South Dakota - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In South Dakota, Home Health Services provide intermittent skilled nursing, physical therapy, occupational therapy, speech-language pathology, and home health aide services to homebound individuals under a physician-ordered plan of care. These services are covered by South Dakota Medicaid under Administrative Rule of South Dakota (ARSD) 67:16:05 and are designed to treat medical conditions in the patient's residence, preventing institutionalization.

The single biggest structural barrier to entry for this service in South Dakota is that the state does not issue state licenses for Home Health Agencies. Because there is no state licensure pathway, the absolute prerequisite to enrolling in South Dakota Medicaid is obtaining federal Medicare Certification (Title XVIII) under 42 CFR Part 484. An agency cannot bill Medicaid until it has successfully passed a rigorous initial Medicare survey conducted by the South Dakota Department of Health or a CMS-approved accrediting organization.

1. Service Definition and Scope

South Dakota Medicaid defines home health services as medically necessary skilled care provided to an eligible recipient in their place of residence. According to ARSD 67:16:05, these services must be ordered by a physician and provided by a qualified home health agency employee.

The scope of practice is strictly clinical and intermittent. It does not include non-medical companion care or continuous private duty nursing under this specific authority. Medicaid limits home health services to one visit per day unless additional visits are medically justified and documented.

• Service Location: Care must be delivered in the patient's residence, which explicitly excludes hospitals or nursing facilities.
• Skilled Nursing: Must be provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) operating under the direct supervision of an RN.
• Therapy Services: Includes physical therapy, occupational therapy, and speech-language pathology services provided by licensed therapists.
• Home Health Aide: Includes personal care and basic health services performed by a certified aide under the supervision of an RN.
• Plan of Care: All services must be established, documented, and periodically reviewed by a physician every 60 days.
• Visit Limitations: South Dakota Medicaid restricts standard home health reimbursement to one visit per day, requiring specific medical justification for exceptions.

2. Regulatory and Oversight Agencies

Because South Dakota does not license home health agencies, oversight is a hybrid of federal certification and state Medicaid enrollment rules. The state survey agency acts on behalf of the federal government to ensure clinical compliance.

Medicaid billing and policy enforcement are handled by the state's Department of Social Services, which manages the provider network and claims processing.

• South Dakota Department of Health (DOH) Office of Health Care Facilities Licensure & Certification: Acts as the CMS survey agency to conduct Medicare certification inspections. https://doh.sd.gov/healthcare-professionals/health-facility-licensure/facility-types/home-health-agencies-hha/
• South Dakota Department of Social Services (DSS): Manages Medicaid provider enrollment, policy administration, and claims processing. https://dss.sd.gov/medicaid/providers/
• Centers for Medicare & Medicaid Services (CMS): The federal authority that dictates the Conditions of Participation (CoPs) for home health agencies. https://www.cms.gov
• CGS Administrators, LLC: The designated Medicare fee-for-service contractor (MAC) for South Dakota that processes the initial CMS-855A enrollment. http://www.cgsmedicare.com

3. Gatekeeping Prerequisites: Who Can Even Apply

South Dakota does not utilize a Certificate of Need (CON) program for home health agencies, nor does it restrict access through closed networks, moratoria, or Request for Proposals (RFPs). The market is technically open to any qualified provider.

However, the lack of a state license creates a strict federal gatekeeper. An agency cannot simply open and apply to Medicaid; it must first achieve Medicare certification, which requires significant upfront capital to operate and treat patients without billing until the initial survey is passed.

• State Licensure Exemption: South Dakota explicitly does not require or issue state licenses for Home Health Agencies; providers operate under federal certification.
• Medicare Certification Prerequisite: Agencies must be fully Medicare-certified (Title XVIII) and receive a CMS tie-in notice before South Dakota Medicaid will accept a provider enrollment application.
• Accreditation Deeming Authority: Due to state survey backlogs, most new agencies must obtain certification through a CMS-approved accrediting organization (ACHC, CHAP, or The Joint Commission) to bypass the state DOH waitlist.
• NPI Requirement: Applicants must obtain an Organizational (Type 2) NPI tied to their legal business name and Federal Employer Identification Number (FEIN).
• OCR Clearance: Providers must obtain Office of Civil Rights (OCR) clearance via the HHS Assurance of Compliance portal prior to Medicare approval.

4. Licensure and Certification Requirements

Since South Dakota does not have a state home health license, the entire facility approval process is dictated by the federal Medicare certification process under 42 CFR Part 484.

Providers must demonstrate compliance with all federal Conditions of Participation (CoPs), which includes passing a comprehensive clinical survey after the agency has become operational and provided care to a minimum number of patients.

• CMS-855A Application: Providers must submit the Medicare enrollment application to CGS Administrators, LLC, and pay the required federal application fee.
• Capitalization Requirement: CMS requires new home health agencies to demonstrate sufficient initial reserve operating funds (typically 3 to 6 months of operating expenses).
• Initial Survey: Conducted by the SD DOH or an approved accrediting body to verify compliance with CMS CoPs, requiring the agency to have active patients at the time of inspection.
• OASIS Transmission: Agencies must demonstrate the technical ability to successfully transmit Outcome and Assessment Information Set (OASIS) data to the state system.
• Emergency Preparedness: Providers must meet CMS emergency preparedness regulations, including a documented all-hazards plan, communication plan, and staff training.

5. Medicaid Provider Enrollment

Once Medicare certification is achieved, agencies must enroll in South Dakota Medicaid to bill for services rendered to Medicaid beneficiaries. South Dakota operates primarily on a fee-for-service basis for these services.

Enrollment is conducted entirely online through the SD DSS Provider Online Portal. Applications that deviate from federal NPPES profiles may be flagged for manual review, delaying approval.

• Enrollment Portal: Applications must be submitted electronically via the SD DSS Provider Online Portal. https://dss.sd.gov/medicaid/portal.aspx
• Provider Type: Agencies must enroll as a Home Health Agency using their Organizational (Type 2) NPI.
• Required Documentation: Applicants must upload their CMS Medicare tie-in notice or official certification letter as proof of eligibility.
• Business Registration: Providers must be registered with the South Dakota Secretary of State and provide a compliant W-9.
• Taxonomy Alignment: Specialty taxonomy codes on the Medicaid application must perfectly match the agency's federal NPPES profile to avoid processing holds.
• Timely Filing: SD DSS advises that enrollment actions should be completed at least 45 days prior to any timely filing deadlines for claims.

6. Staffing, Training and Background Checks

Staffing standards for home health agencies in South Dakota are governed by CMS Conditions of Participation and state Medicaid administrative rules. Agencies must employ qualified clinical leadership and ensure all field staff meet specific training benchmarks.

Background checks are mandatory for all personnel entering patient homes, utilizing state law enforcement resources to ensure patient safety.

• Clinical Director: The agency must have a qualified Registered Nurse (RN) acting as the clinical manager or director of nursing, responsible for all patient care.
• Home Health Aide Training: Aides must complete an approved 75-hour training program, which must include at least 16 hours of clinical instruction, and pass a competency exam.
• Background Checks: Staff are subject to South Dakota Division of Criminal Investigation (DCI) fingerprint-based criminal background checks.
• Therapist Qualifications: Physical Therapists, Occupational Therapists, and Speech-Language Pathologists must hold active, unencumbered South Dakota state licenses.
• Aide Supervision: An RN must perform an on-site supervisory visit for home health aides at least once every 14 days to assess competency and patient satisfaction.

7. Documentation, Policies and Records

Agencies must maintain strict clinical and administrative records that comply with both federal Medicare standards and South Dakota Medicaid rules. Documentation is the primary focus of state surveys and Medicaid audits.

Failure to maintain accurate, contemporaneous records of physician orders and patient assessments is the leading cause of claim recoupment.

• Plan of Care (CMS-485): Must be established, signed, and dated by the ordering physician within strict timeframes prior to billing.
• Visit Notes: Clinical notes must include the date, exact time in and out, specific services rendered, patient response, and the signature of the clinician.
• OASIS Assessments: Comprehensive assessments must be completed at the start of care, resumption of care, recertification (every 60 days), and discharge.
• Record Retention: South Dakota Medicaid requires that all clinical and billing records be retained for a minimum of 6 years from the date of service.
• Patient Rights: Agencies must provide written notice of patient rights, including state hotline numbers for complaints, prior to the start of care.

8. Billing, Rates and Claims

South Dakota Medicaid reimburses home health services on a fee-for-service basis. Providers must navigate the state's MMIS system to submit claims and retrieve remittance advice.

Because Medicaid is the payer of last resort, agencies must ensure that Medicare or any applicable commercial insurance is billed first for dually eligible beneficiaries.

• Claim Format: Claims are submitted using the Institutional (UB-04/837I) format, utilizing standard home health revenue codes (e.g., 042X for Physical Therapy, 055X for Skilled Nursing).
• Prior Authorization: While basic intermittent visits may not require prior authorization, extended services or visits exceeding the one-per-day limit require prior approval from SD DSS.
• Third-Party Liability (TPL): Providers must exhaust and document denials or payments from Medicare and commercial payers before billing SD Medicaid.
• Remittance Advice: Payment details and claim adjudications are accessed and downloaded via the SD Medicaid Provider Online Portal.
• Timely Filing Limit: Claims must generally be submitted within 6 months of the date of service to be eligible for Medicaid reimbursement.

9. Approval Sequence and Timeline

The timeline to become an approved Medicaid home health provider in South Dakota is lengthy, driven entirely by the federal Medicare certification process. Providers should expect the end-to-end process to take 9 to 18 months.

Because agencies must treat patients to pass the initial survey, they must be prepared to operate for several months without the ability to bill Medicare or Medicaid.

• Step 1: Business Formation: Register with the SD Secretary of State, obtain a FEIN, and secure a Type 2 NPI (1 to 2 weeks).
• Step 2: CMS-855A Submission: Submit the Medicare enrollment application to CGS Administrators and await initial approval (60 to 90 days).
• Step 3: OCR Clearance: Submit the Assurance of Compliance to the HHS portal concurrently with the 855A application.
• Step 4: Initial Survey: Undergo a CMS or Accrediting Organization survey after treating a minimum number of patients (typically 3 to 6 months after 855A approval).
• Step 5: CMS Tie-In Notice: Receive official Medicare certification and provider number from CMS (30 to 60 days post-survey).
• Step 6: SD Medicaid Enrollment: Submit the application via the SD DSS portal using the Medicare certification (30 to 45 days for processing).

10. Common Denials and Survey Findings

During initial surveys and subsequent Medicaid audits, agencies in South Dakota frequently face citations for documentation lapses and failure to follow the physician's exact orders.

Medicaid enrollment applications are also commonly delayed due to simple administrative mismatches between federal and state databases.

• Plan of Care Deviations: Providing services, frequencies, or durations that are not explicitly ordered and signed by the physician on the CMS-485.
• OASIS Errors: Inaccurate clinical coding or failure to transmit OASIS data to the state repository within the required 30-day window.
• Supervisory Failures: Missing the mandatory 14-day RN supervisory visit for home health aides, or failing to document the supervision properly.
• Taxonomy Misalignment: The SD DSS portal automatically flags and holds applications if the specialty taxonomy codes deviate from the provider's federal NPPES profile.
• Infection Control: Surveyors frequently cite field staff for failing to demonstrate proper hand hygiene and clean bag technique during home visits.

11. Key Contacts and Resources

Navigating the dual federal and state requirements requires coordination with several distinct agencies. Providers should rely on the official manuals and portals provided by CMS and South Dakota state departments.

For Medicaid-specific billing or enrollment questions, the SD DSS Provider Enrollment team is the primary point of contact.

• SD DOH Office of Health Care Facilities Licensure & Certification: (605) 773-3356, https://doh.sd.gov/healthcare-professionals/health-facility-licensure/facility-types/home-health-agencies-hha/
• SD DSS Medicaid Provider Enrollment: 1-866-718-0084, https://dss.sd.gov/medicaid/providers/enrollment/enrollment.aspx
• SD Medicaid Provider Online Portal: https://dss.sd.gov/medicaid/portal.aspx
• CGS Administrators (Medicare MAC for SD): http://www.cgsmedicare.com
• CMS State Operations Manual (Home Health): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf

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