Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: SD- 10- 002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages TN: SD- 10- 002 Approval Date: 05/ 18112-010 Effective Date 0 1,/ 01/ N 10

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202 -4967 VIII fMS, May 18, 2010 Deborah K. Bowman, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501 -2291 RE: South Dakota #10 -002 Dear Ms. Bowman: This is your official notification that South Dakota State Plan amendment 10 -002 has been approved effective January 1, 2010. This SPA updates mandatory eligibility provisions and estate recovery limitations as required by MIPPA. We want to take this opportunity to thank your staff for the hard and diligent work accomplishing this effort. If you have any questions concerning this amendment, please contact Betty Strecker at 303) 844 -7028. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid & Children's Health Operations CC: Larry Iversen, Medicaid Director Mark Zickrick

MPARPMENT Or HEALTH ANDRUMANNERVU, F% FORM APPROVED O FIMANCIK AM% , " TIVIN 0M, 0 NO W30X) I 1) T11 I t I A 1. NSM411 :: TrAL ": 1) NOTWE F APPIkOVAL OF _ 71TR s 2. STATE PLAN MATERIAL 10.2 SOUTH DAKOTA FOR', HI: At,'I' ll CAW. FFNANONG ADMINWIVATMN I 1fi, f Vxl o1 , ' ' 1'11f: XfAf. W1) . RITY ACT fWWAID) PWAONA15A, 6 TW' 4,1 RON)SR" YPP-MV 7f) AII7 , fRiALI'll CARE FINANCING ADMINISIRATION January 1, 2010 3. - F Wkf - 'iw -- WPI TYPF ( .. AN 4 If, (40 Ij Nf.W S'I /VfU PLAN AMEM)WN' T' 714 WT (Seporare I W . ...... . . . .. .......... . STWFOWEVRE(JUL- AlION CITA`fM* 7. Ff- DURAt. TWMIFTIMPACt Medicare Impmvemeft ibr Patients andP( pVfdamA.ct' of 20T (WPPA), P.L. 11q•27 b, 0YI 1 *70,60 42GFR430,100thr h43O DED MAN51A,"TION 8 . IIA6F N1) M6UK OFT)if, PI AN Sift' TION OR ( IF'r NUMBER 0FTI4E% UPFRSf Pap sull (ftew) Attachment 2.2, 4, Pages 9b, 9b1 , sod 00 Inew) Attachment 2.2- A, Pages 9b and 9bI Attachment 2-6- k Page 22 Attachment 2-6- A, Page 22 r bm ic JI, 5, RTI . I This is a State Plan Arnendment to updato mandatory offigiblilty provisions and estate recovery limitations as required by M04W I . . . . . . ....... . ............. I ........ . . I..- M VMNOR'S RMEW 0.' hed 000: Govf.Awws ( rrict: PxPORTVI) NO COMMWI' 0 01148k AS SPI:(,11- W0 T) MMFNTS Of Cj0VFRWR ()I'v; icti-*.!.(.* pD WII'tiIN45f), S( jiWITTM. I NO REPLY RECEIVE D I& RE IT N Deborah 80wMan 14, ITTLE: N Depot0mrit of Social Services DW(00" of,, Moftal Services M Drive 0 676011.2291 TI "INFRUWAk

53a1 Revision: HCFA- PM -95 -3 (MB) May 1995 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State /Territory: South Dakota 4.17 ( b)( 3) Adjustments or Recoveries, continued Limitations on Estate Recovery - Medicare Cost Sharing: i) Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles: QMB, SLMB, Ql, QDWI, QMB +, and SLMB +. This protection extends to medical assistance for four Medicare cost sharing benefits (Part A and B premiums, deductibles, coinsurance, and co- payments) with dates of service on or after January 1, 2010. The date of service for deductibles, coinsurance, and co- payments is the date the request for payment is received by the State Medicaid Agency. The date of service for premiums is the date the State Medicaid Agency paid the premium. ii) In addition to being a qualified dual eligible the individual must also be age 55 or over. The above protection from estate recovery for Medicare cost sharing benefits (premiums, deductibles, coinsurance, and co- payments) applies to approved mandatory (i. e., nursing facility, home and community -based services, and related prescription drugs and hospital services) as well as optional Medicaid services identified in the State plan, which are applicable to the categories of duals referenced above. TN No: 10 -2 Supersedes Approval Date: 1 Effective Date: 1/1/ 10 TN No: New

ATTACHMENT 2.2 -A Page 9b State: South Dakota Agency Citation(s) Groups Covered A. Mandatory Coverage - Categorically and Other Required Special Groups (Continued) 1902(a)( 10)( E)( i), 25. Qualified Medicare Beneficiaries -- 1905(p), and 1860D- 14(a)( 3)( D) a. Who are entitled to hospital insurance benefits under of the Act Medicare Part A, (but not pursuant to an enrollment under section 1818A of the Act); b. Whose income does not exceed 100 percent of the Federal poverty level; and c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the consumer price index. Medical assistance for this group is limited to Medicare cost - sharing as defined in item 3.2 of this plan.) 1902(a)( 10)( E)( ii), 26. Qualified Disabled and Working Individuals -- 1905(p)( 3)( A)( i), 1905(p), 1905(s), and a. Who are entitled to hospital insurance benefits under 1860D- 14(a)( 3)( D) Medicare Part A under section 1818A of the Act; of the Act b. Whose income does not exceed 200 percent of the Federal poverty level; and c. Whose resources do not exceed twice the maximum standard under SSI. d. Who are not otherwise eligible for medical assistance under Title XIX of the Act. Medical assistance for this group is limited to Medicare Part A premiums under section 1818A of the Act.) TN No. 10 -2 Supersedes Approval Date l Effective Date 1 / 1 / 10 TN No. 93 -003

ATTACHMENT 2.2 -A Page 9b 1 State: South Dakota Agency Citation(s) Groups Covered A. Mandatory Coverage - Categorically Needy and Other Required Special Groups (Continued) 1902(a)( 10)( E)( iii), 27. Specified Low - Income Medicare Beneficiaries -- 1905(p)( 3)( A)( ii), and 1860D- 14(a)( 3)( D) a. Who are entitled to hospital insurance benefits under of the Act Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act), b. Whose income is greater than 100 percent but less than 120 percent of the Federal poverty level; and c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the consumer price index. Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.) TN No. 10 -2 Supersedes Approval Date J 0 Effective Date 1 / 1 / 10 TN No. 93 -003

ATTACHMENT 2.2 -A Page 9b3 State: South Dakota Agency Citation(s) Groups Covered A. Mandato1y Coverage - Categorically Needy and Other Required Special Groups (Continued) 1902(a)( 10)( E)( iv), 1905(p)( 3)( A)( ii), and 1860D- 14(a)( 3)( D) of the Act 29. Qualifying Individuals -- a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act); b. Whose income is greater than 100 percent but less than 120 percent of the Federal poverty level; and c. Whose resources do not exceed three times the SSI resource limit, adjusted annually by the increase in the consumer price index. TN No. 10 -2 Supersedes Approval Date Effective Date 1 /1 /10 TN No. NEW

ATTACHMENT 2.6 -A Page 22 State: South Dakota Citation Condition or Requirement 7. Resource Standard - Medically Needy a. Resource standards are based on family size. 1902(a)( I0)( C)( i) b. A single standard is employed in determining resource of the Act eligibility for all groups. c. In 1902(f) States, the resource standards are more restrictive than in 7.b. above for -- Aged Blind Disabled Supplement 2 to ATTACHMENT 2.6 -A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2 to ATTACHMENT 2.6 -A so indicates. 1902(a)( 1 0)( E), 8. Resource Standard - Qualified Medicare Beneficiaries, 1905(p)( 1)( D), 1905(p)( 2)( B) Specified Low - Income Medicare Beneficiaries and and 186013- 14(a)( 3)( D) Qualifying Individuals of the Act For Qualified Medicare Beneficiaries covered under section 1902(a)( 10)( E)( i) of the Act, Specified Low - Income Medicare Beneficiaries covered under section 1902(a)( I0)( E)( iii) of the Act, and Qualifying Individuals covered under 1902(a)( 10)( E)( iv) of the Act, the resource standard is three times the SSI resource limit, adjusted annually since 1996 by the increase in the consumer price index. 1902(a)( 10)( E)( ii), 1905(s) 9. Resource Standard - Qualified Disabled and Working and 1860D- 14(a)( 3)( D) Individuals of the Act For qualified disabled and working individuals covered under section 1902(a)( 10)( E)( ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is two times the SSI resource limit. TN No. 10 -2 Supersedes Approval Date // Effective Date 1 /1 /10 TN No. 93 -12

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 13-0009-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMEN`t OF HEAIA I I & HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadwav, Suite 700 Denver, CO 80202-4967 Region VIII November 20, 2013 Kim Malsam- Rysdon, Secretary Department of Social Services Richard F. Knell-) Building 700 Governors Drive Pierre, SD 57501- 2291 RE: South Dakota# 13- 0009- MM Dear Ms. Malsam- Rysdon: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 13- 0009- MM. This SPA implements the Affordable Care Act' s provision for addressing the sin,, le state agencies delegation of appeals and determinations. Please be informed that this State Plan Amendment was approved on November 18, 2013 with an effective date of.ianuary 1, 2014. We are enclosing the summary sheet ( CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Laurie Jensen at 303) 844- 7126. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations CC: Kirby Stone, Medicaid Director Amt Schwartz Amy Stewart /s/

State/Territory name: South Dakota Submitted By: Ann Schwartz Last Revision Date: Nov 6, 2013 Submit Date: Aug 23, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0009 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 431.10, 42 CFR 431.11, 42 CFR 431.12, 42 CFR 431.50 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This State Plan Amendment designates the Department of Social Services as the single state agency operating the Medicaid program in South Dakota. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe:   No reply received within 45 days of submittal Other, as specified Describe:   Signature of State Agency Official Page 1 of 2 SD.0209.R00.00 - Jan 01, 2014 12/17/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

SD-0009-MM STATE:

South Dakota

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

A1 – A3

COMPLETE PAGES SUPERSEDED:

Page 1

Section 1.1 (pages 2-6)

Section 1.2 (page 7)

Section 1.3 (page 8)

Attachment 1.1-A (Attorney General certification)

Attachment 1.2-A (Organizational chart)

Attachment 1.2-B (Description of the functions of the single state agency)

Attachment 1.2-C (Description of professional medical and supporting staff)

PARTIAL PAGES SUPERSEDED:

Section 1.4 (page 9)(State Medical Care Advisory Committee only. Tribal consultation will remain in the state plan.)

A1-A2

Notwithstanding any other provisions of the Medicaid State Plan, the agencies designated in A1 and A2 will determine eligibility for coverage to the extent specified in A1 and A2.

Page 1 of 5 Medicaid Administration OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 State Plan Administration Designation and Authority A1 42 CFR 431.10 Designation and Authority State Name: South Dakota As a condition for receipt of Federal funds under title XIX of the Social Security Act, the single state agency named below submits the following state plan for the medical assistance program, and hereby agrees to administer the program in accordance with the provisions of this state plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department. Name of single state agency: Department of Social Services Type of Agency: Title IV-A Agency Health Human Resources Other Type of Agency The above named agency is the single state agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named as the single state agency.) The state statutory citation for the legal authority under which the single state agency administers the state plan is: SDCL 1-36-5.1 and 1-36-7.1 The single state agency supervises the administration of the state plan by local political subdivisions. Yes No The certification signed by the state Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program has been provided. ✔ An attachment is submitted. The state plan may be administered solely by the single state agency, or some portions may be administered by other agencies. The single state agency administers the entire state plan under title XIX (i.e., no other agency or organization administers any portion of it). Yes No TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, 1 Effective Date: 1/1/14

Page 2 of 5 Medicaid Administration The entity or entities that have responsibility for determinations of eligibility for families, adults, and for individuals under 21 are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The entity that has responsibility for determinations of eligibility for the aged, blind, and disabled are: The Medicaid agency Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Indicate which agency determines eligibility for any groups whose eligibility is not determined by the Federal agency: Medicaid agency Title IV-A agency An Exchange The entity or entities that have responsibility for conducting fair hearings with respect to denials of eligibility based on the applicable modified adjusted gross income standard are: Medicaid agency An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act The agency has established a review process whereby the agency reviews appeals decisions made by the Exchange or Exchange appeals entity or other state agency, but only with respect to conclusions of law, including interpretations of state or federal policies. Yes No State Plan Administration Organization and Administration A2 42 CFR 431.10 42 CFR 431.11 Organization and Administration Provide a description of the organization and functions of the Medicaid agency. The Department of Social Services (DSS) is comprised of divisions that provide programs, services, and financial and medical assistance to eligible South Dakotans with the goal of fostering independent and healthy families. DSS also ensures children, the elderly, and individuals with disabilities are safe from abuse and neglect.

The Department of Social Services is the single state agency responsible for administering the Medicaid program. Within DSS, the Division of Medical Services (DMS) oversees the Medicaid program. The Division of Medical Services enrolls medical assistance TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, 2 Effective Date: 1/1/14

Page 3 of 5 Medicaid Administration providers, determines how providers will be reimbursed for services provided under the State Plan, operates a system for processing claims, maintains control mechanisms to minimize improper payments resulting from unintended errors as well as fraud and abuse, issues policies, rules and regulations on program matters, maintains a system for resolving grievances by applicants, recipients, and providers, and collects and reports required program information. The Division of Medical Services works closely with the Division of Economic Assistance (EA) to provide statewide eligibility determinations to South Dakotans eligible for medical assistance under the State Plan. The Division of Economic Assistance is responsible for eligibility determinations for the SNAP, TANF, Energy Assistance, CHIP and Medicaid programs in the state of South Dakota. The South Dakota Department of Social Services, Office of Administrative Hearings, is the impartial and external entity that conducts all Medicaid fair hearings. Upload an organizational chart of the Medicaid agency. An attachment is submitted. Provide a description of the structure of the state's executive branch which includes how the Medicaid agency fits in with other health, human service and public assistance agencies. The Executive Branch includes eight elected officials, the lieutenant governor, and the governor. The governor is the chief executive officer of the State of South Dakota. The governor has decision-making authority over the bureaus and the state’s seventeen departments that compose the cabinet. The cabinet meets regularly. The Department of Social Services is the state’s sole Medicaid agency, and includes other public assistance programs. South Dakota’s other health and human service agencies are the Department of Health and the Department of Human Services.

The South Dakota Department of Health (DOH) delivers wide range of public health services to prevent disease, promote health and ensure access to needed, high-quality health care. DOH administers a wide range of programs, including but not limited to South Dakota's WIC Program, Baby Care Program, All Women Count! Program, and the Tobacco Control Program.

The South Dakota Department of Human Services (DHS) promotes the highest level of independence for all individuals regardless of disability or disorder. DHS includes but is not limited to the following Divisions and Facilities: Developmental Disabilities, Rehabilitation Services, Services to the Blind and Visually Impaired, and the South Dakota Developmental Center.

Entities that determine eligibility other than the Medicaid Agency (if entities are described under Designation and Authority) Remove Type of entity that determines eligibility: Single state agency under Title IV-A (in the 50 states or the District of Columbia) or under Title I or XVI (AABD) in Guam, Puerto Rico, or the Virgin Islands An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act The Federal agency administering the SSI program Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Pursuant to a 1634 agreement, the Social Security Administration determines Medicaid eligibility for Supplemental Security Income recipients. Add Entities that conduct fair hearings other than the Medicaid Agency (if are described under Designation and Authority) Remove Type of entity that conducts fair hearings: An Exchange that is a government agency established under sections 1311(b)(1) or 1321(c)(1) of the Affordable Care Act TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, 3 Effective Date: 1/1/14

Page 4 of 5 Medicaid Administration An Exchange appeals entity, including an entity established under section 1411(f) of the Affordable Care Act Provide a description of the staff designated by the entity and the functions they perform in carrying out their responsibility. Add Supervision of state plan administration by local political subdivisions (if described under Designation and Authority) Is the supervision of the administration done through a state-wide agency which uses local political subdivisions? Yes No State Plan Administration Assurances A3 42 CFR 431.10 42 CFR 431.12 42 CFR 431.50 Assurances The state plan is in operation on a statewide basis, in accordance with all the requirements of 42 CFR 431.50. ✔ All requirements of 42 CFR 431.10 are met. ✔ There is a Medical Care Advisory Committee to the agency director on health and medical services established in accordance with meeting all the requirements of 42 CFR 431.12. ✔ The Medicaid agency does not delegate, to other than its own officials, the authority to supervise the plan or to develop or issue policies, rules, and regulations on program matters. ✔ Assurance for states that have delegated authority to determine eligibility: There is a written agreement between the Medicaid agency and the Exchange or any other state or local agency that has been delegated authority to determine eligibility for Medicaid eligibility in compliance with 42 CFR 431.10(d). Assurances for states that have delegated authority to conduct fair hearings: There is a written agreement between the Medicaid agency and the Exchange or Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d). When authority is delegated to the Exchange or an Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their fair hearing conducted instead by the Medicaid agency. Assurance for states that have delegated authority to determine eligibility and/or to conduct fair hearings: The Medicaid agency does not delegate authority to make eligibility determinations or to conduct fair hearings to entities other than government agencies which maintain personnel standards on a merit basis. ✔ PRA Disclosure Statement TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, 4 Effective Date: 1/1/14

Page 5 of 5 Medicaid Administration According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, 5 Effective Date: 1/1/14

TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, pg 6 Effective Date: 1/1/14

Department of Social Services State of South Dakota Department Secretary Constituent Services & Special Projects Constituent Liaison Administrative Assistant Administrative Assistant Executive Assistant Communications Director Office of the Secretary Deputy Secretary Administrative Hearings Division Attorney Supervisor Adult Services & Aging Division Director Economic Assistance Division Director Division of Medical Services Division Director Office of the Secretary Deputy Secretary Behavioral Health Division Director Human Services Center Division Director Office of the Secretary/Finance Office Chief Financial Officer Division of Legal Services Division Director Division of Child Care Services Division Director Division of Child Protection Services Division Director Division of Child Support Division Director Bureau of Personnel/Department of Social Services Human Resources Manager Timesheets/Benefits Personnel Specialist Bureau of Human Resources/DSS/HSC/BH Human Resources Manager Timesheets/Benefits Personnel Specialist Timesheets/Benefits Personnel Specialist TN: SD-13-0009-MM South Dakota Approval Date: 11/18/13 AB1-3, pg 7 Effective Date: 1/1/14

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 13-0012 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages 5) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 CNU'( E Region VIII November 21, 2013 Kim Malsam-Rysdon, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501- 2291 RE: South Dakota# 13- 0012 Dear Ms. Malsam- Rysdon: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 13- 0012. With this SPA, the State affirms citizenship regulations, specifies reasonable opportunity options, and specifies policy options related to immigrant eligibility in accordance to the Affordable Care Act. Please be informed that this State Plan Amendment was approved on November 19, 2012 with an effective date January 1, 2014. We are enclosing the summary page ( formerly CMS 179) and the amended plan page( s). If you have any questions concerning this amendment, please contact Laurie Jensen at 303) 844- 7126. Sincerely, Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations CC: Kirby Stone, Medicaid Director Ann Schwartz Amy Stewart /s/

SD. 0212.R00.00 - Jan 01, 2014 Page 1 of 2 g 9ID) t t, ( C z 1 1 State/Territory name: South Dakota Transmittal Number: Please enter the Transmittal Number( TN) in the format ST- YY- 0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= a four digit number with leading zeros. The dashes must also be entered. SD- 13-0012 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yyyy) Federal Statute/Regulation Citation 1902( a)( 46)( B); 8 U. S. C. 1611, 1612, 1613, and 1641; 1903( v)( 2),( 3) and( 4); 42 CFR 435. 4; 42 CFR 435.406; Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment This State Plan Amendment contains assurances that South Dakota provides Medicaid to citizens and nationals of the United States and certain non- citizens consistent with the requirements of 42 CFR 435.406. Governor' s Office Review Governor' s office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Ann Schwartz Last Revision Date: Nov 8, 2013 Submit Date: Aug 23, 2013

SUPERSEDING PAGES OF STATE PLAN MATERIAL S' FA,rE: TRANSMITTAL NUMBER: South Dakota 13- 0012 ED PAGE NUMBER OF PLAN SECTION OR PAGE NUMBER OFT11F, SUPFIRSED PLAN SLAT10%, ATTACHMENT: OR ATTACHMENT( tflipplicahle): S89 Non- F inancial Eligibility- Citizenship and Non- citizen Eligibility ( NEW) Attachment 2. 6- A: Page 2. item( 3). paragraphs( a),( b), and ( c) Attachment 2. 6- A: Page 2, item ( 3), paragraphs( a),( b). and ( c). TN 92- 01 Attachment 2. 6- A: Page 3, item( 3), paragraphs( d) and ( e) Attachment 2. 6- A: Page 3, item( 3). paragraphs( d) and ( 0. 1 T\ 91- 19

Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Non-Financial Eligibility S89 Citizenship and Non-Citizen Eligibility 1902( a)( 46)( B) 8 U. S.C. 1611, 1612, 1613, and 1641 1903( v)( 2),( 3) and( 4) 42 CFR 435. 4 42 CFR 435. 406 42 CFR 435. 956 Citizenship and Non- Citizen Eligibility The state provides Medicaid to citizens and nationals of the United States and certain non- citizens consistent with requirements of 42 CFR 435. 406, including during a reasonable opportunity period pending verification of their citizenship, national status or satisfactory immigration status. The state provides Medicaid eligibility to otherwise eligible individuals: 0 Who are citizens or nationals of the United States; and Who are qualified non- citizens as defined in section 431 of the Personal Responsibility and Work Opportunity F Reconciliation Act( PRWORA)( 8 U. S. C. § 1641), or whose eligibility is required by section 402( b) of PRWORA( 8 U. S. C. 1612( b)) and is not prohibited by section 403 of PRWORA ( 8 U. S. C. § 1613); and Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality or satisfactory immigration status consistent with requirements of 1903( x), 1137( 4), 1902( ee) of the SSA and 42 CFR 435. 406, and 956. The reasonable opportunity period begins on and extends 90 days from the date the notice ofreasonable opportunity is received by the individual. The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. 4 Yes C No The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date earlier than the date the notice is received by the individual. t9. Yes C No The date benefits are furnished is: The date of application containing the declaration of citizenship or immigration status. C' The date the reasonable opportunity notice is sent. Other date, as described: TN: SD- 13- 0012- MM Approval Date: 11/ 19/ 2013 Effective Date: 1/ 1/ 14 South Dakota S89, page 1 Pao I of Z

Medicaid Eligibility The state provides Medicaid coverage to all Qualified Non- Citizens whose eligibility is not prohibited by section 403 of PRWORA 8 U. S. C. § 1613). C' Yes C No Indicate which requirements apply: The state requires Lawful Permanent Residents to have 40 qualifying work quarters under Title II of the Social Security Act. Yes t— No The state limits eligibility to 7 years for certain non-citizens. Yes (: No The state elects the option to provide Medicaid coverage to otherwise eligible individuals under 21 and pregnant women, lawfully residing in the United States, as provided in section 1903( v)( 4) of the Act. C Yes (: No An individual is considered to be lawfully residing in the United States if he or she is lawfully present and otherwise meets the eligibility requirements in the state plan. An individual is considered to be lawfully present in the United States if he or she: 1. Is a qualified non- citizen as defined in 8 U. S. C. 1641( b) and( e); 2. Is a non- citizen in a valid nonimmigrant status, as defined in 8 U. S. C. 110l( a)( 15) or otherwise under the immigration laws( as defined in 8 U. S. C. t 101( a)( 17)); 3. Is a non-citizen who has been paroled into the United States in accordance with 8 U. S.C. 1182( d)( 5) for less than I year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; 4. Is a non-citizen who belongs to one of the following classes: Granted temporary resident status in accordance with 8 U. S. C. 1 160 or 1255a, respectively; Granted Temporary Protected Status( TPS) in accordance with 8 U. S. C. § 1254a, and individuals with pending applications for TPS who have been granted employment authorization, Granted employment authorization under 8 CFR 274a. I2(c); Family Unity beneficiaries in accordance with section 301 of Pub. L. 101- 649, as amended; Under Deferred Enforced Departure( DED) in accordance with a decision made by the President; F Granted Deferred Action status; Granted an administrative stay of removal under 8 CFR 241; Beneficiary of approved visa petition who has a pending application for adjustment of status; 5. is an individual with a pending application for asylum under 8 U. S. C. 1158, or for withholding of removal under 8 U. S. C. 1231, or under the Convention Against Torture who- 01 Has been granted employment authorization, or No Is under the age of 14 and has had an application pending for at least 180 days; TN: SD- 13- 0012- MM Approval Date: 11/ 19/ 2013 Effective Date: 1/ 1/ 14 South Dakota S89, page 2 Pang+7 of Z

Medicaid Eligibility 6. llas been granted withholding of removal under the Convention Against Torture, 7. Is a child who has a pending application for Special Immigrant Juvenile status as describes{ in 8 U. S. C. 1101( a)( 27)( J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or 9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106- 386, as amended( 22 U. S. C. 7105( b)); 10. Exce-010n: An individual with deferred action under the Department of I lomeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security' s June 15, 2012 memorandum, shall not be considered to-be lawfully present with respect to any of the above categories in paragraphs( 1) through( 9) of this definition. F-] Other The state assures that it provides limited Medicaid services for treatment of an emergency medical condition, not related to an organ transplant procedure, as defined in 1903( v)(3) of the SSA and implemented at 42 CFR 440.255, to the following individuals who meet all Medicaid eligibility requirements, except documentation of citizenship or satisfactory immigration status and/ or present an SSN: Qualified non-citizens subject to the 5 year waiting period described in 8 U.S. C. 1613; Non-qualified non-citizens, unless covered as a lawfully residing child or pregnant woman by the state under the option in accordance with 1903( v)( 4) and implemented at 435. 406(b). PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26-05, Baltimore, Maryland 21244- 1850. TN: SD- 13- 0012- MM Approval Date: 11/ 19/2013 Effective Date. 1/ 1/ 14 South Dakota 589, page 3 Pawp I of I

Revision: IICFA- W-91- 4 ( B13D) Al I ACI-IMENT 2. 6- A AUGt; S' I 1991 P,I,-, 2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA ELIGIBILITY CONDITIONS AND REQUIREMENTS CitationLsL Condition or Requirement A) General Conditions of Eligibility ( continued) 2. ( Continued) b. For the medically needy, meets the non- financial eligibility conditions of 42 CFR Part 435. Section 1905( p) of the c. For financially eligible qualified Medicare beneficiaries Act covered under section 1902( a)( 10)( E)( i) of the Act, meets the non- financial criteria of section 1905( p) of the Act. Section 1905( x) of the d. For financially eligible qualified disabled and working Act individuals covered under section 1902(a)( 10)( E)( ii) of the Act, meets the non- financial criteria of section 1905( s). TN No. 13- 12 Supersedes Approval Date % 13 Effective Date01/ 01/ 14 TN No. 92- 01

Revision: HCFA- PM- 91- 4 ( Bill)) AT' l ACIIMENT 2. 6- A AUGUST 1991 k'. i e STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA ELIGIBILITY CONDITIONS AND REQUIREMENTS Page 3 is superseded by SD- 13- 12. TN No. 13- 12 Supersedes Approval Date ) Effective Date01/ 01/ 14 TN No. 91- 19

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 13-0013-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion Letter 3) Summary Form (with 179-like data) 4) Superseding Pages Notice 5) Approved SPA Pages 6) Additional Attachments that are part of the state plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

November 21, 2013

Kim Malsam-Rysdon, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291

Dear Ms. Malsam-Rysdon:

Enclosed is an approved copy of South Dakota’s state plan amendment (SPA) 13-0013-MM, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on August 23, 2013. SPA 13-0013-MM incorporates the MAGI-based eligibility process requirements, including the single streamlined application, into South Dakota’s state plan in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The approval of SPA 13-0013-MM includes full approval of your state’s alternative single streamlined application used to apply for multiple human service programs. Until July 31, 2014, the state is using an interim alternative single streamlined online application with the addition of a supplemental form. By July 31, 2014 the state will implement a revised alternative single streamlined online application that addresses CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the new state plan pages and attachments to be incorporated within a separate section at the end of South Dakota’s approved state plan:

• S94, pages S94-1 and S94-2 • Attachment 1 - Economic Assistance Application (Application for Multiple Human Service Programs) • Attachment 2 - South Dakota MAGI Medical Addendum • Attachment 3 - Statement of Use with Respect to the Alternative Single, Streamlined Online Application • Attachment 4 - Statement Related to Coordination of Eligibility and Enrollment

In addition, enclosed is a summary of the state plan pages which are superseded by SPA 13- 0013MM, which should also be incorporated into a separate section in the front of the state plan.

• Superseding pages of state plan material, SPA 13-0013-MM.

2 CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Laurie Jensen at 303- 844-7126, or by e-mail at Laurie.Jensen@cms.hhs.gov.

Sincerely,

/s/

Richard C. Allen Associate Regional Administrator Division of Medicaid & Children’s Health Operations

CC: Kirby Stone, Medicaid Director Ann Schwartz Amy Stewart

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

November 21, 2013

Kim Malsam-Rysdon, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291

Dear Ms. Malsam-Rysdon:

This letter is being sent as a companion to Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) 13-0013-MM, which was submitted to CMS on August 23, 2013. Our review of this submission included a review of the alternative single streamlined application used to apply for multiple human service programs.

Until July 31, 2014, the state is using an interim alternative single streamlined online application with the addition of a supplemental form. The application must be revised to meet the standards outlined in 42 CFR 435.907 and the guidance on alternative applications released by CMS on June 19, 2013.

Please submit a revised alternative single streamlined online application to CMS for review no later than July 1, 2014 to ensure approval by July 31. 2014. For technical assistance with your application, please contact Dena Greenblum at 410-786-8684 or Dena.Greenblum@cms.hhs.gov. If you have any questions or require any further assistance, please contact Laurie Jensen at 303- 844-7126 or Laurie.Jensen@cms.hhs.gov.

Sincerely,

/s/

Richard C. Allen Associate Regional Administrator Division of Medicaid & Children’s Health Operations

CC: Kirby Stone, Medicaid Director Ann Schwartz Amy Stewart

COORDINATION OF ELIGIBILITY AND ENROLLMENT

TRANSMITTAL NUMBER:

TN: 13-0013-MM

STATE:

South Dakota

Notwithstanding the final checked statement on page 2, the single state agency has not entered into an agreement with the Federally-facilitated Marketplace to date. The single state agency will make a good faith effort to enter into a memorandum of agreement with the Federally-facilitated Marketplace by 01/31/2014. At such time the agreement is signed, it will be incorporated by reference into this attachment

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

 Paper Application  Online Application

TRANSMITTAL NUMBER:

13-0013-MM

STATE:

South Dakota

Through July 31, 2014, the state is using an interim online alternative single streamlined application. After July 31, 2014, the state will use a revised online alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.

State/Territory name: South Dakota Submitted By: Ann Schwartz Last Revision Date: Nov 20, 2013 Submit Date: Aug 23, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0013 Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435, Subpart J and Subpart M Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This State Plan Amendment details South Dakota's eligibility and enrollment process, including the application for Medical Assistance, the renewal process, and assurance that the state will coordinate eligibility and enrollment with the federal facilitated exchange as required by 42 CFR 435, Subpart M. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 SD.0213.R00.00 - Oct 01, 2013 11/21/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 2 of 2 SD.0213.R00.00 - Oct 01, 2013 11/21/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

SD 13-0013 MM2 STATE:

South Dakota

PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

S94 – Eligibility Process PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 2, Page 10, section 2.1(a), TN 91-18 Effective Date: 10/1/91, approved: 12/19/91 Section 2, Page 11a, section 2.1(d), TN 92-06 Effective Date: 1/1/92 , approved: 5/19/92

Revision: HCFA-PM-91-4 (BPD)

Page 10 AUGUST, 1991 TN No. 13-13 Supersedes

Approval Date 11/21/13 Effective Date 10/01/13 TN No. 91-18 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA

SECTION 2. COVERAGE AND ELIGIBILITY Citation 2.1 Application, Determination of Eligibility, and Furnishing Medicaid

42 CFR 435.10 and Subpart J

(a) This section is superseded by SD-13-13.

Revision: HCFA-PM-91-8 (MB)

Page 11a OCTOBER 1991 TN No. 13-13 Supersedes

Approval Date 11/21/13

Effective Date 10/01/13 TN No. 92-06 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA

SECTION 2. COVERAGE AND ELIGIBILITY Citation 2.1 Application, Determination of Eligibility, and Furnishing Medicaid

1902(a)(55) of the Act

(d) This section is superseded by SD-13-13.

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 General Eligibility Requirements Eligibility Process S94 42 CFR 435, Subpart J and Subpart M Eligibility Process The state meets all the requirements of 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility, and furnishing Medicaid. ✔ Application Processing Indicate which application the agency uses for individuals applying for coverage who may be eligible based on the applicable modified adjusted gross income standard. The single, streamlined application for all insurance affordability programs, developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act An alternative single, streamlined application developed by the state in accordance with section 1413(b)(1)(B) of the Affordable Care Act and approved by the Secretary, which may be no more burdensome than the streamlined application developed by the Secretary. An attachment is submitted. An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs. An attachment is submitted. Indicate which application the agency uses for individuals applying for coverage who may be eligible on a basis other than the applicable modified adjusted gross income standard: The single, streamlined application developed by the Secretary or one of the alternate forms developed by the state and approved by the Secretary, and supplemental forms to collect additional information needed to determine eligibility on such other basis, submitted to the Secretary. An attachment is submitted. An application designed specifically to determine eligibility on a basis other than the applicable MAGI standard which minimizes the burden on applicants, submitted to the Secretary. An attachment is submitted. The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in 42 CFR 435.1200(f), by telephone, via mail, and in person. The agency also accepts applications by other electronic means: Yes No TN: SD-13-0013-MM South Dakota Approval Date: 11/21/13 S94, page 1 Effective Date: 01/01/2014

Page 2 of 3 Medicaid Eligibility Indicate the other electronic means below: Name of Method Description + On - Line application SD will use its current on-line application with the addition of a supplemental form until changes to meet ACA requirement can be developed and approved. x + Phone application SD will have the ability to accept applications from individuals who apply via phone. A benefits specialist will speak to the individual and complete the application, a signature page will then be mailed to the applicant. x The agency has procedures to take applications, assist applicants and perform initial processing of applications for the eligibility groups listed below at locations other than those used for the receipt and processing of applications for the title IV-A program, including Federally-qualified health centers and disproportionate share hospitals. ✔ Parents and Other Caretaker Relatives Pregnant Women Infants and Children under Age 19 Redetermination Processing Redeterminations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 435.916: ✔ Once every 12 months ■ Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency ■ If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available. ■ Redeterminations of eligibility for individuals whose financial eligibility is not based on the applicable modified adjusted gross income standard are performed, consistent with 42 CFR 435.916 (check all that apply): ■ Once every 12 months Once every 6 months Other, more often than once every 12 months Coordination of Eligibility and Enrollment The state meets all the requirements of 42 CFR 435, Subpart M relative to coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. The single state agency has entered into agreements with the Exchange and with other agencies administering insurance affordability programs. ✔ PRA Disclosure Statement TN: SD-13-0013-MM South Dakota Approval Date: 11/21/13 S94, page 2 Effective Date: 01/01/2014

Page 3 of 3 Medicaid Eligibility According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0013-MM South Dakota Approval Date: 11/21/13 S94, page 3 Effective Date: 01/01/2014

Case # Section # 1 South Dakota MAGI Medical Addendum E-Form #: (if applicable) Who do you need to include on this addendum? Tell us about all the family members who live with you. If you file taxes, we need to know about DO Include: You DON’T have to include: • Yourself • Your unmarried partner who doesn’t need • Your spouse health coverage • Your children under 21 who live with you • Your unmarried partner’s children • Your unmarried partner who needs health coverage • Your parents who live with you, but file • Anyone you include on your tax return, even if their own tax return (if you’re over 21) they don’t live with you • Other adult relatives who file their own tax return • Anyone else under 21 who you take care of and lives with you

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can. This addendum can be uploaded with your online application, or mailed or faxed to your local DSS office. Complete for each person in your family. Start with yourself, then add other adults and children. If you have more than 6 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide immigration status or a social security number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage. If you don’t file a tax return, remember to still add family members who live with you. Tell us about yourself 1. First Name, Middle Name, Last Name, & Suffix 2. Date of birth (mm/dd/yyyy) 3. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.)  Yes. If yes, please answer questions a–c.  No. If no, skip to question c. a. Will you file jointly with a spouse?  Yes  No If yes, name of spouse:

b. Will you claim any dependents on your tax return? Yes  No If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone’s tax return?  Yes  No If yes, please list the name of the tax filer:

How are you related to the tax filer?

4. Do you need health coverage?  Yes  No If no, you may skip questions 5 thru 10 5. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?  Yes  No 6. Are you a U.S. citizen or U.S. national?  Yes  No 7. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?  Yes. Fill in your document type and ID number below. a. Immigration document type b. Document ID number

c. Have you lived in the U.S. since 1996? Yes  No d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military?  Yes  No 8. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?  Yes  No 9. Are you a full-time student?  Yes  No 10. Were you in foster care at age 18 or older?  Yes  No 11. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Alimony paid $ how often? Other deductions $ ____________ how often? ______ Student loan interest $ how often? Type:

12. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Your total income this year $ Your total income next year (if you think it will be different) $

Additional Applicant 13. First Name, Middle Name, Last Name, & Suffix 14. Date of birth (mm/dd/yyyy) 15. Relationship to you? 16. Will this person file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.)  YES. If yes, please answer questions a–c.  No. If no, skip to question c. a. Will this person file jointly with a spouse?  Yes  No If yes, name of spouse:

b. Will this person claim any dependents on your tax return?  Yes  No If yes, list name(s) of dependents:

c. Will this person be claimed as a dependent on someone’s tax return?  Yes  No If yes, please list the name of the tax filer:

How is this person related to the tax filer?

17. Does this person need health coverage?  Yes  No If no, you may skip questions 18 thru 23. 18. Does this person have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?  Yes  No 19. Is this person a U.S. citizen or U.S. national?  Yes  No 20. If this person isn't a U.S. citizen or U.S. national, does he/she have eligible immigration status?  Yes. Fill in the document type and ID number below. a. Immigration document type b. Document ID number

c. Has this person lived in the U.S. since 1996? Yes  No d. Is this person, or their spouse or parent a veteran or an active-duty member of the U.S. military?  Yes  No 21. Does this person live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No Answer the following questions if this person is 22 or younger: 22. Is this person a full-time student?  Yes No 23. Was this person in foster care at age 18 or older? YesNo 24. DEDUCTIONS: Check all that apply, and give the amount and how this person gets it. If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Alimony paid $ _________ how often? Student loan interest $ ____ how often? ____ Other deductions $__ how often? Type:

25. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Total income this year $ Total income next year (if you think it will be different) $

Additional Applicant 13. First Name, Middle Name, Last Name, & Suffix 14. Date of birth (mm/dd/yyyy) 15. Relationship to you? 16. Will this person file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.)  YES. If yes, please answer questions a–c.  No. If no, skip to question c. a. Will this person file jointly with a spouse?  Yes  No If yes, name of spouse:

b. Will this person claim any dependents on your tax return?  Yes  No If yes, list name(s) of dependents:

c. Will this person be claimed as a dependent on someone’s tax return?  Yes  No If yes, please list the name of the tax filer:

How is this person related to the tax filer?

17. Does this person need health coverage?  Yes  No If no, you may skip questions 18 thru 23. 18. Does this person have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?  Yes  No 19. Is this person a U.S. citizen or U.S. national?  Yes  No 20. If this person isn't a U.S. citizen or U.S. national, does he/she have eligible immigration status?  Yes. Fill in the document type and ID number below. a. Immigration document type b. Document ID number

c. Has this person lived in the U.S. since 1996? Yes  No d. Is this person, or their spouse or parent a veteran or an active-duty member of the U.S. military?  Yes  No 21. Does this person live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No Answer the following questions if this person is 22 or younger: 22. Is this person a full-time student?  Yes No 23. Was this person in foster care at age 18 or older?YesNo 24. DEDUCTIONS: Check all that apply, and give the amount and how this person gets it. If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Alimony paid $ _________ how often? Student loan interest $ ____ how often? ____ Other deductions $__ how often? Type:

25. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Total income this year $ Total income next year (if you think it will be different) $

Additional Applicant 13. First Name, Middle Name, Last Name, & Suffix 14. Date of birth (mm/dd/yyyy) 15. Relationship to you? 16. Will this person file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.)  YES. If yes, please answer questions a–c.  No. If no, skip to question c. a. Will this person file jointly with a spouse?  Yes  No If yes, name of spouse:

b. Will this person claim any dependents on your tax return?  Yes  No If yes, list name(s) of dependents:

c. Will this person be claimed as a dependent on someone’s tax return?  Yes  No If yes, please list the name of the tax filer:

How is this person related to the tax filer?

17. Does this person need health coverage?  Yes  No If no, you may skip questions 18 thru 23. 18. Does this person have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores etc.) or live in a medical facility or nursing home?  Yes  No 19. Is this person a U.S. citizen or U.S. national?  Yes  No 20. If this person isn't a U.S. citizen or U.S. national, does he/she have eligible immigration status?  Yes. Fill in the document type and ID number below. a. Immigration document type b. Document ID number

c. Has this person lived in the U.S. since 1996? Yes  No d. Is this person, or their spouse or parent a veteran or an active-duty member of the U.S. military?  Yes  No 21. Does this person live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No Answer the following questions if this person is 22 or younger: 22. Is this person a full-time student?  Yes No 23. Was this person in foster care at age 18 or older? YesNo 24. DEDUCTIONS: Check all that apply, and give the amount and how this person gets it. If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Alimony paid $ _________ how often? Student loan interest $ ____ how often? ____ Other deductions $__ how often? Type:

25. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Total income this year $ Total income next year (if you think it will be different) $

Additional Applicant 13. First Name, Middle Name, Last Name, & Suffix 14. Date of birth (mm/dd/yyyy) 15. Relationship to you? 16. Will this person file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.)  YES. If yes, please answer questions a–c.  No. If no, skip to question c. a. Will this person file jointly with a spouse?  Yes  No If yes, name of spouse:

b. Will this person claim any dependents on your tax return?  Yes  No If yes, list name(s) of dependents:

c. Will this person be claimed as a dependent on someone’s tax return?  Yes  No If yes, please list the name of the tax filer:

How is this person related to the tax filer?

17. Does this person need health coverage?  Yes  No If no, you may skip questions 18 thru 23. 18. Does this person have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?  Yes  No 19. Is this person a U.S. citizen or U.S. national?  Yes  No 20. If this person isn't a U.S. citizen or U.S. national, does he/she have eligible immigration status?  Yes. Fill in the document type and ID number below. a. Immigration document type b. Document ID number

c. Has this person lived in the U.S. since 1996? Yes  No d. Is this person, or their spouse or parent a veteran or an active-duty member of the U.S. military?  Yes  No 21. Does this person live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No Answer the following questions if this person is 22 or younger: 22. Is this person a full-time student?  Yes No 23. Was this person in foster care at age 18 or older? YesNo 24. DEDUCTIONS: Check all that apply, and give the amount and how this person gets it. If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Alimony paid $ _________ how often? Student loan interest $ ____ how often? ____ Other deductions $__ how often? Type:

25. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Total income this year $ Total income next year (if you think it will be different) $

Additional Applicant 13. First Name, Middle Name, Last Name, & Suffix 14. Date of birth (mm/dd/yyyy) 15. Relationship to you? 16. Will this person file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return.)  YES. If yes, please answer questions a–c.  No. If no, skip to question c. a. Will this person file jointly with a spouse?  Yes  No If yes, name of spouse:

b. Will this person claim any dependents on your tax return?  Yes  No If yes, list name(s) of dependents:

c. Will this person be claimed as a dependent on someone’s tax return?  Yes  No If yes, please list the name of the tax filer:

How is this person related to the tax filer?

17. Does this person need health coverage?  Yes  No If no, you may skip questions 18 thru 23. 18. Does this person have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?  Yes  No 19. Is this person a U.S. citizen or U.S. national?  Yes  No 20. If this person isn't a U.S. citizen or U.S. national, does he/she have eligible immigration status?  Yes. Fill in the document type and ID number below. a. Immigration document type b. Document ID number

c. Has this person lived in the U.S. since 1996? Yes  No d. Is this person, or their spouse or parent a veteran or an active-duty member of the U.S. military?  Yes  No 21. Does this person live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No Answer the following questions if this person is 22 or younger: 22. Is this person a full-time student?  Yes No 23. Was this person in foster care at age 18 or older? YesNo 24. DEDUCTIONS: Check all that apply, and give the amount and how this person gets it. If this person pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Alimony paid $ _________ how often? Student loan interest $ ____ how often? ____ Other deductions $__ how often? Type:

25. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. Total income this year $ Total income next year (if you think it will be different) $ *If you have more than 6 people in your family please make additional copies of this page as necessary.

Health Coverage from Jobs You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

EMPLOYEE Information 1. Employee Name (First, Middle, Last) 2. Employee Social Security Number EMPLOYER Information 3. Employer Name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number ( ) 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) ( ) – 12. Email address 13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue) 13a. If you’re in a waiting or probationary period, when can you enroll in coverage? _______ (mm/dd/yyyy)

List the names of anyone else who is eligible for coverage from this job. Name: Name: Name:

No

Tell us about the health plan offered by this employer. 14. Does the employer offer a health plan that meets the minimum value standard*?  Yes  No 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did Not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $ ______ b. How often?  Weekly  Every 2 weeks Twice a month  Quarterly  Yearly 16. What change will the employer make for the new plan year (if known)?  Employer won’t offer health coverage  Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $ ______ b. How often?  Weekly  Every 2 weeks  Twice a month  Quarterly  Yearly Date of change (mm/dd/yyyy):

American Indian or Alaska Native Family Member (AI/AN) Complete this page if you or a family member are American Indian or Alaska Native. Submit this with your Application. Tell us about your American Indian or Alaska Native family member(s). American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may Not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSON 1 AI/AN PERSON 2 1. Name (First Name, Middle Name, Last Name) First

First Middle Middle Last Last 2. Member of a federally recognized tribe? Yes  If yes, tribe name: Yes If yes, tribe name: 3. Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?  Yes  No If No, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? Yes  No  Yes  No If No, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? Yes  No 4. Certain money received may Not be counted for Medicaid or the Children’s Health Insurance Program (CHIP). List any income (amount and how often) reported on your application that includes money from these sources: • Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) • Money from selling things that have cultural significance

$ ___________

How often?

$ ___________ How often? ______ AI/AN PERSON 3 AI/AN PERSON 4 AI/AN PERSON 5 AI/AN PERSON 6 First

First

First

First

Middle Middle Middle Middle Last Last Last Last Yes  If yes, tribe name: Yes  If yes, tribe name: Yes  If yes, tribe name: Yes  If yes, tribe name:  Yes  No If No, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? Yes  No  Yes  No If No, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? Yes  No  Yes  No If No, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? Yes  No  Yes  No If No, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? Yes  No

$ ___________

How often?

$ ___________

How often?

$ ___________

How often?

$ ___________

How often?

Assistance with Completing this Application You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application, submit proof with the application. 1. Name of authorized representative (First Name, Middle Name, Last Name) 2. Address 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. Phone number ( ) – 8. Organization Name 9. ID Number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency. 10. Your Signature 11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only. Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application Start Date (mm/dd/yyyy) 2. First Name, Middle Name, Last Name & Suffix 3. Organization Name 4. ID Number (if applicable)

STEP 5 Read & sign this application. • I’m signing this application under penalty of perjury which means I've provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false and or untrue information. • I know that I must tell the health insurance Marketplace if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household. • I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file. • I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,

is incarcerated. (name of person) We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof. If anyone on this application is eligible for Medicaid • I am giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent. • Does any child on this application have a parent living outside of the home?  Yes  No • If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. if I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may Not have to cooperate. My right to appeal If I think the health insurance Marketplace or Medicaid/Children’s Health Insurance Program (CHIP) has made a mistake, I can appeal its decision. To appeal means to tell someone at the health insurance Marketplace or Medicaid/CHIP that I think the action is wrong, and ask for a fair review of the action. I know that I can be represented in the process by someone other than myself. Sign this application The person who filled out step 1 should sign this application. if you’re an authorized representative you may sign here, as long as you have provided the information required in Appendix C. If submitting electronically, understand that typing your signature has the same legal effect and enforceability as a written signature on an application. Signature Date (mm/dd/yyyy)

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 13-0014-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALHJ& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202- 4967 r, 1, Rf 10 IM A10 S, kl R Region VIII November 20, 2013 Kim Malsam- Rysdon. Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD _57501- 2291 RE: South Dakota# 13- 0014- MM Dear Ms. Malsam- Rysdon: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number ( TN) 13- 0014- MM. This SPA implements the Affordable Care Act' s provision to establish the Modified Adjusted Gross Income ( MAGI) Methodologies that will be used for determining eligibility for most children, pregnant women, parents and caretaker relatives and adults described in 42 CFR 43.5. 119. Please be informed that this State Plan Amendment was approved on November 18, 2013 with an effective date of January 1, 2014. We are enclosing the summary sheet ( CMS- 179) and the amended plan page( s). If you have any questions concerning this amendment. please contact Laurie Jensen at 303) 844- 7126. Sincerely. Richard C. Allen Associate Regional Administrator Division for Medicaid & Children' s Health Operations CC: Kirby Stone, Medicaid Director Ann Schwartz Amy Stewart /s/

State/Territory name: South Dakota Submitted By: Ann Schwartz Last Revision Date: Nov 6, 2013 Submit Date: Aug 23, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0014 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(e)(14); 42 CFR 435.603 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 0.00 Second Year 2015 $ 0.00 Subject of Amendment This State Plan Amendment describes the income methodology South Dakota will use to make eligibility determinations. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 SD.0214.R00.00 - Jan 01, 2014 11/20/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

Page 2 of 2 SD.0214.R00.00 - Jan 01, 2014 11/20/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

SUPERSEDING PAGES OF STATE PLAN MATERIAL TRANSMITTAL NUMBER: 13-0014 STATE: South Dakota PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: S10 - MAGI Income Methodology PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): Notwithstanding any other provisions of the South Dakota Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment 13-0014 will apply to all MAGI-based eligibility groups covered under South Dakota’s Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No TN: SD-13-0014-MM South Dakota Approval Date: 11/18/13 S10, page 1 Effective Date: 1/1/14

Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0014-MM South Dakota Approval Date: 11/18/13 S10, page 2 Effective Date: 1/1/14

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 13-0015-MM This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Superseding Pages Notice 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967

Region VIII

November 25, 2013

Kim Malsam-Rysdon, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291

RE: South Dakota #13-0015-MM

Dear Ms. Malsam-Rysdon:

Enclosed is an approved copy of South Dakota’s state plan amendment (SPA) 13-0015-MM, which was submitted to CMS on August 28, 2013. SPA 13-0015-MM incorporates the MAGI- based mandatory and optional eligibility groups’ requirements into South Dakota’s Medicaid state plan in accordance with the Affordable Care Act. The effective date of this SPA is January 1, 2014.

In a separate email which will be sent out tomorrow, we will send a copy of the following state plan pages and attachments to be incorporated within a separate section at the end of South Dakota’s approved state plan:

 S14, S25, S28, S30, S32, S33, S50, S51, S52, S53, S54, S55, S57, S59

In addition we will send a summary of the state plan pages which are superseded by SPA 13- 0015-MM, which should also be incorporated into a separate section in the front of the state plan.

 Superseding pages of state plan material, SPA 13-0015-MM

CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. If you have any questions concerning this SPA, please contact Laurie Jensen of my staff at (303) 844-7126 or by email at Laurie.Jensen@cms.hhs.gov.

Sincerely,

Richard C. Allen

Associate Regional Administrator

Division for Medicaid & Children’s Health Operations

CC: Kirby Stone, Medicaid Director Ann Schwartz Sarah Aker /s/

State/Territory name: South Dakota Submitted By: Ann Schwartz Last Revision Date: Nov 21, 2013 Submit Date: Aug 27, 2013 Medicaid State Plan Eligibility: Summary Page (CMS 179) Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. SD-13-0015 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 435.110; 1902(a)(10)(A)(i)(I); 1931(b) and (d); 408(a)(11)(A); 1902(a)(52); 1902(e)(1)(B); 1925; 1931( Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 39783.97 Second Year 2015 $ 53045.29 Subject of Amendment This State Plan Amendment describes the eligible populations under the South Dakota Medicaid State Plan and related MAGI-income standards. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Page 1 of 2 SD.0243.R00.00 - Jan 01, 2014 11/25/2013 http://157.199.113.99/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp

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1

SUPERSEDING PAGES OF STATE PLAN MATERIAL

TRANSMITTAL NUMBER:

13-0015

STATE:

South Dakota

Pages or sections of pages being superseded by S14, S25, S28, S30, S51, S52, S53, S54, S55, and S57, and related pages or sections of pages being deleted as obsolete

State Plan Section

Complete Pages Removed

Partial Pages Removed Attachment 2.2-A

Page 1 Page 3 Page 3a Page 4 Page 4a Page 12 Page 13 Page 13a Page 14 Page 14a Page 21 Page 23 Page 23c

Page 2, A.2.b Page 2, A.2.c Page 2a, A.3 Page 5, A.10 Page 9c, B.1 for caretaker relatives & pregnant women Page 20, B.14 Page 25, C.4

Supplement 1 to Attachment 2.2-A

Page 1

Attachment 2.6-A

Page 3b Page 11a Page 19 Page 19a Page 19b Page 21

Page 1, A.2.a(i) and (iii) Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, 5.e(2) Page 18, 5.e Page 25, 11.a(3)

Supplement 1 to Attachment 2.6-A Pages 1-4

Supplement 2 to Attachment 2.6-A

Pages 1-5

2

Supplement 8a to Attachment 2.6-A

Page 1, (A) and (C) Page 2, (C)continued Supplement 8b to Attachment 2.6-A

Page 1, delete (A) for children Supplement 12a to Attachment 2.6-A

Page 1 12a Addendum

Supplement 14 to Attachment 2.6-A Page 1

Page 1 of 15 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S14, page 1 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 2 of 15 Medicaid Eligibility TN: SD-13-0015-MM S14, page 2 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 3 of 15 Medicaid Eligibility Household size Standard ($) + 1 317 x + 2 404 x + 3 467 x + 4 530 x + 5 593 x + 6 655 x + 7 718 x + 8 781 x + 9 844 x + 10 906 x + 11 969 x + 12 1,032 x + 13 1,094 x + 14 1,157 x + 15 1,220 x + 16 1,282 x + 17 1,345 x + 18 1,408 x + 19 1,470 x + 20 1,533 x + 21 1,596 x + 22 1,659 x + 23 1,721 x + 24 1,784 x + 25 1,847 x Additional incremental amount Yes No Increment amount $ 63 TN: SD-13-0015-MM S14, page 3 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 4 of 15 Medicaid Eligibility The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S14, page 4 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 5 of 15 Medicaid Eligibility TN: SD-13-0015-MM S14, page 5 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 6 of 15 Medicaid Eligibility Household size Standard ($) + 1 304 x + 2 380 x + 3 430 x + 4 478 x + 5 528 x + 6 578 x + 7 627 x + 8 675 x + 9 724 x + 10 773 x + 11 822 x + 12 872 x + 13 920 x + 14 969 x + 15 1,018 x + 16 1,069 x + 17 1,115 x + 18 1,164 x + 19 1,213 x + 20 1,263 x + 21 1,311 x + 22 1,359 x + 23 1,409 x + 24 1,457 x + 25 1,506 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S14, page 6 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 7 of 15 Medicaid Eligibility The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S14, page 7 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 8 of 15 Medicaid Eligibility TN: SD-13-0015-MM S14, page 8 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 9 of 15 Medicaid Eligibility Household size Standard ($) + 1 382 x + 2 484 x + 3 561 x + 4 636 x + 5 713 x + 6 790 x + 7 865 x + 8 940 x + 9 1,016 x + 10 1,092 x + 11 1,167 x + 12 1,244 x + 13 1,319 x + 14 1,395 x + 15 1,471 x + 16 1,548 x + 17 1,621 x + 18 1,697 x + 19 1,773 x + 20 1,850 x + 21 1,924 x + 22 1,999 x + 23 2,076 x + 24 2,151 x + 25 2,226 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S14, page 9 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 10 of 15 Medicaid Eligibility The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S14, page 10 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 11 of 15 Medicaid Eligibility TN: SD-13-0015-MM S14, page 11 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 12 of 15 Medicaid Eligibility Household size Standard ($) + 1 358 x + 2 448 x + 3 507 x + 4 563 x + 5 622 x + 6 680 x + 7 738 x + 8 795 x + 9 852 x + 10 910 x + 11 968 x + 12 1,026 x + 13 1,083 x + 14 1,140 x + 15 1,198 x + 16 1,258 x + 17 1,312 x + 18 1,370 x + 19 1,428 x + 20 1,486 x + 21 1,543 x + 22 1,599 x + 23 1,658 x + 24 1,715 x + 25 1,772 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S14, page 12 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 13 of 15 Medicaid Eligibility The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 x Additional incremental amount Yes No Increment amount $ The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S14, page 13 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 14 of 15 Medicaid Eligibility The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 x Additional incremental amount Yes No Increment amount $ The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard Household size Standard ($) + 1 x Additional incremental amount Yes No Increment amount $ The dollar amounts increase automatically each year Yes No TN: SD-13-0015-MM S14, page 14 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 15 of 15 Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: SD-13-0015-MM S14, page 15 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 1 of 8 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ TN: SD-13-0015-MM S25, page 1 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 2 of 8 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S25, page 2 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 3 of 8 Medicaid Eligibility TN: SD-13-0015-MM S25, page 3 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 4 of 8 Medicaid Eligibility Household size Standard ($) + 1 590 x + 2 740 x + 3 842 x + 4 941 x + 5 1,042 x + 6 1,145 x + 7 1,244 x + 8 1,343 x + 9 1,443 x + 10 1,544 x + 11 1,643 x + 12 1,746 x + 13 1,843 x + 14 1,943 x + 15 2,044 x + 16 2,147 x + 17 2,242 x + 18 2,342 x + 19 2,443 x + 20 2,544 x + 21 2,643 x + 22 2,741 x + 23 2,843 x + 24 2,941 x + 25 3,042 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S25, page 4 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 5 of 8 Medicaid Eligibility The dollar amounts increase automatically each year Yes No Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed The state's AFDC payment standard in effect as of July 16, 1996, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, not converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other income standard in-between the minimum and the maximum standards allowed. The amount of the income standard for this eligibility group is: A percentage of the federal poverty level: A dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S25, page 5 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 6 of 8 Medicaid Eligibility TN: SD-13-0015-MM S25, page 6 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 7 of 8 Medicaid Eligibility Household size Standard ($) + 1 563 x + 2 703 x + 3 796 x + 4 885 x + 5 977 x + 6 1,070 x + 7 1,160 x + 8 1,249 x + 9 1,340 x + 10 1,431 x + 11 1,521 x + 12 1,614 x + 13 1,702 x + 14 1,793 x + 15 1,884 x + 16 1,978 x + 17 2,063 x + 18 2,154 x + 19 2,245 x + 20 2,337 x + 21 2,426 x + 22 2,515 x + 23 2,607 x + 24 2,696 x + 25 2,787 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S25, page 7 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 8 of 8 Medicaid Eligibility The dollar amounts increase automatically each year Yes No There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM S25, page 8 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 1 of 9 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for this eligibility group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. TN: SD-13-0015-MM S28, page 1 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 2 of 9 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Pregnancy-related services, as defined at 42 CFR 440.210 (a)(2), include prenatal, delivery, postpartum and family planning services, as well as services related to conditions which may complicate pregnancy. Full Medicaid coverage is provided only for pregnant women with income at or below the income limit described below: Minimum income limit for full Medicaid coverage ■ The minimum income standard used for full coverage under this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income limit for full Medicaid coverage ■ TN: SD-13-0015-MM S28, page 2 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 3 of 9 Medicaid Eligibility The highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) (qualified pregnant women) or section 1931(b) and (d) (low-income families) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent standard. The highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) (qualified pregnant women) or section 1931(b) and (d) (low-income families) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent standard. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The amount of the maximum income limit for full Medicaid coverage is: A percentage of the federal poverty level: A dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S28, page 3 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 4 of 9 Medicaid Eligibility TN: SD-13-0015-MM S28, page 4 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 5 of 9 Medicaid Eligibility Household size Standard ($) + 1 590 x + 2 740 x + 3 842 x + 4 941 x + 5 1,042 x + 6 1,145 x + 7 1,244 x + 8 1,343 x + 9 1,443 x + 10 1,544 x + 11 1,643 x + 12 1,746 x + 13 1,843 x + 14 1,943 x + 15 2,044 x + 16 2,147 x + 17 2,242 x + 18 2,342 x + 19 2,443 x + 20 2,544 x + 21 2,643 x + 22 2,741 x + 23 2,843 x + 24 2,941 x + 25 3,042 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S28, page 5 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 6 of 9 Medicaid Eligibility The dollar amounts increase automatically each year Yes No Income limit chosen for full Medicaid coverage: ■ The minimum income limit The maximum income limit Another income limit in-between the minimum and maximum standards allowed. The amount of the income limit for full Medicaid coverage is: A percentage of the federal poverty level: A dollar amount % Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the statewide standard TN: SD-13-0015-MM S28, page 6 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 7 of 9 Medicaid Eligibility TN: SD-13-0015-MM S28, page 7 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 8 of 9 Medicaid Eligibility Household size Standard ($) + 1 358 x + 2 448 x + 3 507 x + 4 563 x + 5 622 x + 6 680 x + 7 738 x + 8 795 x + 9 852 x + 10 910 x + 11 969 x + 12 1,032 x + 13 1,094 x + 14 1,157 x + 15 1,220 x + 16 1,282 x + 17 1,345 x + 18 1,408 x + 19 1,470 x + 20 1,533 x + 21 1,596 x + 22 1,659 x + 23 1,721 x + 24 1,784 x + 25 1,847 x Additional incremental amount Yes No Increment amount $ TN: SD-13-0015-MM S28, page 8 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 9 of 9 Medicaid Eligibility The dollar amounts increase automatically each year Yes No Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: SD-13-0015-MM S28, page 9 South Dakota Approval Date: 11/25/2013 Effective Date: 01/01/2014

Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for infants under age one is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S30, page 1 Effective Date: 01/01/2014

Page 2 of 5 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. The amount of the income standard for infants under one is: 182 % FPL Income standard for children age one through age five, inclusive ■ Minimum income standard ■ TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S30, page 2 Effective Date: 01/01/2014

Page 3 of 5 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 182 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S30, page 3 Effective Date: 01/01/2014

Page 4 of 5 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Enter the amount of the maximum income standard: 182 % FPL Income standard chosen ■ TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S30, page 4 Effective Date: 01/01/2014

Page 5 of 5 Medicaid Eligibility The state's income standard used for children age six through eighteen is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S30, page 5 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S32, page 1 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S33, page 1 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S50, page 1 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S51 page 1 Effective Date: 01/01/2014

Page 1 of 20 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ■ Be under age 21, or a lower age, as defined within the reasonable classification. ■ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ■ Not be eligible and enrolled for mandatory coverage under the state plan. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. ✔ An attachment is submitted. Current Coverage of All Children under a Specified Age TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 1 Effective Date: 01/01/2014

Page 2 of 20 Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals in adoptions subsidized in full or part by a public agency Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals in nursing facilities, if nursing facility services are provided under this plan Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Also individuals in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), if these services are provided under this plan. Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 2 Effective Date: 01/01/2014

Page 3 of 20 Medicaid Eligibility Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Other reasonable classifications Name of classification Description Age Limit + All children who are in the Custody of the Department of Social Services. Under age 21 x + All children that are in foster care and for whom the Department of Social Services is assuming full or partial financial responsibility. Under age 21 x + All children under the jurisdiction of the South Dakota Department of Corrections who are not inmates of a public insitution under the provisions of 42 CFR 435.1008. Under age 21 x + Adjudicated children under the guardianship of the South Dakota Human Services Center who are receiving inpatient treatment for drug and alcohol dependency. Under age 21 x + Adjudicated children under the guardianship of the South Dakota Human Services Center who are receiving inpatient psychiatric treatment. Under age 21 x Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Click here once S11 form above is complete to view the income standards form. Individuals in adoptions subsidized in full or part by a public agency Income standard used ■ TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 3 Effective Date: 01/01/2014

Page 4 of 20 Medicaid Eligibility Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 4 Effective Date: 01/01/2014

Page 5 of 20 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals in nursing facilities, if nursing facility services are provided under this plan Income standard used ■ Minimum income standard ■ TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 5 Effective Date: 01/01/2014

Page 6 of 20 Medicaid Eligibility The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 6 Effective Date: 01/01/2014

Page 7 of 20 Medicaid Eligibility Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Also individuals in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID), if these services are provided under this plan. Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 7 Effective Date: 01/01/2014

Page 8 of 20 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 8 Effective Date: 01/01/2014

Page 9 of 20 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 9 Effective Date: 01/01/2014

Page 10 of 20 Medicaid Eligibility The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 10 Effective Date: 01/01/2014

Page 11 of 20 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. All children who are in the Custody of the Department of Social Services. Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 11 Effective Date: 01/01/2014

Page 12 of 20 Medicaid Eligibility The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. All children that are in foster care and for whom the Department of Social Services is assuming full or partial financial responsibility. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 12 Effective Date: 01/01/2014

Page 13 of 20 Medicaid Eligibility Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 13 Effective Date: 01/01/2014

Page 14 of 20 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. All children under the jurisdiction of the South Dakota Department of Corrections who are not inmates of a public insitution under the provisions of 42 CFR 435.1008. Income standard used ■ Minimum income standard ■ TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 14 Effective Date: 01/01/2014

Page 15 of 20 Medicaid Eligibility The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 15 Effective Date: 01/01/2014

Page 16 of 20 Medicaid Eligibility Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Adjudicated children under the guardianship of the South Dakota Human Services Center who are receiving inpatient treatment for drug and alcohol dependency. Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 16 Effective Date: 01/01/2014

Page 17 of 20 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 17 Effective Date: 01/01/2014

Page 18 of 20 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Adjudicated children under the guardianship of the South Dakota Human Services Center who are receiving inpatient psychiatric treatment. Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standards for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 18 Effective Date: 01/01/2014

Page 19 of 20 Medicaid Eligibility The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for this classification of children under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI- equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should only be selected for children 19 and older, and only if the state has not elected to cover the Adult Group. Other dollar amount % Income standard chosen ■ Individuals qualify under this classification under the following income standard: The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for this classification under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under the Medicaid state plan as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 19 Effective Date: 01/01/2014

Page 20 of 20 Medicaid Eligibility If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for this classification under a Medicaid 1115 Demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Other Reasonable Classifications Previously Covered The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. Yes No Additional new age groups or reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes No There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S52, page 20 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S53, page 1 Effective Date: 01/01/2014

Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the state plan as of March 23, 2010. Yes No Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October 1, 2019, states may reduce or eliminate coverage for this group. ■ Individuals are covered under this eligibility group, as follows: ■ All children under age 18 or 19 are covered: The reasonable classification of children covered is: Under age 19 Under age 18 Income standard used for this classification ■ Minimum income standard ■ The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. Maximum income standard ■ TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S54, page 1 Effective Date: 01/01/2014

Page 2 of 3 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standard(s) for this classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this classification of children under the Medicaid State Plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for this classification of children under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 200% FPL. A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: ■ % FPL 204 Income standard chosen, which must exceed the minimum income standard ■ Individuals qualify under the following income standard: The maximum income standard. The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective income level for this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S54, page 2 Effective Date: 01/01/2014

Page 3 of 3 Medicaid Eligibility If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, but by no more than 50 percentage points. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for this eligibility group in the state plan as of March 23, 2010. The income standard for this eligibility group is: 204 % FPL There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S54, page 3 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S55, page 1 Effective Date: 01/01/2014

Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under the following age ■ Under age 21 Under age 20 Under age 19 Were in foster care under the responsibility of a state on their 18th birthday. ■ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ■ Have household income at or below a standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013): ■ All children under the age selected A reasonable classification of children under the age selected: Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S57, page 1 Effective Date: 01/01/2014

Page 2 of 2 Medicaid Eligibility Maximum income standard ■ No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 demonstration as of March 23, 2010. A Medicaid 1115 demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard: This eligibility group does not use an income test (all income is disregarded). There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S57, page 2 Effective Date: 01/01/2014

Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: SD-13-0015-MM South Dakota Approval Date: 11/25/2013 S59, page 1 Effective Date: 01/01/2014

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: SD- 13- 022 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: SD- 13- 022 Approval Date: 03/ 04/ 14 Effective Date: 01/ 01/ 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services 1600 Broadway, Suite 700 Denver, CO 80202-4967 Region VIII INTIR,, W MEt7WA E& MEW( X610 4ER1RIS March 7, 2014 Kim Malsam-Rysdon, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501- 2291 RE: South Dakota# 13- 022 Dear Ms. Malsam-Rysdon: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number (TN) 13- 022. This SPA allows the Department to use the financial eligibility findings of the Supplemental Nutrition Assistance Program ( SNAP) to enroll and reenroll children under age 19 in Medicaid. Please be informed that this State Plan Amendment was approved on March 4, 2014 with an effective date of January 1, 2014. We are enclosing the CMS- 179 and the amended plan page( s). If you have any questions concerning this amendment, please contact Laurie Jensen at 303) 844- 7126. Sincerely, s/ Richard C. Allen Associate Regional Administrator Division for Medicaid& Children' s Health Operations CC: Kirby Stone, Medicaid Director Ann Schwartz Sarah Aker

I* F`ARJMI, N I Of tff, VIJJ AND fit 11% N SERVICES FORM AF? RMTD CENTERS H) R MEDIC ARE& MFDK AID SERWTs is lox HOW11193 FRANSMI'l"I'Al-4 ANA) NO'1' 1('' EOI4AI' I' ROVA LIDF "" ' IR;kNS.Nit' r'i' AI, Nt)**IBt k: 2. S1 ATE: STATE. PLAN MAITRIAL SIN 1422 Somh 116" a FOR: 17EPIT EIIS Foil MEDICARE& MEDICAID SERVICES 3. PROGRAM IDENTIFICA I ION. TITLE XJX OP'' I' llf, SWIM, SE( TRITV ACQMEDICAIDI TO: REGIONAL ADMINISTRA FOR 4, PROPOSED LFU E( TINT DATE FATERS FOR MEDICARE& MLI) IWD SERVRTS January 1, 2014 DEPARTMENA OF IIEAETII AND 11UNTANSERVICES 5. TYPE OF fthetl (lne): IlS FAN S I'A I L PLAT If) IJF.(' ONSII) l'!Rt'.I) A,,s' ,NL' k PLAN WAN] ENI-YMENT OMPITJEBIAX% S6THR(. wran 6. FEDERAL STAT( ' IT/RF,(';ULA-I U) NCITATION: 7. F' FDERAL RUDGE'l IMPACT: 1W2QX1M of Me a. FFY MIA 5 0 COO Act k FEY 200: SOLO 8, P;t(;ENt NI[ 3f,-,RoI,"-I-ilt' PI. A,,,NSL(- 110! soR, kTTACIMIE%I: 9. PAGE NUMBER OF FHE SUPERSEDED PLAN SLC FION, OR 11b, 110, 11x1, and Ile New 11 SURRA I OF AMENDMENI'-. AHows the EleparltneM of Saba! Services to use Me hmndW eligibility findings of the Supplemental Nuttition Assistance Program SNAQ to enroll and reenroll children under age 19 in Medicaid. I1. (; OVERNOR' SRI,,VIE*vN'(( he(,AOiyt,): lbanTRNOWS OFTRT REPORTED No ( I)NIMENT FJOTHFR. AS SPE( IIAED E] CO1,1NIENTS 01: GOVERNOR' S OFFICL FN( TO'SED L] NO RLPLN RECEIVED WITHIN 45 DAYS OUSIVNIFFTAL LL. iGNATURE OFSTA FE: ACCI-ICI OFFICIAL 16. REFURN TO: It TV PED NA M L: DEPARTMEN' t OF SO(' IAL SERVICLS DIVISION( 7F MEDICAL SERVICES Kim Malsam- Rysdon 700 GOVERNORS DRIVE PIERRE, S1:) 57N) 14291 14. TITLE: Cat)inet Se p° eta ry 15 DATESCHNIFFITI): FOR REGIONAL OFFICE USE ONLY It DAZE RE( Tlk ED. 01/ 02/ 14 1 18. DATEAPPROVED: 03/04/14 PLAN APPROVED- ONE COPY ATWMEO M. SIGNATI RE OF REGIONAL Off ICIAL: 01/ 01/ 14 s/ 21. Ti PED NAW. Richard C. Allen 22. TI I LF° ARA, DMCHO It REMARKS- FORM CINIS- 179 j0.1- 92i

Page 11b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA SECTION 2. COVERAGE AND ELIGIBILITY Citation 2. 1 Application, Determination of Eligibility and Furnishing Medicaid 1902( e)( 13) continued) of the Act e) Express Lane Option. The Medicaid State agency elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of Medicaid eligibility. The Medicaid State agency agrees to meet all of the Federal statutory and regulatory requirements for this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. 1) The Express Lane option is applied to: Initial determinations Redeterminations X Both 2) A child is defined as younger than age: X 19 20 21 3) The following public agencies are approved by the Medicaid State agency as Express Lane agencies: Supplemental Nutrition Assistance Program (SNAP) TN No. 13- 22 I Supersedes Approval Date l i/ `t Effective Date 01/ 01/ 14 TN No. New

Page 11c STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA SECTION 2. COVERAGE AND ELIGIBILITY 2. 1 Application, Determination of Eligibility and Furnishing Medicaid continued) 4) The following component/components of Medicaid eligibility are determined under the Express Lane option. Also, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between Medicaid eligibility determinations for such children and the determination under the Express Lane option. Income eligibility will be determined under the Express Lane Option. Income SNAP: The gross income test is at or below 130% of the federal poverty level. The net income test is at or below 100% of the federal poverty level. Households must be at or below both gross income and net income tests unless one member of the household is over age 60 or permanently disabled, then only has to be at or below the net income test. Medicaid: The gross income test is at or below 177% FPL. Household SNAP household unit consists of the following: 1. Husband and wife if they reside together; 2. Parents and children under age 22 if they reside together: 3. Children under age 18 if he/ she resides with an non parent adult who has parental and/ or financial control; 4. All individuals who reside together and purchase/prepare meals together. Medicaid household unit consists of tax filer, tax dependent (including spouse living in the home). For non- tax filer, non-tax dependent or a tax dependent with an exception, the household unit consists of the individual and, if living with the individual, the individual's natural, adopted and step children under the age of 19. In the case of individuals under age 19, the individual' s natural, adopted and step parents and natural, adoptive and step siblings under age 19. Deeming No income deeming rules for SNAP or Medicaid. Income Exclusions SNAP: Income exclusions are: educational income; legally obligated child support paid; allowable self- employment costs; in- kind income; vendor payments; HUD utility payments; foster care payments if the child is opted out of SNAP; charitable donations if not intended for the household' s basic month to month needs; loans; reimbursements if not for normal living expenses; third party funds; earnings of child under TN No. 13- 22 Supersedes Approval Date_ 2*/ q Effective Date 01101114 TN No. New

Page 11d age 18 if the child is in school at least 1/ 2 time and the child is residing with a parent or an adult with parental control; lump sum payments; income tax refunds and earned income tax credits; energy assistance; recoupments from the source used to repay the source; Workforce Investment income if it is not on the job training; and income excluded by federal law. SNAP deducts a standard deduction ( based on household size), 20% of earned income; dependent care expenses if needed for training or employment; medical expenses for individuals over age 60 or permanently disabled; and a portion of the household' s shelter expenses from the household' s gross income to arrive at a net income figure to determine the benefit amounts. Farm losses are deducted from other income if the farm grossed at least$ 1000 in the business year. Medicaid: Based on Tax rules. 5) Check off and describe the option used to satisfy the Screen and Enroll requirement before a child may be enrolled under title XXI. a) Screening threshold established by the Medicaid agency as: i) percentage of the Federal poverty level which exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points: specify or ii) percentage of the FPL ( describe how this reflects the value of any differences between income methodologies of Medicaid and the Express Lane agency: or b) Temporary enrollment pending screen and enroll. TN No. 13- 22 Supersedes Approval Date 3l Effective Date 01/ 01114 TN No. New

Page 11e STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA SECTION 2. COVERAGE AND ELIGIBILITY 2. 1 Application, Determination of Eligibility and Furnishing Medicaid continued) X ( c) State' s regular screen and enroll process for CHIP. 6) Check off if the State elects the option for automatic enrollment without a Medicaid application, based on data obtained from other sources and with the child' s or family's affirmative consent to the child' s Medicaid enrollment. 7) Check off if the State elects the option to rely on a finding from an Express Lane agency that includes gross income or adjusted gross income shown by State income tax records or returns. TN No. 13- 22 Supersedes Approval Date Effective Date 01/ 01/ 14 TN No. New

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: SD- 14- 002- MM7 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179- like data) 3) Approved SPA Pages 4) Additional Attachments that are part of the state plan TN: SD- 14- 002- MM7 Approval Dat 06/ 1')," 2014 Effective Date O 1 O P'1 0 14

DEPARTMENT OF HEALTH& HUMAN SERVICES Centers for Medicare& Medicaid Services Denver Regional Office 1600 Broadway, Suite# 700 Denver, CO 80202-4967 CENTERS FOR MEDICARE&, MEDICAID SERVIUS REGION VIII- DENVER June 17, 2014 LJ 14- 0021 Lynne Valenti, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501- 2291 RE: South Dakota 14- 002 ( Hospital PE) Dear Ms. Valenti: We have reviewed the proposed State Plan Amendment ( SPA) submitted under transmittal number( TN) 14- 002). With this SPA, the state may offer Medicaid coverage for individuals' determined presumptively eligible by a qualified hospital in accordance to the Affordable Care Act. Please be informed that this State Plan Amendment was approved on June 13, 2014 with an effective date of January 1, 2014. We are enclosing the summary page ( formerly CMS 179) and the amended plan pages. If you have any questions concerning this amendment, please contact Laurie Jensen at 303- 844- 7126. Sincerely, s/ Richard C. Allen Associate Regional Administrator Divisions of Medicaid& Children' s Health Operations Cc: Marielle Kress

SD. 0814.R00.00 - Jan 01, 2014 Page 1 of 2 edicaid State Plan Eli rOilit : Suninary Page ( CAIS 1 79 State/Territory name: South Dakota Transmittal Number: Please enter the Transmittal Number( TN) in theformat ST-YY-0000 where ST= the state abbreviation, YY= the last two digits of the submission year, and 0000= afour digit number with leading zeros. The dashes must also be entered SD- 14- 002 Proposed Effective Date 01/ 01/ 2014 mm/ dd/ yyyy) Federal Statute/ Regulation Citation 42 CFR 435. 1110 Federal Budget Impact Federal Fiscal Year Amount First Year 2014 0. 00 Second Year 2015 0. 00 Subject of Amendment This SPA defines the presumptive eligibility period and the criteria for hospitals making presumptive eligibility determinations. Governor' s Office Review Governor's office reported no comment Comments of Governor' s office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Signature of State Agency Official Submitted By: Ann Schwartz Last Revision Date: Jun 12, 2014 Submit Date: Mar 19, 2014 TN#: SD- 14- 002- MM7 Approval Date: 6/ 13/ 14 Effective Date: 1/ 1/ 14 South Dakota Summary 179, Page 1 https:// wms- mmdl.cdsvdc.com/ MMDL/faces/ protected/ mac/ c0l/ print/PrintSelector.jsp 06/ 17/ 2014

MS Medicaid Eligibility OMB Control Number 0938- 1148 OMB Expiration date: 10/ 31/ 2014 Presumptive Eligibility by Hospitals S21 42 CFR 435. 1110 One or more qualified hospitals are determining presumptive eligibility under 42 CFR 435. 1 1 10, and the state is providing Medicaid coverage for individuals detennined presumptively eligible under this provision. C: Yes r No Z The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: FE-1 A qualified hospital is a hospital that: Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance 0 with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. Assists individuals in completing and submitting the full application and understanding any documentation requirements. C Yes C' No O The eligibility groups or populations for which hospitals determine eligibility presumptively are: R Pregnant Women Infants and Children under Age 19 Parents and Other Caretaker Relatives Adult Group, if covered by the state Individuals above 133% FPL, under Age 65, if covered by the state Individuals Eligible for Family Planning Services, if covered by the state Former Foster Care Children Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state 0 Other Family/Adult groups: E] Eligibility groups for individuals age 65 and over 0 Eligibility groups for individuals who are blind Eligibility groups for individuals with disabilities Other Medicaid state plan eligibility groups Demonstration populations covered under section 1 115 The state establishes standards for qualified hospitals making presumptive eligibility determinations. 4_ Approval ate: 4 Etrective a e: South Dakota S21, Page 1 Pa,ee l of 3

Medicaid Eligibility C: Yes C No Select one or both: The state has standards that relate to the proportion of individuals determined presumptively eligible who submit a regular application, as described at 42 CFR 435. 907, before the end of the presumptive eligibility period. The state has standards that relate to the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. 90% of all the presumptive eligibility decisions made by the hospital will be the same decision Description of standards: reached by the Department when a full Medicaid eligibility decision is made. F 'The presumptive period begins on the date the determination is made. F The end date of the presumptive period is the earlier of The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. Periods of presumptive eligibility are limited as follows: C No more than one period within a calendar year. Ce' No more than one period within two calendar years. C, No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. C Other reasonable limitation: The state requires that a written application be signed by the applicant, parent or representative, as appropriate. C: Yes {" No t: The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. 1,., The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. F77: An attachment is submitted. TN#: SD- 14- 002- MM7 Approval Date: 6/ 13/ 14 Effective Date: 1/ 1114 South Dakota S21, Page 2 Pale 2 of 3

Medicaid Eligibility The presumptive eligibility determination is based on the following factors: The individual' s categorical or non- financial eligibility for the group for which the individual' s presumptive eligibility is 0 being determined( e. g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. State residency Citizenship, status as a national, or satisfactory immigration status The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. A copy of the training materials has been included. An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4- 26- 05, Baltimore, Maryland 21244- 1850. TN#: SD- 14-002- MM7 Approval Date: 6/ 13/ 14 Effective Date: 1/ 1/ 14 South Dakota S21, Page 3 Pave 3 of 3

SOUTH DAKOTA MEDICAID HOSPITAL PRESUMPTIVE ELIGIBILITY PROGRAM APPLICATION South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 1 A separate application must be completed for each hospital. POLICY STATEMENT Presumptive eligibility allows qualified hospitals to make temporary Medicaid eligibility determinations in accordance with federal law and state policy for: 1) Low Income Parents and other Caretaker Relatives; 2) Pregnant Women; 3) Medicaid Children Under age 19; 4) Former Foster Care Children Age 18-26; and/or 5) Individuals Needing Treatment for Breast or Cervical Cancer. DEFINITIONS A “qualified hospital” is defined as a hospital that: 1. Participates as a hospital provider under the South Dakota Medicaid State Plan; 2. Notifies the South Dakota Department of Social Services (DSS) of its election to make presumptive eligibility determinations; 3. Agrees to make presumptive eligibility determinations consistent with South Dakota policies and procedures; 4. Assists individuals in completing and submitting the full application for Medicaid and understanding any documentation requirements; and 5. Has not been disqualified by the South Dakota Department of Social Services. REQUIREMENTS Qualified hospitals must adhere to South Dakota’s requirements for presumptive eligibility determinations. Failure to meet the minimum performance standards established by the Department of Social Services or to adhere to South Dakota Presumptive Eligibility policies may be cause for disqualification from the Hospital Presumptive Eligibility Program. Performance standards and compliance with South Dakota policies will be evaluated on a quarterly basis. Qualified hospitals failing to meet performance standards or adhere to South Dakota policies will be required to submit a corrective action plan to the Department of Social Services that includes remedial training provided by the Department. If the qualified hospital fails to meet minimum performance standards following remedial training and implementation of the corrective action plan, the hospital may be disqualified from participation in the Hospital Presumptive Eligibility program. The qualified hospital must: 1. Designate an interviewer(s) and notify the South Dakota Department of Social Services of the name, title, and telephone number of all employees conducting presumptive eligibility determinations. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Application, Page 1 Effective Date: 1/1/14

South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 2 2. Notify the Department when new employees are designated to perform presumptive eligibility determinations. 3. Assure employees authorized to perform presumptive eligibility determinations are not employees with authority or responsibility to submit claims to the Medicaid program for reimbursement of Medicaid services. Assure no presumptive eligibility determination functions will be delegated to non-hospital staff, third party vendors, or contractors. 4. Assure that all designated employees complete presumptive eligibility training provided by the Department of Social Services prior to performing presumptive eligibility determinations. Retain documentation of all training completed on file at the hospital. Note: Presumptive eligibility training and determinations are not reimbursable. Qualified hospitals are reimbursed for Medicaid covered services provided to individuals determined to be presumptively eligible. 5. Assure capability of assisting applicants who need the assistance of an interpreter. 6. Provide training to all designated employees on security and privacy laws, regulations, and standards prior to the performing presumptive eligibility determinations. Assure all designated employees sign a statement regarding confidential information obtained during the presumptive eligibility process. Proof of signed confidentiality agreements must be retained on site by the qualified hospital for a minimum of 3 years. Any information obtained during the Presumptive Eligibility application process is considered confidential and may not be disclosed to any persons or agencies other than representatives of the Department of Social Services and its designees. Information is confidential whether the application is approved or denied and may not be shared with collection agencies or any other third-party. 7. Provide Notice of Privacy Practices to the applicant. 8. Verify that the individual is not currently enrolled in Medicaid or CHIP or that the individual has had a prior presumptive eligibility determination in the previous two calendar years. On a monthly basis, the Department will provide qualified hospitals with a list of applicants determined presumptively eligible in the previous two years. 9. Follow procedures found in the Presumptive Eligibility Training Guide– Hospital Presumptive Eligibility. 10. Screen applicants using the Presumptive Eligibility Worksheet and perform necessary calculations to determine if the applicant meets the criteria for presumptive eligibility. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Application, Page 2 Effective Date: 1/1/14

South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 3 11. Issue a presumptive eligibility determination letter on the approved form to the applicant that clearly indicates the outcome of the presumptive eligibility determination. If determined presumptively eligible, explain the next steps the applicant must take to complete the application process, including the end date of presumptive eligibility period and covered Medicaid services during the presumptive eligibility period. 12. Assist applicants in the completion and submission of a full Medicaid application and understanding any documentation requirements. 13. Provide all applicants with contact information for the South Dakota Department of Social Services. 14. If the applicant does not complete a full Medicaid application during the presumptive eligibility interview or at the hospital, provide the applicant with a copy of the application and direct the applicant where to submit the application upon its completion. 15. Forward the completed Presumptive Eligibility Medicaid application, Presumptive Eligibility Worksheet, and a copy of the determination letter to the Division of Economic Assistance, ATTN: Presumptive Eligibility within two working days of the presumptive eligibility determination. 16. Have a computer, internet, telephone, printer, and fax access available for applicants to facilitate the presumptive eligibility and full Medicaid application process. 17. Secure all documents in a locked file cabinet not accessible to public or employees not designated as presumptive eligibility employees or who have not signed a confidentiality statement. 18. Communicate with the Department of Social Services to resolve any issues or concerns and to establish efficient policies and procedures to perform presumptive eligibility determinations. 19. Each qualified hospital must maintain records of the hospital’s activities related to presumptive eligibility determinations. Records must be retained for a minimum of 6 years as required by Administrative Rule of South Dakota (ARSD) §67:16:34:05. Track and report the following data each quarter: 1) Number of individuals screened for presumptive eligibility 2) Number of individuals approved for presumptive eligibility 3) Number of individuals rejected for presumptive eligibility 4) Reasons for each presumptive eligibility rejection TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Application, Page 3 Effective Date: 1/1/14

South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 4 5) Dates on which individuals are screened, approved, and rejected for presumptive eligibility 20. Maintain at least a 90% accuracy rate when performing Hospital Presumptive Eligibility Determinations. 90% of all the presumptive eligibility decisions made by the hospital must be the same decision reached by the Department when a full Medicaid eligibility decision is made. 21. Provide written notice to the Department of intent to withdraw from the Hospital Presumptive Eligibility Program. Written notice may be given at any time. 22. The qualified hospital must monitor the quality of the case processing by reviewing a sample of completed cases. It is recommended that at least one case review per month be completed for each designated employee. If frequent errors are noted, corrective action must be taken. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Application, Page 4 Effective Date: 1/1/14

South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 5 QUALIFICATIONS Qualified hospitals must answer the following questions to complete the presumptive eligibility application. Responses to these questions will be used to assess the hospital’s ability to provide presumptive eligibility determinations in accordance with the above stated requirements. 1. General Information: Hospital Name: Click here to enter text. Address: Click here to enter text. Billing National Provider Identifier (NPI): Click here to enter text. 2. Primary Contact Information for Hospital Presumptive Eligibility Program: Name of Individual completing Application: Click here to enter text. Name of Individual with Primary Responsibility for Hospital Presumptive Eligibility Program: Click here to enter text. Title: Click here to enter text. Telephone Number: Click here to enter text. Email: Click here to enter text. 3. Designate the Medicaid Group(s) the Hospital elects to make Presumptive Eligibility Determinations for. Check all that apply. Low Income Parents and Caretaker Relatives Medicaid Children Under Age 19 Pregnant Women Former Foster Care Children Age 18 to26 Individuals Needing Treatment for Breastor Cervical Cancer. Note: The hospital must be an All Women Count! Program provider. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/ 13/14 HPE Application, Page 5 Effective Date: 1/ 1/ 14

South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 6 4. Designate Presumptive Eligibility Employees. Attach additional sheets as necessary. a) Designated Presumptive Eligibility Interviewer: Name: Click here to enter text. Title: Click here to enter text. Telephone Number: Click here to enter text. Email: Click here to enter text. Qualifications: Click here to enter text. b) Additional Designated Presumptive Eligibility Employees: Name: Click here to enter text. Title: Click here to enter text. Telephone Number: Click here to enter text. Email: Click here to enter text. Qualifications: Click here to enter text. 5. Describe the hospital’s proposed internal process for making Presumptive Eligibility Determinations. Include the specific follow-up and outreach efforts the hospital intends to use to meet the Department’s performance standards of ensuring a 95% full Medicaid determination rate. Click here to enter text. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Application, Page 6 Effective Date: 1/1/14

South Dakota Medicaid | Hospital Presumptive Eligibility Program Application 7 SUBMISSION Completed applications may be mailed to: Division of Medical Services ATTN: Hospital Presumptive Eligibility 700 Governors Drive Pierre, SD 57501 Questions about this application should be addressed to the Division of Medical Services at (605) 773-3495. By signing this application, the qualified hospital, through its below named representative, elects to perform Presumptive Eligibility Determinations in compliance with all terms, conditions, and administrative responsibilities detailed above. It further agrees to be bound by all applicable State or Federal laws not expressly outlined in this application pertaining to the Medicaid eligibility system, presumptive eligibility determinations, security, and privacy. Designated Representative (Please Print): ____________________________________ Signature: _______________________________________________________________ Date Signed: _____________________________________________________________ DSS Internal Use Only DMS Date Received: EA Date Received: Provider Status Verification: APPROVED ___________ DENIED Notes: Training Scheduled: TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Application, Page 7 Effective Date: 1/1/14

Presumptive Eligibility Training Guide Hospital Presumptive Eligibility South Dakota Division of Economic Assistance June 2014 TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 1 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Table of Contents June 14 2 TABLE OF CONTENTS TABLE OF CONTENTS ............................................................................................................................... 2 PREFACE ..................................................................................................................................................... 3 GENERAL INFORMATION .......................................................................................................................... 4 PROGRAM REQUIREMENTS ............................................................................................... 6 NON-DISCRIMINATION ......................................................................................................... 8 TRAINING AND COMMUNICATIONS .................................................................................... 9 CLAIMS PROCESSING ......................................................................................................... 9 SCREENING AND APPLICATION ASSISTANCE .................................................................................... 10 STEP 1: MEDICAL ASSISTANCE SCREENING .................................................................. 10 STEP 2: PRESUMPTIVE ELIGIBILITY SCREENING ...........................................................10 STEP 3: PRESUMPTIVE ELIGIBILITY APPLICATION ASSISTANCE ................................. 11 DETERMINING PRESUMPTIVE ELIGIBILITY .......................................................................................... 12 GENERAL ELIGIBILITY CRITERIA .......................................................................................12 NOTIFYING THE DEPARTMENT OF PRESUMPTIVE ELIGIBILITY DETERMINATION ......16 APPENDIX 1: PRESUMPTIVE ELIGIBILITY WORKSHEET ................................................................... 17 APPENDIX 2: INCOME GUIDELINES ....................................................................................................... 19 LOW INCOME PARENTS OR OTHER CARETAKER RELATIVES WITH DEPENDENT CHILDREN UNDER AGE 19 .................................................................................................19 MEDICAID CHILDREN UNDER AGE 19 ...............................................................................19 PREGNANT WOMEN............................................................................................................ 19 FORMER FOSTER CARE INDIVIDUALS.............................................................................. 19 APPENDIX 3: APPLICANT NOTICE OF ELIGIBILITY ............................................................................. 20 APPENDIX 4: APPLICANT NOTICE OF DENIAL .................................................................................... 22 TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 2 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 3 PREFACE Medicaid is a joint federal and state program established in 1965, under Title XIX of the Social Security Act. The purpose of the Medicaid Program is to assure the availability of quality medical care for low-income individuals and families through payments for specific covered services. The Medicaid program was implemented in South Dakota in 1967. The Department of Social Services (DSS) is the single-state agency responsible for administering the Medicaid program in South Dakota. The Division of Medical Services oversees the Medicaid Program. Eligibility determinations for the Medicaid program are performed by the Division of Economic Assistance. The Hospital Presumptive Eligibility Program allows qualified hospitals to make temporary eligibility determinations in accordance with federal law and state policy for the Medicaid program while an applicant’s full Medicaid application is processed by the Department of Social Services. This guide contains the policies and procedures governing the Hospital Presumptive Eligibility Program in South Dakota. Questions about this guide may be directed to: South Dakota Department of Social Services Division of Economic Assistance 700 Governors Drive Pierre, SD 57501 Phone: (605) 773-4678 Fax: (605) 773-7183 The policies and procedures found in this manual are subject to review and amendment by the South Dakota Department of Social Services. Check this manual frequently for updates. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 3 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 4 GENERAL INFORMATION HOSPITAL PRESUMPTIVE ELIGIBILITY Under 42 CFR §435.1110, a “qualified hospital” may elect to make presumptive eligibility determinations based on a State’s policies and procedures. Presumptive Eligibility is a temporary medical assistance category that allows an individual to receive covered medical services while his/her application for full Medicaid is processed. A hospital may elect to make Presumptive Eligibility determinations for one or more of the following groups: x Low Income Parents and Caretaker Relatives x Medicaid Children Under Age 19 x Pregnant Women x Former Foster Care Children Age 18 to 26 Hospitals must identify the eligibility groups that the hospital elects to make Presumptive Eligibility determinations for on the South Dakota Hospital Presumptive Eligibility Application. Hospitals may not delegate the authority to determine presumptive eligibility to another entity. COVERED SERVICES The following services are eligible for reimbursement during a Presumptive Eligibility period: x Low Income Parents and Caretaker Relatives, Children Under age 19, and Former Foster Care Individuals are eligible to receive all Medicaid covered services. x Pregnant Women are eligible for ambulatory prenatal care. Ambulatory prenatal care includes pregnancy-related Medicaid covered services except charges associated with inpatient care in a hospital or other medical institution and charges associated with delivery of the baby, including miscarriage. A woman is allowed only one presumptive eligibility period per pregnancy. DURATION OF PRESUMPTIVE ELIGIBILITY PERIOD The presumptive eligibility period begins with the date on which a qualified hospital determines that the individual is eligible. An individual is allowed one presumptive eligibility period every two calendar years. A pregnant woman is allowed one presumptive eligibility period per pregnancy. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 4 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 5 Presumptive Eligibility coverage ends on either: x The date the eligibility determination for medical assistance is made by the Department of Social Services, if a complete application is filed by the last day of the month following the month in which the Presumptive Eligibility determination is made; or x The last day of the month following the month in which the Presumptive Eligibility determination was made. QUALIFIED HOSPITAL PRESUMPTIVE ELIGIBILITY APPLICATION A “qualified hospital” is defined as a hospital that: 1. Participates as a provider under the South Dakota Medicaid State Plan; 2. Notifies the South Dakota Department of Social Services of its election to make presumptive eligibility determinations; 3. Agrees to make presumptive eligibility determinations consistent with South Dakota policies and procedures; 4. Assists individuals in completing and submitting the full application for medical assistance and understanding any documentation requirements; and 5. Has not been disqualified by the Department of Social Services. Hospitals must submit an application to become a qualified hospital. Providers may contact the Division of Medical Services at (605) 733-3495 to request a South Dakota Hospital Presumptive Eligibility Application. DISQUALIFICATION OF QUALIFIED HOSPITAL The State of South Dakota is required to establish standards for qualified hospitals. The qualified hospital must agree to make presumptive eligibility determinations consistent with South Dakota policies and procedures. The State of South Dakota is required to take action, including, but not limited to, disqualification of a hospital as a qualified hospital if the State determines the hospital is not making, or is not capable of making presumptive eligibility determinations in accordance with applicable South Dakota policies and procedures or meeting the standards established by the Department of Social Services. The hospital may only be disqualified from the Hospital Presumptive Eligibility Program after the Department of Social Services has provided the hospital with additional training or taken other reasonable corrective measures. Performance standards and compliance with South Dakota policies will be evaluated on a quarterly basis. Qualified hospitals failing to meet performance standards or adhere to South Dakota policies will be required to submit a corrective action plan to the Department of Social Services that includes remedial training provided by the Department. If the qualified hospital fails to meet minimum performance standards following remedial training and the corrective TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 5 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 6 action plan, the hospital may be disqualified from participation in the Hospital Presumptive Eligibility program. Qualified hospitals may withdraw from the Presumptive Eligibility program at any time upon written notice to the South Dakota Department of Social Services. PROGRAM REQUIREMENTS The State of South Dakota has established the following requirements for qualified hospitals participating in the Presumptive Eligibility Program. Qualified hospitals must: 1. Designate an interviewer(s) and notify the South Dakota Department of Social Services of the name, title, and telephone number of all employees conducting presumptive eligibility determinations. 2. Notify the Department when new employees are designated to perform presumptive eligibility determinations. 3. Assure employees authorized to perform presumptive eligibility determinations are not employees with authority or responsibility to submit claims to the Medicaid program for reimbursement of Medicaid services. Assure no presumptive eligibility determination functions will be delegated to non-hospital staff, third party vendors, or contractors. 4. Assure that all designated employees complete presumptive eligibility training provided by the Department of Social Services prior to performing presumptive eligibility determinations. Retain documentation of all training completed on file at the hospital. Note: Presumptive eligibility training and determinations are not reimbursable. Qualified hospitals are reimbursed for Medicaid covered services provided to individuals determined to be presumptively eligible. 5. Assure capability of assisting applicants who need the assistance of an interpreter. 6. Provide training to all designated employees on security and privacy laws, regulations, and standards prior to the performing presumptive eligibility determinations. Assure all designated employees sign a statement regarding confidential information obtained during the presumptive eligibility process. Proof of signed confidentiality agreements must be retained on site by the qualified hospital for a minimum of 3 years. Any information obtained during the Presumptive Eligibility application process is considered confidential and may not be disclosed to any persons or agencies other than representatives of the Department of Social Services and its designees. Information is confidential whether the application is approved or denied and may not be shared with collection agencies or any other third-party. 7. Provide Notice of Privacy Practices to the applicant. 8. Verify that the individual is not currently enrolled in Medicaid or CHIP or that the individual has had a prior presumptive eligibility determination in the previous two TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 6 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 7 calendar years. On a monthly basis, the Department will provide qualified hospitals with a list of applicants determined presumptively eligible in the previous two years. 9. Follow procedures found in the Presumptive Eligibility Training Guide– Hospital Presumptive Eligibility. 10. Screen applicants using the Presumptive Eligibility Worksheet and perform necessary calculations to determine if the applicant meets the criteria for presumptive eligibility. 11. Issue a presumptive eligibility determination letter on the approved form to the applicant that clearly indicates the outcome of the presumptive eligibility determination. If determined presumptively eligible, explain the next steps the applicant must take to complete the application process, including the end date of presumptive eligibility period and covered Medicaid services during the presumptive eligibility period. 12. Assist applicants in the completion and submission of a full Medicaid application and understanding any documentation requirements. 13. Provide all applicants with contact information for the South Dakota Department of Social Services. 14. If the applicant does not complete a full Medicaid application during the presumptive eligibility interview or at the hospital, provide the applicant with a copy of the application and direct the applicant where to submit the application upon its completion. 15. Forward the completed Presumptive Eligibility Medicaid application, Presumptive Eligibility Worksheet, and a copy of the determination letter to the Division of Economic Assistance, ATTN: Presumptive Eligibility within two working days of the presumptive eligibility determination. 16. Have a computer, internet, telephone, printer, and fax access available for applicants to facilitate the presumptive eligibility and full Medicaid application process. 17. Secure all documents in a locked file cabinet not accessible to public or employees not designated as presumptive eligibility employees or who have not signed a confidentiality statement. 18. Communicate with the Department of Social Services to resolve any issues or concerns and to establish efficient policies and procedures to perform presumptive eligibility determinations. 19. Each qualified hospital must maintain records of the hospital’s activities related to presumptive eligibility determinations. Records must be retained for a minimum of 6 years as required by Administrative Rule of South Dakota (ARSD) §67:16:34:05. Track and report the following data each quarter: 1) Number of individuals screened for presumptive eligibility TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 7 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 8 2) Number of individuals approved for presumptive eligibility 3) Number of individuals rejected for presumptive eligibility 4) Reasons for each presumptive eligibility rejection 5) Dates on which individuals are screened, approved, and rejected for presumptive eligibility 20. Maintain at least a 90% accuracy rate when performing Hospital Presumptive Eligibility Determinations. 90% of all the presumptive eligibility decisions made by the hospital must be the same decision reached by the Department when a full Medicaid eligibility decision is made. 21. Provide written notice to the Department of intent to withdraw from the Hospital Presumptive Eligibility Program. Written notice may be given at any time. 22. The qualified hospital must monitor the quality of the case processing by reviewing a sample of completed cases. It is recommended that at least one case review per month be completed for each designated employee. If frequent errors are noted, corrective action must be taken. NON-DISCRIMINATION Title IV of the Federal Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973 prohibit discrimination on the groups of race, sex, color, national origin, or handicap in the administration of federally-funded programs. This includes Medicaid and CHIP programs. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 8 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 9 TRAINING AND COMMUNICATIONS The qualified hospital must designate a primary contact for the Presumptive Eligibility Program for the Department of Social Services who is responsible for communication to the Department regarding program changes, questions, personnel changes, and other issues. Qualified hospitals must designate all employees involved in the Presumptive Eligibility process. All designated employees must obtain training from the Department of Social Services prior to performing Presumptive Eligibility functions. Each employee will be required to certify that they have received training on South Dakota policies and procedures and agree to perform presumptive eligibility determinations in accordance with the requirements outlined by the Department of Social Services. The qualified hospital must retain a copy of employee certifications. After the Department has approved the hospital’s Presumptive Eligibility Application, the Department will work with the primary contact to schedule face-to-face training with designated employees. During the training period, the qualified hospital and the Department of Social Services will make ten joint presumptive eligibility determinations. Joint determinations will not count towards the qualified hospital’s Medicaid determination rate. In the event that the qualified hospital requires remedial training, the Department and the qualified hospital will make another ten joint presumptive eligibility determinations. Additional trainings may be scheduled as the qualified hospital designates new employees for presumptive eligibility determinations. CLAIMS PROCESSING Qualified hospitals should delay submitting claims for services provided to individuals determined eligible by the Presumptive Eligibility Program for one week from the eligibility start date to ensure the eligibility information is transmitted to the Division of Medical Services and to prevent claims from being inappropriately denied. Claims must be for a covered Medicaid Service and submitted in accordance with ARSD 67:16. Presumptive Eligibility claims should be submitted in the same manner as all other claims submitted by the entity. No special processing is needed. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 9 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 10 SCREENING AND APPLICATION ASSISTANCE STEP 1: MEDICAL ASSISTANCE SCREENING Qualified hospitals are required to verify if an applicant is currently enrolled in Medicaid before providing services to the applicant. All providers are encouraged to use the Medicaid Eligibility Verification System (MEVS) or the South Dakota Medicaid Interactive Voice Response (IVR) and Telephone Service Unit by calling 1-800-452-7691 to verify eligibility. If an applicant is enrolled in Medicaid, do not have the applicant complete an application and do not complete a Presumptive Eligibility determination. If a baby is born to a mother enrolled in Medicaid, do not have the mother complete an application and do not complete a Presumptive Eligibility determination. The baby will be eligible for the Automatic Newborn program when the birth is reported to the Department of Social Services. The hospital may contact the Division of Economic Assistance to report the birth. If an applicant is not currently enrolled in Medicaid, assist the applicant in completing an application and determine eligibility for the Presumptive Eligibility Program. STEP 2: PRESUMPTIVE ELIGIBILITY SCREENING Presumptive Eligibility periods are limited to no more than one period within two calendar years per applicant. Pregnant Women are eligible for one Presumptive Eligibility period per pregnancy. Qualified hospitals are required to verify if an applicant has been enrolled in a Presumptive Eligibility period within two calendar years of the date of the presumptive eligibility application. On a monthly basis, the Department will provide qualified hospitals with a list of applicants determined presumptively eligible in the previous two years. If an applicant has a presumptive eligibility period within the previous two calendar years, give the applicant information about how to complete a full Medicaid application. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 10 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 11 STEP 3: PRESUMPTIVE ELIGIBILITY APPLICATION ASSISTANCE Qualified hospitals must use the Presumptive Eligibility Medicaid Application. This form may be obtained from the Department of Social Services, Division of Economic Assistance, 605-773- 4678. At minimum, qualified hospitals must complete the questions denoted with an asterisk for a presumptive eligibility determination. The qualified hospital must also gather enough information to complete the Presumptive Eligibility Worksheet found in Appendix 1. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 11 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 12 DETERMINING PRESUMPTIVE ELIGIBILITY GENERAL ELIGIBILITY CRITERIA Social Security Number: A Social Security Number (SSN) or attestation of an application for a SSN should be provided for each applicant, if the applicant is willing to provide it. Self- declaration of the SSN is sufficient and can be listed on the application where requested. No card or proof is necessary. Lack of an SSN on the application may not delay or impact a presumptive eligibility determination. Citizenship/National or Qualified Alien: The applicant must be a citizen or national of the United States or a qualifying immigrant with one of the following immigration statuses: Afghan Special Immigrant Amerasian Immigrant admitted pursuant to Section 584 Asylee admitted under Section 208 of the INA A battered alien (includes battered alien’s child and parent of a battered alien child) Alien granted conditional entry under 203(a)(7) of the INA Alien granted status as a Cuban/Haitian entrant as defined in Section 501(a) An alien whose deportation is being withheld under 243(h) or 241(b)(3) of the INA Iraqi Special Immigrant Alien Lawfully admitted for permanent residence (LPR) under the INA living lawfully in the United States for five years or longer Alien who is a U.S. Active duty military member, includes spouses and unmarried dependent children under 19 Alien who was an honorably discharged U.S. military veteran, includes spouse and unmarried dependent children under 19 An American Indian born in Canada A member of a federally recognized tribe born outside U.S. An alien granted parole for at least one year by the UNS pursuant to Section 212(d)(5) of the INA A refugee under Section 207 of the INA An alien certified as a Victim of Severe Form of Trafficking If an applicant is not a U.S. citizen or a naturalized citizen, the applicant must be asked for his/her alien status and must qualify under one of the groups outlined above. Undocumented aliens or immigrants that do not qualify under a group outlined above should be referred to the Department of Social Services for a full Medicaid eligibility determination. Residency: In order to be eligible for South Dakota Medicaid, an applicant must be a resident of the State of South Dakota. A South Dakota address must be provided on the application. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 12 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 13 State residency is established by physically residing in South Dakota and declaring intent to remain. An applicant is not considered a resident if the applicant is in South Dakota for a temporary reason such as a vacation, business trip, or attending a South Dakota college without intent to remain in South Dakota after completion of the course of study. Household Size: Household size includes the parent or caretaker relative, the parent or caretaker relative’s spouse, if the spouse lives with the individual, and all of their dependent children, including unborn children. Others, such as a boyfriend or girlfriend, or other relatives are not counted in household size, even if they live within the household. Earned Income: Income includes wages and tips before taxes and other deductions. Calculation Steps: 1) Always use the most current month to determine gross monthly (before taxes) income. 2) If determining income for more than one job, add the gross amounts for each job. 3) The total is the gross monthly income amount. Enter this amount on the Presumptive Eligibility Worksheet in Appendix 1. Unearned Income: Medicaid counts some unearned income of individuals in the household. Unearned income is considered to be income received by an individual that is not received through wages or tips. This may include: x Pensions x Social Security x Retirement Accounts x Alimony Examples of Non-Countable Income Certain income is not counted in the applicant’s income determination. Do not include income from the following: x Federal Veteran’s Benefits x Child Support x Worker’s Compensation x Scholarships, fellowship grants and awards used for educational purposes. x Income of Children: The income of children is not included unless the amount of the child’s income requires the child to file a tax form. x Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF). x Supplemental Security Income Note: The Department will provide a more detailed list and examples of countable and non- countable income during training. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 13 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 14 Self-Employment Step 1: Identify “adjusted gross income” from appropriate line of federal income tax form or by self- attestation from the applicant: Line 4 on Form 1040 EZ Line 21 on Form 1040 A Line 37 on Form 1040 If the applicant had wages, salaries, tips, etc. (line 7) that does not reflect the current monthly amount, this amount should be deducted and recalculated at the current monthly rate. Step 2: If applicable, add the following sources of income from the last year’s tax form or by self- attestation from the applicant: Any Social Security benefits not already included in adjusted gross income (line 20a on Form 1040) Tax-exempt interest taxpayer expects to receive or accrue during year (line 8b on Form 1040) Foreign earned income excluded from gross income (based on Form 2555, line 26 or Form 2555-EZ, line 17) (Line 7 on Form 1040) Step 3: If applicable, make the following income modifications: Count lump sum payments (e.g., gifts, prizes, income and property tax refunds only in month received) Subtract educational scholarships, awards or fellowships used for education purposes Subtract certain types of income for American Indian/Alaskan Native individuals. For applicants who expect to be claimed as a tax dependent by a grandparent, another relative, or another taxpayer who is not a parent or step-parent, count cash support exceeding $500) provided by the person claiming the applicant as a tax dependent. Step 4: Divide annual total by 12 to get a monthly amount. If an applicant has, or expects, changes from the most recent tax forms for self-employment income, the applicant should address the change that makes the average monthly income from the most recent return inappropriate for assessing eligibility for presumptive eligibility. Allowable Business Expenses include: x Cost of stock and inventory; x Cost of operating machinery or equipment; x Rent for the business property; x Taxes on the business property, such as real estate and vehicle taxes; x Mortgage interest, vehicle loan interest , and interest on loans made to the business; x Fire, theft, flood, or similar insurance, liability insurance, and contributions to industrial compensation and unemployment insurance; wages paid to employees; costs of employee benefits, such as health insurance, dependent care assistance, and life insurance; x Business transportation, such as lease payments, license and registration, vehicle insurance, gas, oil, tires, report costs, garage rent, tolls, parking; TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 14 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 15 x Advertising costs; x Utilities; x Depreciation; x Federal, state, or local income tax payments; x Entertainment expenses; x Personal transportation; x Cost of purchasing capital equipment; x Payments on the principal of loans; and x Carryover of previous year’s losses. A business may report a net loss for the year. The prorated amount of the loss is subtracted from the budget group’s countable income for the month. If the remaining income is not enough to cover living expenses, the applicant must explain how these costs are being met. Note: Seasonal income is counted during the months worked. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 15 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Preface and General Information June 14 16 NOTIFYING THE DEPARTMENT OF PRESUMPTIVE ELIGIBILITY DETERMINATION Qualified hospitals are required to notify the Division of Economic Assistance of Presumptive Eligibility approvals within 2 working days. The following items should be submitted to the Department no later than 2 working days after the Presumptive Eligibility determination: Presumptive Eligibility Medicaid Application Presumptive Eligibility Worksheet Notice to Applicant If an applicant has been denied Presumptive Eligibility, the applicant has the option to have his/her application sent to the Department of Social Services for a Medicaid determination. This application, along with the notice to the applicant, should be forwarded to the Department of Social Services, Division of Economic Assistance within 2 working days. The following items should be submitted by fax no later than 2 working days after the Presumptive Eligibility denial: Presumptive Eligibility Medicaid Application Notice to Applicant Qualified hospitals must submit documents by fax (605) 773-7183 to: Department of Social Services Division of Economic Assistance ATTN: Presumptive Eligibility TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 16 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Presumptive Eligibility Appendix 1 June 14 17 APPENDIX 1: PRESUMPTIVE ELIGIBILITY WORKSHEET Applicant Name: ___________________________________________________ Applicant Social Security Number: ________________________________________ Is the applicant a citizen/national? Yes No If NO, is the applicant a qualified alien: Yes No If YES, how is the alien qualified? _____________________________________ Is the applicant a resident of South Dakota? Yes No Does the applicant have a Social Security Number? Yes No If NO, has the applicant applied for a Social Security Number? Yes No Determine Household Size: The household size consists of the applicant, the applicant’s spouse, the applicant’s natural, adopted and step children under the age of 19 living in the home. In the case of a dependent child under age 19, the applicant’s household consists of the applicant, the applicant’s natural, adopted and step siblings under age 19 living in the home, and the applicant’s parents or caretaker relatives. Names and relationship of individuals living in the home: Name Relationship to Applicant Total Household Size TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 17 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Presumptive Eligibility Appendix 1 June 14 18 Determine Monthly Income: Include income of all members included in the household size except children. Amount of monthly household earned income from wages, tips or self-employment: Amount of monthly unearned income Total Income (=) Compare the Total Income to the Household Size on the appropriate chart located on the Department’s website; links to the appropriate charts are located in Appendix 2. The total income must be at or below the Monthly Dollar Amount on the applicable chart for the Household Size. x Low Income Parents and Other Caretaker Relative x Medicaid Children under Age 19 x Pregnant Women Eligibility Determination: Is the applicant eligible for Presumptive Eligibility Yes No If YES, check the program: Low Income Parents and Other Caretaker Relative Medicaid Children under Age 19 Pregnant Women Former Foster Care TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 18 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Presumptive Eligibility Appendix 2 June 14 19 APPENDIX 2: INCOME GUIDELINES Income Guidelines and additional eligibility information is available on the Department’s website. Please see the following links below: LOW INCOME PARENTS OR OTHER CARETAKER RELATIVES WITH DEPENDENT CHILDREN UNDER AGE 19 x http://dss.sd.gov/medicaleligibility/familieschildren/lifincomeguidelines.asp MEDICAID CHILDREN UNDER AGE 19 x http://dss.sd.gov/medicalservices/chip/childwithprivate.asp PREGNANT WOMEN x http://dss.sd.gov/medicaleligibility/womenservices/incomeguidelineslimited.asp FORMER FOSTER CARE INDIVIDUALS There is no income test for this group. The Department of Social Services, Division of Economic Assistance may be contacted to verify that the applicant was in State Foster Care. TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 19 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Presumptive Eligibility Appendix 3 June 14 20 APPENDIX 3: APPLICANT NOTICE OF ELIGIBILITY HOSPITAL LETTERHEAD] Medicaid Presumptive Eligibility Notice of Presumptive Eligibility Date] Applicant Name] Applicant Address] Applicant CITY/STATE/ZIP] The following individual has been determined presumptively eligible to receive Medicaid coverage. Coverage is temporary, unless you take action. If you want to apply to continue with South Dakota Medicaid coverage after your temporary eligibility ends, a completed application must be submitted to the South Dakota Department of Social Services no later than the last day of the month following the month this notice was signed). If the application is not received by that day, eligibility will stop on that day. If you are not found eligible for ongoing coverage your Presumptive Medicaid coverage will end effective the date that determination is made. Individual’s Name Individual’s Social Security Number Individual’s Aid Category (Check one) Last: First: Middle: Low Income Parent/Caretaker Relative Medicaid Child Under Age 19 Pregnant Woman Former Foster Care Individual x Pregnant Women are only covered for ambulatory prenatal care. Ambulatory prenatal care includes pregnancy-related Medicaid covered services except charges associated with inpatient care in a hospital or other medical institution and charges associated with delivery of the baby This is not a formal ongoing Medicaid eligibility determination. See checked section below regarding your Presumptive Eligibility period: TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 20 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Presumptive Eligibility Appendix 3 June 14 21 Your completed application for medical assistance has been sent to the South Dakota Department of Social Services for a formal Medicaid eligibility determination. Your presumptive eligibility period will end when the Department of Social Services makes a formal eligibility determination for Medicaid. You will receive a notice from the Department of Social Services regarding the outcome of this determination. You must submit a complete application to the Department of Social Services/Division of Economic Assistance to have a formal ongoing Medicaid eligibility determination processed. We have provided you with the application. You may submit the application by fax to (605) 773-7183 or by mail to the following address: Department of Social Services Division of Economic Assistance ATTN: Presumptive Eligibility 700 Governors Drive Pierre, SD 57501 This Presumptive Eligibility determination was made by: Qualified Hospital Name: ______________________ Designated Employee Name: _____________________ Phone Number: _______________________ Email Address: ________________________ TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 21 Effective Date: 1/1/14

South Dakota Division of Economic Assistance | Presumptive Eligibility Appendix 4 June 14 22 APPENDIX 4: APPLICANT NOTICE OF DENIAL HOSPITAL LETTERHEAD] Medicaid Presumptive Eligibility Notice of Denial Date] Applicant Name Applicant Address Applicant CITY/STATE/ZIP The application for presumptive eligibility has been denied for the following applicant because: Applicant Name] your family income is over the allowable limit you are not a resident of South Dakota you are not a United States Citizen or Qualified Alien you did not meet a Medicaid eligibility category you have asked that your application be withdrawn you have not provided the information we requested Other, indicate reason: ____________________________________ Temporary eligibility determinations are final There is no right to appeal a temporary eligibility decision. You may re-apply for Medicaid benefits at any time. x Online Applications are available at: https://apps.sd.gov/ss36snap/web/Portal/Default.aspx or https://www.healthcare.gov/ x Paper applications are available at this facility or available at your local Department of Social Services office. A list of local offices can be found at: http://dss.sd.gov/offices/ x You may also apply by phone, to do this please contact your local DSS office. This Presumptive Eligibility determination was made by: Qualified Hospital Name: ______________________ Designated Employee Name: _____________________ Phone Number: _______________________ Email Address: ________________________ TN#: SD-14-002-MM7 South Dakota Approval Date: 6/13/14 HPE Guide, Page 22 Effective Date: 1/1/14

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Table of Contents State/Territory Name: SD State Plan Amendment (SPA) #:18-0002

1) Approval Letter 2) CMS 179 3) SPA Pages

CMS-10434 OMB 0938-1188 Package Information Package ID SD2018MS0001O Program Name N/A SPA ID SD-18-0002 Version Number 2 Submitted By Sarah Aker Package Disposition Priority Code P1 Submission Type Official State SD Region Denver, CO Package Status Approved Submission Date 2/20/2018 Approval Date 4/9/2018 6:23 AM EDT Page 1 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Approval Notice DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Date: 04/09/2018 Head of Agency: Lynne A. Valenti Title/Dept : Cabinet Secretary Address 1: 700 Governors Drive Address 2: City : Pierre State: SD Zip: 57501 MACPro Package ID: SD2018MS0001O SPA ID: SD-18-0002 Subject Out of state former foster care eligibility Dear Lynne A. Valenti This is an informal communication that will be followed with an official communication to the State's Medicaid Director. The Centers for Medicare and Medicaid Services (CMS) is pleased to inform you that we are recommending approval for your request for State Plan Amendment, SD-18-0002. Reviewable Unit Effective Date Financial Eligibility Requirements for Non-MAGI Groups 5/1/2018 Mandatory Eligibility Groups 5/1/2018 Former Foster Care Children 5/1/2018 This SPA removes the out of state former foster care youth eligibility group from South Dakota Medicaid's State Plan. Sincerely, Lela Teal Special Assistant Approval Documentation Name Date Created SD-18-0002 Approval Letter 4/12/2018 12:45 PM EDT Page 2 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date N/A State Information State/Territory Name: South Dakota Medicaid Agency Name: Department of Social Services Submission Component State Plan Amendment Medicaid CHIP Page 3 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date N/A SPA ID and Effective Date SPA ID SD-18-0002 Reviewable Unit Proposed Effective Date Superseded SPA ID Financial Eligibility Requirements for Non- MAGI Groups 5/1/2018 Mandatory Eligibility Groups 5/1/2018 SD-13-0015 Former Foster Care Children 5/1/2018 SD-13-0015 Page 4 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The proposed state plan amendment removes out of state former foster care youth as an eligibility group under the state plan. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2018 $0 Second 2019 $0 Federal Statute / Regulation Citation 42 CFR 435.150 and SSA 1902(a)(10)(A)(i)(IX) Page 5 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other Page 6 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Indicate how public comment was solicited: Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Public Hearing or Meeting Other method Upload copies of public notices and other documents used Name Date Created Register 10.30.2017 2/7/2018 11:28 AM EST Upload with this application a written summary of public comments received (optional) Name Date Created Summary of Comments 2/7/2018 11:47 AM EST Indicate the key issues raised during the public comment period (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Page 7 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date N/A One or more Indian health programs or Urban Indian Organizations furnish health care services in this state Yes No This state plan amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian Organizations Yes No  The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, prior to submission of this SPA Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner:  All Indian Health Programs Date of solicitation/consultation: Method of solicitation/consultation: 10/30/2017 South Dakota Medicaid emailed notice along with a copy of the SPA.  All Urban Indian Organizations Date of solicitation/consultation: Method of solicitation/consultation: 10/30/2017 South Dakota Medicaid emailed notice along with a copy of the SPA. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below:  All Indian Tribes Date of consultation: Method of consultation: 10/30/2017 South Dakota Medicaid emailed notice along with a copy of the SPA. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Summary of Comments 2/7/2018 11:43 AM EST Tribal Consultation 2/20/2018 9:48 AM EST Page 8 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Name Date Created Indicate the key issues raised (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue Page 9 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Medicaid State Plan Eligibility Financial Eligibility Requirements for Non-MAGI Groups MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID N/A SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date 5/1/2018 The state applies the following financial methodologies for all eligibility groups whose eligibility is not based on modified adjusted gross income (MAGI) rules (described in 42 C.F.R. §435.603): A. Financial Eligibility Methodologies  The state determines financial eligibility consistent with the methodologies described in 42 C.F.R. §435.601. B. Eligibility Determinations of Aged, Blind and Disabled Individuals Eligibility is determined for aged, blind and disabled individuals based on one of the following: SSA Eligibility Determination State (1634 State) The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies. State Eligibility Determination (SSI Criteria State) The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies. State Eligibility Determination (209(b) State) The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI. C. Financial Responsibility of Relatives  The state determines the financial responsibility of relatives consistent with the requirements and methodologies described in 42 C.F.R. §435.602. D. Additional Information (optional) Page 10 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date 5/1/2018 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? SSI Beneficiaries NEW Individuals Receiving Mandatory State Supplements NEW Individuals Who Are Essential Spouses NEW Institutionalized Individuals NEW              Page 11 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Eligibility Group Name Covered In State Plan Include RU In Package ? Included in Another Submission Package Source Type ? Continuously Eligible Since 1973 Blind or Disabled Individuals Eligible in 1973 NEW Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI Benefits in 1972 NEW Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA increases since April, 1977 NEW Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI NEW Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security NEW Working Disabled under 1619(b) NEW Disabled Adult Children NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW            Page 12 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date 5/1/2018 B. The state elects the Adult Group, described at 42 C.F.R. §435.219. Yes No C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: • N/A Page 13 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and were in foster care when they turned age 18 or aged out of foster care. Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date 5/1/2018 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group B. Individuals Covered 1. The state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) and were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act. 2. Additionally, the state covers individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. Page 14 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | SD2018MS0001O | SD-18-0002 Package Header Package ID SD2018MS0001O Submission Type Official Approval Date 4/9/2018 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-18-0002 Initial Submission Date 2/20/2018 Effective Date 5/1/2018 C. Additional Information (optional) Page 15 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 4/16/2018 11:46 AM EDT Page 16 of 16 SD - Submission Package - SD2018MS0001O - (SD-18-0002) - Eligibility 04/16/2018 https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 19- 0002 This file contains the following documents in the order listed: 1) Approval Letter 2) 179 3) Approved SPA Pages TN: SD- 19- 0002 Approval Date: 09/03/ 2019 Effective Date: 01/ 01/ 2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 52-26-12 Baltimore, MD 21244- I 850 tvrs cfNtEns Fon Mto¡c nE & MtDtc^tD sE¡vtcfs CINTER FON üEDICAID & CHIP SÉRYICES Financial Management Group September 3,2019 M. Greg DeSautel, MD Cabinet Secretary Department of Social Services 700 Governors Drive Pierre, South Dakota 57501-2291 Re: South Dakota 19-0002 Dear Dr. DeSautel: rWe have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 19-0002. Effective for services on or after January l, 2019, this amendment provides for a supplemental payment for private hospitals. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment TN 19-0002 is approved effective January 1,2019. The CMS- 179 andthe amended plan page are attached. If you have any questions, please contact Christine Storey at (303) 844-7044 Sincerely, Kristin Fan Director cc: Jocelyn Ihrig Christine Storey

DEPARTMENT OF IIEALTII AND HTJMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES To: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MÀTERIAL ( Check One): f]xnw srATE PLAN 2. STATE: South Dakota 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE socrAL sEcuRrrY Acr (MED|cArD) 4. PROPOSED EFFECTIVE DATE January 1,2019 lrrrnxnunxr FORMAPPROVEI) oMB NO.0938-0193 nnnrnxounNT To BE coNSTDERED As NEw pLAN I. TRANSMITTALNUMBER: sD-19-002 COMPLETE BLOCKS ó THRU IO IF THIS IS AN AMENDMENT 6. FEDER.AL STATUTE/REGULATION CITATION: SSA and 42 CFR 447 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Trønsmìtlal each 7. FEDERALBUDGETIMPACT: a. FFY 2019: $911,86t b. FFY 2020: $911,861 8. PAGE NUMBER OF THE SUPERSBDED PLAN SECTION OR ATTACHMßNT ( If Applicable): Attachment 4.19-A 14 rO. SUB.IECT OF AMENDMENT: The state plan amendment establishes supplemental payments for in-state private hospitals 12, 13. TYPED M. Greg DeSautel, MD 15lA DATE SUBMITTED: February 8, 2019 Revised: 812812019, 09/03/20 1I 17. DATE RE€EIVED: 19. EFFECTIVE DATE OF üonrnn, AS SPECTFTED: 16. RETURNTO: DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES 7OO GOVERNORS DRIVE PtERRE, SD 57501-2291 2I. TYPED NAME: 23. REMARKS: JA$T"T%f![ERIAL: Kr..sh'n Fa^ r8. DATEAPPRoVED: SEp 0S Z0lg TIÏYOFFICIAL: FOR OFFICE USE ONLY PI.AN APPROVED, OND COPY AI'TACHED FORM CMS-179 rc7-92\ 22. rtrL*: D ¡f t t l/4 &

Attachment 4.19-A Page 14

The Department of Social Services (DSS) supports ensuring access and proper coordination of care. The department will make supplemental payments to further these goals to the following private providers in the following amounts:

Provider Amount Avera $367,135 Bennett County $11,673 Black Hills Surgical $16,826 Mobridge Regional $3,799 Rapid City Regional $763,510 Sanford $444,145

Supplemental payments will be made annually using data calculated for the period of May 1 to April 30. Annual Payments for the supplemental payment period will be made during the last quarter of the state fiscal year.

The payment will be made to the provider through the MMIS system. Payments will be made directly to the qualifying provider through a supplemental payment mechanism and will appear on their remittance advice. Each provider will receive written notification at the time of payment of the payment amount from the Division of Medical Services.

Payments made in error will be recovered via a supplemental recovery mechanism and will appearon the provider's remittance advice. The agency will notify the provider in writing explaining the error prior to the recovery. The Federal share of payments made in excess will be returned to CMS in accordance with 42 CFR Part 433, Subpart F.

The maximum aggregate payment to all qualifying hospitals shall not exceed the available upper payment limit in accordance with 42 CFR 447.272.

TN # 19-02 CED. Be. Supersedes. Approval patehPn 3: 2819 Effective Date 01/01/19

TN # New

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 19-00 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS 179 Form 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group March 18, 2021 William Snyder, Medicaid Director Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291 RE: TN 19-0011 Dear Mr. Snyder: The Centers for Medicare and Medicaid Services (CMS) has completed its review of South Dakota’s State Plan Amendment (SPA) Transmittal #19-0011, submitted on December 20, 2019. This SPA clarifies that substance use disorder (SUD) early intervention services provided by a SUD agency are covered and SUD treatment services may be provided in an institution for mental disease (IMD) in accordance with Section 5052 of Public Law 115-271. CMS approved SPA #19-0011 on March 17, 2021, with an effective date of November 1, 2019, as requested by the state. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the South Dakota State Plan. During the course of review of the SPA, CMS also reviewed “collateral contacts” that are included under the rehabilitative services benefit. These items are described on the same pages of the amended changes. Based on our same page review, CMS has determined that more information about collateral contacts is needed in order to ensure compliance with Medicaid statute and regulations as outlined in a companion letter issued with this approval. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303)844-7068. Sincerely, Ruth A. Hughes, Acting Director Division of Program Operations Enclosures cc: Brenda Tidball-Zeltinger, Deputy Secretary, South Dakota Medicaid Matthew Ballard, Deputy Director, South Dakota Medicaid Mandy Strom, CMS North Branch-Division of Program Operations Digitally signed by Ruth A. Hughes Date: 2021.03.18 10:55:55 -05'00'

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group March 18, 2021 William Snyder, Medicaid Director Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291 RE: TN 19-0011 Companion letter Dear Mr. Snyder: This letter is being sent as a companion to our approval of South Dakota state plan amendment (SPA) 19-0011. The SPA clarifies that early intervention services provided by a substance use disorder agency are covered and substance use disorder services may be provided in an institution for mental disease in accordance with Section 5052 of Public Law 115-271. Our review of SPA 19-0011 included a review of “collateral contacts” that are included under the rehabilitative services benefit. These items are described on the same pages in which the state added modifications to the SPA. Regulations at 42 CFR 430.10 require that the state plan be a comprehensive written statement describing the nature and scope of the state's Medicaid program and that it contain all information necessary for CMS to determine whether the plan can be approved to serve as the basis for Federal financial participation (FFP) in the state program. Based on our review, CMS has determined that more information about collateral contacts (Supplement to Attachment 3.1-A, Item 13d, pages 31a – 31c) is needed in order to ensure that the state is in compliance with Medicaid statute and regulations. To that end, CMS welcomes the opportunity to work with you and your staff to discuss options for resolving the concerns outlined below: Collateral Contacts The SPA describes “collateral contacts” as a component service of “outpatient treatment services” and “intensive outpatient treatment services” for Substance Use Disorder Agency Services. However, collateral contacts are not considered Medicaid coverable services pursuant to section 1905(a) of the Social Security Act because they are not “care and services” furnished to Medicaid eligible individuals. The “collateral” can participate in a service but only if the service is Medicaid coverable as medical assistance and the service is for the direct benefit of the beneficiary. For example, the activity of gathering information from a collateral is not covered medical assistance. However, development of a treatment plan for the beneficiary may involve gathering information from a collateral. In this latter instance, the service is for the direct benefit of the beneficiary, even

though a collateral was involved. Other examples of services that include the participation of a “collateral” in a service for the benefit of the recipient are family therapy or family psycho- education. In such cases, the general expectation is that the beneficiary would be present for the service with the collateral; however, there may be some treatment sessions where the clinician’s judgment is not to include the beneficiary. While the presence of a beneficiary is an important factor for coverage, the critical issue is that the service is a coverable 1905(a) service for the direct benefit of the beneficiary and not the collateral. The SPA description of “collateral contacts” appears to set forth three purposes for these contacts – to seek information from collaterals for treatment planning; to educate or train collaterals in order that they can assist a beneficiary; and to refer collaterals to other needed services. Specifically, the SPA indicates: Collateral Contacts: Telephone or face-to-face contact with an individual other than the identified recipient to plan appropriate treatment, assist an individual so they can respond therapeutically to the recipient’s substance abuse problem, or to refer the recipient, family, or both, to other necessary community supports. The first purpose, seeking information from a collateral, could be accounted for in the rate paid for a covered Medicaid service for the beneficiary. To accomplish this, the state needs to include a service description in the state plan for a service such as “development of a treatment plan” and include in the service description language such as, “Collateral contacts are for the purpose of seeking information to assist in the development of the beneficiary’s treatment plan.” The reimbursement page in the state plan would need to account for this activity in the rate paid for the covered service. The state’s other two purposes for the collateral contacts actually propose that the collaterals receive a service or participate in a service, albeit for the direct benefit of the beneficiary. As noted above, participation by a collateral in a covered service can be accounted for in the rate paid for a covered service for the beneficiary. When a state proposes that a collateral receive a service or participate in a service, it is important that the state clarify that the service is delivered to the beneficiary and the collateral together and that the collateral’s participation in the service is for the direct benefit of the beneficiary. The SPA, as written, does not include such a clarification. Accordingly, the SPA would need to be revised to identify the covered service or services for the beneficiary in which a collateral would participate, and include an assurance that the service is for the direct benefit of the beneficiary. Again, a service description would need to be included in the SPA. The service description would also need to include language such as, “The participation of the collaterals in the service is for the purpose of treating the beneficiary’s condition and is for the direct benefit of the beneficiary.” The State has 90 days from the date of this letter, to address the issues described above. Within that period the State may submit a SPA to address the inconsistencies or submit a Corrective Action Plan describing how the State will resolve the issued identified above in a timely manner. Failure to respond will result in the initiation of a formal compliance process. During the 90 days, CMS will provide any required technical assistance.

If you have any questions regarding this this letter, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303)844-7068. Sincerely, Ruth A. Hughes, Acting Director Division of Program Operations Enclosures cc: Brenda Tidball-Zeltinger, Deputy Secretary, South Dakota Medicaid Matthew Ballard, Deputy Director, South Dakota Medicaid Mandy Strom, North Branch-Division of Program Operations Digitally signed by Ruth A. Hughes Date: 2021.03.18 10:56:39 -05'00'

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Revision: HCFA-PM-91-8 (MB) ATTACHMENT 2.6-A OCTOBER 1991 Page 3a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA ELIGIBILITY CONDITIONS AND REQUIREMENTS Citation(s) Condition or Requirement (A) General Conditions of Eligibility (continued) 42 CFR 433.145 Section 1912 of the Act 5. Is required, as a condition of eligibility, to assign his or her own rights, or the rights of any other person who is eligible for Medicaid and on whose behalf the individual has legal authority to execute an assignment, to medical support and payments for medical care from any third part. (Medical support is defined as support specified as being for medical care by a court or administrative order.) Approval Date _______ Effective Date 11/01/19 TN No. 19-11 Supersedes TN No. - 

TN # 19-011 SUPERCEDES TN # 18-004 Approval Date _______ Effective Date 11/01/19 Page 31a SUPPLEMENT TO ATTACHMENT 3.1-A 2. Substance use disorder agencies accredited by the single state agency for substance abuse. Services are covered for an individual for whom an integrated assessment has been prepared that includes a primary diagnosis of substance use disorder. The agency must prepare an individual treatment plan as a result of the integrated assessment. Crisis intervention services do not require an integrated assessment or individual treatment plan. Substance Use Disorder Agency Services a. Integrated assessment. The integrated assessment includes both functional and diagnostic components. The assessment shall establish the historical development and dysfunctional nature of the recipient’s alcohol and drug abuse or dependence and shall assess the recipient’s treatment needs. b. Crisis intervention services. Crisis intervention services are provided to a recipient in a crisis situation related to the recipient's use of substances, including crisis situations where co-occurring mental health symptoms may be present. The focus of the intervention is to restore the recipient to the level of functioning before the crisis or provide means to place the recipient into a secure environment. c. Early intervention services. Nonresidential services provided to individuals that may have substance use related problems, but do not meet the diagnostic criteria for a substance use disorder. The following services at a minimum must be included: i. Initial screening and planning within 48 hours of initial contact. ii. Crisis intervention services as described above in item b. iii. Individual or family counseling regarding substance abuse and dependence. Family counseling services to the recipient’s family and significant others is for the direct benefit of the recipient, in accordance with the recipient’s needs and treatment goals identified in the recipient’s treatment plan, and for the purpose of assisting in the recipient’s recovery. iv. Discharge planning services to include continued care planning and counseling, referral to and coordination of care with other resources that will assist a client's recovery, including educational, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services which includes the availability of tuberculosis and human immunodeficiency virus services. d. Outpatient treatment services provided by an accredited nonresidential program to a recipient or a person harmfully affected by alcohol or other drugs through regularly scheduled counseling services. The following services are covered: i. Individual, group and family counseling regarding substance abuse and dependence. Group and family counseling services to the recipient’s family and significant others is for the direct benefit of the recipient, in accordance with the recipient’s needs and treatment goals identified in the recipient’s treatment plan, and for the purpose of assisting in the recipient’s recovery. ii. Discharge planning services to include continued care planning and counseling, referral to and coordination of care with other resources that will assist a client's recovery, including educational, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services which includes the availability of tuberculosis and human immunodeficiency virus services. iii. Collateral Contacts which is a telephone or face-to-face contact with an individual other than the identified recipient in order to plan appropriate treatment, to assist an individual so the individual can respond therapeutically to the recipient’s substance abuse problem, or to refer the recipient, family, or both, to other necessary community supports. e. Intensive outpatient treatment services are provided by an accredited nonresidential program providing services to a recipient in a clearly defined, structured, intensive outpatient treatment program on a regularly scheduled basis. The following services are covered: i. Individual, group, and family counseling regarding alcohol and drug abuse and dependence. Group and family counseling services to the recipient’s family and significant others is for the direct benefit of the recipient, in accordance with the recipient’s needs and treatment goals identified in the recipient’s treatment plan, and for the purpose of assisting in the recipient’s recovery. ii. Discharge planning which must include continued care planning and counseling, referral to and coordination of care with other resources that will assist a recipient's recovery, including education, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services to include the availability of tuberculosis and human immunodeficiency virus services. 

TN # 19-011 SUPERCEDES TN # 18-004 Approval Date _______ Effective Date 11/01/19 Page 31b SUPPLEMENT TO ATTACHMENT 3.1-A iii. Collateral Contacts which is a telephone or face-to-face contact with an individual other than the identified recipient in order to plan appropriate treatment, to assist an individual so the individual can respond therapeutically to the recipient’s substance abuse problem, or to refer the recipient, family, or both, to other necessary community supports. f. Day treatment services are provided by an accredited program providing services to a recipient in a clearly defined, structured, intensive treatment program. The following services are covered: i. Individual, group, and family counseling regarding alcohol and drug abuse and dependence. Group and family counseling services to the recipient’s family and significant others is for the direct benefit of the recipient, in accordance with the recipient’s needs and treatment goals identified in the recipient’s treatment plan, and for the purpose of assisting in the recipient’s recovery. ii. Discharge planning which must include continued care planning and counseling, referral to and coordination of care with other resources that will assist a recipient's recovery, including education, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services to include the availability of tuberculosis and human immunodeficiency virus services. g. Clinically-managed low-intensity residential treatment services provided by an accredited residential program providing services to a recipient in a structured environment designed to aid re-entry into the community. Clinically-managed, low-intensity residential treatment programs are not institutions for mental diseases as described in 42 CFR 435.1010. The following services are covered: i. Individual, group, and family counseling regarding alcohol and drug abuse and dependence. Group and family counseling services to the recipient’s family and significant others is for the direct benefit of the recipient, in accordance with the recipient’s needs and treatment goals identified in the recipient’s treatment plan, and for the purpose of assisting in the recipient’s recovery. ii. Discharge planning to continued care planning and counseling, referral to and coordination of care with other resources that will assist a recipient's recovery, including education, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services to include the availability of tuberculosis and human immunodeficiency virus services. h. Medically-monitored intensive inpatient treatment programs are an accredited residential program providing services to a recipient in a structured environment. These medically-monitored intensive inpatient treatment program may be provided to eligible individuals in an eligible IMD as allowed in Attachment 3.1- M. The following services are covered: i. Individual, group, and family counseling regarding alcohol and drug abuse and dependence. Group and family counseling services to the recipient’s family and significant others is for the direct benefit of the recipient, in accordance with the recipient’s needs and treatment goals identified in the recipient’s treatment plan, and for the purpose of assisting in the recipient’s recovery. ii. Discharge planning to include continued care planning and counseling, referral to and coordination of care with other resources that will assist a recipient's recovery, including education, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services to include the availability of tuberculosis and human immunodeficiency virus services. 

TN # 19-011 SUPERCEDES TN # 18-004 Approval Date _______ Effective Date 11/01/19 Page 31c SUPPLEMENT TO ATTACHMENT 3.1-A Substance Use Disorder Agencies Non-Covered Services The following services are non-covered for substance use disorder agencies: a. Treatment for a diagnosis of substance use disorder that exceeds the limits established by the division, unless prior authorization is approved by the division; b. Out-of-state substance use disorder treatment unless the division determines that appropriate in- state treatment is not available; c. Treatment for a gambling disorder; d. Room and board for residential services; e. Substance use disorder treatment before the integrated assessment is completed; f. Substance use disorder treatment after 30 days if the treatment plan has not been completed; g. Substance use disorder treatment if a required review has not been completed; h. Court appearances, staffing sessions, or treatment team appearances; and i. Substance use disorder services provided to a recipient incarcerated in a correctional facility. Substance Use Disorder Agencies Practitioners and Qualifications All agency staff providing addiction counseling must meet the standards for addiction counselors or addiction counselor trainees in accordance with South Dakota Board of Addiction and Prevention Professionals requirements. Each agency must have a clinical supervisor that supervises clinical services. Clinical supervisors must be licensed as either a certified addiction counselor or licensed addiction counselor. The table below lists the services each provider can provide, provider qualifications, and supervisory requirements: Practitioner Type Services Furnished Qualifications Supervisory Requirements Licensed Addiction Counselor x Integrated assessment; x Crisis intervention; x Early intervention services; x Individual, group, and family counseling; x Discharge planning; and x Collateral contacts. Must meet be licensed as a Licensed Addiction Counselor by the South Dakota Board of Addiction and Prevention Professionals. None Certified Addiction Counselor x Integrated assessment; x Crisis intervention; x Early intervention services; x Individual, group, and family counseling; x Discharge planning; and x Collateral contacts. Must meet be certified as a Certified Addiction Counselor by the South Dakota Board of Addiction and Prevention Professionals. None Addiction Counselor Trainee x Integrated assessment; x Crisis intervention; x Early intervention services; x Individual, group, and family counseling; x Discharge planning; and x Collateral contacts. Must meet be recognized as an Addiction Counselor Trainee by the South Dakota Board of Addiction and Prevention Professionals. Must be supervised by a certified addiction counselor or licensed addiction counselor. 

ATTACHMENT 3.1-M Page 1 TN # 19-011 Approval Date_______ Effective Date 11/01/19 SUPERCEDES TN # New State/Territory: South Dakota State Option to Provide Medicaid Coverage for Certain Individuals with Substance Use Disorders who are Patients in Certain Institutions for Mental Diseases South Dakota Medicaid covers substance use disorder treatment services provided to eligible individuals in an eligible institution for mental disease (IMD) in accordance with Section 1915(l) of the Social Security Act. Eligible Individuals Eligibility is limited to Medicaid recipients age 21 through 64 who have at least one substance use disorder and reside in an eligible IMD primarily to receive withdrawal management or substance use disorder treatment services. General Assurances The State provides the following assurances regarding the scope of IMD services: 1. Coverage is limited to services provided during the period beginning October 1, 2019 and ending September 30, 2023. 2. Coverage is limited to a maximum of 30 days per 12-month period per eligible individual from the date an eligible individual is first admitted to an eligible IMD. IMD Assurances The State provides the following assurances regarding eligible IMDs: 1. Eligible IMDs follow reliable evidence-based practices and offer at least two forms of medication-assisted treatment (MAT) onsite, including one antagonist and one partial agonist for opioid use disorder. The State ensures IMDs meet these requirements through standards established by the State’s Single State Agency for Substance Abuse Services for providers. 2. Eligible IMDs provide services at lower levels of clinical intensity or establish relationships with Medicaid-enrolled providers offering services at lower levels of care. The State ensures IMDs meet these requirements through standards established by the State’s Single State Agency for Substance Abuse Services for providers. Evidence-Based Clinical Screening Assurance The State provides the following assurance regarding evidence-based clinical screenings: 1. Eligible individuals receive an appropriate evidence-based clinical screening prior to receiving services in an eligible IMD, including initial and periodic reassessments to determine the appropriate level of care, length of stay, and setting for each individual. Eligible IMDs are required to perform an integrated assessment. The integrated assessment includes both functional and diagnostic components. The assessment shall 

ATTACHMENT 3.1-M Page 2 TN # 19-011 Approval Date_______ Effective Date 11/01/19 SUPERCEDES TN # New establish the historical development and dysfunctional nature of the recipient’s alcohol and drug abuse or dependence and shall assess the recipient’s treatment needs. Continuum of Services Assurance The State provides the following assurances regarding the continuum of services: 1. South Dakota Medicaid covers the following outpatient levels of care under the state plan: a. Early intervention services; b. Outpatient treatment services; c. Intensive outpatient treatment services; and d. Day treatment services (also referred to as partial hospitalization). 2. South Dakota Medicaid covers the following residential and inpatient levels of care under the state plan: a. Clinically-managed low-intensity residential treatment services; and b. Medically-monitored intensive inpatient treatment services. Transition of Care Assurances The State provides the following assurance regarding transition of care: 1. Recipients residing in an IMD are required to be transitioned to the community upon discharge. Eligible IMDs are required to provide discharge planning services. Discharge planning services must include continued care planning and counseling, referral to and coordination of care with other resources that will assist a recipient's recovery, including education, vocational, medical, legal, social, mental health, employment, and other related alcohol and drug services, and referral to and coordination of medical services to include the availability of tuberculosis and human immunodeficiency virus services. 

ATTACHMENT 4.19-B INTRODUCTION Introduction Page 1 Payment rates for the services listed below are effective for services provided on or after the corresponding date. Fee schedules are published on the Department’s website at http://dss.sd.gov/medicaid/providers/feeschedules/. Effective dates listed on the introductory page supersede the effective dates listed elsewhere in Attachment 4.19-B. Unless otherwise noted in the referenced state plan pages, reimbursement rates are the same for both governmental and private providers. Service Attachment Effective Date Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Attachment 4.19-B, Page 4 April 1, 2019 Physician Services Attachment 4.19-B, Page 6 April 1, 2019 Optometrist Services Attachment 4.19-B, Page 9 April 1, 2019 Chiropractic Services Attachment 4.19-B, Page 10 April 1, 2019 Independent Mental Health Practitioners Attachment 4.19-B, Page 11 April 1, 2019 Nutritionist and Dietician Services Attachment 4.19-B, Page 11 April 1, 2019 Home Health Services Attachment 4.19-B, Page 12 April 1, 2019 Durable Medical Equipment Attachment 4.19-B, Page 13 April 1, 2019 Clinic Services Attachment 4.19-B, Page 15 April 1, 2019 Dental Services Attachment 4.19-B, Page 16 April 1, 2019 Physical Therapy Attachment 4.19-B, Page 17 April 1, 2019 Occupational Therapy Attachment 4.19-B, Page 18 April 1, 2019 Speech, Hearing, or Language Disorder Services Attachment 4.19-B, Page 19 April 1, 2019 Dentures Attachment 4.19-B, Page 21 April 1, 2019 Prosthetic Devices Attachment 4.19-B, Page 22 April 1, 2019 Eyeglasses Attachment 4.19-B, Page 23 April 1, 2019 Diabetes Self-Management Training Attachment 4.19-B, Page 26 April 1, 2019 Community Health Workers Attachment 4.19-B, Page 26 April 1, 2019 Community Mental Health Centers Attachment 4.19-B, Page 26 April 1, 2019 Substance Use Disorder Agencies Attachment 4.19-B, Page 26 November 1, 2019* Nurse Midwife Services Attachment 4.19-B, Page 31 April 1, 2019 Transportation Attachment 4.19-B, Page 38 April 1, 2019 Personal Care Services Attachment 4.19-B, Page 38 April 1, 2019 Freestanding Birth Centers Attachment 4.19-B, Page 39 April 1, 2019 Professional Services Provided in a Freestanding Birth Center Attachment 4.19-B, Page 39 April 1, 2019 *Room and board is not included in these rates. TN# 19-11 SUPERCEDES Approval Date _________ Effective Date 11/01/19 TN# 19-06 

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 20-0003 This file contains the following documents in the order listed:

1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 May 28, 2020 Bill Snyder Medicaid Director Department of Social Services 700 Governors Drive Pierre, SD 577501 Re: South Dakota State Plan Amendment (SPA) SD-20-003 Dear Mr. Snyder: We have reviewed the proposed amendment to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to your Medicaid state plan, as submitted under transmittal number (TN) SD-20-003. This amendment proposes to implement temporary policies, which are different from those policies and procedures otherwise applied under your Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof). On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a

retroactive effective date of March 1, 2020. The emergency period will terminate, and this state plan provision will no longer be in effect, upon termination of the public health emergency, including any extensions. Pursuant to section 1135(b)(5) of the Act, for the period of the public health emergency, CMS is modifying the requirement at 42 C.F.R. 430.20 that the state submit SPAs related to the COVID- 19 public health emergency by the final day of the quarter, to obtain a SPA effective date during the quarter, enabling SPAs submitted after the last day of the quarter to have an effective date in a previous quarter, but no earlier than the effective date of the public health emergency.

The State of South Dakota also requested a waiver of public notice requirements applicable to the SPA submission process. Pursuant to section 1135(b)(1)(C) of the Act, CMS is waiving public notice requirements applicable to the SPA submission process. Public notice for SPAs is required under 42 C.F.R. §447.205 for changes in statewide methods and standards for setting Medicaid payment rates, 42 C.F.R. §447.57 for changes to premiums and cost sharing, and 42 C.F.R. §440.386 for changes to Alternative Benefit Plans (ABPs). Pursuant to section 1135(b)(1)(C) of the Act, CMS is approving the state’s request to waive these notice requirements otherwise applicable to SPA submissions.

The State of South Dakota also requested a waiver to modify the tribal consultation timeline applicable to this SPA submission process. Pursuant to section 1135(b)(5) of the Act, CMS is also allowing states to modify the timeframes associated with tribal consultation required under section 1902(a)(73) of the Act, including shortening the number of days before submission or conducting consultation after submission of the SPA.

These waivers or modifications of the requirements related to SPA submission timelines, public notice, and tribal consultation apply only with respect to SPAs that meet the following criteria: (1) the SPA provides or increases beneficiary access to items and services related to COVID-19 (such as by waiving or eliminating cost sharing, increasing payment rates or amending ABPs to add services or providers); (2) the SPA does not restrict or limit payment or services or otherwise burden beneficiaries and providers; and (3) the SPA is temporary, with a specified sunset date that is not later than the last day of the declared COVID-19 public health emergency (or any extension thereof). We nonetheless encourage states to make all relevant information about the SPA available to the public so they are aware of the changes.

We conducted our review of your submittal according to the statutory requirements at section 1902(a) of the Act and implementing regulations. This letter is to inform you that South Dakota’s Medicaid SPA Transmittal Number SD-20-003 is approved effective March 1, 2020. Enclosed is a copy of the CMS-179 summary form and the approved state plan pages.

Please contact Mandy Strom at (303) 844-7068 or by email at Mandy.Strom@cms.hhs.gov if you have any questions about this approval. We appreciate the efforts of you and your staff in responding to the needs of the residents of the State of South Dakota and the health care community. Sincerely, Anne Marie Costello Deputy Director Center for Medicaid & CHIP Services Enclosures Anne M. Costello -S Digitally signed by Anne M. Costello -S Date: 2020.05.28 11:54 51 -04'00'

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF __| 1. TRANSMITTAL NUMBER: 2. STATE: SD-20-003 South Dakota

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE March 1, 2020

5. TYPE OF PLAN MATERIAL (Check One):

[NEW STATE PLAN [AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS ANAMENDMENT (Separate Transmittal for each amendment)

6. FEDERALSTATUTE/REGULATION CITATION:

Section 1135 of the Social Security Act

7. FEDERAL BUDGET IMPACT: a. FFY 2020: $0.00 b. FFY 2021: $0.00

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 7.4, Pages 1-9

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (ff Applicable):

10. SUBJECT OF AMENDMENT:

The proposed state plan amendment suspends cost sharing for COVID-19 testing, testing-related services, and treatment for any quarter in which the increased FMAP is claimed and requests additional flexibilities due to the COVID-19 emergency.

11. GOVERNOR’S REVIEW (Check One): HEGOVERNOR’S OFFICE REPORTED NO COMMENT [COMMENTS OF GOVERNOR’S OFFICE ENCLOSED

INO REPLY RECEIVED WITHINAS DAYS OF SUBMITTAL

CIOTHER, AS SPECIFIED:

14. TITLE: Cabinet Secretary

15. DATE SUBMITTED: May 19, 2020

16. RETURN TO:

DEPARTMENT OF SOCIAL SERVICES

DIVISION OF MEDICAL SERVICES 700 GOVERNORS DRIVE PIERRE, SD 57501-2291

| FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED: May 19, 2020

18. DATE APPROVED:

May 28, 2020

| PLAN APPROVED - ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL:

March 1, 2020

20. SIGNATURE OF REGIONAL OFFICIAL: _ Anne M. Costello 22217 as Are

-S

Date: 2020.05.28 11:55:23 —2e00

21. TYPED NAME:

Anne Marie Costello

22. TITLE: Deputy Director, CMCS

| 23.REMARKS:

FORM CMS-179 (07-92)

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW Section 7 – General Provisions 7.4. Medicaid Disaster Relief for the COVID-19 National Emergency On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements as a result of the COVID-19 pandemic, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and waivers will no longer be available, upon termination of the public health emergency, including any extensions. The State Medicaid agency (agency) seeks to implement the policies and procedures described below, which are different than the policies and procedures otherwise applied under the Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak (or any renewals thereof), or for any shorter period described below: NA NOTE: States may not elect a period longer than the Presidential or Secretarial emergency declaration (or any renewal thereof). States may not propose changes on this template that restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. Request for Waivers under Section 1135 __X___ The agency seeks the following under section 1135(b)(1)(C) and/or section 1135(b)(5) of the Act: a. __X___ SPA submission requirements – the agency requests modification of the requirement to submit the SPA by March 31, 2020, to obtain a SPA effective date during the first calendar quarter of 2020, pursuant to 42 CFR 430.20. b. __X___ Public notice requirements – the agency requests waiver of public notice requirements that would otherwise be applicable to this SPA submission. These requirements may include those specified in 42 CFR 440.386 (Alternative Benefit Plans), 42 CFR 447.57(c) (premiums and cost sharing), and 42 CFR 447.205 (public notice of changes in statewide methods and standards for setting payment rates). Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW c. __X___ Tribal consultation requirements – the agency requests modification of tribal consultation timelines specified in the South Dakota Medicaid state plan, as described below: South Dakota provided notification to the tribes of submission of this state plan amendment to CMS on the date the SPA was submitted, May 19, 2020. Tribal consultation will occur concurrently with the submission of this SPA through June 17, 2020. The State will review and respond to any comments received in relation to this notification. Any comments received while the state plan amendment is under review by CMS will be shared with CMS. Section A – Eligibility 1. __ __ The agency furnishes medical assistance to the following optional groups of individuals described in section 1902(a)(10)(A)(ii) or 1902(a)(10)(c) of the Act. This may include the new optional group described at section 1902(a)(10)(A)(ii)(XXIII) and 1902(ss) of the Act providing coverage for uninsured individuals. 2. _____ The agency furnishes medical assistance to the following populations of individuals described in section 1902(a)(10)(A)(ii)(XX) of the Act and 42 CFR 435.218: a. _____ All individuals who are described in section 1905(a)(10)(A)(ii)(XX) Income standard: _____________ -or-

b. _____ Individuals described in the following categorical populations in section 1905(a) of the Act: Income standard: _____________ 3. _____ The agency applies less restrictive financial methodologies to individuals excepted from financial methodologies based on modified adjusted gross income (MAGI) as follows. Less restrictive income methodologies: Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW Less restrictive resource methodologies: 4. _____ The agency considers individuals who are evacuated from the state, who leave the state for medical reasons related to the disaster or public health emergency, or who are otherwise absent from the state due to the disaster or public health emergency and who intend to return to the state, to continue to be residents of the state under 42 CFR 435.403(j)(3). 5. _____ The agency provides Medicaid coverage to the following individuals living in the state, who are non-residents: 6. _____ The agency provides for an extension of the reasonable opportunity period for non- citizens declaring to be in a satisfactory immigration status, if the non-citizen is making a good faith effort to resolve any inconsistences or obtain any necessary documentation, or the agency is unable to complete the verification process within the 90-day reasonable opportunity period due to the disaster or public health emergency. Section B – Enrollment 1. _____ The agency elects to allow hospitals to make presumptive eligibility determinations for the following additional state plan populations, or for populations in an approved section 1115 demonstration, in accordance with section 1902(a)(47)(B) of the Act and 42 CFR 435.1110, provided that the agency has determined that the hospital is capable of making such determinations. 2. _____ The agency designates itself as a qualified entity for purposes of making presumptive eligibility determinations described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Subpart L. 3. _____ The agency designates the following entities as qualified entities for purposes of making presumptive eligibility determinations or adds additional populations as described below in accordance with sections 1920, 1920A, 1920B, and 1920C of the Act and 42 CFR Part 435 Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW Subpart L. Indicate if any designated entities are permitted to make presumptive eligibility determinations only for specified populations. 4. _____ The agency adopts a total of _____ months (not to exceed 12 months) continuous eligibility for children under age enter age _____ (not to exceed age 19) regardless of changes in circumstances in accordance with section 1902(e)(12) of the Act and 42 CFR 435.926. 5. _____ The agency conducts redeterminations of eligibility for individuals excepted from MAGI- based financial methodologies under 42 CFR 435.603(j) once every _____ months (not to exceed 12 months) in accordance with 42 CFR 435.916(b). 6. _____ The agency uses the following simplified application(s) to support enrollment in affected areas or for affected individuals (a copy of the simplified application(s) has been submitted to CMS). a. _____ The agency uses a simplified paper application. b. _____ The agency uses a simplified online application. c. _____ The simplified paper or online application is made available for use in call-centers or other telephone applications in affected areas. Section C – Premiums and Cost Sharing 1. __X___ The agency suspends deductibles, copayments, coinsurance, and other cost sharing charges as follows: The State waives cost-sharing for testing services (including in vitro diagnostic products), testing- related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies (including drugs), for any quarter in which the temporary increased FMAP is claimed. 2. _____ The agency suspends enrollment fees, premiums and similar charges for: a. _____ All beneficiaries b. _____ The following eligibility groups or categorical populations: 3. _____ The agency allows waiver of payment of the enrollment fee, premiums and similar charges for undue hardship. Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW Section D – Benefits Benefits: 1. _____ The agency adds the following optional benefits in its state plan (include service descriptions, provider qualifications, and limitations on amount, duration or scope of the benefit): 2. __X___ The agency makes the following adjustments to benefits currently covered in the state plan: The State suspends the face-to-face requirements for community mental health centers stated in Supplement to Attachment 3.1-A. 3. _____ The agency assures that newly added benefits or adjustments to benefits comply with all applicable statutory requirements, including the statewideness requirements found at 1902(a)(1), comparability requirements found at 1902(a)(10)(B), and free choice of provider requirements found at 1902(a)(23). 4. _____ Application to Alternative Benefit Plans (ABP). The state adheres to all ABP provisions in 42 CFR Part 440, Subpart C. This section only applies to states that have an approved ABP(s). ƒǤ ̴̴̴̴̴ Š‡ ƒ‰‡ › ƒ••—”‡• –Šƒ– –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–• ™‹ŽŽ „‡ ƒ†‡ ƒ˜ƒ‹Žƒ„Ž‡ –‘ ‹†‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” •Ǥ „Ǥ ̴̴̴̴̴ †‹˜‹†—ƒŽ• ”‡ ‡‹˜‹‰ •‡”˜‹ ‡• —†‡” • ™‹ŽŽ ‘– ”‡ ‡‹˜‡ –Š‡•‡ ‡™Ž› ƒ††‡† ƒ†Ȁ‘” ƒ†Œ—•–‡† „‡‡ˆ‹–•ǡ ‘” ™‹ŽŽ ‘Ž› ”‡ ‡‹˜‡ –Š‡ ˆ‘ŽŽ‘™‹‰ •—„•‡–ǣ Telehealth: 5. _____ The agency utilizes telehealth in the following manner, which may be different than outlined in the state’s approved state plan: Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW Drug Benefit: 6. _____ The agency makes the following adjustments to the day supply or quantity limit for covered outpatient drugs. The agency should only make this modification if its current state plan pages have limits on the amount of medication dispensed. 7. _____ Prior authorization for medications is expanded by automatic renewal without clinical review, or time/quantity extensions. 8. _____ The agency makes the following payment adjustment to the professional dispensing fee when additional costs are incurred by the providers for delivery. States will need to supply documentation to justify the additional fees. 9. _____ The agency makes exceptions to their published Preferred Drug List if drug shortages occur. This would include options for covering a brand name drug product that is a multi-source drug if a generic drug option is not available. Section E – Payments Optional benefits described in Section D: 1. _____ Newly added benefits described in Section D are paid using the following methodology: ƒǤ ̴̴̴̴̴ —„Ž‹•Š‡† ˆ‡‡ • Š‡†—Ž‡• Ȃ Effective date (enter date of change): _____________ Location (list published location): _____________ „Ǥ ̴̴̴̴̴ –Š‡”ǣ Increases to state plan payment methodologies: 2. _____ The agency increases payment rates for the following services: Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW a. _____ Payment increases are targeted based on the following criteria: b. Payments are increased through: ‹Ǥ ̴̴̴̴̴  •—’’Ž‡‡–ƒŽ ’ƒ›‡– ‘” ƒ††Ǧ‘ ™‹–Š‹ ƒ’’Ž‹ ƒ„Ž‡ —’’‡” ’ƒ›‡– Ž‹‹–•ǣ ‹‹Ǥ ̴̴̴̴̴  ‹ ”‡ƒ•‡ –‘ ”ƒ–‡• ƒ• †‡• ”‹„‡† „‡Ž‘™Ǥ Rates are increased: _____ Uniformly by the following percentage: _____________ _____ Through a modification to published fee schedules – Effective date (enter date of change): _____________ Location (list published location): _____________ _____ Up to the Medicare payments for equivalent services. _____ By the following factors: Payment for services delivered via telehealth: 3. _____ For the duration of the emergency, the state authorizes payments for telehealth services that: ƒǤ ̴̴̴̴̴ ”‡ ‘– ‘–Š‡”™‹•‡ ’ƒ‹† —†‡” –Š‡ ‡†‹ ƒ‹† •–ƒ–‡ ’ŽƒǢ „Ǥ ̴̴̴̴̴ ‹ˆˆ‡” ˆ”‘ ’ƒ›‡–• ˆ‘” –Š‡ •ƒ‡ •‡”˜‹ ‡• ™Š‡ ’”‘˜‹†‡† ˆƒ ‡ –‘ ˆƒ ‡Ǣ

Ǥ ̴̴̴̴̴ ‹ˆˆ‡” ˆ”‘ —””‡– •–ƒ–‡ ’Žƒ ’”‘˜‹•‹‘• ‰‘˜‡”‹‰ ”‡‹„—”•‡‡– ˆ‘” –‡Ž‡Š‡ƒŽ–ŠǢ †Ǥ ̴̴̴̴̴  Ž—†‡ ’ƒ›‡– ˆ‘” ƒ ‹ŽŽƒ”› ‘•–• ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ †‡Ž‹˜‡”› ‘ˆ ‘˜‡”‡† Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW •‡”˜‹ ‡• ˜‹ƒ –‡Ž‡Š‡ƒŽ–Šǡ ȋ‹ˆ ƒ’’Ž‹ ƒ„Ž‡Ȍǡ ƒ• ˆ‘ŽŽ‘™•ǣ ‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• ‹ ‘”’‘”ƒ–‡† ‹–‘ ˆ‡‡Ǧˆ‘”Ǧ•‡”˜‹ ‡ ”ƒ–‡•Ǥ ‹‹Ǥ ̴̴̴̴̴  ‹ŽŽƒ”› ‘•– ƒ••‘ ‹ƒ–‡† ™‹–Š –Š‡ ‘”‹‰‹ƒ–‹‰ •‹–‡ ˆ‘” –‡Ž‡Š‡ƒŽ–Š ‹• •‡’ƒ”ƒ–‡Ž› ”‡‹„—”•‡† ƒ• ƒ ƒ†‹‹•–”ƒ–‹˜‡ ‘•– „› –Š‡ •–ƒ–‡ ™Š‡ ƒ ‡†‹ ƒ‹† •‡”˜‹ ‡ ‹• †‡Ž‹˜‡”‡†Ǥ Other: 4. _____ Other payment changes: Section F – Post-Eligibility Treatment of Income ͳǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• –‘ ‘†‹ˆ› –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ˆ‘” ‹•–‹–—–‹‘ƒŽ‹œ‡† ‹†‹˜‹†—ƒŽ•Ǥ Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡ ‹• ‡“—ƒŽ –‘ ‘‡ ‘ˆ –Š‡ ˆ‘ŽŽ‘™‹‰ ƒ‘—–•ǣ ƒǤ ̴̴̴̴̴ Š‡ ‹†‹˜‹†—ƒŽǯ• –‘–ƒŽ ‹ ‘‡ „Ǥ ̴̴̴̴̴ ͵ͲͲ ’‡” ‡– ‘ˆ –Š‡  ˆ‡†‡”ƒŽ „‡‡ˆ‹– ”ƒ–‡

Ǥ ̴̴̴̴̴ –Š‡” ”‡ƒ•‘ƒ„Ž‡ ƒ‘—–ǣ ̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴̴ ʹǤ ̴̴̴̴̴ Š‡ •–ƒ–‡ ‡Ž‡ –• ƒ ‡™ ˜ƒ”‹ƒ ‡ –‘ –Š‡ „ƒ•‹ ’‡”•‘ƒŽ ‡‡†• ƒŽŽ‘™ƒ ‡Ǥ ȋ‘–‡ǣ Ž‡ –‹‘ ‘ˆ –Š‹• ‘’–‹‘ ‹• ‘– †‡’‡†‡– ‘ ƒ •–ƒ–‡ ‡Ž‡ –‹‰ –Š‡ ‘’–‹‘ †‡• ”‹„‡† –Š‡ ‘’–‹‘ ‹ ǤͳǤ ƒ„‘˜‡ǤȌ The state protects amounts exceeding the basic personal needs allowance for individuals who have the following greater personal needs: Section G – Other Policies and Procedures Differing from Approved Medicaid State Plan /Additional Information PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

State/Territory: South Dakota TN: 20-003 Supersedes TN: NEW information collection is 0938-1148 (Expires 03/31/2021). The time required to complete this information collection is estimated to average 1 to 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to receive a waiver under Section 1135 of the Social Security Act. All responses are public and will be made available on the CMS web site. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclosure*** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Centers for Medicaid & CHIP Services at 410-786-3870. Approval Date: _____ ϱͬϮϴͬϮϬ _____ Effective Date: 3/1/20

Table of Contents State/Territory Name: South Dakota

State Plan Amendment (SPA) #: 20-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, MD 21244-1850 Financial Management Group Laurie R. Gill Cabinet Secretary Department of Social Services 700 Governors Drive Pierre, South Dakota 57501-2291 Re: South Dakota 20-0007 Dear Ms. Gill: We have reviewed the proposed amendment to Attachment 4.19-A and Attachment 4.19-B of your Medicaid State plan submitted under transmittal number (TN) 20-0007. Effective for services on or after July 1, 2020, this amendment implements inflationary rate increases appropriated by the state during the 2020 legislative session. In addition, this amendment provides clarification that Diagnostic Related Group (DRG) groupers are updated annually, effective January each year. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a) and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment TN 20-0007 is approved effective July 1, 2020. The CMS-179 and the amended plan pages are attached. If you have any questions, please contact Christine Storey at Christine.storey@cms.hhs.gov or Josh Smith at lajoshica.smith@cms.hhs.gov. Sincerely, Rory Howe Acting Director For November 23, 2020

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0193 TRANSMITTAL AND NOTICE OF APPROVAL OF 1, TRANSMITTAL NUMBER: 2. STATE:

STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES

SD-20-007 South Dakota

3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE July 1, 2020

5. TYPE OF PLAN MATERIAL (Check One):

[NEW STATE PLAN

CJAMENDMENT TO BE CONSIDERED AS NEW PLAN

MAMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal [for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

42 CFR 447.201, 42 CFR 447 Subpart C, and Section 1923 of the Social Security Act

7. FEDERAL BUDGET IMPACT: a. FFY 2020: $1,247,204.38 b. FFY 2021: $4,566,813.64

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Attachment 4.19-A, page 1, 5, 7, 8, 10a, 10b and Attachment 4.19-B, Introduction page 1 and page 1a

9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Attachment 4.19-A, page 1, 5, 7, 8, 10a, 10b and Attachment 4.19-B, Introduction page 1 and page ta

10. SUBJECT OF AMENDMENT:

The amendment implements inflationary rate increases appropriated by the state during the 2020 legislative session and clarifies that

DRG groupers are updated annually effective January 1 each year.

11. GOVERNOR’S REVIEW (Check One): BECOVERNOR’S OFFICE REPORTED NO COMMENT CICOMMENTS OF GOVERNOR’S OFFICE ENCLOSED

[INO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

CIOTHER, AS SPECIFIED:

t 13. )YPED NAME:

16. RETURN TO:

DEPARTMENT OF SOCIAL SERVICES

DIVISION OF MEDICAL SERVICES ie R. Gill 700 GOVERNORS DRIVE aun RG PIERRE, SD 57501-2291 14. TITLE: Cabinet Secretary

15. DATE SUBMITTED: August 26, 2019

_FOR REGIONAL OFFICE USE ONLY gee) i es ea

17. DATE RECEIVED:

18. DATE APPROVED:

11/23/20

| : _PLAN APPROVED-ONE COPY ATTACHED |

19, EFFECTIVE DATE OF APPROVED MATERIAL: 7/1/20

21. TY! 3 TYPED NAME Rory Howe

20, For

22, TITLE: Acting Director, FMG

| 23.REMARKS:

FORM CMS-179 (07-92) fees ‘

11/23/20: State authorizes pen n ink change to box 15: Date should read August 26, 2020

INPATIENT HOSPITAL PAYMENT METHODOLOGY Attachment 4.19-A Page 1 GENERAL The South Dakota Medicaid program has reimbursed hospitals for inpatient services under a prospective Diagnosis Related Groups (DRGs) methodology, with a few exceptions, since January 1, 1985. The State uses the federal definitions of DRGs, classifications, weights, geometric mean lengths of stay, and outlier cutoffs. The DRG Grouper is updated annually effective January 1 each year each year. The agency provides a link to Medicare’s DRGs on its website at http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx. The agency calculates Medicaid-specific weight and geometric mean length of stay factors annually using the latest three years of non-outlier claim data, this three-year claims database updated annually to establish new weight and geometric length of stay factors with each new grouper. The agency developed hospital-specific costs per Medicaid discharge amounts for all instate hospitals using Medicare cost reports and non-outlier claims data for the hospitals’ fiscal years ending after June 30, 1996 and before July 1, 1997. The agency applied an inflation factor, specific to each hospital’s fiscal year end, to the cost per discharge amounts of all hospitals with more than thirty (30) Medicaid discharges during the base year to establish target amounts for the most recently completed federal fiscal year. There is a cap on the hospitals’ target amounts, under which no hospital is allowed a target amount that exceeds 110% of the statewide weighted average of all target amounts. South Dakota Medicaid reimburses out-of-state hospitals on the same basis as the Medicaid agencies in the states where the hospitals are located. If the hospital's home state refuses to provide the amount they would pay for a given claim, the payment will be at 44.15% of billed charges. Payment is for individual discharge or transfer claims only. Out of state specialty hospitals are reimbursed at 44.15% of billed charges unless otherwise approved by the state. There is no annual cost settlement with out-of-state hospitals or instate DRG hospitals unless an amount is due the South Dakota Medicaid program. For claims with dates of service beginning July 1, 2020, the reimbursement for instate DRG hospitals and all out-of-state hospitals not paid the above-stated percentage of charges is increased by 2.0 percent over what the calculated amounts were for State fiscal year 2019 after any cost sharing amount due from the patient and any third party liability amounts have been deducted, and after computation of any cost outlier payment. The agency will increase reimbursements to South Dakota hospitals classified as Medicare Critical Access or Medicaid Access Critical by 2.0 percent for claims with dates of service on and after July 1, 2020. SPECIFIC DESCRIPTION Each year the agency calculates a hospital’s target amounts for non-outlier claims by dividing the hospital's average cost per discharge for non-outlier claims by the hospital's case mix index. To ensure budget neutrality, the agency adjusts annually a hospital’s target amount for any change in that hospital’s case mix index resulting from the establishment of new program specific weight factors. For each hospital, the case mix index is the calculated result of accumulating the weight factors for all claims submitted during the base period and dividing by the number of claims. TN # 20-07 Supersedes Approval Date _______ Effective Date07/01/20 TN # 19-06 11/23/20

Attachment 4.19-A Page 5 5. Rehabilitation Units (only upon request and justification); 6. Children’s Care Hospitals; 7. Indian Health Service Hospitals; 8. Hospitals with less than 30 Medicaid discharges during the hospital’s fiscal year ending after June 30, 1993, and before July 1, 1994; and 9. Specialized Surgical Hospitals. Payment for rehabilitation hospitals and units, perinatal units, and children’s care hospitals will continue on the Medicare retrospective cost base system with the following exceptions: 1. Costs associated with certified registered nurse anesthetist services that relate to exempt hospitals and units will be included as allowable costs. 2. Malpractice insurance premiums attributable to exempt units or hospitals will be allowed using 7.5% of the risk portion of the premium multiplied by the ratio of inpatient charges to total Medicaid inpatient charges for these hospitals or units. The agency provides a link to Medicare’s DRGs on its website at http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx Payment for psychiatric hospitals, psychiatric units, rehabilitation hospitals, rehabilitation units, perinatal units, and children’s care hospitals is on a per diem basis based on the facility’s reported, allowable costs, as established by the State. This per diem amount is updated annually as directed by the Legislature based on review of economic indices and input from interested parties not to exceed the rate as established by the medical care component of the Consumer Price Index of the most recent calendar year. The per diem for state operated psychiatric hospitals is updated annually based on facility’s reported allowable costs, as established by the state. Specialized surgical hospitals payments for payable procedures will be based upon group assignments. Payment rates are effective April 1, 2019 and will be listed on the agency’s website http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx. Payable procedures include, but are not limited to: nursing, technician, and related services; patient’s use of facilities; drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the surgical procedures; diagnostic or therapeutic services or items directly related to the surgical procedures; administrative and recordkeeping services; housekeeping items and supplies; and materials for anesthesia. Items not reimbursable include those payable under other provisions of State Plan, such as physician services, laboratory services, X-ray and diagnostic procedures, prosthetic devices, ambulance services, orthotic devices, and durable medical equipment for use in the patient’s home, except for those payable as directly related to the surgical procedures. Payments to Indian Health Service inpatient hospitals will be per diem and based upon the approved rates published each year in the Federal Register by the Department of Health and Human Services, Indian Health Service, under the authority of sections 321(a) and 322(b) of the Public Health Service Act (42 U.S.C. 248 and 249(b)), Public Law 83-568 (42 U.S.C. 2001(a)), and the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.). Instate hospitals with less than 30 discharges during the hospital’s fiscal year ending after June 30, 1993, and before July 1, 1994, are paid 95% of billed charges. For claims with dates of service on and after July 1, 2020, the amount of reimbursement for psychiatric hospitals, rehabilitation hospitals, perinatal units, psychiatric units, rehabilitation units, children’s care hospitals, and specialized surgical hospitals will be increased 2.0% over the April 1, 2019 calculations after any cost sharing amounts due from the patient, any third-party liability amounts have been deducted and other computation of any cost outlier payment. EXCEPTION TO PAYMENT METHODOLOGIES FOR ACCESS-CRITICAL AND AT-RISK HOSPITALS South Dakota Medicaid will reimburse hospitals classified as Medicare Critical Access or Medicaid Access Critical at the greater of actual allowable cost or the payment received under the provisions contained in this Attachment. TN # 20-07 Supersedes Approval Date Effective Date 07/01/20 TN# 19-06 11/23/20

Attachment 4.19-A Page 7 TN 20-07 Supersedes TN 19-07 Approval Date _______ Effective Date 07/01/20

Group 2, psychiatric hospitals operated by the State of South Dakota; and Group 3, other hospitals (any hospital not in Group 1 or 2). Payments to Group 1 hospitals qualifying under the Medicaid inpatient utilization method are based on the standard deviation that a facility’s qualifying rate exceeds the Medicaid inpatient utilization mean for all participating hospitals. Payments to Group 1 hospitals qualifying under the low-income utilization method are based on the standard deviation that a facility’s qualifying rate exceeds the low-income utilization mean for all participating hospitals. Payments to Group 1 hospitals will be made according to the payment schedule on the Department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2020. The amount of payment for each hospital is calculated as follows: The Department determines the number of facilities qualifying at greater than the mean, greater than 1 standard deviation above the mean, greater than 2 standard deviations above the mean, and greater than 3 standard deviations above the mean. The total amount of funding budgeted for disproportionate share payments is then allocated starting with those facilities qualifying at greater than the mean. Facilities qualifying at greater than 1 standard deviation, greater than 2 standard deviations, and greater than 3 standard deviations above the mean are paid double, triple, and quadruple, respectively, the amount for facilities qualifying at greater than the mean. The payment amounts are adjusted until all the budgeted funds are spent. The proposed disproportionate share payment for each facility is then compared to the payment limit that has been established for each facility. If the payment limit is less than the proposed disproportionate share payment, then the payment limit amount will be the disproportionate share payment for that particular facility. The sum of the payments made to the facilities where the payment limit was met is then subtracted from the total amount budgeted. The remaining budgeted funds are then allocated equally among the facilities where the payment limits have not been met. The subsequent allocation again is determined to ensure that facilities qualifying at greater than 1 standard deviation, greater than 2 standard deviations, and greater than 3 standard deviations above the mean are paid double, triple, and quadruple, respectively, the amount for facilities qualifying at greater than the mean. Payments to Group 2 hospitals qualifying under the Medicaid inpatient utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the Medicaid inpatient utilization mean for all participating hospitals. Payments to Group 2 hospitals qualifying under the low-income utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the low-income utilization mean for all participating hospitals. 11/23/20

Attachment 4.19-A Page 8 TN 20-07 Supersedes TN 19-07 Approval Date _______ Effective Date 07/01/20

Payments to Group 2 hospitals will be made according to the payment schedule on the Department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2020. Payments to Group 3 hospitals qualifying under the Medicaid inpatient utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the Medicaid inpatient utilization mean for all participating hospitals. Payments to Group 3 hospitals qualifying under the low-income utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the low-income utilization mean for all participating hospitals. Payments to Group 3 hospitals will be made according to the payment schedule on the Department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2020. If necessary, payments to qualified hospitals will be adjusted for the projected impact of the hospital’s specific disproportionate share hospital payment limit as required by OBRA ’93. The agency will make disproportionate share hospital program payments to qualifying hospitals one time during the last quarter of the State fiscal year. If the total of disproportionate share payments to all qualified hospitals for a year is going to exceed the State disproportionate share hospital payment limit, as established under 1923(f) of the Act, the following process will be used to prevent overspending the limit: First, the amount of over- expenditure will be determined; Then the over-expenditure amount will be deducted from the total payments to Group 2 hospitals; and Payments to individual Group 2 hospitals will be reduced based on their percentage of Group 2 total payments. 11/23/20

Attachment 4.19-A Page 10a TN# 20-07 Supersedes TN# 18-05 Approval Date ______ Effective Date 07/01/20 HEALTH PROFESSION EDUCATION The Department of Social Services supports the direct graduate medical education (GME) of health professionals through the use of Medicaid funds. All in-state, private hospitals which are accredited by the Accreditation Council for Graduate Medical Education (ACGME) are eligible for health profession education payments. Those hospitals are identified through the use of their most recently-filed Medicare 2552-10, cost reports. Specifically, worksheet E-4 (Line 1.00) is utilized to identify the number of weighted full-time equivalents for primary care physicians at participating facilities. The agency calculates the Medicaid hospital patient days using the Division of Medical Services (DMS) Cost Settlement Details report of adjudicated claims for the same period as the Medicare 2552 cost report. Hospitals seeking GME payments must submit an application for the previous state fiscal year’s costs to DMS prior to the end of the current state fiscal year. The agency will make payments for costs incurred in the previous state fiscal year, as defined below, annually prior to the end of the current state fiscal year. Payments will be made through the state’s Medicaid Management Information System (MMIS) payment system. Payments will be made directly to the qualifying hospitals through a supplemental payment mechanism. The payment will appear on the facility’s remittance advice. Each hospital will also receive written notification at the time of payment of the payment amount from DMS. GME payments made in error will be recovered via a supplemental recovery mechanism and will appear on the facility’s remittance advice. The agency will notify the facility in writing explaining the error prior to the recovery. The Federal share of payments made in excess will be returned to CMS in accordance with 42 CFR Part 433, Subpart F. A hospital that applied for GME funding in the previous 24 months must provide written notice to DMS no less than 30 days prior to the effective date it intends to terminate operation of a GME program. A hospital must provide written notice to DMS by January 1 if it will not be applying for GME funding for the previous state fiscal year’s costs. The agency will determine the annual lump sum, onetime payment pool. The annual payment will be made during the last quarter of the state fiscal year. The pool will be distributed based upon the allocation percentage of each hospital. The hospital allocation percentage will be developed using prior year total Medicaid inpatient days and weighted intern and resident (I & R) full time equivalency (FTE). The state uses the prior year’s cost report data as a proxy for the current year. For example, the state fiscal year 2008 calculation of allocations from the payment pool was the following: (a) Weighted I & R FTEs (b) Medicaid Hospital Patient Days (c) (a*b) Weighted FTE Days (d) Hospital Allocation Percentage Payment Pool Total Hospital A 17 11,450 194,650 35.34% $1,052,009 Hospital B 22 10,692 232,230 42.16% $1,255,116 Hospital C 23 5,342 123,988 22.51% $670,107 Totals 62 27,484 550,868 100.00% $2,977,233 Total state funds available for payment through the pool are listed on the department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2020. The FMAP at the time the annual payment is made will be applied to the state portion of the payment. 11/23/20

Attachment 4.19-A Page 10b TN# 20-07 Supersedes TN# 18-05 Approval Date ______ Effective Date 07/01/20 Rural Residency Program The Center for Family Medicine is eligible for payment of direct GME via a separate funding pool for its operation of a rural family medicine residency program. The Center for Family Medicine must be accredited by the ACGME to be eligible for health profession education payments. The state will make equal interim payments to providers on a quarterly basis. Costs must be submitted on a quarterly basis to validate costs for the previous quarter using the state developed South Dakota Rural Residency Program Cost Report and Rural Residency Cost Report Guidelines. The payment will be made to the Center for Family Medicine through the MMIS system. Payments will be made directly to the provider through a supplemental payment mechanism and will appear on their remittance advice. The Center for Family Medicine will receive written notification at the time of payment of the payment amount from DMS. GME payments made in error that cannot be adequately addressed through adjustment of future quarterly payments will be recovered via a supplemental recovery mechanism and will appear on the provider’s remittance advice. The agency will notify the provider in writing explaining the error prior to the recovery. The Federal share of payments made in excess will be returned to CMS in accordance with 42 CFR Part 433, Subpart F. The Center for Family Medicine must provide written notice to DMS no less than 30 days prior to the effective date it intends to terminate operation of its GME program or written notice to DMS no less than 30 days prior to the effective date it will no longer be applying for GME funding. The agency will determine the annual rural residency program payment pool for the upcoming state fiscal year prior to the start of the fiscal year on July 1. The total state funds available for payment through the rural residency program pool are listed on the department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2020. The FMAP at the time the quarterly payment is made will be applied to the state portion of the payment. 11/23/20

Introduction Page 1 ATTACHMENT 4.19-B INTRODUCTION Payment rates for the services listed below are effective for services provided on or after the corresponding date. Fee schedules are published on the Department’s website at http://dss.sd.gov/medicaid/providers/feeschedules/. Effective dates listed on the introductory page supersede the effective dates listed elsewhere in Attachment 4.19-B. Unless otherwise noted in the referenced state plan pages, reimbursement rates are the same for both governmental and private providers. Service Attachment Effective Date Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Attachment 4.19-B, Page 4 July 1, 2020 Physician Services Attachment 4.19-B, Page 6 July 1, 2020 Optometrist Services Attachment 4.19-B, Page 9 July 1, 2020 Chiropractic Services Attachment 4.19-B, Page 10 July 1, 2020 Independent Mental Health Practitioners Attachment 4.19-B, Page 11 July 1, 2020 Nutritionist and Dietician Services Attachment 4.19-B, Page 11 July 1, 2020 Home Health Services Attachment 4.19-B, Page 12 July 1, 2020 Durable Medical Equipment Attachment 4.19-B, Page 13 July 1, 2020 Clinic Services Attachment 4.19-B, Page 15 July 1, 2020 Dental Services Attachment 4.19-B, Page 16 July 1, 2020 Physical Therapy Attachment 4.19-B, Page 17 July 1, 2020 Occupational Therapy Attachment 4.19-B, Page 18 July 1, 2020 Speech, Hearing, or Language Disorder Services Attachment 4.19-B, Page 19 July 1, 2020 Dentures Attachment 4.19-B, Page 21 July 1, 2020 Prosthetic Devices Attachment 4.19-B, Page 22 July 1, 2020 Eyeglasses Attachment 4.19-B, Page 23 July 1, 2020 Diabetes Self-Management Training Attachment 4.19-B, Page 26 July 1, 2020 Community Health Workers Attachment 4.19-B, Page 26 July 1, 2020 Community Mental Health Centers Attachment 4.19-B, Page 26 July 1, 2020 Substance Use Disorder Agencies Attachment 4.19-B, Page 26 July 1, 2020 Nurse Midwife Services Attachment 4.19-B, Page 31 July 1, 2020 Transportation Attachment 4.19-B, Page 38 July 1, 2020 Personal Care Services Attachment 4.19-B, Page 38 July 1, 2020 Freestanding Birth Centers Attachment 4.19-B, Page 39 April 1, 2019 Professional Services Provided in a Freestanding Birth Center Attachment 4.19-B, Page 39 July 1, 2020 TN# 20-07 SUPERCEDES Approval Date

Effective Date 07/01/20 TN# 19-06 11/23/20

Page 1a ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES South Dakota Medicaid will make payments to medical providers who sign agreements with the State under which the provider agrees: (a) to accept as payment in full the amounts paid in accordance with the payment structures of the State; (b) to keep such records as are necessary to fully disclose the extent of the services provided to individuals receiving assistance under the State Plan; and (c) to furnish the State Agency with such information, regarding any payments claimed by such person or institution for services provided under the State Plan, as the agency may request from time to time. The following describes policy and methods the agency uses to establish payment rates for each type of care and service, other than inpatient hospital or nursing home services, included in the State Plan. In no instance will the amount of payment under the provisions of this attachment exceed the payment made by the general public for identical services. 1. Inpatient Hospital Services (See Attachment 4.19-A) 2a. Outpatient Hospital Services Effective August 2, 2016, Medicare Prospective Payment System hospitals will be paid using the Medicaid Agency’s Outpatient Prospective Payments System (OPPS). Under OPPS, services are reimbursed using Ambulatory Payment Classifications. Effective August 2, 2016, the Department will establish a conversion factor and discount factor specific to each hospital. The hospital specific conversion factor and discount factors are published on the State agency’s website at http://dss.sd.gov/medicaid/providers/feeschedules/dss/. Effective July 1, 2020, Medicare Prospective Payment System hospitals paid using the Medicaid Agency’s OPPS will be increased by 2.0 percent. South Dakota Medicaid will pay remaining participating outpatient hospitals with more than 30 Medicaid inpatient discharges during the hospital’s fiscal year ending after June 30, 1993 and before July 1, 1994 on the basis of Medicare principles of reasonable reimbursement with the following exceptions: 1. Costs associated with certified registered nurse anesthetist services are allowable costs. These costs are identified on the CMS 2552-10 on Worksheet A-8 and included in the facilities’ costs. 2. All capital and education costs incurred for outpatient services are allowable costs. These costs are identified on the CMS 2552-10 on Worksheet D Part III and included in the facilities’ costs. 3. Payments to Indian Health Service outpatient hospitals will be per visit and based upon the approved rates published each year in the Federal Register by the Department of Health and Human Services, Indian Health Service, under the authority of sections 321(a) and 322(b) of the Public Health Service Act (42 U.S.C. 248 and 249(b)), Public Law 83-568 (42 U.S.C. 2001(a)), and the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.). The State agency will make payments for visits of the same type of service on the same day at the same provider location only if the services provided are different or if they have different diagnosis codes. TN # 20-07 SUPERSEDES Approval Date _______ Effective Date 07/01/20 TN # 19-06 11/23/20

Table of Contents

State/Territory Name: South Dakota State Plan Amendment (SPA) #: 21-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Laurie R. Gill, Cabinet Secretary Department of Social Services Division of Medical Services 700 Governors Drive Pierre, SD 57501-2291 RE: South Dakota State Plan Amendment (SPA) Transmittal Number 21-0001 Dear Ms. Gill: We have reviewed the proposed South Dakota State Plan Amendment (SPA) to Attachment 4.19-B of your state plan, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on January 27, 2021. This plan amendment allows substance use disorder (SUD) agencies to be reimbursed an originating site fee for acting as a telemedicine originating site. Based upon the information provided by the State, we have approved the amendment with an effective date of January 01, 2021. We are enclosing the approved CMS-179 and a copy of the new state plan pages. If you have any additional questions or need further assistance, please contact LaJoshica (Josh) Smith via 214- 767-6453 or lajoshica.smith@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures April 26, 2021

             

    


 

    


  


 


 

 
    
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Page 6 ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES 5a. Physician Services The rates below are effective for services on or after the date listed on the Attachment 4.19-B Introduction Page, Page 1. a. Services other than clinical diagnostic laboratory tests. 1. Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. If there is no fee established, the payment will be 40% of the provider’s usual and customary charge. 2. If there is no fee established for supplies furnished incidental to the professional services of a physician, the payment will be paid 90% of the provider’s usual and customary charge. b. Anesthesia services. Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. c. Clinical diagnostic laboratory tests. 1. Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. The established fee will not exceed Medicare’s fee on a per test basis as required by Section 1903(i)(7) of the Social Security Act. 2. Tests for which Medicare has not established a fee will be paid the lower of a fee established by the State agency or priced by report. The reimbursement rate for these services is determined using one of a variety of different reimbursement methodologies. The reimbursement rates for services priced by report are determined using a similar service, product, or procedure that has an established rate, or a percentage of the provider’s usual and customary charge. The specific methodology depends on the service, product, or procedure performed. d. Payment for physician services provided via telemedicine is made as follows: 1. Only providers eligible to enroll in the Medicaid program are eligible for payment of telemedicine services. Providers must bill the appropriate CPT procedure code with the modifier “GT” indicating the services were provided via telemedicine. 2. Originating sites, the physical location of the recipient at the time the service is provided, will be paid the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. All originating sites must be an enrolled provider. Approved originating sites are: i. Office of a physician or practitioner. ii. Outpatient Hospitals. iii. Critical Access Hospitals. iv. Rural Health Clinics. The facility fee is not considered an encounter and will be reimbursed according to the fee schedule. v. Federally Qualified Health Centers. The facility fee is not considered an encounter and will be reimbursed according to the fee schedule. vi. Indian Health Service (IHS) Clinics. The facility fee is not considered an encounter and will be reimbursed according to the fee schedule. vii. Community Mental Health Centers. viii. Substance Use Disorder Agencies. ix. Nursing Facilities. x. School Districts. 3. Distant sites, the physical location of the practitioner providing the service, will be paid the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. TN # 21-01 SUPERSEDES Approval Date _______ Effective Date 01/01/21 TN # 19-12 4/26/21

Table of Contents

State/Territory Name: South Dakota State Plan Amendment (SPA) #: 21-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106

Medicaid and CHIP Operations Group

April 20, 2021

William Snyder, Medicaid Director Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291

RE: TN 21-0002

Dear Mr. Snyder:

The Centers for Medicare and Medicaid Services (CMS) has completed its review of South Dakota’s State Plan Amendment (SPA) Transmittal #21-0002, submitted on March 17, 2021. This SPA seeks an extension to the exception to the Medicaid Recovery Audit Contractor (RAC) program.

CMS approved SPA #21-0002 on April 20, 2021, with an effective date of June 1, 2021 for a two- year period only, with a termination date of May 31, 2023. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the South Dakota State Plan.

If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303) 844-7068.

Sincerely, James G. Scott, Director Division of Program Operations

Enclosures

cc: Brenda Tidball-Zeltinger, Deputy Secretary, South Dakota Medicaid Matthew Ballard, Deputy Director, South Dakota Medicaid Renae Hericks, South Dakota Medicaid Mandy Strom, CMS North Branch-Division of Program Operations

Digitally signed by James G. Scott -S Date: 2021.04.20 14:56:48 -05'00'

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TN No. 21-0002 Supersedes TN No. 19-0008 Approval Date ________ Effective Date 06/01/21 Page 36b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA SECTION 4. GENERAL PROGRAM ADMINISTRATION Citation 4.5b Medicaid Recovery Audit Contractor Program Section 1902(a)(42)(b)(i) of the Social Security Act The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan. X The State is seeking an extension to the exception to establishing such program for the following reasons: (1) The State maintains a low rate of errors in Medicaid payments, as evidenced by the most recent PERM review; and (2) The State’s estimate of the potential amount of payment errors to be recovered is low based in part on relatively low Medicaid enrollment and associated expenditures such that there would not be enough revenue generated to fund an adequate enough contingency fee to attract sufficient bidding attention from vendors; and (3) In fiscal year 2020 the State had total Medicaid and CHIP expenditures of $992.65 million. For this period the State had an average monthly enrollment of 115,731 eligible recipients and a total of 141,620 eligible recipients during the fiscal year. Of these individuals 113,291 were enrolled in the Primary Care Case Management or the Health Home program. The State Medicaid agency has contracts of the type(s) listed in Section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute. 

Table of Contents State/Territory Name: SD State Plan Amendment (SPA) #: 21-0011 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St,, Room 355 @ iY | Sy

Kansas City, Missouri 64106 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Medicaid and CHIP Operations Group

December 22, 2021

Sarah Aker, Medicaid Director Department of Social Services Richard F. Kneip Building 700 Governors Drive

Pierre, SD 57501-2291

RE: TN 21-0011 Dear Ms. Aker:

The Centers for Medicare and Medicaid Services (CMS) has completed its review of South Dakota’s State Plan Amendment (SPA) Transmittal #21-0011, submitted on December 6, 2021. The SPA provides assurances that the State is in compliance with federal regulations regarding third party liability.

CMS approved SPA #21-0011 on December 22, 2021, with an effective date of November 1, 2021. Enclosed is a copy of the CMS-179 summary form, as well as the approved pages for incorporation into the South Dakota State Plan.

If you have any questions regarding this amendment, please contact Mandy Strom at

mandy.strom@cms.hhs.gov or (303)844-7068.

Sincerely,

Dinitalls cinnnd bes

James G. Scott, Director Division of Program Operations

Enclosure ce:

Matthew Ballard, South Dakota Medicaid Renae Hericks, South Dakota Medicaid

DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0193, 1. TRANSMITTAL NUMBER 2. STATE TRANSMITTAL AND NOTICE OF APPROVAL OF 21.0011 sD STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES ee ee

TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4. PROPOSED EFFECTIVE DATE November 1, 2021

5. FEDERAL STATUTE/REGULATION CITATION Section 1902(a)(25) of the SSA and 42 CFR 433.136 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT

Attachment 4.22-A, Page 2

6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY_2022 $ 0 b FFY 2023 $0

8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable)

Attachment 4.22-A, Page 2 TN#15-006

9. SUBJECT OF AMENDMENT

This State Plan Amendment provides assurances that the State is in compliance with federal regulations regarding third party liability.

“10. GOVERNOR'S REVIEW (Check One)

GOVERNOR'S OFFICE REPORTED NO COMMENT |_..j COMMENTS OF GOVERNOR'S OFFICE ENCLOSED | _|NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

[ootuer, as specirien:

41 SIGNATURE OF STATE AGENCY OFFICIA!

15. RETURN TO

“42. TYPED NAME a DEPARTMENT OF SOCIAL SERVICES Laurie R. Gifl d ~ DIVISION OF MEDICAL SERVICES 73. 700 GOVERNORS DRIVE val PIERRE, SD 57501-2291 14. DATE SUBMITTED December 6, 2021 FOR CMS USE ONLY

16. DATERECEIVED 1) ember 6, 2021

17. DATE APPROVED December 22, 2021

PLAN APPROVED - ONE COPY ATTACHED

48. EFFECTIVE DATE OF APPROVED MATERIAL November 1, 2021

19, SIGNOTHRE AF ADDRAVING AEEICAL

20. TYPED NAME OF APPROVING OFFICIAL James G. Scott

21, TITLE OF APPROVING OFFICIAL Director, Division of Program Operations

22. REMARKS

FORM CMS-179 (09/24)

instructions on Back





Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 22-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) Companion Letter 3) CMS Form 179 4) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICFS Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas Gty, Missouri 64106 Medicaid and CIIlP Operations Group Sarah Aker, Medicaid Director Department of Social Services Richard F. Kneip Building 700 Governors Drive PieITe, SD 57501-2291 RE: TN 22-0014 Dear Ms. Aker: April 25, 2023 CMS CENlfftS FOR MEOICARE & MEOICAIO SERVICE$ CENTER FOR MEDICAID & CHIP SERVICES The Centers for Medicare & Medicaid Services (CMS) has completed our review of South Dakota's State Plan Amendment (SPA) Transmittal #22-0014, submitted on October 24, 2022. The SPA clarifies how the premium assistance program determines if premium assistance is estimated to be cost effective and aligns with policies and cuITent practice. CMS approved SPA #22-0014 on Ap1il 25, 2023, with an effective date of October 1, 2022. Enclosed is a copy of the CMS-179 summaiy fo1m, as well as the approved pages for incorporation into the South Dakota State Plan. Dming the review of the SP A, CMS recommended the state consider systems changes to allow the enrollment of private plan, non-Medicaid providers into state claiming systems for the purposes of providing cost-sharing protections to Premium Assistance Program beneficiaiies in accordance with cost sharing policies approved under the state plan. This change would also assist the state in tracking cost-shai-ing for Premium Assistance Program beneficiai·ies to ensure they do not exceed the five percent limit. In addition, CMS will be sending a companion letter along with the approval of this SPA to docmnent the state's commitment to coming into compliance with the cost-sharing tracking requirements along with the implementation of its new systems, scheduled for March 2024. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303)844-7068. Enclosures James G. Scott, Director Division of Program Operations cc: Matthew Ballard, South Dakota Medicaid Renae Hericks, South Dakota Medicaid

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106

Medicaid and CHIP Operations Group

April 25, 2023

Sarah Aker, Medicaid Director Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291

RE: TN 22-0014 Companion letter

Dear Ms. Aker:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services’ (CMS) approval of South Dakota’s State Plan Amendment (SPA) #22-0014, which proposes to update how the state determines premium assistance to be cost effective. During the course of our review of SPA #22-0014, we identified a cost sharing policy and procedure that is not consistent with federal requirements. This letter serves to memorialize the agreement that the state will implement a cost- sharing tracking system for all beneficiaries who are subject to cost-sharing under the state plan.

Sections 1906 and 1906A of the Social Security Act permit states to elect to provide a premium assistance program to beneficiaries otherwise eligible for Medicaid who have access to cost-effective private insurance. Under a premium assistance program, states must provide a cost sharing wrap, and ensure premium assistance beneficiaries receive the same cost sharing protections as other Medicaid beneficiaries. Sections 1916A(a)(2)(B), (b)(1)(B)(ii) and (b)(2)(A) of the Social Security Act (the Act), implemented at 42 CFR §447.56(f), set an aggregate cap on the total premiums and cost sharing charged to a given Medicaid beneficiary (or, in the case of a family with multiple beneficiaries, all beneficiaries in the household) to five percent of the beneficiary’s family income. This five percent aggregate cap may be applied, at state option, on either a monthly or quarterly basis (“aggregate cap period”).

As discussed during a phone call on March 2, 2023 with South Dakota agency staff, the state has not yet implemented a system to track beneficiaries’ premiums and cost sharing payments prior to beneficiaries reaching their household aggregate cap. South Dakota informed CMS that it was aware of this issue and that it intends to comply with federal policy concerning cost sharing and premium tracking through an eligibility system upgrade which will enable the state to automate the tracking of beneficiary’s incurred premium and cost sharing towards their family aggregate.

South Dakota has confirmed that this upgrade is scheduled to be implemented by March 1, 2024. Until the automated tracking system is implemented, South Dakota will ensure that premium assistance beneficiaries can report to the state agency when they have incurred cost sharing on eligible medical expenses in excess of five percent of the beneficiary’s family income as approved under the state plan. Tracking cost sharing and premiums is not integral to the purpose of SPA #22-0014. In accordance with SMD #10-020, CMS explained to the state the option it has to resolve this issue separately from the approval of the SPA. MS CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Please respond within 90 days of receipt of this letter to provide written acknowledgement of receipt of this letter and confirmation of the terms described to bring state operations into compliance with tracking requirements under 42 CFR §447.56(f). During this 90-day period, CMS welcomes the opportunity to work with you and your staff. Should you or your staff have any questions, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303)844-7068. Sincerely, James G. Scott, Director Division of Program Operations cc: Matthew Ballard, South Dakota Medicaid Renae Hericks, South Dakota Medicaid

DEPARTMENT OF HEALTH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STA TE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 2 - 0 0 1 4 SD -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT {e) XIX 0 XXI 4. PROPOSED EFFECTIVE DATE October 1, 2022 FORM APPROVED 0MB No. 0938-0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2023 $ 0 Section 1906 of the Social Security Act b. FFY 2024 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Section 4.22, Page 70 OR ATTACHMENT (If Applicable) Attachment 4.22-C, Pages 1 and 2 Section 4.22, Page 70 (TN 08-2) 9. SUBJECT OF AMENDMENT Clarifies how the premium assistance program determines if premium assistance is estimated to be cost effective and aligns the policies with current practice. 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 0 OTHER, AS SPECIFIED 15. RETURN TO DEPARTMENT OF SOCIAL SERVICES 12_ TY ED NAME -----~ DIVISION OF MEDICAL SERVICES 700 GOVERNORS DRIVE _L_a_u_rie_ R_. G_i_ll _______________ ~ PIERRE, SD 57501-2291 13. TITLE Cabinet Secretary 14. DATE SUBMITTED October 24, 2022 16. DATE RECEIVED FOR CMS USE ONLY 17. DATE APPROVED October 24 2022 A ril 25 2023 PLAN APPROVED · ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL 19 October 1 2022 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 22. REMARKS FORM CMS-179 (D9/24) 21. TITLE OF APPROVING OFFICIAL Instructions on Back erations

Revision: HCFA-PM-94-1 (MB) FEBRUARY 1994 Page 70 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State/Territory: SOUTH DAKOTA SECTION 4. GENERAL PROGRAM ADMINISTRATION Citation 4.22 Third Party Liability (continued} 42 CFR 433.151 (a) (f) The Medicaid agency has written cooperative agreements for the Section 1902(a)(60) of the Act 1906 of the Act TN No. 22-0014 Supersedes TN No. 08-2 enforcement of rights to and collection of third party benefits assigned to the State as a condition of eligibility for medical assistance with the following: (Check as appropriate.) _ X_ State title IV-0 agency. The requirements of 42 CFR 433.152(b) are met. ...,lL_Other appropriate State agency(ies) - DSS-Office of Recoveries & Fraud Investigations __ Other appropriate agency(ies) of another state - Courts and law enforcement officials. (g) The Medicaid agency assures that the State has in effect the laws relating to medical child support under Section 1908 of the Act. (h) The Medicaid agency specifies the guidelines used in determining the cost effectiveness of an employer-based group health plan by selecting one of the following: __ The secretary's method as provided in the State Medicaid Manual, Section 3910. _ x_ The State provides methods for determining cost effectiveness on ATTACHMENT 4.22-c. Approval Date 4/25/2023 Effective Date 10/1 /22

State/Territory: South Dakota ATTACHMENT 4.22-C Page 1 State Methodology of Determining Cost-Effectiveness of Individual and Group Health Plans Enrollment in the Premium Assistance Program is voluntary. Premium assistance enrollees are able to see providers enrolled in Medicaid and/or the private insurance for any Medicaid eligible services. For Medicaid eligible recipients, enrollment in the Premium Assistance Program does not change the recipient's eligibility for benefits through the state plan or cost sharing obligations under the state plan. The Medicaid agency pays all premiums, deductibles, coinsurance and other cost sharing obligations for items and services covered under the State plan, subject to any nominal Medicaid copayment, for premium assistance beneficiaries. Individuals enrolled in the Premium Assistance Program are afforded the same recipient protections provided to all other Medicaid enrollees. Any cost-sharing imposed in excess of the 5 percent cap is adjusted through claims reprocessing by the Medicaid agency. I. South Dakota Medicaid determines the cost-effectiveness for payment of qualifying group or individual market health insurance premiums using the following methodology: 1. Any Medicaid-eligible recipient who has an existing, ongoing, and medically- confirmed medical condition determined by the South Dakota Medicaid to be considered a cost- effective condition is deemed to meet the cost-effective criteria. Examples of medical conditions considered cost-effective include cancer, neonatal intensive care, transplants, motor vehicle accidents, head trauma, and heart conditions. 2. When the criteria of 1. is not met, cost-effectiveness will be calculated as follows: a.Determine: i. The annual anticipated cost for Medicaid services generally covered by the private health insurance based on the recipient's claim history and other relevant information. ii. Total the results of each of the following calculations: a. The group or individual market health insurance premium less the employer contribution. b. A predetermined annual administration cost per participant. c. The expected cost to South Dakota Medicaid for any deductibles, coinsurance and/or copayments. b.Subtract the result of ii. from the result of i. c. If the result is a cost savings greater than or equal to $1,000, the policy is considered cost-effective. d. If the result is less than $1,000 in cost savings, the policy is not considered cost-effective. 3. When the criteria of 1. and 2. are not met, specific information relating to the individual circumstances of the Medicaid-eligible recipient may be provided. On a case-by-case basis and at the sole discretion of South Dakota Medicaid, a determination of cost- effectiveness can be made if sufficient evidence is provided to demonstrate savings to South Dakota Medicaid. II. Redetermination Review 1. South Dakota Medicaid will complete a redetermination review at least yearly for all Premium Assistance Program enrollees. The yearly review shall consist of: TN No. 22-0014 Supersedes TN No. NEW a. Verifying South Dakota Medicaid eligibility; and Approval Date 4/25/2023 Effective Date 10/1/22

ATTACHMENT 4.22-C Page 2 b. Completing a cost-effective analysis using the cost-effectiveness methodology 2. South Dakota may re-determine eligibility at any point if: a. The monthly premium of the group or individual market health insurance increases; b. There is a change in eligibility category or status for South Dakota Medicaid; c. The services offered by the group or individual market health insurance decrease; d. There is a change in the deductible, co-insurance or any other cost-sharing provisions of the group or individual market health policy; or e. There is reason to believe a change has occurred which may affect eligibility for the Premium Assistance Program. 3. Failure to submit required documents for redetermination or failure to meet the cost effectiveness criteria may result in disenrollment from the Premium Assistance Program. Ill. Coverage of Non-South Dakota Medicaid Family Members 1. The Premium Assistance Program will pay the premiums for additional family members who are not South Dakota Medicaid eligible, if the individual's premium amount cannot be separated from the family premium amount. In this circumstance, the entire amount of the family's premium will be used to calculate cost effectiveness. 2. South Dakota will not pay a deductible, copayment, or coinsurance obligation on behalf of non-Premium Assistance Program individuals covered under a family's insurance. IV. Purchasing or paying for health insurance coverage is deemed not cost effective when: 1. A recipient is also enrolled in Medicare; 2. A recipient is enrolled in a limited benefits Medicaid program; 3. Payment of health insurance premiums have been fully reimbursed or offset by a third party, including, but not limited to: a. An employer. b. An individual court-ordered to provide medical support. 4. The group or individual market health insurance only provides catastrophic, limited benefit, limited duration, or indemnity coverage. V. Premium Assistance Payments 1. Payments may be made directly to the insurer, employer, or the recipient. 2. The initial insurance premium payment will be made immediately upon program approval and on the first business day of each qualifying month thereafter. TN No. 22-0014 Supersedes TN No. NEW Approval Date 4/25/2023 Effective Date 10/1/22

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 23-0002 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Financial Management Group

May 23, 2023 Sarah Aker, Medicaid Director Department of Social Services Department of Medical Services 700 Governors Drive Pierre, South Dakota 57501-2291

Re: South Dakota Title XIX FMAP State Plan Amendment, Transmittal #23-0002 Dear Ms. Aker: We have reviewed the proposed Federal Medical Assistance Payment (FMAP) State Plan Amendment (SPA) SD 23-0002, which was submitted to the Centers for Medicare & Medicaid Services on February 24, 2023. This SPA describes the methodology used by the state for determining the appropriate FMAP rates, including the increased FMAP rates, available under the provisions of the Affordable Care Act applicable for the medical assistance expenditures under the Medicaid program associated with enrollees in the new adult group adopted by the state and described in 42 CFR 435.119.

Based on the information provided, the Medicaid SPA 23-0002 is approved with an effective date of July 1, 2023. We are enclosing the approved Form CMS-179 and the Medicaid state plan pages.

If you have any additional questions or need further assistance, please contact Stuart Goldstein at (410) 786-0694 or by email at Stuart.Goldstein@cms.hhs.gov

Sincerely,

Charlie Arnold Division of Financial Policy

Enclosures

cc: Sarah Aker, State Medicaid Director SD

CENTERS FOR MEDICARE & MEDICAID SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2.STATE 2 3 0 0 0 2 SD -- ---- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e) XIX () XXI 4. PROPOSED EFFECTIVE DATE July 1, 2023 FORM APPROVED me No. 0938.o,s3 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) 4 2 CFR 435.119 and 42 CF R Part 440, Subpart C a FFY 2023 $ 0 b. FFY 2024 $ 0 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGENUMBEROFTHESUPERSEDEDPLAN SECTION Supplement 18 to Attachment 2.6-A, Pages 1-6 OR ATTACHMENT (If Applicable) 9. SUBJECT OF AMENDMENT Adopt the provisions governing the appropriate FMAP rate for expenditures for individuals enrolled in the adult group described in 42 CFR 435.119 and receiving benfits in accordance with 42 CFR Part 440, Subpart C. 10. GOVERNOR'S REVIEW {Check One) (!) GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 0 OTHER, AS SPECIFIED: 1. ! ~. ~~- ~ .: • ~ 15. RETURN TO DEPARTMENT OF SOCIAL SERVICES --~ DIVISIO N OF MEDICAL SERVICES ·-· Sarah Aker 700 GOVERNORS DRIVE -----------------------i PIERRE, SD 57501 -2291 13. TITLE D irector 14. DATE SUBMITTED February 24, 2023 FOR CMS USE ONLY ------------------------------------------ 16. DATE RECEIVED ] 7. DATE APPROVED Fetruary 24, 2023 M ___ ay'-2_3..;.., _20_2_3 ________________ _ PLAN APPROVED • E COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL July 1, 2023 20. TYPED NAME OF APPROVING OFFICIAL Charlie Arnold 22. REMARKS FORM CMS-179 (09/24) 21 . TITLE OF APPROVING OFFICIAL Instructions on Back

Supplement 18 to Attachment 2.6A Page 1

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State Plan Under Title XIX of the Social Security Act State:

METHODOLOGY FOR IDENTIFICATION OF APPLICABLE FMAP RATES The State will determine the appropriate FMAP rate for expenditures for individuals enrolled in the adult group described in 42 CFR 435.119 and receiving benefits in accordance with 42 CFR Part 440 Subpart C. The adult group FMAP methodology consists of two parts: an individual-based determination related to enrolled individuals, and as applicable, appropriate population-based adjustments. Part 1 – Adult Group Individual Income-Based Determinations For individuals eligible in the adult group, the state will make an individual income-based determination for purposes of the adult group FMAP methodology by comparing individual income to the relevant converted income eligibility standards in effect on December 1, 2009, and included in the MAGI Conversion Plan (Part 2) approved by CMS on . In general, and subject to any adjustments described in this SPA, under the adult group FMAP methodology, the expenditures of individuals with incomes below the relevant converted income standards for the applicable subgroup are considered as those for which the newly eligible FMAP is not available. The relevant MAGI-converted standards for each population group in the new adult group are described in Table 1.

South Dakota 02/01/2014 23-0002 05/23/2023 07/01/2023

Supplement 18 to Attachment 2.6A Page 2 Table 1: Adult Group Eligibility Standards and FMAP Methodology Features Covered Populations Within New Adult Group Applicable Population Adjustment Population Group Relevant Population Group Income Standard Resource Enrollment Special Other Proxy Cap Circumstances Adjustments For each population group, indicate the lower of: • The reference in the MAGI Conversion Plan (Part 2) to the relevant income standard and the appropriate cross-reference, or Enter "Y" (Yes), "N'' (No), or "NA" in the appropriate column to indicate if • 133% FPL. the population adjustment will apply to each population group. Provide If a population group was not covered as of 12/1/09, additional information in corresponding attachments. enter "Not covered". A B C D E F Parents/Caretaker Attachment A, Column C, Line 1 of the CMS approved Relatives MAGI Conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan. No No No No Disabled Persons, non- Not Covered institutionalized N/A N/A N/A N/A Disabled Persons, Attachment A, Column C, Line 3 of the CMS approved institutionalized MAGI Conversion Plan, including any subsequent CMS approved modifications to the MAGI Conversion Plan. No No No No Children Age 19 or 20 Not Covered N/A N/A N/A N/A Childless Adults Not Covered N/A N/A N/A N/A 2 TN -23-0002 Approval Date - 05/23/2023 Effective Date - 07/01/2023

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Part 2 – Population-based Adjustments to the Newly Eligible Population Based on Resource Test, Enrollment Cap or Special Circumstances

A. Optional Resource Criteria Proxy Adjustment (42 CFR 433.206(d))

1. The state:

܆ Applies a resource proxy adjustment to a population group(s) that was subject to a resource test that was applicable on December 1, 2009.

܆ Does NOT apply a resource proxy adjustment (Skip items 2 through 3 and go to Section B).

Table 1 indicates the group or groups for which the state applies a resource proxy adjustment to the expenditures applicable for individuals eligible and enrolled under 42 CFR 435.119. A resource proxy adjustment is only permitted for a population group(s) that was subject to a resource test that was applicable on December 1, 2009. The effective date(s) for application of the resource proxy adjustment is specified and described in Attachment B. 2. Data source used for resource proxy adjustments:

The state:

܆ Applies existing state data from periods before January 1, 2014.

܆ Applies data obtained through a post-eligibility statistically valid sample of individuals.

Data used in resource proxy adjustments is described in Attachment B.

3. Resource Proxy Methodology: Attachment B describes the sampling approach or other methodology used for calculating the adjustment.

B. Enrollment Cap Adjustment (42 CFR 433.206(e))

1. ܆ An enrollment cap adjustment is applied by the state (complete items 2 through 4).

܆ An enrollment cap adjustment is not applied by the state (skip items 2 through 4 and go to Section C).

23-0002 05/23/2023 07/01/2023 - -

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2. Attachment C describes any enrollment caps authorized in section 1115 demonstrations as of December 1, 2009 that are applicable to populations that the state covers in the eligibility group described at 42 CFR 435.119 and received full benefits, benchmark benefits, or benchmark equivalent benefits as determined by CMS. The enrollment cap or caps are as specified in the applicable section 1115 demonstration special terms and conditions as confirmed by CMS, or in alternative authorized cap or caps as confirmed by CMS. Attach CMS correspondence confirming the applicable enrollment cap(s).

3. The state applies a combined enrollment cap adjustment for purposes of claiming FMAP in the adult group:

܆ Yes. The combined enrollment cap adjustment is described in Attachment C ܆ No. 4. Enrollment Cap Methodology: Attachment C describes the methodology for calculating the enrollment cap adjustment, including the use of combined enrollment caps, if applicable.

C. Special Circumstances (42 CFR 433.206(g)) and Other Adjustments to the Adult Group FMAP Methodology

1. The state:

܆ Applies a special circumstances adjustment(s).

܆ Does not apply a special circumstances adjustment.

2. The state:

܆ Applies additional adjustment(s) to the adult group FMAP methodology (complete item 3).

܆ Does not apply any additional adjustment(s) to the adult group FMAP methodology (skip item 3 and go to Part 3).

3. Attachment D describes the special circumstances and other proxy adjustment(s) that are applied, including the population groups to which the adjustments apply and the methodology for calculating the adjustments.

23-0002 05/23/2023 07/01/2023 - -

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Part 3 – One-Time Transitions of Previously Covered Populations into the New Adult Group A. Transitioning Previous Section 1115 and State Plan Populations to the New Adult Group

܆ Individuals previously eligible for Medicaid coverage through a section 1115 demonstration program or a mandatory or optional state plan eligibility category will be transitioned to the new adult group described in 42 CFR 435.119 in accordance with a CMS-approved transition plan and/or a section 1902(e)(14)(A) waiver. For purposes of claiming federal funding at the appropriate FMAP for the populations transitioned to new adult group, the adult group FMAP methodology is applied pursuant to and as described in Attachment E, and where applicable, is subject to any special circumstances or other adjustments described in Attachment D. ܆ The state does not have any relevant populations requiring such transitions.

Part 4 - Applicability of Special FMAP Rates A. Expansion State Designation

The state:

܆ Does NOT meet the definition of expansion state in 42 CFR 433.204(b). (Skip section B and go to Part 5)

܆ Meets the definition of expansion state as defined in 42 CFR 433.204(b), determined in accordance with the CMS letter confirming expansion state status, dated __ . _______________

B. Qualification for Temporary 2.2 Percentage Point Increase in FMAP.

The state:

܆ Does NOT qualify for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7).

܆ Qualifies for temporary 2.2 percentage point increase in FMAP under 42 CFR 433.10(c)(7), determined in accordance with the CMS letter confirming eligibility for the temporary FMAP increase, dated ___ . The state will not claim any federal funding for individuals determined eligible under 42 CFR 435.119 at the FMAP rate described in 42 CFR 433.10(c)(6). __________ 23-0002 05/23/2023 07/01/2023 - - -

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Effective Date –

Part 5 - State Attestations The State attests to the following: A. The application of the adult group FMAP methodology will not affect the timing or approval of any individual’s eligibility for Medicaid.

B. The application of the adult group FMAP methodology will not be biased in such a manner as to inappropriately establish the numbers of, or medical assistance expenditures for, individuals determined to be newly or not newly eligible.

ATTACHMENTS Not all of the attachments indicated below will apply to all states; some attachments may describe methodologies for multiple population groups within the new adult group. Indicate those of the following attachments which are included with this SPA:

܆ ܆ ܆ ܆ ܆ Attachment A – Conversion Plan Standards Referenced in Table 1 Attachment B – Resource Criteria Proxy Methodology Attachment C – Enrollment Cap Methodology Attachment D – Special Circumstances Adjustment and Other Adjustments to the Adult Group FMAP Methodology Attachment E – Transition Methodologies

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 23-0002 05/23/2023 07/01/2023 -

02/10/2011 Population Group Net standard as of 12/1/09 Converted standard for FMAP claiming Same as converted eligibilty standard? (yes, no, or n/a) Source of information in Column C (New SIPP conversion or Part 1 of approved state MAGI conversion plan) Data source for Conversion (SIPP or state data) A B C D E F Conversions for FMAP Claiming Purposes Parents/Caretaker Relatives Dollar standards by family size 1 $563 $590 2 $703 $740 3 $796 $842 4 $885 $941 5 $977 $1,042 6 $1,070 $1,145 7 $1,160 $1,244 8 $1,249 $1,343 9 $1,340 $1,443 10 $1,431 $1,544 11 $1,521 $1,643 12 $1,614 $1,746 13 $1,702 $1,843 14 $1,793 $1,943 15 $1,884 $2,044 16 $1,978 $2,147 17 $2,063 $2,242 18 $2,154 $2,342 19 $2,245 $2,443 20 $2,337 $2,544 21 $2,426 $2,643 22 $2,515 $2,741 23 $2,607 $2,843 24 $2,696 $2,941 25 $2,787 $3,042 add-on N/A N/A Noninstitutionalized Disabled Persons Institutionalized Disabled Persons SSI FBR% Children Age 19-20 Childless Adults n/a: Not applicable. *The contents of this table will be updated automatically in case of modifications to the CMS approved MAGI Conversion Plan n/a n/a n/a n/a n/a ABD conversion template n/a n/a n/a Most Recent Updated Summary Information for Part 2 of Modified Adjusted Gross Income (MAGI) Conversion Plan* SOUTH DAKOTA 1 Part 1 of approved state MAGI conversion plan SIPP 2 3 4 5 yes n/a n/a n/a n/a n/a n/a 300% 300% n/a n/a n/a

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 23-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 1/16 Records / Submission Packages - View All SD - Submission Package - SD2022MS0004O - (SD-23-0003) - Eligibility Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes Review Assessment Report Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Package Information Package ID SD2022MS0004O Program Name N/A SPA ID SD-23-0003 Version Number 4 Submitted By Renae Hericks Package Disposition Priority Code P2 Lead Division DMEP Submission Type Official State SD Region Denver, CO Package Status Approved Submission Date 2/24/2023 Approval Date 5/23/2023 2:45 PM EDT

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 2/16 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date N/A State Information State/Territory Name: South Dakota Medicaid Agency Name: Department of Social Services Submission Component DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services May 23, 2023 Sarah Aker Medicaid Director Department of Social Services 700 Governors Drive Pierre, SD 57501 Re: Approval of State Plan Amendment SD-23-0003 Dear Sarah Aker, On February 24, 2023, the Centers for Medicare & Medicaid Services (CMS) received South Dakota State Plan Amendment (SPA) SD-23-0003, in which the state proposed to to adopt the the eligibility group serving individuals under age 65 with incomes at or below 133% of the federal poverty level (FPL), as described in section 1902(a)(10)(A)(VIII) of the Social Security Act. We approve South Dakota State Plan Amendment (SPA) SD-23-0003 with an effective date(s) of July 01, 2023. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services State Plan Amendment Medicaid CHIP 0 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 3/16 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date N/A SPA ID and Effective Date SPA ID SD-23-0003 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 7/1/2023 SD-20-0001 Pregnant Women 7/1/2023 SD-13-0015 Adult Group 7/1/2023 New Page Number of the Superseded Plan Section or Attachment (If Applicable):

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 4/16 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Implement adult group eligibility and full coverage for pregnant women. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 5/16 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other 0 0 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 6/16 Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: Select the type of website Date of Posting: Jan 9, 2023 Website URL: https://dss.sd.gov/medicaid/medicaidst ateplan.aspx Upload copies of public notices and other documents used Name Date Created Public Notice 2/9/2023 5:02 PM EST Upload with this application a written summary of public comments received (optional) Name Date Created Expansion Public Comment 2/23/2023 4:30 PM EST Indicate the key issues raised during the public comment period (optional) Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Website of the State Medicaid Agency or Responsible Agency Website for State Regulations Other Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue 0 0 0 □ □ □ C □ □ □ □ □ □ □ □ □ □ □ □ I I

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 7/16 Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date N/A One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan. Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 1/9/2023 Email notification 1/24/2023 Tribal Consultation Meeting Date of solicitation/consultation: Method of solicitation/consultation: 1/9/2023 Email notification 1/24/2023 Tribal Consultation Meeting States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 1/9/2023 Email notification 1/24/2023 Tribal Consultation Meeting The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Tribal Consultation Email 2/9/2023 5:14 PM EST Tribal Consultation Meeting Minutes 2/23/2023 4:38 PM EST Tribal Consultation Presentation - Medicaid_Expansion_and_Unwinding 2/23/2023 4:38 PM EST Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, and in accordance with the state consultation plan, prior to submission of this SPA. All Indian Health Programs All Urban Indian Organizations All Indian Tribes 0 0 0 0 I I I

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 8/16 Name Date Created Indicate the key issues raised (optional) Access Quality Cost Payment methodology Eligibility Benefits Service delivery Other issue □ □ □ □ □ □ □ □

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq3… 9/16 Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date 7/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women APPROVED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries APPROVED Qualified Disabled and Working Individuals NEW

[!] [!] [!] [!] [!] [!] [!] [!] C C C C C C C C C C C C □ □ C □ □ □ □ □ □ □ □ □ □ □ 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 10/16 Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Specified Low Income Medicare Beneficiaries APPROVED Qualifying Individuals APPROVED

C C □ □ 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 11/16 Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date 7/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Adult Group APPROVED C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No

0 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 12/16 Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Women who are pregnant or post-partum, with household income at or below a standard established by the state. Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date 7/1/2023 The state covers the mandatory pregnant women group in accordance with the following provisions: A. Characteristics 1. Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. 2. Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 C.F.R. 435.110. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used The state uses the following income standard for this group: FPL 133.00% Yes No 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 13/16 Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date 7/1/2023 D. Benefits for Pregnant Women Benefits for individuals in this eligibility group consist of the following: 1. All pregnant women eligible under this group receive full Medicaid coverage under this state plan. 2. Pregnant women whose income exceeds the income limit specified for full coverage of pregnant women receive only pregnancy-related services. 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 14/16 Pregnant Women MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID SD-13-0015 System-Derived SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date 7/1/2023 E. Basis for Pregnant Women Income Standard 1. Minimum income standard The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. b. The minimum income standard for this eligibility group is 133% FPL. 2. Maximum income standard b. The state's maximum income standard for this eligibility group is: G. Additional Information (optional) Yes No a. The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. i. The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10)(A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. ii. The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10)(A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. iii. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. iv. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. v. 185% FPL 0 0 0 0 0 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 15/16 Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Adult Group MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. Not Started In Progress Complete Package Header Package ID SD2022MS0004O Submission Type Official Approval Date 5/23/2023 Superseded SPA ID New User-Entered SPA ID SD-23-0003 Initial Submission Date 2/24/2023 Effective Date 7/1/2023 The state covers the Adult Group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Have attained age 19 but not age 65 2. Are not pregnant 3. Are not entitled to or enrolled for Part A or B Medicare benefits 4. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance with 42 CFR 435, subpart B. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used The amount of the income standard for this group is 133% FPL. D. Coverage of Dependent Children Parents or caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. 1. Under age 19, or 2. A higher age of children, if any covered under the Reasonable Classifications of Children eligibility group (42 CFR 435.222) on March 23, 2010: 0 0

5/23/23, 1:12 PM Medicaid State Plan Print View https://macpro.cms.gov/suite/tempo/records/item/lUBGxuxnAYNcw8V8rAi1iLjGeHwXRmZtl2LIcjf-vAMo-BtAWpTgO6QfW7sfytGJjTskhdvPqCEg8Oq… 16/16 MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0004O | SD-23-0003 Package Header Package ID SD2022MS0004O Submission Type Official Approval Date N/A Superseded SPA ID N/A SPA ID SD-23-0003 Initial Submission Date N/A Effective Date N/A E. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/23/2023 3:11 PM EDT

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 23-0007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All SD - Submission Package - SD2022MS0006O - (SD-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services May 12, 2023 Sarah Aker Medicaid Director Department of Social Services 700 Governors Drive Pierre, SD 57501 Re: Approval of State Plan Amendment SD-23-0007 Dear Ms. Aker, On March 16, 2023, the Centers for Medicare & Medicaid Services (CMS) received South Dakota State Plan Amendment (SPA) SD-23-0007, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve South Dakota State Plan Amendment (SPA) SD-23-0007 with an effective date of January 01, 2023. If you have any questions regarding this amendment, please contact Mandy Strom at mandy.strom@cms.hhs.gov or (303) 844-7068. Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services CMS Cf US JOR MEDICARE &MEDICAJO SIIMCES

Records / Submission Packages - View All SD - Submission Package - SD2022MS0006O - (SD-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID N/A SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date N/A State Information State/Territory Name: South Dakota Medicaid Agency Name: Department of Social Services Submission Component State Plan Amendment Medicaid CHIP 0 0 0

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID N/A SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date N/A SPA ID and Effective Date SPA ID SD-23-0007 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 SD-20-0001 Former Foster Care Children 1/1/2023 SD-18-0002

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID N/A SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives To expand eligibility for former foster care children who have aged out of foster care in a state other than the state in which they are currently seeking Medicaid coverage. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation 1902(a)(10)(A)(i)(IX) 42 CFR 435.150 Section 1002(a)(2) of the SUPPORT Act (Pub. L. No. 115-271) Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID N/A SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/18/2023 1:30 PM EDT No comment Comments received No response within 45 days Other 0 0 0 0

Records / Submission Packages - View All SD - Submission Package - SD2022MS0006O - (SD-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW

[!] [!] [!] [!] [!] [!] [!] [!] S1I &i!I Iii &i!I ■ &i!I &i!I &i!I □ □ □ □ □ ■ □ □ □ □ □ 0 0 • 0 0 0 0 0 0 0 0 -

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries APPROVED Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries APPROVED Qualifying Individuals APPROVED

■ 621 ii ii ii ■ □ □ □ □ 0 0 0 0 0

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/18/2023 1:09 PM EDT Yes No 0 0

Records / Submission Packages - View All SD - Submission Package - SD2022MS0006O - (SD-23-0007) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 CMS-10434 OMB 0938-1188 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives CONVERTED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW

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Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries APPROVED Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries APPROVED Qualifying Individuals APPROVED

■ 621 ii ii ii ■ □ □ □ □ 0 0 0 0 0

Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2022MS0006O | SD-23-0007 Package Header Package ID SD2022MS0006O Submission Type Official Approval Date 5/12/2023 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0007 Initial Submission Date 3/16/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/18/2023 1:01 PM EDT Yes No 0 0

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 23-0018 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All SD - Submission Package - SD2023MS0004O - (SD-23-0018) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City,, MO 64106 Center for Medicaid & CHIP Services November 30, 2023 Brenda Tidball-Zeltinger Director, Division of Medical Services Department of Social Services 700 Governors Drive Pierre, SD 57505 Re: Approval of State Plan Amendment SD-23-0018 Dear Brenda Tidball-Zeltinger, On September 11, 2023, the Centers for Medicare and Medicaid Services (CMS) received South Dakota State Plan Amendment (SPA) SD-23-0018 to expand Hospital Presumptive Eligibility (HPE) to include the Adult Medicaid Expansion group. We approve South Dakota State Plan Amendment (SPA) SD-23-0018 with an effective date(s) of August 01, 2023. This SPA supersedes HPE SPA 14-0002. CMS has reviewed the HPE application, provider training materials, and the Reviewable Units that were submitted with this SPA. If you have any questions regarding this amendment, please contact Tyler Deines at tyler.deines@cms.hhs.gov or by phone at (202) 571-8533. Sincerely, James G. Scott Director, Division of Program Operations Center for Medicaid & CHIP Services - CMS amns fOR MEDICARE & MEDICAID SIJIVICIS

Records / Submission Packages - View All SD - Submission Package - SD2023MS0004O - (SD-23-0018) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 CMS-10434 OMB 0938-1188 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID N/A SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date N/A State Information State/Territory Name: South Dakota Medicaid Agency Name: Department of Social Services Submission Component State Plan Amendment Medicaid CHIP • • 0 -

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID N/A SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date N/A SPA ID and Effective Date SPA ID SD-23-0018 Reviewable Unit Proposed Effective Date Superseded SPA ID Presumptive Eligibility 8/1/2023 New Presumptive Eligibility by Hospitals 8/1/2023 SD-14-002 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID N/A SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Updates the South Dakota Medicaid State Plan Hospital Presumptive Eligibility application and training materials to include the expanded adult eligibility group. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation 42 CFR 435.1102 and 435.1103 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID N/A SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/11/2023 3:38 PM EST No comment Comments received No response within 45 days Other 0 • • •

Records / Submission Packages - View All SD - Submission Package - SD2023MS0004O - (SD-23-0018) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 CMS-10434 OMB 0938-1188 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID New User-Entered SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 The state provides Medicaid services to individuals during a presumptive eligibility period following a determination by a qualified entity. Presumptive eligibility covered in the state plan includes: Eligibility Groups Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Presumptive Eligibility for Children under Age 19 NEW Parents and Other Caretaker Relatives - Presumptive Eligibility NEW Presumptive Eligibility for Pregnant Women NEW Adult Group - Presumptive Eligibility NEW Individuals above 133% FPL under Age 65 - Presumptive Eligibility NEW Individuals Eligible for Family Planning Services - Presumptive Eligibility NEW Former Foster Care Children - Presumptive Eligibility NEW Individuals Needing Treatment for Breast or Cervical Cancer - Presumptive Eligibility NEW Hospitals Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Presumptive Eligibility by Hospitals APPROVED

□ D □ □ D □ D □ D □ □ □ ■ □ ■ □ ■ D 0 0 0 0 0 0 0 0 0 -

Presumptive Eligibility MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID New User-Entered SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/11/2023 3:39 PM EST

Records / Submission Packages - View All SD - Submission Package - SD2023MS0004O - (SD-23-0018) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Presumptive Eligibility Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 CMS-10434 OMB 0938-1188 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID SD-14-002 System-Derived SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 A. Qualifications of Hospitals A qualified hospital is a hospital that: 1. Participates as a provider under the state plan or a Medicaid 1115 Demonstration, notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. 2. Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. 3. Assists individuals in completing and submitting the full application and understanding any documentation requirements. The state provides an assurance that it has policies and procedures in place to enable qualified hospitals to determine presumptive eligibility under 42 CFR 435.1110, and the state is providing Medicaid coverage for individuals determined presumptively eligible under this provision. The state attests that presumptive eligibility by hospitals is administered in accordance with the following provisions: Yes No □ □ 0 0 -

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID SD-14-002 System-Derived SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 B. Eligibility Groups or Populations Included The eligibility groups or populations for which hospitals determine eligibility presumptively are: 1. Pregnant Women 2. Infants and Children under Age 19 3. Parents and Other Caretaker Relatives 4. Adult Group, if covered by the state 5. Individuals above 133% FPL under Age 65, if covered by the state 6. Individuals Eligible for Family Planning Services, if covered by the state 7. Former Foster Care Children 8. Certain Individuals Needing Treatment for Breast or Cervical Cancer, if covered by the state The state limits qualified hospitals for this group to providers who conduct screenings for breast and cervical cancer under the state’s Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program. Yes No 9. Other Medicaid state plan eligibility groups: 10. Demonstration populations covered under section 1115 • • ■ ■

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID SD-14-002 System-Derived SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 C. Standards for Participating Hospitals The state establishes reasonable standards for qualified hospitals making presumptive eligibility determinations. Percentage of individuals found eligible for Medicaid 90.00% D. Presumptive Eligibility Period 1. The presumptive period begins on the date the determination is made. 2. The end date of the presumptive period is the earlier of: The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. 3. Periods of presumptive eligibility are limited as follows: Yes No The state has a standard requiring that a percentage of individuals who are determined presumptively eligible submit a regular application, as described at 42 CFR 435.907, before the end of the presumptive eligibility period. The state has a standard requiring that a percentage of individuals who are determined presumptively eligible be determined eligible for Medicaid based on the submission of an application before the end of the presumptive eligibility period. The state has elected one or more other reasonable standard(s). a. No more than one period within a calendar year. b. No more than one period within two calendar years. c. No more than one period within a six-month period, starting with the effective date of the initial presumptive eligibility period. d. No more than one period within a twelve-month period, starting with the effective date of the initial presumptive eligibility period. e. Other reasonable limitation: 0 0 □ □ □ 0 0 0 0

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID SD-14-002 System-Derived SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 E. Application for Presumptive Eligibility Name Date Created SD PE App 11-01-2023 11/17/2023 9:11 AM EST 5. Describe the presumptive eligibility screening process: The Hospital Presumptive Eligibility Program allows qualified hospitals to screen individuals for temporary medical assistance coverage while their full Medicaid application is processed. Hospitals must submit an application to become a qualified hospital. Qualified hospitals are required to verify if an applicant is currently enrolled in Medicaid before providing services to the applicant. Applicants enrolled in Medicaid should not complete an application or have a presumptive eligibility screening. Babies born to mothers enrolled in Medicaid are eligible for the Automatic Newborn Medicaid program and do not require a presumptive eligibility determination. Individuals may have one (1) presumptive eligibility period every two (2) calendar years or for pregnant women, once per pregnancy. If an applicant has a presumptive eligibility period within the previous two (2) calendar years, the applicant should be informed on how to complete a full Medicaid application. Qualified hospitals will use the Hospital Presumptive Eligibility Application for individuals eligible for screening. Qualified hospitals must gather enough information to complete the Presumptive Eligibility Worksheet in Appendix 1 of the Presumptive Eligibility Training Guide. Either the Notice of Eligibility from Appendix 3 or the Notice of Denial from Appendix 4 must be sent to the applicant based on whether they meet all of the general eligibility criteria, including the income criteria for a coverage group in Appendix 2. Qualified hospitals must notify the Division of Economic Assistance of presumptive eligibility determination approvals by submitting the following items no later than two (2) working days following the determination: 1) Presumptive Eligibility Medicaid Application; 2) Presumptive Eligibility Worksheet; and 3) Notice to Applicant. Applicants denied coverage through the presumptive eligibility process have the option to have their application sent to the Department of Social Services for a Medicaid determination. This application, along with the notice to the applicant, must be forwarded to the Department of Social Services, Division of Economic Assistance within two (2) working days. The eligibility period for individuals found eligible through the presumptive eligibility process ends on either the date the eligibility determination is made by the Department of Social Services, if a complete application is filed by the last day of the month following the month in which the presumptive eligibility determine was made, or the last day of the month following the month in which the presumptive eligibility determination was made. F. Presumptive Eligibility Determination The presumptive eligibility determination is based on the following factors: 1. The individual’s categorical or non-financial eligibility for the group for which the individual’s presumptive eligibility is being determined (e.g., based on age, pregnancy status, status as a parent/caretaker relative, disability, or other requirements specified in the Medicaid state plan or a Medicaid 1115 demonstration for that group) 2. Household income must not exceed the applicable income standard for the group for which the individual's presumptive eligibility is being determined, if an income standard is applicable for this group. 1. The state uses a standardized screening process for determining presumptive eligibility. 2. The state uses the single streamlined paper and/or online application form for Medicaid and Presumptive Eligibility, approved by CMS. A copy of the single streamlined paper and/or online application with questions necessary for a PE determination highlighted or denoted is included. a. Paper - A copy of the application form is included. b. Online - A copy of the application form is included. 3. The state uses a separate paper application form for presumptive eligibility, approved by CMS. A copy of the application form is included. 4. The state uses an online portal or electronic screening tool for presumptive eligibility approved by CMS. Screenshots of the tool included. a. A reasonable estimate of MAGI-based income is used to determine household income. b. Gross income is used to determine household size. c. Other income methodology 3. State residency 4. Citizenship, status as a national, or satisfactory immigration status □ □ □ □ 0 0 0 □ □ □ □ I

Presumptive Eligibility by Hospitals MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0004O | SD-23-0018 Package Header Package ID SD2023MS0004O Submission Type Official Approval Date 11/30/2023 Superseded SPA ID SD-14-002 System-Derived SPA ID SD-23-0018 Initial Submission Date 9/11/2023 Effective Date 8/1/2023 G. Qualified Entity Requirements 2. A copy of the training materials has been uploaded for review during the submission process. Name Date Created SD HPE Guide 10.31.23 11/3/2023 3:42 PM EDT H. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 12/11/2023 3:41 PM EST 1. The state assures that it has communicated the requirements for qualified hospitals, and has provided adequate training to the hospitals. □ I

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 23-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All SD - Submission Package - SD2020MS0004O - (SD-23-0021) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services February 26, 2024 Heather Petermann Medicaid Director Department of Social Services 700 Governors Drive Pierre, SD 57501 Re: Approval of State Plan Amendment SD-23-0021 Dear Director Petermann, On December 01, 2023, the Centers for Medicare and Medicaid Services (CMS) received South Dakota State Plan Amendment (SPA) SD-23-0021, in which the state proposed to expand eligibility to individuals under age 21 who are under a state-only funded adoption assistance agreement, and to confirm the scope of coverage under the state plan for certain reasonable classifications of children. We approve South Dakota State Plan Amendment (SPA) SD-23-0021 with an effective date(s) of November 01, 2023. If you have any questions regarding this amendment, please contact Tyler Deines at tyler.deines@cms.hhs.gov Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services - CMS amns fOR MEDICARE & MEDICAID SIJIVICIS

Records / Submission Packages - View All SD - Submission Package - SD2020MS0004O - (SD-23-0021) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 CMS-10434 OMB 0938-1188 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date N/A State Information State/Territory Name: South Dakota Medicaid Agency Name: Department of Social Services Submission Component State Plan Amendment Medicaid CHIP • • 0 -

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date N/A SPA ID and Effective Date SPA ID SD-23-0021 Reviewable Unit Proposed Effective Date Superseded SPA ID Optional Eligibility Groups 11/1/2023 SD-20-0001 Children with Non-IV-E Adoption Assistance 11/1/2023 SD-13-0015 Individuals above 133% FPL under Age 65 11/1/2023 SD-13-0015 Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The SPA clarifies the pages to ensure it is clear that children with non-IV-E adoption assistance under age 21 are eligible for Medicaid coverage. In addition, the SPA clarifies to ensure that it is clear that reasonable classifications of children under age 21 with an income above 133% of the federal poverty level are eligible for Medicaid coverage. The SPA reflects historical interpretation and no individuals will gain or lose Medicaid coverage due to this clarification. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $0 Second 2025 $0 Federal Statute / Regulation Citation 42 CFR 435.218 and 42 CFR 435.227 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/27/2024 11:21 AM EST No comment Comments received No response within 45 days Other 0 • • •

Records / Submission Packages - View All SD - Submission Package - SD2020MS0004O - (SD-23-0021) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 CMS-10434 OMB 0938-1188 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 A. Options for Coverage The state provides Medicaid to specified optional groups of individuals. The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper- based state plan to MACPro): Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Optional Coverage of Parents and Other Caretaker Relatives NEW Reasonable Classifications of Individuals under Age 21 CONVERTED Children with Non-IV-E Adoption Assistance APPROVED Independent Foster Care Adolescents CONVERTED Optional Targeted Low Income Children CONVERTED Individuals above 133% FPL under Age 65 APPROVED Individuals Needing Treatment for Breast or Cervical Cancer NEW Individuals Eligible for Family Planning Services NEW Individuals with Tuberculosis NEW Individuals Electing COBRA Continuation Coverage NEW Aged, Blind and Disabled Yes No

- 0 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ ■ 0

Eligibility Group Name Covered In State Plan Include RU In Package  Included in Another Submission Package Source Type  Individuals Eligible for but Not Receiving Cash Assistance NEW Individuals Eligible for Cash Except for Institutionalization APPROVED Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules APPROVED Optional State Supplement Beneficiaries NEW Individuals in Institutions Eligible under a Special Income Level NEW PACE Participants NEW Individuals Receiving Hospice NEW Children under Age 19 with a Disability APPROVED Age and Disability- Related Poverty Level NEW Work Incentives APPROVED Ticket to Work Basic NEW Ticket to Work Medical Improvements NEW Family Opportunity Act Children with a Disability NEW Individuals Receiving State Plan Home and Community-Based Services NEW Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers NEW

[!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ ■ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 [!] □ □ 0 □ □ 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 B. Medically Needy Options for Coverage The state provides Medicaid to specified groups of individuals who are medically needy. Yes No • 0

Optional Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-20-0001 System-Derived SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/27/2024 11:22 AM EST

Records / Submission Packages - View All SD - Submission Package - SD2020MS0004O - (SD-23-0021) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Children with special needs for medical or rehabilitative care for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid immediately before the adoption agreement was executed, or who had income at that point in time at or below a standard established by the state . CMS-10434 OMB 0938-1188 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-13-0015 User-Entered SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 The state covers the children with non IV-E adoption assistance group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 21 or a lower age, as specified in C. 2. Have a state adoption assistance agreement in effect between the adoptive parent(s) and a state. 3. The state adoption agency has determined that they cannot be placed for adoption without Medicaid coverage because of special needs for medical or rehabilitative care. 4. Immediately prior to execution of the adoption agreement, were eligible under the Medicaid state plan of the state with the adoption assistance agreement or, at the state's option, immediately prior to execution of the adoption agreement had income no more than the income standard (which could be no income test) specified in Section D. 5. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan. B. Financial Methodologies When income is considered, MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. -

Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-13-0015 User-Entered SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 C. Individuals Covered 1. The state covers all children under a specified age limit for whom there is an adoption assistance agreement in place from any state. a. The age of children covered under this eligibility group is. b. In addition, the state covers reasonable classifications of children. Yes No i. Under age 21 ii. Under age 20 iii. Under age 19 iv. Under age 18 Yes No • • • • • • • •

Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-13-0015 User-Entered SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 D. Income Standard Used 1. The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. 2. The state does not use an income standard or disregard all income for this group. Yes No• •

Children with Non IV-E Adoption Assistance MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-13-0015 User-Entered SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 F. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/27/2024 11:23 AM EST

Records / Submission Packages - View All SD - Submission Package - SD2020MS0004O - (SD-23-0021) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility Groups - Options for Coverage Individuals above 133% FPL under Age 65 MEDICAID | Medicaid State Plan | Eligibility | SD2020MS0004O | SD-23-0021 Individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state. CMS-10434 OMB 0938-1188 Package Header Package ID SD2020MS0004O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID SD-13-0015 User-Entered SPA ID SD-23-0021 Initial Submission Date 12/1/2023 Effective Date 11/1/2023 The state covers the optional individuals above 133% FPL group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 65 2. Are not otherwise eligible for and enrolled in mandatory coverage under the state plan 3. Are not otherwise eligible for and enrolled in optional full Medicaid coverage under the state plan 4. Have household income that exceeds 133% FPL but is at or below the standard set by the state B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. -

C. Individuals Covered 1. The state covers all individuals who meet the characteristics described in section A. 2. The state covers the following populations: Name of population Description Adoption Individuals under age 19 in adoptions subsidized in part or in full by a public agency. DOC All children under age 19 that are under the jurisdiction of the South Dakota Department of Corrections who are not inmates of a public institution under the provisions of 42 CFR 435.1008. DSS Custody All children under age 19 in the custody of the South Dakota Department of Social Services. DSS Financial Responsibility All children under age 19 that are in foster care and for whom the South Dakota Department of Social Services is assuming full or partial financial responsibility. HSC Drug and Alcohol Dependency Adjudicated children under age 19 that are under the guardianship of the South Dakota Human Services Center who are receiving inpatient treatment for drug and alcohol dependency. HSC Inpatient Psychiatric Adjudicated children under age 19 under the guardianship of the South Dakota Human Services Center who are receiving inpatient psychiatric treatment. Yes No a. All children under a specified age limit: b. Reasonable classifications of children c. Parents and other caretaker relatives as defined in the Parents and Other Caretaker Relatives eligibility group, except for with respect to income d. Pregnant women e. Other 0 • □ □ □ □ □

D. Income Standard Used 1. The state uses the same income standard for all individuals covered. 2. The income standard for this eligibility group is: Yes No a. Percentage of the federal poverty level. b. No income test (the income standard is infinite). 0 • • 0

E. Coverage of Dependent Children Parents or caretaker relatives living with a child under the age specified below are not covered unless the child is receiving benefits under Medicaid, CHIP or through the Exchange or otherwise enrolled in minimum essential coverage, as defined in 42 CFR 435.4. 1. Under age 19, or 2. A higher age of children, if any covered under the Reasonable Classifications of Children eligibility group (42 CFR 435.222) on March 23, 2010: 0 •

F. Phase-In The state elects to phase-in coverage to individuals in this group. Yes No • 0

G. Additional Information (optional)

PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/27/2024 11:25 AM EST

Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 23-0023 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

Records / Submission Packages - View All SD - Submission Package - SD2023MS0005O - (SD-23-0023) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St., Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services February 26, 2024 Heather Petermann Director, Division of Medical Services Department of Social Services 700 Governors Drive Pierre, SD 57505 Re: Approval of State Plan Amendment SD-23-0023 Dear Director Petermann, On February 01, 2024, the Centers for Medicare and Medicaid Services (CMS) received South Dakota State Plan Amendment (SPA) SD-23-0023 to provide twelve months of continuous eligibility for children. We approve South Dakota State Plan Amendment (SPA) SD-23-0023 with an effective date of January 01, 2024. If you have any questions regarding this amendment, please contact Tyler Deines at tyler.deines@cms.hhs.gov or by phone at (202) 571-8533. Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services - CMS amns fOR MEDICARE & MEDICAID SIJIVICIS

Records / Submission Packages - View All SD - Submission Package - SD2023MS0005O - (SD-23-0023) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0005O | SD-23-0023 CMS-10434 OMB 0938-1188 Package Header Package ID SD2023MS0005O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0023 Initial Submission Date 2/1/2024 Effective Date N/A State Information State/Territory Name: South Dakota Medicaid Agency Name: Department of Social Services Submission Component State Plan Amendment Medicaid CHIP • • 0 -

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0005O | SD-23-0023 Package Header Package ID SD2023MS0005O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0023 Initial Submission Date 2/1/2024 Effective Date N/A SPA ID and Effective Date SPA ID SD-23-0023 Reviewable Unit Proposed Effective Date Superseded SPA ID Continuous Eligibility for Children 1/1/2024 N/A Page Number of the Superseded Plan Section or Attachment (If Applicable):

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0005O | SD-23-0023 Package Header Package ID SD2023MS0005O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0023 Initial Submission Date 2/1/2024 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives Provides 12 months of continuous eligibility (CE) for children under the age of 19. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $1133882 Second 2025 $1511843 Federal Statute / Regulation Citation 1902(e)(12) and 2107(e)(1)(K) of the Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available

Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0005O | SD-23-0023 Package Header Package ID SD2023MS0005O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A SPA ID SD-23-0023 Initial Submission Date 2/1/2024 Effective Date N/A Governor's Office Review PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/27/2024 11:32 AM EST No comment Comments received No response within 45 days Other 0 • • •

Records / Submission Packages - View All SD - Submission Package - SD2023MS0005O - (SD-23-0023) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children MEDICAID | Medicaid State Plan | Eligibility | SD2023MS0005O | SD-23-0023 CMS-10434 OMB 0938-1188 Package Header Package ID SD2023MS0005O Submission Type Official Approval Date 02/26/2024 Superseded SPA ID N/A User-Entered SPA ID SD-23-0023 Initial Submission Date 2/1/2024 Effective Date 1/1/2024 The state provides continuous eligibility for children in accordance with the following provisions: A. Mandatory Continuous Eligibility for Hospitalized Children The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Options for Continuous Eligibility for Children The state provides continuous eligibility to children. 1. Continuous eligibility is provided to all children of the following age: 2. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child's age exceeds the age limit to which this provision applies b. The end of the continuous eligibility period, which is: 3. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application Yes No a. Under age 19 b. Under other age i. 12 months ii. Another period of continuous eligibility, not to exceed 12 months 0 0 0 0 0 0 -

and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 2/27/2024 11:33 AM EST

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group October 1, 2024 Heather Petermann Medicaid Director South Dakota Department of Social Services 700 Governors Drive Pierre, South Dakota 57501-2291 Re: South Dakota State Plan Amendment (SPA) 24-0012-A Dear Director Petermann: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0012-A. This amendment eliminates cost sharing for medical services. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and the implementing regulations 42 CFR 447.50 through 447.57 (excluding 447.55). This letter is to inform you that South Dakota Medicaid SPA 24-0012-A was approved on October 17, 2024, with an effective date of July 1, 2024. With the approval and implementation of SPA 24-0012-A, the issue raised in companion letter to SPA 22-0014 dated April 25, 2023, is resolved. A system to track cost sharing payments prior to reaching the household aggregate cap is no longer necessary with the elimination of cost sharing for medical assistance. If you have any questions, please contact Tyler Deines at 202-571-8533 or via email at tyler.deines@cms.hhs.gov. Sincerely, James G. Scott, Director Division of Program Operations cc: Matthew Ballard, South Dakota Medicaid CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Medicaid Premiums and Cost Sharing: Summary Page (CMS 179) Statei'Territory name: South Dakota Transmittal Number: Enler the Transmittal Number (TN), including dashes, in the format SS-YY-NNN Nor SS-YY-NNN N-xxxx (with = being optional to .fpedjic SPA types), where SS = 2-character staJe abbreviaJion, YY = last 2 digits of .fubmifsion year, NNNN = 4-digit number with leading zeros, and xxxx = OPTIONAL, 1- to 4-character alpha/numeric suffix. SD-24-0012-A Proposed Effective Date 07/01/2024 (mm/ dd/yyyy) Federal Statute/Regulation Cit'.ltion Section 1916 and 1916Aoft:he Social Security Act and 42 CFR447.50-.57 Federal Budget lmpact Federal Fiscal Year First Year 2024 Second Year 2025 Subject of Amendment Elimination of cost sharing from medical services. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: $ 258857.00 $ 1035427. 00 Signature of State Agency Official Submitted By: Last Revision Date: Matthew Ballard Sep 27, 2024 Submit Date: Aug 6, 2024 Amount /, /, /,

 

       

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Table of Contents State/Territory Name: South Dakota State Plan Amendment (SPA) #: 24-0014 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS Form 179 3) Approved SPA Pages

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106 Medicaid and CHIP Operations Group October 23, 2024 Heather Petermann Medicaid Director South Dakota Department of Social Services 700 Governors Drive Pierre, South Dakota 57501-2291 Re: South Dakota State Plan Amendment (SPA) 24-0014 Dear Director Petermann: The Centers for Medicare & Medicaid Services (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (TN) 24-0014. This amendment proposes an inflationary rate increase and various coverage and service updates. We conducted our review of your submittal according to statutory requirements in Title XIX of the Social Security Act and the implementing regulations. This letter is to inform you that South Dakota Medicaid SPA 24-0014 was approved on October 23, 2024, with an effective date of July 1, 2024. If you have any questions, please contact Tyler Deines at 202-571-8533 or via email at tyler.deines@cms.hhs.gov . Sincerely, James G. Scott, Director Division of Program Operations Enclosures cc: Matthew Ballard, South Dakota Medicaid CENTERS FOR MEDICARE & ME0ICAI0 SERVICES CENTER FOR MEDICAID & CHIP SERVICES

DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 1. TRANSMITTAL NUMBER 2. STATE 2 4 - 0 0 1 4 SD ---- -------- -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT (e) XIX 0 XXI 4. PROPOSED EFFECTIVE DATE July 1, 2024 FORM APPROVED 0MB No. 0938--0193 5. FEDERAL STATUTE/REGULATION CITATION 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a FFY 2024 $ 3,428,325 4a GJ;:R Sl:lesha1:1leF G PaFl 44Q 447 See Attached b. FFY 2025 $ 1317131302 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Page 4a of Attachment 2.6-A OR ATTACHMENT (If Applicable) Page 1 of Supplement 12 to Attachment 2.6-A Page 4a (TN# 04-4) of Attachment 2.6-A Page 1 (TN# 04-4) of Supplement 12 to Attachment 2.6-A Pages 8, 13, and 43 of Supplement to Attachment 3.1-A Pages 8 !+!I# 91 l§j, ia !+!I# l9 Qlj, aM 43 fHI# 21 OOH) ef s .. ~~leA!eRIIB AltaehA!eRI a.l A Pages 1, 3, 5, 7, 8, 8a, 9, 10a, and 10b of Attachment4.19-A Pages 1(TN# 23-0016), 3 (TN# 12-3), 5, 7, 8 (TN# 23-0016), Sa (TN# 11-6), 9 (TN# 11-3), 1 0a, and 10b (TN# 23-0016) of Attachment 4.19-A Introduction Page 1, 1a, 1b, 6, 13, and 22 of Attachment 4.19-B Pages 1-3 of Supplement 1 to Attachment 4 .19-B IRlfeSue!ieR Pagel !+!I# 24 QQHJ, la fHI# 2a 0016), lb f+l'I# l9 Q4J, 6 fill# l9 12), la fFl'I# l9 Qlj, aRS 22 !+!I# ll 4jefAltaehA!eRI U9 B Page 7, 9, and 10 of Attachment 4.19-0 Pages 1-3 (TN# 91-17)of Supplement 1 to Attachment 4.19-B See Attached Page 7, 9, and 10 (TN# 23-0012) of Attachment 4.19-D 9. SUBJECT OF AMENDMENT Implements the intlationary rate increases appmpriated by the state legislah.ire dYring the 2024 legislative session etfecti1,1e Jyly 1, See Attached 10. GOVERNOR'S REVIEW (Check One) ® GOVERNOR'S OFFICE REPORTED NO COMMENT O OTHER, AS SPECIFIED: 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUB MITT AL 11. SIGNATURE OF STATE AGENC'r OFFICIAL 15. RETURN TO DEPARTMENT OF SOCIAL SERVICES - 1-2-. -TY- P-ED_ N_A_M_E _________________ DIVISION OF MEDICAL SERVICES Heather Petermann 700 GOVERNORTS DRIVE 13. TITLE PIERRE, SD 57501-2291 Director 14. DATE SUBMITTED August5, 2024 16. DATE RECEIVED Au 1st 5 2024 FOR CMS USE ONLY 17. DATE APPROVED PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL I July 1, 2024 October 23 2024 20. TYPED NAME OF APPROVING OFFICIAL James G. Scott 21. TITLE OF APPROVING OFFICIAL Director Division of Pro 22. REMARKS Boxes 5, 8, 9 and 15: Pen and ink changes approved by the state on 10/22/2024 FORM CMS-179 (09/24) Instructions on Back erations

Revision: CMS-PM-02-1 MAY2002 ATTACHMENT 2.6-A Page 4a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA Citation(s) Section 1924 of the Act 42 CFR 435. 725 42 CFR 435.733 42 CFR 435.832 TN No. 24-0014 Supersedes TN No. 04-4 ELIGIBILITY CONDITIONS AND REQUIREMENTS Condition or Requirement (B) Post-eligibility Treatment of Institutionalized Individuals' Incomes (continued) 2. The following monthly amounts for personal needs are deducted from total monthly income in the application of an institutionalized individual's or couple's income to the cost of institutionalized care: Personal Needs Allowance (PNA) of not less than $30 for individuals and $60 for couples for all institutionalized persons. a. Aged, blind, disabled: Individuals $ 100.00 Couples $200.00 For the following persons with greater need: SUPPLEMENT 12 TO ATTACHMENT 2.6-A describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met and, where appropriate, identifies the organization unit which determines that a criterion is met. b. AFDC related: Children $ 60.00 Adults $ 60.00 For the following persons with greater need: SUPPLEMENT 12 TO ATTACHMENT 2.6-A describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met and, where appropriate, identifies the organization unit which determines that a criterion is met. c. Individual under age 21 covered in the plan as specified in Item B.7 of ATTACHMENT 2.2-A: $60.00 Approval Date 10/23/24 Effective Date 7/01 /24

Revision: CMS-02-1 SUPPLEMENT 12 to ATTACHMENT 2.6-A MAY 2002 Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE In addition to the personal needs allowance of $100 (individual) / $200 (couples), the personal needs allowance will include the following: For institutionalized individuals with earned income, the personal needs allowance will also be the gross earnings up to $75.00. For individuals paying court ordered child or spousal support, the personal needs allowance will also be the amount actually paid out for the support payment, up to the court ordered amount. For individuals with a trust, the personal needs allowance will also be the amount paid for attorney, guardian or conservator fees to maintain the trust up to the amount specified by the courts; or, if the court does not specify an amount, up to an amount considered reasonable by the State Medicaid agency. Disclosure Statement for Post-Eligibility Preprint According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is #0938-0673. The time required to complete this information collection is estimated at 3 hours per response, including the time to review instructions, searching existing data resources, gathering the data needed and completing and reviewing the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, MD, 21244-1850 and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC, 20503. Approval Date 10/23/24 Effective Date 7/01/24 TN # 24-0014 Supersedes TN # 04-4

SUPPLEMENT TO ATTACHMENT 3.1-A 6a. Podiatrist Services Covered services are limited to surgical and nonsurgical podiatry services within the licensed podiatrist's scope of practice under state law. Podiatrists' services must be determined medically necessary by the state. Routine foot care, including cutting or removal of corns or calluses, trimming of nails and preventative or hygienic care of the feet, is covered for recipients diagnosed with metabolic, neurologic, or peripheral vascular disease. Services not covered include stock orthopedic shoes unless they are part of a leg brace, treatment of flatfoot, treatment of fungal infection of the toenail, and surgical or non-surgical treatment of subluxations of the foot undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity. TN# 24-0014 Supersedes TN# 91-15 Approval Date 10/23/24 Effective Date 7/01/24 Page 8

Page 13 SUPPLEMENTTOATTACHMENT3.1-A 7C. Medical supplies, equipment, and appliances suitable for use in any setting in which normal life activities take place are provided in accordance with federal regulations at 42 CFR 440.70(b)(3) based on medical necessity. Rental equipment is no longer covered when any of the following conditions exist: 1. The prescription for the equipment is not valid; 2. The equipment has been returned to the provider; or 3. The recipient is no longer using the equipment. Supplies necessary for the effective use or proper functioning of covered medical equipment are covered when: 1. The equipment is covered by Medicaid; 2. The recipient's condition meets the coverage criteria for equipment; and 3. The equipment is owned by the recipient. Supplies for rented durable medical equipment are included in the Medicaid rental payment, unless specifically listed on the department's billing guidance website. Replacement of medical equipment is allowed only when a medical condition exists which necessitates the replacement of the particular piece of equipment. The prescribing physician must determine whether a medical necessity exists and must document the need on the prescription for the replacement equipment. Non-covered items may be requested by the recipient's physician. Requests for non-covered items must demonstrate medical necessity and be prior authorized by the department. TN #24-0014 Supersedes TN# 19-01 Approval Date 10/23/24 Effective Date 07/01/24

Page 43 SUPPLEMENTTOATTACHMENT3.1-A 24. Any Other Medical Care and Any Other Type of Remedial Care Recognized Under State Law. Specified by the Secretary a. Transportation. Ground and air ambulance services are covered if other methods of transportation are contraindicated by the recipient's condition. Secure medical transportation to or from a covered medically necessary service is covered for recipients who are confined to a wheelchair or stretcher. Community transportation to or from a covered medically necessary service is covered. Purchase of tickets from commercial carriers (airlines, bus, etc.) to or from a covered medically necessary appointment outside the recipient's city of residence is covered. Mileage incurred by the recipient or a volunteer driver to or from a covered medically necessary service outside the recipient's city of residence is covered. Meals and Lodging incurred as a result of travel of at least 150 miles or more one way from the recipient's city of residence to receive covered specialty care or treatments and that results in an overnight stay is covered for the recipient and if necessary one escort or volunteer driver. Transportation must be to the closest medical facility or medical provider capable of providing the necessary services, unless the recipient has a written referral or a written authorization from the recipient's medical provider to seek treatment at a different facility or from a different provider. b. Services provided in religious non-medical home health care institutions. Not provided. c. Reserved. d. Nursing facility services for patients under 21 years of age. No limitations. e. Emergency hospital services. No limitations. TN #24-0014 Supersedes TN# 21-0013 Approval Date 10/23/24 Effective Date 07/01/24

Attachment 4.19-A Page 1 INPATIENT HOSPITAL PAYMENT METHODOLOGY GENERAL The South Dakota Medicaid program has reimbursed hospitals for inpatient services under a prospective Diagnosis Related Groups (DRGs) methodology, with a few exceptions, since January 1, 1985. The State uses the federal definitions of DRGs, classifications, weights, geometric mean lengths of stay, and outlier cutoffs. The DRG Grouper is updated annually effective January 1 each year each year. The agency provides a link to Medicare’s DRGs on its website at http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx. The agency calculates Medicaid-specific weight and geometric mean length of stay factors annually using the latest three years of non-outlier claim data, this three-year claims database updated annually to establish new weight and geometric length of stay factors with each new grouper. The agency developed hospital-specific costs per Medicaid discharge amounts for all instate hospitals using Medicare cost reports and non-outlier claims data for the hospitals’ fiscal years ending after June 30, 1996 and before July 1, 1997. The agency applied an inflation factor, specific to each hospital’s fiscal year end, to the cost per discharge amounts of all hospitals with more than thirty (30) Medicaid discharges during the base year to establish target amounts for the most recently completed federal fiscal year. There is a cap on the hospitals’ target amounts, under which no hospital is allowed a target amount that exceeds 110% of the statewide weighted average of all target amounts. South Dakota Medicaid reimburses out-of-state hospitals at 44.15% of the provider’s usual and customary charges unless otherwise approved by the State. The State may reimburse out-of- state hospitals on the same basis as the Medicaid agency where the hospital is located if the hospital’s home state Medicaid agency agrees to calculate the claim payment. Payment is for individual discharge or transfer claims only. Out of state specialty hospitals are reimbursed at 44.15% of billed charges unless otherwise approved by the state. There is no annual cost settlement with out-of-state hospitals or instate DRG hospitals unless an amount is due the South Dakota Medicaid program. For claims with dates of service beginning July 1, 2024, instate DRG hospitals’ target and capital/ education amounts are increased by 4.0 percent. OPPS hospitals that did not receive an inflationary increase to their OPPS conversion factor are receiving DRG target and capital/education increase of 4.0 percent plus an additional hospital specific DRG target and capital/education increase. The hospital specific DRG rate increase was calculated to provide the hospital the equivalent of the additional annual reimbursement amount the hospital would have received if their OPPS conversion factor was increased by 4.0 percent. SPECIFIC DESCRIPTION Each year the agency calculates a hospital’s target amounts for non-outlier claims by dividing the hospital's average cost per discharge for non-outlier claims by the hospital's case mix index. To ensure budget neutrality, the agency adjusts annually a hospital’s target amount for any change in that hospital’s case mix index resulting from the establishment of new program specific weight factors. For each hospital, the case mix index is the calculated result of accumulating the weight factors for all claims submitted during the base period and dividing by the number of claims. Approval Date 10/23/24 TN # 24-0014 Supersedes TN# 23-0016 Effective Date 07/01/24

Attachment 4.19-A Page 3 SERVICES COVERED BY DIAGNOSTIC RELATED GROUP PAYMENTS The State agency has adopted Medicare's definition of inpatient hospital services covered by DRG payment. Providers must submit claims for reimbursement for physician services on a separate CMS 1500 form. OUTLIER PAYMENTS The State agency will calculate additional payments to hospitals for discharges which meet the criteria of an "outlier," a case with extremely high charges which exceed cost outlier thresholds set by the agency. To qualify for a cost outlier payment, 70% of the claim's total billed charges must exceed the larger of the cost outlier amount published on the agency's website at http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx or 1.5 times the DRG payment for the claim. The additional payment allowed for a cost outlier will be 90% of the difference between 70% of billed charges and the larger of the published outlier amount or 1.5 times the DRG payment. The total payment allowed for an outlier claim will be the DRG payment plus the outlier payment plus the daily capital/education amount for each day of the hospital stay. SURGICALLY-IMPLANTED DEVICES AND APPLIANCES The Medicaid program will reimburse claims submitted for inpatient hospital services by in- state acute care hospitals that had more than 30 Medicaid discharges during the hospitals' fiscal year ending after June 30, 1996, and before July 1, 1997, that are considered to be cost outlier claims as defined by ARSD 67:16:03:01 (3) and contain revenue codes 275 or 278 according to the following guidelines: 1. The State agency will limit reimbursements for aggregate charges in excess of $50,000 associated with revenue codes 275 or 278 to the providers' actual costs plus 10%; and 2. The agency will remove the aggregate charges for revenue codes 275 or 278 in excess of $50,000 from the calculation of the claim and charges associated with the remainder of the claim will be reimbursed according to ARSD 67: 16:03:06. For use by the agency in the reimbursement calculations, the provider must submit to the agency as documentation copies of the suppliers' invoices for items associated with revenue codes 275 and 278. TN# 24-0014 Supersedes TN# 12-3 Approval Date 10/23/24 Effective Date 7/01/24

TN # 24-0014 Supersedes TN# 23-0016 Approval Date 10/23/24 Effective Date 07/01/24 Attachment 4.19-A Page 5 5. Rehabilitation Units (only upon request and justification); 6. Children’s Care Hospitals; 7. Indian Health Service Hospitals; 8. Hospitals with less than 30 Medicaid discharges during the hospital’s fiscal year ending after June 30, 1993, and before July 1, 1994; 9. Specialized Surgical Hospitals; 10. Long-Term Acute Care Hospital. Payment for rehabilitation hospitals and units, perinatal units, and children’s care hospitals will continue on the Medicare retrospective cost base system with the following exceptions: 1. Costs associated with certified registered nurse anesthetist services that relate to exempt hospitals and units will be included as allowable costs. 2. Malpractice insurance premiums attributable to exempt units or hospitals will be allowed using 7.5% of the risk portion of the premium multiplied by the ratio of inpatient charges to total Medicaid inpatient charges for these hospitals or units. The agency provides a link to Medicare’s DRGs on its website at http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx Payment for psychiatric hospitals, psychiatric units, rehabilitation hospitals, rehabilitation units, perinatal units, long-term acute care hospitals and children’s care hospitals is on a per diem basis based on the facility’s reported, allowable costs, as established by the State. This per diem amount is updated annually as directed by the Legislature based on review of economic indices and input from interested parties not to exceed the rate as established by the medical care component of the Consumer Price Index of the most recent calendar year. The per diem for state operated psychiatric hospitals is updated annually based on facility’s reported allowable costs, as established by the state. Specialized surgical hospitals payments for payable procedures will be 66 percent of usual and customary charges for ancillary services and 60 percent of usual and customary charges for room and board. Payable procedures include, but are not limited to: nursing, technician, and related services; patient’s use of facilities; drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the surgical procedures; diagnostic or therapeutic services or items directly related to the surgical procedures; administrative and recordkeeping services; housekeeping items and supplies; and materials for anesthesia. Items not reimbursable include those payable under other provisions of State Plan, such as physician services, laboratory services, X-ray and diagnostic procedures, prosthetic devices, ambulance services, orthotic devices, and durable medical equipment for use in the patient’s home, except for those payable as directly related to the surgical procedures. Payments to Indian Health Service inpatient hospitals will be per diem and based upon the approved rates published each year in the Federal Register by the Department of Health and Human Services, Indian Health Service, under the authority of sections 321(a) and 322(b) of the Public Health Service Act (42 U.S.C. 248 and 249(b)), Public Law 83-568 (42 U.S.C. 2001(a)), and the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.). Instate hospitals with less than 30 discharges during the hospital’s fiscal year ending after June 30, 1993, and before July 1, 1994, are paid 95% of billed charges. For claims with dates of service on and after July 1, 2024, the amount of reimbursement for psychiatric hospitals, rehabilitation hospitals, perinatal units, psychiatric units, rehabilitation units, children’s care hospitals, and long- term acute care hospitals will be increased 4.0% over the July 1, 2023 calculations after any third-party liability amounts have been deducted and other computation of any cost outlier payment. EXCEPTION TO PAYMENT METHODOLOGIES FOR ACCESS-CRITICAL AND AT-RISK HOSPITALS South Dakota Medicaid will reimburse hospitals classified as Medicare Critical Access or Medicaid Access Critical at the greater of actual allowable cost or the payment received under the provisions contained in this Attachment.

Attachment 4.19-A Page 7 TN 24-0014 Supersedes TN 23-0016 Approval Date 10/23/24 Effective Date 07/01/24 Group 2, psychiatric hospitals operated by the State of South Dakota; and Group 3, other hospitals (any hospital not in Group 1 or 2). Payments to Group 1 hospitals qualifying under the Medicaid inpatient utilization method are based on the standard deviation that a facility’s qualifying rate exceeds the Medicaid inpatient utilization mean for all participating hospitals. Payments to Group 1 hospitals qualifying under the low-income utilization method are based on the standard deviation that a facility’s qualifying rate exceeds the low-income utilization mean for all participating hospitals. Payments to Group 1 hospitals will be made according to the payment schedule on the Department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2024. The amount of payment for each hospital is calculated as follows: The Department determines the number of facilities qualifying at greater than the mean, greater than 1 standard deviation above the mean, greater than 2 standard deviations above the mean, and greater than 3 standard deviations above the mean. The total amount of funding budgeted for disproportionate share payments is then allocated starting with those facilities qualifying at greater than the mean. Facilities qualifying at greater than 1 standard deviation, greater than 2 standard deviations, and greater than 3 standard deviations above the mean are paid double, triple, and quadruple, respectively, the amount for facilities qualifying at greater than the mean. The payment amounts are adjusted until all the budgeted funds are spent. The proposed disproportionate share payment for each facility is then compared to the payment limit that has been established for each facility. If the payment limit is less than the proposed disproportionate share payment, then the payment limit amount will be the disproportionate share payment for that particular facility. The sum of the payments made to the facilities where the payment limit was met is then subtracted from the total amount budgeted. The remaining budgeted funds are then allocated equally among the facilities where the payment limits have not been met. The subsequent allocation again is determined to ensure that facilities qualifying at greater than 1 standard deviation, greater than 2 standard deviations, and greater than 3 standard deviations above the mean are paid double, triple, and quadruple, respectively, the amount for facilities qualifying at greater than the mean. Payments to Group 2 hospitals qualifying under the Medicaid inpatient utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the Medicaid inpatient utilization mean for all participating hospitals. Payments to Group 2 hospitals qualifying under the low-income utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the low-income utilization mean for all participating hospitals.

Attachment 4.19-A Page 8 TN 24-0014 Supersedes TN 23-0016 Approval Date 10/23/24 Effective Date 07/01/24 Payments to Group 2 hospitals will be made according to the payment schedule on the Department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2024. Payments to Group 3 hospitals qualifying under the Medicaid inpatient utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the Medicaid inpatient utilization mean for all participating hospitals. Payments to Group 3 hospitals qualifying under the low-income utilization method will be based on the standard deviation that a facility’s qualifying rate exceeds the low-income utilization mean for all participating hospitals. Payments to Group 3 hospitals will be made according to the payment schedule on the Department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2024. If necessary, payments to qualified hospitals will be adjusted for the projected impact of the hospital’s specific disproportionate share hospital payment limit as required by OBRA ’93. The agency will make disproportionate share hospital program payments to qualifying hospitals prior to the end of the State fiscal year. If the total of disproportionate share payments to all qualified hospitals for a year is going to exceed the State disproportionate share hospital payment limit, as established under 1923(f) of the Act, the following process will be used to prevent overspending the limit: First, the amount of over- expenditure will be determined; Then the over-expenditure amount will be deducted from the total payments to Group 2 hospitals; and Payments to individual Group 2 hospitals will be reduced based on their percentage of Group 2 total payments.

Attachment 4.19-A Page 8a The Department will recover any disproportionate share payments in excess of hospital- specific limits made to qualifying hospitals from those qualifying hospitals. The federal share of the amount recovered may either be returned or redistributed to the remaining qualifying hospitals proportionately based upon their low-income utilization rate or Medicaid inpatient utilization rate (whichever utilization rate results in a higher payment) by using how many standard deviations above the mean the hospital qualified. TN# 24-0014 Supersedes TN# 11-6 Approval Date 10/23/24 Effective Date 07/01/24

Attachment 4.19-A Page9 The State has in place a public process which complies with the requirements of Section 1902 (a) (13) (A) of the Social Security Act. Psychiatric Residential Treatment Facilities The Department will pay facilities based on a per diem rate prospectively calculated based upon the State fiscal year. The Department will use the same methodology for governmental and private facilities. Providers must submit a cost report on forms designated by the Department identifying allowable costs incurred during the fiscal year. The Department will calculate rates for the facilities based upon each facility's actual allowable costs. Allowable costs include those costs that are ordinary, necessary, reasonable, and adequate to meet costs incurred by those facilities that are related to resident care services in conformance with State and Federal laws and regulations. Allowable cost centers include salaries and benefits for facilities' personnel, payroll taxes, professional fees and contract services, travel/transportation, supplies, occupancy, equipment, depreciation, and other. Non- allowable costs include bad debt, advertising, public relations, and costs not incurred by the facility including the value of donated goods and services. Providers must maintain a daily census report that identifies the number of residents that received services on any particular day. The Department divides allowable and reasonable costs by the census data to calculate the payment rate for the next rate setting period. The census data for a resident is limited to those days in which the resident is actually present in the facility, and is subject to audit by the Department to verify its accuracy in conjunction with the submitted cost report. Each facility must submit an annual Department-approved cost report by September 30 of each year identifying actual, previous State fiscal year historical costs. All cost reports are subject to desk review by the Department. If audit adjustments are made, the facility is notified immediately either by telephone, in writing, or electronic mail. The Department will establish desk audit rates for each facility based on the cost report desk review. The Department calculates the final rate using a minimum occupancy limit of 90% so facilities with occupancy less than 90% will receive per diem rates based upon 90% occupancy. The rate calculated is considered payment in full for all allowable services delivered by the provider to eligible Medicaid recipients. South Dakota Medicaid will pay out-of-state facilities based upon the rate for comparable services established by the Medicaid agency in the state where the facility is located. If no rate is established by the Medicaid agency in that state, then the per diem rate payable to the out-of-state facility will be the lower of billed charges or the average of the per diem rates in effect for in-state facilities at the time the services are first provided by the out- of-state facility. For extraordinary or unusual circumstances South Dakota Medicaid may negotiate a higher per diem on a case-by-case basis. Negotiated per diem rates may not exceed the cost of the services provided by the facility. TN# 24-0014 Supersedes TN# 11-3 Approval Date 10/23/24 Effective Date 7/01/24

Attachment 4.19-A TN# 24-0014 Supersedes TN# 23-0016 Approval Date 10/23/24 Effective Date 07/01/24 Page 10a HEALTH PROFESSION EDUCATION The Department of Social Services supports the direct graduate medical education (GME) of health professionals through the use of Medicaid funds. All in-state, private hospitals which are accredited by the Accreditation Council for Graduate Medical Education (ACGME) are eligible for health profession education payments. Those hospitals are identified through the use of their most recently-filed Medicare 2552-10, cost reports. Specifically, worksheet E-4 (Line 1.00) is utilized to identify the number of weighted full-time equivalents for primary care physicians at participating facilities. The agency calculates the Medicaid hospital patient days using the Division of Medical Services (DMS) Cost Settlement Details report of adjudicated claims for the same period as the Medicare 2552 cost report. Hospitals seeking GME payments must submit an application for the previous state fiscal year’s costs to DMS prior to the end of the current state fiscal year. The agency will make payments for costs incurred in the previous state fiscal year, as defined below, annually prior to the end of the current state fiscal year. Payments will be made through the state’s Medicaid Management Information System (MMIS) payment system. Payments will be made directly to the qualifying hospitals through a supplemental payment mechanism. The payment will appear on the facility’s remittance advice. Each hospital will also receive written notification at the time of payment of the payment amount from DMS. GME payments made in error will be recovered via a supplemental recovery mechanism and will appear on the facility’s remittance advice. The agency will notify the facility in writing explaining the error prior to the recovery. The Federal share of payments made in excess will be returned to CMS in accordance with 42 CFR Part 433, Subpart F. A hospital that applied for GME funding in the previous 24 months must provide written notice to DMS no less than 30 days prior to the effective date it intends to terminate operation of a GME program. A hospital must provide written notice to DMS by January 1 if it will not be applying for GME funding for the previous state fiscal year’s costs. The agency will determine the annual lump sum, onetime payment pool. The annual payment will be made during the last quarter of the state fiscal year. The pool will be distributed based upon the allocation percentage of each hospital. The hospital allocation percentage will be developed using prior year total Medicaid inpatient days and weighted intern and resident (I & R) full time equivalency (FTE). The state uses the prior year’s cost report data as a proxy for the current year. For example, the state fiscal year 2008 calculation of allocations from the payment pool was the following: (a) Weighted I & R FTEs (b) Medicaid Hospital Patient Days (c) (a*b) Weighted FTE Days (d) Hospital Allocation Percentage Payment Pool Total Hospital A 17 11,450 194,650 35.34% $1,052,009 Hospital B 22 10,692 232,230 42.16% $1,255,116 Hospital C 23 5,342 123,988 22.51% $670,107 Totals 62 27,484 550,868 100.00% $2,977,233 Total state funds available for payment through the pool are listed on the department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2024. The FMAP at the time the annual payment is made will be applied to the state portion of the payment.

Attachment 4.19-A TN# 24-0014 Supersedes TN# 23-0016 Approval Date 10/23/24 Effective Date 7/1/24 Page 10b Rural Residency Program The Center for Family Medicine is eligible for payment of direct GME via a separate funding pool for its operation of a rural family medicine residency program. The Center for Family Medicine must be accredited by the ACGME to be eligible for health profession education payments. The state will make equal interim payments to providers on a quarterly basis. Costs must be submitted on a quarterly basis to validate costs for the previous quarter using the state developed South Dakota Rural Residency Program Cost Report and Rural Residency Cost Report Guidelines. The payment will be made to the Center for Family Medicine through the MMIS system. Payments will be made directly to the provider through a supplemental payment mechanism and will appear on their remittance advice. The Center for Family Medicine will receive written notification at the time of payment of the payment amount from DMS. GME payments made in error that cannot be adequately addressed through adjustment of future quarterly payments will be recovered via a supplemental recovery mechanism and will appear on the provider’s remittance advice. The agency will notify the provider in writing explaining the error prior to the recovery. The Federal share of payments made in excess will be returned to CMS in accordance with 42 CFR Part 433, Subpart F. The Center for Family Medicine must provide written notice to DMS no less than 30 days prior to the effective date it intends to terminate operation of its GME program or written notice to DMS no less than 30 days prior to the effective date it will no longer be applying for GME funding. The agency will determine the annual rural residency program payment pool for the upcoming state fiscal year prior to the start of the fiscal year on July 1. The total state funds available for payment through the rural residency program pool are listed on the department’s website, http://dss.sd.gov/medicaid/providers/feeschedules/, effective July 1, 2024. The FMAP at the time the quarterly payment is made will be applied to the state portion of the payment.

ATTACHMENT 4.19-B INTRODUCTION Introduction Page 1 Payment rates for the services listed below are effective for services provided on or after the corresponding date. Fee schedules are published on the Department's website at http://dss.sd.gov/medicaid/providers/feeschedules/. Effective dates listed on the introductory page supersede the effective dates listed elsewhere in Attachment 4.19-B. Unless otherwise noted in the referenced state plan pages, reimbursement rates are the same for both governmental and private providers. Service Attachment Early and Periodic Screening, Attachment 4.19-B, Page 4 Diagnosis, and Treatment (EPSDT) Physician Services Attachment 4.19-B, Page 6 Optometrist Services Attachment 4.19-B, Page 9 Chiropractic Services Attachment4.19-B, Page 10 Independent Mental HeaItn Practitioners Attachment 4.19-B, Page 11 Nutritionist and Dietician Attachment 4.19-B, Page 11 Services Home Health Services Attachment4.19-B, Page 12 Durable Medical Equipment Attachment 4 .19-B, Page 13 Clinic Services Attachment 4 .19-B, Page 15 Dental Services Attachment4.19-B, Page 16 Physical Therapy Attachment4.19-B, Page 17 Occupational Therapy Attachment4.19-B, Page 18 Speech, Hearing, or Language Attachment4.19-B, Page 19 Disorder Services Dentures Attachment 4.19-B, Page 21 Prosthetic Devices Attachment 4.19-B, Page 22 Eyeglasses Attachment 4.19-B, Page 23 Diabetes Self-Management Training Attachment 4.19-B, Page 26 Community Health Workers Attachment 4.19-B, Page 26 Community Mental Health Centers Attachment 4.19-B, Page 26 Substance Use Disorder Attachment 4.19-B, Page 26 Agencies Nurse Midwife Services Attachment 4.19-B, Page 31 Pregnancy PCCM Program Attachment 4.19-B, Page 39a Transportation Attachment 4.19-B, Page 38 Personal Care Services Attachment 4.19-B, Page 38 Freestanding Birth Centers Attachment 4.19-B, Page 39 Professional Services Provided in a Freestanding Attachment 4.19-B, Page 39 Birth Center *Room and board is not included in these rates. TN# 24-0014 SUPERCEDES TN# 24-0011 Approval Date: 10/23/24 Effective Date July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 June 1, 2024 June 1, 2024 * July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 July 1, 2024 Effective Date: 07/01/24

Page 1a ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES South Dakota Medicaid will make payments to medical providers who sign agreements with the State under which the provider agrees: (a) to accept as payment in full the amounts paid in accordance with the payment structures of the State; (b) to keep such records as are necessary to fully disclose the extent of the services provided to individuals receiving assistance under the State Plan; and (c) to furnish the State Agency with such information, regarding any payments claimed by such person or institution for services provided under the State Plan, as the agency may request from time to time. The following describes policy and methods the agency uses to establish payment rates for each type of care and service, other than inpatient hospital or nursing home services, included in the State Plan. In no instance will the amount of payment under the provisions of this attachment exceed the payment made by the general public for identical services. 1. Inpatient Hospital Services (See Attachment 4.19-A) 2a. Outpatient Hospital Services Effective August 2, 2016, Medicare Prospective Payment System hospitals will be paid using the Medicaid Agency’s Outpatient Prospective Payments System (OPPS). Under OPPS, services are reimbursed using Ambulatory Payment Classifications. Effective August 2, 2016, the Department will establish a conversion factor and discount factor specific to each hospital. The hospital specific conversion factor and discount factors are published on the State agency’s website at http://dss.sd.gov/medicaid/providers/feeschedules/dss/. Effective July 1, 2024, the conversion factor for Medicare Prospective Payment System hospitals paid using the Medicaid Agency’s OPPS will be increased by 4.0 percent for hospitals with a conversion factor less than the Medicare conversion factor. South Dakota Medicaid will pay remaining participating outpatient hospitals with more than 30 Medicaid inpatient discharges during the hospital’s fiscal year ending after June 30, 1993 and before July 1, 1994 on the basis of Medicare principles of reasonable reimbursement with the following exceptions: 1. Costs associated with certified registered nurse anesthetist services are allowable costs. These costs are identified on the CMS 2552-10 on Worksheet A-8 and included in the facilities’ costs. 2. All capital and education costs incurred for outpatient services are allowable costs. These costs are identified on the CMS 2552-10 on Worksheet D Part III and included in the facilities’ costs. 3. Payments to Indian Health Service outpatient hospitals will be per visit and based upon the approved rates published each year in the Federal Register by the Department of Health and Human Services, Indian Health Service, under the authority of sections 321(a) and 322(b) of the Public Health Service Act (42 U.S.C. 248 and 249(b)), Public Law 83-568 (42 U.S.C. 2001(a)), and the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.). The State agency will make payments for visits of the same type of service on the same day at the same provider location only if the services provided are different or if they have different diagnosis codes. TN # 24-0014 Supersedes TN# 23-0016 Approval Date 10/23/24 Effective Date 07/01/24

Page 1b ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES 4. The agency will make prospective payments to outpatient hospitals based upon Medicare principles and the above exceptions using the CMS 2552-10 Report, Worksheet C, Part 1 lines 50-200 as submitted by the hospitals to determine the Medicare outpatient cost-to-charge ratios (CCRs) for the ancillary cost centers for each hospital. All participating hospitals must submit their Medicare cost reports to the agency within 150 days following the end of their fiscal year. For each hospital, the agency will use average of the ancillary CCRs for that hospital to calculate the hospital-specific reimbursement percentage to apply to outpatient charges from that hospital to determine the prospective Medicaid payment. The remaining instate hospitals will be reimbursed at 90% of billed charges. Hospitals’ charges shall be uniform for all payers and may not exceed the usual and customary charges to private pay patients. Reimbursement for outpatient services at out-of-state hospitals is calculated at 38.2% of the hospitals’ usual and customary charges unless otherwise approved by the State. Reimbursement for outpatient hospital dialysis units will be based on the applicable above-stated outpatient payment methodology. Approval Date 10/23/24 Effective Date 07/01/24 TN # 24-0014 Supersedes TN # 19-04

Page 6 ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES 5a. Physician Services The rates below are effective for services on or after the date listed on the Attachment 4.19-B Introduction Page, Page 1. a. Services other than clinical diagnostic laboratory tests. 1. Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. If there is no fee established, the payment will be 40% of the provider’s usual and customary charge. 2. If there is no fee established for supplies furnished incidental to the professional services of a physician, the payment will be paid 90% of the provider’s usual and customary charge. b. Anesthesia services. Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. Effective July 1, 2024, the anesthesia conversion factor will be reimbursed at 100% of Medicare’s established rate. The rate will be rebased annually on January 1. Anesthesia modifiers AD, QK, QX, and QY will be reimbursed in alignment with Medicare’s payment effect over a two year implementation period as follows: For the period of July 1, 2024 to June 30, 2025 the payment effect will be 75% of the allowable amount. For the period of July 1, 2025 or later the payment effect will be 50%. c. Clinical diagnostic laboratory tests. 1. Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. The established fee will not exceed Medicare’s fee on a per test basis as required by Section 1903(I)(7) of the Social Security Act. 2. Tests for which Medicare has not established a fee will be paid the lower of a fee established by the State agency or priced by report. The reimbursement rate for these services is determined using one of a variety of different reimbursement methodologies. The reimbursement rates for services priced by report are determined using a similar service, product, or procedure that has an established rate, or a percentage of the provider’s usual and customary charge. The specific methodology depends on the service, product, or procedure performed. d. Payment for physician services provided via telemedicine is made as follows: 1. Only providers eligible to enroll in the Medicaid program are eligible for payment of telemedicine services. Providers must bill the appropriate CPT procedure code with the modifier “GT” indicating the services were provided via telemedicine. 2. Originating sites, the physical location of the recipient at the time the service is provided, will be paid the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. All originating sites must be an enrolled provider. Approved originating sites are: i. Office of a physician or practitioner. ii. Outpatient Hospitals. iii. Critical Access Hospitals. iv. Rural Health Clinics. The facility fee is not considered an encounter and will be reimbursed according to the fee schedule. v. Federally Qualified Health Centers. The facility fee is not considered an encounter and will be reimbursed according to the fee schedule. vi. Indian Health Service (IHS) Clinics. The facility fee is not considered an encounter and will be reimbursed according to the fee schedule. vii. Community Mental Health Centers. viii. Substance Use Disorder Agencies. ix. Nursing Facilities. x. School Districts. 3. Distant sites, the physical location of the practitioner providing the service, will be paid the lower of the provider’s usual and customary charge or the amount established on the State agency's fee schedule published on the agency' s website https://dss.sd.gov/medicaid/providers/feeschedules/dss/. Approval Date 10/23/24 Effective Date 07/01/24 TN # 24-0014 Supersedes TN # 21-01

Page 13 ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES 7c. Durable Medical Equipment, Medical Supplies, and Orthotic Devices Payment will be the lower of the provider’s usual and customary charge or the amount established on the State agency’s fee schedule published on the agency’s website http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx. The rates are effective for services on or after the date listed on the Attachment 4.19B Introduction Page, Page 1. Durable medical equipment (DME) subject to the limit described in Section 1903(i)(27) of the Social Security Act are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota rural rate as published by Medicare effective January 2019 and then January of each year starting after 2019. If no rural rate exists, items subject to this limit will be reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota non-rural rate as published by Medicare effective January 2019 and then January of each year starting after 2019. DME items not subject to Section 1903(i)(27) of the Social Security Act, are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. If no rural rate exists, supplies are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota non-rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. DME items for which Medicare has not established a fee will be paid using of a fee established by the State agency or priced by report. The reimbursement rate for these items is determined using one of a variety of different reimbursement methodologies. The reimbursement rates for DME items priced by report are determined using a similar DME item that has an established rate or a percentage of the provider’s usual and customary charge. The specific methodology depends on the DME item. Reimbursement for rental items are reimbursed at the lesser of the provider’s usual and customary amount or the amount established on the State agency’s fee schedule. Rent to purchase equipment is considered purchased when 12 rental payments have been made without a break in the rental of 3 or more consecutive months. A new rental period begins following a break of 3 or more consecutive months. Items considered a continuous rental by the department are identified on the fee schedule. Payment for equipment maintenance and repairs is the lesser of the provider's usual and customary charge or the purchase price of a new piece of equipment. Purchase price is established according to this section. Payment for supplies necessary for the effective use or proper functioning of covered medical equipment are reimbursed at the lesser of the provider's usual and customary charge or the amount established on the State agency’s fee schedule. Effective July 1, 2024, payment for supplies are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. If no rural rate exists, supplies are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota non-rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. Supplies for which Medicare has not established a fee will be paid the using a fee established by the State agency or priced by report. The reimbursement rate for these services is determined using one of a variety of different reimbursement methodologies. The reimbursement rates for supplies priced by report are determined using a similar supply that has an established rate or a percentage of the provider’s usual and customary charge. The specific methodology depends on the supply. Orthotic devices are reimbursed at the lesser of the provider’s usual and customary charge or the amount established on the State agency’s fee schedule. Effective July 1, 2024, payment for orthotic devices are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. If no rural rate exists, orthotic devices are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota non- rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. Orthotic devices for which Medicare has not established a fee will be paid a fee established by the State agency or priced by report. The reimbursement rate for these services is determined using one of a variety of different reimbursement methodologies. The reimbursement rates for services priced by report are determined using a similar device that has an established rate or a percentage of the provider’s usual and customary charge. The specific methodology depends on the device. Approval Date 10/23/24 Effective Date 07/01/24 TN # 24-0014 Supersedes TN # 19-01

Page 22 ATTACHMENT 4.19-B PAYMENTS FOR MEDICAL AND REMEDIAL CARE AND SERVICES 12c. Prosthetic Devices The agency’s rates were set as of July 1, 2012, and are effective for prosthetic devices on or after that date. The agency-developed fee schedule is based upon review of the most recent year’s paid claims information, national coding lists, and documentation submitted by providers and associated medical professional organizations. The fee schedule is published on the agency’s website http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx. Effective July 1, 2024, payment for prosthetic devices are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. If no rural rate exists, supplies are reimbursed at the lesser of the provider’s usual and customary amount or 90% of the Medicare South Dakota non-rural rate as published by Medicare effective July 2024 and then January of each year starting in 2025. Prosthetic devices for which Medicare has not established a fee will be paid a fee established by the State agency or priced by report. The reimbursement rate for these services is determined using one of a variety of different reimbursement methodologies. The reimbursement rates for services priced by report are determined using a similar device that has an established rate or a percentage of the provider’s usual and customary charge. The specific methodology depends on the device. Except as otherwise noted in the plan, the agency-developed fee schedule rates are the same for all governmental and private providers. Payments are based upon the published fee schedule unless the provider bills a lower amount. Approval Date 10/23/24 Effective Date 7/01/24 TN # 24-0014 Supersedes TN # 12-10

REVISION: HCFA-PM-91-4 (BPD) AUGUST 1991 SUPPLEMENT 1 to ATTACHMENT 4.19-B Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES- OTHER TYPES OF CARE Payment of Medicare Part A. Part B, and Part C Deductible/Coinsurance 1. Payments are limited to State plan rates and payment methodologies for the groups and payments listed below and designated with the letters "SP". For specific Medicare services which are not otherwise covered by this State plan, the Medicaid agency uses Medicare payment rates unless a special rate or method is set out on Page 3 in item _ of this attachment (see 3. below). 2. Payments are up to the full amount of the Medicare rate for the groups and payments listed below, and designated with the letters "MR". 3. Payments are up to the amount of a special rate, or according to a special method, described on Page 3 in item _______ of this attachment, for those groups and payments listed below and designated with the letters "NR". 4. Any exceptions to the general methods used for a particular group or payment are specified on Page 3 in item ___ of this attachment (see 3. above). TN #24-0014 Supersedes TN# 91-17 Approval Date 10/23/24 Effective Date 07/01/24

REVISION: HCFA-PM-91-4 (BPD) AUGUST 1991 SUPPLEMENT 1 to ATTACHMENT 4.19-B Page2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES- OTHER TYPES OF CARE Payment of Medicare Part A, Part B, and Part C Deductible/Coinsurance QMBs: Other Medicaid Recipients: PartA MR Part B MR Part C MR Deductibles ...MB... Coinsurance Deductibles ...MB... Coinsurance Deductibles ...MB... Coinsurance Part A ...MB... Deductibles MR Coinsurance Part B ...MB... Deductibles ...MB... Coinsurance Part C ...MB... Deductibles MR Coinsurance Dual: Part A ...MB... Deductibles MR Coinsurance Eligible (QMB Plus): Part B ...MB... Deductibles MR Coinsurance Part C ...MB... Deductibles MR Coinsurance TN #24-0014 Supersedes TN# 91-17 Approval Date 10/23/24 Effective Date 07/01/24

REVISION: HCFA-PM-91-4 (BPD) AUGUST 1991 SUPPLEMENT 1 to ATTACHMENT 4.19-B Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: SOUTH DAKOTA METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES- OTHER TYPES OF CARE TN #24-0014 Supersedes TN# 91-17 Payment of Medicare Part A. Part B, Part C Deductible/Coinsurance NIA Approval Date 10/23/24 Effective Date 07/01/24

Part I Page 7 TN #24-0014 Supersedes TN #23-0012 Approval Date 10/23/24 Effective Date 07/01/24 Any costs in excess of the 110% limitation will not be recognized. The ceiling limitations will apply to all nursing facilities participating in the State Medicaid Program. d) Capital costs shall be limited to $20.95 per resident day, effective July 1, 2023, for all nursing facilities participating in the State Medicaid Program. (See Section C, Provision Number(s) 3, 4, 5, and 6). Effective July 1, 2024, the capital cost limitation will be inflated by 4.3 percent as provided for in the State legislative appropriation. The appropriation for the inflationary percentage adjustment is included as part of the annual appropriation act for the ongoing and current expenses of state government. The act is approved by the legislative appropriation committee, the legislature, and Governor. The state plan will be updated to incorporate the actual adjustments once the adjustments are officially determined by the state’s legislature. 3. A return on net equity shall be an allowable cost for proprietary facilities. The allowable rate of return shall be the average mid-point of the prime interest rate and the rate of 180-day U.S. Treasury Bills, as reported on the last business day of June, September, December, and March. The rate of return shall not exceed 10% and will be calculated on the provider’s fiscal year-end balance sheet of the cost report required in Section A, Provision Number 3. 4. Building depreciation shall be limited to 3% on masonry and 4% on frame buildings and shall be calculated on the straight-line method. Generally- accepted accounting procedures will be used in determining the life of any addition(s) and improvements to primary structures. Effective July 1, 1999, the capital basis for depreciation of new construction, major renovation, and or any facilities acquired through purchase, must be subject to a salvage value computation of at least 15% (Section C, Provision Number 6). 5. Depreciation on fixed equipment shall be calculated on the straight-line method, following the American Hospital Association (AHA) Guidelines for any item(s) purchased after January 1, 1987. 6. Depreciation on major moveable equipment, furniture, automobiles, and specialized equipment shall be calculated on the straight-line method, following the American Hospital Association (AHA) Guidelines for any item purchased after January 1, 1987. Deviation from the AHA Guidelines may be granted in those instances in which facilities can provide the Department with documented historical proof of useful life.

Part I Page 9 TN #24-0014 Supersedes TN #23-0012 Approval Date 10/23/24 Effective Date 07/01/24 b) Capital Cost—Dollar Limitation The Capital Cost Components will consist of: (1) Building insurance, (2) Building Depreciation, (3) Furniture and Equipment Depreciation, (4) Amortization of Organization and Pre-Operating Costs, (5) Mortgage Interest, (6) Rent on Facility and Grounds, (7) Equipment Rent and, (8) Return on Net Equity. The Capital Cost will be limited to $20.95 per resident day for all participating nursing facilities, effective July 1, 2023. Effective July 1, 2024, the capital cost limitation will be inflated 4.3 percent as provided for in the State legislative appropriation. The appropriation for the inflationary percentage adjustment is included as part of the annual appropriation act for the ongoing and current expenses of state government. The act is approved by the legislative appropriation committee, the legislature, and Governor. The state plan will be updated to incorporate the actual adjustments once the adjustments are officially determined by the state’s legislature. 1. Leased Facility—maximum capital costs for a leased facility are limited to the following: a) The maximum capital costs is limited to the lower of actual costs or to the capital cost limitation per Section C, Provision Number 2.b. The capital cost components for computing the above limit shall consist of: (a) rent on facility/grounds and equipment; (b)building insurance; (c) building depreciation; (d) furniture and equipment depreciation; (e) amortization of organization and pre-operating costs; (f) capital related interest; and, (g) return on net equity. The capital cost items are allowable only if incurred and paid by the lessee. Capital costs will not be recognized in any other manner than as outlined in this section if incurred by the lessor (owner) and passed on to the lessee. b) The maximum allowable for lease payment(s) for facilities negotiating a new lease and facilities renewing existing leases after June 30, 1999, are limited to the lower of actual lease costs or 70% of the average per diem cost of the capital costs for owner managed facilities, excluding hospital affiliated facilities.

Part I Page 10 TN #24-0014 Supersedes TN #23-0012 Approval Date 10/23/24 Effective Date 07/01/24 c) No reimbursement shall be allowed for additional costs related to sub- leases. 2. For reimbursement purposes outlined under this plan, any lease agreement entered into by the operator and the landlord shall be binding on the operator or his successor(s) for the life of the lease, even though the landlord may sell the facility to a new owner. For reimbursement purposes outlined under this plan, the only exceptions for permitting the breaking of a lease prior to its natural termination date shall be: a) The new owner becomes the operator; or b) The owner secures written permission from the Secretary to break the lease. 3. The maximum allowable capital cost for an owner-managed facility shall be limited to $20.95 per resident day for all nursing facilities. Effective July 1, 2024, the capital cost limitation will be inflated by 4.3% as provided for in the State legislative appropriation. The appropriation for the inflationary percentage adjustment is included as part of the annual appropriation act for the ongoing and current expenses of state government. The act is approved by the legislative appropriation committee, the legislature, and Governor. The state plan will be updated to incorporate the actual adjustments once the adjustments are officially determined by the state’s legislature. 4. New construction notification—Effective July 1, 1999, all nursing facilities that are planning to undertake new construction of a nursing facility, and/or a major expansion, and/or renovation project are required to notify the Department in writing prior to the start of construction, regarding the scope and estimated cost(s) of the project. For purposes of this, notification requirement any improvement, repair or renovation project will be defined as any improvement or repair with an estimated cost of $125,000 or more.

This plan amendment updates the provider lists and provides increases to the supplemental payment amounts for the inpatient and nursing facility providers that have a signed care coordination agreement.

Approval Document

This plan amendment proposes to make revisions to the state's Rural Health Clinic's (RHC's) and Federal Qualified Health Center's (FQHC's) state plan payment methodology.

Approval Document

This amendment updates the Attachment 3 .1-L Substance Use Disorders/institutions for Mental Diseases template pages as well as revisions to the list of providers included in the random moment in time study cost pool for school-based direct services and/or administrative claiming activities.

Approval Document

On September 09, 2025, the Centers for Medicare and Medicaid Services (CMS) received South Dakota State Plan Amendment (SPA) SC-25-0010 to implement an inflationary increase to reimbursement rates for Health Home services.

Approval Document

This amendment covers peer support services and a rate increase for Community Mental Health Centers and Substance Use Disorder Agency services.

Approval Document

This plan amendment updates the supplemental payment amounts for inpatient and nursing facilities.

Approval Document

This amendment adds Alternative Benefit Plan (ABP) coverage for doula services.

Approval Document

This amendment covers of screening, diagnostic, and targeted case management services for eligible juveniles who are inmates of a public institution in accordance with Section 5121 of the Consolidated Appropriations Act of 2023 and the termination of coverage of targeted case management services provided to adults with mental illness and to youth transitioning out of residential services.

Approval Document

This amendment proposes an exception to the four walls requirement for clinic services provided by Indian Health Service (IHS) or Tribal facilities and for clinic services delivered to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address.

Approval Document

This plan amendment proposes updates to reflect/align reimbursement for direct school-based health services.

Approval Document

This amendment proposed a two-year extension of the exception from establishing a Medicaid Recovery Audit Contractor (RAC) program.

Approval Document

This Amendment changes to Preadmission Screening and Resident Review (PASRR) policies.

Approval Document

This Amendment adds coverage for pregnancy-related doula services.

Approval Document

This amendment updates the name of the designee to review State Plan Amendments for South Carolina.

Approval Document

This amendment inflationary rate increases and various coverage and service updates.

Approval Document

This amendment eliminates cost sharing for medical services.

Approval Document

SPA implements an inflationary increase to the Health Home Per Member Per Month and Clinical Outcome Measure payment rates as appropriated by the state legislature during the 2024 legislative session effective July 1, 2024 and assures that the requirements for general and annual reporting of child and adult core sets are met.

Approval Document

This plan amendment extends the supplemental payments for qualifying, private hospitals and nursing facilities for an additional state fiscal year (SFY).

Approval Document

This plan amendment proposes an inflationary increase to Community Mental Health Centers and Substance Use Disorder Agencies.

Approval Document

This amendment allows for coverage of select over-the-counter drugs manufactured by a firm that does not have a signed rebate agreement with the United States Department of Health and Human Services. Additionally, it allows South Dakota Medicaid to enter into value-based agreements with manufacturers on a voluntary basis.

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This amendment is coverage of substance use disorder treatment services provided to eligible individuals in an eligible institution for mental diseases.

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This amendment allows Alternative Benefit Plan (ABP) coverage of a primary care case management program (PCCM) for pregnant women and of adult vaccinations and their administration without cost sharing in order to align with the South Dakota State Plan.

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This amendment establishes a primary care case management program (PCCM) for pregnant individuals.

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This amendment changes to provider qualifications for Community Mental Health Centers (CMHCs).

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With this SPA the state expands eligibility to individuals under age 21 who are under a state-only funded adoption assistance agreement, and to confirm the scope of coverage under the state plan for certain reasonable classifications of children.

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This SPA provides twelve months of continuous eligibility for children.

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This amendment proposes to exempt children with non-Title IV-E adoption assistance under age 21 and individuals under age 21 with an income above 133% of the federal poverty level from the PCCM program.

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The SPA proposes to move South Dakota Medicaid from the Resource Utilization Group Ill (RUG Ill) reimbursement model to the Patient Driven Payment Model (PDPM) reimbursement model for Nursing Facility services.

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This amendment covers adult vaccinations and their administration without cost sharing.

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This Amendment expands Hospital Presumptive Eligibility (HPE) to include the Adult Medicaid Expansion group.

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This SPA authorizes increased federal financial participation (FFP) for newly-eligible individuals receiving postpartum coverage and further includes the addition of Attachment D, which describes the special circumstances and other proxy adjustments that are applied to account for the proportion of individuals covered under the extended postpartum coverage option who would otherwise be eligible for coverage in the adult group and for the newly eligible FFP under section 1905(y) of the Social Security Act;

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This SPA implements the five-percent inflationary increase to the Health Home Per Member Per Month and Clinical outcome measure payment rates appropriated by its state legislature during the 2023 legislative session

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This amendment inflationary increases appropriated by the state legislature and updates the Physician Administered Drug Payment Methodologies.

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The purpose of the amendment is to update the quality measures and associated weights for the health home quality incentive payment methodology. The updated methodology was reduced from ten weighted measures to seven. The total quality incentive payment pool for this disbursement remained the same

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This amendment extends the supplemental payments for qualifying, private hospitals and nursing facilities for an additional state fiscal year.

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This SPA adds the newly expanded adult eligibility group as an included population and implements per member per month payments for eligible Indian Health Services (IHS), Tribal 638, Urban Indian Health, and Federally Qualified Health Centers/Rural Health Clinic (FQHC/RHC) facilities.

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This state plan amendment implements annual Health Home active recipient re-tiering and adjust the Tier 4 rate for budget neutrality. South Dakota will provide a supplemental quality incentive payment to Health Homes when the Health Home intervention produces at least $3 million in savings through efficiencies.

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Implements inflationary rate increases, rebates select services, and clarifies long-term acute care hospital reimbursement.

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This SPA implements inflationary rate and targeted rate increases appropriated by the state legislature during the 2021 legislative session, increases the pharmacy dispensing fee, clarifies out-of-state inpatient hospital reimbursement, and clarifies DRG grouper 522 coverage.

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TIS SPA codifies a 2.4 percent inflationary increase in appropriations resulting from recently passed SD legislation.

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Revises the qualifying criteria for traumatic brain injury or spinal cord injury add-on payment for individuals residing in a nursing facility. In addition, it allows flexibility for individuals to qualify for this add-on payment in circumstances where completing an actual rehabilitation program is not appropriate.

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This plan amendment updates the quality incentive payment methodology for providers by improving the Health Home composite measures and aligning the clinical outcome payment methodology to it.

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Reimbursement update for Physician and Laboratory Services

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Removes Obsolete Language Pertaining to Outpatient Hospital Reimbursement Methodology Used in the SFY 2013, Replacing it with Reimbursement Calculations for SFY 2014.

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This State Plan Amendment clarifies non-payment for healthcare and hospital-acquired conditions (HAGS).

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Revision of payment methodology for Indian Health Services clinics and outpatient hospitals.

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Census disregard, exempts 2010 Census wages from income determination.

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