South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:16 - Covered medical services
Chapter 67:16:43 - Care management - Medically complex children
Section 67:16:43:04 - Admission requirements

Universal Citation: SD Admin Rules 67:16:43:04

Current through Register Vol. 51, page 43, September 23, 2024

Admission to a medically complex program is a covered service if the following criteria are met:

(1) Medical documentation substantiates that the service is medically necessary. Medical documentation includes a diagnosis, a complete medical history, copies of progress notes from physicians or other professionals providing care or services, laboratory tests, X rays, physician or other licensed practitioner orders and a treatment plan outlining the needed care, and any other documentation which may be necessary to determine medical necessity for the child's admission;

(2) Home health care is not a viable option as determined by the department based on the child's medical needs, the availability of home health services, and cost effectiveness;

(3) The facility has notified the child's school district that the child has been referred to the facility for services and may be in need of an educational program;

(4) The cost of care does not exceed the cost of care in the child's home; and

(5) Professional nursing services are necessary on a 24-hour basis and the child requires at least two of the following services:

(a) Intravenous medications more than twice a day which must be administered by a registered nurse;

(b) Drug therapy stabilization which requires skilled monitoring on a 24-hour basis;

(c) Nutritional therapy during an unstable period;

(d) Alternative nutritional feeding, such as nasogastric or gastrostomy feeding, during an unstable period;

(e) Tracheostomy care during an unstable period;

(f) Colostomy or ileostomy care during an unstable period;

(g) Skilled skin care and monitoring for the treatment of a decubitus ulcer;

(h) Monitoring of oxygen saturation when oxygen is being administered;

(i) Skilled nursing observation and assessment following casting or surgeries;

(j) Direct paraprofessional care for more than eight hours a day which is supervised by a medical professional;

(k) Peritoneal dialysis during an unstable period;

(l) Infectious disease care during an unstable period;

(m) Use of a ventilator during an unstable period; or

(n) Professional monitoring to manage end stage disease process.

For purposes of this rule, an unstable period is that period of time necessary for a child to return to a medically stable state following a disease process, illness, or surgery.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(1)(2)(4).

Covered services must be medically necessary, § 67:16:01:06.02.

Disclaimer: These regulations may not be the most recent version. South Dakota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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