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 in Public Comment Period
SPA# Description Effective Public Comment Start Date Public Comment Period Ends
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
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

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

Approved State Plan Amendments
SPA# Description Effective Public Comment Start Date Public Comment Period Ends Submitted to CMS Approved

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
24-0001 Pregnancy Primary Care Case Management (PCCM) Program - Medicaid
Establishes a pregnancy primary care case management program in the Medicaid State Plan for pregnant Medicaid recipients to improve health outcomes for mom and baby.		 04/01/24 12/27/23 01/26/24 02/02/24 03/14/24
24-0003

Community Mental Health Worker Qualification
Updates the provider qualifications for CMHC staff members providing certain direct services and support to clients from an associate degree to a high school diploma or equivalent with clinical supervision to align with revised state standards for services provided by a CMHC.

 02/01/24 01/22/24 01/21/24 03/04/24 03/11/24
23-0023

Continuous Coverage Eligibility – Medicaid
Provides 12 months of continuous eligibility (CE) for children under the age of 19 in Medicaid as required by Section 5112 of the Consolidated Appropriations Act, 2023.

 01/01/24 12/27/23 01/26/24 02/01/24 02/26/24
23-0022 Reasonable Classification for Children - PCCM
Clarifies that children under age 21 with non-IV-E adoption assistance or with an income above 133% of the federal poverty level are exempt from the PCCM program.		 11/01/23 10/16/23 11/15/23 12/01/23 02/26/24
23-0021 Reasonable Classification for Children - Eligibility
Clarifies that children under age 21 with non-IV-E adoption assistance or with an income above 133% of the federal poverty level are eligible for Medicaid coverage consistent with historical interpretation.		 11/01/23 10/16/23 11/15/23 12/01/23 02/26/24
23-0019 Adult Vaccine Coverage - Medicaid
Provides assurance of Medicaid coverage of vaccines and their administration for adults without cost sharing as required by section 11405 of the Inflation Reduction Act (IRA). 		10/01/23 09/25/23 10/25/23 11/06/23 01/24/24
23-0020 Adult Vaccine Coverage - CHIP
Provides assurance of CHIP coverage of vaccines and their administration for adults without cost sharing as required by section 11405 of the Inflation Reduction Act (IRA).		 10/01/23 11/06/23 11/06/23 12/29/23 01/23/24
23-0012 Nursing Facility Reimbursement
Proposes to move Medicaid from the Resource Utilization Group III (RUG III) reimbursement model to the Patient Driven Payment Model (PDPM) reimbursement model for Nursing Facility services.		 07/01/23 04/24/23 05/24/23 06/06/23 01/03/24
23-0018 Hospital Presumptive Eligibility
Updates the eligibility applications and associated training materials to include the expanded adult eligibility group.		 08/21/23 07/31/23 08/30/23 09/11/23 11/30/23
23-0015 Extended Postpartum Coverage Period - Financial Claiming
Establishes a proxy methodology to account for the proportion of individuals covered under the extended postpartum coverage option who would otherwise be eligible for the adult group Federal Medical Assistance Percentage (FMAP).		 07/01/23 06/26/23 07/26/23 08/31/23 11/15/23
23-0017 SFY24 Health Home Inflationary Increase
Implements the Health Home inflationary rate increase appropriated by the state legislature during the 2023 legislative session.		 07/01/23 06/12/23 07/12/23 08/07/23 10/11/23
23-0016 SFY24 Provider Inflationary Increase
Implements the provider inflationary rate increases appropriated by the state legislature during the 2023 legislative session and updates the Physician Administered Drug payment methodology to rebase rates to 100% of Medicare’s Part B Drug and Biologicals Average Sales Price payment file on a quarterly basis.		 07/01/23 06/20/23 07/20/23 07/31/23 10/05/23
23-0014 Health Home Quality Measures
Update the quality measures and associated weights for the Health Homes quality incentive payment methodology.		 06/01/23 05/08/23 06/07/23 06/21/23 09/15/23
23-0011 Care Coordination Supplemental Payment
Updates the care coordination provider list and supplemental payment amounts.		 05/01/23 04/11/23 05/11/23 05/22/23 07/28/23
23-0013 SFY24 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 2023 legislative session. 		06/01/23 05/08/23 06/07/23 06/21/23 07/26/23
23-0009 Extended Postpartum Period Coverage - CHIP
Provides 12 months continuous postpartum coverage to beneficiaries who are eligible for and enrolled in CHIP while pregnant. 		07/01/23 02/06/23 03/08/23 03/15/23 06/05/23
23-0008 Extended Postpartum Period Coverage - Medicaid
Provides 12 months continuous postpartum coverage to beneficiaries who are eligible for and enrolled in Medicaid while pregnant. 		07/01/23 02/06/23 03/08/23 03/15/23 06/05/23
22-0011 COVID-19 Vaccine, Testing, and Treatment Medicaid Assurance
Provides assurances that the state complies with the American Rescue Plan provisions which require states to cover COVID-19 testing, treatment, and vaccines.		 03/11/21 07/18/22 08/17/22 09/09/22 06/02/23
23-0010 Over-the-Counter Drug Coverage
Simplifies the over-the-counter (OTC) drug coverage language as recommended by Centers for Medicare and Medicaid Services (CMS) (does not alter coverage).		 04/01/23 03/20/23 04/19/23 05/01/23 05/25/23
23-0005 Managed Care (PCCM) Eligibility and PMPM Payments
Incorporates CMS's Managed Care template pages while adding the newly expanded adult eligibility group  and implements Per Member Per Month payments for eligible IHS, Tribal 638, Urban Indian Health, and FQHC/RHC facilities.		 07/01/23 01/23/23 02/22/23 02/24/23 05/23/23
23-0002 Medicaid Expansion – Financial Claiming
Establishes the Federal Medical Assistance Percentage (FMAP) rate for the newly expanded adult eligibility group.		 07/01/23 01/09/23 02/08/23 02/24/23 05/23/23
23-0003 Medicaid Expansion - Eligibility
Expands the current covered eligibility groups to include adults ages 18-65 with incomes at or below the FPL.		 07/01/23 01/09/23 02/08/23 02/24/23 05/23/23
23-0001 Medicaid Expansion - Alternative Benefit Plan
Establishes the benefit plan for individuals in the newly expanded adult eligibility group.		 07/01/23 01/09/23 02/08/23 02/24/23 05/23/23
23-0007 Former Foster Care Eligibility
SPA adds eligibility for former foster care children who have aged out of foster care in another state, are now a resident of South Dakota seeking Medicaid coverage.		 01/01/23 02/13/23 03/15/23 03/16/23 05/12/23
22-0014 Premium Assistance Program
Clarifies how the premium assistance program determines if assistance is estimated to be cost effective and aligns the policies with current practice.		 10/01/22 09/12/23 10/12/22 10/24/22 04/25/23
23-0004 Health Home Retiering
Implements a revised Health Home Program tier 4 payment in relation to retiering enrolled recipients.		 01/01/23 12/27/22 01/26/23 02/02/23 04/21/23
22-0015 Recovery Audit Contractors Exemption
Seeks an extension of a previous RAC exemption ending May 31, 2023.		 06/01/22 11/14/22 12/14/22 12/28/22 02/22/23

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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