1 67:16:01:08. Services not covered. In addition to items and services specified as not
covered in other sections of this article, the following items and services are not covered
under the medical assistance program:
(1) Items or services which that have been determined by the state dental or medical
consultant, or through peer reviews, to be not medically necessary, safe, or effective;
(2) Items or services for which the recipient has no legal obligation to pay, or for
which are charges are imposed by an immediate relatives or members relative of the recipient
or a member of the recipient's household;
(3) Over-the-counter drugs, home remedies, food supplements, nutritional items,
vitamins, or alcoholic beverages, except as covered under chapter 67:16:14 or 67:16:42;
(4) Diagnosis or treatment given in the absence of the patient;
(5) Cosmetic or reconstructive surgery to improve the appearance of an individual, if
not incidental to prompt repair following an accidental injury or any cosmetic surgery that
goes beyond that which what is necessary to improve the functioning of a malformed body
member, excluding:
(a) Reconstructive surgery following a medically necessary mastectomy; or
(b) Surgery that is incidental to prompt repair following an accidental injury;
(6) Items or services provided by practitioners or agencies a practitioner or agency in
the employ of or under contract with the federal, state, or local government, except state:
(a) State institutions for the developmentally disabled that are certified as
skilled nursing or intermediate care facilities, the state psychiatric hospital, the public health
service, or the national health service;
(b) State or local government hospitals or clinics;
2 (c) The United States Public Health Service; or
(d) The National Health Service Corps;
(7) Organ transplants, except as authorized under chapter 67:16:31;
(8) Acupuncture;
(9) Biofeedback;
(10) Chronic pain rehabilitation program services or chronic pain management
services, except prescription drugs as allowed under chapter 67:16:14;
(11) Alcohol and drug rehabilitation therapy, except for services provided under
chapter 67:16:48;
(12) Procedures for implanting an embryo;
(13) Gastric bypass, gastric stapling, gastroplasty, or any similar surgical procedure,
or the associated conservative weight loss management, unless prior authorized;
(14) Self-help devices, exercise equipment, protective outerwear, personal comfort
services or environmental control equipment, such as air conditioners, humidifiers,
dehumidifiers, heaters, or furnaces;
(15) Medical equipment for a resident in a health care facility, except as authorized
under chapter 67:44:03;
(16) Autopsies;
(17) Custodial care, except as authorized under chapter 67:44:03;
(18) Nursing facility services for individuals age 21 twenty-one and over and under
age 65 sixty-five in institutions for individuals with a mental disease;
(19) Broken appointments;
3 (20) Reports required solely for insurance or legal purposes, unless requested by the
department, the Department of Health, or the Department of Human Services;
(21) Concurrent The second and any subsequent claim submitted for concurrent care
by more than one provider of the same discipline for the same diagnosis without a medical
referral detailing the medical necessity of the concurrent care. For concurrent care without
medical referral, the department will pay only the first claim submitted;
(22) A health service that is not documented in the recipient's medical record as
required by chapter 67:16:34;
(23) Vocational training, educational activities, teaching, or counseling, except
outpatient diabetes self-management education training programs covered under chapter
67:16:46;
(24) Record keeping, charting, or documentation related to providing a covered
service, unless specifically allowed covered in this article;
(25) Payment of mileage unless specifically covered under this article;
(26) Drugs and biologicals, which that the federal government has determined to be
less than effective, as listed in § 67:16:14:05 according to 42 U.S.C. § 1395y(c) (February 3,
2026);
(27) Services, procedures, or drugs, which that are considered experimental by the
United States Department of Health and Human Services or another federal agency, not
including services, procedures, or drugs approved by the Food and Drug Administration
under an emergency use authorization that are being utilized in accordance with the
emergency use authorization;
(28) Procedures and services to reverse sterilization;
4 (29) Computers, computer hookups, or computer printers, unless prior authorized
authorization has been received from the department pursuant to § 67:16:01:06.03;
(30) Gambling addiction services or therapy; and
(31) Penile implants.
Source: SL 1975, ch 16, § 1; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7
SDR 89, effective July 1, 1981; 9 SDR 11, effective August 1, 1982; 9 SDR 164, effective
June 30, 1983; 10 SDR 79, effective February 1, 1984; 11 SDR 26, effective August 21,
1984; 11 SDR 86, effective December 30, 1984; 15 SDR 204, effective July 6, 1989; 17 SDR
4, effective July 16, 1990; 17 SDR 184, effective June 6, 1991; 17 SDR 194, effective June
24, 1991; 18 SDR 98, effective December 9, 1991; 19 SDR 26, effective August 23, 1992; 19
SDR 165, effective May 3, 1993; 20 SDR 144, effective March 10, 1994; 22 SDR 32,
effective September 11, 1995; 28 SDR 166, effective June 12, 2002; 35 SDR 88, effective
October 23, 2008; 40 SDR 122, effective January 7, 2014; 43 SDR 80, effective December 5,
2016; 46 SDR 50, effective October 10, 2019; 47 SDR 129, effective June 3, 2021.
General Authority: SDCL 28-6-1(1)(2).
Law Implemented: SDCL 28-6-1.
Cross-Reference: Covered services must be medically necessary, § 67:16:01:06.02.
5 67:16:25:06.01. Transportation services provided by community transportation
provider. Community transportation services, as described in § 67:16:25:06.02, are covered
if the following requirements are met:
(1) The transportation provider is a governmental entity, a secure medical
transportation provider, or registered as a nonprofit organization with the South Dakota
Secretary of State secretary of state;
(2) The transportation provider is domiciled in the State of South Dakota this state or
enrolled as a Medicaid medicaid transportation provider in the entity or organization's
provider's state of domicile;
(3) The entity or organization transportation provider has a signed transportation
provider agreement with the department to furnish nonemergency medical transportation to
recipients; and
(4) Transportation is from:
(a) From an eligible recipient's residence or bus stop nearest to the recipient's
residence, place of work, or school, to a medical provider; between
(b) Between medical providers; or from
(c) From a medical provider to the recipient's residence or bus stop nearest to
the recipient's residence, place of work, or school;
(d) To or from medically necessary examinations or treatment, if the services
are covered under article 67:16 and are provided by a provider who is enrolled or eligible for
enrollment in the medical assistance program; or
6 (e) To the closest facility or medical provider capable of providing the
necessary services, unless the recipient has a written referral or a written authorization from a
medical provider in the recipient's medical community.
A recipient's residence does not include a hospital, penal institution, detention center,
campus setting, nursing facility, an intermediate care facility for individuals with intellectual
disabilities, or an institute for the treatment of an individual with a mental disease;
(5) Transportation is to or from medically necessary examinations or treatment, if the
services are covered under article 67:16 and are provided by a provider who is enrolled or
eligible for enrollment in the medical assistance program; and
(6) Transportation is to the closest facility or medical provider capable of providing
the necessary services, unless the recipient has a written referral or a written authorization
from a medical provider in the recipient's medical community.
Source: 16 SDR 234, effective July 1, 1990; 17 SDR 201, effective July 1, 1991; 20
SDR 126, effective February 10, 1994; 25 SDR 69, effective November 12, 1998; 26 SDR
157, effective June 7, 2000; 35 SDR 253, effective May 12, 2009; 40 SDR 122, effective
January 8, 2014; 44 SDR 94, effective December 4, 2017; 45 SDR 82, effective December
10, 2018; 48 SDR 39, effective October 3, 2021.
General Authority: SDCL 28-6-1(1)(2).
Law Implemented: SDCL 28-6-1.
7 67:16:25:06.02. Reimbursable services -- Community transportation provider. If
the requirements of § 67:16:25:06.01 are met, reimbursable community transportation
services are limited to the following:
(1) Transport of a recipient, and an accompanying adult, if the transportation
accompaniment is medically necessary due to the recipient's age or medical condition; and
(2) Mileage.
Transportation expenses payable by a third party are not eligible for reimbursement
under this chapter.
Source: 20 SDR 126, effective February 10, 1994; 26 SDR 157, effective June 7,
2000; 35 SDR 253, effective May 12, 2009.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-Reference: Covered services must be medically necessary, § 67:16:01:06.02.
8 67:16:26:05. Provider must collect from third-party source before submitting
claim to department -- Medical assistance program payer of last resort -- Payment
provision. Because the medical assistance program is the payer of last resort, a provider must
pursue the availability of third-party payment sources whether or not the sources are
identified by the department.
The provider must be able to document the provider's pursuit of the availability of a
third-party payment source, except for claims listed in § 67:16:26:07.02. The documentation
must be maintained in the recipient's records. Documentation may include a signed statement
by the recipient informing the provider of all third-party payment sources.
Once the provider has identified a third-party payment source, the provider must
submit a completed claim for payment of services to the third-party source before requesting
payment from the department. Except for an electronic claim, if a claim is subsequently
submitted to the department for payment, evidence of third-party payment or rejection must
accompany the claim. For an electronic claim, the provider must maintain and submit to the
department, on request, evidence of the third-party payment or rejection. The provider is
eligible to receive the recipient's third party liability responsibility payment from the medical
assistance program, up to the amount or the amount allowed under the department's payment
schedule less, minus the third-party liability amount, whichever is less.
The department may not pay for any service that has been denied by the third-party
liability source as not meeting the requirements for submitting a claim.
Source: 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective
July 1, 1981; 16 SDR 226, effective June 24, 1990; 17 SDR 194, effective June 24, 1991; 26
9 SDR 168, effective July 1, 2000; 31 SDR 214, effective July 6, 2005; 40 SDR 122, effective
January 7, 2014.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
Cross-References:
Department determination of possible existence of third-party source -- Claim denial,
§ 67:16:26:07.
Certain claims eligible for payment before third-party benefits recovered --
Department to pursue reimbursement, § 67:16:26:07.02.
Department determination of possible existence of third-party source -- Claim denial,
§ 67:16:26:07.
Records, ch chapter 67:16:34.
10 67:16:41:01. Definitions. As Terms used in this chapter mean:
(1) "Certified social worker - private, independent practice" means an individual
certified under SDCL 36-26-17;
(2) "Certified social worker - private, independent practice candidate" means an
individual who is licensed as a certified social worker under SDCL 36-26-14 and is working
toward becoming a certified social worker - private, independent practice under an approved
supervision agreement, as required by § 20:59:05:05;
(3) "Clinical nurse specialist" means an individual who is licensed under SDCL 36-
9-85 to perform the functions contained in SDCL 36-9-87;
(4) "Collateral contact" means," telephone or face-to-face contact with an individual,
other than the recipient receiving treatment, to plan:
(a) Plan appropriate treatment, to assist;
(b) Assist others in responding therapeutically regarding the recipient's
difficulty or illness, or to link; or
(c) Link the recipient, family, or both, to other necessary and therapeutic
community support;
(5) (2) "Diagnostic assessment" means," a written comprehensive evaluation of
symptoms that indicate a diagnosis of a mental disorder and which meet the requirements of
§ 67:16:41:04;
(6) (3) "Family" means," a unit of two or more persons individuals, related by blood
or by past or present marriage. A family may also include other individuals living another
individual who lives in the same household with the recipient, individuals who will reside in
the home in the future, or individuals who reside resides elsewhere, if the individual's
11 participation is necessary to accomplish the recipient’s treatment plan goals, and the
individual is considered an essential and integral part of the family unit identified in the
treatment plan;
(7) (4) "Group" means," a unit of at least two, but no more than ten, individuals who,
because of the commonality and the nature of their diagnoses, can derive mutual benefit from
psychotherapy and the therapy can be demonstrated to be medically necessary for the
individuals to jointly participate, in order to accomplish treatment plan goals through a group
psychotherapy session;
(8) "Licensed professional counselor - mental health" means an individual certified
under SDCL 36-32-65 to 36-32-67, inclusive;
(9) "Licensed professional counselor working toward a mental health designation"
means an individual who is licensed as a licensed professional counselor under SDCL 36-32-
64 and is working toward a mental health designation under the supervision required by
SDCL subdivision 36-32-65(4);
(10) "Licensed marriage and family therapist" means an individual licensed under
SDCL 36-33-43 to 36-33-45, inclusive;
(11) (5) "Mental disorder" means," an organic disorder of the brain or a clinically
significant disorder of thought, mood, perception, orientation, or behavior;
(12) (6) "Mental health services" means," nonresidential psychiatric or psychological
diagnostic assessment and treatment that is goal-oriented and designed for the care and
treatment of an individual having who has a primary diagnosis of a mental disorder;
(13) (7) "Mental health treatment" means," goal-oriented therapy designed for the
care and treatment of an individual having who has a primary diagnosis of a mental disorder;
12 (14) (8) "Psychologist" means," for services provided in South Dakota, a person
licensed under SDCL 36-27A-12 or 36-27A-13; for. For services provided in another state, a
person licensed as a psychologist in the state where the services are provided. For purposes
of the medical assistance program, a person practicing under SDCL 36-27A-11 is specifically
excluded from this definition;
(15) (9) "Psychotherapy" means," the face-to-face or telehealth treatment of a
recipient, through by a mental health provider using a psychological or psychiatric method.
The treatment is a planned, structured program based on a primary diagnosis of mental
disorder and is directed to influence and produce a response for a mental disorder and to
accomplish measurable goals and objectives specified in the recipient's individual treatment
plan to treat an individual with a primary or provisional mental health disorder;
(16) "Psychotherapy session" means a planned and structured face-to-face or
telehealth treatment episode between a mental health provider and one or more recipients;
(17) (10) "Telehealth" means," a method of delivering services, including through the
use of interactive audio-visual or audio-only technology, in accordance with SDCL chapter
34-52; and
(18) (11) "Treatment plan" means," a written, individual individualized, and
comprehensive plan that is based on the information and outcome of the a recipient's
diagnostic assessment and which that is designed to improve the recipient's mental disorder.
Source: 22 SDR 6, effective July 26, 1995; 26 SDR 168, effective July 1, 2000; 37
SDR 53, effective September 23, 2010; 45 SDR 82, effective December 10, 2018; 48 SDR
39, effective October 3, 2021.
13 General Authority: SDCL 28-6-1(1)(2)(4).
Law Implemented: SDCL 28-6-1.
14 67:16:41:03. Mental health provider. A mental health service covered under this
chapter must be performed by a mental health provider who has a signed provider agreement
with the department to provide mental health services. A mental health provider must be a:
(1) A psychologist, a licensed under SDCL 36-27A-12 or 36-27A-13, or for services
provided in another state, a person licensed as a psychologist in the state where the services
are provided. For purposes of the medical assistance program, a person practicing under
SDCL 36-27A-11 is specifically excluded from this definition;
(2) A licensed professional counselor - mental health, a certified under SDCL 36-32-
65 to 36-32-67, inclusive;
(3) A licensed professional counselor working toward a mental health designation, a
who is licensed as a licensed professional counselor under SDCL 36-32-64 and is working
toward a mental health designation under the supervision required by SDCL subdivision 36-
32-65(5);
(4) A clinical nurse specialist, a licensed under SDCL chapter 36-9;
(5) A certified social worker-PIP – private independent practice, a certified under
SDCL 36-26-17;
(6) A certified social worker - PIP – private independent practice candidate, or a who
is licensed as a certified social worker under SDCL 36-26-14 and is working toward
becoming a certified social worker - private independent practice under an approved
supervision agreement pursuant to § 20:59:05:05;
(7) A licensed marriage and family therapist who has a signed provider agreement
with the department to provide mental health services, licensed under SDCL chapter 36-33;
or
15 (8) A licensed marriage and family therapist who is licensed as a marriage and family
therapist under SDCL 36-33-43 and is working toward a mental health designation under the
supervision required by SDCL subdivision 36-32-65(5).
A mental health provider must have a National Provider Identification (NPI) number
and may not provide services under another provider's medical assistance provider NPI
number.
An individual who does not meet the certification or licensure requirements of the
applicable profession may not enroll qualify as a mental health provider or may not
participate in the delivery of mental health services, except for the administration or scoring
of psychological or neuropsychological tests.
Source: 22 SDR 6, effective July 26, 1995; 26 SDR 168, effective July 1, 2000; 37
SDR 53, effective September 23, 2010; 40 SDR 122, effective January 7, 2014; 45 SDR 82,
effective December 10, 2018.
General Authority: SDCL 28-6-1(1)(2)(4).
Law Implemented: SDCL 28-6-1(1)(2)(4).
Cross-Reference: Provider requirements, ch chapter 67:16:33.