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

1. (1) Payment to an in-state facility 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. (2) Payment to an out-of-state facility 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 an out-of-state facility for care not available at an in-state facility is the rate recognized for the facility by the Medicaid agency in the state in which the facility is located;
3. (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. (4) A swing-bed hospital is reimbursed at a daily rate established by the department. The daily rates are located on the department's fee schedule website; and
5. (5) Coinsurance under the Medicare program is payable at the Medicare coinsurance rate.

Source: SL 1975, ch 16, § 1; 2 SDR 16, effective September 4, 1975; 2 SDR 88, effective July 1, 1976; 7 SDR 23, effective September 18, 1980; 7 SDR 76, effective February 11, 1981; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 8 SDR 11, effective August 13, 1981; 11 SDR 26, effective August 21, 1984; 15 SDR 68, effective November 7, 1988; 16 SDR 26, effective August 13, 1989; 18 SDR 67, effective October 13, 1991; transferred from § 67:16:04:08 , 21 SDR 8, effective July 25, 1994; 24 SDR 185, effective July 6, 1998; 26 SDR 21, effective August 24, 1999; 38 SDR 224, effective July 1, 2012; 42 SDR 51, effective October 13, 2015 ; 50 SDR 11, effective August 7, 2023 .

General Authority: SDCL 28-6-1 .

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

Prior versions effective: 2015-10-13, 2012-07-01.