DAKOTACARE: North Sioux City

Frequently Asked Questions

At DAKOTACARE, it's our goal to help you fully understand your health care coverage, so we have put the answers to our most commonly asked questions here. Take a moment to read them, and if you don't see the answer you're looking for, contact us, and we’ll find it for you.

NOTE:  The following questions and responses apply to DAKOTACARE group and individual (HMO) plans only.  They do not apply to self-funded plans with DAKOTACARE Administrative Services, Inc. (DAS).  If you are uncertain of your plan type, check your ID card, ask your plan administrator, or call DAKOTACARE.

Q1: My company doesn't offer vision coverage.  Can I purchase it from DAKOTACARE myself?
A1:  Vision coverage or any other optional rider benefits can only be purchased by your employer.  DAKOTACARE offers only group coverage.  However, it may be a good idea to let your employer or Human Resource department know that you are interested in additional coverage.  They may want to add it to their current plan at renewal time. 

Q2: How long is my child covered after he/she graduates from high school? College?
A2:  A dependent who graduates from high school and does not continue on as a full-time student is covered through their 26th birthday (unless totally disabled).  However, full-time students, are covered until their graduation month or their 29th birthday (whichever comes first) as long as they did not obtain the age of 24 prior to July 1, 2007.

Q3: How long does it take for DAKOTACARE to process an application for coverage?
A3:  It takes 5-10 days for our office to process an enrollment application. It is important to be thorough when filling out the application as it can delay processing if there is any missing information. A delay in processing would mean that any claims would be suspended, and ID cards would be held until the missing information has been collected.

Q4: When should I call Customer Service?
A4:  Any time you have questions on how your plan works, or inquiries on claim payments. Call us toll free at 1-800-325-5598 or email us at customer-service@dakotacare.com.

Q5: Do copayments count toward my out-of-pocket maximum?
A5:  No, but deductibles and coinsurance count toward your out-of-pocket maximum.

Q6: I just found out that my chiropractor is not a "participating provider".  What does this mean for coverage, and is there something I can do about it?
A6:  As of January 1, 1998, chiropractic services are covered only if your chiropractor is a participating provider, which means he/she must be a member of the Chiropractic Associates of South Dakota (CASD).  If your chiropractor is a non-CASD provider, one thing you can do is encourage him/her to join the CASD Network so that his/her services may be covered.  NOTE:  There would be an exception if you live outside South Dakota and receive services from a non-network chiropractor.

Q7: I have a Choice plan. When does the $25 copayment apply vs. the deductible and coinsurance?
A8:  The copayment covers the office visit component of any physician's services when you are seen for a medical diagnosis.  Please see your plan description for more details.

Q8: Why was my claim denied for pre-existing conditions?
A10:  Until a member has been covered for a period of 12 months, as shown by the records of DAKOTACARE, payment shall not be made for expenses incurred due to any illness, injury or condition which existed during the six month period prior to the date of enrollment if, during that time any professional medical advice, diagnosis, care or treatment, was recommended or received by the member.  Please see your Member Handbook.

Q9: I have five dependents on my plan. Do we all need to meet the deductible and coinsurance requirements?
A11:  No, DAKOTACARE applies a single maximum for deductibles and coinsurance for individuals or, if a family, a family maximum which accumulates amounts for any and all dependents in total.

Q10: How long do I have to add a newborn baby to the policy?
A12:  Your application for coverage must be completed within 30 days after a "qualifying event" to add dependents to your health plan.  This 30-day period is called a special enrollment period.  A special enrollment period occurs due to an event such as a birth, adoption, marriage or involuntary loss of coverage.

Q11: If I don't put my spouse and children on my application when I first apply for coverage, can I add them later?
A13:  After you have met any internal waiting period, you have 30 days to submit an application for you and/or your spouse and children.  If you choose to waive coverage at that time for either yourself or your dependents, you must then wait until the next open enrollment period offered by your employer.  Your employer will offer an open enrollment period once a year during the month prior to their renewal date.  You may complete an application anytime during that month for you and/or your dependents.  However, you must show proof of previous creditable coverage for the past 18 months (without a break longer than 63 days) or you will receive up to 18 months of pre-existing condition limitation.

Q12: My spouse has lost his coverage and would like to apply for mine. What type of documentation do we need from his previous insurance carrier?
A14:  If your spouse has lost his/her previous coverage involuntarily and would like to apply for coverage with DAKOTACARE, you must request a Certificate of Coverage from the prior plan and attach it to the DAKOTACARE enrollment application.  All individuals applying for coverage must provide a Certificate of Coverage to avoid waiting periods for pre-existing conditions.

Q13: Where do I call to find out if a certain medication is covered or to find out how much my co-pay would be for a certain medication?
A16: Please contact CVS Caremark at 1-866-406-8773 for any pharmacy questions.  CVS Caremark is the company chosen by DAKOTACARE to manage your pharmacy benefits to help you save money and get the best service on prescriptions for you and your family.  (Note: If you are a member of the State of South Dakota Health Plan, the South Dakota Risk Pool, or the South Dakota QuitLine, please contact Express Scripts, Inc. (ESI) at 1-877-212-9529 for your pharmacy questions.)