Cabinet Secretary
Matt Althoff

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School-Based Medicaid Program

Schools provide a unique opportunity to deliver health care services to Medicaid-enrolled children. The South Dakota school-based Medicaid program reimburses Local Education Agencies (LEAs) for covered direct health services and allowable Medicaid outreach and enrollment activities.

Program Purpose

South Dakota Medicaid and LEAs share the responsibility of promoting access to health care for students in the public school system and coordinating students’ health care needs with other providers.

Direct Services and Cost Settlement

South Dakota Medicaid covers the following medically necessary services provided by school districts enrolled with South Dakota Medicaid:

  • Psychological
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Audiology
  • Nursing

All services provided by school districts must meet the conditions outlined in the School District Services provider manual.

Individual claims for each direct service activity rendered to or on behalf of a student are required under the direct service program. Payment for direct service claims is limited to the federal share of a school district’s established rate. The school district is responsible for the state share of the service.

South Dakota Medicaid contacts enrolled school districts annually to establish rates. Rates are established for the period of July 1 to June 30. A school district’s rate is based on the projected cost of a service or a contracted rate.

Cost settlement will occur annually beginning in October 2026. Sivic Solutions Group (SSG) will administer the random moment time study to capture each school district’s percent of time spent performing allowable Medicaid direct service activities. The cost settlement will result in overpayments being returned to the state and school districts being reimbursed fully if the service costs more than the set rate.

Medicaid Administrative Claiming

Medicaid Administrative Claiming (MAC) allows LEAs to be reimbursed for their costs associated with school-based health and outreach activities that are not claimable under the direct service cost settlement program, including but not limited to:

  • Medicaid outreach and enrollment
  • Translation
  • Referral and coordination of care
  • Medicaid or CHIP-related training

MAC reimbursement to LEAs is made from Medicaid Federal funds.

Unlike the cost settlement program, individual claims for each administrative activity are not required. LEA staff time spent performing allowable Medicaid-related administrative activities is captured through random moment time studies administered by Sivic Solutions Group (SSG).

LEAs participating in the South Dakota MAC program must have a signed Intergovernmental Agreement with the Department of Social Services.

LEAs may opt into or out of the MAC program during any given quarter by contacting Sivic Solutions Group at SDsupport@sivicsolutionsgroup.com.

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