1. DSS Updates

2. Who is Eligible for Medicaid?
Provide Healthcare Coverage: 118,674 (SFY16 Average Monthly)
Low income children, pregnant women, adults and families
Elderly or disabled
Children in foster care
Adult coverage is limited to:
Parent/Caregiver/Relatives of Low Income Children - 52% FPL (family of three $10,560 annual income)
SFY 2016 Average Monthly Eligible South Dakotans:
Aged/Blind Adults – 6,919
Disabled Adults – 16,196
Pregnant Women (pregnancy only) – 1,210
Low-income Adults – 13,136
Children of Low-income Families Title XIX – 67,680
(Disabled Children 3,026)
Children covered by CHIP – 13,533
Total Average Monthly – 118,674
Nearly 1 of every 7 South Dakotans in any given month will have health coverage through Medicaid or CHIP
1 of every 3 children under the age of 19 in South Dakota has health coverage through Medicaid or CHIP
50% of children born in South Dakota will be on Medicaid or CHIP during the first year of their life
35.5% of South Dakota Medicaid enrollees are Native American
Medicaid Participation
SFY 2016
Medicaid Participation by Eligibility Category
SFY 2016 – 118,674

3. Medicaid Enrollment and Expenditures

4. Budget Updates

5. FY17 Budget 2.7% Provider Inflation
3 year plan to align provider rates to 90% of methodology
Additional funding for the following groups
Assisted Living
In-Home Services (homemaker, personal care, nursing)
Ambulance Services
Outpatient Psychiatric
Inpatient Psychiatric

6. BRCA Testing & Preventative Treatment
Breast & Cervical Cancer (BRCA) Testing and Preventative Treatment
Almost 15% of ovarian cancers and 5-10% of breast cancer cases can be traced to mutations in the BRCA1 and BRCA2 genes.
Women with BRCA gene mutations have a 55-65% risk of developing breast cancer by age 70 compared to a 12% risk in the general population.
Prior authorization required for both the test and treatment and based on experience in other states, it is unlikely that approved tests would exceed 10% to 25% of total potential BRCA-positive recipients.
Some recipients may elect to more frequently monitor their health with screenings before turning to preventive surgery or elect to take chemoprevention drugs.

7. BRCA Testing & Preventative Treatment
Full cost for Cancer treatment can cost over $958,000.
Projecting initial costs for testing and treatment for 17 women.
$33,618 for Testing – per individual approximately $1,978
$610,473 for Treatment – per individual approximately $35,910

8. FY18 Budget Provider inflation 1%
Additional funding to support 3 year plan for 90% of methodology cost.
Governor Daugaard recommending funding to complete the second half of year 2.
Ambulance
Assisted Living
In-Home Services (including homemaker and nursing services)
Outpatient Psychiatric Services (Medical Services)
Group Care (CPS)
You can find the summary that includes all provider groups online at :

9. FY18 Budget
FY18 Recommended Budget Outpatient Hospital Reimbursement Methodology Change ($1.1 million total funds)
Medicare Critical Access Hospitals
Funding for 14 outpatient hospitals defined federally as Medicare Critical Access.
Makes reimbursement more consistent among this group consistent with Medicare methodology.
Ambulatory Payment Classification (APC)
Implemented (APC) methodology for larger hospitals in CY2016 to align with Medicare.
Year 1 (SFY2017) budget neutral.
Funding for FY18 requested to partially mitigate revenue impacts.

10. Medicaid Federal Policy Changes

11. Medicaid Federal Policy Change
When American Indians eligible for Medicaid receive healthcare “through” IHS, the federal government pays 100%
When American Indians eligible for Medicaid receive healthcare outside of IHS, the federal government pays about 54%
Over the past two years, discussions with the federal government related to funding for American Indians resulted in federal government policy change regarding American Indians also eligible for Indian Health Service and Medicaid
More services are considered “received through IHS
No longer limited to services provided in an IHS facility
IHS is still responsible to provide health care to American Indians
$92.7 million state funds FY2016
$85 million in FY2015

12. Medicaid Federal Policy Change
Governor Daugaard convened the Health Care Solutions Coalition in 2015 to develop a strategy to improve health care access and outcomes for American Indians and to leverage the federal policy change
The HCSC final report can be found at and while several recommendations are tied to Medicaid expansion, work continues to expand implementation of tele-health and behavioral health services provided by tribal programs and IHS

13. Medicaid Federal Policy Change
Participation by individuals and providers must be voluntary
Provider must sign care coordination agreements with IHS, share medical records with IHS, develop alternative service sites
IHS must maintain responsibility for the patient’s care and accept/update Medical records
State Medicaid Agency – track care coordination agreement, ensure appropriate billing
With the election and administration change, Governor Daugaard is not recommending Medicaid expansion
Policy change inconsequential – providers and IHS have no incentive to implement the policy without Medicaid expansion

14. Opportunities for Reform
Opportunity to fix this long standing reimbursement issue and improve access to health care are still a possibility through Medicaid reform
Governor Daugaard is working with South Dakota’s congressional delegations, state legislators, tribes, and providers and will be working with the Trump administration to find a way to permanently fix this long standing funding issue and improve access to health care through Medicaid reform
Advocate for federal law change to allow 100% federal funds for American Indians regardless of where they receive services

15. Opportunities for Reform
As reforms including block grant or per capital allocations are considered, other potential issues for states to consider
Block grants have historically been reduced over time
The coalition will focus its efforts moving forward on opportunities to increase access to quality health care through Medicaid reform.

16. Access Monitoring Review Plan

17. Access Monitoring Review Plan
Federal requirement for CMS to review Medicaid rates to ensure access to care for the Medicaid population.
New Final Rule released in Fall 2015
Every state required to complete an Access Monitoring Review Plan by October 2016
Plans must be published for Public Comment before submission to CMS.
Plans must be updated every 3 years.
Access Monitoring Review Plans must:
Address the availability of care/providers and how health care needs are met;
Review access to Primary Care, Physician Specialists, Behavior Health, Pre/Post-Natal Care, and Home Health services;
Compare between Medicaid rates and other health care payers; and
Be developed with recipient, provider, and stakeholder feedback.

18. Access Monitoring Review Plan
What information does SD’s access plan contain?
Description of South Dakota
Rural/Frontier Nature
Statewide Health Care Access Issues
Beneficiary Characteristics/Access
Recipient Feedback Regarding Access
CAHPS Survey Data
Provider Participation
Medicaid Reimbursement
Provider Work Groups
Summary of Rates
Plan was submitted to CMS in October Plan is available online:

19. Other Updates

20. Provider Portal
Portal developed collaboratively with providers in 2016.
Went live in November 2016.
Current Provider Portal functionalities include the following:
Remittance Advices for Medicaid, PCP Program, Health Homes
PCP and Health Home Caseload Reports
Future functionalities include:
Hospital annual claims detail reports (early 2017)
ASA Nursing Home Census Status Reports (early 2017)
Eligibility Enquiries (early 2017)
Sign up for the Medical Services listserv for further information
More information can also be found at

21. Telehealth
IHS Telehealth Contract awarded September 2016 to Avera Health (Avera eCare)
Telemedicine services will be offered at 16 sites managed by IHS in the Great Plains Area.
Contract will provide telehealth to support IHS Emergency Departments and behavioral health and specialty services at IHS. IHS expects service delivery to start in Early Spring (March/April.
December 2016: SD Medicaid expanded the list of services able to be provided via telehealth to align more closely with Medicare.

22. RAC Exemption
SD submitted a State Plan Amendment (SPA) to request another exemption to federal requirements for Recovery Audit Contractors in May 2016.
SD is the only state to have a continuous exemption since 2010.
SPA was approved on September 1, 2016 and granted a three year exemption from federal RAC

23. Other Updates
SD Medicaid submitted a rules package to the November Rules Hearing of the State Legislature that allows SD to provide in-state liver transplants.
2016 Medicaid Report is available online: