South Dakota Medicaid Waiver Application Process: HOPE Waiver Step by Step

Two Departments, Two Tracks Running in Parallel

The most important thing to understand about South Dakota's HOPE Waiver application is that two entirely separate state departments must approve your parent — and you should start both tracks simultaneously, not sequentially.

Department of Human Services (DHS), Division of LTSS — handles the clinical assessment. An LTSS Specialist evaluates whether your parent meets nursing-facility level of care.

Department of Social Services (DSS), Economic Assistance — handles the financial eligibility determination. This is the Medicaid application itself.

Families lose months by completing one before starting the other. Both can process in parallel.

Step 1: Contact Dakota at Home (Week 1)

Call the centralized intake line at 1-833-663-9673 or submit a referral through dakotaathome.sd.gov. Tell them you need an assessment for long-term care services.

During the intake call, have these ready:

• Your parent's diagnoses and current medications
• Primary care physician name and phone number
• Rough estimate of monthly income (Social Security, pension, other)
• County and zip code where your parent lives
• Specific daily activities your parent struggles with (bathing, transferring, medication management)

The intake coordinator will schedule an in-home assessment with an LTSS Specialist. The expected timeline is roughly 2–4 weeks, depending on workforce and location.

Step 2: The LTSS Functional Assessment (Weeks 2–5)

An LTSS Specialist visits your parent's home to conduct a comprehensive evaluation using the interRAI assessment tool. This generates a Resource Utilization Group (RUG) score that quantifies your parent's care needs.

What the Specialist assesses:

• Physical ability to perform activities of daily living (transferring, bathing, dressing, toileting, eating)
• Cognitive function — memory, decision-making, orientation to time and place
• Behavioral symptoms — wandering, aggression, resistance to care
• Medication management ability
• Fall risk and safety hazards in the home environment

To clear the clinical hurdle, your parent must demonstrate a consistent, documented need for hands-on assistance with multiple ADLs — the kind of daily help that would otherwise require nursing facility placement.

How you can prepare:

• Don't coach your parent to perform at their best. The assessment needs to reflect their worst days, not their best.
• Document specific incidents: falls in the past 90 days, medication errors, times they've gotten lost, meals they've skipped
• If your parent has dementia, note whether they try to hide their limitations during formal evaluations (this is extremely common)
• Have your parent's medication list, physician records, and any hospital discharge summaries organized and available

The LTSS Specialist will also assess whether the applicant requires at least one waiver-authorized service at least once per month and confirm they're not currently in a hospital or nursing facility.

Step 3: The Medicaid Financial Application (Start in Week 1–2)

Don't wait for the clinical assessment results. File the Medicaid application with DSS Economic Assistance as soon as possible.

2026 financial eligibility limits for the HOPE Waiver:

Documents DSS will require:

• Five years of bank statements (all accounts)
• Investment account statements (IRAs, 401(k)s, brokerage)
• Tax returns for the past two years
• Social Security benefit verification letter
• Pension or annuity statements
• Property deeds and mortgage statements
• Vehicle titles
• Life insurance policies (cash value counts as an asset)
• Records of any gifts, transfers, or property sales in the past 60 months

Critical South Dakota traps:

• IRAs and 401(k)s count as assets even in active payout status. A $50,000 IRA that's distributing $400/month is still a $50,000 countable asset. This is stricter than many states.
• No medically needy spend-down. If gross income exceeds $2,982, there's no option to deduct medical expenses to get under the cap. The only solution is a Miller Trust (Qualified Income Trust).
• 60-month look-back. Every gift, transfer, or below-market-value sale in the past five years triggers a penalty period. DSS will audit every bank statement line by line.

DSS has a federally mandated processing timeline: 45 days for standard applications, up to 90 days if a disability determination is needed.

Step 4: The Miller Trust (If Income Exceeds $2,982)

If your parent's gross monthly income is even $1 over the $2,982 cap, they're disqualified — unless they establish a Qualified Income Trust (Miller Trust).

The trust is an irrevocable legal instrument that routes all of your parent's monthly income through a dedicated bank account with a third-party trustee. The trust document must name the South Dakota DSS as the primary remainder beneficiary — meaning after your parent dies, the state recovers its Medicaid expenditures from any remaining trust funds.

Professional Medicaid planning and Qualified Income Trust preparation can cost $1,500–$4,000. It's a consequential legal instrument, and any error in the drafting or administration can result in retroactive loss of Medicaid eligibility.

Step 5: Approval and Service Authorization (Weeks 8–14)

Once both departments approve your parent — clinical eligibility through LTSS and financial eligibility through DSS — the LTSS Specialist develops a formal care plan. This plan specifies which services your parent is authorized to receive: personal care hours, homemaker services, adult day, respite, home modifications, Structured Family Caregiving, or some combination.

The care plan is not a suggestion — it's the authorization that tells providers what Medicaid will pay for.

What If You're Denied?

If DSS denies financial eligibility or LTSS denies clinical eligibility, you have 30 days to request an administrative fair hearing. This is a strict deadline, so contact the relevant office promptly if you miss it.

Common denial reasons and how to address them:

• Income over the cap without a Miller Trust: Establish the trust and reapply
• Assets over $2,000: Spend down on exempt items (home modifications, prepaid burial, medical equipment) and reapply
• Didn't meet nursing-facility level of care: Request a reassessment, and this time document functional limitations more thoroughly. A physician's letter detailing daily care needs strengthens the case.

The South Dakota Home Care Navigator includes the complete application checklist with document templates, a Miller Trust overview, and a financial worksheet to run the eligibility calculation before you apply.

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