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Many South Dakota residents need a high-quality healthcare plan that provides the medical coverage they need without surpassing their financial means. South Dakota’s Medicaid program offers expansive coverage to qualified residents and might be exactly what you’re looking for in a medical plan. As of June 2023, 146,957 South Dakotans were enrolled in the program. This guide will give you an overview of Medicaid in South Dakota, its eligibility requirements, coverage, and benefits, and how to apply for the program.
If you want to extend your coverage beyond South Dakota Medicaid, purchasing a third-party or private insurance plan is a surefire way to get more benefits. These policies also help you avoid costly medical charges not covered by South Dakota’s Medicaid program. To prevent shouldering the debt of unexpected medical expenses, many South Dakotans extend their Medicaid coverage to include a more comprehensive range of benefits and services by way of private health insurance. Understanding South Dakota’s Medicaid program and your third-party/private insurance options will help you determine the best plan for your needs.
South Dakota’s Medicaid program is a federally and state-funded healthcare program providing eligible residents with numerous medical services and treatments for free or at a reduced rate. The South Dakota Department of Social Services, often abbreviated to DSS, runs the state’s Medicaid program and helps low-income families obtain medical coverage regardless of economic situation. DSS also controls the South Dakota Children’s Health Insurance Program, better known as CHIP.
South Dakota Medicaid and CHIP cover several healthcare services, from doctor’s appointments to hospice care and medical transportation.
The state determines a Medicaid recipient’s premiums by their family’s income. For example, a low-income family may receive free Medicaid, while a wealthy family may have to pay a monthly fee.
The South Dakota Medicaid card acts as a beneficiary’s medical ID and proves their enrollment. It features the enrollee’s full name (first name, middle initial, and last name), a nine-digit identification number, the beneficiary’s date of birth, and a three-digit generation number. Every enrollee must show their Medicaid card to receive healthcare coverage.
It’s important to note that having a South Dakota Medicaid card doesn’t guarantee coverage or eligibility. Also, family cards aren’t available. Every member receives their own card and can’t use one that doesn’t contain their ID number.
South Dakota residents can apply for Medicaid by contacting their local DSS office or calling (877) 999-5612 and requesting a paper application. A representative will file your request and send a paper application through the mail. Once you have the application, fill it out and send it back to the Department of Social Services office or return it in person.
You can also apply for Medicaid in South Dakota using one of the following methods:
If you need help completing your Medicaid application, call (877) 999-5612 or your local DSS office. A representative will guide you through the process and ensure you provide all the necessary information.
South Dakota requires residents to meet specific criteria to qualify for Medicaid. These eligibility requirements are as follows:
Applications also must be pregnant, care for an 18-year-old child or younger, or have a disability or a relative with a disability living with them.
Aspiring enrollees also must meet the state’s financial requirements to obtain Medicaid coverage. South Dakota bases these requirements on an applicant’s family size and monthly income. Below are the monthly financial requirements for South Dakota Medicaid based on maximum gross family income:
Low-income families have different financial requirements and must have at least one dependent child (a child below 18 or a full-time student who will graduate before 19) and meet the following monthly economic qualifications based on maximum gross family income:
You can order a South Dakota Medicaid card by contacting a benefits specialist at your local Department of Social Services office. Tell the benefits specialist your information, and they will send you a new card. If you didn’t apply for Medicaid at a DSS office, call (877) 999-5612 for further information.
You can renew your South Dakota Medicaid card using the process described above. Contact your DSS office and ask a benefits specialist for a replacement. They will file your replacement request and send you a new card as soon as possible. You can also call (877) 999-5612 if you didn’t apply for Medicaid at a Department of Social Services office.
So, what is South Dakota Medicaid coverage?
Medicaid in South Dakota covers multiple medical services, treatments, and prescriptions and even includes transportation to healthcare facilities. Below are some common benefits included in South Dakota’s Medicaid program:
Unlike many state-funded healthcare programs, South Dakota Medicaid covers numerous dental procedures for adults and children. It covers dental exams, cleanings, sealants for permanent molars, X-rays, fillings, tooth removal procedures, front teeth permanent crowns and root canals, as well as partial and full dentures. However, the program has a $2,000 yearly limit. If an adult member exceeds the limit, they must pay for the service out of pocket. For those who have more serious dental issues and anticipate requiring more visits to the dentists, investing in private dental plans in South Dakota is advisable.
Children receive the same dental coverage as adult members but can obtain two free fluoride treatments per year. South Dakota Medicaid also covers braces for children but requires pre-approval. Under this policy, the child must have a dental problem that makes speaking, chewing, eating, or breathing difficult and requires braces to fix.
If you believe your child qualifies for braces, have their dentist fill out the Pre-Orthodontic Certification Form and send it to your local DSS office.
South Dakota Medicaid covers most prescription drugs. However, some drugs require prior authorization to qualify for coverage. It also limits most prescriptions to a 30-day supply.
That said, members can receive a 90-day supply of some generic maintenance medications and birth control.
The policy doesn’t cover most over-the-counter products or medications. Referring to the Preferred Drug List (PDL) is a helpful way of pre-determining if your drug is covered.
South Dakota Medicaid members can access numerous extended healthcare services without cost. It covers several mental health treatments, substance use disorder programs, chiropractic care, and more. To learn more about South Dakota’s Medicaid extended healthcare coverage, contact your DSS office. Routine checkups and basic medical treatments will only get you so far. Many patients require additional care, but they go without because of financial concerns, lack of coverage, and restricted access. Investing in quality disability insurance is an excellent way to assist with some of the costs incurred with not being able to work either temporarily or permanently, and to help with the cost of medical needs.
South Dakota’s Medicaid program covers emergency and non-emergency travel to the nearest medical facility, health home provider, or primary care provider. However, beneficiaries must complete a NEMT form for each trip and submit it to the DSS office. Also, the provided service or treatment must be included in your Medicaid policy to qualify for reimbursement.
The program will also cover meals and lodging if the medical provider is 150 miles or more from your city and requires an overnight stay.
Enrollees receiving out-of-state medical care don’t qualify for Medicaid coverage unless they receive prior authorization, are within 50 miles of the South Dakota border, or attend an appointment in Bismarck, North Dakota. If a doctor recommends an out-of-state practitioner, Medicaid must approve the prior authorization request before you receive care. If you don’t receive prior authorization, you will have to cover the cost of the service or treatment.
If you happen to be vacationing outside of South Dakota for leisure, always invest in proper travelers insurance.
Medicaid in South Dakota doesn’t provide special benefits to student enrollees. Students over 18 receive the same coverage as adult beneficiaries, while students under 18 receive CHIP benefits.
Neither does the program offer unique benefits to seniors. However, Medicaid includes several services and treatments that assist senior citizens in and out of their homes. For example, South Dakota Medicaid offers personal care services that help senior residents if they need additional assistance.
Below are just a few covered services and treatments available in South Dakota Medicaid that benefit seniors.
Many federally and state-funded healthcare plans feature unique benefits to various subgroups. However, not every policy includes special advantages to specific cultures, age groups, or military members. Below are a few common subgroups that may receive special coverage in South Dakota’s Medicaid program.
American Indians enrolled in IHS (Indian Health Services) can also obtain South Dakota Medicaid to receive additional coverage. Medicaid works closely with IHS and covers various treatments and services not included in IHS.
Additionally, Medicaid exempts American Indians from paying copays if they receive or have received care through IHS or a Tribal facility like Urban Indian Health.
Although military veterans can enroll in Medicaid in South Dakota, it doesn’t offer unique benefits. They receive the same care as other enrollees and can access various treatments, medical services, and medications without charge or at a discount.
However, South Dakota has several programs that help veterans, active military members, and their families. Contact your VA office for more information about these services and how they may apply to your circumstances.
While South Dakota Medicaid offers expansive medical coverage, it doesn’t include everything. The following are some services and treatments South Dakota Medicaid doesn’t cover:
If you don’t understand what your healthcare plan covers, contact your local DSS office. A representative will explain your Medicaid coverage and inform you of excluded services and treatments.
It is also important to note that the South Dakota Medicaid program does not provide assistance to aid in the cost of funerals. Due to the rising cost of funerals, and to protect your family against financial hardship, secure them with comprehensive funeral insurance.
Understanding your Medicaid coverage will help avoid costly medical bills and surprise fees. Below is a summary of common healthcare services and South Dakota Medicaid eligibility.
| Dental | |
|---|---|
| X-Rays and Exams | Adults and children enrolled in South Dakota Medicaid can receive two dental exams and cleanings per year free of charge. The program also covers dental X-rays for adult and youth beneficiaries. However, Medicaid limits adult coverage to $2,000 a year before requiring enrollees to pay out of pocket. |
| Wisdom Teeth | Medicaid in South Dakota covers teeth removal services, including wisdom teeth extraction. |
| Vision | |
|---|---|
| Eye Exams | South Dakota Medicaid covers intermediate and comprehensive eye exams for adults and children enrolled in the program. It also pays for medically necessary refraction tests. |
| Glasses | Enrollees can obtain lenses and frames for their eyeglasses (excluding athletic glasses) with South Dakota Medicaid. They can also receive replacement glasses without charge after 15 months have passed since receiving their glasses. However, restrictions apply, so contact your DSS office for more information. |
| Laser Eye Surgery | South Dakota Medicaid doesn’t cover Lasik eye surgery or other corrective eye procedures. |
| Surgery | |
|---|---|
| Rhinoplasty | Medicaid views rhinoplasty surgeries as cosmetic procedures and only covers them if they repair injuries or improve bodily function. However, a beneficiary must receive prior authorization to qualify. |
| Breast Reduction | The state’s Medicaid program covers medically necessary breast reduction surgeries with prior authorization. However, beneficiaries must meet specific criteria to qualify. You can review South Dakota Medicaid’s breast reduction qualifications here. |
| Hospital | |
|---|---|
| Hospital stays | South Dakota Medicaid includes inpatient hospitalization coverage for in-state hospitals, hospitals in Bismarck, North Dakota, and hospitals within 50 miles of the South Dakota border. However, medical facilities must file a notification form on day six of admission. |
| Ambulance transportation | Beneficiaries can obtain ambulance transportation coverage only for life-threatening emergencies. It doesn’t cover ambulance transportation for non-emergencies. |
| Giving birth | Medicaid in South Dakota includes delivery services. It also covers postpartum care if the beneficiary contacts their benefits specialists to enroll in the plan. Postpartum care plans last for 12 months after delivery. |
| Sexual Health | |
|---|---|
| Gynecology | South Dakota’s All Women Count! program pays for Pap smears for women between 30 and 64 and mammograms for those between 40 and 64. Women between 30 and 39 need prior authorization to receive mammogram coverage. |
| Erectile Dysfunction | South Dakota’s Medicaid program doesn’t cover erectile dysfunction medications or treatments. |
| Birth Control (Including IUDs) | South Dakota residents can receive free birth control when they are determined eligible by Medicaid. It also pays for LARC (long-acting reversible contraceptive) device insertion and removal every 18 months. |
| Fertility Treatment | Medicaid in South Dakota doesn’t cover fertility treatments or procedures like fertility counseling, artificial insemination, and fertility promotion agents. |
| Specialist Services | |
|---|---|
| Dermatology | South Dakota Medicaid may cover medically necessary dermatology services. However, it doesn’t cover cosmetic treatments, so contact your DSS office to learn what services Medicaid covers. |
| Physiotherapy | The state’s Medicaid plan includes medically necessary physical therapy services. |
| Massage Therapy | Medicaid in South Dakota doesn’t cover massage therapy, acupuncture, and other non-medically necessary therapy services. It views these services as cosmetic and requires enrollees to pay out of pocket. |
| Podiatry and Foot Care | Although South Dakota Medicaid didn’t pay for podiatrist appointments before 2022, beneficiaries with neurologic, metabolic, or peripheral vascular conditions can receive routine foot care without charge. However, it limits service to medically necessary treatments and excludes flatfoot and subluxation treatments. |
| Allergist and Allergy Testing | South Dakota Medicaid covers allergy testing if it doesn’t use experimental, unproven, or investigational treatments. It also excludes allergen immunotherapy for numerous antigens. You can review these excluded antigens here. |
| Sleep Physician Services and CPAP Machines | Medicaid members can receive CPAP and BIPAP equipment if a doctor diagnoses them with moderate to severe OSA, complex or central sleep apnea, a neuromuscular condition, restrictive lung disease, limited thoracic expansion, or hypoventilation syndrome. They also must meet specific criteria to qualify. |
While Medicaid in South Dakota covers numerous treatments, services, and medications, many residents want additional coverage to pay for medical treatments not induced in their plan. Purchasing a third-party or private insurance plan is one of the best ways to expand your healthcare coverage while maintaining Medicaid benefits. Enrolling in a third-party or private insurance plan provides multiple benefits to South Dakota residents, including:
At Insurdinary, we understand finding a quality third-party or private insurance plan can be difficult for some residents. That’s why we specialize in helping people find first-class insurance policies that fit their needs as well as their budget. We work with a vast network of insurance providers and are able to make the process as swift and straightforward as possible.
Insurdinary, and its network of partners offer many different types of insurance. In addition to health, dental, disability, life, funeral and travel insurance as discussed on this page, you may also be interested to explore the following:
