South Dakota Health Insurance: Find Affordable Plans

In South Dakota, you can get affordable health insurance through government-funded programs, employers, or health insurance companies. The Medicare and Medicaid programs target low-income households, while the Health Insurance Marketplace provides options for individual and family plans.

This guide explains South Dakota’s multi-tiered health insurance system in detail.

• Marketplace plans: Any legal resident of South Dakota can purchase individual health insurance through the Health Insurance Marketplace.
• Open enrollment: You can purchase new affordable health insurance plans each year during the open enrollment period from November 1, 2021 through January 15, 2022.
• Special enrollment: Outside of open enrollment, life events such as marriage, relocation, or the birth or adoption of a child allow for a change of health plan during a special enrollment period. If you qualify for Medicaid or the Children’s Health Insurance Program (CHIP), you can sign up at any point.
• Health Insurance Marketplace: South Dakota does not have a state health exchange but operates through the federal Health Insurance Marketplace. You can sign up for health insurance plans using the HealthCare.gov platform.
• Off-market plans: Health plans are available outside the Health Insurance Marketplace directly from insurers or from other sources. In 2021, South Dakota enacted legislation allowing the Farm Bureau to sell health plans, which aren’t considered health insurance and aren’t regulated in the same way as those in the Health Insurance Marketplace.
• Coverage types: Health insurance statistics show that employer health plans cover more than 50% of South Dakota residents. Around 12.8% and 16.1% are covered by Medicaid and Medicare respectively. Military plans cover 1.8% of the South Dakota population, and 8.3% of residents are in non-group plans. Almost 10% of residents don’t have any health insurance.

South Dakota uses the federal Health Insurance Marketplace; you can enroll in a plan using HealthCare.gov. The Health Insurance Marketplace provides a straightforward four-step approach to enrolling in an affordable health insurance plan.

• First, go to the Get Coverage page. Select South Dakota and begin your application. You will be prompted for your name, email address, password, and security questions, which will allow you to create an account.
• After your account has been created, your next step is to apply for marketplace coverage. Again, the system will prompt you to enter personal and family details, including income, family size, where you live, and other relevant details.
• After applying, all of the health plans and programs you are eligible for will be listed. Plans can be easily compared using a side-by-side display of each feature (e.g., premiums and deductibles) to help you make an informed choice. The system advises whether you or your dependents qualify for Medicaid or the Children’s Health Insurance Program (CHIP). It will also let you know if you qualify for any available tax credits.
• Finally, make your plan choice and enroll.

If you cannot access the website or require assistance, HealthCare.gov provides a call center at 1-800-318-2596. Health plans can be explained to you and enrollment completed over the phone. You can also apply through a local agent or broker, or through the mail.

The process for enrolling in health insurance plans, whether individually or as a family, is essentially the same. However, when deciding on family plans, there are more issues to consider: chronic health problems, prescriptions, or specialist coverage are some questions fit, young, single individuals may not have to consider.

Insurance for individuals in South Dakota

If you are not covered by an employer job plan, you can purchase individual health plans through the Health Insurance Marketplace. Self-employed individuals without employees are also eligible for these health plans.

There are different types of plans you can choose from:

• A Health Maintenance Organization plan (HMO) offers the best choice if you don’t make many visits to a doctor or a specialist or require prescriptions. It has lower monthly premiums and higher deductibles. HMO plans are the least expensive plans. However, there are restrictions with an HMO plan. You’ll need to get a referral if you want to see a specialist, you’ll need to name a primary care physician, and you’re limited to using the HMO plan’s in-network medical providers.
• A Preferred Provider Organization (PPO) plan is a better idea if you regularly visit doctors or specialists. You’ll have more flexibility with a PPO plan, although you’ll pay more for it. You aren’t limited to in-network providers, you don’t need to name a primary care physician, and you’ll never need to obtain a referral to see a specialist.
• A Point of Service Plan (POS) is a hybrid of an HMO and a PPO. You can use out-of-network providers, but any time you want to see a specialist, you’ll need to get a referral.

The Health Insurance Marketplace in South Dakota is small, with only two health insurance carriers providing affordable individual health insurance plans: Avera and Sanford.

Both insurers offer plans ranging across bronze, Silver, Gold, and Platinum levels. Under the Affordable Care Act, all bronze through to Platinum level plans must cover 10 specified health benefits. These are:

• Diagnostic laboratory services
• Disability services and assistive devices
• Emergency services (emergency room visits)
• Maternity services (pregnancy, birth, and newborn care)
• Mental health and substance use treatments
• Out of hospital care for patients not confined to bed (ambulatory)
• Overnight hospital stays
• Pediatric care
• Prescription medications
• Preventive services and habitual disease treatment

Additionally, there is a low-cost alternative plan for covering catastrophic health events for adults under 30. In some circumstances, adults over 30 years in hardship conditions can also enroll for this health cover. Catastrophic plans are characterized by low premiums but high deductibles.

Insurance for families in South Dakota

Selecting the most suitable family health plan can be a complex exercise. Balancing the needs of the whole and every individual requires some foresight. Ask yourself such questions as:

• What if a family member develops a chronic health condition, e.g., asthma or an inherited condition?
• Is specialist care likely to be needed?
• Will the children require orthodontics such as braces?
• Is vision care, such as glasses or contacts, likely to be necessary in the future?
• Are you an athletic family likely to suffer from contact injuries?

You’ll need to decide between the affordability of monthly premium levels, annual deductible fees, and copayments for services against the available plans. For example, do you choose a higher premium plan with better service coverage, or take the chance of being out-of-pocket with a lower-cost premium plan that has a large deductible? On top of that, you may need to consider buying dental or vision plans.

A careful comparison of health plan benefits using the HealthCare.gov site comparison tool will help you make the best decision.

Plans available through the Health Insurance Marketplace are grouped into four categories — Bronze, Silver, Gold, and Platinum. Each type provides a different level of medical expense reimbursement, monthly premium levels, and deductible percentages.

Premium costs can be lower for many people in South Dakota due to subsidies. For example, health plan holders on low incomes qualify for premium tax credits. In 2020, more than 90% of enrollees qualified for these subsidies, dramatically lowering the premium cost to only $136 per month.

In 2022, average premium costs decreased in the South Dakota Health Insurance Marketplace relative to 2021.

• Bronze plans are the cheapest health insurance plans with low premiums. However, this benefit is offset by a high annual deductible and a 40% coinsurance payment for medical expenses. This type of plan is best suited to people who don’t often require medical services. The average bronze level premium in South Dakota for 2022 was $434.
• Silver plans have higher monthly premiums than bronze-level plans. However, the offset for a higher premium is a lower deductible and a lower coinsurance payment of 30%. In 2022, the average premium for Silver plans in South Dakota was $592.
• Gold plans are the highest tier of available health insurance. The higher-level premiums are offset by the lowest deductibles and the lowest coinsurance payment at 20%. The average premium cost in 2022 for Gold plans in South Dakota was $610.

South Dakota has two primary programs providing health coverage for low-income individuals and families: Medicaid and the Children’s Health Insurance Program (CHIP). Medicaid provides free or low-cost health coverage to low-income individuals of all ages, while CHIP is specifically for children under 19 from low-income households.

Medicaid in South Dakota 

Jointly funded by the federal and state governments, Medicaid is administered by the South Dakota Department of Social Services. Distinct groups of South Dakota residents are covered for mandated medical services. These include pregnant women, newborns, disabled children and adults, parent and caretaker families, and seniors.

Strict income and asset limits apply to Medicaid eligibility, with each group assigned a maximum income limit to qualify. For example, people with quadriplegia living independently have an income limit of up to $2,382 per month.

Medicaid programs cover costs for specified medical services, including:

• Diagnostic laboratory tests and x-rays
• Doctor’s visits
• Family planning
• Home healthcare
• Inpatient hospital stays and outpatient appointments
• Midwifery and pediatric care

South Dakota also provides vision, dental, and prescription drug benefits to eligible individuals.

You can apply for Medicaid via the Department of Social Services website.

CHIP in South Dakota 

CHIP (Children’s Health Insurance Program) provides health coverage for children at the state level. Often, these children are from households ineligible for Medicaid, or their parents have employer-sponsored health insurance that doesn’t cover their children. CHIP helps in these circumstances, ensuring these children can receive essential medical services.

In South Dakota, CHIP benefits are available to those under 19 from low-income households. Relevant medical services include dental care, vision assessment, and eyeglasses or contact lenses. Also included are regular doctor’s visits.

Children with or without individual health insurance can sign up for CHIP. However, different income limits apply to the two groups. For instance, a family of three with individual health insurance can only earn up to $3,423 per month before becoming ineligible for CHIP. On the other hand, the same size family without individual health coverage can earn up to $3,825 before becoming ineligible.

Special state programs in South Dakota

In addition to Medicaid and CHIP, South Dakota runs a breast and cervical cancer program and provides services beyond Medicaid for people with developmental disabilities.

•  The All Women Count! (AWC) Program provides breast and cervical cancer screening diagnostic services for low-income women.
• A Statewide Family Support Program called Family Support 360 offers assistance for families with developmentally disabled children.

The federal government regulates Medicare, which is generally for seniors 65 and over. However, Medicare can also be available for those under 65 years with disabilities or specific chronic health conditions like kidney failure.

In South Dakota, people receiving Medicare have two options:

• Original Medicare is the basic form of Medicare managed by the federal government. It consists of Part A (inpatient care), and Part B (preventive care and outpatient medical services). It pays for hospital care, preventive services, durable medical equipment, and other medical services, but does not cover prescriptions. Supplemental plans are available to help with prescription costs – these plans are known as Medicare Part D.
• Medicare Advantage (also known as Part C) provides all-inclusive packages. Hospital, medical, and prescription drug coverage are combined, effectively combining Parts A, B, and D. In addition, along with these bundled plans, insurers provide optional inclusions such as dental or vision benefits. Individual insurers can also offer Part D plans as stand-alone health packages.

If you choose Original Medicare, you can also purchase supplemental plans to extend your coverage. Medicare Part D covers prescription medications, while Medicare Supplement Insurance (Medigap) covers deductibles, copays, and other out-of-pocket Medicare costs. In South Dakota, almost 50 insurers offer Medigap plans. Federal policy obligates insurers to deliver standardized policies to cover the same basic benefits.

Eligibility

To qualify for Medicare, you must be at least 65 years old or have a qualifying disability. In most cases, a qualifying disability is a condition that makes you eligible for at least 24 months of payments from the Social Security Disability Insurance program or Railroad Retirement Board. You may be able to qualify sooner if you have end-stage renal disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Enrollment

If you start receiving your Social Security or Railroad Retirement Board benefits at least four months before you turn 65, you’ll be automatically enrolled in Medicare. Otherwise, you must fill out an application online or contact your local Social Security office. You can enroll in Medicare during the following periods:

• Initial enrollment: Your initial enrollment period starts three months before your 65th birthday and ends three months after your 65th birthday. If you’ve never had Medicare, you can enroll during this period. If you started receiving Medicare when you were younger, you can also make changes to your plan.
• General enrollment: Choose this enrollment period if you missed your initial enrollment period. The Medicare general enrollment period is January 1 to March 31. You can choose Original Medicare, Medicare Advantage, Medigap, or Part D.
• Medicare Advantage open enrollment: You can make changes to your Medicare Part C, also known as Medicare Advantage, from January 1 to March 31.
• Open enrollment: You can join, switch plans, or drop your coverage from October 15 to December 7 each year.
• Special enrollment periods: You may qualify for a special enrollment period if you lose your coverage or have changes to your eligibility outside the regular enrollment periods.

Medicare Resources

The South Dakota Senior Health Information & Insurance Education (SHINE) program provides Medicare beneficiaries, their families, or their caregivers with free, unbiased, and confidential advice and counseling on their Medicare options in South Dakota. This includes providing information about Original Medicare, Medicare Advantage Plans, Medicare Part D, and other aspects of Medicare. These trained and certified counselors can also help you with other health insurance questions and will never try to sell you a plan.

Short-term health insurance in South Dakota is limited to an initial period of fewer than 12 months with renewals allowed. Thus, the total length of cover, including renewals, can go up to 36 months. Short-term health insurance plans can be a cheap health insurance alternative to traditional health insurance, but these plans are often limited and aren’t required to meet Affordable Care Act standards.

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• All Women Count! (AWC) Program | Last accessed November 2021
• Family Support 360 | Last accessed November 2021
• Farm Bureau to sell non-insurance plans in the state | Last accessed November 2021
• Final Administrative Rules for Short-term Health Insurance | Last accessed November 2021
• Health Insurance Statistics for South Dakota | Last accessed November 2021
• How do I apply for South Dakota Medicaid? | Last accessed November 2021
• How much does health insurance cost in South Dakota? | Last accessed November 2021
• How to compare Medigap policies | Last accessed November 2021
• If you’d like to change to a Marketplace plan | Last accessed November 2021
• Mandatory & Optional Medicaid Benefits | Last accessed November 2021
• Medical Programs Available in South Dakota | Last accessed November 2021
• Medical Programs Available in South Dakota | Last accessed November 2021
• Medicare | What’s Medicare Supplement Insurance (Medigap)? | Last accessed November 2021
• Qualifying events that can get you coverage | Last accessed November 2021
• Short-term health insurance in South Dakota | Last accessed November 2021
• South Dakota Health Insurance Marketplace: history and news of the state’s exchange | Last accessed November 2021
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• Understanding Medicare Advantage Plans | Last accessed November 2021