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

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

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

   1. (a) Intravenous medications more than twice a day which must be administered by a registered nurse;
   2. (b) Drug therapy stabilization which requires skilled monitoring on a 24-hour basis;
   3. (c) Nutritional therapy during an unstable period;
   4. (d) Alternative nutritional feeding, such as nasogastric or gastrostomy feeding, during an unstable period;
   5. (e) Tracheostomy care during an unstable period;
   6. (f) Colostomy or ileostomy care during an unstable period;
   7. (g) Skilled skin care and monitoring for the treatment of a decubitus ulcer;
   8. (h) Monitoring of oxygen saturation when oxygen is being administered;
   9. (i) Skilled nursing observation and assessment following casting or surgeries;
   10. (j) Direct paraprofessional care for more than eight hours a day which is supervised by a medical professional;
   11. (k) Peritoneal dialysis during an unstable period;
   12. (l) Infectious disease care during an unstable period;
   13. (m) Use of a ventilator during an unstable period; or

   14. (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.

Source: 23 SDR 2, effective July 15, 1996; 44 SDR 94, effective December 4, 2017.

General Authority: SDCL 28-6-1 (1)(2)(4) .

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

Prior versions effective: 1996-07-15.