Health Insurance Marketplace in South Dakota
If you live in South Dakota, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll.
Spanish language speakers can contact cuidadodesalud.gov
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the Arkansas insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Medicaid in South Dakota
South Dakota has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under South Dakota’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Who can help you (the Navigators)
The South Dakota Community Action Partnership will work with partners to assist South Dakota’s 92,441 uninsured consumers to prepare electronic and/or paper applications that will establish eligibility and enrollment in coverage through the Marketplace and potentially qualify for an insurance affordability program. The South Dakota Navigators Coalition will also provide outreach and education to raise awareness about the Marketplace, and will refer consumers to consumer assistance programs when necessary.
The Great Plains Tribal Chairmen’s Health Board (GPTCHB) is a community based consumer focused non-profit that will provide enrollment assistance to American Indians residing on and near the eight Reservations in South Dakota and the four Reservations and one Indian Service Area in North Dakota and those residing in major urban areas served by Urban Indian Health Centers in these two States.
Who you can contact for more help
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
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Accountable Care Organizations in South Dakota
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- Sanford Health SD – Health Care Innovation Award
- Delta Dental Plan of South Dakota SD – Health Care Innovation Award
Health care facilities where Innovation Models are being tested
- Good Samaritan Society – Sioux Falls Center Sioux Falls, SD –BPCI Initiative: Model 3
- Good Samaritan Society – Sioux Falls Village Sioux Falls, SD –BPCI Initiative: Model 3
- Good Samaritan Society – Luther Manor Sioux Falls, SD –BPCI Initiative: Model 3
- City of Sioux Falls dba Falls Community Health Sioux Falls, SD – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in South Dakota
On September 26, 2012, Governor Dennis Daugaard (R) announced that South Dakota would not establish an exchange.1However, the state intends to maintain regulatory authority over the health insurance market and perform the plan management function for the exchange.2 The decision to have a federally-facilitated exchange was made after an inter-agency work group and a taskforce of stakeholders and legislators explored the possibility of establishing a state-based exchange.3,4
On March 19, 2012, South Dakota enacted a law prohibiting plans in a state exchange from offering abortion coverage, except when it is necessary to preserve the life or health of the pregnant woman.5
Contracting with Plans: On March 11, 2013, Director of the Division of Insurance Merle Scheiber sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) requesting to maintain control over plan management functions despite not having entered into a state-federal partnership exchange. The Division of Insurance (DOI) has the legal authority and operational capacity to oversee certification of Qualified Health Plans (QHPs). DOI will use the System for Electronic Rate and Form Filing (SERFF) to collect and analyze information on plan rates, covered benefits, and cost-sharing requirements. DOI will also ensure continued plan compliance, manage consumer complaints, and oversee decertification of issuers.6
Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. In the fall of 2012, Governor Daugaard selected the Wellmark Blue Cross Blue Shield’s Blue Select plan to be the South Dakota’s EHB benchmark.7
The South Dakota Office of the Governor received a federal Exchange Planning grant of $1 million in 2010. In May 2012, the Division of Insurance was award a Level One Establishment grant of $5.9 million to further the state’s planning and design of an exchange, including creation of a risk adjustment and reinsurance plan, studying the effects of adverse selection, designing an outreach and education plan, and writing an RFP for a comprehensive IT development plan.8
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
South Dakota is not participating in Medicaid expansion.
On March 29, 2013, South Dakota received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.9
1. Press release from the office of Governor Daugaard. “South Dakota Will Not Build Health Insurance Exchange.” September 26, 2012. http://news.sd.gov/newsitem.aspx?id=13607
2. Division of Insurance Newsletter, South Dakota Department of Labor and Regulation. Fall 2012.http://dlr.sd.gov/insurance/publications/newsletter_fall12.pdf
3. South Dakota’s State Planning and Establishment Grant Project Report, Quarter 4. October 28, 2011.http://healthreform.sd.gov/documents/4thQuarterlyExchangePlanningGrantsReport_000.pdf
4. South Dakota’s Health Insurance Exchange Task Force Subcommittee Listing. June 17, 2011.http://healthreform.sd.gov/reports/HIE%20Task%20Force%20Subcommittee%20Listing.pdf
5. HB 1185. South Dakota’s 2012 act regarding coverage for abortions by plans in the exchange.http://legis.state.sd.us/sessions/2012/Bills/HB1185ENR.pdf
6. Letter from Director Scheiber to Gary Cohen. March 11, 2013.
7. Division of Insurance Newsletter, South Dakota Department of Labor and Regulation. Fall 2012.
8. HealthCare.gov factsheet. “South Dakota Affordable Insurance Exchange Grants Awards List.” Accessed June 8, 2012. http://www.healthcare.gov/news/factsheets/2011/05/exchanges/sd.html
9. Letter from Gary Cohen to Director Scheiber. March 29, 2013. http://cciio.cms.gov/Archive/Technical-Implementation-Letters/sd-pm-letter-03-29-2013.pdf
Also of interest
Provided by the Henry J. Kaiser Family Foundation