Medicaid in South Dakota
South Dakota voters approved Constitutional Amendment D in November 2022, expanding Medicaid to adults ages 19 to 64 with incomes up to 138% FPL (about $22,025 for a single person for 2027 coverage). Expanded coverage began July 1, 2023. Before that, childless adults could not get Medicaid at any income level.
Because of expansion, South Dakota no longer has the coverage gap that still exists in states like Wyoming and Texas. If your income is below 138% FPL, apply for Medicaid. Above that, you can shop on the marketplace with premium tax credits.
South Dakota's uninsured rate is approximately 8.5%, with about 76,000 residents lacking coverage. Being uninsured disproportionately affects Native American communities and rural areas with limited healthcare access.
What plans cost in 2027
South Dakota marketplace premiums are relatively high. KFF puts the state's average benchmark Silver premium for a 40-year-old at $704 a month for 2027, up from $655 in 2026 (about 7.5% higher). Western South Dakota (including the Rapid City area) tends to have higher premiums than the Sioux Falls metro.
South Dakota had roughly 35,000 marketplace enrollees in 2025. The enhanced subsidies expired after 2025 and were not extended, so for 2027 there is no premium tax credit above 400% FPL (about $86,560 for a household of two). Open Enrollment for 2027 coverage runs from November 1, 2026, through January 15, 2027, on HealthCare.gov. Enroll by December 15 for coverage that starts January 1.
Carriers in South Dakota (2027)
Three insurers offer individual marketplace plans in South Dakota for 2027. Two are tied to the state's major health systems:
- Sanford Health Plan is backed by Sanford Health, one of the largest rural health systems in the country. Sanford operates hospitals and clinics across South Dakota, including its flagship Sanford USD Medical Center in Sioux Falls. Their marketplace plans naturally include the extensive Sanford provider network.
- Avera Health Plansis backed by Avera Health, the other major health system in South Dakota. Avera operates hospitals and clinics throughout the state, with Avera McKennan Hospital in Sioux Falls as its anchor facility. Avera's network is particularly strong in eastern South Dakota.
- Wellmark of South Dakota(Wellmark Blue Cross and Blue Shield) offers plans in 42 of South Dakota's 66 counties, including Pennington County (Rapid City). It does not sell marketplace plans in Minnehaha County (Sioux Falls) for 2027.
Avera and Sanford are available in most counties, giving the majority of South Dakotans a choice between two plans tied to two competing health systems. This is an unusual market structure where the insurers and the providers are vertically integrated.
Key regions
Sioux Falls metro
Minnehaha County (Sioux Falls) is South Dakota's largest city and has the best healthcare infrastructure in the state. Both Sanford USD Medical Center and Avera McKennan Hospital are located here, creating genuine competition. Avera and Sanford both sell marketplace plans here. Premiums in the Sioux Falls area tend to be the lowest in the state.
Rapid City and the Black Hills
Pennington County (Rapid City) is the western population center. Monument Health (formerly Regional Health) is the major hospital system. All three marketplace insurers sell plans here, but the smaller provider market means less competition and typically higher premiums than Sioux Falls. Specialty care access can be limited, with referrals sometimes going to Denver or Minneapolis.
Tribal reservations
South Dakota has nine Native American reservations, including Pine Ridge (Oglala Lakota), Rosebud, and Standing Rock. The Indian Health Service (IHS) operates facilities on reservations, but these are chronically underfunded. Native Americans qualify for special ACA provisions: cost-sharing reductions at all income levels and monthly special enrollment periods. However, marketplace plans may have very few in-network providers near reservation communities.
Rural eastern and central South Dakota
Small communities across the state rely on critical access hospitals and regional clinics. Both Sanford and Avera have rural clinic networks, but specialist access often requires travel to Sioux Falls or Rapid City. Premiums in these areas tend to be higher than in Sioux Falls.
Estimate your subsidy
Subsidy Estimator
Enter your info below to get a rough estimate of your monthly premium tax credit for a 2027 marketplace plan.
South Dakota-specific things to know
Check Medicaid first if your income is low. Adults earning up to about $22,025 per year (138% FPL for a single person) can qualify for South Dakota Medicaid under the 2023 expansion. If you apply on HealthCare.gov with income in that range, your application is sent to the state for a Medicaid determination. Community health centers and IHS facilities also offer care, but they are not a substitute for comprehensive coverage.
Vertical integration shapes your choices.Avera and Sanford are owned by the state's two dominant health systems. If you use Sanford doctors, the Sanford plan will have those providers in-network. If you use Avera providers, the Avera plan is the natural fit. Switching plans effectively means switching health systems in many cases, which is worth considering carefully.
Navigator and enrollment help. South Dakota has certified navigators available through community organizations. The Helpline Center and other local nonprofits provide free enrollment assistance. With smaller tax credits and new rules for 2027, getting help is worthwhile.
Resources
- HealthCare.gov for marketplace enrollment (South Dakota uses the federal marketplace)
- South Dakota DSS Medicaid for Medicaid eligibility and enrollment
- Helpline Center for enrollment assistance and community resources