South Dakota

Click here to download the COVID-19 Virtual Visit & Reimbursement Guide for South Dakota (Updated 4/30/21)

Medicaid Policies

TELEHEALTH DEFINITION: “The delivery of health care services through the use of HIPAA-compliant interactive audio-video.” Does not include audio-only, email, text, mail, or fax.

SERVICE PARITY: “No health insurer may exclude a service for coverage solely because the service is provided through telehealth and not provided through in-person consultation or contact between a health care professional and a patient.” Additionally, insurers “may not discriminate between coverage benefits for health care services that are provided in person and the same health care services that are delivered through telehealth.”

• These requirements DO NOT apply to policies that ONLY provide coverage for: Specified disease; Hospital indemnity; Fixed indemnity; Accident-only; Credit accident and health insurance; Vision; Prescription drug; Medicare supplement; Long-term care; Disability income insurance; Coverage issued as a supplement to liability insurance; Workers' compensation or similar insurance; Automobile medical payment insurance; or Individual health benefit plans of six-months or less duration that are not renewable.

REMOTE MONITORING: Not covered outside of public health emergency

ORIGINATING SITES: Practitioner office, outpatient hospital, CAHs, RHCs, FQHCs, IHS clinics, CMHCs, nursing facilities, schools

*proposed update* ORIGINATING SITES: The Department of Social Services intends to make changes to the South Dakota Medicaid State Plan to allow substance use disorder agencies to be reimbursed an originating site fee for acting as a telemedicine originating site.

PROVIDERS AT DISTANT SITES: Certified social workers, clinical nurse specialists, community health workers, community mental health center, diabetes edu program, dietician, FQHC, IHS clinics, marriage & family therapists, professional counselors, NPs, nutritionists, physicians, PAs, podiatrists, psychologist, RHCs, speech language pathologists*, SUD agencies, tribal 638 facilities

* Speech therapy services can be provided via telemedicine AFTER an initial face-to-face visit

FQHCs & RHCs:

• PROSPECTIVE PAYMENT SYSTEM (PPS) REIMBURSEMENT STRUCTURE
• Can bill for telephonic evaluation and management services using codes 98966, 98967, 98968 and be reimbursed at the fee schedule rate. Submit using the FQHC/RHCs non-PPS billing NPI.
• Alternatively, FQHC/RHC and IHS/Tribal 638 providers may bill for evaluation and management services performed telephonically using CPT codes 99201 - 99215 with the modifier 52 appended. Providers will be reimbursed at 75 percent of the applicable encounter rate. Submit using the PPS NPI. Cost-sharing applies. Provider must utilize telemedicine technology with both real time video/audio if the recipient is able to access such technology. The provider must document in the medical record that the use real time video/audio technology was not possible or was unsuccessful.

OTHER SD MEDICAID POLICIES:

• HIPAA compliant technology must be used
• There are telehealth coverage limitations based on patient’s medicaid coverage
• Same community limitation: Originating site and distant site may not be located in the same community UNLESS the originating site is a nursing facility
• Mental health services:
  • Telemedicine services may be provided for outpatient services, child or youth & family services, comprehensive assistance with recovery and empowerment, or community support services program - individualized mobile programs of assertive community treatment “may be reimbursable as identified on the division's fee schedule.”

Temporary COVID-19 Policies (SD Medicaid)

NEWLY ELIGIBLE SERVICES:

• Applied Behavior Analysis Services (if the recipient and provider have previously met for in-person services)
• Remote patient monitoring IF the patient was hospitalized for COVID, is at risk for illness due to being 65+ or in assisted living facility, or is at risk for illness due to underlying condition
• Teledentistry 
• Telephonic evaluation/management for patients experiences symptoms of COVID-19

NEWLY ELIGIBLE PROVIDERS AT DISTANT SITES: Audiologist, OTs, optometrists, physical therapists

WAIVED REQUIREMENTS: No penalty for using non-HIPAA compliant technology

OTHER TEMPORARY SD MEDICAID POLICIES:

• Same community limitation: Originating site and distant site may not be located in the same community UNLESS the originating site is a nursing facility OR telemedicine is being used to reduce risk of exposure to COVID-19
• Suspends initial face-to-face visit requirement for speech therapy
• FQHCs and RHCs: 
  • FQHCs, RHCs, and IHS/Tribal 638 providers may provide audio-only Independent Mental Health Practitioner (IMHP) services (and SUD services, if properly accredited) IF the provider or patient is at risk for COVID/under quarantine/social distancing AND the recipient does not have access to face-to-face audio/visual technology
    • Audio-only services are reimbursed at the encounter rate
  • Well child check-ups: bill a check-up delivered via telemedicine with “52” modifier
    • Maximum reimbursement rate is 75% of encounter rate for FQHCs/RHCs and IHS/Tribal 638 providers
  • Telephonic evaluation and management: FQHCs/RHCs/IHS/Tribal 638 providers bill 98966, 98967, 98968
    • Reimbursed at fee schedule rate OR
  • Telephonic evaluation and management: Billed with CPT codes 99201 - 99215 with the modifier 52 appended
    • Reimbursed at 75% of applicable encounter rate
    • Providers must utilize real-time audio/visual technology for evaluation and management services if the patient has access. If not, the provider must document that use of real-time audio/visual technology was not possible or unsuccessful.
  • Remote patient monitoring (for patients at risk of severe illness or hospitalized due to COVID and requiring further monitoring): FQHCs and RHCs can bill on a fee-for-service basis using non-PPS NPI (if service is ordered by one of the allowable practitioner types)

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