How It Works and Who It’s For

To qualify for coverage through the South Dakota Marketplace, you must:

• Live in South Dakota

• Be lawfully present in the U.S.

• Not be incarcerated

• Not be enrolled in Medicare

You may be eligible for premium subsidies and cost-sharing reductions based on your household income, as long as you do not have access to affordable employer-sponsored insurance, Medicaid, or CHIP. Medicaid expansion took effect in South Dakota in 2023, so some residents now qualify for Medicaid rather than Marketplace subsidies.

Open Enrollment Period in South Dakota

• Open Enrollment for 2025: November 1, 2024 – January 15, 2025

• Enroll by December 15 for coverage starting January 1, 2025

• Enroll between December 16 and January 15 for coverage starting February 1, 2025

Outside this period, you need a Special Enrollment Period (SEP) to enroll or change plans, usually triggered by qualifying life events such as loss of coverage, marriage, or moving.

Special Enrollment Period (SEP) Rules

You may qualify for a SEP if you experience a qualifying life event, including:

• Loss of other health coverage

• Marriage or divorce

• Birth or adoption of a child

• Change in residence

Most SEPs last 60 days from the event.

Types of Health Insurance Plans Available

Marketplace plans in South Dakota are offered in four “metal” tiers:

*No Platinum plans have been offered in recent years.

• Catastrophic Plans: For those under 30 or with a hardship exemption; low premiums, high deductibles, and coverage for all essential benefits after the deductible is met.

Plan Types:

• PPO: Broader network, out-of-network coverage, higher premiums

• HMO: Lower premiums, limited network, referrals required

• EPO: Must use network providers, no out-of-network coverage except emergencies

Eligibility for Subsidies and Cost Assistance

• Premium Tax Credits: Available for incomes between 100% and 400% of the federal poverty level, with expanded eligibility through 2025. Nearly all Marketplace enrollees in South Dakota qualify for subsidies, which lower monthly costs.

• Cost-Sharing Reductions (CSR): For incomes up to 250% FPL on Silver plans, reducing deductibles and out-of-pocket costs.

• Medicaid/CHIP: South Dakota expanded Medicaid in 2023. Adults up to 138% FPL are now eligible for Medicaid, and children in higher-income families may qualify for CHIP.

How to Compare and Choose a Plan in South Dakota

When comparing plans, consider:

• Premiums: Monthly cost

• Deductibles/Out-of-Pocket Maximums: What you’ll pay before coverage kicks in

• Provider Networks: Ensure your doctors and hospitals are in-network

• Drug Formularies: Check if your medications are covered

Tips:

• Self-employed: Consider high-deductible plans with HSAs for tax benefits.

• Families: Look for pediatric dental/vision, family out-of-pocket limits.

• Retirees: Marketplace coverage bridges the gap until Medicare at 65.

Top Insurance Providers on the South Dakota Exchange

For 2025, three insurers offer Marketplace coverage in South Dakota:

• Avera Health Plans

• Sanford Health Plan

• Wellmark Blue Cross Blue Shield of South Dakota

Plan options and availability vary by region; some areas have two insurers, while others have all three.

Navigating South Dakota’s Online Enrollment Portal

How to Apply:

1. Go to the federal enrollment website and create an account.

2. Enter household and income information to check eligibility for subsidies or programs.

3. Compare available plans by premiums, coverage, and network.

4. Select a plan and complete enrollment.

5. Pay your first premium to activate coverage.

You can also enroll with help from an insurance agent, broker, Navigator, or certified application counselor. Free, impartial assistance is available statewide.

Alternatives to the Marketplace

• Short-term health plans: Starting September 1, 2024, limited to three months (renewable for one month, max four months); not ACA-compliant, may exclude pre-existing conditions.

• Off-exchange private plans: Purchased directly from insurers; no subsidies available.

• Faith-based health-sharing ministries: Not insurance, lack ACA protections, but may be an option for some.

Common Mistakes to Avoid During Enrollment

• Forgetting to update income, which can affect subsidy eligibility or result in tax repayment

• Missing enrollment deadlines

• Choosing the wrong metal tier for your healthcare needs

• Not checking if your providers are in-network

• Not making the first premium payment to activate coverage

State-Specific Health Programs or Initiatives

• Medicaid Expansion: South Dakota expanded Medicaid in 2023, increasing eligibility for low-income adults.

• Navigator Assistance: Free, impartial enrollment help is available statewide.

• Healthy South Dakota: State health programs promote healthy living, disease prevention, and access to care.

• Public Health Initiatives: Programs for cancer screening, chronic disease management, oral health, and more are available to residents.

South Dakota’s Marketplace offers a variety of plans, strong consumer protections, and robust assistance resources for residents seeking affordable health coverage.