South Dakota Medicaid Application Packet — Long-Term Services and Supports

SOUTH DAKOTA MEDICAID APPLICATION PACKET — LONG-TERM SERVICES AND SUPPORTS

TABLE OF CONTENTS

1. Cover Letter to South Dakota DSS
2. Applicant and Household Information
3. Program Selection and Level of Care
4. Financial Eligibility — Income
5. Financial Eligibility — Resources
6. Primary Residence and Home Equity
7. Spousal Impoverishment Protections
8. Sixty-Month Look-Back and Transfers
9. Qualified Income Trust (Miller Trust)
10. Spend-Down Plan
11. Document Checklist
12. Authorized Representative and HIPAA
13. Applicant Certification and Signature
14. Sources and References

1. COVER LETTER TO SOUTH DAKOTA DSS

To: South Dakota Department of Social Services
Division of Economic Assistance — Long-Term Care Unit
700 Governors Drive
Pierre, SD 57501-2291
Phone: 1-877-999-5612 (DSS Customer Service)

From: [________________________________] (Applicant or Authorized Representative)
[________________________________] (Mailing Address)
[________________________________] (City, State, ZIP)
[________________________________] (Phone / Email)

Date: [__/__/____]

Re: Application for South Dakota Medicaid — Long-Term Services and Supports
Applicant: [________________________________]
SSN (last 4): xxx-xx-[____]
Date of Birth: [__/__/____]
Program: ☐ Nursing Facility (NF) Medicaid ☐ HOPE Waiver (HCBS) ☐ Aged, Blind, and Disabled (ABD) Regular Medicaid

Dear Eligibility Specialist:

Enclosed please find the completed Application for Assistance (DSS Form 100) and Long-Term Care supplement, together with all supporting documentation listed in the Document Checklist (Section 11). Please direct all correspondence to the undersigned authorized representative under the HIPAA authorization included at Section 12.

Respectfully submitted,

[________________________________]
[Print name and title — applicant, attorney-in-fact, guardian, or attorney]

2. APPLICANT AND HOUSEHOLD INFORMATION

Community Spouse (if married):

3. PROGRAM SELECTION AND LEVEL OF CARE

☐ Nursing Facility (NF) Medicaid — applicant resides in or is being admitted to a Medicaid-certified nursing facility. Pre-Admission Screening and Resident Review (PASRR) Level I attached.

☐ HOPE Waiver (Home and Community-Based Options and Person-Centered Excellence) — applicant elects to receive LTSS in the community in lieu of institutional placement. Level-of-Care assessment by Dakota at Home is required. Phone: 1-833-663-9673.

☐ ABD Regular Medicaid — applicant is aged 65+, blind, or disabled and seeks medical-only coverage (no LTSS).

Level-of-Care documentation:

• ☐ Physician certification of need for nursing-facility level of care attached
• ☐ MDS 3.0 / OBRA assessment attached (NF applicants)
• ☐ Dakota at Home assessment scheduled for [__/__/____] (HOPE)
• ☐ PASRR Level I (and Level II if indicated) attached

4. FINANCIAL ELIGIBILITY — INCOME

Income cap (NF / HOPE), 2026: $2,982/month (single applicant) — 300% of the SSI Federal Benefit Rate. (Verify current figure with DSS.)

☐ Applicant's gross income is at or below the cap — no Miller Trust required.
☐ Applicant's gross income exceeds the cap — Qualified Income Trust required (see Section 9).

Patient Liability / Cost of Care (NF): Gross income minus (a) Personal Needs Allowance (currently $60/month — verify), (b) health-insurance premiums, (c) Community Spouse Monthly Income Allowance (see Section 7), and (d) limited deductions for maintenance of the home.

5. FINANCIAL ELIGIBILITY — RESOURCES

Asset (resource) limit, 2026:

• Single applicant: $2,000 countable
• Married, both applying: $3,000 countable
• Married, one applying: applicant $2,000; community spouse up to CSRA maximum (see Section 7)

Excluded resources (typical):

• ☐ Primary residence (subject to home-equity cap — Section 6)
• ☐ One automobile
• ☐ Household goods and personal effects
• ☐ Irrevocable pre-need burial contract (within state limits)
• ☐ Term life insurance and small face-value whole life (≤ $1,500 face)
• ☐ Property essential to self-support (limited)

6. PRIMARY RESIDENCE AND HOME EQUITY

Federal home-equity cap (2026): $752,000 (subject to annual CPI adjustment under 42 U.S.C. § 1396p(f)). South Dakota uses the federal floor; verify with DSS.

Home is excluded if:

• ☐ Applicant resides in the home, OR
• ☐ Community spouse resides in the home, OR
• ☐ Minor child, blind/disabled child, or sibling with equity interest residing for ≥ 1 year resides in the home, AND
• ☐ Applicant signs Intent-to-Return statement (institutionalized applicants).

Intent to Return statement:

I, [________________________________], state that although I am presently residing in a long-term care facility, it is my intent to return to my home located at [________________________________] if my condition permits. I do not intend to abandon my homestead.

Signature: [________________________________] Date: [__/__/____]

Estate recovery notice acknowledged: ☐ — Applicant understands that, under SDCL § 28-6-23 et seq. and 42 U.S.C. § 1396p(b), the State may seek recovery against the probate estate (and certain non-probate assets) for Medicaid benefits paid after age 55 or for institutional services at any age.

7. SPOUSAL IMPOVERISHMENT PROTECTIONS

2026 (effective 7/1/2025 – 6/30/2026):

Resource Assessment "Snapshot": As of the first day of the first continuous 30-day period of institutionalization on or after September 30, 1989, total countable resources of the couple are determined; the community spouse retains one-half, subject to the floor and ceiling above.

☐ Fair-hearing request to increase CSRA above maximum (income-first or resource-first, per SDCL and ARSD 67:46) — required if community-spouse income falls below MMMNA.

8. SIXTY-MONTH LOOK-BACK AND TRANSFERS

Look-back period: 60 months immediately preceding the date of application or, for institutionalized applicants, the date the applicant is both institutionalized and otherwise eligible (whichever is later). 42 U.S.C. § 1396p(c).

Transfer-penalty divisor (2026): approximately $9,291.62/month (statewide average private-pay NF cost — verify current DSS figure). Daily divisor ≈ $305.42.

Penalty period (months) = total uncompensated value transferred ÷ monthly divisor. Penalty begins on the later of (a) the date of transfer or (b) the date the applicant is otherwise eligible for Medicaid and would be receiving institutional/HCBS services but for the penalty.

Total uncompensated transfers within look-back: $[__________]
Estimated penalty period: [____] days

Exempt transfers (no penalty):

• ☐ Transfer to spouse or to another for sole benefit of spouse
• ☐ Transfer to blind or disabled child (any age)
• ☐ Transfer to disabled individual under 65 (sole benefit, in trust)
• ☐ Caregiver-child exception — child resided in the home for ≥ 2 years immediately before institutionalization and provided care that delayed placement (documentation required)
• ☐ Sibling exception — sibling with equity interest residing in home ≥ 1 year before institutionalization
• ☐ Transfer for fair market value
• ☐ Transfer with intent other than Medicaid qualification (rebuttable presumption — burden on applicant)

Undue-hardship waiver (42 U.S.C. § 1396p(c)(2)(D)): ☐ Requested — attach hardship statement.

9. QUALIFIED INCOME TRUST (MILLER TRUST)

Required when applicant's gross monthly income exceeds the income cap ($2,982/month single, 2026). Authority: 42 U.S.C. § 1396p(d)(4)(B); SDCL ch. 55-1A; ARSD 67:46.

Required QIT terms:

• ☐ Irrevocable
• ☐ Composed only of the applicant's income (typically one specific income source — Social Security or pension — directed monthly into the trust account)
• ☐ Trustee is a third party (not the applicant)
• ☐ Distributions during applicant's life limited to PNA, health-insurance premiums, spousal allowance, and patient liability to the NF / HCBS provider
• ☐ South Dakota Medicaid named as residual beneficiary up to the amount paid on the applicant's behalf

A copy of the executed trust instrument and the funding bank-account documentation is attached.

10. SPEND-DOWN PLAN

If countable resources exceed the limit, the applicant proposes the following permissible spend-down:

Prohibited spend-down: gifts to family, uncompensated transfers, voluntary debt forgiveness — these will trigger the 60-month look-back penalty.

11. DOCUMENT CHECKLIST

☐ DSS Form 100 (Application for Assistance) — signed and dated
☐ Long-Term Care supplement
☐ Photo identification (driver's license / state ID / passport)
☐ Social Security card (applicant and spouse)
☐ Medicare card and supplemental insurance cards
☐ Birth certificate or proof of citizenship (or qualified-non-citizen documentation)
☐ Marriage certificate / divorce decree / death certificate of spouse
☐ Proof of South Dakota residency
☐ Five years of bank statements (all accounts — checking, savings, CDs, money market)
☐ Five years of brokerage and retirement-account statements
☐ Five years of life-insurance policies (declarations and cash-surrender values)
☐ Five years of deeds, mortgages, and real-property transfers
☐ Five years of vehicle titles and transfers
☐ Most recent two years of federal tax returns
☐ Award letters: SSA, VA, pension, annuity
☐ Two months of pay stubs (if working)
☐ Burial contract / cemetery deed
☐ Trust instruments (any and all)
☐ Power of attorney / guardianship / conservatorship orders
☐ Health-insurance premium statements
☐ PASRR Level I (NF applicants)
☐ Physician level-of-care certification
☐ Executed Qualified Income Trust and funding bank statement (if income > cap)
☐ Authorized-representative form and HIPAA authorization
☐ Authorization for release of financial information (DSS form)

12. AUTHORIZED REPRESENTATIVE AND HIPAA

I, [________________________________], the applicant (or legal representative under power of attorney / guardianship dated [__/__/____]), authorize the South Dakota Department of Social Services and the Department of Human Services / Dakota at Home to communicate with and release information to:

This authorization includes protected health information under HIPAA (45 C.F.R. § 164.508), financial information, eligibility determinations, notices, and appeal rights. This authorization remains in effect until revoked in writing.

Signature: [________________________________] Date: [__/__/____]

13. APPLICANT CERTIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of South Dakota and the United States that the information provided in this application and supporting documents is true, correct, and complete to the best of my knowledge and belief. I understand that:

• Knowingly making a false statement to obtain Medicaid is a crime under SDCL § 22-46 (financial exploitation if perpetrated against an elder), federal 42 U.S.C. § 1320a-7b, and SDCL § 22-29-1 et seq. (perjury).
• I must report changes in income, resources, household composition, address, and health-insurance coverage to DSS within ten (10) days.
• The State may verify all statements through electronic data matches, financial-institution inquiries, and other lawful means.
• Estate recovery may apply to my estate after my death.

Applicant signature: [________________________________] Date: [__/__/____]

Authorized representative signature (if applicable): [________________________________] Date: [__/__/____]

Witness: [________________________________] Date: [__/__/____]

14. SOURCES AND REFERENCES

Federal authority:

• 42 U.S.C. § 1396 et seq. (Title XIX) — https://www.ssa.gov/OP_Home/ssact/title19/1900.htm
• 42 U.S.C. § 1396p (transfers, liens, recoveries; QITs at § 1396p(d)(4)(B)) — https://www.ssa.gov/OP_Home/ssact/title19/1917.htm
• 42 C.F.R. Part 435 (Medicaid eligibility) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-435

South Dakota authority:

• SDCL Chapter 28-6 (Medical Assistance) — https://sdlegislature.gov/Statutes/28-6
• ARSD Article 67:16 (Medical Services) — https://sdlegislature.gov/Rules/Rule/67:16
• ARSD Article 67:46 (Long-Term Care) — https://sdlegislature.gov/Rules/Rule/67:46
• SD DSS Medicaid program — https://dss.sd.gov/medicaid/
• SD DSS LTC eligibility — https://dss.sd.gov/economicassistance/ltc/
• DHS Division of Long-Term Services and Supports — https://dhs.sd.gov/ltss/
• HOPE Waiver Provider Manual (DSS) — https://dss.sd.gov/docs/medicaid/providers/billingmanuals/HCBS/Home_and_Community_Based_Options_and_Person-Centered_Excellence.pdf
• Dakota at Home (HCBS intake / LOC screening) — 1-833-663-9673 — https://dakotaathome.sd.gov/

Application forms:

• DSS Form 100 (Application for Assistance) — https://dss.sd.gov/economicassistance/forms.aspx

Reference (verify against primary sources):

• 2026 SD Medicaid figures — https://www.medicaidplanningassistance.org/medicaid-eligibility-south-dakota/

This template is provided for informational purposes only and does not constitute legal advice. Eligibility figures change annually. Verify all amounts and policies with the South Dakota Department of Social Services before filing. Consult a licensed South Dakota elder-law attorney before submission.