South Dakota’s Department of Social Services says Medicaid expansion enrollees with income above 100% of the federal poverty level will have cost shares starting October 1, 2028. The charges apply to services that are not exempt, and the state says they will not total more than 5% of a family’s income. Copayments are limited to nominal amounts for most Medicaid enrollees today, so the change is a real shift for adults on expansion coverage. It comes from the 2025 federal law known as H.R.1, and the 2028 start leaves two years to learn which services carry a charge.
The group affected is expansion adults, the people ages 19 through 64 who gained Medicaid when states widened eligibility, and only those whose income sits above the poverty line. Expansion enrollees at or below the line are not the group the law names. For someone on expansion coverage, the question is whether income lands above that line, and which of the services used in a year fall outside the exemptions. A visit that is exempt costs nothing extra, and a visit that is not could carry a copayment of up to $35.
Copays are two years away, but the six-month renewals that decide who is still enrolled when they begin start January 1, 2027. The SNAP & Medicaid Renewal Organizer pairs a renewal and reporting calendar with a pack for each of the 51 states, so the dates that come first are written down.
Get the 51 state packs for Medicaid renewals in the SNAP & Medicaid Renewal Organizer →
What the federal law sets for expansion adults
The rule sits in subsection (k) of the federal Medicaid cost-sharing statute, added by Public Law 119-21. It covers “specified individuals,” defined as people in the expansion group whose family income exceeds the poverty line. Beginning October 1, 2028, a state plan must provide for cost sharing “in an amount greater than $0,” in an amount the state determines. No charge may exceed $35 for an item or service, and the total for all family members may not pass 5 percent of family income, counted monthly or quarterly as the state chooses.
The same subsection bars any enrollment fee or premium for this group and exempts a list of services outright. Primary care, mental health, substance use disorder care, and services from federally qualified health centers, certified community behavioral health clinics and rural health clinics cannot carry a charge. South Dakota’s own list matches that shape, adding prenatal care, pediatric care and necessary emergency room care, and the state says Alaska Native and American Indian enrollees are exempt from copayments.
The statute also lets a state allow providers to “require, as a condition for the provision of care” payment of the authorized charge, though a provider may still reduce or waive it case by case. A copayment under this rule is therefore more than a bill that arrives later, because a state can let the clinic ask for it before treating the patient. Whether South Dakota will permit that is not stated on its H.R.1 page.
How South Dakota describes its cost shares
The state’s page says copayments “cannot be more than $35 or a certain percentage of an individual’s income” and “will only be required on certain services.” That wording leaves the per-service dollar amounts unstated. An April 23, 2026 presentation to the state’s Medicaid advisory committee gives more detail: cost shares may not exceed $35 per service, the 5 percent family limit may be applied monthly or quarterly, and the exempt groups include pregnant women, people under 21, hospice patients and institutionalized individuals.
That advisory committee presentation also marks where the exemptions stop. Pharmacy services and prescription drugs are listed as not exempt, and so is urgent care, while emergency services, primary care and mental health services are exempt. For an expansion adult above the poverty line, a prescription filled at a pharmacy and a same-day urgent care visit are the kinds of everyday use the charges would reach.
Today’s copays and the dates before 2028
KFF analysts Anna Mudumala and Jennifer Tolbert wrote in May 2026 that cost sharing for Medicaid is generally limited to nominal amounts now, though it may be higher for people with incomes above 100% of poverty. They describe the October 1, 2028 start as the point when states must begin imposing cost sharing on expansion adults with income between 100% and 138% of the poverty level, up to $35 per service. The 138% mark is the income ceiling for expansion coverage itself.
South Dakota’s page puts the change on a longer calendar. Some noncitizens lose Medicaid eligibility on October 1, 2026. On January 1, 2027, expansion enrollees move to renewals every six months and retroactive coverage drops from three months to one month for expansion adults. The cost shares arrive last, on October 1, 2028, which means every expansion enrollee passes through at least two renewals under the new schedule before the first copayment is due.
Planning for South Dakota’s Medicaid cost shares
The free source is South Dakota’s own H.R.1 page, which lists the cost-sharing rules beside the renewal, work-requirement and retroactive-coverage changes. It names the exempt services and says the copayment ceiling is $35. The Department of Social Services also lists a Health Insurance Marketplace line, 800-318-2596, for people who lose Medicaid coverage.
The detail to track is income relative to the poverty line, because that line decides whether any cost share applies. The state has not published a fee for each service, and the statute leaves the amount to each state “greater than $0,” so South Dakota’s final schedule is the document that settles what a visit costs. Until then the $35 ceiling and the 5 percent family limit are the only hard numbers.
The federal statute and the state page agree on the structure: a charge only on services outside the exemption list, a ceiling per service and a ceiling per family. What neither fixes is how many expansion adults will see a charge, since that depends on income against the poverty line and on which services a person uses. Public Law 119-21 sets the start at October 1, 2028, and South Dakota’s agency has said it will follow that date.
Six-month renewals come before 2028 copays
Expansion adults in South Dakota renew every six months starting January 1, 2027, and coverage has to be kept before any copayment applies. The SNAP & Medicaid Renewal Organizer holds a renewal and reporting calendar and a pack for each of the 51 states, so the 2027 dates are written down ahead of the 2028 charges.
Get the Medicaid renewal and reporting calendar in the SNAP & Medicaid Renewal Organizer →
This article was produced with AI assistance and reviewed by The Money Overview’s editorial team.
