South Dakota Medicaid Office

South Dakota Medicaid office (DSS)

South Dakota Medicaid runs out of the Department of Social Services (DSS), not a stand-alone Medicaid agency. DSS handles every part of the program — eligibility through county/regional offices, the Medicaid Customer Portal at eaportal.sd.gov for online business, and a state Medicaid Customer Service line for benefit questions. Most member transactions happen through the portal or by phone; the local DSS office handles in-person paperwork.

Three phone numbers South Dakota Medicaid members should keep

Online member tools

• Medicaid Customer Portal — eaportal.sd.gov. One portal for applications, renewals, document upload, case status, and text/email notification sign-up.
• Provider Selection Tool — pcphhselection.appssd.sd.gov. Members enrolled in the Primary Care Provider Program use this to choose or change their PCP.
• HomeAgainSD — homeagain.sd.gov for Money Follows the Person transitions out of institutional care.

Member voice in policy

South Dakota Medicaid maintains two advisory bodies — the Medicaid Advisory Committee (MAC) for clinical and policy advice and the Medicaid Beneficiary Advisory Council (BAC) for member experience input. Both review program changes and recommend policy direction. Suspected provider fraud, waste, or abuse goes to ProgramIntegrity@state.sd.us.

Who qualifies for South Dakota Medicaid?

South Dakota voters approved Medicaid Expansion in November 2022 (Amendment D), and the state began enrolling expansion adults on July 1, 2023. Today's eligibility picture is 10 distinct coverage groups, each with its own income test and rules. Two unusual SD features distinguish its rule set: Medicaid Expansion adults can have private health insurance and still qualify ("with or without private health insurance"), and CHIP splits its income tests into two separate brackets — one for children with existing private insurance and a higher one for children without.

Adult coverage groups

• Medicaid Expansion - Adult Group — adults ages 19 through 64, with or without private health insurance, can qualify for FREE or low-cost South Dakota Medicaid including checkups, dental care, and vision care.
• Low-Income Families — a parent or other caretaker relative living with a dependent child. A caretaker relative includes parent, grandparent, brother, sister, stepparent, and similar. A dependent child is under 18 (or 18 if still a full-time high school student expected to graduate before age 19).

Children and pregnancy

• Children's Health Insurance Program (CHIP) — under 19, SD resident. Income tests differ for children with private insurance vs. without.
• Pregnant Women — full coverage during pregnancy; postpartum and family planning continue for 12 months following the end of pregnancy.
• Newborns — automatically eligible if born to a mother on South Dakota Medicaid; coverage runs from birth through the end of the month the child turns one, as long as the child stays in South Dakota.

Aged, blind, disabled

• Medicare Savings Program — three tiers (Qualified Medicare Beneficiary pays Part A/B premium + deductibles + coinsurance; Special Low-Income Medicare Beneficiary pays Part B premium; Qualified Individual-1 pays Part B premium). Resource limit is $9,950 for an individual and $14,910 for a couple.
• Individuals in Assisted Living Facilities, Nursing Facilities, or Homes — must be 65+ or blind/disabled, require a nursing-home level of care, monthly income at or below 300% of the SSI Standard Benefit Amount ($2,982 in 2026), and resources at or below $2,000.
• HOPE Waiver (Home & Community-Based Options and Person Centered Excellence) — joint waiver between the DSS Division of Long Term Services and Supports and DSS proper. Two tracks: one for individuals in assisted living or community home facilities, one for individuals living in their own homes. The home-living track also offers Structured Family Caregiving — a shared-living arrangement that lets the participant live with a primary caregiver.

Specialized programs

• Breast and Cervical Cancer Program — for uninsured women screened by the Department of Health's Breast and Cervical Cancer Control Program who need treatment. Annual income up to $39,125.

South Dakota Medicaid income limits and federal changes

South Dakota publishes its current monthly gross income limits per coverage group. The Adult Group (Medicaid Expansion) and Pregnancy Coverage use the same income table. CHIP splits into two separate tables based on whether a child already has private insurance. The Low-Income Families category — South Dakota's name for the historical Section 1931 parent/caretaker group — sits at a much lower income level than the expansion group.

Medicaid Expansion (Adult Group) and Pregnancy — monthly gross income

CHIP — separate income tests by current insurance status

Low-Income Families — monthly gross income

Long-term care and other categories

• Nursing Facility / Assisted Living / HOPE Waiver — monthly income limit 300% of the SSI Standard Benefit Amount ($2,982 in 2026); resource limit $2,000.
• Medicare Savings Program — resource limit $9,950 individual / $14,910 couple; income limits based on family size and adjusted income.
• Breast and Cervical Cancer Program — yearly income up to $39,125 for uninsured women in treatment.

Federal H.R. 1 changes coming to South Dakota Medicaid

On July 4, 2025, President Trump signed the Federal Reconciliation Bill (H.R. 1) into law. DSS has summarized the changes that affect South Dakota Medicaid:

*Work requirement exemptions: American Indians and Alaska Natives; SNAP or TANF work requirement participants; caretakers of a disabled person of any age or dependent child age 13 or younger; pregnancy/postpartum Medicaid recipients; people who are disabled or meet certain medical requirements; people who are currently incarcerated or were within the past 90 days.

How to apply for South Dakota Medicaid

South Dakota Medicaid keeps the application path simple: one online portal, one combined paper form, and your local DSS office. Long-term care and Medicare Savings applicants use separate paper forms designed for those tracks specifically.

Three ways to apply for general Medicaid

• Online (fastest) — apply at eaportal.sd.gov. The portal is the central tool for applications, renewals, document upload, case status, and notification preferences.
• Paper application — print the Family Self-Sufficiency Application (FSSA), complete it, and return to your local DSS office.
• In person at a local DSS office — find your local office at dss.sd.gov/findyourlocaloffice.

Specialized applications

• Long-Term Care — Form EA240 (Application for Resource Assessment, Long-Term Care, or other) for applicants who need nursing facility, HOPE Waiver, or other LTSS coverage. Submit through your local DSS office.
• Medicare Savings Program — Form 270 (Medicare Savings Application). Mail or drop off at a local office.
• Long-Term Care Partnership Program — separate state program at ltcpartnership.sd.gov that lets people who buy qualifying long-term care insurance protect a portion of their assets from Medicaid's LTC asset count.

What happens after you apply

Federal Medicaid rules give DSS up to 45 days to decide a non-disability application and up to 90 days for applications based on disability. Coverage can be retroactive — but watch the dates: starting January 1, 2027, retroactive coverage drops to 1 month for Medicaid Expansion adults and 2 months for adults and children in any other coverage group, per federal H.R. 1.

Renewals — already a yearly process, soon to be every 6 months for Expansion

DSS begins your renewal process 12 weeks before your coverage is set to end and tries to renew you automatically using available information. If more information is needed, a renewal packet is mailed about 10 weeks before coverage ends. Members complete renewal online through the Medicaid Customer Portal, by mail/fax/in person at a local DSS office, or by phone. Beginning January 1, 2027, Medicaid Expansion enrollees will renew every 6 months instead of every 12 (American Indians and Alaska Natives are exempt).

What South Dakota Medicaid covers

South Dakota Medicaid runs as fee-for-service — DSS pays providers directly. The state has not contracted with managed care organizations for its general Medicaid program. The defining structural feature is the Primary Care Provider (PCP) Program: four specific populations are REQUIRED to enroll with a PCP, who must then write referrals for almost every non-emergency service from another provider. Skipping the PCP referral is one of the most common reasons members end up with surprise bills.

Who must enroll with a PCP

• SSI recipients — blind or disabled people age 19 and older
• Parents and other caretaker relatives
• Children on Medicaid or the Children's Health Insurance Program (CHIP)
• Pregnant women

If you fall in one of these groups and don't choose a PCP yourself, DSS will assign one. You can pick or change your PCP online using the Online Provider Selection Tool; new PCP selections take effect the first day of the following month.

How PCP referrals work

Most services from any provider other than your PCP require a referral from your PCP before the service. This includes specialists, hospital services (including non-emergency ER service), and acute/urgent care visits. A referral can be a telephone referral, a physician order, a prescription, or a certificate of medical necessity — a paper card is not required. The Medicaid Recipient Handbook lists which services require a referral and which do not.

Covered services

South Dakota Medicaid pays for medically necessary services including doctor, hospital, dentist, optometrist, and chiropractor visits. Preventive care is fully covered:

• Full-coverage adults — yearly Well-Adult check-up and screenings, dental exams and cleanings, eye exam, and immunizations.
• Children — yearly Well-Child Care check-ups, dental exams and cleanings, eye exam, and immunizations.
• Pregnant women — prenatal exams and labs; pregnancy coverage is full adult coverage and continues 12 months postpartum.

Out-of-state services

Services received more than 50 miles from the South Dakota border require out-of-state prior authorization before the appointment. Within 50 miles of the border, South Dakota Medicaid pays at in-state rates without separate authorization.

Emergency room use

South Dakota Medicaid covers ER visits for serious health problems that could cause lasting injury or death — severe bleeding, chest pain, shortness of breath, severe pain, severe allergic reaction, loss of consciousness. Members are responsible for the bill for non-referred, non-emergency ER services. Acute care and urgent care clinics offer walk-in care for minor injuries and illnesses; PCP members should call their PCP before going to urgent care.

If you're getting a bill you think Medicaid should cover

Don't ignore medical bills. Common issues: you weren't eligible on the service date, the provider isn't enrolled with SD Medicaid, you didn't get a PCP referral, or the service needed prior authorization. Call DSS Medicaid Customer Service at 1-800-597-1603 to sort out the cause.

Other state Medicaid pages