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Provider Information

Managed Care Program

The Managed Care Program is designed to improve access, availability, and continuation of care while reducing inappropriate utilization, over-utilization, and duplication of Medical Assistance Program covered services while operating a cost-effective program.

The Managed Care Program, Provider and Recipient in Medicaid Efficiency Program (PRIME), is based on the primary care case management (PCCM) model.

  • The program is operational statewide, is applicable for recipients eligible under Title XIX and Title XXI of the Social Security Act and is administered by South Dakota Department of Social Services Division of Medical Services. Reimbursement is based on fee for service plus a monthly case management fee.

  • The Primary Care Provider Program is a managed health care system which approximately 80 percent of the state's Medical Assistance recipients are required to enroll. Certain Medical Assistance recipients must choose one primary care provider (PCP) to be their health care case manager. This program creates a "partnership" between the PCP and the Medical Assistance Program recipient where the PCP is responsible for providing or directing all Managed Care designated services.

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