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FAQs

Common Questions about Medicaid Expansion

What documents do I need to apply?

Individuals may apply for Medicaid online, by mail, or in person. You will need the following documents to apply.

  • Medicaid application.
    • If applying online, you will fill the form out on the web.
    • If applying by mail, you can either print it or request a Department of Social Services (DSS) office mails it to you.
    • If applying in person, you can fill it out ahead of time or at the DSS office.
  • Name, date of birth, and Social Security Number for all applying
  • Employer information and income documentation. Examples include paystubs, W-2 forms, or wage and tax statements
  • Current health insurance information, if applicable

I didn’t qualify previously. Should I apply again?

Medicaid coverage group has expanded to adults. If you applied, even a few months ago, you may be eligible with Medicaid Expansion.

  • People 19-64 with or without children
  • Live in South Dakota
  • Be a US citizen or a qualified immigrant
  • Have or have applied for a Social Security Number (SSN)
  • Not eligible or currently enrolled in Medicare
  • Income limit (based on household size) up to and including 138% of the Federal Poverty Limit.

*Assets (or resources) are not considered when eligibility is determined for Medicaid Expansion.

Can I still qualify if I don't have a home address?

You do not need to have a home address to apply.

For correspondence, applications must include a mailing address where you are able to receive mail.

How long will it take for me to find out if I'm approved?

In most cases, applicants will receive a letter in the mail telling them if they are eligible or not within 45 days. If you are eligible, you will also receive a South Dakota Medicaid card.

What if my application is found not eligible for Medicaid, including Medicaid Expansion?

If you are found not eligible, your information will be automatically transferred to the Marketplace, which will send you mail. You can also go directly to Healthcare.gov and start a Marketplace account. After creating an account or logging in, select “Find my application” to complete and submit a Marketplace application (an application number will be on the letter the Marketplace mailed to you).

Need help figuring out the Marketplace? Our unbiased navigators are trained to help people understand and find the best option for their healthcare needs.

 

 

If I have a Marketplace plan and may be eligible for Medicaid Expansion, will I be automatically approved for Medicaid Expansion?

No. If you have a Marketplace plan and believe you are eligible for expansion, apply for Medicaid. Do not end your Marketplace plan before you get a final decision on Medicaid eligibility.

If you are approved for Medicaid or CHIP, you will need to cancel your Marketplace plan.

 

What health services does Medicaid cover?

Essential benefits covered under Medicaid

  1. Preventive services, wellness services, and chronic disease management
  2. Outpatient care
  3. Hospitalizations
  4. Pregnancy including maternity and newborn care
  5. Mental health and substance use disorder services including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Pediatric services, including oral and vision care
  10. Emergency services

The federal government regulates the copay amount that may be charged in Medicaid. Some examples of copays are

  • $50 for a hospital admission
  • $3.00 for a physician visit
  • $3.30 for brand-name drugs

At this time Medicaid expansion does not cover or fully cover these services at this time.

  1. Dental
  2. Optometry
  3. Eyeglasses

For more information on covered services visit

https://dss.sd.gov/formsandpubs/docs/MEDSRVCS/MedicalAssistanceRecipientHdbk.pdf

What coverage is available to my children if I have insurance provided by my employer?

If your employer provides health insurance coverage for you, your spouse and/or children could potentially qualify for Marketplace plan savings OR Medicaid/CHIP. 

Marketplace Coverage

Marketplace coverage is available with premium tax credits if the coverage offered by your employer is deemed “unaffordable”. If the premium for your spouse and dependent children is more than 9.12% of your modified adjusted gross income, you could qualify for premium subsidies (Employer Health Plan Affordability Calculator).

Medicaid or CHIP Coverage

Medicaid coverage is available for children, based on income and household size (Medicaid & CHIP Income Guidelines). This coverage is available even if you have private or employer funded coverage.

If I’ve been denied Medicaid coverage, are my kids still eligible?

Medicaid eligibility is typically determined separately for adults and children. The fact that an adult in the household has been denied Medicaid coverage does not automatically affect the eligibility of their children.

Eligibility for children is primarily based on the income and household size of the child’s custodial parent(s) or legal guardian(s). South Dakota also offers Children’s Health Insurance Program (CHIP), providing healthcare coverage to children in low-income families. CHIP programs often have higher income limits than Medicaid and can cover children who do not qualify for Medicaid.

To determine if your children are eligible for Medicaid or CHIP, you should submit a separate application for them. This application will assess their eligibility based on their specific circumstances, such as income, household size, and age.

Can I qualify for Medicaid if I have Medicare coverage?

Having Medicare does not automatically exclude you from Medicaid coverage. However, it can complicate your eligibility and the coordination of benefits. It is possible to have both Medicaid and Medicare coverage. This is known as “dual eligibility.” If you meet the requirements for both programs, you can benefit from the combined coverage.

To be eligible for both Medicaid and Medicare, you need to meet the income and asset limits set by your state for Medicaid. You must also meet Medicare’s eligibility criteria, which include age or disability status.

To apply for both programs, you should start by applying for Medicare through the Social Security Administration (SSA). Once you have Medicare, you can contact 211 to apply for Medicaid benefits.

  • People with Medicare coverage do not qualify for Medicaid expansion, but may qualify for other Medicaid programs such as the Medicare Savings Program which pays for Medicare Part A and Part B premiums, deductibles and coinsurance. 
  • LEARN MORE

Common Questions about Health Insurance and the Marketplace

How do I know which insurance plan is right? 

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With so many options it can be hard to know which health insurance plan is right for you.
Luckily the health insurance marketplace has plans that fit your budget and meet your needs.
Find a plan that suits your lifestyle.
Balance how much you pay each month with how much health care you normally need.
For example, if you’re healthy and don’t see a doctor often a plan with a low monthly payment may be right for you.
Have more questions? Meet your navigator today.

What health insurance terms should I know?

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When it comes to health insurance you might be wondering what words should i know?
Let’s start with premium. That’s how much you pay each month for health insurance.
Tax credits can lower your monthly payment and are only available through the marketplace.
Open enrollment is the time each year when people can sign up or change a health insurance plan.
A navigator is a trained individual who helps people sign up for health insurance.
Have more questions? Meet your navigator today.

Can I get health insurance outside of Open Enrollment?

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You might be wondering, can I get health insurance any time of the year?
Well, the answer varies. Open enrollment is the time each year when people can sign up for a health insurance plan.
Special enrollment is the time outside open enrollment when people qualify based on life events. Some events that may make you eligible include losing coverage, having a child, or getting married.
Members of federally recognized tribes can enroll in a plan anytime up to once a month and apply for Medicaid or chip if eligible.
Have more questions? Meet with a navigator today.

How do I know if I qualify for the Health Insurance Marketplace?

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A question commonly asked is how do I know if I qualify for savings through the health insurance marketplace?
To be eligible for savings through the marketplace, you must live in the U.S., be a U.S. citizen or national and have an income that qualifies you for savings.
If you are eligible for health insurance through your job, you may not qualify.
When you purchase health insurance through the marketplace you may be eligible for tax credits. These tax credits help lower your monthly payments for health insurance.
Have more questions? Meet your navigator today.

For More Info

This page is supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,600,000 with 100 percent funded by CMS/HHS. The content are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.