South Dakota Medicaid, also known as South Dakota Medicaid, provides health coverage to eligible low-income adults, children, pregnant women, elderly adults and people with disabilities in South Dakota. Medicaid is administered by the South Dakota Department of Social Services.
What are the eligibility requirements for SD Medicaid?
To qualify for Medicaid in South Dakota, you must meet certain income and asset limits. Income limits are based on the Federal Poverty Level and vary by category. For example, in 2023 the income limit for pregnant women is 213% of the FPL, while for parents/caretakers it is 61% of the FPL. Asset limits also apply and are generally $3,000 for adults and $6,000 for households with a disabled individual. You must also be a resident of South Dakota and a U.S. national, citizen, legal alien, or permanent resident. Certain non-citizens may also qualify.
What services are covered by SD Medicaid?
South Dakota Medicaid covers a comprehensive range of health services, including:
- Doctor visits
- Hospital care
- Emergency services
- Prenatal and maternity care
- Prescription drugs
- Mental health services
- Substance abuse treatment
- Medical equipment and supplies
- Physical, occupational and speech therapy
- Lab tests and X-rays
- Home health services
- Nursing home care
- Preventive services like immunizations, check-ups, and cancer screenings
- Family planning services
- Pediatric services including EPSDT for children
- Dental care for children
- Non-emergency medical transportation
Some services may require prior authorization or have limitations. For example, there are limits on the number of covered chiropractic visits and physical therapy sessions per year. Dental care is limited for adults on Medicaid.
Are there any services not covered by SD Medicaid?
Yes, there are some services that are not covered by South Dakota Medicaid, including:
- Cosmetic or plastic surgery solely for cosmetic purposes
- Infertility treatment services
- Services provided outside the United States
- Experimental medical and surgical procedures
- Acupuncture
- Naturopathic services
- Routine foot care, except for diabetes
There may also be limitations on services like dental care for adults and chiropractic care. Providers may recommend services they believe are medically necessary, but South Dakota Medicaid makes the final determination on whether it is a covered benefit.
What are the costs for services covered by SD Medicaid?
Most services covered by South Dakota Medicaid have no costs for enrollees. There are no monthly premiums or deductibles. Copays may apply for some services like prescriptions and emergency room visits, but copays are limited to $4 per service for most Medicaid recipients.
Copays may be higher for enrollees in the Medicaid for Employed Disabled program, ranging from $2-$8 depending on the service. Nursing home residents on Medicaid may also have to contribute part of their income towards the cost of care.
How do I apply for SD Medicaid?
You can apply for Medicaid benefits in South Dakota in several ways:
- Online at https://dss.sd.gov/medicaid/
- In person at your local Department of Social Services office
- By phone at 1-800-597-1603
- By printing and mailing in an application form
When applying, you will need to provide information on household income, assets, expenses and health insurance coverage. Proof of this information, like pay stubs and bank statements, may be required. You can get help with your application from a caseworker at your local DSS office.
How long does it take to get approved for SD Medicaid?
It can take up to 45 days to get an eligibility determination after submitting a Medicaid application in South Dakota. The process may be faster or slower depending on how quickly you provide all required documentation.
If you are in immediate need of health services, you can request a temporary Medicaid card while your full application is processed. This can provide coverage for a limited time while awaiting a final decision.
What are the different types of SD Medicaid programs?
South Dakota Medicaid has several different programs catering to specific eligibility categories and income levels:
- Medicaid: Offers full Medicaid benefits based on income limits by category (children, pregnant women, parents, etc.)
- CHIP: Covers uninsured children up to age 19 in families above Medicaid limits (covers kids in families up to 213% of FPL)
- Medicaid for Employed Disabled: For disabled individuals able to work with income up to 250% of FPL
- Medicaid for Pregnant Women: Expanded coverage for pregnant women from 60 days prior to birth up to 60 days postpartum, income limit is 213% of FPL
- Home and Community Based Waivers: Help seniors and disabled individuals get care at home rather than in a facility
- Medicaid Long Term Care: Covers nursing home care and home health services for seniors and disabled individuals
South Dakota has not expanded Medicaid under the Affordable Care Act. Eligibility for adults is limited, with parents/caretakers having the highest income limits at 61% of FPL.
Can I get retroactive coverage through SD Medicaid?
Yes, Medicaid benefits in South Dakota can cover medical bills retroactively for up to 3 months prior to your application date, if you were eligible during that previous period. To receive retroactive coverage, any unpaid medical bills you have from those previous months must be submitted to South Dakota Medicaid for payment consideration.
Does SD Medicaid provide dental coverage?
South Dakota Medicaid does cover dental care, but the level of coverage depends on your age:
- Children under age 21: Comprehensive dental care is covered including regular checkups, dental cleanings, fillings, tooth extractions, braces, etc.
- Adults 21 and over: Limited dental coverage including exams, x-rays, fillings, tooth extractions, dentures and some oral surgery. More extensive procedures require prior approval.
Dental benefits for adults are limited, so you may need to pay out of pocket for services beyond basic care and procedures that are not approved. But children have access to comprehensive dental coverage through Medicaid and the Children’s Health Insurance Program (CHIP).
Does SD Medicaid provide vision coverage?
South Dakota Medicaid provides coverage for some vision care services. Benefits include:
- Comprehensive eye exams once every 2 years for adults 21 and over
- Annual comprehensive eye exams for children
- Eyeglasses for children under 21
- Limited coverage for eyeglasses for adults over 21
Contact lenses are generally not covered unless deemed medically necessary. Eye surgery may be covered if it is medically necessary and not for cosmetic purposes only. But routine vision coverage for adults is limited, so you may need to pay out of pocket for much of your eye care.
How do I keep my SD Medicaid coverage?
To maintain Medicaid eligibility in South Dakota, you must complete your annual renewal paperwork and documentation of income when requested. Medicaid coverage periods in SD last up to 12 months, so you need to renew each year.
You should also promptly report any changes in your household, income, living situation, or access to other health insurance. Changes can affect your eligibility and must be reported within 10 days. Keep your contact information like mailing address and phone number up to date as well.
Failing to complete your renewal or report changes in circumstances could cause you to lose Medicaid coverage, so be sure to stay on top of any requests from South Dakota Medicaid to avoid lapses.
Can SD Medicaid be used in other states?
Generally, South Dakota Medicaid is accepted only by providers within the state, except in special circumstances. For example, if you have an emergency while traveling out of state, Medicaid may pay for emergency care you receive in another location. Some children in foster care may also be eligible for out-of-state coverage.
South Dakota does not participate in any formal Medicaid reciprocity agreements with neighboring states. So in most cases, South Dakota Medicaid cannot be used when receiving routine care in other states. You would need to arrange alternate insurance coverage when traveling or relocating outside of South Dakota.
Are Medicaid managed care plans available in SD?
Most South Dakota Medicaid recipients must enroll in a managed care plan to receive services. The plans help coordinate care and providers. As of 2023, available managed care plans include:
- Dakota Care
- Avera Health Plan
- Wellcare
- Sanford Health Plan
American Indians and Alaska Natives may choose to opt out of enrolling in a Medicaid managed care plan and instead receive care through Indian Health Services. But most other recipients must select and be enrolled in one of these available plans.
Conclusion
In summary, South Dakota Medicaid provides comprehensive health coverage for over 130,000 low-income residents who meet eligibility criteria. Benefits include doctor visits, hospital services, prescriptions, long term care, pediatric services and more. While adult dental and vision coverage is limited, children have access to robust benefits. Managed care enrollment, annual renewals, and reporting changes help ensure members get coordinated, quality care within the program’s requirements and budget.
