Covered Services and Payment Information

This is important information for you, please take the tie to read this and keep it for future reference.  If you have questions regarding eligibility call your local Department of Social Services Office (DSS)/caseworker.  If you have questions on Medicaid's covered services, call South Dakota Department of Social Services, Office of Medical Services at (605) 773-3495.

The Medicaid program, also known as the Title 19 program, provides medical assistance to low income people who meet eligibility standards.  The program is financed jointly by State and Federal Government and is managed by the South Dakota Department of Social Services.

The eligibility categories within Medicaid include:

1.    SSI recipients: (aged, blind and disabled), and nursing home residents who meet financial requirements;

2.    Members of families eligible for Temporary Assistance for Needy Families (TANF), or qualified low income families;

3.    Low income qualified Medicare individuals;

4.    Low-income children;

5.    Low-income pregnant women; and

6.    Foster children.

Certain South Dakota Medicaid eligible recipients are required to participate in the Managed Care Program.  The South Dakota Medicaid Care program is designed to improve access to medical care as well as improve the quality of medical care you receive.  Medicaid managed care recipients are required to receive managed care covered services from their Primary Care Provider (PCP) and/or have medically necessary managed care specialty services prior referred/authorized by their Primary Care Provider.  

For more information on Managed Care, ask your local Department of Social Services (DSS)/caseworker for the Managed Care Information hand-out.

The eligibility categories which participate in managed care include:

1.    SSI recipients: blind, disabled and meet financial requirements;

2.    Members of families eligible for Temporary Assistance for Needy Families (TANF), or qualified low income families;

3.    Low income children; and

4.    Pregnant women.

NOTE:  If you have Medicare or live in an institution (including a medical facility such as a nursing home), you will not be enrolled in the Managed Care Program.

If you are in Managed Care, you will be notified by your caseworker that you must choose a Primary Care Provider.  (A Primary Care Provider or PCP is the physician or facility chosen by you or assigned by the Department to provide primary care case management services.)  Your caseworker will give you a selection form and a list of Primary Care Providers in your area.  You then need to complete the form by choosing a PCP for each eligible member of your family.

Once you are eligible, you will receive a Medicaid identification card.  You must show your identification card before you receive medical services.

You must have your Medicaid card anytime you get medical care.  You should carry your Medicaid card with you at all times.  failure to present your Medicaid card is cause for payment denial.  Payment for such denied services becomes your responsibility.  If you are a manages care recipient and get medical services before you get your PSP's approval, Medicaid may not cover the costs, and you may be responsible for paying the bill.ical Bills Get Paid?

When you receive a covered service by a provider (doctor, hospital, etc.), the provider will submit a bill to Medicaid for payment.  Medicaid will not make payment to the recipient.  Medicaid will pay the provider directly.

When Medicaid makes a payment for a covered service, that particular service is considered paid in full.  The provider can NOT bill any remaining balance of the covered service to the recipient, their family, friends or political subdivisions.  However, the provider can bill for any cost sharing charges allowable under the Medicaid program.  Cost-sharing participants include those individuals who are at least 18 years of age and who are not residents of a long-term care facility or recipients of home and community-based services on the date covered service was provided.  Services relating to pregnancy, family planning, nutritional therapy and nutritional supplements for individuals under age 21, and emergency hospital services are exempt from cost sharing.

If the service is not covered by Medicaid, then you are responsible for the payment in full.

Anytime a Managed Care recipient is seen by their Primary Care Provider, Medicaid will pay their cost-share.  This is only effective if the recipient sees the PCP as indicated on the recipient file.  If does not include if a recipient is referred to another doctor by their PCP or if the recipient is seen through an in-house referral.ork Plan

South Dakota Medicaid recipients who choose to go out of their private health insurance network plan for services, need to be aware that South Dakota Medicaid may not make reimbursement for the services that are provided out of their private health insurance network.

It is your responsibility to ask your medical provider if the particular service he is providing to you is covered by the Medicaid program.  Many covered services have limitations or restrictions.  Do NOT assume that all of the medical services you receive are covered and paid by Medicaid.

Nursing Home:    

Covers room and board, nursing care, therapy care, meals, and general medical supplies, Medicaid will not pay for Durable Medicaid Equipment for residents in a nursing home.

Physician:    

Covers medical and surgical services preformed by a doctor; supplies and drugs given at the doctors office; and X-rays and laboratory tests needed for diagnosis and treatment.

Hospital:    

Inpatient:    Covers room and board, regular nursing services, supplies and equipment, operating and delivery rooms, X-rays, lab and therapy

Outpatient:    Covers emergency room services and supplies, lab, X-rays and other radiology services, therapy care, drugs and biologicals, and outpatient surgery.

Managed Care Recipient: "True" Emergency services are covered under Medicaid without a PCP's referral/authorization.  However, just because a service is provided in the Emergency Room, doesn't necessarily mean it is a "True" Emergency.

Before going to the hospital emergency room, you should contact your Primary Care Provider at the telephone number listed on your Medicaid identification card.  They can authorize the service or provide an alternative.  There will be someone available 24 hours a day, 7 days a week.

If you go to the emergency room without your PCP's authorization, THE HOSPITAL WILL NOT REFUSE TO SEE YOU.  If the emergency room doctor determines your services "NON-EMERGENCY SERVICES", Medicaid WILL NOT pay for the services.  You will be responsible to pay for those 'non-emergency" or clinic services.

Prescriptions:

Covers a large range of, but not all prescription drugs, insulin, family planning prescription, supplies, and devices.  A prescription is required by a doctor.  The pharmacist will know if a particular drug is paid by Medicaid.

Managed Care Recipients:  If the prescription is written by anyone other than your PCP, and the service is not an emergency, you must have a proper referral/authorization from your PCP or on call PCP.

Prescriptions for emergency services must be properly noted on the prescription by the prescribing physician.

Telephone prescriptions are allowed at the discretion of the prescribing physical.  When the prescribing physician is someone other than your PCP, the proper referral/authorization information must be provided to the pharmacist.

Vision:

Covers exam, glasses, frames, and contact lens when necessary for the correction of certain conditions.  You may receive replacement eyeglasses if a minimum of 15 months has passed since the present eyeglasses were received and a lens change is medically necessary.  An exception is made when new eyeglasses are required because of a change in correction of a least .5 diopters.

Family Planning:

Covers diagnosis and treatment, drugs, supplies, devices, procedures and counseling for persons of childbearing age.

Sterilization:

Covers sterilization procedures when all the following criteria is met:

1.    The recipient is at least 21 years old;

2.    The recipient is a legally competent individual;

3.    The recipient has signed an informed consent form after the recipient's 21st birthday; and 

4.    At least 30 days but not more than 180 days have passed between the date the informed consent form was signed and the date of the sterilization.

Podiatry:

Covers office visits, supplies, X-rays, glucose and culture check, and a wide range of surgery procedures.

Dental:

Covers exams and X-rays, cleaning, filling, surgery, extractions, crowns, root canal, dentures (full & partial), and anesthesia.

Ambulance:

Covers ground and air ambulance trips, attendant, oxygen, and loaded mileage (plus some other necessary services) when medically necessary to transport the recipient to the closest medical provider capable of providing the needed care when any other means of transportation would endanger the life of the recipient.

Wheelchair:

Covers non-emergency transportation services for medical treatment, to and from the recipient's home to a medical provider, between medical providers or from a medical provider to the recipient's home.  The recipient must be confined to a wheelchair to receive this service.

Other Transportation Services:

Covers non-emergency transportation services to and from the recipient's home to the closest medical provider capable of providing the medically necessary examinations or treatments,  These in-state and out-of-state transportation services are limited to the closest provider and are not based on the locations of the PCP chosen by the recipient or PCP referral/authorization that are not to the closest provider.  Meal and lodging allowances are made only if an overnight stay is required and any mileage allowance is limited to miles traveled out-side the city limits.

Covers reusable equipment that is primarily medical in nature.  The item must be medically necessary.  EQUIPMENT NOT COVERED INCLUDES: exercise equipment, protective outer ware, personal comfort or environmental control equipment such as air conditioners, humidifiers, dehumidifiers, heaters or furnaces.  Medical equipment is provided to nursing home residents by the nursing home.  Medicaid pays for this equipment through the payment through the payment to the nursing home.  Exceptions:  Hearing aids are covered even for individuals in nursing homes.  Replacement hearing aids may be provided only after a minimum of three years has elapsed since the original fitting and as long as the original hearing aids are no longer serviceable.

Out Of State Coverage:

If you have to go to an out-of-state provider, you must be sure of the following:

1.    The provider is a South Dakota Medicaid Provider;

2.    If you are a managed care recipient, you have a referral/authorization from your PCP; and 

3.    The services are covered under South Dakota Medicaid guidelines.  Ask your PCP if a service is covered.

Medicaid will cover out-of-state medical emergency services with the same limits as in-state services should that provider agree to enroll as a South Dakota Medicaid Provider.

EPSDT:

Covers screening and diagnostic services to determine physical or mental status, and treatment to correct or eliminate defects or chronic conditions.  Also covers certain medical equipment, nutritional therapy, treatment for alcohol and drug chemical dependency, additional dental services and orthodontia (teeth braces), and inpatient psychiatric care.  Several of these services require prior authorization from the Department of Social Services (State Office).  Be sure to check with your provider regarding these requirements. 

EPSDT screens help prevent health problems from occurring (or help keep health problems from becoming worse) and are very important services for your children.  Take your children to your doctor for a regular EPSDT check-ups.

*Prescriptions written by these providers require a referral/authorization from your Primary Care Provider.

Questions about eligibility, please contact your local Department of Social Services.

Questions concerning covered services, contact your medical provider, or the Office of Medical Services in Pierre at (605) 945-5006.  You may also visit our website at http://www.state.sd.ud/medical (for Medicaid) or at http://www.state.sd.us/chip (for CHIP).

The Department of Social Services and your medical provider may not discriminate against you because of your race, color, creed, religion, sex, ancestry, national origin, handicap, diagnosis or condition, financial or marital status.  If you feel you have been discriminated against, call the Department of Social Services' Personnel Office at (605) 773-3777.

If you feel the Department of Social Services made an incorrect eligibility or payment decision, you may request a fair hearing by contacting the local Department of Social Services Office or by contacting the Office of Administrative Hearings in Pierre at (605) 773-3701.

If you knowingly make a false statement or representation to become eligible for Medicaid or use Medicaid, or fail to provide all required information (including potentially liable third parties) you may be prosecuted under state criminal laws and federal fraud and abuse laws.

If you notice any discrepancies in your medical bills, or if you are billed a balance (other than your cost share) after Medicaid has made payment, please contact the Office or Medical Services in Pierre at (605) 772-3495.

Any payment of medical assistance by or through the Department of Social Services to an individual who is an inpatient in a nursing home, an intermediate care facility for the mentally retarded, or other medical institution, is a debt due the Department.

Any payment on behalf of any person fifty-five years of age or older for nursing facility services, intermediate care facility services for the mentally retarded, hospital, and Prescription drug services, is a debt due the Department.

The above debts may also be recovered from the estate of the surviving spouse of a medical assistance recipient.  For more information please contact the Department of Social Services, Office of Recoveries and Investigations (605) 773-3653

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