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South Dakota Medicaid and the new work rules
South Dakota Medicaid covers adults 19-64 with income up to 138% of the federal poverty line through the voter-created Medicaid Expansion group, plus a separate and much lower-income parent/caretaker-relative category and the aged, blind and disabled categories. is run by South Dakota Department of Social Services (DSS). South Dakota expanded Medicaid on July 1, 2023, which is why the new federal work requirement reaches this state — and why what you do before January 1, 2027 matters.
From January 1, 2027, most adults have to show 80 hours a month
The requirement applies to adults aged 19 to 64 covered through Medicaid expansion — around 29,741 people in South Dakota. It is not only about paid work: study, job training, volunteering and a mix of them all count , and earning at least $580 a month satisfies it on its own.
DSS checks first and asks second. It says it will use available data sources to work out whether you are excluded or have already met the hours, and will only request documents if the information is not already in your file or electronically available. If it does need something, it sends a Request for Information — at application if you apply on or after January 1, 2027, or at your first regularly scheduled renewal in 2027 — and gives you 30 days to respond. If you do not have the documents it asks for, DSS says it will send you a form to fill out instead. From January 1, 2027 you can see your own status in the BEES Customer Portal, which will show which coverage group you are in, whether you are excluded or meet a mandatory exception, and, if neither applies, your community engagement hours and whether you are meeting the requirement. Your local DSS office can also tell you.
If your hours swing from month to month, say so. The rule is written per month, which is the wrong shape for farm and fishing work, construction, tourism and seasonal retail — a good month and a dead month average out to a living, but the dead month is the one that fails. Federal law has a provision for exactly this: a seasonal worker can satisfy the requirement using their average monthly income over the previous six months instead of hours worked in the month being checked. It is at 42 CFR 435.552(a)(7), and the law defines who counts as seasonal by pointing at the tax code rather than listing jobs, so do not decide for yourself that it misses you. If your work is seasonal or your hours are irregular, tell the state that when you report, and ask for the six-month average to be used.
That is the state's own estimate of how many will lose coverage.
The South Dakota Department of Social Services estimated 1,213 people — about 4% of the expansion group — could be disenrolled once the requirement takes effect, presented to the Board of Social Services on April 21, 2026. The method matters: of 29,504 people enrolled in expanded Medicaid at the end of 2025, DSS could not determine status for 6,066, and assumed one in five of those would fail to qualify, based on what other states saw after implementing their own work requirements. Of the group as a whole, DSS found about 39% already comply through another federal program with work requirements, about 29% already meet the hours, about 37% qualify for the tribal membership exclusion and about 29% for the caregiver exclusion — people can fall into more than one category. DSS Secretary Matt Althoff described 1,213 as the number 'if we do nothing', adding: 'We don't intend to do nothing.' KFF, a health policy organization rather than a government source, had earlier projected around 13,000 disenrollments in South Dakota when the bill passed the U.S. House; no federal agency has published a South Dakota-specific figure.
Most of that is expected to be paperwork rather than people becoming ineligible. Which is the whole reason to sort out your address and your proof now rather than at the last minute.
You do not have to prove anything if any of these describe you
Exemptions are meant to be applied by the state automatically from records it already holds, but records are imperfect. If one of these fits you and you still get asked to report hours, say so and ask them to check — don't assume the notice is right.
What you can earn and still qualify
Monthly income, before tax, for the whole household. These are the state's own published figures, which is what its caseworkers actually apply. If you are close to a line, apply anyway — some income does not count, and only the agency can run the calculation for your situation.
Adults 19 to 64138% of the poverty line
- 1 person
- $1,835
- 2 people
- $2,488
- 3 people
- $3,142
- 4 people
- $3,795
- 5 people
- $4,448
- 6 people
- $5,102
- 7 people
- $5,755
- 8 people
- $6,407
Parents and caretakers39% of the poverty line
- 1 person
- $590
- 2 people
- $740
- 3 people
- $842
- 4 people
- $941
- 5 people
- $1,042
- 6 people
- $1,145
- 7 people
- $1,244
- 8 people
- $1,343
Pregnant138% of the poverty line
- 1 person
- $1,835
- 2 people
- $2,488
- 3 people
- $3,142
- 4 people
- $3,795
- 5 people
- $4,448
- 6 people
- $5,102
- 7 people
- $5,755
- 8 people
- $6,407
Source: South Dakota Department of Social Services, 'South Dakota Medicaid Coverage Groups' (dss.sd.gov/economicassistance/medical_programs.aspx), figures current as of October 1, 2026 and built on the 2026 federal poverty guidelines. A note on precision: No conflict was found between South Dakota's published dollar figures and the federal poverty guidelines they derive from, and the Secretary of State's ballot pamphlet corroborates the expansion figures independently. We publish the state figure.
Two other changes land on the same day
Renewals get more frequent, and back-dated coverage gets shorter.
P.L. 119-21 §71112, amending 42 U.S.C. §1396a(a)(34). Applies to applications submitted on or after January 1, 2027.
South Dakota has no law that would end expansion automatically
It is not a guarantee.
None today. There is no trigger law in the South Dakota Codified Laws, and the constitutional provision that creates expansion — Article XXI, Section 10 — contains no funding contingency, no FMAP threshold and no sunset clause of any kind. KFF, which tracks these, lists South Dakota's expansion as having no trigger law in place, while separately noting that South Dakota 'is or was considering action to put a trigger law in place'. Both halves of that are correct, and the second half is now a question on the ballot.
Because expansion sits in the constitution rather than in a statute, the Legislature cannot repeal it or attach a trigger to it by ordinary bill. Only voters can change it. That protection has been tested twice and is about to be tested a third time. In January 2026 the House rejected House Joint Resolution 5002, which would have asked voters to repeal Article XXI, Section 10 outright, on a 27-39 floor vote after clearing committee 8-4. One reason it failed was that a narrower measure was already on its way to the ballot.
Where the protection stops. The protection reaches the Legislature, not the voters. South Dakota's constitution can be amended by a simple majority at a general election, so anything voters created, voters can condition or undo — and on November 3, 2026 they are being asked to do exactly that. Constitutional Amendment I, referred by the Legislature as House Joint Resolution 5001 (2025) on votes of 59-7 in the House and 31-3 in the Senate, would rewrite Article XXI, Section 10 so that the state's obligation to cover the expansion group runs only 'for the period beginning July 1, 2023, and ending on the day that the federal medical assistance percentage ... is reduced below ninety percent.' Federal support is at 90% today, so nothing changes on passage. What changes is what happens if Washington ever pays less.
What Amendment I would actually do is genuinely disputed, by officials of the same party, and the disagreement is printed on the ballot itself. Attorney General Marty Jackley writes the ballot language, and his title says the amendment 'Repeals Expanded Medicaid Coverage if Federal Funding for the Program Drops below 90%', while his explanation says it 'ends the expanded Medicaid coverage' in that event, after which 'Medicaid coverage will once again only apply to low income children, pregnant women, disabled individuals, and the elderly.' The amendment's own sponsors say that is wrong. Rep. Will Mortenson, who introduced it, called the title and explanation '100% inaccurate' and said it 'would absolutely not immediately remove Medicaid coverage for the expansion population' — in his reading it merely lifts the constitutional requirement and lets legislators then decide whether to keep, change or end expansion. Lt. Gov. Tony Venhuizen, an original sponsor, said he was 'a little concerned that it implies that this is automatic, and it is not.' Jackley stands by his wording. The pro statement in the official ballot pamphlet, signed by Venhuizen, Sen. Casey Crabtree and Mortenson, says the amendment 'would NOT automatically end Medicaid expansion'; the con statement, from South Dakota Nurses Association president Deb Fischer-Clemens, reads it as automatic and agrees with the Attorney General. The difference is not academic. On one reading a drop in the federal share ends coverage for roughly 30,000 people by itself; on the other it hands the question to a Legislature that declined to expand for over a decade until voters forced it. Lawmakers have estimated that if the federal share fell to 70%, South Dakota would need about $72 million a year to keep expansion going.
As it stands. No trigger exists as of October 1, 2026, and expansion remains a constitutional requirement. Whether that is still true in 2027 is on the November 3 ballot, and advance voting is already open. The honest summary is that South Dakota's expansion is protected from its Legislature but not from its electorate, and the electorate is voting within weeks.
Do this now
Update your address and phone number first. Everything about the new rules arrives by mail, and a stale address is the most common reason people lose coverage they are still entitled to. Then check whether an exemption applies to you.
About the phone numbers: The recipient lines are staffed 8 a.m. to 5 p.m. Central only, with no after-hours option, and South Dakota spans two time zones — a 4:30 p.m. call from Rapid City is 5:30 p.m. in Pierre and will not be answered. For anything to do with an application or a renewal packet, the Economic Assistance line on 1-877-999-5612 or your own local DSS office is usually faster than the statewide hotline.
Deaf, hard of hearing or speech-impaired: Use 711 (South Dakota Relay).
South Dakota's Medicaid application and notices are published in English, and DSS offers free interpreters and translated assistance notices in 15 other languages: Spanish, German, Traditional Chinese, Karen, Vietnamese, Nepali, Serbo-Croatian, Amharic, Fulfulde, Tagalog, Korean, Russian, Oromo, Ukrainian and French. Call 605-773-3165 and ask for an interpreter in your language; TTY users should use 711. The Community Engagement fact sheet about the new work rules is published in both English and Spanish. Lakota and Dakota are not on the state's list of interpreter languages, so a Lakota or Dakota speaker who needs help with an application is best served through their tribal health program or an Indian Health Service patient registration office, which work directly with DSS, or by asking the DSS Constituent Liaison on 1-800-597-1603 to arrange assistance.
Most people who lose coverage lose it over paperwork, not eligibility
Nationally, most people who lose Medicaid lose it over paperwork rather than because they stopped qualifying. From January 1, 2027 that matters more, not less.
NOTICE OF ELIGIBILITY DETERMINATION
Case number: ███████
Date of this notice: 1January 12, 2027
Our records do not show that you met the community engagement requirement for the reporting period.
2If you believe this is incorrect, or if an exemption applies to you, contact us on or before February 11, 2027.
3Coverage for other members of your household is not affected by this notice.
What the federal data says about coverage here
Public federal data describes how each state runs its program. Almost all of it is written for policy analysts. Here is what those numbers mean if you are the person enrolled.
Provider supply here is around the national middle.
Book an appointment before you need one, not when you do.
Where you live in this state changes what coverage is worth. South Dakota has 909,824 people spread across 66 counties at 11.7 people per square mile. Thirty of those counties are classified rural and 34 are frontier — fewer than six people per square mile. More than two-thirds of the state is federally designated a Health Professional Shortage Area. HRSA's own quarterly count, as of June 30, 2026, gives South Dakota 111 designated primary care shortage areas covering 310,255 people — roughly a third of the state's population — and puts the share of their primary care need that is actually met at 34.59%, with 61 more practitioners required to lift the designations. The state's own health department puts the practical consequence plainly: for some South Dakotans this means travelling over 50 miles to see a primary care provider, and further still to see a specialist. The hospitals are lopsided too. Of 38 certified critical access hospitals, 29 sit east of the Missouri River, where about 70% of the population lives — so West River distances are a different order of magnitude. The Department of Health's own needs assessment measured them: Buffalo to the nearest critical access hospital in Sturgis is 89 miles one way, Faith to Philip is 81 miles, and Bison to Mobridge is 120 miles. Two things follow for coverage. Because South Dakota has no Medicaid managed care, there is no plan network to be outside of — any enrolled provider will do, including out-of-state ones near the border, and DSS covers non-emergency medical travel on 1-866-403-1433, which is worth knowing about before a long drive rather than after. And because the work requirement counts hours rather than distance, people in frontier counties with the thinnest job markets have the least room to make up shortfalls, while the exemption South Dakota does offer for travel applies only to travelling for a serious or complex medical condition. HRSA Designated Health Professional Shortage Areas Statistics, data as of June 30, 2026 (data.hrsa.gov); HRSA Maternal and Child Health Bureau Title V Information System, South Dakota overview, 2025 reporting cycle; South Dakota Department of Health Office of Rural Health 2020 Primary Care Needs Assessment; South Dakota Department of Health shortage-area maps (Primary Medical Care, May 2026)
You are exempt from the work requirement — and enrolling still matters
This matters more in South Dakota than almost anywhere. The state has nine federally recognized tribes — Cheyenne River Sioux, Crow Creek Sioux, Flandreau Santee Sioux, Lower Brule Sioux, Oglala Sioux, Rosebud Sioux, Sisseton-Wahpeton Oyate, Standing Rock Sioux and Yankton Sioux — and DSS reports that American Indians made up 35.92% of everyone on South Dakota Medicaid in state fiscal year 2025, an average of 52,643 people a month. The exclusion is wide and it is automatic. DSS's own wording is 'American Indian or Alaska Native, including people who are eligible for Indian Health Service', which reaches further than enrolled tribal membership, since IHS eligibility can extend to descendants of members of federally recognized tribes. When DSS assessed its own expansion caseload in April 2026 it found that about 37% of the group — well over ten thousand people — already qualify on this ground alone. The exclusion is not limited to the work requirement either: DSS states that American Indians and Alaska Natives, including anyone IHS-eligible, are also exempt from the new six-month renewal cycle and from the cost-sharing that starts in October 2028. On proving it, South Dakota has said something genuinely useful. Asked at its July 23, 2026 Medicaid Advisory Committee whether providers should refrain from asking tribal members for documentation, DSS answered that 'at this time, the State does not anticipate seeking documentation for tribal members' — the state expects to establish this from information it already holds, because tribal status is already part of how it determines eligibility. If DSS does ask, it sends a Request for Information with 30 days to respond, and if you do not have documents it says it will send a form instead; the documents normally accepted for American Indian and Alaska Native status in Medicaid are a tribal enrollment or membership card bearing a tribal seal or signature, or a Certificate of Degree of Indian Blood that shows tribal enrollment. Enrolling in Medicaid does not duplicate free IHS care and is not a trade-off against it. Federal law pays 100% of the cost of Medicaid services delivered to American Indian and Alaska Native members through IHS, tribal 638 and urban Indian facilities, so your enrollment funds the clinic rather than drawing on it, and lets it bill for specialty referrals its own limited budget could not cover. IHS remains the payer of last resort by federal law, which means Medicaid pays first. DSS consults the elected executives of all nine tribes quarterly alongside IHS Great Plains Area, South Dakota Urban Indian Health and the Great Plains Tribal Chairmen's Health Board, and it has been working the work-requirement changes through that process since 2025, with the next consultation on October 20, 2026. One live caveat: the state's published language assistance covers 15 languages, and Lakota and Dakota are not among them.
Questions people ask about this
Do the new Medicaid work rules apply to me in South Dakota?
How many hours a month do I have to work?
Who is exempt from the work requirement in South Dakota?
When do the South Dakota work rules start?
What is the income limit for South Dakota Medicaid?
How do I apply for South Dakota Medicaid covers adults 19-64 with income up to 138% of the federal poverty line through the voter-created Medicaid Expansion group, plus a separate and much lower-income parent/caretaker-relative category and the aged, blind and disabled categories.?
How often do I have to renew South Dakota Medicaid?
Guides for neighboring states
The rules change completely at the state line. If you moved recently, or you're helping family somewhere else, start with their state rather than this one.
Two things are happening at once in South Dakota and they pull in opposite directions.
The work requirement is the one you can act on: DSS mailed a Community Engagement fact sheet to every Medicaid Expansion recipient in August 2026 and started sending individual notices on September 1, so a letter about this has already gone out, and if your address or phone number is stale at DSS you have missed it. Fix that first, at eaportal.sd.gov or your local office, and sign up there for text or email alerts — the actual reviews begin at renewals from March 2027 and everything arrives by mail. If you are American Indian or Alaska Native, or eligible for the Indian Health Service, you are excluded from the work requirement and from the new six-month renewals, and DSS has said it does not expect to ask tribal members for documentation, so this is one you should not have to do anything about. The second thing you cannot fix by paperwork: on November 3, 2026, Constitutional Amendment I asks voters whether the state's constitutional duty to cover the expansion group should end if federal funding ever drops below 90%. The Attorney General's ballot language says it repeals coverage automatically; the lawmakers who wrote it say it only lets the Legislature decide. Advance voting is already open.
Updating your address takes two minutes and protects everything else. Do that first, then check the exemption list above.
Go to Apply online through the SD BEES Customer Portal →