S.D. Admin. R. 67:16:04:60

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:04:60 - Basis of payment

Payment to participating providers of nursing facility services is made on the following basis:

(1) Payment to in-state facilities is calculated using the per diem rates according to § 67:16:04:54, multiplying the case mix adjusted direct care per diem rate by the resident's Patient Driven Payment Model weight established by the resident assessment, and adding the nondirect care rate for each day the Medicaid resident is an inpatient resident;

(2) Payment to out-of-state facilities providing nursing facility services to residents of South Dakota is the lesser of the Medicaid rate established by the state in which the facility is located or the South Dakota statewide average Medicaid rate for all in-state facilities. Payment to out-of-state facilities for care not available at in-state facilities is the rate recognized for the facility by the Medicaid agency in the state in which the facility is located;

(3) Payment for reserved bed days is governed by the provisions of § 67:45:02:04 and is based on the resident's latest resident assessment and Patient Driven Payment Model nursing case mix group at the time of the resident's absence;

(4) Swing-bed hospitals are reimbursed at a daily rate established by the department. The daily rates are located on the department's fee schedule website. Swing-bed hospitals are reimbursed for assisted living at the current maximum rate paid for assisted living; and

(5) Coinsurance under the Medicare program is payable at the Medicare coinsurance rate.

S.D. Admin. R. 67:16:04:60

SL 1975, ch 16; 42 SDR 51, effective 10/13/2015; 50 SDR 011, effective 8/7/2023

General Authority: SDCL 28-6-1.

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

Payment adjustment due to review of resident assessment, § 67:45:03:08.