Medicaid FAQ Sheets

Table of Contents 

• What Is Medicaid?
• What Healthcare Does Medicaid Cover?
• How Much Does Medicaid Cost?
• How to Qualify for Medicaid in South Dakota
• How to Apply for Medicaid in South Dakota
• How to Make Changes to Your Application
• How to Check Your Application Status
• What Happens After You Apply for Medicaid?
• How to Appeal a Denial of Benefits
• What Happens to My Medicaid If I Move?
• Need More Help?
• View or Download Our Free Guide

What Is Medicaid?

Medicaid is a federal U.S. health insurance program that provides health coverage to millions of Americans. The program primarily covers low-income adults, children, pregnant women, elderly adults and people with disabilities.

Federal guidelines for the Medicaid program are established by the Centers for Medicare and Medicaid Services (CMS). Learn more about Medicaid at a national level on the CMS website here.

The South Dakota Medicaid program is administered by the South Dakota Department of Social Services. Learn more about Medicaid in South Dakota on the Department of Social Services website here.

What Healthcare Does Medicaid Cover?

Through Medicaid, people gain access to health care services that may not be affordable without it. Additionally, some programs and benefits include special protections—such as provider networks and payment methods—that help ensure services are accessible. Medicaid also provides preventive care and other services to help people stay healthy and avoid costlier care.

Medicaid covers medical and health care services such as:

• Doctors visits
• Vision and dental care
• Family planning services
• Preventive health education
• Hearing services
• Home healthcare
• Hospice and hospital care (inpatient and outpatient)
• Maternity services
• Mental healthcare
• Nurse midwife services
• Nursing home services
• Prescription drugs
• Renal dialysis
• Transplants
• Transportation services

*Additional services, such as nursing homes or personal care services, may be available to those who have special needs.

Medicaid does not cover the following types of medical services:

• Cosmetic procedures or surgeries
• Certain dental services like braces and gold caps
• Unnecessary hospital expenses, like TV rentals or meals for guests
• Infertility services or treatments
• Recreational therapy
• Experimental treatments, supplies, equipment or drugs
• Sitter services
• Any services not covered under the State Plan for Medical Assistance

Learn more about medical and health care services that are covered by Medicaid in South Dakota on pages 1 through 5 in the Recipient Handbook here.

How Much Does Medicaid Cost?

Medicaid recipients in South Dakota may need to pay a monthly premium, which is a monthly fee for enrollment in the program. Premiums range from $0 to $15. Premium amounts are based on the recipient’s annual income.

Recipients may sometimes need to pay a small out-of-pocket cost for treatments, which are known as copayments. Copayment amounts depend on the recipient’s age, household income and what the state pays for the specific service. There is a limit to the amount you can pay in copayments each month.

Services that require copayments include the following:

• Accessing emergency transportation services or the hospital’s emergency department for non-emergency medical conditions
• Chiropractic services
• Occupational therapy
• Optometric services
• Outpatient hospital services
• Physical therapy
• Podiatry services
• Speech therapy
• *Physician office visits

*Copayments are required for physician, or doctor, office visits unless the visit is for a preventive wellness exam, immunizations, family planning, or for urgent care that is provided at an urgent care facility.

Each Medicaid participant through the South Dakota Department of Social Services has their own individual health care plan. Some participants may be required to pay fees, and some recipients may not be required to pay fees, i.e., are exempt.

Medicaid participants who fall into one of the below categories are exempt from copayment fees:

• Those younger than 19 years of age in households with incomes less than or equal to 133 percent of the Federal Poverty Level (FPL)
• Those in households with incomes less than or equal to 100 percent of the FPL
• Those receiving pregnancy-related services
• Inpatients in a hospital, nursing facility, intermediate care facility for persons with intellectual disabilities (ICF/ID), or other medical institution
• Adult participants who receive services provided under a 1915(c) waiver
• Participants who have other healthcare coverage that is the primary payer for the services provided
• Participants receiving hospice care
• Children in foster care receiving aid or assistance under Title IV, Part B of the Social Security Act
• Participants receiving adoption or foster care assistance under Title IV, Part E of the Social Security Act, regardless of age
• Women eligible under the breast and cervical cancer eligibility group
• Native American and Alaskan Native participants

To learn more about Medicaid copayments, click here.

How to Qualify for Medicaid in South Dakota

To qualify for Medicaid in South Dakota, you must meet all of the following:

• Be a resident of South Dakota
• Be a U.S. citizen or have a qualifying immigration status
• Meet the Medicaid program’s income limits

Income limits vary depending on household size, medical status and other factors and are subject to change annually. Find the current Medicaid income limits based on household size in South Dakota here.

Find further information on South Dakota Medicaid eligibility here.

How to Apply for Medicaid in South Dakota

To apply for Medicaid in South Dakota, complete the following three steps:

1. Review the application requirements and gather documentation related to your health, medical condition and household.

Learn what documents you need on the first page of the application here.

2. Choose how you are going to apply, whether online, by mail, by fax or in person.

To apply for Medicaid online, click here to access the South Dakota Benefits Portal.

To apply for Medicaid by mail or fax, click here to access the application form, fill it out, and mail it with the necessary documents to a local Department of Social Services office. Find contact information for local field offices in South Dakota here.

To apply for Medicaid in person, click here to find your nearest Social Services Office.

3. Submit your application and complete the Medicaid interview. 

If you apply in person, you will complete an interview at the time of your application submission to verify your eligibility for the program.

If you apply online, by mail or by fax, you will complete the interview over the phone.

If you have questions about the application process or require assistance, contact your nearest local South Dakota Social Services Office. Find contact information for local field offices in South Dakota here or refer to the list below.

How to Make Changes to Your Application

South Dakota Medicaid recipients must report changes that can influence their eligibility status, including:

• Income changes
• A new address
• A change in their child care provider
• Family changes (new baby, new household resident, death, etc.)
• Changes to working hours
• Marital status changes
• Changes to medical expenses
• Insurance changes
• A withdrawal of an application

To update your information:

• Submit the changes online through the South Dakota Benefits Portal here.
• Complete the change request form here and submit it:
  • By mail to a local Department of Social Services office.
  • In person at a local Department of Social Services office.

Find contact information for local field offices here.

How to Check Your Application Status

You can check the status of your application in the following ways:

• By logging into your account through the South Dakota Benefit Portal here.
• By contacting a local Department of Social Services office. Find contact information for local field offices here.

What Happens After You Apply for Medicaid?

The South Dakota Department of Social Services will review your application to verify if you are eligible for Medicaid. In some cases, the state may ask for additional information before approving your application. South Dakota will mail applicants a letter detailing if their Medicaid application was approved or denied.

It takes approximately 45 days to process a Medicaid application. If you are approved, you will receive a Medicaid identification card within 2 weeks of when you receive your approval notification.

How to Appeal a Denial of Benefits

Medicaid applications will be denied when applicants do not meet the eligibility requirements. Also, beneficiaries can have their benefits terminated or reduced if their eligibility status changes while they are enrolled.

If your Medicaid application is denied or the amount of your benefits is reduced, you have the right to file an appeal. You must send a written appeal request within 28 days of when you receive notice of the denial or benefits reduction.

You can submit your written appeal request to a local Department of Social Services office. Find contact information for local field offices here.

You can also submit your written appeal request directly to the main Department of Social Services:

• By email to admhrngs@dss.state.sd.us
• By mail to:

Office of Administrative Hearings
Kneip Building
700 Governors Drive
Pierre, SD 57501-2291

The South Dakota Department of Social Services will review your claim and may ask for additional information or evidence of your eligibility.

If you are granted a hearing, you will receive a notice with the date, time and location of the hearing. Learn more about the appeal process on page 35 of the Recipient Handbook here.

What Happens to My Medicaid If I Move?

South Dakota Medicaid recipients must report changes that can influence their eligibility status, including relocating to a new address.

If you move to a new residence within South Dakota, you can update your address by:

• Submitting the changes online through the South Dakota Benefits Portal here.
• Completing the change request form here and submitting it:
  • By mail to a local Department of Social Services office.
  • In person at a local Department of Social Services office.

Find contact information for local field offices here.

Note: Medicaid benefits do not transfer. If you move to a new state, you must reapply for Medicaid in your new location. If you have further questions about moving with Medicaid, visit the national Medicaid Contact Us here.

Need More Help?

For help with a Medicaid application or for any further questions about the Medicaid program, contact the South Dakota Medicaid eligibility:

• By phone at (605) 773-4678

• By fax at (605) 773-7183

You can also visit or call a local Social Services Office for further assistance. Find your nearest Social Services Office location and contact information here.

Click here for the Department of Social Services’ contact form.

View or Download Our Free Guide

While we are not affiliated with the government in any way, our private company engaged writers to research the Medicaid program and compiled a guide and these answers to frequently asked questions. Our goal is to help you get the benefits that you need by providing useful information on the process.

Our free Medicaid Guide is filled with helpful information about how to apply, program eligibility and how to get in touch with local offices. You can view or download our free guide here.

Last Updated: September 22, 2022