Medicaid-Marketplace OverviewThe Federally-facilitated Marketplace (FFM) is offering health coverage in South Dakota in 2015 through a state partnership model. The FFM will make assessments of Medicaid/CHIP eligibility and then transfer the applicant's account to the state agency for a final eligibility determination. South Dakota has not expanded Medicaid coverage to low-income adults.
Medicaid and CHIP Eligibility Levels
To view the modified adjusted gross income (MAGI)-based eligibility levels, expressed as a percentage of the federal poverty level (FPL) and by monthly dollar amount and family size for Medicaid and the Children's Health Insurance Program (CHIP) beginning on January 1, 2014, visit the National Medicaid and CHIP Eligibility Levels page.
|State||Medicaid Expansion||Children - Medicaid||Separate CHIP||Pregnant Women||Parents3||Other Adults|
|Ages 0-11||Ages 1-52||Ages 6-182||Medicaid||CHIP|
1. These eligibility standards include CHIP-funded Medicaid expansions.
2. Children in separate CHIP programs are typically charged premiums. This table does not include notations of states that have elected to provide CHIP coverage from conception to birth.
3. In states that use dollar amounts rather than percentages of the federal poverty level (FPL) for 2013 to determine eligibility for parents, we converted those amounts to a percent of the FPL and selected the highest percentage to reflect eligibility level for the group. In addition, in states that are adopting the Medicaid expansion, we have indicated the upper income limit for parents to also be 133% of the FPL, since parents can be eligible for coverage under the new adult group. The actual dollar standards that states will use to determine eligibility are quoted in the monthly income tables.
Monthly Medicaid and CHIP Enrollment Data
Each month, CMS releases state-reported data on State Medicaid and CHIP program Enrollment. The enrollment data for each month is a point-in-time count of total Medicaid and CHIP enrollment on the last day of the month, and is not solely a count of those newly enrolled during the reporting period. Below, this data is compared to average enrollment from July-September 2013, the period before the initial open enrollment period of the Health Insurance Marketplaces. Additional information and enrollment data is available on the Medicaid and CHIP Application, Eligibility Determination, and Enrollment Data page.
|State||State Medicaid & CHIP Enrollment||National|
|Total Medicaid & CHIP Enrollment (currentMonth) (Preliminary)||Comparison of currentMonth data to July-September 2013 Average Enrollment||Total Medicaid & CHIP Enrollment, all States (currentMonth) (Preliminary)||Comparison of currentMonth data to July-September 2013 Average Enrollment|
|Net Change||% Change||Net Change||% Change|
Medicaid and CHIP Applications
The Affordable Care Act established a streamlined enrollment process through which individuals can gain access to affordable insurance coverage for which they are eligible. The law directed the Secretary of Health and Human Services (HHS) to develop a model application that will be used to apply for coverage through the Marketplace, Medicaid and CHIP. States have the option to adopt the Secretary of HHS’s model application form for affordable insurance programs or to adopt an alternative application that meets federal requirements.
- South Dakota's Medicaid/CHIP Application is currently in progress
Targeted Enrollment Strategies
In response to CMS Guidance provided on May 17, 2013, many states have adopted one or more "targeted enrollment strategies" designed to facilitate enrollment and retain coverage for eligible individuals in Medicaid/CHIP. The states that have adopted one or more targeted enrollment strategies are listed on the Targeted Enrollment Strategies page.
Medicaid and CHIP State Plan Amendments
The state Medicaid and CHIP plans spell out how each state has chosen to design its program within the broad requirements for federal funding. As always, states amend their Medicaid and CHIP state plans in order to inform CMS of programmatic and financing changes and to secure legal authority for those changes. The Affordable Care Act included many new opportunities for states to augment and improve their Medicaid and CHIP programs. As a result there has been a great deal of state plan amendment activity over the past several years in the areas of eligibility, benefits design and financing, as well as new approaches to providing health homes, long-term services and supports, and enrollment strategies like hospital presumptive eligibility. See below for a state-specific list of approved Medicaid and CHIP SPAs.
Demonstrations and Waivers
Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.
Medicaid Delivery System
States have choices in their approach to delivery system design under the Medicaid and CHIP programs. States are increasingly moving to the use of managed care and other integrated care models in serving their Medicaid beneficiaries. On average, more than 70 percent of the Medicaid population is enrolled in some form of managed care.
CHIP Program Information
The Children’s Health Insurance Program was established in 1997 to provide new coverage opportunities for children in families with incomes too high to qualify for Medicaid, but who cannot afford private coverage. Like Medicaid, CHIP is administered by the states, but is jointly funded by the federal government and states. States had the opportunity to design their CHIP programs as an expansion of Medicaid, as a stand-alone program or through a combined approach.
Medicaid/CHIP Participation Rates
The participation rate is the percentage of eligible children enrolled in Medicaid and CHIP in the state. Data from 2013 show 88.3 percent of the eligible children in the United States are enrolled in Medicaid and CHIP programs. More information about the participation rate among children in South Dakota is available on InsureKidsNow.gov.
Medicaid/CHIP Eligibility Verification Plans
Medicaid and CHIP agencies now rely primarily on information available through data sources (e.g., the Social Security Administration, the Departments of Homeland Security and Labor) rather than paper documentation from families for purposes of verifying eligibility for Medicaid and CHIP.
MAGI Conversion Plans
CMS provided states with a template for completing their “MAGI Conversion Plans” that are designed to reflect the MAGI-based eligibility standards that are used to determine Medicaid and CHIP eligibility. The MAGI-conversion process involved a translation of pre-2014 net income eligibility standards into MAGI-based eligibility standards. Moving to MAGI replaced income disregards with simpler, more universal income eligibility rules that are generally aligned with the rules that are used to determine eligibility for the premium tax credits in the Marketplace. To complete the transformation to MAGI, states needed to “convert” their net-income based eligibility standards to MAGI-based standards.