South Dakota

In South Dakota:
  • There were a total of 120,474 beneficiaries enrolled in South Dakota Medicaid as of July 2011. Of these, 91,268 were enrolled into the primary care case management system (PCCM) program, called the Provider and Recipient in Medicaid Efficiency Program (PRIME). South Dakota delivers physical health services through PRIME. Enrollment in the program is mandatory for certain Medicaid populations, including children in families receiving TANF, children covered by CHIP, children from families that qualify for the state’s Low Income Families Program, adults receiving SSI, and women eligible for low income pregnancy coverage. Only a few categories of beneficiaries are excluded, including children with special health care needs. Those not enrolled in the PRIME program receive their health services through a fee-for-service program.
  • Medicaid dental benefits are provided on a fee-for-service basis. Delta Dental serves as the state’s dental claims administrator.
  • The state provides 1915(c) waiver services to Medicaid beneficiaries of all ages with developmental and intellectual disabilities through the Family Support 360 program. Family Support 360 provides personal and respite care, service coordination, and additional services to help beneficiaries remain living at home or in the community.

As of 2012, South Dakota had 94,471 individuals (aged 0 – 20) eligible for the Well-Child Care program, the state’s Medicaid benefit for children and adolescents (known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, the state achieved a screening ratio of 62% and a participant ratio of 48%. In 2012, 40,990 individuals received a dental service with 37,012 receiving preventive dental services.


Last updated January 2014.

Medical Necessity
South Dakota’s Medicaid program has a single medical necessity definition for all services. It does not have distinct definitions for children, oral health services, or behavioral health services. According to the state’s administrative rules, a service must meet the following criteria to be considered medically necessary:
  1. It is consistent with the recipient’s symptoms, diagnosis, condition, or injury;
  2. It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider’s peer group;
  3. It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;
  4. It is not furnished primarily for the convenience of the recipient or the provider; and
  5. There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.”
Initiatives to Improve Access

Reporting & Data Collection
South Dakota’s Medicaid program relies on fee-for-service claims submissions to gather data on the EPDST benefit. Dental claims are processed by Delta Dental, which transfers claims data back to the Department of Social Services
The Department of Social Services offers providers a list of well-child billing codes on its website that crosswalks each screening code to the state’s EPSDT periodicity schedule.
The state collects effectiveness of care measures to monitor PCCM providers on a number of clinical standards including immunization status, asthma control, and follow-up after hospitalization for mental illness.  The state also utilizes the complaint resolution process, recipient surveys, twenty-four hour access surveys, and caseload monitoring to identify quality and (or) access issues among providers.
Behavioral Health
South Dakota manages its behavioral health services through the same primary care case management (PCCM) system it uses to deliver physical care. The Division of Community Behavioral Health oversees children’s behavioral health services. A Behavioral Health Services Work Group was formed in to help South Dakota think about how to leverage all of its available resources, including Medicaid. The workgroup’s final report was released in 2011.
The South Dakota Department of Education’s Birth to 3 Connections program provides a range of early intervention services to children who have a disability or a developmental delay, including delays In social and emotional development. Beginning in 2008, the Department of Education instructed the state’s Birth to 3 providers to enroll with South Dakota Medicaid in order to obtain reimbursement for eligible children.
Support to Providers and Families
Support to Families
South Dakota Medicaid operates a recipient information page for the state’s Well-Child Care program. The page contains an FAQ on covered services, suggested Well-Child exam schedules, locating Medicaid providers, and reminders on how to keep children healthy.
South Dakota also produces a Recipient Handbook for Medicaid beneficiaries. In addition to providing a general overview of the state’s Medicaid program, the handbook contains sections dedicated to baby care and well-child care. The well-child care materials include a suggested check-up schedule and an immunization schedule that serve to make parents aware of the Bright Futures periodicity schedule adopted by the state.
Support to Providers
South Dakota Medicaid operates a provider page on its website that includes resources for providers, such as the state’s EPSDT administrative rules, Preventive Screening Codes, and the Professional Services Billing Manual, which provides information on EPSDT services, screening schedules, billing, and claim requirements. The state has incorporated the American Academy of Pediatrics’ Bright Futures guidelines into its guidance to providers on well-child care.
Care Coordination
Primary Care Case Management (PCCM)
Medicaid enrollees in the PCCM program are required to select one primary care provider who is responsible for providing primary care services, referrals for necessary specialty services, and monitoring the health care and utilization of all managed care covered services.
Oral Health
Support to Families
The South Dakota Department of Social Services prepared a set of Dental Frequently Asked Questions (FAQs) for Medicaid beneficiaries. The FAQ contains information on dental shortages and makes recommendations for beneficiaries who are having trouble finding a dentist who accepts Medicaid. The Department of Social Service’s website also contains a link to the federal website to help beneficiaries find a Medicaid-participating dentist in their area.
Bright Futures Curriculum
The American Academy of Pediatrics’ Bright Futures periodicity schedule is explicitly referenced in South Dakota’s administrative rules. These rules specify that dental screenings under the EPSDT benefit must be completed according to the following schedule:
“(3)  For dental healthcare, a dental screening by a dentist when the child is one year old. After the age of one, the dental screenings follow the schedule established under subdivision (1) of this section.”