Medicare Advantage Plans in South Dakota

Fact Checked
Published: June 25, 2021

Individuals enrolled in Original Medicare are probably aware that its coverage is somewhat limited. An option for enhanced benefits is choosing a Medicare Advantage Plan in South Dakota. Offered by Medicare-approved private companies, these plans provide the same basic coverage as Original Medicare Parts A and B. The difference is that Medicare Advantage Plans typically cover expenses not included in Original Medicare, such as prescription drugs.

  • In 2019, there were 23 Medicare Advantage Plans available in South Dakota.
  • 19% of the total Medicare population in South Dakota is enrolled in Medicare Advantage Plans as of 2018.
  • In 2018, Original Medicare spent an average of $8,782 per beneficiary in South Dakota, which is 13% lower than the national average.
  • Available Medicare Advantage Plans range from seven to 22 across South Dakota’s 66 counties.

The Medicare Advantage Plan you choose affects such out-of-pocket expenses as premiums, deductibles, and copays. If you’ve been insured through a private company in the past, you may already be aware of some of their requirements, such as obtaining specialist referrals or choosing a primary care provider. The insurance provider and your geographic location will also impact which plans are available to you.

Medicare Advantage Plans in South Dakota

Types of Medicare Advantage Plans

South Dakota offers several Medicare Advantage Plan options, including HMOs, PPOs, PFFS, and SNPs. Although specific plan types stipulate their own rules and cost-sharing obligations, beneficiaries of a Medicare Advantage Plan are provided with the same protections as those enrolled in Original Medicare.

Health Maintenance Organizations (HMO)

HMO Plans provide a network of health care professionals and facilities, offering the most affordable coverage options. Members are required to select one of its network’s primary care physicians to supervise their medical care and write referrals for specialists. HMOs also usually include prescription drug coverage. Some plans offer point-of-service options, permitting out-of-network provider care; however, copays are typically much higher.

Preferred Provider Organizations (PPO)

Similar to HMOs, PPO Plans also offer in-network provider options for members who want to get the lowest costs for services. However, PPOs allow more flexibility than HMOs by also covering care from out-of-network providers at a higher cost for services. While you’ll pay the lowest out-of-pocket expenses by staying in-network, you’re permitted to see any provider who accepts the plan. You also have the option of including supplemental Medicare drug coverage if your plan doesn’t provide it.

Private Fee-For-Service Plans (PFFS)

Insurance companies offering PFFS Plans determine the rate they’ll pay their providers and your financial responsibility. Depending on the plan, you may see partial or full provider networks and no network requirements. As with PPOs, you’re permitted to see any provider who accepts the plan’s terms; however, you’ll pay the lowest costs by staying in-network. While some plans don’t include drug coverage, you may opt to purchase a supplemental Medicare drug plan.

Special Needs Plans (SNP)

SNPs are designed to accommodate individuals with particular circumstances or conditions, such as those who live in nursing homes, those who have disabling or chronic health conditions, or are eligible for both Medicaid and Medicare. SNPs are required to provide prescription drug coverage, and they’re specifically tailored to cover the groups they serve. Most plans require beneficiaries to select a primary care physician who manages routine care and specialist referrals.

Enrollment and eligibility for Medicare Advantage Plans in South Dakota

Medicare Advantage Eligibility

Individuals who meet one of the following requirements are eligible to enroll in one of South Dakota’s Medicare Advantage Plans:

  • They are a U.S. citizen or permanent resident with at least five years of documented residency.
  • They are at least 65 years old or younger with qualifying circumstances or conditions.
  • They live within the geographic location in which services are offered.
  • They qualify for Medicare Parts A and B.
  • They don’t have Medigap coverage.

South Dakota seniors who are already receiving Railroad Retirement or Social Security benefits are automatically enrolled in Medicare Parts A and B on their 65th birthday.

Enrolling in Medicare Advantage

Enrollees may join or switch to Medicare Advantage Plans during specified enrollment periods, including:

  • Initial enrollment period. This is a seven-month period that begins three months before your 65th birthday; it includes your birth month and the three months after. You’re permitted to sign up for a Medicare drug plan or a Medicare Advantage Plan during this period. You may also switch from your current Medicare Advantage Plan to another if you had a disability that allowed you Medicare coverage before your 65th birthday.
  • Open enrollment period. Running from October 15th to December 7th each year, you may opt to enroll in a Medicare Advantage Plan or switch to a different one. New coverage begins the following January 1st if you submit your request during this time frame.
  • Medicare Advantage enrollment period. If you’re enrolled in a Medicare Advantage Plan, you may switch to a different one or return to Original Medicare between January 1st and March 31st each year.

There may also be other life-changing events that allow for a special enrollment period, such as moving from your current plan’s service area or losing eligibility.

Prescription drug coverage

Medicare offers two ways to help you get the prescription drug coverage you need.

  • You can enroll in Medicare Part D, which is the drug coverage plan that can be added to Original Medicare and some PFFS Plans.
  • You may also opt to enroll in a Medicare Advantage Plan that provides drug coverage as one of its benefits.

Either way, it’s a good idea to sign up for a plan that includes drug coverage, even if you don’t require medications during enrollment. You’re assured of having the coverage you need in unexpected circumstances, and you avoid paying penalties for late enrollment.

Medicare Advantage Resources in South Dakota

Several agencies in South Dakota can provide you with the necessary support and information about selecting a Medicare Advantage Plan that meets your needs and budget. The Health Information, Counseling, and Advocacy Program (HICAP) is one of the state’s resources that offers counselors who are specially trained to evaluate your health care needs and assist you with comparing the plans and benefits that are available to you. You may contact a HICAP counselor through South Dakota’s Department of Insurance, Area Agencies on Aging, or local nonprofit law firms.

South Dakota Department of Insurance

The South Dakota Department of Insurance publishes information about obtaining Medicare supplemental insurance and which cancer policies work in conjunction with a Medicare supplement. The site also outlines pertinent details about Medicare Select, such as how its network system works and which companies offer the product.

Contact Information: Website | 605-773-3563

Eastern South Dakota Senior Health Information & Insurance Education

SHIINE is a federally funded program administered through South Dakota’s Department of Human Services, and more specifically, its Division of Long Term Services and Support. The state provides three divisions, Eastern, Central, and Western for its seniors to receive the resources they need, such as answers to their Medicare questions. The department’s volunteers offer unbiased guidance to help seniors protect their benefits and avoid fraud.

Contact Information: Website |  800-536-8197

East River Legal Services

Located in Sioux Falls, East River Legal Services offers the area’s economically disadvantaged residents legal guidance in a variety of areas, including assistance for older individuals trying to navigate the complexities of available medical programs, such as Medicare. The facility’s volunteers also provide information regarding available Social Security services and affordable housing. In addition to helping seniors, East River Legal Services is also available for individuals, families, and veterans facing many challenges.

Contact Information: Website | 605-336-9230

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