PIERRE | As Gov. Dennis Daugaard considers whether to expand Medicaid coverage to more low-income South Dakota residents, he is seeking assurances the expansion can be paid for, and may add a requirement that new recipients must have jobs.

Daugaard may reveal his intentions in his budget address to the state next week, a top aide said Thursday.

The governor has been seeking definite proof that the $46 million annual cost for Medicaid expansion starting in 2020 can be covered by savings on current spending on Medicaid services in South Dakota, a member of his senior management team said.

State Health Secretary Kim Malsam-Rysdon told members of the governor’s Health Care Solutions Coalition that the governor remains interested in requiring work for new Medicaid recipients in return for receiving services under the expansion. The matter is in discussion with the federal Centers for Medicare and Medicaid Services, she said.

“We want people to work,” she explained. “I would expect us to look at that further.” She explained it was a value statement on the part of the governor. “We need workforce across our state,” she said.

An estimated 49,000 more people could be covered by the Medicaid expansion, according to state officials. People could receive Medicaid services if their incomes didn’t exceed 133 percent of the federal poverty level. For a one-person household, that amount is $15,889.50 this year.

Thirty states have approved Medicaid expansion as part of the federal Affordable Care Act; South Dakota so far has not. Daugaard’s concern is the federal government could require states at some later date to pay more than the 10 percent match that is scheduled to start in 2020.

The coalition is working with the federal Medicaid agency on the potential for South Dakota to receive relief from being billed by the federal Indian Health Service when a tribal member is sent to a non-HIS medical provider.

State government frequently pays about half of the costs in those instances.

The bottom-line question for the governor is whether eliminating that IHS requirement in turn would provide enough savings to pay for Medicaid expansion.

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At the same time, tribal members don’t want to lose existing services.

“My concern is for the tribes running their own program,” said Jerilyn Church, of Rapid City. She and Malsam-Rysdon are the co-chairwomen of the coalition.

Church, a member of the Cheyenne River Sioux Tribe, is chief executive officer for the Great Plains Tribal Chairmen’s Health Board. She said there aren’t enough primary-care doctors to go around in the state of South Dakota.

“We don’t want to limit access and we’re going to look for every means possible to address it,” Church said. The federal trust responsibility to provide Native American people with health care isn’t based on income, she said. The challenge is finding ways to leverage federal IHS funding to provide more services to more people, she said.

The coalition is looking at services that could be added for tribal members as part of the arrangement.

The coalition members are considering use of tele-health hubs to connect doctors and clinics, offering broader pre-natal care and behavioral health services, making community health representatives available to help people navigate within the health systems and adding partnership projects involving several tribal governments.

Rep. Don Haggar, R-Sioux Falls, expressed doubt that the swap will work out financially. “We’re underestimating the cost; that’s my concern,” said Haggar, who serves on the coalition.

The coalition hasn’t made its formal recommendations. A final meeting of the main group is set for Dec. 16. That comes one week after the governor’s speech and four weeks before the opening day of the 2016 session of the Legislature.

Malsam-Rysdon said the coalition isn’t interested in paying for subsidies to enroll people in insurance policies or providing co-pay assistance.

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