Cabinet Secretary
Matt Althoff
Medicaid Provider Care Management
South Dakota Medicaid offers three care management programs designed to enhance the quality and coordination of care for Medicaid recipients. Most Medicaid recipients participate in one of these programs, and providers may engage in one or more of them. Each program targets specific populations with goals that include:
- Improving the quality of care
- Coordinating healthcare services and improving health outcomes
- Containing costs
Designated Providers
These programs assign recipients a designated provider responsible for delivering primary and routine care. Designated providers also coordinate specialty healthcare needs, including making referrals to specialists. Providers can view their caseload of assigned recipients through the Provider Portal, with updates available by the 2nd of each month.
Referral Requirements
To promote effective care coordination, all three programs require referrals for services provided by someone other than the recipient’s designated provider. However, recipients can access certain exempt services without a referral. For detailed information, refer to the Referral Manual.
Selecting or Changing Providers
Providers with recipient approval, can select or change their care management provider online through the Online Selection Tool .
For further assistance, contact South Dakota Medicaid or visit the resources linked above.
Primary Care Provider Program
The Primary Care Provider (PCP) Program is South Dakota Medicaid’s general care management program, with most Medicaid recipients participating. Unlike the other care management programs, eligibility for the PCP Program is not based on specific health conditions or statuses.
Role of Primary Care Providers
PCPs in the program are responsible for delivering comprehensive primary healthcare services to Medicaid recipients enrolled in their practice and listed on their caseload. Key responsibilities of PCPs include:
- Providing 24/7 access by telephone for information, referrals, and treatment during non-office hours
- Managing the healthcare of recipients on their caseload
PCPs receive a monthly case management fee for each recipient on their caseload. This payment is in addition to reimbursement for any covered services the PCP provides.
Enrollment Process
To participate in the PCP Program, providers must complete the PCP Addendum as part of the South Dakota Medicaid Provider Agreement.
Health Home Program
The Health Home Program provides enhanced care coordination services for Medicaid recipients with chronic conditions. This program aims to improve health outcomes and streamline care for individuals managing conditions such as:
- Asthma
- COPD
- Diabetes
- Heart disease
- Hypertension
- Obesity
- Substance use disorders
- Mental health conditions
- Pre-diabetes
- Tobacco use
- Cancer
- Hypercholesterolemia
- Depression
- Musculoskeletal and neck/back disorders
Core Services and Program Objectives
Health Home providers deliver "core services," which focus on:
- Reducing inpatient hospitalizations and emergency room visits
- Integrating physical and behavioral health services
- Enhancing transitional care between institutions and the community
Providers receive a monthly case management fee for each recipient who uses a core service within a quarter. Additionally, Health Homes may qualify for an annual quality incentive payment. These payments are supplementary to reimbursement for any covered services provided.
Enrolling as a Health Home Provider
Providers interested in joining the program must enroll as part of a clinic by completing the Health Home Application. Individual providers within the clinic are also required to complete an Attestation Form.
For more details, visit the Health Home Program webpage.
BabyReady Program
The BabyReady Program is designed to enhance maternal health outcomes by providing improved care coordination, ensuring services align with established standards of care, and reducing barriers to care.
Provider Responsibilities and Benefits
Participating providers are responsible for coordinating care for recipients on their caseload. Providers receive:
- A monthly case management fee for care coordination
- Enhanced reimbursement for meeting prenatal and postpartum care program objectives
These payments are in addition to standard reimbursement for any covered services provided by BabyReady providers.
Enrollment Process
Providers interested in the BabyReady Program must enroll as part of a clinic by completing:
Additionally, individual providers within the clinic must complete an Addendum.
For more information, visit the BabyReady webpage.
Key Resources
- Diagnosis Look-up Tool
- Fee Schedules
- Prior Authorizations
- Procedure Code Look-up Tool
- Provider Manuals
- Provider Enrollment