South Dakota Medicaid Long Term Care Programs, Benefits & Eligibility Requirements
Summary
Medicaid’s rules, benefits and name can all vary by state. This article focuses on South Dakota Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or ABD Medicaid. This is different from regular Medicaid, which is for financially limited people of all ages.
South Dakota Medicaid Long Term Care Programs
Nursing Home / Institutional Medicaid
South Dakota Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited South Dakota seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:
- Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
- Skilled nursing care
- Physician’s visits
- Prescription medication
- Medication management
- Mental health counseling
- Social activities
Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.
South Dakota Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $60/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.
South Dakota Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.
Home and Community Based Services (HCBS) Waivers
Home and Community Based Services (HCBS) Waivers will pay for long-term care services and supports that help financially limited South Dakota seniors who require a Nursing Facility Level of Care remain living in the community instead of residing in a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long term care services for South Dakota residents who live in their home, the home of a loved one, an assisted living facility, a community living home or a structured family caregiving home. While South Dakota’s HCBS Waivers will cover some long-term care services and supports in those settings, it will not cover room and board costs.
The HCBS Waiver relevant to South Dakota seniors is the HOPE Waiver.
HOPE Waiver
South Dakota’s HOPE Waiver (HOPE stands for Home and Community-Based Options and Personal Centered Excellence) provides long-term care services and supports to South Dakota residents who require a Nursing Facility Level of Care but live in their own home, the home of a loved one, an assisted living facility, a community living home or a structured family caregiving home. While the HOPE Waiver can cover long-term care benefits in those settings, it will not cover room and board costs. To determine if HOPE Waiver applicants require a Nursing Facility Level of Care, the state will evaluate the applicant’s need for daily, complex nursing procedures, their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and their need for skilled therapies and mental health services.
HOPE Waiver benefits include adult day care, chore services, home modifications, housekeeping services and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Benefits will be made available depending on the needs and circumstances of each individual.
Unlike Nursing Home Medicaid, the HOPE Waiver is not an entitlement. Instead, it has a limited number of enrollment spots (roughly 2,800 per year as of 2023), and once those spots are full additional applicants are placed on a waitlist.
Aged, Blind, and Disabled Medicaid
South Dakota’s Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to financially limited South Dakota residents who are aged (age 65+), blind or disabled. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for financially needy people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via ABD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.
South Dakota ABD Medicaid recipients can receive long-term care benefits through the state’s Personal Care Services program.
Personal Care Services
South Dakota ABD Medicaid beneficiaries who need help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and/or the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning, laundry) to live independently can receive long-term care benefits through the Personal Care Services (PCS) program. The state will screen program applicants to determine if they meet the level of care criteria.
PCS program participants must live in their own home or the home of a loved one. They can not live in adult foster care, assisted living or any other institutional setting.
PCS program will provide up to 500 hours per year of personal care assistance to program participants. This includes help with mobility, bathing, dressing, eating, toileting, household services, maintenance nursing (daily injections, blood draws, etc.) and medication management.
Like ABD Medicaid itself, South Dakota’s PCS program is an entitlement. This means that all eligible applicants are guaranteed by law to receive benefits.
Program of All-Inclusive Care for the Elderly (PACE)
PACE coordinates medical, social service and long-term care coverages into one comprehensive plan and delivery system for ABD Medicaid recipients, including Medicare benefits for those who are “dual eligible.” PACE also administers vision and dental care, and PACE day centers provide adult day care, meals, social activities and regular health checkups. PACE program participants are required to need a Nursing Facility Level of Care, but they must live in their home or somewhere else in the community. Although South Dakota does not have a PACE program of its own as of Jan. 1, 2024, there are programs in neighboring North Dakota, Nebraska and Iowa. While seniors can not use PACE programs (or receive any kind of Medicaid benefits) in other states, or transfer their Medicaid coverage from state to state, they can re-apply for Medicaid in a new state without any waiting period if they relocate. To learn more about PACE, click here.
Eligibility Criteria For South Dakota Medicaid Long Term Care Programs
To be eligible for South Dakota Medicaid, a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.
South Dakota Nursing Home Medicaid Eligibility Criteria
Financial Requirements
South Dakota residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through South Dakota Medicaid. For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for South Dakota Nursing Home Medicaid for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, South Dakota Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $60/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.
For married applicants with both spouses applying, the 2024 asset limit for nursing home coverage through South Dakota Medicaid is a combined $3,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.
Functional Requirements
The functional, or medical, criteria for nursing home coverage through South Dakota Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. The South Dakota Department of Social Services will administer a functional assessment of Nursing Home Medicaid applicants to determine if that level of care is required. The assessment will take into consideration an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning, and laundry).
South Dakota Medicaid Home and Community Based Services (HCBS) Waivers Eligibility Criteria
Financial Requirements
South Dakota residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Services (HCBS) Waivers. For a single applicant in 2024, the asset limit for HCBS Waivers in South Dakota is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for HCBS Waivers in South Dakota for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants with both spouses applying, the 2024 asset limit for HCBS Waivers in South Dakota is a combined $3,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.
Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers through South Dakota Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if HCBS Waiver applicants require a Nursing Facility Level of Care, the state will administer a functional evaluation using the Home Care Assessment tool. An applicant’s need for daily, complex nursing procedures, their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and their need for skilled therapies and mental health services are all considered when making this assessment.
South Dakota Aged, Blind, and Disabled Medicaid Eligibility Criteria
Financial Requirements
South Dakota residents have to meet an asset limit and an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid. For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for South Dakota ABD Medicaid for a single applicant is $943/month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.
For married applicants, the 2024 asset limit for South Dakota’s ABD Medicaid is $3,000 combined, and the income limit is $1,415/month combined. This applies to married couples with both spouses applying or with just one spouse applying.
Functional Requirements
The only functional requirement for basic healthcare coverage through Aged, Blind, and Disabled (ABD) Medicaid in South Dakota is being aged (65 or over), blind or disabled. For ABD Medicaid applicants/recipients who need long-term care benefits, the state will administer an assessment of the applicants and their ability to perform the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, cooking, cleaning, laundry) to determine the kind of long-term care services they require and the state will cover.
How South Dakota Medicaid Treats the Home for Eligibility Purposes
One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:
- If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage/debt) is less than $713,000 (as of 2024) then the home is exempt.
- If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives.
- If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $713,000.
These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.
South Dakota Medicaid applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in South Dakota and how you can protect your home from it, click here.
Applying For South Dakota Medicaid Long Term Care Programs
The first step in applying for South Dakota Medicaid Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.
The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that program. Applying for South Dakota Medicaid when not financially eligible will result in the application, and benefits, being denied.
During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the South Dakota Medicaid applicant. These documents will be needed for the official Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.
After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, South Dakota residents can apply for Medicaid by downloading this application and returning it to their local Department of Social Services office.
For step-by-step guides to applying for each of the 3 types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.
Choosing a South Dakota Medicaid Nursing Home
After being approved for nursing home coverage through South Dakota Medicaid, seniors need to choose which Medicaid-accepting nursing home best meets their needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes accept Medicaid, and those that do may not have available spaces. Finding the right residence can be a challenge, especially if you’re looking in a specific location.
South Dakota has about 100 nursing homes that accept Medicaid. There are a dozen or so nursing homes within 25 miles of Sioux Falls, roughly 10 nursing homes around Rapid City and five clustered around Aberdeen. Outside of the clusters near those cities, facilities are spread throughout the state, and most communities just have one.
Residents in some South Dakota communities regularly travel across state lines for personal or business reasons, including healthcare. But Medicaid coverage does not cross state lines. So, someone with South Dakota Medicaid would not be covered for nursing homes in Sioux City, Iowa, for example, even if a facility there was convenient or well-suited for the South Dakota resident.
When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The South Dakota Long Term Services and Supports webpage has a link to the latest Nursing Facility Bed Availability Report that lists all the facilities in the state by region with reports on the number of occupied beds. The healthcare professionals who work with you are another great source of information.
After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it offer social activities? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.
CMS data collected from 2019-2022 shows that nursing homes in South Dakota fare well in terms of health conditions and fire safety. South Dakota nursing homes averaged 4.5 fire safety violations per facility from 2019-2022, which is much better than the national average of 13.5. During that same time frame, nursing homes in South Dakota averaged 13.7 health deficiencies, while the national average was 25.7.