Recipient Information

Covered Services

Below you will find information on the services covered by the South Dakota Medical Assistance Program, also referred to as Medicaid. It is advised that you also double check with you doctor or pharmacist on particular services that may or may not be covered by the program. It is the recipient's responsibility to pay for the services not covered by the South Dakota Medical Assistance Program.

If you should have any questions in regards to what is covered and what is not covered, please call 1-800-597-1603 or visit with your medical provider.

• Ambulance - Covers medically necessary ground and air ambulance trips, medically necessary ancillaries, and loaded mileage to take the recipient to the closest medical provider capable of providing the needed care. The service will only be covered if another type of transportation would endanger the life or health of the recipient. A call for an ambulance in the absence of other transportation is not appropriate for non-emergency services.
• Chiropractor - Covers only manual manipulation of the spine when X-rays taken verify displacement of the spine. Medical Assistance will not pay for more than 30 manipulations in any 12-month period.
• Clinics - Covers medical services and supplies furnished under the direction of a doctor.
• Dental - Covers exams, X-rays, cleanings, fillings, and provides limited coverage for root canals, crowns, partial dentures, complete dentures and anesthesia. Some services require pre-authorization. Find a SD Dentist.
  
  • Orthodontic Services: Orthodontic treatment for children may be covered. In most situations, a child must have an orthodontic condition that would impair the ability to eat, chew and speak. Pre-authorization is required for all orthodontic care.
  • If you have further questions about dental or orthodontic services, please contact Delta Dental of South Dakota at 1-800-627-3961.
• Diabetes Education - Covers up to 10 hours of initial diabetes self-management education. Also covers two hours per year of follow-up education. Assessment of need and documented physician order required.
• Durable Medical Equipment (DME) - Covers reusable equipment that is medically necessary and that complies with set service limits.
  
  • Note: Only one nebulizer every five years per family is allowed. Replacement hearing aids may be provided only after a minimum of three years has elapsed since the original fitting and if the original hearing aids are no longer serviceable.
    
  • Equipment NOT covered includes: exercise equipment; protective outerwear; and personal comfort or environmental control equipment such as air conditioners, humidifiers, dehumidifiers, heaters or furnaces. Medical equipment, other than hearing aids, for nursing home residents is provided by the nursing home.
• Family Planning - Covers diagnosis and treatment, drugs, supplies, devices, procedures and counseling for people of childbearing age.
• Home Health - Covers nursing care, therapy and medical supplies when provided in the recipient's home with doctor's order.
• Hospital
  
  • Inpatient - Covers room and board, regular nursing services, supplies and equipment, operating and delivery rooms, X-rays, lab and therapy.
    
  • Outpatient - Covers emergency room services and supplies, lab, X-rays and other radiology services, therapy care, drugs and outpatient surgery.
• Hysterectomy - The federal regulation pertaining to a hysterectomy requires the recipient has been informed that the hysterectomy will render the individual permanently incapable of reproducing.
  • The recipient must sign a statement acknowledging receipt of infertility information prior to surgery. The Acknowledgment of Information for Hysterectomy Form meets this requirements and must be completed.
  • The physician may write a statement that the recipient was sterile prior to the hysterectomy and the reason for the sterility. The statement must be signed and dated by the physician and the statement must be attached to the claim. 
  • When a recipient requires a hysterectomy due to a life threatening emergency, and the physician determines that prior acknowledgment is not possible, the physician must certify in writing that the hysterectomy was performed under a life-threatening emergency in which he or she determined prior acknowledgment was not possible.
  • The physician must also include a description of the nature of the emergency. This statement, signed and dated by the physician, must be attached to the claim.
• Mental Health - Covers psychiatric and psychological evaluations and individual-group-family psychotherapy for the care and treatment of mental illness or disorders. Counseling is not a covered service. Limited to 40 hours of treatment in any 12-month period.
• Nursing Home - Covers room and board, nursing care, therapy care, meals and general medical supplies. Medical Assistance will NOT pay for durable medical equipment for residents in a nursing home.
• Out-of-State Coverage
  When receiving out-of-state services, make sure:
1. The provider is a SD Medical Assistance Provider;
   
2. If you are a managed care recipient, you must contact your PCP prior to service (non-emergent);
   
3. The services are covered under SD Medical Assistance guidelines. Ask your provider if a service is covered.
• Medical Assistance will cover out-of-state emergency services with the same limits as in-state services if the provider accepts SD Medical Assistance.
• Personal Care - Covers basic personal care, grooming and household services, if related to a medical need essential to the patient's health. The service must be provided in the recipient's home. Must be physician ordered and included in the case service plan.
• Physician - Covers medical and surgical services performed by a doctor, supplies and drugs given at the doctor's office, X-rays and laboratory tests needed for diagnosis and treatment.
• Podiatry - Covers office visits, supplies, X-rays, glucose and culture check and limited surgical procedures.
• Prescriptions - Covers a large range of, but not all, prescription drugs, diabetic supplies, family planning prescriptions, supplies and devices. Does not cover most “over-the-counter” medications or products.
• Rehab Hospital - Covers extensive rehabilitative therapy following an illness or injury.
• Sterilization - Covers sterilization procedures when all are met:
  • The recipient is at least 21 years old;
    
  • The recipient is a legally competent individual;
    
  • The recipient has signed an informed consent form after the recipient's 21st birthday; and
    
  • 30 to 180 days have passed between when the form was signed and the date of sterilization.
• Other Transportation Services - Covers non-emergency transportation services to and from an eligible recipient's home to the closest appropriate medical provider. Mileage allowances are not available for travel within city limits. Meal and lodging allowances are only made if the provider is at least 100 miles from the recipient's city of residence and travel is to obtain specialty care or treatment that results in an overnight stay.

  Transportation to the closest Primary Care Provider (PCP) is reimbursable except if the PCP is within the recipient's city limits. NEMT will only be reimbursed if a "good cause" exception has been granted from the South Dakota Managed Care Program. Lodging and meals are not reimbursable when travel is to a PCP.

• Vision - Covers exam, glasses and frames, and contact lenses when necessary for the correction of certain conditions. You can receive replacement eyeglasses only after 15 months have passed and a lens change is medically necessary.
• Wheelchair Transportation - Covers non-emergency transportation services for medical treatment to and from the recipient's home to a medical provider, between medical providers, or from a medical provider to the recipient's home. The recipient must be confined to a wheelchair to receive this service. Stretcher services also included.

More Services Covered for Children

• Well-Child Exams - Well-Child Care visits help prevent illnesses before they happen. They also provide treatment for any illnesses your child may have. These services are available for children under age 21 who receive Medical Assistance.
  
  Well-Child exams cover screening and diagnostic services to determine physical or mental status and treatment to correct or eliminate defects or chronic conditions. Also covers certain medical equipment, nutritional therapy, treatment for alcohol and drug chemical dependency, additional dental and orthodontic services as well as inpatient psychiatric care.

Several of these services require prior authorization from the Department of Social Services. Be sure to check with your provider regarding these requirements.