South Dakota
South Dakota’s Medicaid agency and its state plan are the official source for these rules. This page summarizes them as researched in October 2026; check the state’s own documents, listed under Sources, before relying on them.
At a glance
- Rate method
- Cost-based
- Case-mix level
- Resident-level
- Classification
- PDPM
- Rate updates
- Once a year
- Managed care (LTC)
- No
- Quality program
- None
- Paid outside the rate
- Small
- Bed hold
- Hospital and leave
- Published rates
- Rates only
- Assisted living
- Covered
- Personal needs allowance
- $100 / month
Overview
- South Dakota sets two facility-specific per diems each July 1 from the home's own cost report: a case-mix adjusted direct care rate (cost divided by the home's average PDPM nursing score, capped at 115%/125% of the median with 80% paid between the caps) and a non-direct care rate (health and subsistence and administration capped at 105%/110% of median, capital capped per day, spread over the greater of actual occupancy or the statewide average minus 3 points).
- On each claim the direct rate is multiplied by the resident's own PDPM nursing weight and the non-direct rate is added.
- Each home's total increase is then limited to the percentage the Legislature appropriates (+1.4% for 7/1/2026).
- In the 7/1/2026 file (93 homes) the median posted total is $251.67 at a weight of 1.0.
What matters in South Dakota
- Direct care is paid per resident: the home's direct rate times that resident's PDPM nursing weight, from 0.66 (PA1) to 4.06 (ES3).
- Posted totals assume a weight of 1.0; median 7/1/2026 total is $251.67 ($114.79 direct + $141.15 non-direct) across 93 homes.
- Rate growth is capped by the Legislature: each home's rate can rise only the appropriated percentage (+4.3% SFY2025, +1.4% SFY2027).
- No provider tax, no managed care and no quality add-on; nursing home care is plain fee-for-service.
- Medicaid pays Medicare Part A and Medicare Advantage SNF coinsurance in full, not the usual 'lesser of' cap.
- Bed holds pay 100% of the rate: 5 days per hospital stay and up to 15 consecutive therapeutic leave days.
Frequently asked
Does South Dakota Medicaid pay one nursing home rate per facility or per resident?
Per resident for direct care. Each home has one direct and one non-direct rate; the claim pays the direct rate times the resident's PDPM nursing weight (0.66 to 4.06) plus the non-direct rate. Posted totals assume a weight of 1.0.
How much does South Dakota Medicaid pay toward Medicare SNF coinsurance for dual eligibles?
The full coinsurance. Since 7/1/2024 the state plan pays Part A and Part C (Medicare Advantage) coinsurance up to the full Medicare rate, and ARSD 67:16:04:60 says coinsurance is payable at the Medicare coinsurance rate.
What limits how fast South Dakota nursing home Medicaid rates can rise?
The Legislature's appropriation. Even after rebasing to cost, each home's combined rate may rise no more than the appropriated percentage, and the non-direct rate is cut to fit. All 93 homes rose about 1.4% on 7/1/2026.
How much is paid outside the posted rate in South Dakota?
Small: a $182,000 supplemental pool (SFY2026) and cost-based tribal rates; no UPL/IGT program for public homes.
Does South Dakota require a minimum share of spending on care?
None found; no minimum share of the rate must be spent on care or staff.
How is the South Dakota nursing home provider tax charged?
None; South Dakota has no nursing facility provider tax (a 5.5% tax applies to ICF/IID only).
How the rate is set
How the method got here
| Effective | From | To | Change | Headline | Source |
|---|---|---|---|---|---|
| 2000-07-01 | Flat facility per diem without resident-level acuity | Case-mix adjusted direct care rate paid per resident by the SD M3PI index (RUG-III 34) plus a facility non-direct rate | South Dakota adopted resident-specific case-mix payment for direct care (2019 MACPAC baseline, source date 7/1/2000). | Resident-level RUG-III case mix adopted | https://www.macpac.gov/publication/nursing-facility-payment-p… |
| 2023-07-01 | RUG-III 34 (M3PI) weights; capital cap $12.01/day (2006) inflated by half the Means Building Index; rates set annually from cost reports with a fixed 3% inflation that was made obsolete in 2009 (2019 baseline) | PDPM nursing weights per resident; rebased on 2021 cost reports inflated by the SNF market basket to 12/31/2022; capital cap $20.95/day; each home's later increases capped at the appropriated percentage; Access Critical and tribal homes exempt from ceilings | SPA 23-0012 rebased rates to recent cost, switched case mix from RUG-III to PDPM, and tied future increases to the legislative appropriation. | Rebased to 2021 costs; RUG-III replaced by PDPM | https://dss.sd.gov/docs/medicaid/medicaidstateplan/4_GeneralP… |
Verified October 11, 2026
Cost basis
- Uses cost reports
Yes
- Cost report
State form 'Statistical and Cost Summary for Nursing Facilities', due 150 days after the facility's fiscal year end; CMS Pub. 15 principles apply.
- Base year and rebasing
Rebased for 7/1/2023 on cost reports with year ends April 1, 2021 - March 31, 2022 ('2021 cost reports'). From 7/1/2024 rate reviews occur annually using the year-end cost reports from the April 1 - March 31 period immediately before July 1 (4.19-D Section A.3, TN 23-0012). Annual increases are, however, limited to the appropriated percentage (Section C.6).
- Components
Component Method Notes Direct care (case-mix adjusted) Per diem direct care cost / the home's average PDPM nursing case mix score. 100% paid up to 115% of the median (homes with average case mix 1.00+), 80% of the cost between 115% and 125%, nothing above 125%. Not subject to the occupancy factor. In the 7/1/2026 file 11 homes sit at a common $143.04 direct rate, apparently the cap. Health and subsistence (incl. plant/operation and other operating) 100% up to 105% of the median, 80% between 105% and 110%, nothing above 110%. Divided by the occupancy factor. Administration Same 105%/110% band, median of freestanding non-chain homes. Divided by the occupancy factor. Capital Actual capital cost (depreciation, interest, rent, insurance, return on net equity for proprietary homes) capped at $20.95/resident day from 7/1/2023, inflated 4.3% for 7/1/2024 (about $21.85). Leases renewed after 6/30/1999 capped at 70% of average owner capital cost. Return on equity at the prime/T-bill midpoint, max 10%. - Inflation
Costs inflated by the CMS SNF market basket from the cost report midpoint to 12/31/2022 for the 2023 rebase (4.19-D Section B.2). After that, the effective update is the Legislature's appropriated percentage, which also caps each home's combined rate (Section C.6): +4.3% for SFY2025 (TN 24-0014); about +1.4% for SFY2027 (computed from the 7/1/2025 and 7/1/2026 fee schedules).
Verified October 11, 2026
Case mix
- System
PDPM
- Applied at
Resident-level
- How it works
ARSD 67:16:04:60(1): payment = the home's case mix adjusted direct care rate x the resident's PDPM weight from their assessment + the non-direct rate, for each Medicaid day.
- Classification
PDPM nursing component, 25 groups, with the CMS 10/1/2020 nursing CMIs (PA1 0.66 to ES3 4.06), per the DSS 'Nursing Facility PDPM Case Mix Weights' table effective 7/1/2026.
- Applies to
Direct care component only; non-direct care is the same for every resident.
- Acuity measured from
'Case mix score' = average PDPM nursing group weight for residents in the facility over the cost report period (ARSD 67:16:04:33(4)), used to normalize direct cost; whether limited to Medicaid residents was not stated.
- Updated
Per resident with each MDS; the home's direct and non-direct rates change annually July 1. Hospitalized before the OBRA admission MDS: manual payment at a default weight of 1.0.
- Move to PDPM
Moved from RUG-III 34-group (M3PI index maximizing) to PDPM nursing weights effective 7/1/2023 (SPA SD 23-0012, approved 1/30/2024; ARSD amended 50 SDR 11, effective 8/7/2023).
Verified October 11, 2026
Low-acuity residents
None found as a separate reduced or flat rate. Low-acuity residents are paid through the PDPM weight itself (PA1 0.66, PA2 0.71 on the direct rate only). 4.19-D Section D.4 pays the two per diems to every Medicaid resident 'excluding those classified as Assisted Living Care', and swing-bed hospitals are paid the maximum assisted living rate for assisted living care, but no current rule was found that assigns NF residents to an assisted-living classification; logged as an open question.
Verified October 11, 2026
Capital
Actual cost, capped: $20.95 per resident day effective 7/1/2023, inflated 4.3% on 7/1/2024 (about $21.85). Includes return on net equity for proprietary homes. Leased homes capped at the lower of actual or the limit; new/renewed leases after 6/30/1999 at 70% of average owner capital cost. 15% salvage value on new construction/purchases from 7/1/1999. A buyer gets the seller's rate until its own cost reports are used (ARSD 67:16:04:56.01).
Verified October 11, 2026
Budget adjustment factor
Medicaid Rate Limitation (4.19-D Section C.6, TN 23-0012): each home's combined direct + non-direct rate may rise no more than the percentage in the state appropriation act; any excess is removed from the non-direct rate. SFY2025: 4.3% (also applied to the capital cap). SFY2027 (7/1/2026): every home rose between 1.39% and 1.85% (median 1.40%) versus 7/1/2025. Also: rates are limited to the lower of the Medicaid rate or the home's average private-pay charge (case-mix adjusted), with pro-rata cuts to both components (Section D.5; Access Critical and tribal homes exempt).
Verified October 11, 2026
Add-ons and money outside the rate
Paid outside the posted rate
- Level
small
- Estimate
Well under 5%: the only payment outside posted per diems is the 4.19-D page 17b supplemental pool of about $182,000 a year (not all to nursing homes) against roughly $282M SFY2025 spending on nursing homes/assisted living/hospice; extraordinary-care add-ons are case-by-case.
- Components
Access/coordination supplemental payments: ~$182,000 (SFY2026). Extraordinary-care negotiated add-ons: size unknown.
Verified October 11, 2026
Payments by owner type
- Applies
yes
- Detail
Tribal homes operated under PL 93-638 are paid on historical costs plus prospective costs, outside the ceilings and the private-pay limit (Flandreau Santee Sioux Tribe $1,145.97/day vs a $251.67 median). State-operated NFs are paid actual cost with quarterly settlement (Part II). County/city homes get no extra payment; there is no IGT program. Access Critical status (also ceiling-exempt) depends on location/access, not ownership.
- Funding
Regular state/federal match; tribal (IHS/638) services may draw 100% federal match. No IGT or lease arrangements.
Verified October 11, 2026
Quality program
- Active
No
- Notes
No quality or pay-for-performance component in 4.19-D (TN 23-0012/24-0014/26-0005) or ARSD 67:16:04.
Verified October 11, 2026
Provider tax
- Charged
none
- Standard amount
No nursing facility provider tax or quality assessment found in 4.19-D or ARSD 67:16:04.
- Lower for high-Medicaid homes
no
- Returned in the rate
Not applicable.
Verified October 11, 2026
Provider tax notes
None for nursing facilities. The only provider tax in 4.19-D is 5.5% of net revenues for ICF/IID (and state-operated facilities), allowed as a cost.
Verified October 11, 2026
Supplemental payments
(1) 4.19-D page 17b (TN 26-0005, effective 6/1/2026, approved 9/8/2026): 'access and coordination of care' supplemental payments to named private providers - Aurora Plains Academy $8,016, Avera $25,127, Bennett County $567, Legacy $120,846, Monument Health $5,643, Sanford $21,751 (about $182,000 total) - based on CY2025 claims, paid in the last quarter of the SFY, within the 42 CFR 447.272 UPL. (2) No IGT/UPL program for county or public nursing homes found. (3) No MCO directed payments (no MCOs).
Verified October 11, 2026
Other add-ons
None in the standard rate. Extraordinary-care add-ons (see special_payment_systems) are negotiated per resident and are credited against the home's costs at the next rate setting (4.19-D D.12).
Verified October 11, 2026
Units paid separately
(1) Extraordinary care add-on (4.19-D D.11, prior authorization): chronic ventilator, chronic wound care, behaviorally challenging (incl. sex offenders/inmates), traumatic brain or spinal cord injury, TPN, and multiple chronic complex conditions get the case-mix rate plus a negotiated all-inclusive rate up to actual cost, re-evaluated at least quarterly; not available during Medicare A/MA SNF stays, hospice or hospitalization. (2) Access Critical homes (SDCL 34-12-35.5) and tribal PL 93-638 homes are exempt from the ceilings and the private-pay limit and paid on their own costs (e.g., Flandreau Santee Sioux Tribe $1,145.97 total on 7/1/2026). (3) State-operated NFs: actual cost, quarterly provisional rates with settlement (Part II). (4) Swing beds: $176.25/day (7/1/2026). (5) Out-of-state: lesser of home-state rate or SD statewide average. (6) Hospice room and board paid to the hospice.
Verified October 11, 2026
Payment rules
Managed care for long-term care
- Status
no
- Detail
No MCOs; nursing facility per diems are paid FFS by DSS (2025 SD Medicaid Report: PCCM 'Primary Care Provider program' only; providers 'reimbursed under the usual fee-for-service system').
Verified October 11, 2026
Who pays
fee_for_service. South Dakota has no Medicaid managed care organizations; about 80% of enrollees are in a primary care case management program (PCP case manager paid a monthly fee), but nursing facility care is paid fee-for-service by DSS from rates set under ARSD 67:16:04.
Verified October 11, 2026
Managed care rate floor
Not applicable: South Dakota has no Medicaid managed care plans (2025 South Dakota Medicaid Report, https://dss.sd.gov/docs/medicaid/reports/2025_Medicaid_Report…).
Verified October 11, 2026
Included in the daily rate
Included: routine nursing, oxygen and concentrators, CPAP/BiPAP and trach/suction supplies, OTC drugs, nursing supplies, standard DME (walkers, wheelchairs, pressure pads), enteral/parenteral dietary supplements, laundry, social services/activities, therapy by facility staff or contractors, non-ambulance transport, hearing aid batteries. Billed by others: prescription drugs, physician, lab and radiology, mental health, therapy by non-employees, prosthetics, independent practitioners, ambulance.
Verified October 11, 2026
Bed hold
- Hospital stays
Paid at 100% of the per diem, up to 5 days per acute hospitalization (physician-ordered); the resident must return for 24 hours before more reserve days. Also applies to stays at the SD Human Services Center.
- Leave days
Paid at 100% of the per diem, up to 15 consecutive days if in the plan of care; after 15 days the return is a new admission. No annual cap stated.
- Occupancy rule
None found.
- Notes
Reserved days paid at the resident's latest PDPM nursing group (ARSD 67:16:04:60(3)). No payment to state-owned institutions.
Verified October 11, 2026
Personal needs allowance
- Per month
100
- Effective
2024-07-01 (state plan Supplement 12 to Attachment 2.6-A, TN 24-0014)
- Notes
$200 for couples. Plus gross earnings up to $75 for working residents, court-ordered support actually paid, and trust maintenance fees. The amount before 7/1/2024 was not confirmed. Not indexed.
Verified October 11, 2026
Medicare coinsurance days
- Method
full
- Rule
Supplement 1 to 4.19-B (TN 24-0014, eff. 7/1/2024) designates Part A, Part B and Part C deductibles and coinsurance for QMBs, other Medicaid recipients and QMB-Plus duals as 'MR' - paid up to the full amount of the Medicare rate. ARSD 67:16:04:60(5): 'Coinsurance under the Medicare program is payable at the Medicare coinsurance rate.'
- Effect
Homes receive the full Part A day 21-100 coinsurance (and Medicare Advantage cost-sharing) for duals, rather than $0 under a lesser-of rule.
Verified October 11, 2026
Required care spending
- Applies
no
- Rule
No direct-care spending floor or recoupment found in 4.19-D or ARSD 67:16:04.
Verified October 11, 2026
Occupancy rules
- Applies
yes
- Rule
Non-direct care costs (health and subsistence, administration, plant, other operating, capital) are divided by the greater of the home's actual occupancy or the statewide average occupancy minus 3 percentage points; direct care is exempt. Waived for the first 12 months of a new (non-replacement) facility; in months 13-24 the greater of the statewide average minus 3 or the last quarter of year one.
Verified October 11, 2026
MDS accuracy penalties
The DHS Long-Term Services and Supports nurse consultant validates resident assessments and classifications at least every 15 months (ARSD ch. 67:45:03, per the NF billing manual). No separate penalty schedule was found.
Verified October 11, 2026
Published rates and changes
How often rates change
- A home's rate changes
annual
- When
July 1 (SFY): new direct and non-direct rates from the latest April-March cost reports, limited to the appropriated increase. Interim changes only for audit errors, amended cost reports ($0.05+/day) or new laws. Per resident, the direct-care payment changes with every MDS (PDPM weight).
Verified October 11, 2026
When rates change
July 1 each year (state fiscal year), full 12 months.
Verified October 11, 2026
Posted rates
- Home-level rates published
Yes
- Format
pdf (Nursing Facility Fee Schedule: direct, non-direct and total rate per home; separate PDPM case-mix weight table)
- Cadence
Annual (July 1)
- History
Current (7/1/2026) and Previous (7/1/2025) files only.
- Home identifier
Facility name only
Verified October 11, 2026
Rate build-ups
- Published
No
- Where
Not found; the fee schedule shows only the two component rates and total.
- What they show
Direct rate, non-direct rate and total (at weight 1.0) per home; no medians, ceilings or cost build-up.
- Format
pdf
Verified October 11, 2026
Recent changes
| Effective | Change | Headline | Direction | Size | Source |
|---|---|---|---|---|---|
| 2023-07-01 | Rates rebased on 2021 cost reports with SNF market basket inflation, case mix switched from RUG-III to PDPM nursing weights, capital cap raised to $20.95/day, and future increases capped at the appropriated percentage (SPA 23-0012, approved 1/30/2024). | Rates rebased and case mix moved to PDPM | structural | capital cap $12.01 (2006 base) -> $20.95/day | https://dss.sd.gov/docs/medicaid/medicaidstateplan/4_GeneralP… |
| 2024-07-01 | Legislature's 4.3% inflation applied to nursing facility rates and the capital cost cap (SPA 24-0014, approved 10/23/2024). | SFY2025 nursing facility rates raised 4.3 percent | increase | +4.3% | https://dss.sd.gov/docs/medicaid/medicaidstateplan/4_GeneralP… |
| 2024-07-01 | Medicare Part A, B and C (Medicare Advantage) deductibles and coinsurance for QMBs and other duals are paid up to the full Medicare rate (SPA 24-0014, superseding TN 91-17). | Medicare and Medicare Advantage coinsurance paid in full | increase | https://dss.sd.gov/docs/medicaid/medicaidstateplan/4_GeneralP… | |
| 2024-07-01 | Personal needs allowance set at $100 a month for individuals ($200 couples) in the state plan (SPA 24-0014, superseding TN 04-4). | Personal needs allowance set at $100 monthly | structural | $100/month | https://dss.sd.gov/docs/medicaid/medicaidstateplan/2_Coverage… |
| 2026-06-01 | New access and coordination supplemental payments to six named private providers, about $182,000 in total, based on CY2025 claims (SPA 26-0005, approved 9/8/2026). | Small supplemental payment pool for six providers | increase | about $182,000 total | https://dss.sd.gov/docs/medicaid/medicaidstateplan/4_GeneralP… |
| 2026-07-01 | SFY2027 rates rose about 1.4% for every home versus 7/1/2025 (computed from the DSS Current and Previous fee schedules). | SFY2027 nursing facility rates up 1.4 percent | increase | +1.4% (median; range 1.39%-1.85%) | https://dss.sd.gov/docs/medicaid/providers/feeschedules/Nursi… |
Verified October 11, 2026
Assisted living
Medicaid assisted living
- Covered
yes
- Program
HOPE (Home-and-Community-Based Options and Person-Centered Excellence) 1915(c) waiver, operated by the Department of Human Services (ARSD 67:44:03), which lists assisted living as a covered service.
- What is paid
Assisted living services; room and board treatment not confirmed (presumed paid by the resident).
- Rate
Lesser of the provider's usual and customary fee or the DHS website fee (ARSD 67:44:03:11); the dollar rate was not retrieved (DHS site is JavaScript-only).
- Limits
Nursing facility level of care required; waiver slot limits not checked.
Verified October 11, 2026
Sources
- South Dakota State Plan Attachment 4.19-D (TN 23-0012, 24-0014, 26-0005) · state plan
- ARSD 67:16:04 Nursing Facility Rate Setting (:33, :49, :51, :54, :54.01, :54.02, :56.01, :60) · regulation
- ARSD 67:45:02:04 Payment for reserved bed days · regulation
- State Plan Attachment 4.19-C Payment for Reserved Bed Days · state plan
- Supplement 1 to Attachment 4.19-B, Medicare Part A/B/C deductible and coinsurance (TN 24-0014) · state plan
- Supplement 12 to Attachment 2.6-A, Personal Needs Allowance (TN 24-0014) · state plan
- DSS Nursing Facility Fee Schedule, effective 7/1/2026 (Current) and 7/1/2025 (Previous) · rate file
- DSS Nursing Facility PDPM Case Mix Weights, effective 7/1/2026 · rate file
- SD Medicaid Billing and Policy Manual: Skilled Nursing Facility and Nursing Facility Services (July 2024) · agency page
- 2025 South Dakota Medicaid Report · agency page
- ARSD 67:44:03 HOPE waiver (:06 services, :11 payment limits) · regulation
- DSS Swing-Bed Services Fee Schedule, effective 7/1/2026 · rate file
- MACPAC 2019 compendium, South Dakota tab (baseline only) · secondary
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