Cabinet Secretary
Matt Althoff

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Medicaid State Plan

The South Dakota Medicaid State Plan is a contract between the state of South Dakota and the Federal government describing how South Dakota administers its Medicaid Program. The plan information listed here is for informational purposes only. The official plan is maintained by the South Dakota Department of Social Services.

State Plan Amendments (SPA) in Public Comment Period
SPA# Description Effective Public Comment Start Date Public Comment Period Ends
25-0013 Doula and Targeted Case Management Services - Alternative Benefit Plan
Brings the Alternative Benefit Plan for the expanded adult population into alignment with two Medicaid State Plan amendments currently pending approval to add coverage of doula services (SPA #24-0017) and targeted case management services (SPA #25-0003).		 01/01/25 04/14/25 05/14/24
25-0009

Provider Enrollment Retroactive Billing
Updates the state plan to include the established process to determine whether and when it is appropriate to approve an enrollment with a retroactive billing eligibility date as recommended by CMS.

 04/01/25 03/24/25 04/23/25
25-0008

Clinic Services Four Walls Exception
Provides assurance that South Dakota Medicaid covers clinic services furnished outside the clinic to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address and outside a clinic operated by the IHS or by a Tribe or Tribal organization by clinic personnel under the direction of a physician as required by CMS.

01/01/25 03/17/25 04/16/25

State Plan Amendments in CMS Review
SPA# Description Effective Public Comment Start Date Public Comment Period Ends Submitted to CMS
25-0008

Clinic Services Four Walls Exception
Provides assurance that South Dakota Medicaid covers clinic services furnished outside the clinic to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address and outside a clinic operated by the IHS or by a Tribe or Tribal organization by clinic personnel under the direction of a physician as required by CMS.

01/01/25 03/17/25 04/16/25 03/18/25
25-0004 Targeted Case Management
Implements targeted case management services in the 30 days prior to release from public institutions for eligible juveniles under 21 years of age or between ages 18-26 for recipients in the former foster care group in accordance with Section 5121 of the Consolidated Appropriations Act, 2023.		 01/01/25 12/16/24 01/15/24 01/30/25
25-0003 Juvenile Justice and Targeted Case Management
Implements targeted case management services in the 30 days prior to release from public institutions for eligible juveniles under 21 years of age or between ages 18-26 for recipients in the former foster care group in accordance with Section 5121 of the Consolidated Appropriations Act, 2023.		 01/01/25 12/16/24 01/15/24 01/30/25

Approved State Plan Amendments
SPA# Description Effective Public Comment Start Date Public Comment Period Ends Submitted to CMS Approved
25-0002 Medicaid Recovery Audit Contractor Program
Seeks an exemption to the federal requirement mandating the state to establish a Medicaid Recovery Audit Contractor Program. The State already maintains a low error rate and does not believe an adequate amount of revenue would be generated to attract vendors to the program.		 06/01/25 11/18/24 12/18/24 01/10/25 03/10/25
24-0007 School District Services and Medicaid Administrative Claiming
Adds school-district services and reimbursement for direct school-based health services and Medicaid Administrative Claiming (MAC) to the State Plan to reflect current coverage. The update also includes a school district services cost settlement methodology.		 08/06/24 08/05/24 09/04/24 09/17/24 03/10/25
24-0016 Preadmission Screening and Annual Resident Reviews (PASRR) Services
Clarifies the state plan to reflect current practice for Preadmission Screening and Annual Resident Reviews (PASRR) specialized services in nursing facilities and the available categorical determinations options. The SPA does not change the State’s current level of care determination process.		 10/01/24 09/30/24 10/30/24 11/04/24 01/17/25
24-0017 Doula Services
Proposes to implement coverage and reimbursement for doula services including continuous physical, emotional, and informational support to the birthing parent during the prenatal, labor & delivery, and postpartum periods. Services will be provided by qualified individuals with doula certifications from programs approved by South Dakota Medicaid.		 01/01/25 10/21/24 11/20/24 11/27/24 01/10/25
24-0015 Substitution of Coverage - CHIP Eligibility
Removes the 90-day waiting period prior to CHIP enrollment for substitution of coverage.		 07/01/24 08/26/24 09/24/24 09/25/24 12/16/24
24-0014 SFY25 Inflationary Increase and Clean-Up SPA
Implements the inflationary rate increases appropriated by the state legislature during the 2024 legislative session effective July 1, 2024, and updates multiple areas of the State Plan to align with South Dakota Administrative Rule and current practice. 		07/01/24 06/17/24 07/17/24 08/05/24 10/23/24
24-0012 Elimination of Recipient Cost Share for Medical Services
Exempts cost-sharing for Medicaid recipients and medical services that are currently subject to cost-sharing.		 07/01/24 05/28/24 06/28/24 07/24/24 10/18/24
24-0013 Health Home Inflationary Increase and Assurance
Implements the inflationary rate increases appropriated by the state legislature during the 2024 legislative session and assures that the requirements for general and annual reporting of child and adult core sets are met.		 07/01/24 06/17/24 07/17/24 08/05/24 10/11/24
24-0010 CY23 Care Coordination Supplemental Payment
Updates the care coordination provider list and supplemental payment amounts. 		 06/01/24 05/28/24 06/28/24 06/28/24 08/13/24
24-0011 SFY25 Behavioral Health Inflationary Increase
Implements community mental health center (CMHC) and substance use disorder (SUD) agency inflationary increases appropriated by the state legislature during the 2024 legislative session.		 06/01/24 05/28/24 06/28/24 06/28/24 06/28/24
24-0008 Prescription Drug Coverage
Allows for coverage of select over-the-counter drugs manufactured by a firm that does not have a signed rebate agreement with the United States Department of Health and Human Services, including iron supplements for pregnant women. The SPA also allows for South Dakota Medicaid to enter into value-based agreements with manufacturers on a voluntary basis.		 04/01/24 03/18/24 04/17/24 05/03/24 07/30/24
24-0009 Substance Use Disorder Treatment Coverage
Restores permanent coverage of substance use disorder (SUD) services provided to eligible individuals in institutions for mental disease (IMDs).		 10/01/23 04/02/24 05/02/24 05/09/24 07/11/24
24-0006 Continuous Coverage Eligibility – CHIP
Provides 12 months of continuous eligibility (CE) for children under the age of 19 in CHIP as required by Section 5112 of the Consolidated Appropriations Act, 2023.		 01/01/24 01/22/24 01/21/24 03/04/24 05/15/24
24-0002 and 24-0005 Alternative Benefit Plan
Allows for Alternative Benefit Plan (ABP) coverage of a primary care case management program (PCCM) for pregnant individuals and of adult vaccinations and their administration without cost sharing in order to align with the South Dakota State Plan.		 04/01/24
and 01/01/23		 12/27/23
and 01/16/24		 01/26/24
and 02/15/24		 02/05/24
and 03/02/24		 04/04/24

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South Dakota Medicaid State Plan
Table of Contents

1.0 SINGLE STATE AGENCY ORGANIZATION

2.0 COVERAGE AND ELIGIBILITY

2.1 Application, Determination of Eligibility and Furnishing Medicaid

2.2 Coverage and Conditions of Eligibility

2.3 Residence

2.4 Blindness

2.5 Disability

2.6 Financial Eligibility

2.7 Medicaid Furnished Out of State

3.0 SERVICES: GENERAL PROVISIONS

3.1 Amount, Duration, and Scope of Services

3.2 Medicaid, Medicare and Other Insurance

3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases

3.4 Special Requirements Applicable to Sterilization Procedures

3.5 Families Receiving Extended Medicaid Benefits

4.0 GENERAL PROGRAM ADMINISTRATION

5.0 PERSONNEL ADMINISTRATION

6.0 FINANCIAL ADMINISTRATION

7.0 GENERAL PROVISIONS

A MEDICAID ADMINISTRATION

S MEDICAID ELIGIBILITY

ALTERNATIVE BENEFIT PLAN