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Medicaid eligibility and enrollment in South Dakota

Medicaid expansion took effect July 1, 2023, after passage of 2022 ballot measure

Medicaid eligibility expanded in July 2023

South Dakota’s legislature and governor repeatedly rejected Medicaid expansion. But the issue was put to the state’s voters in the 2022 election, and voters approved Medicaid expansion by a 56% to 44% margin. The measure called for the state to expand Medicaid eligibility on July 1, 2023.

South Dakota received federal approval to initiate expansion as of July 2023, and for the specific benefits package that the newly eligible population is receiving. Over the next five years, South Dakota will receive about $1.5 billion in additional federal Medicaid funding due to the eligibility expansion, including the enhanced federal funding for Medicaid expansion as well as two years of additional funding available under the American Rescue Plan.1

Under the new eligibility guidelines, a single adult qualifies for Medicaid in South Dakota with an income of up to about $20,120. (That number increases a little each year; once the 2024 poverty level numbers are in use in the spring of 2024, the income limit will rise to about $20,782 for a single adult.2)

South Dakota initially projected that 52,000 low-income South Dakota residents would be newly eligible for Medicaid under the expanded eligibility guidelines. But South Dakota has not been actively publicizing the availability of expanded Medicaid, and only 17,520 South Dakota residents had enrolled in expanded Medicaid by December 2023. As a result of the slower-than-expected enrollment, the state now estimates that about 40,000 people will enroll by 2025.3

South Dakota lawmakers are considering a resolution in 2024 that calls for another ballot measure to be presented to voters, asking whether a work requirement should be imposed for the Medicaid expansion population. The resolution passed in the Senate and was sent to the House for consideration.4 If the measure were to appear on the ballot and South Dakota voters were to approve it, the U.S. Department of Health & Human Services would have to approve the work requirement.

Medicaid expansion via ballot measure has been successful in all of the states where voters have had an opportunity to directly decide whether the state should expand Medicaid. This includes Maine, Utah, Idaho, Nebraska, Oklahoma, and Missouri.

South Dakota accepted federal Medicaid expansion in July 2023

  • 128,677 – Number of South Dakotans covered by Medicaid/CHIP as of January 20245
  • 40,000 – Number of South Dakota residents expected to enroll in expanded Medicaid by 20253
  • 41,958 – Number of SD residents disenrolled from Medicaid as of November 20236
  • $1.5 billion – Federal money South Dakota will receive over the first five years of Medicaid expansion1

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 households (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). Postpartum Medicaid coverage for new mothers continues for 12 months after the baby is born (instead of ending after 60 days, as was the case before mid-2023).7
  • 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).
  • Adults under age 65 are eligible for Medicaid with income up to 138% of the poverty level (due to Medicaid expansion, which took effect in July 2023).

In addition, coverage is available to people who are 65 or older, blind, or disabled, if they have low incomes and low asset/resource levels.8

Federal poverty level calculator

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 or South Dakota DSS online
  • 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.


How is South Dakota handling Medicaid renewals after the pandemic?

Throughout the COVID pandemic, from March 2020 through March 2023, states were not allowed to disenroll anyone from Medicaid, even if they no longer met the eligibility criteria (some states chose to apply this continuous coverage rule to their CHIP populations as well, but South Dakota did not). The federal continuous coverage requirement ended March 31, 2023, and states could resume routine disenrollments as early as April 1.

States have a year-long “unwinding” period during which eligibility must be redetermined for everyone enrolled in Medicaid. South Dakota had noted that they had about 22,000 enrollees who “appear ineligible” for Medicaid. But before they could be removed from the program, their ineligibility had to be verified.

South Dakota opted to begin the return to normal eligibility redeterminations and disenrollments as soon as allowed under federal rules, with renewal processing beginning in February 2023 and disenrollments possible as of April 1 (only four other states opted to have their initial round of disenrollments effective in April).

41,958 South Dakota residents had been disenrolled from Medicaid by November 20236

According to South Dakota’s enrollment data page, total Medicaid enrollment dropped from 152,987 in March 2023 to 139,770 in April, and to 131,627 in May. So in just the first two months, enrollment had dropped by more than 21,000 people, amounting to nearly 14% of the people who had Medicaid in March.

But as noted above, some of those people likely became eligible for Medicaid again after expanded eligibility rules for adults took effect. By January 2024, total enrollment stood at 128,677 — only slightly lower than it had been in May 2023. Disenrollments had continued throughout the rest of 2023, but enrollments under Medicaid expansion had served to keep enrollment higher than it would otherwise have been.5

For each month’s renewals, the state first tries to auto-renew coverage based on existing data. But for those whose coverage cannot be auto-renewed, the state sends a renewal packet (marked “urgent”) with instructions for completing the renewal on paper, online, over the phone, or in person at a county office. The packet is sent out about six weeks before the coverage is due to renew.

South Dakota is in a unique position during the unwinding process, as Medicaid expansion took effect in the state in July 2023, just three months after the first round of disenrollments due to the end of the COVID-related continuous coverage rule. Some people who lost Medicaid in April, May, or June may have found that they were once again eligible for Medicaid starting in July, under the new expansion rules (for those whose renewal date is July 2023 or later, they would not lose coverage in that case, but would simply transition to the Medicaid expansion eligibility category). So for those individuals, the state was screening for potential eligibility under the expansion guidelines and letting the person know that they should reapply starting in June (for coverage effective July 1). Reminder notices about this were sent to these individuals in June.

People who are no longer eligible for Medicaid will generally find that they can either enroll in an employer’s plan (if available), or sign up for a plan through the South Dakota marketplace/exchange. Most exchange enrollees qualify for substantial income-based subsidies to offset the cost of their coverage (and in some cases, their out-of-pocket costs).

Does South Dakota have a Medicaid work requirement?

No, although the state sought federal approval to implement a pilot program work requirement for low-income parents in the existing Medicaid program. 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.

As noted above, lawmakers are considering a resolution in 2024 that calls for a ballot measure that would ask voters to weigh in on whether Medicaid expansion should have a work requirement (which would also require HHS approval).

South Dakota Medicaid expansion history

South Dakota expanded Medicaid in July 2023, nearly a decade after Medicaid expansion took effect in many other states. 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, and the legislature has also continued to oppose Medicaid expansion. But as has been the case in every other state where voters got to weigh in directly on the issue, South Dakota voters approved a constitutional amendment (Amendment D) to expand Medicaid eligibility as called for in the ACA.

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 have expanded 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 — but with the enhanced federal Medicaid expansion funding match — was a non-starter under the Obama administration, and was also rejected by the Trump administration when proposed by Utah and Georgia).

Although states that expanded Medicaid are paying 10% of the cost, Daugaard noted that his proposal would have ended 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 would become 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 it would spend on its 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 was made toward 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 had an opportunity to decide the matter for themselves on the 2022 ballot, and they approved Medicaid expansion. 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.

To get the measure on the ballot, Medicaid expansion supporters in South Dakota gathered more than 38,000 signatures. There were concerns that the measure might need 60% approval to pass, as voters also had the opportunity to vote on South Dakota Constitutional Amendment C in the June 2022 primary election. That measure was defeated, but if it had been approved it would have required 60% voter approval for future ballot measures that increased taxes or require the state to appropriate more than $10 million. But since Amendment C did not pass, Amendment D only needed a simple majority to pass (it ultimately got 56% of the vote).


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.

Footnotes

  1. Fiscal Note on Medicaid expansion” South Dakota Legislature. June 17, 2021″ and “South Dakota’s Low-Income Residents, Native Communities, and Budget Could All Soon Benefit From Medicaid Expansion” (additional ARP funding) Center on Budget and Policy Priorities. October 20, 2022.  
  2. 2024 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed February 23, 2024. 
  3. Pace of Medicaid enrollment remains slower than expected” South Dakota Searchlight. February 16, 2024.  
  4. South Dakota SJR501” BillTrack50. Accessed February 23, 2024. 
  5. DSS Statistical Information” South Dakota Department of Social Services. Accessed February 23, 2024.  
  6. Medicaid Enrollment and Unwinding Tracker” KFF. February 22, 2024.  
  7. State Plan Amendment (SPA) #: 23-0008” Centers for Medicare & Medicaid Services. June 5, 2023. 
  8. South Dakota Medicaid Eligibility for Long Term Care: Income & Asset Limits” American Council on Aging. November 22, 2023. 

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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.

South Dakota section

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