What Does South Dakota Medicaid Cover: Dental, Vision, and Rx

South Dakota Medicaid covers doctor visits, hospital stays, prescription drugs, dental and vision care, hearing aids, mental health and substance use treatment, pregnancy and newborn care, rehabilitation therapy, durable medical equipment, home health, hospice, nursing facility care, home and community-based waiver services, and non-emergency medical transportation. Since July 1, 2024, there are no copays for most recipients, so covered services generally cost nothing out of pocket. The only remaining cost share applies to long-term care and HCBS waiver services under post-eligibility treatment of income rules.¹

Doctor, Hospital, and Everyday Medical Care

The core benefit includes one routine annual check-up for adults, inpatient and outpatient hospital care, office exams, lab tests, X-rays, and drugs administered in a provider’s office. Most specialty care requires a referral from a Care Management provider, but the first four urgent care visits each plan year do not.²

Several additional services are built in, each with its own limits:

Chiropractic manual spinal manipulation, up to 30 sessions per plan year (July 1 through June 30).²
Diabetes self-management training: up to 10 hours upon diagnosis, then 2 hours of follow-up per year.²
Dietitian or nutritionist visits, capped at 1 hour per day and 5 hours per year, with exceptions for recipients under 21 with prior authorization.²
Family planning: office visits, birth control, STD testing and treatment, and sterilization at age 21 or older (sterilization requires a consent form signed at least 30 days ahead).²
Podiatry office visits, X-rays, and limited surgical procedures.²
Renal dialysis.³

Prescription Drugs

Most prescription medications are covered. Claims and prior authorizations run through OptumRx, and the state uses Medispan for drug pricing.⁴ Some drugs need prior authorization before the pharmacy can dispense them.

Over-the-counter medications generally are not covered. A narrow set of OTC products is reimbursable when prescribed by a physician and supplied by a manufacturer with a signed CMS rebate agreement, currently non-sedating antihistamines and pediculicides such as permethrin.⁴

Dental Coverage

Dental benefits differ sharply by age. Delta Dental of South Dakota administers claims for both groups.⁵

Children Age 20 and Younger

Covered care includes two exams, two cleanings, and two fluoride treatments per benefit year, plus X-rays, fillings, extractions, crowns, root canals, and dental sealants on permanent molars.⁵ Silver diamine fluoride is covered up to twice per tooth per year, with a lifetime maximum of four applications per tooth.⁶ Orthodontic braces are covered only in extreme cases that interfere with eating, chewing, speaking, or breathing, and require pre-approval. Partial and complete dentures are available at age 16 or older, limited to once every five years.

Adults Age 21 and Older

Adults also get two exams, two cleanings, and two fluoride treatments per benefit year, along with fillings, X-rays, extractions, and crowns. Root canals are limited to front teeth. Partial and full dentures are covered once every five years.⁵ Non-emergency adult dental services are capped at $2,000 per benefit year. Several categories are exempt from that cap: preventive services, emergency care for severe pain or infection, dentures and partials, bridges, and hospital-based dental procedures.⁷

Vision and Eye Care

Eye exams, lenses, and frames are covered for children and adults with no age restriction on exams or refractions. Covered lens types include single vision, bifocal, trifocal, and progressive lenses. Polycarbonate lenses are covered for anyone 20 or younger and for adults with a prosthetic eye, monocular vision, or corrected acuity of 20/50 or worse in one eye.⁸

Contact lenses are covered when medically necessary, for example irregular astigmatism, anisometropia greater than 4 diopters, or refractive error greater than 6 diopters. Standard contact replacements are limited to two lenses per year, and extended-wear and daily disposable contacts are not covered.⁸

Replacement glasses are covered when at least 15 months have passed since the current pair and the prescription has changed by at least 0.50 diopters, or when the glasses are broken beyond repair and returned to the provider. Children can get replacements for lost or outgrown glasses. Adults cannot get Medicaid-funded replacements for lost glasses, and must file a police report to get a replacement pair for stolen glasses.⁸

Hearing Aids and Audiology

Audiological evaluations, including bone and air conduction tests, speech audiometry, and hearing aid selection, are covered when a licensed clinical audiologist or physician performs them.⁹ Hearing aids are covered when hearing loss reaches at least 30 decibels at key frequencies. Monaural, binaural, bone-anchored (BaHa), and CROS or BiCROS aids are available depending on age. Reimbursement covers the ear mold, fitting, follow-up visits, and cleaning for 24 months, plus manufacturer warranty services.¹⁰

Replacement hearing aids generally require three years from the original fitting, an expired warranty, and documentation that the originals are no longer serviceable. Recipients 20 and younger may get earlier replacements for lost or stolen aids once the warranty has expired. Batteries are covered for full-coverage recipients who are not in nursing homes.¹⁰

Behavioral Health and Substance Use Treatment

Therapy services for the general Medicaid population are limited to 40 hours per plan year.² Community Mental Health Centers offer a broader range: individual, group, and family therapy, psychiatric evaluation and medication management, crisis intervention, peer support, psychosocial rehabilitation, and care coordination.¹¹ Specialized outpatient programs are available for children with serious emotional disturbance and for adults with serious mental illness, including the intensive assertive community treatment (IMPACT) program.¹²

Inpatient psychiatric hospitalization is covered under inpatient hospital services, including county and tribal mental health holds.¹³ Psychiatric residential treatment facility care is covered for people 20 and younger with prior authorization.¹⁴ Residential mental health treatment for adults is not a reimbursable Medicaid service in South Dakota.¹⁵

For substance use disorders, Medicaid covers screenings, assessments, and outpatient treatment.² Adult residential treatment is available at certain levels of care, including clinically managed low-intensity residential programs, medically monitored intensive inpatient programs, and intensive methamphetamine services; several of these require prior authorization. Inpatient hospitalization specifically for chemical dependency treatment is not covered.¹³

Rehabilitation Therapy

Physical therapy, occupational therapy, and speech therapy are covered when medically necessary. A physician, physician assistant, or nurse practitioner must prescribe the therapy in writing, and that prescription is valid for one year. An active written care plan must be certified by the ordering provider within 30 days of starting therapy.¹⁶

Maintenance therapy is generally not covered, though it may be approved when needed to sustain function or prevent a condition from worsening. Acupuncture, massage, dry needling, and equestrian therapy are explicitly excluded.¹⁶ School districts can also bill Medicaid for therapy provided to students under 21 when the services are written into an Individualized Education Program or Individual Family Service Plan.¹⁷

Pregnancy, Delivery, and Newborn Care

The BabyReady program covers all prenatal checkups, labor, and delivery for pregnant recipients who enroll before 32 weeks.¹⁸ Full Medicaid coverage continues for 12 months after the pregnancy ends.¹⁹ Covered obstetrical services include prenatal exams, labor management, vaginal and cesarean delivery, postpartum care, up to six depression screenings in a 12-month period, medically necessary ultrasounds, and doula services when referred by a qualified provider.²⁰ Manual and electric breast pumps are covered when natural feeding isn’t possible.

First-time Medicaid-enrolled mothers can also take part in Bright Start, which pairs them with a personal nurse from pregnancy through the child’s second birthday.²⁰ Newborns born to Medicaid-eligible mothers are automatically covered with no income or resource limit through the end of the month they turn one.²¹

Preventive Care for Children (EPSDT)

Children 20 and younger receive comprehensive preventive care under the federal Early and Periodic Screening, Diagnostic, and Treatment benefit. Well-child visits follow the American Academy of Pediatrics’ Bright Futures schedule and include a physical exam, developmental history, CDC-schedule immunizations, age-appropriate lab tests, and health education.²²

Required screenings include blood lead testing at 12 and 24 months, vision screening starting as early as age 3, hearing screening, behavioral and emotional screening at every well-child visit, and maternal depression screening at the 1, 2, 4, and 6-month visits. Fluoride varnish is covered up to three times per year for children under 21, and an oral health risk assessment is recommended by 6 months.²²

EPSDT also goes further than the adult benefit in one important way: states must provide any medically necessary service to treat a condition found during screening, even if that service is not otherwise part of the state’s standard Medicaid plan.²³

Durable Medical Equipment and Supplies

Wheelchairs, walkers, crutches, prosthetics, orthotics, and disposable medical supplies are covered when prescribed by a physician and listed on the state fee schedule. Equipment must be for home use, not for use in a hospital or nursing facility. Prior authorization is required for items like bone growth stimulators, continuous glucose monitors, and hospital-grade breast pump rentals beyond one month.¹⁰

The state decides whether to rent or purchase based on cost. Short-term needs of six months or less are typically rented; longer-term needs are purchased. Items costing less than $120 are generally purchased outright.²⁴ Backup equipment is not separately covered.¹⁰

Home Health and Hospice

Home health services are covered when ordered by a physician and provided by a Medicare-certified, Medicaid-enrolled home health agency. Covered services include skilled nursing, home health aide visits, medical social services, physical, occupational, speech, and respiratory therapy, and postpartum home visits. Visits are generally limited to one per day, no more than five days per week, and daily visits can be authorized for up to four weeks with documented need. For children under 21, those limits can be exceeded with an approved EPSDT prior authorization.²⁵

Hospice is covered for recipients certified by a physician as terminally ill with a life expectancy of six months or less. The first two benefit periods are 90 days each, and subsequent periods are 60 days, each requiring recertification. Four levels of care are available: routine home care, continuous home care during crisis periods (8 to 24 hours per day of predominantly nursing care), inpatient respite care to relieve caregivers (up to 5 consecutive days), and general inpatient care for pain or symptom management that can’t be handled at home. Adults 21 and older who elect hospice waive Medicaid coverage for other services related to the terminal condition, except care provided or arranged by the hospice or attending physician; recipients 20 and younger can continue to receive other Medicaid services alongside hospice.²⁶

Nursing Facility Care

Nursing facility care is covered for people who meet a nursing facility level of care, meaning they need daily nursing management, help with activities of daily living, or skilled therapeutic services at least once a week. Prior authorization from the Department of Human Services is required, along with a preadmission screening for serious mental illness or intellectual disabilities.²⁷

Routine services bundled into the facility’s daily rate include shelter, meals, social services, laundry, general nursing, oxygen and respiratory supplies, medical equipment like wheelchairs and walkers, and over-the-counter medications. Prescription drugs, physician visits, lab work, and mental health services can be billed separately, and facilities must also provide or arrange for routine dental care. Residents may take up to 5 consecutive reserve bed days for a hospital stay and up to 15 consecutive therapeutic leave days for personal reasons such as family visits.²⁷

Home and Community-Based Waivers

South Dakota runs four Medicaid waivers designed to help people live at home or in the community rather than in an institution.²⁸ Each serves a different population.

The HOPE waiver (Home and Community-Based Options and Person-Centered Excellence) serves people 65 and older and adults 18 and older with a qualifying disability who meet a nursing facility level of care.²⁹ Covered services include homemaker and personal care, in-home nursing, adult companion and chore services, adult day programs, assisted living, structured family caregiving, respite, home-delivered meals, nutritional supplements, emergency response systems, environmental accessibility adaptations like ramps and grab bars, specialized medical equipment, community transition coordination, and one-time transition supports up to $5,000 for people leaving an institution.³⁰

The CHOICES waiver serves children and adults with intellectual and developmental disabilities. Covered services include residential habilitation (from group homes to monitored living with remote support), supported employment and career exploration, day services, and assistive technology, capped at $5,000 per participant per year.³¹

Family Support 360 is a self-directed waiver for individuals with intellectual and developmental disabilities, including children at home and adults living independently or with relatives. Participants or guardians choose their own staff and schedules.³² Federally matched services include support coordination, respite, personal care, companion services, supported employment, environmental accessibility adaptations, vehicle modifications, specialized medical equipment and supplies, nutritional supplements, and specialized therapies such as art, music, and equestrian therapy. State-funded benefits add child care, housing assistance in crisis situations, recreation capped at $1,000 per plan year, and emergency vehicle repairs.³³

The Assistive Daily Living Services (ADLS) waiver is for individuals 18 and older with quadriplegia who can direct their own personal care. Covered services include personal attendant care, consumer preparation training, in-home nursing, respite, a personal emergency response system, environmental accessibility adaptations limited to $4,000 per plan year, specialized medical equipment, and vehicle modifications capped at $30,000 every 10 years.³⁴ Applicants must be SSI recipients or otherwise Medicaid-eligible and medically stable.³⁵

To apply for any of these waivers, contact Dakota at Home at 833-663-9673.²⁹

Transportation to Medical Appointments

Medicaid covers transportation to medical appointments and for picking up prescriptions, durable medical equipment, and optical supplies. Ambulance transport is covered only for life-threatening emergencies. Secure medical transportation handles wheelchair or stretcher access, and community transportation covers trips from home or school to providers, pharmacies, or equipment suppliers.³⁶

The Non-Emergency Medical Travel (NEMT) program reimburses mileage when you have to travel outside your city of residence for a medical appointment. Lodging and meals may also be reimbursed if the provider is at least 150 miles away and the visit requires an overnight stay. You enroll through the NEMT portal and submit a signed appointment verification form after each visit, and claims must be filed within six months.³⁷ Out-of-state travel more than 50 miles beyond the South Dakota border, other than to Bismarck, North Dakota, requires prior authorization.³⁸

Telehealth

Live video telemedicine is covered, and for behavioral health specifically, audio-only sessions are covered when the recipient lacks access to video. Telehealth services follow the same coverage rules and reimbursement rates as in-person visits. Eligible behavioral health providers include substance use disorder agencies, community mental health centers, and independent mental health practitioners. Applied behavior analysis can be delivered via telehealth, but a face-to-face visit is required within the first 30 days and every 90 days after.³⁹

What South Dakota Medicaid Does Not Cover

Several services and items are specifically excluded:

Cosmetic procedures, unless incidental to an accidental injury or needed for the function of a malformed body part.
Experimental or unproven treatments.
Acupuncture, biofeedback, and gambling addiction services.
Sterilization reversal and penile implants.
Self-help devices such as safety rails and exercise equipment, environmental control equipment like air conditioners and humidifiers, and protective outerwear.
Computers, unless used as augmentative communication devices with prior authorization.
Non-prescription vitamins, food supplements, and most over-the-counter drugs.
Gastric bypass and similar weight-loss surgeries, which require prior authorization and meet strict criteria when approved at all.
Custodial care and vocational training, except outpatient diabetes self-management education.
Inpatient hospitalization for chemical dependency treatment.

Getting services without a required referral, going past a service limit, or using an emergency room for a non-emergency can leave you financially responsible for the bill.²⁴⁰

1
South Dakota Department of Social Services. Cost Sharing
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South Dakota Department of Social Services. Medical Assistance Recipient Handbook
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South Dakota Department of Social Services. Provider Fee Schedules
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South Dakota Department of Social Services. Pharmacy Program Information
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South Dakota Department of Social Services. Dental Services
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South Dakota Department of Social Services. Children Dental Services
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South Dakota Department of Social Services. Adult Dental Services
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South Dakota Department of Social Services. Optometric and Optical Services
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South Dakota Department of Social Services. Audiology Services
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South Dakota Department of Social Services. Durable Medical Equipment
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South Dakota Department of Social Services. Community Mental Health Center Services
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South Dakota Department of Social Services. Mental Health Brochure
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South Dakota Department of Social Services. Inpatient Hospital Services
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South Dakota Department of Social Services. Psychiatric Residential Treatment Facility Services
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U.S. Department of Health and Human Services, ASPE. State Behavioral Health Conditions – South Dakota
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South Dakota Department of Social Services. Therapy Services
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South Dakota Department of Social Services. School District Services
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South Dakota Department of Social Services. BabyReady
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South Dakota Department of Social Services. Pregnancy Handbook
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South Dakota Department of Social Services. Obstetrical Services
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South Dakota Department of Social Services. Medical Programs
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South Dakota Department of Social Services. Well-Child Services
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Centers for Medicare and Medicaid Services. Early and Periodic Screening, Diagnostic, and Treatment
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South Dakota Legislature. ARSD 67:16:29 – Medical Equipment and Supplies
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South Dakota Department of Social Services. Home Health Agency Services
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South Dakota Department of Social Services. Hospice Services
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South Dakota Department of Social Services. Skilled Nursing Facilities and Nursing Facilities
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South Dakota Department of Social Services. Home and Community-Based Services
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South Dakota Department of Human Services. HOPE Waiver
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South Dakota Department of Social Services. HOPE Waiver Billing Manual
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South Dakota Legislature. CHOICES Waiver Overview
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South Dakota Department of Human Services. Family Support 360
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South Dakota Department of Social Services. Family Support 360 Billing Manual
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South Dakota Department of Social Services. Assistive Daily Living Services Billing Manual
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South Dakota Department of Human Services. Services for People With Quadriplegia
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South Dakota Department of Social Services. Transportation Services
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South Dakota Department of Social Services. Non-Emergency Medical Travel
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South Dakota Department of Social Services. NEMT Frequently Asked Questions
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South Dakota Department of Social Services. Telemedicine
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South Dakota Department of Social Services. General Coverage Principles