South Dakota’s Medicaid fee schedule for 2026 covers State Fiscal Year 2026 — from July 1, 2025 through June 30, 2026. The South Dakota Department of Social Services (DSS) manages and publishes all reimbursement rates for this period.
Rates are not listed on a single web page. Instead, the DSS organizes them by provider type in separate downloadable PDF files.
This guide walks you through what rates are in effect, where to find them, who qualifies, and what changed for providers in 2026.
Whether you are a Medicaid provider, a patient, or a billing specialist, this article gives you the verified numbers and the official sources you need.
What Is the South Dakota Medicaid Fee Schedule?
The South Dakota Medicaid fee schedule is a set of official documents that list exactly how much the state will pay providers for specific medical services. Each service is tied to a CPT or HCPCS billing code, and each code has a set dollar amount.
These documents are maintained by the South Dakota DSS and are updated at the start of each State Fiscal Year (SFY). The current SFY 2026 period runs from July 1, 2025 to June 30, 2026.
Where to Download the 2026 Fee Schedule
The full, code-level fee schedule is a downloadable document — not a web page. Here is how to find it:
- Go to the South Dakota DSS Provider Page
- Click on “Fee Schedules” in the navigation menu
- Select the provider type that matches your service category
- Download the PDF for SFY 2026
Each PDF covers a different provider type, such as physician services, lab services, durable medical equipment (DME), home and community-based services (HCBS), and more. There is no single master file with every code in one place.
What the Fee Schedule Includes
The downloadable fee schedule files contain reimbursement rates for:
- CPT and HCPCS procedure codes
- Physician and clinical services
- Laboratory and diagnostic tests
- Durable medical equipment (DME)
- Home and community-based services (HCBS)
- Waiver program services
- Dental, pharmacy, and transportation services
Providers must bill Medicaid based on their usual and customary charges. The fee schedule sets the maximum the state will pay. If your charge is lower than the listed rate, Medicaid pays the lower amount.
2026 SFY Rate Increases: What Changed
South Dakota Medicaid implemented rate changes effective July 1, 2025, which apply to all services paid in SFY 2026. Providers received a 1.25% inflationary rate increase applied broadly to many service categories not otherwise targeted.
Several service categories also received targeted increases beyond the standard 1.25%. These targeted adjustments were applied at the individual code level, not as a blanket percentage. The DSS published a detailed provider communication listing the specific codes affected.
1.25% Across-the-Board Inflationary Increase
This increase applied to most services that were not separately listed for a targeted adjustment. It reflects annual cost-of-living and operational cost growth built into the SFY 2026 budget.
Targeted Code-Level Increases
Certain procedure codes received larger increases based on program-specific reviews. Transportation base rates were among those specifically listed in the July 2025 DSS update document. Providers should review the full update PDF from DSS for a complete list of affected codes.
Source: South Dakota DSS — Medicaid Reimbursement and Care Management Referral Updates (July 7, 2025 provider communication PDF). Available on the DSS provider communications page.
Health Home Per Member Per Month (PMPM) Rates for 2026
Health Home services in South Dakota are paid on a Per Member Per Month (PMPM) basis. These rates are tiered by the complexity of member needs and apply to payments made after July 1, 2025.
The same rates apply to both governmental and private providers. Below are the published PMPM tiers from the official DSS fee schedule PDF:
| Tier | PMPM Rate Range |
|---|---|
| Tier 1 | $13.01 |
| Tier 2 | $41.91 – $47.68 |
| Tier 3 | $69.35 – $70.79 |
| Tier 4 | $176.90 – $276.41 |
Tier placement depends on the member’s acuity level and care management needs. Higher tiers reflect members with more complex chronic conditions requiring intensive coordination.
Source: South Dakota DSS — Health Home Per Member Per Month Payment (PMPM) Fee Schedule — Current PDF
HCBS Waiver Rates for 2026
Home and Community-Based Services (HCBS) waivers help people with disabilities and older adults receive care at home instead of in a nursing facility. South Dakota publishes separate fee schedule PDFs for each waiver program.
The HOPE Waiver is one of the most commonly referenced HCBS programs. It covers personal care, homemaker services, nursing, and residential respite, among other supports.
HOPE Waiver Unit Rates (SFY 2026)
These rates are per 15-minute unit or per day, as listed in the official HOPE Waiver Fee Schedule PDF:
| Service | Unit | Rate |
|---|---|---|
| Nursing – Registered Nurse (RN) | Per 15 min | $22.60 |
| Nursing – Licensed Practical Nurse (LPN) | Per 15 min | $18.83 |
| Homemaker | Per 15 min | $10.88 |
| Personal Care | Per 15 min | $10.88 |
| Residential Respite | Per day | $294.31 |
| Assisted Living Waiver (base) | Per day | $79.95 |
Assisted living rates have additional tiered components on top of the base daily rate depending on the level of care provided.
Source: South Dakota DSS — HOPE Waiver Fee Schedule (PDF) — View Document
2026 Medicaid Eligibility Income & Asset Limits in South Dakota
Many people search for the “fee schedule” when they actually need the income and asset eligibility limits — the thresholds that determine whether someone qualifies for Medicaid coverage.
If you want to check whether you or a family member qualifies, use our Medicaid Eligibility Calculator to get an instant estimate based on your income and household size.
South Dakota has three main Medicaid eligibility tracks, each with its own income and asset rules. All figures below are verified for 2026.
1. Long-Term Care and HCBS Waiver Programs
These limits apply to Nursing Home Medicaid and all Home and Community-Based Services (HCBS) waiver programs.
| Rule | Amount |
|---|---|
| Income Limit (Single Applicant) | $2,982 / month |
| Asset Limit (Single Applicant) | $2,000 |
| Community Spouse Asset Allowance (CSRA) | Up to $162,660 |
| Max Monthly Maintenance Needs Allowance | Up to $4,066.50 / month |
If your income exceeds $2,982 per month, you may still qualify using a Miller Trust (also called a Qualified Income Trust). This legal tool redirects income into a trust so it is not counted against the Medicaid limit. Consult an elder law attorney for help setting one up.
2. Regular Medicaid for Aged, Blind, and Disabled (ABD)
This track covers individuals who need help with Activities of Daily Living (ADLs) but do not require full nursing home placement.
| Rule | Amount |
|---|---|
| Income Limit (Single) | $994 / month |
| Income Limit (Couple) | $1,491 / month |
| Asset Limit (Single) | $2,000 |
| Asset Limit (Couple) | $3,000 |
3. MAGI-Based Medicaid (Children, Pregnant Women, ACA Adults)
MAGI stands for Modified Adjusted Gross Income. This track covers people under age 65 — including ACA expansion adults, pregnant women, and children.
For a full breakdown of how these figures compare nationally, see our guide to Medicaid income limits by state in 2026.
| Group | Monthly Income Limit |
|---|---|
| ACA Expansion Adults (Single) | ~$1,799 / month |
| ACA Expansion Adults (Family of 3) | ~$3,064 / month |
| Pregnant Women (Single) | ~$1,730 / month |
| Children 0–18 (Single Parent Household) | ~$2,659 / month |
These limits are based on 138% of the Federal Poverty Level (FPL) for ACA adults, and higher percentages of FPL for children and pregnant women. Exact figures may vary slightly depending on household size and tax filing status.
Source: Medicaid.gov — South Dakota Medicaid State Plan Amendment | Medicaid Planning Assistance — South Dakota Eligibility Guide
Provider Billing and Policy Updates for 2026
Providers billing South Dakota Medicaid in 2026 should be aware of three major operational focus areas. Staying current on these can prevent claim denials and payment delays.
Telehealth Billing Rules
For 2026, South Dakota Medicaid requires providers to verify state-specific Place of Service (POS) codes when billing telehealth. While Medicare extended many pandemic-era telehealth flexibilities, state Medicaid programs — including South Dakota’s — often apply stricter rules, especially for audio-only services.
Key actions:
- Check the South Dakota Medicaid Provider Manual before billing any audio-only telehealth codes
- Confirm that the provider-patient relationship was established in compliance with state rules
- Do not assume Medicare telehealth rules apply automatically to Medicaid claims
Provider Revalidation and Enrollment Integrity
A major compliance focus in 2026 is provider data integrity. South Dakota Medicaid is cross-checking provider enrollment records. Mismatches between your CAQH profile and your South Dakota Medicaid portal data can trigger automatic claim denials.
Steps to protect your payments:
- Log into the South Dakota Medicaid Provider Portal
- Confirm your NPI, taxonomy code, and address match your CAQH profile exactly
- Complete any pending revalidation requests before your deadline
Medicare Conversion Factor and South Dakota Medicaid Alignment
The 2026 Medicare Physician Fee Schedule set the conversion factor at approximately $33.40 (Non-Qualified Provider rate), finalized in late 2025. South Dakota Medicaid benchmarks certain codes against Medicare rates, but state-specific variances apply.
This means some codes may have been adjusted in the SFY 2026 fee schedule files to reflect the updated Medicare baseline. Providers should compare their current Medicaid rates against the updated fee schedule PDFs to catch any code-level changes that affect their specialty.
For a broader look at how Medicaid reimbursement works across all states, the Medicaid Fee Schedule 2026 national guide covers federal baselines and state-by-state variance patterns.
Source: CMS — 2026 Medicare Physician Fee Schedule Final Rule | South Dakota DSS — Provider Billing Manuals at dss.sd.gov
Important Data Gap Notice
As of June 2026, the South Dakota DSS has not published a single consolidated “master” fee schedule listing every CPT/HCPCS code across all provider types in one file. Rates are distributed across multiple provider-type PDFs available through the fee schedules index.
No across-the-board COLA press release for South Dakota Medicaid providers has been issued for 2026 beyond the confirmed 1.25% inflationary adjustment and targeted code increases effective July 1, 2025. Rate changes continue to be handled at the individual code level through the official PDF files.
If you need a complete code-by-code rate table, download the relevant provider-type PDFs directly from dss.sd.gov/medicaid/providers/feeschedules/.
Frequently Asked Questions (FAQ)
Q: Where can I find the South Dakota Medicaid fee schedule for 2026?
Go to the South Dakota DSS Provider Page at dss.sd.gov/medicaid/providers/ and click “Fee Schedules.” Download the PDF for your provider type. There is no single combined file — schedules are organized by service category.
Q: Did South Dakota Medicaid rates increase in 2026?
Yes. A 1.25% inflationary increase took effect July 1, 2025 for most services in SFY 2026. Several codes also received targeted increases above that baseline. Check the DSS July 2025 provider communication for the specific codes affected.
Q: What is the income limit for South Dakota Medicaid in 2026?
It depends on the program. Long-term care applicants have a $2,982/month limit. ABD Medicaid (single) is $994/month. ACA expansion adults qualify at roughly $1,799/month. Use our Medicaid Eligibility Calculator for a personalized estimate.
Q: What is the HOPE Waiver personal care rate per 15 minutes in 2026?
The SFY 2026 rate for personal care services under the HOPE Waiver is $10.88 per 15-minute unit. The same rate applies to homemaker services. These rates are listed in the official HOPE Waiver Fee Schedule PDF published by South Dakota DSS.
Q: Does South Dakota Medicaid follow Medicare’s 2026 fee schedule?
Not exactly. South Dakota Medicaid benchmarks some codes against the Medicare Physician Fee Schedule, which uses a 2026 conversion factor of approximately $33.40. However, state-specific rates and variances apply. Always use the DSS fee schedule PDF — not Medicare rates — for billing.
Q: What are the 2026 Health Home PMPM rates in South Dakota?
Tier 1 is $13.01/month. Tier 2 ranges from $41.91 to $47.68. Tier 3 is $69.35 to $70.79. Tier 4 ranges from $176.90 to $276.41. Rates apply for payments made after July 1, 2025 and are the same for governmental and private providers.
Next Steps
If you are a provider, download your program-specific fee schedule PDF from the South Dakota DSS Fee Schedules page and compare your current billing codes against the SFY 2026 rates.
If you are a patient or caregiver, check whether you qualify using the income and asset limits above — or run your numbers through the Medicaid Eligibility Calculator for a fast, personalized result.
Last updated: June 2026. Information in this article is based on official publications from the South Dakota Department of Social Services (DSS) and federal Medicaid sources. Always verify current rates directly at dss.sd.gov before submitting claims.
