizen of the United States or an alien eligible under the provisions of § 67:46:01:10;

(3) The individual is unable to pay the total cost of lifesaving care and treatment for the renal failure;

(4) The individual has not deprived himself or herself, directly or indirectly, of any property or assets for the purpose of qualifying for assistance;

(5) The individual does not have a third-party payer. For purposes of this rule, Medicare and Indian Health Services are not considered third-party payers. In addition, the department is not considered a third-party payer if the individual is determined to be a qualified Medicare beneficiary, a special low-income Medicare beneficiary, or a Medicare beneficiary who has income of at least 120 percent but less than 135 percent of the federal poverty level, and the individual's Medicaid benefits are limited to payment of the individual's part A or B premiums, deductibles, or coinsurance;

(6) The individual is a proper candidate for care and treatment as determined by §§ 67:46:10:02, 67:46:10:15, and 67:46:10:16 and is willing to receive it;

(7) The individual's income, considered according to § 67:46:10:05, is less than 150 percent of the federal poverty level established in § 67:11:01:03; and

(8) Excluding items listed in § 67:46:10:06, the equity value of resources is less than $4,000 for a single individual and $6,000 for an individual with a spouse.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:03, effective August 23, 1992; 21 SDR 86, effective December 29, 1994; 21 SDR 162, effective March 23, 1995; 22 SDR 2, effective July 17, 1995; 30 SDR 193, effective June 13, 2004.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

Cross-Reference: Qualified Medicare beneficiaries, ch 67:46:11.

67:46:10:05. Income considered. When determining income eligibility, the department considers the household's earned and unearned income. For a salaried household member, earned income includes income in cash or in kind, before deductions, such as income taxes, social security taxes, insurance premiums, or savings bonds, earned through the receipt of wages, salary, commissions, or fees.

For a self-employed household member, earned income is the taxable income declared on the most recent tax return plus all depreciation allowances claimed as a deduction on the return.

All other income is considered unearned income and is considered when received.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:04, effective August 23, 1992; 21 SDR 86, effective December 29, 1994; 22 SDR 2, effective July 17, 1995.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:06. Exclusions from resources. All resources are considered available to the household unless excluded. The following resources are excluded:

(1) Personal residence and the contiguous land;

(2) Personal property, such as household furniture, life insurance policies, items essential for daily living, and automobiles;

(3) Income-producing property within the limits established in § 67:46:10:04; and

(4) Income-producing personal property, such as equipment, inventory of a small business, or tools needed to produce income during or following rehabilitation services.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; 9 SDR 11, effective August 1, 1982; transferred from § 67:16:23:05, effective August 23, 1992; 21 SDR 86, effective December 29, 1994; 22 SDR 2, effective July 17, 1995.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:07. Eligibility determination. Applications shall be reviewed by the department and approval or rejection shall be made to the applicant in writing within sixty days from the date of application. Approval for assistance, when granted, shall be for a period of one year or for a period of one year after the date of a successful transplant, whichever occurs first.

Source: 2 SDR 88, effective July 1, 1976; 6 SDR 66, effective January 10, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; transferred from § 67:16:23:06, effective August 23, 1992.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:08. Program limitations. All payments for assistance and services under the chronic renal disease program shall be made within the budget limitation of the program.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 8 SDR 58, effective November 29, 1981; transferred from § 67:16:23:07, effective August 23, 1992.

General Authority: SDCL 28-6A-2.

Law Implemented: SDCL 28-6A-2.

67:46:10:09. Scope of services and benefits. Services and benefits payable under the program include:

(1) Institutional dialysis;

(2) Home dialysis, including supplies, equipment, and special water softeners;

(3) Renal transplants;

(4) Hospitalization;

(5) Prescription drugs necessary for dialysis or transplants and not covered by other sources; and

(6) Travel expense reimbursements for the recipient, in accordance with chapter 67:16:49.

Source: 2 SDR 88, effective July 1, 1976; 6 SDR 66, effective January 10, 1980; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:08, effective August 23, 1992; 21 SDR 86, effective December 29, 1994; 22 SDR 2, effective July 17, 1995; 30 SDR 193, effective June 13, 2004; 40 SDR 122, effective January 7, 2014; 43 SDR 31, effective September 12, 2016; 47 SDR 24, effective September 10, 2020.

General Authority: SDCL 28-6A-12 , 28-6-1.1.

Law Implemented: SDCL 28-6A-2.

67:46:10:10. Basis of payment. Payment for services under the program shall be made to the provider. All payments for services provided shall be based on the criteria used to establish rates for services and benefits in chapters 67:16:02, 67:16:03, 67:16:14, 67:46:10, and 67:16:25.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:09, effective August 23, 1992.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:11. Payment limit. Total payments made on behalf of an individual eligible under this chapter may not exceed $5,000 in a fiscal year.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:10, effective August 23, 1992; 21 SDR 86, effective December 29, 1994.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:12. Claim submission limit. All claims for services provided under this chapter must be submitted to the department according to the provisions of § 67:16:35:04.

Source: 9 SDR 28, effective September 5, 1982; transferred from § 67:16:23:10.01, effective August 23, 1992; 40 SDR 122, effective January 7, 2014.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:13. Date of eligibility. Eligibility for benefits under this chapter shall start with the first day of the month in which the application is signed.

Source: 2 SDR 88, effective July 1, 1976; 6 SDR 66, effective January 10, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:11, effective August 23, 1992.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:14. Provider limitations. Payments to medical providers under the program shall be limited to providers qualified for reimbursement from the Medicare program administered by the social security administration.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; transferred from § 67:16:23:14, effective August 23, 1992.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:15. Medical eligibility. Medical eligibility for benefits under this chapter is limited to persons who meet both of the following criteria:

(1) Presence of terminal irreversible renal failure of such severity that conservative management will not support life. The person requires peritoneal dialysis, hemodialysis, or renal transplant in order to sustain life; and

(2) A sufficient degree of understanding and motivation to assure that the person will participate in continuing dialysis. The person is willing to adhere to dietary and intake restrictions.

A report from the renal disease center or the applicant's or recipient's attending physician shall confirm that the requirements in this section are met before initial or continuing eligibility is determined.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 7 SDR 121, effective July 2, 1981; transferred from § 67:16:23:15, effective August 23, 1992.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:16. Acceptance for treatment. The person must be accepted for evaluation and treatment by a renal disease center which has been certified as such by the Medicare program administered by the social security administration.

Source: 2 SDR 88, effective July 1, 1976; 7 SDR 66, 7 SDR 89, effective July 1, 1981; transferred from § 67:16:23:16, effective August 23, 1992.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.

67:46:10:17. Base income disregard. Repealed.

Source: 7 SDR 121, effective July 2, 1981; 9 SDR 11, effective August 1, 1982; transferred from § 67:16:23:18, effective August 23, 1992; repealed, 21 SDR 86, effective December 29, 1994.

67:46:10:18. Copayment. A recipient of benefits under this chapter must make a copayment to the provider. The amount of the copayment is five percent of the amount allowed in § 67:46:10:10.

Source: 7 SDR 121, effective July 2, 1981; 9 SDR 11, effective August 1, 1982; transferred from § 67:16:23:19, effective August 23, 1992; 21 SDR 86, effective December 29, 1994.

General Authority: SDCL 28-6A-12.

Law Implemented: SDCL 28-6A-2.