Lynne A. Valenti
Cabinet Secretary

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Medical Programs Available in South Dakota

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.

Children With Private Health Insurance

Household Size

Maximum Gross Monthly Income

1

$ 1,880

2

$ 2,532

3

$ 3,183

4

$ 3,834

5

$ 4,487

6

$ 5,137

7

$ 5,788

8

$ 6,441

 

Children Without Private Health Insurance

Household Size

Maximum Gross Monthly Income

1

$ 2,101

2

$ 2,830

3

$ 3,558

4

$ 4,285

5

$ 5,014

6

$ 5,742

7

$ 6,469

8

$ 7,198

Low-Income Families

Low income families in South Dakota (with or without private health insurance) may be eligible for FREE or low cost 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.

Low-Income Families

Household Size

Maximum Gross Monthly Income

1

$ 613

2

$ 771

3

$ 881

4

$ 988

5

$ 1,097

6

$ 1,207

7

$ 1,315

8

$ 1,421

 

Pregnant Women

The Department of Social Services provides South Dakota Medicaid to pregnant women who meet income and resource limits and general eligibility guidelines. Pregnant women may qualify for limited coverage or full coverage.

  • Limited Medical Coverage for Pregnant Women provides limited medical coverage to pregnant women meeting the income limits and general eligibility requirements. The income limits are more liberal than the Full Medical Coverage for Pregnant Women program. Medical coverage is limited coverage directly related to their pregnancy and delivery. Coverage also includes 60 days postpartum care and family planning services.
  • Full Medical Coverage for Pregnant Women provides full medical coverage to pregnant women meeting the income limits and general eligibility requirements. The income limits are more restrictive than the Limited Medical Coverage for Pregnant Women Program. Postpartum and family planning services are available during the two months following the end of the pregnancy.

Full Coverage Pregnancy

Household Size

Maximum Gross Monthly Income

1

$ 408

2

$ 516

3

$ 592

4

$ 666

5

$ 742

6

$ 817

7

$ 893

8

$ 967

 

Limited Coverage Pregnancy

Household Size

Maximum Gross Monthly Income

1

$ 1,387

2

$ 1,869

3

$ 2,349

4

$ 2,829

5

$ 3,311

6

$ 3,791

7

$ 4,272

8

$ 4,753

 

South Dakota Medicaid for Certain Newborns

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

Eligibility Requirements
  • 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.

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.

Eligibility Requirements
  • 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 ($2,205) 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.

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.

Eligibility Requirements
  • 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 $23,544..
  • 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.)

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.

Eligibility Requirements for MAWD
  • The individual must be employed.
  • The individual must have a significant disability.
  • The individual must have resources less than $8000.
  • The individual must have less than $755 of monthly unearned income (money such as VA or SSDI – not money earned from your job or business.

Family Support Services

Family Support Services provide South Dakota Medicaid for South Dakotans with a developmental disability such as Down’s Syndrome, autism or cerebral palsy.

Eligibility Requirements
  • The individual must live in the family home on a full-time basis.
  • Only children living with natural, adopted, stepfamily or relatives who act in parental capacity may qualify.
  • The individual must be found disabled by the Social Security Administration or the Department of Social Services.
  • The individual's monthly income must be less than 300 percent of the SSI Standard Benefit Amount ($2,205) 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.
In addition to the standard Medicaid covered services, the following services are available through Family Support Services:
  • Service Coordination: Includes services that will assist the individual to access needed services and the full range of South Dakota Medicaid, as well as needed medical, social, educational and other services.
  • Respite Care: Includes services provided to individuals unable to care for themselves. It is furnished on a frequency determined in the individual’s care plan because of the absence or need for relief of those persons normally providing care.
  • Specialized Medical and Adaptive Equipment and Supplies: Includes devices, controls or appliances, that enable individuals to increase their abilities to perform activities of daily living, or to perceive, control or communicate with their environment.
  • Nutritional Supplements: Certain nutrition supplements that are not a covered service under the full range of South Dakota Medicaid.
  • Personal Care: Assistance with eating, bathing, dressing, personal hygiene, or activities of daily living. This service may include assistance with preparation of meals, but does not include the cost of the meals themselves. When specified in the plan, this service may also include such housekeeping chores as bed making, dusting, and vacuuming, which are incidental to the care furnished, or which are essential to the health and welfare of the individual, rather than the individual’s family.
  • Companion Care: Non-medical service specifically for children in transition from childhood to adulthood and includes supervised integrated socialization, role modeling, and independent living skill development. This is a skill development service and may include such tasks as assistance and/or supervision of meal preparation, laundry, and shopping.
    • Examples of companion care services include: increasing skills in the areas of preparing a budget and shopping list, shopping, making appropriate choices and making the purchase; taking part in a community event to develop appropriate socialization skills and become integrated into the community; preparation of a meal, doing laundry or other household tasks.
  • Environmental Accessibility Adaptations (Home/vehicle modifications): Those physical adaptations required by the individual’s plan of care, which are necessary to ensure the health, welfare and safety of the individual, or which enables the individual to function with greater independence without which, the individual would require institutionalization.
    • Such adaptations may include the installation of ramps, and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems necessary to accommodate the medical equipment and supplies which are necessary for the welfare of the individual. May also include modifications to vehicles such as lifts and tie downs to accommodate wheelchairs. All services should be provided in accordance with applicable state of local building codes.

Home and Community Based Services for Developmentally Disabled

Home and Community Based Services provides South Dakota Medicaid for individuals with developmental disabilities who would otherwise be institutionalized in a Medicaid-funded hospital, nursing facility or an intermediate care facility.

Eligibility Requirements
  • A person must be developmentally disabled.
  • A person must be aged, blind or disabled.
  • A person must reside in the home of a parent, other relative, legal guardian, adult foster care home licensed by the state, special therapeutic foster home licensed by the state, community residential facilities approved by the Department of Human Services, supervised apartment approved by the Department of Human Services, or community habilitation facilities approved by the Department of Human Services of an individual’s own home.
  • A person's monthly income must be less than 300 percent of the SSI Standard Benefit Amount ($2,205). 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 Home and Community Based Service Program:
  • Case Management and Consumer Support: This includes adaptive equipment needed not to exceed $500 per person per year. Examples of adaptive equipment would be communication devices, eyeglasses, hearing aids, etc.
  • Habilitation and Consumer Training: Habilitation and training includes instruction and training in community living skills, personal living skills, social and communication skills, gross and fine motor skills and activities of daily living.

Other Information for Home and Community Based Services can be found here: Department of Human Services' Division of Developmental Disabilities

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.

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 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.

South Dakota Medicaid for Individuals in Assisted Living Facilities, Nursing Facilities or Homes.

Individuals in assisted living centers, Nursing Facilities or Homes who meet all eligibility criteria may qualify for South Dakota Medicaid.

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. ($2,199)
  • The resource limit is $2,000. Resources include items such as checking and savings accounts and certificates of deposit.

South Dakota Medicaid for 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.

Eligibility Requirements
  • 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

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.
Travel expenses to and from renal treatment.

Quadriplegics 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 $2,205 month.
  • The resource limit is $2,000. Resources include items such as checking and savings accounts and certificates of deposit.

Elderly Individuals who would Require Nursing Home Care if not for Special Services Performed in their Home

Elderly individuals living independently in their own homes may be eligible for South Dakota Medicaid.

Eligibility Requirements
  • A person must be in need of nursing facility care.
  • A person must not be a resident of a hospital, nursing facility or an intermediate care facility for the mentally retarded.
  • A person must be a resident of South Dakota and meet certain citizenship requirements of the United States.
  • The monthly income limit is 300 percent of the SSI Standard Benefit Amount. ($2,205)
  • The resource limit is $2,000. Resources include items such as checking or savings accounts and certificates of deposit.
In addition to the standard Medicaid covered services, South Dakota Medicaid will cover the following services:
  • Homemaker Services: Teaching and providing home management skills, promoting self-care, making beds, changing linens, washing dishes, laundry work, floor care and housecleaning. Providing meal preparation, shopping and menu planning. Providing non-South Dakota Medicaid in mobility, personal comfort and grooming of the individual. Arranging for transportation.
  • Private Duty Nursing: Nursing services provided by a licensed nursing professional for recipients with chronic and stable conditions who require more individual and continuous care than is available from a part-time or intermittent nursing service.
  • Adult Day Care: Services providing out-of-home structured health and social services on a regularly scheduled basis and in daytime settings.
  • Emergency Response Systems: An emergency response system is an electronic device enabling individuals to alert neighbors or family and summon assistance in the event of an emergency.
  • Meals-Nutritional Supplements: Meals may be arranged in those areas where no home delivered meals program is available. The service may include a prepared meal, a frozen entrée or a nutritional supplement.

Refugee South Dakota Medicaid

The Refugee South Dakota Medicaid (RMA) program was established to provide health care to refugees in need who do not meet qualifications for any other health care program. Refugee South Dakota Medicaid is available to eligible refugees for eight months from month of entry into the United States.

South Dakota Medicaid for Youth Formerly in Foster Care

The Former Foster Care Medical Program provides extended medical coverage for youth age 18 to 26 that are leaving State foster care after their 18th birthday. Referrals for this program are normally generated by the Division of Child Protection Services’ staff. You may also call 1.877.999.5612 for further information.

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