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South Dakota and the ACA’s Medicaid expansion

Medicaid expansion is on the November 2022 ballot, but might need 60% voter approval in order to pass

No Medicaid eligibility expansion in South Dakota

South Dakota is one of 12 states where federal funding to expand Medicaid has not yet been accepted by the state. So eligibility rules in the state remain the same as they were prior to the Affordable Care Act (ACA). Former Governor Dennis Daugaard supported Medicaid expansion by 2015 (after initially opposing it), but the issue did not have lawmakers’ support. Current Governor Kristi Noem is opposed to Medicaid expansion.

Accordingly, coverage under Medicaid is only available in South Dakota for those with low income who are either children, elderly, pregnant, disabled, or very low-income parents/caretakers of minor children (parents are only eligible with household income up to 63% of the poverty level, which works out to just over $14,500 a year for a household with three people). Children comprise more than two-thirds of the state’s Medicaid population.

Low-income childless adults without a disability are ineligible for Medicaid regardless of how low their income is, but they’re not eligible for premium subsidies to offset the cost of private coverage unless their income is at least 100% of the poverty level. This leaves an estimated 14,000 low-income South Dakota adults in the coverage gap, with no access to any financial assistance with their health coverage.

If Medicaid is expanded as called for in the ACA, a single person would qualify for Medicaid in South Dakota with an income of up to about $18,754 (that number increases a little each year as the poverty level rises).

South Dakota Medicaid expansion decision is in voters’ hands in 2022, but may require 60% approval

Federal poverty level calculator

Most of the states that have expanded Medicaid have done so via legislation. But as time goes on and lawmakers and/or governors in a dwindling number of states continue to reject federal funding to expand Medicaid, the issue is increasingly being taken directly to voters. Medicaid expansion has already taken effect in Maine, Utah, Idaho, Nebraska, Oklahoma, and Missouri as a result of ballot measures that were approved by voters.

And South Dakota voters will be next to have the opportunity to determine whether Medicaid is expanded in the state under the terms laid out in the ACA. Medicaid expansion supporters in the state gathered more than 38,000 signatures to get a constitutional amendment (Amendment D) on the 2022 ballot.

However, the measure might need 60% approval to pass, depending on the outcome of another ballot measure, which is on the June 2022 primary ballot. South Dakota Constitutional Amendment C, if approved by voters, would require 60% voter approval for future ballot measures that increased taxes or require the state to appropriate more than $10 million. If voters approve Amendment C, it would mean that Amendment D would have to be approved by at least 60% of voters in order to pass.

But if Amendment D is successful, it would call for the state to submit a state plan amendment to the federal government within 90 days of passage, detailing the state’s plan for the expansion of Medicaid. Polling indicates that voters in South Dakota are in favor of Medicaid expansion, and Medicaid expansion ballot measures have thus-far been successful in every state where they have appeared on the ballot. The South Dakota State Medical Association is also pushing for Medicaid expansion in the state.

Although Republican lawmakers in South Dakota have long opposed Medicaid expansion, some are now pushing for legislation to expand Medicaid in order to have a measure of control over the issue, in advance of the 2022 election.

Does South Dakota have a Medicaid work requirement?

Instead of expanding Medicaid during any of the legislative sessions since 2010, South Dakota opted to seek federal approval for a pilot program work requirement for low-income parents in the existing Medicaid program (the pilot program would have applied in just two counties initially).

Former Governor Dennis Daugaard laid out the details of the work requirement in his State of the State address in January 2018, and the state published the proposed waiver application in May 2018. The waiver proposal has been pending CMS approval since 2018, but the Biden administration notified states in 2021 that Medicaid work requirements were essentially a non-starter; all of the previously approved work requirements were revoked by the Biden administration in 2021, and no pending work requirement proposals have been approved. South Dakota began voluntary enrollment in the Career Connector program in July 2018.

South Dakota has not accepted federal Medicaid expansion

  • 129,870 – Number of South Dakotans covered by Medicaid/CHIP as of July 2021
  • 45,000 – Number of additional South Dakota residents who would be covered if the state accepted expansion
  • 16,000 – Number of people who have NO realistic access to health insurance without Medicaid expansion
  • $384 million – Federal money Mississippi is leaving on the table in 2022 by not expanding Medicaid

Who is eligible for Medicaid in South Dakota?

Medicaid in South Dakota (also called the South Dakota Medical Assistance Program, which includes both Medicaid and CHIP) is available to eligible low-income families (note that all of these income limits include a built-in 5% income disregard that’s used for MAGI-based Medicaid eligibility):

  • Pregnant women with household incomes up to 138% of the federal poverty level (FPL)
  • Children aged 0 to 18 with household income up to 187% of FPL are eligible for Medicaid; Children with household incomes up to 209% of poverty are eligible for CHIP (Children’s Health Insurance Program).
  • Parents with dependent children are eligible with incomes up to 63% of poverty.

How does Medicaid provide financial assistance to Medicare beneficiaries in South Dakota?

Many Medicare beneficiaries receive Medicaid’s help with paying for Medicare premiums, affording prescription drug costs, and covering expenses not covered by Medicare – such as long-term care.

Our guide to financial assistance for Medicare enrollees in South Dakota includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.

How do I apply for Medicaid in South Dakota?

Medicaid enrollment is open year-round. You can apply for South Dakota Medicaid online, over the phone, or by submitting a paper application. If you have questions, you can reach the SD Department of Social Services at 1-605-773-3165.

  • Online: Visit HealthCare.gov
  • By phone: Call HealthCare.gov at 1-800-318-2596.
  • Paper applications: Download an application for Medicaid or CHIP from the South Dakota Department of Social Services website.  The application must then be mailed, faxed, or taken in person to a local Social Services office.

South Dakota Medicaid enrollment numbers

As of mid-2021, enrollment in South Dakota’s Medicaid program stood at 129,870 people. Because the state has not expanded Medicaid, enrollment has not grown the way it did in most other states. There were 115,501 enrollees in late 2013, and most of the subsequent growth has happened during the COVID pandemic.

States are receiving additional federal Medicaid funding during the pandemic emergency period, but on the condition that Medicaid enrollees not be dropped from the program. So eligibility redeterminations have not been conducted since March 2020, which means Medicaid enrollment has generally trended upward, nationwide, ever since then.

South Dakota Medicaid history

South Dakota’s Medicaid program became effective in October 1967, nearly two years after Medicaid was created. For many states, 2014 represented a significant shift in eligibility, particularly for childless adults. However, South Dakota Medicaid eligibility guidelines have not yet changed under the ACA. Non-disabled childless adults are ineligible for Medicaid, regardless of how low their incomes are. But as noted above, that might change after voters have an opportunity to weigh in on Medicaid expansion on the 2022 ballot.

South Dakota Medicaid expansion history

South Dakota officials announced in September 2015 that their proposal to expand Medicaid had received “an initial go-ahead” from HHS. then-Governor Dennis Daugaard’s senior advisor Kim Malsam-Rysdon noted that the plan was still preliminary, but it appeared promising and would expand eligibility to far more people than the state’s 2014 proposal, which would only have expanded coverage to residents with incomes below the poverty level (HHS rejected that proposal, as Medicaid expansion capped at the poverty level was a non-starter under the Obama administration, and was also rejected by the Trump administration when proposed by Utah).

Of the population that would have been newly eligible for coverage under Medicaid expansion, more than a quarter — about 14,000 people — are Native Americans, although Native Americans make up just nine percent of the South Dakota population. Native Americans are disproportionately impacted by the state’s refusal to expand Medicaid. Although they are eligible for free care through Indian Health Services, the treatment options are limited at those facilities. The approval from HHS to allow non-IHS providers to enter into care coordination agreements with IHS facilities was expected help to open up treatment options for Native Americans with Medicaid coverage, with full funding from the federal government, but Daugaard had noted that it’s a complicated process, and not all providers enter into those agreements.

Although states that expanded Medicaid are paying 10% of the cost (as of 2020; it remains at that level in future years as well), Daugaard noted that his proposal would end up being a financial net-positive for the state. That’s because he was working with the federal government and Native American tribal leaders to use Medicaid funding for Native Americans who are eligible for expanded Medicaid and who receive treatment outside of Indian Health Services (IHS) facilities. Those costs are covered in part by the state, and Daugaard said that South Dakota would save more there than they would spend on their portion of the Medicaid expansion costs. Daugaard said that he wouldn’t continue his push for Medicaid expansion if it ended up needing additional money from the state’s general fund.

In December 2015, Governor Daugaard explained the details of his $4.8 billion budget proposal, including his proposal to expand Medicaid to cover 55,000 people who weren’t currently eligible. Daugaard said that the state should “seize the opportunity” to use federal funding to expand coverage, if possible.

In February 2016, HHS agreed to establish arrangements under which non-IHS providers could enter into “care coordination agreements” with IHS facilities, and Native Americans enrolled in Medicaid would be able to receive care at those non-IHS facilities and the full cost would be covered by federal Medicaid funds (as opposed to the state paying a portion and the federal government paying a portion). But Daugaard noted that the practical implementation of the new HHS provision could be complicated, and that there was still work to be done to determine whether the savings from the new IHS rule would save enough money to make Medicaid expansion budget-neutral in South Dakota.

A few days later, Daugaard said that it was too late in the 2016 legislative session to get the ball rolling on Medicaid expansion, and said that he would remove Medicaid expansion from his proposed budget. He indicated that a special session was a possibility, but that waiting until the 2017 legislative session was also a possibility. In June 2016, Daugaard confirmed that the issue would have to wait until the 2017 legislative session, as he was opting not to call a special session in 2016.

In early 2017, in his State of the State address, Daugaard noted that he was optimistic about working with the Trump administration to ensure that the federal government would begin to fully fund medical care for Native Americans, regardless of where the care was provided, without requiring “health care providers to jump through several hoops,” as he believed the Obama-era arrangement did. He did not mention Medicaid expansion in that address.

The issue of Medicaid expansion was essentially off the table in South Dakota as of early 2017. The coalition tasked with recommending how the state should expand coverage updated their conclusions in December 2016 to note that Governor Daugaard was no longer recommending Medicaid expansion for 2017, in light of the incoming Trump administration’s plans to overhaul Medicaid nationwide with block grants or per-capita allotments. Ultimately, that did not come to pass at the federal level, but no progress has been made towards Medicaid expansion in South Dakota in the meantime.

Kristi Noem took office as governor in 2019, and opposes Medicaid expansion. But voters in the state have an opportunity to decide the matter for themselves on the 2022 ballot.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Apply for Medicaid in South Dakota

Apply year round through HealthCare.gov or by phone at 1-800-318-2596. Download applications for Medicaid and CHIP from the South Dakota Department of Social Services website; then mail, fax, or take the application in person to a local Social Services office.  Have questions? Call (605) 773-3165.

Eligibility: Pregnant women with household incomes up to 133% of FPL; children with household incomes up to 204% of FPL (for CHIP); parents with dependent children are eligible with incomes up to 58% of FPL.

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