1 ARTICLE 67:16
COVERED MEDICAL SERVICES Chapter
67:16:01 General provisions.
67:16:02 Physician and other health services.
67:16:03 Hospital services.
67:16:04 Nursing facility rate setting.
67:16:05 Home health services.
67:16:06 Dental services.
67:16:07 Podiatric services.
67:16:08 Optometric and optical services.
67:16:09 Chiropractic services.
67:16:10 Rehabilitation hospital services, Repealed.
67:16:11 Early and periodic screening.
67:16:12 Family planning services.
67:16:13 Community mental health center services.
67:16:14 Prescription drugs.
67:16:15 Long-term care supplements, Repealed.
67:16:16 Facilities for the mentally impaired.
67:16:17 Application for long-term care, Transferred.
67:16:18 Long-term care eligibility, Transferred.
67:16:19 Long-term care income requirements, Transferred.
67:16:20 Long-term care resource requirements, Transferred.
2 67:16:21 Budgeting for long-term care, Transferred.
67:16:22 Long-term care notice requirements, Transferred.
67:16:23 Chronic renal disease program, Transferred.
67:16:24 Personal care services.
67:16:25 Transportation services.
67:16:26 Third-party liability.
67:16:27 Home and community-based services, Transferred.
67:16:28 Ambulatory surgical centers (ASCs).
67:16:29 Medical equipment.
67:16:30 Qualified Medicare beneficiaries, Transferred.
67:16:31 Organ transplants.
67:16:32 Community spouses, Transferred.
67:16:33 Provider requirements.
67:16:34 Records.
67:16:35 Claims.
67:16:36 Hospice services.
67:16:37 School districts.
67:16:38 Case management -- Severely and persistently mentally ill,
Repealed.
67:16:39 Care management -- Primary care provider.
67:16:40 Care management -- Rehabilitation, psychiatric, neonatal.
67:16:41 Mental health services by independent practitioners.
67:16:42 Nutritional therapy and nutritional supplements.
3 67:16:43 Care management -- Medically complex children.
67:16:44 Federally qualified health centers and rural health clinics.
67:16:45 Reserved.
67:16:46 Diabetes education program.
67:16:47 Residential treatment for children.
67:16:48 Treatment for substance use disorders.
67:16:49 Non-emergency medical travel services.
67:16:50 Preadmission screening and resident review.
4 CHAPTER 67:16:50
PREADMISSION SCREENING AND RESIDENT REVIEW
Section
67:16:50:01 Definitions.
67:16:50:02 Preadmission screening and resident review.
67:16:50:03 Level I screen.
67:16:50:04 Circumstances that do not require a Level II evaluation.
67:16:50:05 Exempt hospital discharge.
67:16:50:06 Categorical determinations for Level I.
67:16:50:07 Level II review.
67:16:50:08 Level II State Mental Health Authority evaluation.
67:16:50:09 Level II State Mental Health Authority determination.
67:16:50:10 Level II State Intellectual Disability Authority evaluation.
67:16:50:11 Level II State Intellectual Disability Authority determination.
67:16:50:12 Determination of specialized services.
67:16:50:13 Notification of Level II determination.
67:16:50:14 Termination of a preadmission screening and resident review.
67:16:50:15 Timeliness of a Level II determination.
67:16:50:16 Determination may not be countermanded.
67:16:50:17 Length of stay.
67:16:50:18 Individual not requiring nursing facility services but requiring
specialized services for preadmission screening and resident review
condition -- Thirty-month determination.
5 67:16:50:19 Significant change.
67:16:50:20 New admission and readmission.
67:16:50:21 Interfacility transfer.
67:16:50:22 Out-of-state placement.
67:16:50:23 Fair hearings.
6 67:16:50:01. Definitions. Terms used in this chapter mean:
(1) "Active treatment," the implementation of a program of specialized and generic
training, treatment, health services, and related services, which leads to the acquisition of
the behaviors necessary for an individual to function with as much self-determination and
independence as possible, and to prevent regression or loss of current optimal functional
status;
(2) "Dementia," a disorder characterized by the development of multiple cognitive
deficits due to the direct physiological effects of a general medical condition, to the
persisting effect of a substance, or to multiple etiologies;
(3) "Developmental disability," as defined by SDCL 27B-1-18;
(4) "Intellectual disability," a condition characterized by significant limitations in
both intellectual functioning and adaptive behavior that originates before the age of twenty-
two;
(5) "Level I screen," a screening pursuant to 42 C.F.R. § 483.102 (July 12, 2006),
used to identify if a person has a serious mental illness or an intellectual or developmental
disability;
(6) "Level II," an evaluation of a person identified in a Level I screen to confirm
the preadmission screening and resident review condition and determine if nursing facility
services and specialized services are needed;
(7) "Nursing facility," as defined in SDCL 34-12-1.1;
(8) "Resident review," a review to determine the appropriateness for a resident to
remain in a nursing facility and if the resident needs specialized services;
7 (9) "Serious mental illness," a condition that meets the requirements for diagnosis,
level of impairment, and duration of illness pursuant to 42 C.F.R. § 483.102 (July 12,
2006);
(10) "Specialized services," the services specified by the state for an individual
which, when combined with the services provided by a nursing facility or other service
provider, results in active treatment;
(11) "State Intellectual Disability Authority," the Department of Human Services
Division of Developmental Disabilities;
(12) "State Medicaid Authority," the department's Division of Medical Services;
and
(15) "State Mental Health Authority," the department's Division of Behavioral
Health.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
8 67:16:50:02. Preadmission screening and resident review. A medicaid-certified
nursing facility shall, upon an individual's admission or if a resident's condition has a
significant change:
(1) Evaluate a resident or applicant for a serious mental illness and an intellectual
or developmental disability;
(2) Offer the resident or applicant the most appropriate setting for their needs; and
(3) Provide the resident or applicant the services needed in an appropriate setting.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
9 67:16:50:03. Level I screen. A referring or accepting provider shall conduct a
Level I screen to determine if an individual seeking medicaid-certified nursing facility
services has a serious mental illness or an intellectual or developmental disability.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
10 67:16:50:04. Circumstances that do not require a Level II evaluation.
Following the Level I screen, an individual is exempt from a Level II evaluation if:
(1) There is no substantiated diagnosis of a serious mental illness or an intellectual
or developmental disability;
(2) The individual is readmitted pursuant to § 67:16:50:20;
(3) The individual is transferred pursuant to § 67:16:50:21;
(4) There is a diagnosis of situational depression or anxiety that is of short duration
and in direct relation to an occurrence in an individual's life, and it does not appear that it
will lead to a chronic disability;
(5) The individual does not have a serious mental illness diagnosis and is using
psychotropic medication; or
(6) The individual has a primary diagnosis of dementia or a related disorder.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
11 67:16:50:05. Exempt hospital discharge. An individual is exempt from the
preadmission screening and resident review process following a hospital discharge if:
(1) The individual is admitted to a medicaid-certified nursing facility, directly from
a hospital, after receiving acute inpatient care at the hospital;
(2) The individual requires medicaid-certified nursing facility services for the
condition that required care in the hospital; and
(3) The individual's attending physician has certified, before admission to the
medicaid-certified nursing facility, that the individual is likely to require less than thirty
calendar days of medicaid-certified nursing facility services.
The medicaid-certified nursing facility must have a completed exempt hospital
discharge form on file for an individual if the exemption criteria for any subdivision in this
rule applies. If an individual enters a medicaid-certified nursing facility as an exempt
hospital discharge and is later found to require more than thirty days of nursing care, the
facility must request a preadmission screening and resident review prior to the expiration
of that thirty days.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
12 67:16:50:06. Categorical determinations for Level I. The State Mental Health
Authority or State Intellectual Disability Authority shall make an advance group
categorical determination for a nursing facility applicant or resident who may have a
preadmission screening and resident review condition when:
(1) The individual has been diagnosed by a physician with a terminal illness, or has
hospice involvement that includes a life expectancy of six months or less;
(2) The individual has a severe physical illness that has resulted in a coma or
ventilator dependence;
(3) A physician identifies the need for the individual to have convalescent care
following an inpatient hospitalization of less than one hundred days;
(4) The individual’s respite stay is less than thirty days; or
(5) The individual receives provisional emergency admission not to exceed seven
days with placement in the nursing facility following suspected abuse or neglect or a
natural disaster that involves loss of housing or unsafe housing for the individual, and law
enforcement or adult protective services are involved.
If a categorical determination is made, a Level I screen must be completed and
submitted. An abbreviated evaluation report is sent to the individual, the State Mental
Health Authority or State Intellectual Disability Authority, the admitting or retaining
nursing facility, and the discharging hospital, if applicable. The abbreviated evaluation
report must also be sent to the individual's attending physician or made available for review
at the facility.
Source:
13 General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
14 67:16:50:07. Level II review. The State Mental Health Authority or State
Intellectual Disability Authority shall conduct a Level II review to determine whether a
medicaid-certified nursing facility, specialized services, or both, is appropriate for an
individual.
The individual must be reviewed for appropriateness of placement, regardless of
the source of payment for the nursing facility services. A determination must be made
whether the individual requires the level of services provided by the facility, and whether
or not an individual can benefit from specialized services.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
15 67:16:50:08. Level II State Mental Health Authority evaluation. An
independent evaluator shall complete the Level II evaluation based on an independent
physical and mental evaluation performed by a person or entity other than the State Mental
Health Authority for an individual with an identified serious mental illness as required in
42 C.F.R. § 483.106 (April 28, 1993). A preadmission screening and resident review Level
II evaluation must involve:
(1) The individual being evaluated;
(2) The individual's legal representative, if applicable; and
(3) The individual's family, if available and the individual consents.
The Level II evaluation must be adapted to the cultural background, language,
ethnic origin, and means of communication used by the individual being evaluated.
Data must be collected and evaluated pursuant to 42 C.F.R. §§ 483.132 and 483.134
(October 1, 2024).
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
16 67:16:50:09. Level II State Mental Health Authority determination. The
independent evaluator, as described in 42 C.F.R. § 483.106 (April 28, 1993), shall submit
an evaluation report and all data collected to the authority for final determination. The
authority shall determine if the individual requires the level of services provided by the
medicaid-certified nursing facility and if specialized services are appropriate.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
17 67:16:50:10. Level II State Intellectual Disability Authority evaluation. The
State Intellectual Disability Authority shall complete the Level II evaluation for an
individual with an identified intellectual or developmental disability. A preadmission
screening and resident review evaluation must involve:
(1) The individual being evaluated;
(2) The individual's legal representative, if applicable; and
(3) The individual's family, if available and the individual consents.
The evaluation the State Intellectual Disability Authority performs must be adapted
to the cultural background, language, ethnic origin, and means of communication used by
the individual being evaluated.
The minimum data that must be collected and evaluated is defined in 42 C.F.R. §§
483.132 and 483.134 (October 1, 2024).
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
18 67:16:50:11. Level II State Intellectual Disability Authority determination.
The State Intellectual Disability Authority shall complete a Level II evaluation using all
evaluated data and completed assessments to determine if an individual requires the level
of services provided by the medicaid-certified nursing facility and if specialized services
are appropriate.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
19 67:16:50:12. Determination of specialized services. If the State Mental Health
Authority or State Intellectual Disability Authority determines that an individual requires
medicaid-certified nursing facility services, the authorities must also determine whether
the individual would benefit from specialized services.
If the authorities determine that the individual requires both medicaid-certified
nursing facility services and specialized services, the facility may admit or retain the
individual, and the authorities must provide or arrange to provide the specialized services
needed by the individual in the medicaid-certified nursing facility.
If the authorities determine that the individual does not require medicaid-certified
nursing facility services but would benefit from specialized services, the authorities must
provide the individual with information regarding service options.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
20 67:16:50:13. Notification of Level II determination. The State Mental Health
Authority, State Intellectual Disability Authority, or both when applicable, shall issue a
written notification of the Level II review determination. The notification must include:
(1) Whether a Medicaid nursing facility level of services is needed;
(2) Whether specialized services are needed;
(3) The placement options available to the individual that are consistent with the
review determination;
(4) The appeal rights of the individual; and
(5) The evaluation report.
A copy of the Level II determination notification must be sent to the individual, the
appropriate state authorities, the admitting or retaining nursing facility, and the discharging
hospital, if applicable. A copy of the Level II determination notification must also be sent
to the individual's attending physician, or made available for review at the facility.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
21 67:16:50:14. Termination of a preadmission screening and resident review.
The preadmission screening and resident review process may be terminated by the State
Mental Health Authority or State Intellectual Disability Authority at any time during the
evaluation or determination if the individual being evaluated is found to not have a serious
mental illness or an intellectual or developmental disability.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
22 67:16:50:15. Timeliness of a Level II determination. The State Mental Health
Authority and State Intellectual Disability Authority shall make each Level II
determination within an annual average of seven to nine business days of receipt of the
Level I referral.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
23 67:16:50:16. Determination may not be countermanded. The State Medicaid
Authority may not countermand a Level II determination made by the State Mental Health
Authority or State Intellectual Disability Authority either in the claims process or through
other utilization control or review processes.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
24 67:16:50:17. Length of stay. For the purpose of establishing length of stay in a
medicaid-certified nursing facility, thirty months of continuous residence in a medicaid-
certified nursing facility may include temporary absences for hospitalization or therapeutic
leave, and may consist of consecutive residences in more than one medicaid-certified swing
bed or nursing facility.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
25 67:16:50:18. Individual not requiring nursing facility services but requiring
specialized services for preadmission screening and resident review condition --
Thirty-month determination. If an individual has resided in a medicaid-certified nursing
facility prior to a determination of eligibility, and was determined not eligible for nursing
home services, but requires specialized services, the State Mental Health Authority or State
Intellectual Disability Authority, in consultation with the individual's family, the
individual's legal representative, if applicable, and the individual's family, if available and
the individual consents, must:
(1) For an individual who has continuously resided in a medicaid-certified nursing
facility at least thirty months:
(a) Offer the individual the choice of remaining in the nursing facility or
receiving services in an alternative setting;
(b) Inform the individual of the institutional and noninstitutional
alternatives covered under the state medicaid plan;
(c) Inform the individual of any effect on the individual's eligibility for
medicaid services under the state plan, or any effect on readmission, if the individual
chooses to leave the nursing facility; and
(d) Provide or arrange specialized services for the individual's serious
mental illness or intellectual or developmental disability; or
(2) For an individual who has resided in a medicaid-certified nursing facility for
less than thirty months:
(a) Arrange for the safe and orderly discharge of the individual from the
facility;
26 (b) Prepare and orient the individual for discharge; and
(c) Provide or arrange specialized services to treat the individual's serious
mental illness or intellectual or developmental disability.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
27 67:16:50:19. Significant change. If a significant change occurs for an individual
known or suspected to have a preadmission screening and resident review condition, the
medicaid-certified nursing facility must initiate a new preadmission screening and resident
review utilizing the Level I screen. The referral for a new review must occur within
fourteen days of a significant change being identified by the nursing facility.
For purposes of this section, a significant change is a decline or improvement in an
individual's status that:
(1) Would not normally resolve itself without intervention by staff or by
implementing clinical interventions;
(2) Impacts more than one area of the individual's health status; and
(3) Requires interdisciplinary review or revision of the care plan.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
28 67:16:50:20. New admission and readmission. An individual admitted to any
medicaid-certified nursing facility for the first time, who is not being readmitted, is subject
to preadmission screening and resident review.
A readmission occurs when an individual is readmitted to a medicaid-certified
nursing facility from a hospital to which the individual was transferred, from the nursing
facility, for the purpose of receiving medical care. A preadmission screening and resident
review is not required for a readmission.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
29 67:16:50:21. Interfacility transfer. A preadmission screening and resident review
is not required for an interfacility transfer. The transferring nursing facility is responsible
for ensuring that copies of the individual's preadmission screening and resident review
accompany the individual.
For purposes of this section, an interfacility transfer occurs when the individual is
transferred from one medicaid-certified nursing facility to another, with or without an
intervening hospital stay.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
30 67:16:50:22. Out-of-state placement. The appropriate authority of the state in
which an individual is a resident, or would be a resident at the time medicaid eligibility is
obtained, if not this state, shall make the required preadmission screening and resident
review determination.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 28-6-1.
31 67:16:50:23. Fair hearing. An individual, or the individual's legal representative,
may request a hearing by notifying the department, orally or in writing, within thirty days
of receiving the department's determination. Hearings are conducted under the provisions
of chapter 67:17:02. Any costs associated with an individual's legal counsel are the
responsibility of the individual.
Source:
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-26-16, 28-6-1.
32
ARTICLE 67:62
MENTAL HEALTH
Chapter
67:62:01 Definitions.
67:62:02 Accreditation.
67:62:03 Governance.
67:62:04 Core service responsibilities.
67:62:05 General management requirements.
67:62:06 Personnel.
67:62:07 Clients' rights.
67:62:08 Clinical processes.
67:62:09 Environmental sanitation safety and fire prevention.
67:62:10 Outpatient services.
67:62:11 Child or youth and family services.
67:62:12 Comprehensive assistance with recovery and empowerment.
67:62:13 Community support services program -- Individualized
mobile programs of assertive community treatment.
67:62:14 Qualified mental health professional.
67:62:15 Preadmission screening and resident reviews, Repealed.
33 CHAPTER 67:62:15
PREADMISSION SCREENING AND RESIDENT REVIEW
Section
67:62:15:01 Definitions, Repealed.
67:62:15:02 Level I screening, Repealed.
67:62:15:03 Level II review exemptions, Repealed.
67:62:15:04 Exempt hospital discharge, Repealed.
67:62:15:05 Categorical determinations for Level I, Repealed.
67:62:15:06 Level II review, Repealed.
67:62:15:07 Level II determination -- Data requirements, Repealed.
67:62:15:08 Determination of services, Repealed.
67:62:15:09 Determination of specialized mental health services, Repealed.
67:62:15:10 Timeliness of determinations of Level II review, Repealed.
67:62:15:11 Notification of Level II determination, Repealed.
67:62:15:12 Determination may not be countermanded, Repealed.
67:62:15:13 Appeal of ineligibility of Level II determination, Repealed.
67:62:15:14 Length of stay, Repealed.
67:62:15:15 Individuals not requiring swing bed or nursing facility services but
requiring mental health services -- 30 month determination,
Repealed.
67:62:15:16 Significant change, Repealed.
67:62:15:17 New admission and readmission, Repealed.
34 67:62:15:18 Interfacility transfers, Repealed.
67:62:15:19 Out of state placement, Repealed.
35 67:62:15:01. Definitions. Terms used in this chapter mean:
(1) "Active treatment," the implementation of a program of specialized and generic
training, treatment, health services, and related services, which lead to the acquisition of
the behaviors necessary for the individual to function with as much self-determination and
independence as possible, and to prevent regression or loss of current optimal functional
status;
(2) "Dementia," disorders characterized by the development of multiple cognitive
deficits, including memory impairment, which are due to the direct physiological effects
of a general medical condition, to the persisting effects of a substance, or to multiple
etiologies ;
(3) "Nursing facility," a facility licensed as a nursing facility by the Department of
Health and maintained and operated for the express or implied purpose of providing care
to one or more persons, whether for consideration or not, who are not acutely ill but require
nursing care and related medical services of such complexity as to require professional
nursing care under the direction of a physician twenty-four hours a day;
(4) "Preadmission screening and resident review," a process made up of a Level I
screening completed by the department, and a Level II review completed by the
department, to determine eligibility when an individual with a mental disorder, as defined
in § 67:62:01:01, applies to reside in a Medicaid certified swing bed or nursing facility;
(5) "Specialized mental health services," psychiatric services that result in the
continuous and aggressive implementation of an individualized plan of care developed by
an interdisciplinary team consisting of a physician, a qualified mental health professional,
and other professionals, which prescribes specific therapies and activities for the treatment
36 of individuals experiencing an acute episode of serious mental illness. requiring
supervision by trained mental health professionals, to obtain improvement in function
thereby permitting a reduction in the level of intensity to less than the level of specialized
services at the earliest possible time; and
(6) "Swing bed," a licensed hospital bed approved by the Department of Health to
provide short-term nursing facility care pending the availability of a nursing facility bed
Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
37 67:62:15:02. Level I screening. The department shall conduct a Level I screening
that identifies each individual who is seeking Medicaid certified swing bed or nursing
facility services who may have a mental illness Repealed.
Source: 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25(4).
38 67:62:15:03. Level II review exemptions. An individual is exempt from a Level
II review if:
(1) The diagnosis of mental illness is unsubstantiated;
(2) The individual is readmitted to a Medicaid certified swing bed or nursing
facility from a hospital to which the individual was transferred for the purpose of receiving
care;
(3) The individual is transferred from one Medicaid certified swing bed or nursing
facility to another, and a preadmission screening and resident review has previously been
completed;
(4) The physician identifies the need for convalescent care following
hospitalization for a duration of less than one hundred days;
(5) The physician orders a respite stay of thirty days or less;
(6) The individual has a diagnosis of situational depression that:
(a) Is of short duration;
(b) Is in direct relation to an occurrence in an individual's life; and
(c) Does not appear to be a chronic disability;
(7) The individual is using psychotropic medication in the absence of a major
mental illness diagnosis; or
(8) The individual has a diagnosis of an anxiety disorder that is not identified as
severe and does not appear to be leading to a chronic disability.
The department shall complete a Level I screening form to notify appropriate
parties of the determination of the exemption Repealed.
39 Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
40 67:62:15:04. Exempt hospital discharge. An individual is exempt from a
preadmission screening and resident review (PASRR) following a hospital discharge if:
(1) The individual is admitted to a Medicaid certified swing bed or nursing facility,
directly from a hospital, after receiving acute inpatient care at the hospital;
(2) The individual requires Medicaid certified swing bed or nursing facility
services for the condition that required care in the hospital; and
(3) The individual's attending physician has certified, before admission to the
Medicaid certified swing bed or nursing facility, that the individual is likely to require less
than thirty calendar days of Medicaid certified swing bed or nursing facility services.
If an individual enters a Medicaid certified swing bed or nursing facility as an
exempt hospital discharge and is later found to require more than thirty days of nursing
care, the facility must request a PASRR prior to the expiration of that thirty days Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
41 67:62:15:05 Categorical determinations for Level I. The department shall make
a categorical determination in one of the following situations:
(1) A terminal illness diagnosis, determined by a physician or hospice involvement
that includes a life expectancy of 6 months or less;
(2) A severe physical illness that has resulted in coma or ventilator dependence;
(3) The age of an individual is 75 years or older; or
(4) A primary diagnosis of dementia, including Alzheimer's disease or a related
disorder or a non-primary diagnosis of dementia without a primary diagnosis that is a
serious mental illness.
For any of these situations, the department shall complete a Level I screening form.
A copy of the form shall be sent to the appropriate facility. A categorical determination
may warrant Medicaid certified swing bed or nursing facility services but does not warrant
mental health services or specialized services Repealed.
Source: 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25(4).
42 67:62:15:06. Level II review. The department shall conduct a Level II review that
consists of determining the appropriateness of a Medicaid certified swing bed or nursing
facility, and possible mental health services, including specialized mental health services
for individuals identified in the Level I screening.
Each individual is reviewed for appropriateness of placement, regardless of the
source of payment for the swing bed or nursing facility services. A determination whether
or not an individual requires the level of services provided by the facility and whether or
not an individual can benefit from mental health services is made Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
43 67:62:15:07. Level II determination -- Data requirements. The data used for a
Level II determination includes:
(1) A comprehensive social and developmental history and physical, including:
(a) Medical history;
(b) Review of body systems;
(c) Evaluation of the individual's neurological system in the areas of motor
functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves,
and abnormal reflexes; and
(d) Additional evaluations conducted by appropriate specialists in case of
abnormal findings;
(2) A comprehensive medication history including current or immediate past use
of medications that could mask symptoms or mimic mental illness;
(3) A psychosocial evaluation of the individual, including current living
arrangements and medical and support systems;
(4) A comprehensive psychiatric or psychological evaluation including a complete
psychiatric and development history; evaluation of intellectual functioning, memory
functioning, and orientation; description of current attitudes and overt behaviors; affect,
suicidal, or homicidal ideation, paranoia, and degree of reality testing (presence and content
of delusions) and hallucinations; and
(5) A functional assessment of the individual's ability to engage in activities of
daily living and the level of support that would be needed to assist the individual to perform
these activities. This assessment shall conclude whether this level of support can be
44 provided to the individual in an alternative community setting or if a nursing facility
placement is warranted Repealed.
Source: 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25(4).
45 67:62:15:08. Determination of services. The department shall determine if the
individual requires the level of services provided by a Medicaid certified swing bed or
nursing facility due to the individual's physical or mental condition. If the department
determines that an individual requires a Medicaid certified swing bed or nursing facility
services, the facility may admit or retain the individual. If the department determines that
an individual does not require Medicaid certified swing bed or nursing facility services, the
individual may not be admitted Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
46 67:62:15:09. Determination of specialized mental health services. If the
department determines that the individual requires Medicaid certified swing bed or nursing
facility services, the department must also determine whether the individual may benefit
from mental health services.
If the department determines that an individual requires both Medicaid certified
swing bed or nursing facility services and specialized mental health services as defined in
§ 67:62:15:01, the facility may admit or retain the individual and the state shall provide or
arrange for the provision of the specialized mental health services needed by the individual
in the Medicaid certified swing bed or nursing facility.
If the department determines that the individual does not require Medicaid certified
swing bed or nursing facility services, but may benefit from mental health services, the
department shall provide the individual with information regarding service options
Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
47 67:62:15:10. Timeliness of determinations of Level II review. The department
shall make each Level II determination within an annual average of seven-to-nine business
days of receipt of the Level I screening and all of the data required in § 67:62:15:07
Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
48 67:62:15:11. Notification of Level II determination. The department shall issue
a written notification of the Level II review determination. The notification must contain:
(1) The name of each professional who performed an evaluation used to make the
Level II determination;
(2) The date each portion of the evaluation was administered; and
(3) Any other information used to make the Level II determination.
The department shall provide a copy of the notification to the individual on whom
the Level II review was completed; the individual's legal representative, if applicable; the
Medicaid certified swing bed or nursing facility; and any other party affected by the Level
II determination Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
49 67:62:15:12. Determination may not be countermanded. A Level II
determination made by the division may not be countermanded by the department
Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
50 67:62:15:13. Appeal of ineligibility of Level II determination. The individual,
or the individual's legal representative, may request a fair hearing within 30 calendar days
of receipt of the notice of ineligibility pursuant to SDCL chapter 1-26 by notifying the
department in writing. Upon request, the individual, or the individual's legal representative,
will be provided with information in an accessible format. Any costs associated with legal
counsel obtained to represent the individual are not the responsibility of the department
Repealed.
Source: 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25(4).
51 67:62:15:14. Length of stay. For the purposes of establishing length of stay in a
Medicaid certified swing bed or nursing facility, the 30 months of continuous residence in
a Medicaid certified facility may include temporary absences for hospitalization or
therapeutic leave and may include consecutive residences in more than one Medicaid
certified swing bed or nursing facility Repealed.
Source: 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25(4).
52 67:62:15:15. Individuals not requiring swing bed or nursing facility services
but requiring mental health services -- 30 month determination. If the individual is
determined not eligible for swing bed or nursing home services, but requires mental health
services, the department, in consultation with the individual's family or legal representative
and caregivers, shall:
(1) If the individual has continuously resided in a Medicaid certified swing bed or
nursing facility at least 30 months prior to a determination of eligibility and determined not
eligible for swing bed or nursing home services, but who require mental health services,
the department, in consultation with the individual's family or legal representative and
caregivers, shall:
(a) Offer the choice of remaining in the facility or receiving services in an
alternative setting;
(b) Inform the individual of the institutional and non-institutional
alternatives covered under the state Medicaid plan;
(c) Clarify the effect on the individual's eligibility for Medicaid services
under the state plan if the individual chooses to leave the Medicaid certified swing bed or
nursing facility, including the effect on readmission to the Medicaid certified swing bed or
nursing facility; and
(d) Provide, or arrange the provision of, mental health services for the
mental illness; or
(2) If the individual has been residing in the Medicaid certified swing bed or
nursing facility less than 30 months prior to a determination of eligibility and determined
not eligible for swing bed or nursing home services, but who requires mental health
53 services, the department, in consultation with the individual's family or legal representative
and caregivers, shall:
(a) Arrange for the safe and orderly discharge of the individual from the
facility;
(b) Prepare and orient the individual for discharge; and
(c) Provide, or arrange for the provision of, mental health services for the
mental illness Repealed.
Source: 43 SDR 80, effective December 5, 2016.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25(4).
54 67:62:15:16. Significant change. A significant change is a decline or
improvement in an individual's status that:
(1) Will not normally resolve itself without intervention by staff or by
implementing standard disease-related clinical interventions;
(2) Impacts more than one area of the individual's health status; and
(3) Requires interdisciplinary review or revision of the care plan.
A self-limiting decline is not considered a significant change. If a significant change
occurs for an individual known or suspected to have a mental illness, the Medicaid certified
swing bed or nursing facility must make a referral to the department for a possible Level
II review. This referral must occur as soon as evidence of the significant change is
identified Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
55 67:62:15:17. New admission and readmission. A new admission occurs if an
individual is admitted to a Medicaid certified swing bed or nursing facility for the first
time, or when an admission does not qualify as a readmission. Unless excepted under
§ 67:62:15:04, a new admission is subject to a preadmission screening and resident review
(PASRR).
A readmission occurs when an individual is readmitted to a Medicaid certified
swing bed or nursing facility, from a hospital to which the individual, who was in a facility,
had been transferred, for the purpose of receiving medical care. A readmission that meets
the criteria set forth in this section does not require a PASRR Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
56 67:62:15:18. Interfacility transfers. An interfacility transfer occurs if the
individual is transferred from one Medicaid certified swing bed or nursing facility to
another, with or without an intervening hospital stay. An interfacility transfer is not subject
to a preadmission screening and resident review. If an individual transfers from a Medicaid
certified swing bed or nursing facility to a hospital, or to another Medicaid certified swing
bed or nursing facility, the transferring facility must ensure that copies of the individual's
preadmission screening and resident review findings accompany the individual Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
57 67:62:15:19. Out of state placement. The required preadmission screening and
resident review determination must be conducted by the state in which the individual:
(1) Resides; or
(2) Will reside at the time Medicaid eligibility is obtained Repealed.
Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November
27, 2023.
General Authority: SDCL 1-36-25.
Law Implemented: SDCL 1-36-25.
Cross Reference: Out-of-State arrangements, 42 C.F.R. § 483.110.