Dss medicaid application sd

Cabinet Secretary
Matt Althoff

South Dakota Medicaid Coverage Groups

Medicaid provides health care coverage for people who qualify. To be eligible for Medicaid, individuals must fall into a coverage group and meet certain financial and non-financial eligibility criteria. Each coverage group has its own eligibility rules. Learn more about South Dakota’s available medical programs and the eligibility criteria for each program below.

Medicaid Expansion - Adult Group

Adults, ages 19 to 64, meeting the income limits and other general eligibility requirements (with or without private health insurance) may be eligible for FREE or low-cost South Dakota Medicaid including regular checkups, dental care, and vision care.

Children’s Health Insurance Program (CHIP)

The South Dakota Children's Health Insurance Program, more commonly referred to as CHIP, provides quality health care (including regular check-ups, Well-Child Care exams, dental and vision care) for children and youth.

To be eligible for CHIP, children must be under the age of 19 and current residents of South Dakota.

Children who are uninsured or already have health insurance may be eligible for CHIP based on income and eligibility guidelines.

Low-Income Families

Low income families in South Dakota (with or without private health insurance) may be eligible for South Dakota Medicaid including regular checkups, Well-Child Care exams, dental care, and vision care.

To be eligible, the family must consist of a parent or other adult caretaker relative and a dependent child. A caretaker relative may be parent, grandparent, brother, sister, stepparent, etc. A dependent child is a child under age 18 who is living with a parent or a caretaker relative. If a child is 18 years old and still a fulltime student in high school, the child is considered a dependent child if he or she is expected to complete high school before reaching age 19.

Pregnant Women

The Department of Social Services provides South Dakota Medicaid to pregnant women who meet income and resource limits and general eligibility guidelines. Full medical coverage is available to pregnant women meeting the income limits and general eligibility requirements.

Postpartum and family planning services are available during the two months following the end of the pregnancy. Effective July 1, 2023, full coverage is available for the postpartum period of twelve months following the end of the pregnancy for those who begin their postpartum period on or after this date.

Newborns

Children born to women eligible for South Dakota Medicaid are also eligible for South Dakota Medicaid.

• The child must be born to a woman eligible for and receiving South Dakota Medicaid on the date of the child’s birth.
• There is no resource or income limit.
• Coverage continues from the month of birth until the end of the month in which the child turns one year of age as long as the child continues to live in South Dakota.

Medicare Savings Program

The Medicare Savings Program assists individuals with payment on their Medicare expenses. This program can save people up to $2,096.40 each year.

Coverage Groups

• Qualified Medicare Beneficiary: Pays for the Medicare Part A and Part B premium, deductibles and co-insurance.
• Special Low-Income Medicare Beneficiary: Pays for the Medicare Part B premium only.
• Qualified Individiual-1: Pays for the Medicare Part B premium only.

Eligibility Requirements

• Income limit is based on the family size and adjusted income of the adults in the household.
• Resource limit is $9,430 for an individual and $14,130 for a couple. Resources includes items such as checking and savings accounts and certificates of deposit.

When you apply, you must send proof of Medicare enrollment. If you have questions concerning Medicare enrollment call 800.772.1213 or visit Medicare's Website.

Individuals in Assisted Living Facilities, Nursing Facilities or Homes

Individuals must meet all eligibility criteria to qualify for South Dakota Medicaid.

• A person must be 65 years or older. If under age 65, a person must be blind or disabled.
• A person must be a resident of South Dakota and meet certain citizenship requirements of the United States.
• Medical needs of the individual are such that they require a level of care provided in a nursing home.
• The monthly income limit is 300 percent of the SSI Standard Benefit Amount. ($2,829 in 2024)
• The resource limit is $2,000. Resources include items such as checking and savings accounts and certificates of deposit.

Breast and Cervical Cancer Program

The Breast and Cervical Cancer Program is for South Dakota women who need treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer.

• A woman must have been screened for breast and cervical cancer under the Breast and Cervical Cancer Control Program, administered by the Department of Health.
• A woman must be uninsured.
• A woman must meet age requirements.
• An individual’s yearly income can be up to $26,450.
• Eligibility coverage ends when a woman's course of treatment is completed or the state has determined that she no longer meets the criteria for this eligibility category. (For example, coverage will end if a woman attains age 65 or has insurance coverage.)

Learn more about the Breast and Cervical Cancer Program at the Department of Health.

HOPE Waiver for Individuals in Assisted Living or Community Home Facilities

Individuals must meet all eligibility criteria to qualify for South Dakota Medicaid. The Home & Community-Based Options and Person Centered Excellence (HOPE) Waiver is a joint waiver between the Division of Long Term Services and Supports of the Department of Human Services and the Department of Social Services. It allows for home and community-based services to be provided to individuals at risk for institutionalization.
Eligibility Requirements

• A person must be 65 years or older. If under age 65, a person must be blind or disabled.
• A person must be a resident of South Dakota and meet certain citizenship requirements of the United States.
• Medical needs of the individual are such that they require a level of care provided in a nursing home.
• The monthly income limit is 300 percent of the SSI Standard Benefit Amount. ($2,829 in 2024)
• The resource limit is $2,000. Resources include items such as checking and savings accounts and certificates of deposit.’

HOPE Waiver for Individuals Living in their Homes

Individuals must meet all eligibility criteria to qualify for South Dakota Medicaid. The Home & Community-Based Options and Person Centered Excellence (HOPE) Waiver is a joint waiver between the Division of Long Term Services and Supports of the Department of Human Services and the Department of Social Services. It allows for home and community-based services to be provided to individuals at risk for institutionalization.
Individuals may be eligible for Structured Family Caregiving, which is a shared living arrangement that offers participants an opportunity to reside with a primary/principal caregiver in the participant's own home or in the home of the primary caregiver.
Eligibility Requirements

• A person must be 65 years or older. If under age 65, a person must be blind or disabled.
• A person must be a resident of South Dakota and meet certain citizenship requirements of the United States.
• Medical needs of the individual are such that they require a level of care provided in a nursing home.
• The monthly income limit is 300 percent of the SSI Standard Benefit Amount. ($2,829 in 2024)
• The resource limit is $2,000. Resources include items such as checking and savings accounts and certificates of deposit.

CHOICES Waiver for Children and Adults with Disabilities

Individuals must meet all eligibility criteria to qualify for South Dakota Medicaid. The Community, Hope, Opportunity, Independence, Careers, Empowerment, Success (CHOICES) Waiver is a program that provides services to children and adults with intellectual and developmental disabilities.

Eligibility Requirements

• A person must be developmentally disabled.
• A person must be appropriate for home and community based placement.
• A person's monthly income must be less than 300 percent of the SSI Standard Benefit Amount ($2,829 in 2024). The resource limit is $2,000 for an individual.

In addition to the standard Medicaid covered services, the following services are available through the CHOICES program:

• Case Management: Assist individuals to access services and identify natural supports.
• Residential: Helps individuals live as independently as possible, supports health & safety needs, and ranges from around-the-clock supervision to daily check-ins.
• Supported Employment: Supports to gain employment and earn at least minimum wage.
• Day Habilitation: Unpaid activities to support daily living skills for those whom employment is not a goal.
• Nursing: Health and preventative education, screenings and assessments, medical care monitoring, and support of the person’s overall health and wellbeing.
• Medical Equipment and Drugs: Supports people to perform activities of daily living.
• Other Medically Related Services – Speech, Hearing, Language: Direct therapies and services ordered by physicians.

Family Support 360 Waiver for Children and Adults with Disabilities

Individuals must meet all eligibility criteria to qualify for South Dakota Medicaid. The Family Support 360 Program provides people and their families with services and supports to meet their unique needs. The program is self-directed, which means the person and their family choose the services, the staff who provide them, and a schedule based on their needs.

Eligibility Requirements

• A person must be developmentally disabled.
• A person must be living in their own home or a family member’s home.
• A person's monthly income must be less than 300 percent of the SSI Standard Benefit Amount ($2,829 in 2024). The resource limit is $2,000 for an individual.

In addition to the standard Medicaid covered services, the following services are available through the Family Support 360 program:

• Service Coordination: Assist individuals to access services and identify natural supports.
• Environmental Accessibility Adaptive Equipment: Changes to the home to improve independence.
• Vehicle Modifications: Changes to your vehicle to improve community access.
• Companion Services: Services to improve social and independent living skills.
• Supported Employment: Supports to gain employment and earn at least minimum wage.
• Personal Care: Help with tasks such as bathing, eating, and personal hygiene.
• Special Medical Adaptive Equipment and Supplies: Items to help with activities of daily living.
• Nutritional Supplements: Prescribed to support an individual’s dietary needs.
• Respite Care: Short term relief for caregivers.
• Other Available Services: Supports for families who provide much of the day-to-day care which enhance the opportunities for their person throughout their lifespan (e.g., development of knowledge & skills, making connections with others who have similar experiences, and qualifying goods & services).

Disabled Children's Program

The Disabled Children's Program provides South Dakota Medicaid for certain disabled children in South Dakota. The program is intended for children with disabilities who have medically fragile conditions requiring skilled nursing care in a medical facility if they were not being cared for at home.

• The child must be under age 19.
• The child must be found disabled by the Social Security Administration or the Department of Social Services using disability standards from the Social Security Act.
• The child must require medical care in the home comparable to a level of care needed in a hospital, nursing facility or intermediate care facility. A child who is medically stable, even though disabled, is not considered in need of a level of care. A child is medically stable if his or her health care and medical needs are such that he or she would not require care in a medical institution.
• Health care services received in the home must have been ordered by a physician and could only be performed by a physician or nurse if the child were in a medical facility.
• Cost of the child’s monthly health care services at home must be the same or less than the cost of treating the child within a medical facility.
• The child’s monthly income must be less than 300 percent of the SSI Standard Benefit Amount ($2,829 in 2024) and resources must be less than $2,000. (Resources include items such as checking and savings accounts and certificates of deposit.) Income and resources of the parents are not considered to determine eligibility.

Assisted Daily Living Services Waiver for Individuals with Quadriplegia

Assistive Daily Living Services (ADLS) Waiver for Individuals with Quadriplegia who would Require Nursing Home Care if not for Special Services Performed in their Home

Individuals with quadriplegia living independently in their own homes may be eligible for South Dakota Medicaid. Individuals who are eligible are entitled to full South Dakota Medicaid coverage.

Eligibility Requirements

• A person must be age 18 or older and have quadriplegia.
• The income limit can be up to $2,829 in 2024 a month.
• The resource limit is $2,000 for an individual. Resources include items such as checking and savings accounts and certificates of deposit.

In addition to the standard Medicaid covered services, the following services are available through the ADLS Waiver:

• Personal Attendant Services - includes services such as bathing, grooming, oral hygiene, assistance with self-administration of medications, routine bowel, and bladder care. Meal preparation and housekeeping may be provided if there is no other family member in the home to provide that service. Family or friends may be paid for this service if they meet all the personal attendant qualifications.
• Case Management - includes initial and annual eligibility assessments, development of an individual service plan and identifying resources in the individual's community.
• Consumer Preparation- instructing the individual on hiring and training personal attendants, personal health maintenance training and support.
• Skilled Nursing Services- includes nursing services under the direction of the individual's physician and includes services that cannot be provided by the individual's personal attendant.
• Emergency Response Services- provides monthly payment for emergency response services such as Lifeline.
• Respite- care and supervision needed due to the temporary absence of a parent, guardian, or other immediate caregiver
• Specialized Medical Equipment & Supplies- devices, controls, or appliance that enable participants to increase their ability to perform activities of daily living. Examples include adaptive positioning devices, mobility aids, adaptive equipment, and augmentative communication devices and services.
• Vehicle Modifications - adaptations or alterations to an automobile or van to accommodate the special needs of the participant. Examples include adaptive driving features, lifts, ramps, and wheelchair securement/seating systems.
• Environmental Accessibility Adaptations- physical adaptations to a participant's residence to enable the participant to function at a greater independence within the home. Examples include ramps, grab bars, and widening of doorways.

Other Information for Home and Community Based Services can be found here: Department of Human Services.

South Dakota Medicaid for Workers with Disabilities (MAWD)

The South Dakota Medicaid for Workers with Disabilities program is for South Dakotans who are employed and have a significant disability. This program allows individuals with disabilities to return to work or remain working.

• The individual must be employed.
• The individual must have a significant disability.
• The individual must have resources less than $8000.
• Your total income must be below 250% of the Federal Poverty Level (FPL). Your monthly countable unearned income must be less than the SSI Federal Benefit Rate (plus a $20 income disregard).

Individuals with Chronic Renal Disease

The program is intended for individuals who are experiencing chronic renal failure and are unable to pay the total cost of lifesaving care and treatment of renal failure.

• The individual does not have a third party payer, (Medicare and Indian Health Services are not considered third party payers).
• The individual is a proper candidate for care and treatment as determined by the renal disease center or the individual’s physician.
• The household’s income must be less than 150% of the Federal Poverty Guideline.
• The resource limit is $4,000 for a single individual and $6,000 for an individual with a spouse. Resources include items such as checking and savings accounts and certificates of deposit.
• Must meet certain other non-financial criteria, such as state residency and citizenship.

Covered services are limited to those provided for long-term dialysis or transplants due to irreversible, chronic renal failure. The following services may be paid under this program:

1. Dialysis treatments (Inpatient, outpatient or home).
2. Hospitalization (Transplant operations).
3. Supplies, equipment, and water softeners necessary for home dialysis.
4. Prescription drugs necessary for dialysis or transplants.

South Dakota Medicaid for Youth Formerly in Foster Care

The Former Foster Care Medical Program provides extended medical coverage for youth aged 18 to 26 that are leaving State or Tribal foster care after their 18th birthday. Referrals for this program are normally generated by the Division of Child Protection Services’ (CPS) staff. You may also call 877.999.5612 for further information.

Eligibility Requirements

• The youth must have been in foster care under the responsibility of the State of South Dakota or another state or with Tribal CPS on his/her 18th birthday.
• The youth must be a resident of South Dakota.
• There is no resource or income limit if the youth aged out of South Dakota (state or tribal) foster care.
• Eligibility continues from the month the youth is no longer under the responsibility of the State or Tribe until the end of the month in which the youth attains age 26 if s/he meets all other eligibility requirements.

South Dakota Medicaid for Individuals in Adult Foster Care Facilities

Individuals in adult foster care homes that meet all eligibility criteria may qualify for South Dakota Medicaid.

• A person must be 65 years or older. If under age 65, a person must be blind or disabled.
• A person must be a resident of South Dakota and meet certain citizenship requirements of the United States.
• Medical needs of the individual are such that they require a level of care that must be provided in an adult foster care home.
• The applicant’s monthly income minus allowable deductions must be less than the current state reimbursement rate to an adult foster care home.
• The resource limit is $2,000. Resources include items such as checking and savings accounts and certificates of deposit.

Adults Currently and Formerly Receiving Supplemental Security Income

South Dakota Medicaid for Individuals Currently and Formerly Receiving Supplemental Security Income (SSI)

Individuals Currently Receiving Supplemental Security Income (SSI)
These individuals are automatically eligible for Medicaid based on their eligibility for the cash assistance program.

Eligibility is determined by the Social Security Administration.

Individuals Previously Receiving Supplemental Security Income (SSI)
Individuals who received SSI and are no longer eligible due to cost of living increases or receipt of Title II benefits from the Social Security Administration may be eligible for South Dakota Medicaid through the Disabled Adult Child (DAC), Pickle, or Early or Disabled Widow(er)s programs.

Eligibility is determined by the Department of Social Services. Eligibility requirements for DAC, Pickle, or Early or Disabled Widow(er)s programs:

• A person must have previously received an SSI cash payment.
• A person must currently receive Title II benefits from the Social Security Administration.
• A person must meet the income and resource eligibility requirements for South Dakota Medicaid. The resource limit is $2,000 for an individual.

Refugee Medical Assistance

The Refugee Medical Assistance (RMA) program was established to provide health care to refugees in need who do not meet qualifications for any other health care programs. RMA is a short-term, wholly federally funded transitional program available to ensure refugees receive the medical care they need while they transition to live in the United States.

RMA is available for twelve months from month of entry into the United States to refugees who meet the eligibility criteria, including income and resource requirements.

Other Links

• Community Assistance Program
• Energy & Weatherization Assistance
• Quality Control
• Supplemental Nutrition Assistance Program
• Temporary Assistance for Needy Families
• Voter Registration Services
• Workforce Innovation and Opportunities Act (WIOA)

See Also.

• Child Care Services
• Child Support