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Acute Care Services
Long-Term Care Services


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Benefits by State: South Dakota (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes 5% of payment up to $50/visit Prospective cost based rate per episode of care using Medicare payment rates as ceiling CN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes 5% of payment for mental health services Mental Health Clinics not covered Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies CN
Federally Qualified Health Center Services
Yes $3/visit Substance abuse treatment not covered Prospective cost based rate/visit CN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes $50/non-emergency admission Admissions to DRG-exempt hospitals/units Cosmetic surgery must be post-trauma, substance abuse treatment not covered Prospective payment/discharge using DRG, cost based payment for psych, rehab and other special hospitals/units CN
Outpatient Hospital Services
Yes 5% of payment up to $50/visit, non-emergency only Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma Cost based payment CN
Rehabilitation Services: Mental Health and Substance Abuse
Yes 5% of payment for mental health services Substance abuse services limited to pregnant women Prospective cost based rate CN
Rural Health Clinic Services
Yes $3/visit Substance abuse treatment not covered Prospective cost based rate/visit CN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service CN
Chiropractor Services
Yes $1/procedure 30 visits/year Fee for service CN
Dental Services
Yes $3/procedure Specified services Fee for service, or percentage of charge for unlisted services CN
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes Cosmetic surgery limited to post-trauma conditions Fee for service, or percentage of charge for unlisted services CN
Nurse Midwife Services
Yes $3/visit Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies CN
Nurse Practitioner Services
Yes $3/visit Substance abuse treatment not covered Fee for service at 90% of physician fee CN
Optometrist Services
Yes $3/visit Refractive exams only Fee for service CN
Physician Services
Yes $3/visit Substance abuse treatment not covered Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies CN
Podiatrist Services
Yes $2/procedure Routine foot care and treatment of flat feet not covered Fee for service for frequently performed services, 40% of charge up to Medicare limits for low volume procedures, supplies paid 90% of charge CN
Psychologist Services
Yes $3/visit 40 hours therapy/year Fee for service CN
Prescription Drugs
Prescription Drugs
Yes $3/brand Rx Specified over the counter products Adult vitamins limited to pregnancy supplements, over the counter products not covered except insulin AWP-10.5%, plus $4.75 dispensing fee for traditional pharmacies and $5.55 dispensing fee for non-traditional pharmacies CN
Physical Therapy and Other Services
Occupational Therapy Services
Yes Fee for service CN
Physical Therapy Services
Yes Fee for service for frequently performed services, 40% of charge up to Medicare limits for low volume procedures, supplies paid 90% of charge CN
Services for Speech, Hearing and Language Disorders
Yes Fee for service for frequently performed services, 40% of charge up to Medicare limits for low volume procedures CN
Products and Devices
Dentures
Yes $3/denture or reline Yes 1 full upper and/or lower denture or 1 partial denture or reline/5 years Fee for service, or percentage of charge for unlisted services CN
Eyeglasses
Yes $2/lens, frame or repair 1 pair eyeglasses/15 months if minimum diopter correction criteria met, 2 replacement contact lenses/year Fee for service CN
Hearing Aids
Yes 1 hearing aid/3 years if original no longer serviceable Fee for service CN
Medical Equipment and Supplies
Yes 5% of payment for med equipment item, $1/med supply item, $2/day enteral supply, $5/day parenteral supply Fee for service, some items paid percentage of charge CN
Prosthetic and Orthotic Devices
Yes 5% of payment Orthopedic shoes must be attached to brace Percentage of charge CN
Transportation Services
Ambulance Services
Yes Fee for service CN
Non-Emergency Medical Transportation Services
Yes See service-specific FN CN
Other Services
Diagnostic, Screening and Preventive Services
Yes Fee for service or percentage of charge CN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes Fee for service for high volume procedures, percentage of charge for low volume procedures CN
Targeted Case Management
Yes Prospective cost based rate CN


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 2, 4 & 8 - See service-specific FN Dependent upon the services provided CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes Specified med equipment and supplies Fee for service, med equipment paid at 75% of charge CN
Hospice Care
Yes Beneficiary must make an election statement Prospective rates based on Medicare methodology CN
Personal Care Services
Yes 120 hours/3 months Cost based payment CN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days Prospective cost based per diem CN
Inpatient Psychiatric Services, under age 21
Yes Cost based payment CN
Intermediate Care Facility Services for the Mentally Retarded
Yes 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care Prospective cost based per diem with limits CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes For LOC determination upon admission 5 hosp leave days/hospitalization, 15 consecutive therapeutic leave days if in plan of care Prospective per diem based on cost, with limits CN
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: Any identified copayment requirements are applicable to beneficiaries age 19 and older.
 
 
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