Health Insurance in South Dakota

Medicaid in South Dakota

South Dakota has not expanded Medicaid. Eligibility remains limited to traditional categories: children, pregnant women (up to 133% FPL), parents with very low incomes (about 52% FPL, roughly $8,100 for a family of three), people with disabilities, and elderly individuals. Childless adults do not qualify for Medicaid at any income level.

This creates a coverage gap. An estimated 20,000 South Dakotans earn too much for Medicaid but too little to qualify for marketplace subsidies (which start at 100% FPL in non-expansion states, about $15,060 for a single person). A 2022 ballot initiative to expand Medicaid (Amendment D) was defeated by voters. The state legislature has also declined to pursue expansion.

South Dakota's uninsured rate is approximately 8.5%, with about 76,000 residents lacking coverage. The coverage gap disproportionately affects Native American communities and rural areas with limited healthcare access.

What plans cost in 2026

South Dakota marketplace premiums are relatively high for a rural state. A benchmark Silver plan for a 40-year-old ranges from about $550 to $700 per month before subsidies. Western South Dakota (including the Rapid City area) tends to have higher premiums than the Sioux Falls metro, reflecting higher per-capita healthcare costs in less populated areas.

South Dakota had roughly 35,000 marketplace enrollees in 2025. With enhanced subsidies expiring after 2025, the subsidy cliff returns at 400% FPL (about $62,160 for a family of two). For those in the coverage gap (below 100% FPL), there is no financial help available for marketplace plans.

Carriers in South Dakota (2026)

Two insurers offer individual marketplace plans in South Dakota for 2026, both 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 Plans is 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.

Both carriers 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. Both marketplace carriers are available. 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. Both carriers operate 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

South Dakota-specific things to know

The coverage gap is real. If you earn less than roughly $15,060 per year (100% FPL for a single person) and do not qualify for Medicaid through another category (disability, pregnancy, dependent children), you cannot get marketplace subsidies in South Dakota. Community health centers and IHS facilities offer some care for uninsured individuals, but these are not a substitute for comprehensive coverage.

Vertical integration shapes your choices. Both marketplace carriers are owned by the 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. Given the complexity of subsidy calculations for 2026, 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