(New 7/1/2014 ML #3404)

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The Medicaid Program was authorized in 1965 during a special session of the North Dakota Legislature for the purpose of strengthening and extending the provision of medical care and services to certain groups of people whose resources are insufficient to meet such costs. Medicaid began in North Dakota effective January 1, 1966. Corrective, preventive and rehabilitative medical services are provided to help individuals and families retain or attain capability for independence, self-care, and self-support.

In 2010, the Patient Protection and Affordable Care Act of 2010 commonly called the Affordable Care Act (ACA) , was signed into law by President Obama on March 23, 2010. This law represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965, with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the costs of healthcare for individuals and the government.

In 2013, the North Dakota Legislature approved the expansion of the Medicaid Program as a result of the passage of the Affordable Care Act. The expanded Medicaid program is available to individuals between the ages of 21 and 65 with household incomes up to 138% of the federal poverty level (FPL).

(New 7/1/14 ML #3404)

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It is known that in addition to imposing financial difficulties, illness and health problems have their effects on personality functioning and interpersonal relationships. Illness can be used as an escape from unpleasant responsibilities and can distort family relationships. Unmet health needs can, therefore, be detrimental to the overall growth and adjustment of individuals and families.

The immediate purpose of the Medicaid Program is to provide an effective base upon which to provide comprehensive and uniform medical services that will enable persons previously limited by their circumstances to receive needed medical care. It is within this broad concept that the Medicaid Program in North Dakota participates with the medical community, to the greatest extent possible, in attempting to strengthen existing medical services in the state.

(New 7/1/2014 ML #3404)

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Following are instructions relating to applications for ACA Medicaid . Additional information concerning administrative procedures, application processing, case maintenance, and appeals are contained in Service Chapter 448-01 through 448-01-60.

(New 7/1/14 ML #3404)

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Public Law 88-352, Section 601 (Title VI) of the Civil Rights Act of 1964 states:

No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." (Section 504 of the Rehabilitation Act of 1973 as amended, prohibits discrimination solely on the basis of handicap for those otherwise qualified.)

The Department of Human Services makes available all services and assistance without regard to race, color, religion, national origin, age, sex, political beliefs, disability, or status with respect to marriage or public assistance, in accordance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990, and the North Dakota Human Rights Act of 1983. Persons who contract with or receive funds to provide services for the North Dakota Department of Human Services are obligated to abide by the provisions of these laws. The Department of Human Services makes its programs accessible to persons with disabilities. Persons needing accommodation or who have questions or complaints regarding the provisions of services according to these Acts may contact the Civil Rights Officer, North Dakota Department of Human Services, Judicial Wing, State Capitol, 600 E. Boulevard, Bismarck, ND 58505 or the US Department of Health and Human Services, Office for Civil Rights, Region VIII, 999 18th Street, Suite 417, Denver, Colorado 80202 or call 1-800-368-1019 or 1-800-537-7697 (TTY) or 303-844-2025 (FAX).

Refer to Service Chapter 300-01, Non-discrimination to Clients, for additional guidelines.

(Revised 9/1/2021 ML #3636)

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All applications, information and records concerning any applicant or recipient of Medicaid shall be confidential and shall not be disclosed or used for any purpose not directly connected with the administration of the Medicaid program. Application, information and records may not be released to elected officials or to any other person not directly connected with the administration of the Medicaid program. Refer to Service Chapter 448-01-25 for additional guidelines.

Federal law and regulations:

Federal law and regulations require that the State Plan have protections in place to ensure that the use or disclosure of information concerning applicants and recipients be limited to purposes directly connected with the administration of the plan. Those purposes include establishing eligibility, determining the amount of medical assistance, providing services, and conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the plan. (42 U.S.C. § 1396a(a)(7); 42 C.F.R. § 431.300-306).

NOTE: Information from certain sources may not be released, even with a signed release form. For details see 448-01-25-10-05 “Confidential Information that Must Not be Released”.

Since there are many federal requirements when releasing client information, it is recommended that the SFN 1059, Authorization to Disclose Information, be used, as this form was developed to meet all of those requirements. If any other form is used, contact State Medicaid Policy to confirm that it meets federal requirements.

Sharing income, household composition, etc. information with social work staff:

Information cannot be released unless the applicant or recipient has authorized the release of information (form or verbally).

Sharing information with Social Workers for investigations of abuse, neglect, or protective services:

Information requests by social workers are not made for the purpose of administration of Medicaid, but are with regard to abuse investigations. The family may not be receptive, but that is not a valid reason to release the information. A signed release is necessary to share specific information about the child/family. ‘Protective Service Alerts’ from the North Dakota Department of Health and Human Services , Children and Family Services (CFS) Division and other States are often sent to all county staff. These alerts request information regarding the family’s whereabouts. These alerts, do not fall under ‘administration of the Medicaid program’ so specific information cannot be released. However, it is allowable to disclose the county and state in which the individual is residing and the county social service office that may be contacted for child protective service information, to the requestor as well as to their own county child protective service unit. Any additional information, including ‘How eligibility staff knows this information’ or ‘The family has applied or is receiving services’ may not be disclosed.

Sharing information with Child Support and other specific assistance programs:

Can share information with Child Support as federal regulations specifically require. Can share information between Medicaid and SSA for Title II and Title XVI benefits as federal regulations specifically require. Can share information between TANF and SNAP per federal regulations to coordinate benefits between the programs.

Sharing information with Foster Care social workers when an application is received and the child is already on Medicaid:

The county has care, custody, and control, so is acting on behalf of the child. Also, the child is going from one Medicaid case to another for the purpose of establishing eligibility. Copies of identifying information such as a birth certificate may be made for the Foster Care file so that both files contain the proper documentation. Only pertinent information needed to determine the child’s eligibility should be provided. A social worker needs the parent’s income information to determine if the child is IV-E eligible. If that has been established, the social worker should NOT be requesting the information, nor should the eligibility worker be releasing it without a signed release of information.

Sharing information with Law Enforcement:

Medicaid cannot provide information about a specific applicant or recipient to law enforcement unless it has to do with administration of Medicaid.

Release of information on application:

These statements allow county and state staff to obtain information from other sources, but do not give permission to release information to others.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-09)

The assignment of rights to benefits is automatic under North Dakota Century Code sections 50-24.1-02 and 50-24.1-02.1. The assignment is effective to the extent of actual costs of care paid under the North Dakota Medicaid Program. As a condition of eligibility, the applicant or recipient may be required to execute a written assignment whenever appropriate to facilitate establishment of liability of a third party or private insurer. Form SFN 560, "Assignment of Benefits," may be used for this purpose. If it becomes necessary to secure signatures on additional documents, specific instructions will be provided on a case-by-case basis.

The Department and county agency must take reasonable measures to obtain from the applicant or recipient health coverage information to determine the liability of third parties and private insurers.

For purposes of this section: "Private insurer" includes any commercial insurance company offering health or casualty insurance to individuals or groups, including both experience-related insurance contract and indemnity contracts; any profit or nonprofit prepaid plan offering either medical services or full or partial payment for services covered by the Medicaid program; and any organization administering health or casualty insurance plans for professional associations, employer-employee benefit plans, or any similar organization offering these payments or services, including self-insured and self-funded plans. "Third party" means any individual, entity, or program that is or may be liable to pay all or a part of the expenditures for services furnished under Medicaid, including a parent or other person who owes a duty to provide medical support to or on behalf of a child for whom Medicaid benefits are sought.

(Revised 11/1/2020 ML #3600)

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The SFN 20 “SURS Referral Form” must be completed in all instances where there is a suspicion of fraud.

To assist with determining what constitutes a suspicion of fraud the following items should be considered:

Was information listed on the application(s) on file false? —meaning they were employed or had other assets or household members, etc., that were not disclosed at the time of application

Were false statements made by the household member – meaning denying (specifically indicated no) assets or employment on a certain date when there really were assets or employment

Recipient admitted they knew they should have reported

Other proof or evidence there was false information given in order to receive benefits

If you have any questions regarding determining a suspicion of fraud you may contact the Fraud, Waste, and Abuse Administrator at 701-328-4024 or via email medicaidfraud@nd.gov .

(Revised 1/1/2022 ML #3652)

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No lien or encumbrance of any kind shall be required from or be imposed against the individual's property prior to his death, because of Medicaid paid or to be paid in his behalf (except pursuant to the judgment of a court incorrectly paid in behalf of such individual). (42 CFR 433.36)

A recovery of Medicaid correctly paid will be made from the estate of an individual who was 55 years of age or older when the recipient received such assistance or who had been permanently institutionalized regardless of age, with the exception of payments made for coverage through a private carrier. Recovery is pursued only after the death of the recipient's spouse , if any, and only at a time when the recipient has no surviving child who is under age 21, or who is age 21 or older and who is blind or permanently and totally disabled defined by the Social Security Administration. Note : Individuals eligible under Medicaid Expansion currently receive their coverage through an Alternative Benefit Plan (ABP), which is considered receiving coverage through a private carrier. Effective August 1, 2015, the department CANNOT file a claim against the estate to recover premiums paid by Medicaid, for insurance received through a private carrier, which meets this definition. All other Estate Recovery provisions remain unchanged.

The recovery of Medicaid paid for individuals under age 65 is only for assistance paid on or after October 1, 1993. Medicaid benefits incorrectly paid because of a recipient error can be recovered regardless of the individual’s age at the time the assistance was received. Overpayments due to recipient errors that are still outstanding are subject to recovery upon the individual’s death without regard to whether or not there is a surviving spouse ‘Permanently institutionalized individuals ’ are persons who, before reaching age 55, began residing in a nursing facility, the state hospital, an intermediate care facility for mental disease (IMD), a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for the intellectually disabled (ICF-IID), or receiving swing bed care in hospitals, resided there continuously for at least six months and did not subsequently reside in any other living arrangement for at least 30 consecutive days, and have received written notice that they are consider to be permanently institutionalized. Permanently institutionalized individuals have a right to appeal their permanently institutionalized status.

Individuals applying for coverage under ACA Medicaid may have other insurance coverage except for individuals eligible under the Optional Children's Group (COE 078).

There is no penalty for individuals who drop their Health Insurance coverage when they apply for ACA Medicaid, with the exception of those determined eligible under ACA Healthy Steps through December 31, 2019. Effective January 1, 2020, the penalty for dropping Health Insurance Coverage will no longer be effective.

(Revised 4/1/2020 ML #3576)

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States are required to pursue known third parties that may be liable to pay for care or services. The Department and county agency are required to make reasonable efforts to obtain the necessary information needed to pursue third parties. This includes following up on any leads that indicate there may be a third party payer, and assisting applicants and recipients in obtaining necessary information.

As a condition of eligibility, legally able applicants or recipients and their spouse s must cooperate with the Department and county agency in identifying and providing information to assist Medicaid in pursuing third parties who may be liable to pay for care or services, unless there is good cause not to cooperate.

This policy is not intended to place an unreasonable burden on applicants or recipients, or to shift the state's responsibility to pursue third parties. If Department and county staff have the ability to obtain the information, it cannot be shown that an applicant or recipient is not cooperating. If the necessary information cannot be obtained without the applicant or recipient’s cooperation, and the applicant or recipient has the ability to assist, this provision applies. As part of cooperation, the Department or agency may require an individual to:

Appear at a state or local office designated by the Department or county agency to provide verbal or written information or evidence relevant to the case;

Appear as a witness at a court or other proceeding;

Provide information, or attest to lack of information, under penalty of perjury;

Complete SFN 566 , "Medicaid Questionnaire and Assignment," (which is available on eforms).

Pay to the agency any medical payments received that are covered by the assignment of benefits; and

Take any other reasonable steps to assist the state in securing third party payments and in identifying information to assist the state in pursuing any liable third party.

An exception to cooperation exists when the recipient is receiving Extended or Transitional Medicaid Benefits.

It is never a condition of a child’s eligibility that a parent or caretaker cooperates. A parent or caretaker who does not cooperate will not be eligible for Medicaid, but the children in the ACA Medicaid Household remain eligible. When a parent or legally responsible caretaker relative is not eligible because they are not cooperating, the earned and unearned income of that individual must still be considered in determining eligibility for the ACA Medicaid Household.

The determination of whether an applicant or recipient is cooperating is made by the county agency in conjunction with their Economic Assistance regional representative. The determination may be based on information received from the Third Party Liability unit. The applicant or recipient has the right to appeal the decision.

When an applicant initially applies for Medicaid, it can usually be assumed that there will be cooperation. If the recipient then fails to cooperate, without "good cause," eligibility for that recipient is terminated. For applications in which a recipient clearly states that he or she will not cooperate, and there is no "good cause," that recipient is ineligible for Medicaid. Once the individual begins cooperating, eligibility can be restored or established. Eligibility can begin retroactively if the individual cooperates for the period to be covered. If an individual who failed to cooperate, and eligibility was terminated, later reapplies for assistance, the individual will remain ineligible until the individual begins to cooperate.

(New 7/1/2014 ML #3404)

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The requirement to cooperate may be waived when an applicant or recipient has "good cause" not to cooperate.

There is no particular form used to claim "good cause"; however, the applicant or recipient will need to provide information and evidence to substantiate the claim. If "good cause" is claimed the applicant or recipient can be eligible for Medicaid while the decision is pending.

The determination of whether there is good cause is made by the county agency . The county agency may waive the requirement to cooperate if it determines that cooperation is against the best interests of a child in the unit. Cooperation is against the best interests of a child only if the applicant or recipient’s cooperation is reasonably anticipated to result in:

Physical or emotional harm to a child in the ACA Medicaid Household; or

Physical or emotional harm to the parent or caretaker with whom the child is living, of such nature or degree that it reduces such person’s capacity to care for the child adequately.

There must be evidence to substantiate a claim of "good cause." Exemptions on the basis of physical or emotional harm, either to the child, parent, or caretaker must be of a genuine and serious nature. Mere belief that cooperation might result in harm is not a sufficient basis for finding "good cause." Evidence upon which the county agency bases its finding must be supported by written statements and contained in the case record.

It is the applicant or recipient’s responsibility to provide the county agency with the evidence needed to establish "good cause." The applicant or recipient is normally given 20 days from the date of claim to collect the evidence. In exceptional cases, the county agency may grant reasonable additional time to allow for difficulty in obtaining proof. Records of law enforcement, social service, or adoption agencies may be readily available to document instances of physical harm, perhaps without requiring further investigation. Documentation of anticipated emotional harm to the child, parent, or caretaker, however, may be somewhat more elusive. Whenever the claim is based in whole or in part on anticipated emotional harm, the county agency must consider the following:

The present emotional state, and the emotional health history, of the individual subject to emotional harm;

The intensity and probable duration of the emotional impairment;

The degree of cooperation to be required; and

The extent of involvement of the child in pursuing third parties who may be liable to pay for care or services.

Upon request, the county agency is required to assist the applicant or recipient in obtaining evidence necessary to support a "good cause" claim. This, however, is not intended to place an unreasonable burden on staff, shift the applicant or recipient’s basic responsibility to produce evidence to support the claim, or to delay a final determination.

The county agency is directly responsible for investigating a "good cause" claim when it believes that the applicant or recipient’s claim is authentic, even though confirming evidence may not be available. When the claim is based on a fear of serious physical harm and county agency staff believes the claim, investigation may be conducted without requiring corroborative evidence by the applicant or recipient. It may involve a careful review of the case record, evaluation of the credibility of the applicant or recipient’s statements, or a confidential interview with an observer who has good reasons for not giving a written statement. Based on such an investigation, and on professional judgment, the county agency may find that "good cause" exists without the availability of absolute corroborative evidence.

Except for extenuating circumstances, the "good cause" issue must be determined with the same degree of promptness as for the determination of other factors of eligibility (45 days). The county agency may not deny, delay, or discontinue assistance pending the resolution of the "good cause" claim.

The applicant or recipient and the Third Party Liability unit must be informed of the "good cause" decision. The applicant or recipient must be informed, in writing, of the county agency’s final decision that "good cause’ does or does not exist and the basis for the findings. A copy of this communication must be maintained in the case record. If "good cause" was determined not to exist, the communication must remind the applicant or recipient of the obligation to cooperate if he or she wishes to be eligible for Medicaid, of the right to appeal the decision, and of the right to withdraw the application or have their eligibility terminated.

The county agency must review the "good cause" decision at least every twelve months. If "good cause" continues to exist, the applicant or recipient must again be informed in writing. If circumstances have changed so "good cause" no longer exists, the applicant or recipient must be informed, in writing, and given the opportunity to cooperate, terminate assistance, withdraw the application, or appeal the decision. The Third Party Liability unit must also be informed of whether or not "good cause" continues to exist.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-12.1)

Any recipient of Medicaid benefits, who is enrolled in a cost-effective health plan, may have the health plans premium paid by Medicaid. (This provision began in North Dakota in June 1993.)

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-12.1)

For purposes of the cost-effective health insurance sections:

Cost-effective" means that Medicaid payments for a set of Medicaid-covered services are likely to exceed the cost of paying the health plan premium, coinsurance charges, and deductibles for those services.

"Health plan" means any plan under which a third party is obligated by contract to pay for health care provided to an applicant for or recipient of Medicaid.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-12.1)

Applicants for and recipients of Medicaid benefits must provide the information necessary to determine if a health plan is cost-effective.

Recipients with a health plan the Department has determined is cost-effective must cooperate with all of the conditions or requirements of the health plan. Applicants and recipients must take any optional coverage provided through the plan when it is cost-effective to do so. Failure to cooperate with plan requirements, or to select cost-effective options of the plan, will: Result in termination of payments for the health plan premiums; and Result in nonpayment for services, by Medicaid , which the health plan would pay, or would have paid, had the recipient conformed to the requirements of the health plan.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-12.1)

Health plans requiring a formal cost-effective determination should be submitted to the Medicaid Eligibility Division on SFN 817, "Health Insurance Cost-Effectiveness Review," along with any other information the worker feels is pertinent (i.e. a copy of the health plan, available payment reports, information regarding pre-existing conditions . . .). The form asks for information about the policy coverage, the individuals covered, and the premium. The Medicaid Eligibility Division will obtain or request any additional information needed and will make a timely determination (within 15 days) of cost-effectiveness. The county agency will be notified of that determination. An application for assistance should not be held up beyond the standard of promptness pending a cost-effective determination.

When an individual has more than one health plan, both plans may be considered cost-effective if they do not provide duplicate coverage.

If an individual is eligible for Medicare Part B, but is not enrolled in Part B, enrollment in any other health plan is not considered cost-effective.

Premium payments normally are only allowed for eligible Medicaid recipients. A family policy, however, may cover ineligible members. Payment of the full premium amount is allowed when it is determined that the health plan is cost-effective. The needs of the ineligible family members are not taken into consideration when determining cost-effectiveness.

The following health plans are usually not considered to be cost-effective.

Medicare supplement policies for individuals with routine medical needs (the exceptions are recipients with higher medical needs and the recipient's covered costs exceed the premium);

Hospital indemnity policies if the recipient is not currently collecting benefits;

Policies where the absent parent is the policy holder;

Specific illness policies (i.e. cancer ins.) if the individual covered does not have the illness;

Accident insurance policies, if the recipient is not currently collecting benefits; or

Policies where all of the members of the ACA Medicaid Household, who are covered by the health plan, have a client share (recipient liability).

If the cost-effectiveness of any of these policies is questionable, the policy should be submitted to the Medicaid Eligibility Division for a formal determination.

All cost-effective health plans must be reviewed at least annually.

Changes in a plan’s, premium, coverage or individuals included in the plan must be reported to the Medicaid Eligibility Division.

Cost-effective health plan premiums will be paid effective with the month in which the information is sent to the Medicaid Eligibility Division for approval or is required to maintain the health plan.

(Revised 11/1/2025 Release 25.14 )

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(N.D.A.C. Section 75-02-02.1-02)

Application.

All individuals wishing to make application for Medicaid must have the opportunity to do so, without delay.

A relative or other interested party may file an application on behalf of a deceased individual to cover medical costs incurred prior to the deceased individual's death.

An application is a request for assistance on a prescribed form designed and approved by the North Dakota Department of Health and Human services.

There is no wrong door when applying for Medicaid or any of the Healthcare coverages. The experience needs to be as seamless and with as few barriers as possible.

North Dakota Medicaid applications must be maintained electronically in the case file.

A prescribed application form must be signed by the applicant, an authorized representative or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant.

The date of application is the date an application, signed by an appropriate person, is received at a zone office, the Medical Services Division, a disproportionate share hospital, or a federally qualified health center. The date received must be documented. Applications received electronically are considered received based on the time/date stamp Applications received in person must be date stamped as received when the individual delivers it to the zone office. Applications left in a drop box refer to policy at 448-01-15-10

Note: Applications must be registered in the eligibility system as soon as possible upon receipt, but no later than the fifth day following receipt. Applications will be considered received on the day submitted.

An application is required to initially apply for Medicaid, to re-apply after a Medicaid application was denied, to re-apply after a Medicaid case has closed, or to open a new Medicaid case for a child who has been adopted through the state subsidized adoption program.

Zone offices must accommodate any recipient requesting to have a face-to-face or telephone interview when applying for Medicaid. However, an interview is not required to apply for assistance.

Information concerning eligibility requirements, available services, and the rights and responsibilities of applicants and recipients must be furnished.

Acceptable forms for applying for Medicaid:

The Department's online "Application for Assistance", located at https://applyforhelp.nd.gov The electronic file received by the state from the Federally Facilitated Marketplace (FFM) containing the single streamlined application; or The SFN 1909 "Application for Health Care Coverage and Help Paying Costs"; or Telephonic applications utilizing any one of the prescribed applications; or SFN 405, "Application for Assistance"; or SFN 641, "Title IV-E/Title XIX Application- Foster Care"; or Applications provided by disproportionate share hospitals or federally qualified health centers are SFN 405 with "Hospital" stamped on the front page; or Interstate Compact on Adoption and Medical Assistance (ICAMA) for 6.01 "Notice of Medicaid Eligibility/Case Activation" stating North Dakota is responsible for the Medicaid coverage of the specific child; or SFN 958, " Health Care Application for the Elderly and Disabled". However, notification must be sent to the individual requesting information needed to make the ACA eligibility determination; or SFN 1803, "Subsidized Adoption Agreement"; or The Low-Income Subsidy (LIS) file from SSA

2. Review

A review requires the evaluation of all financial and non-financial requirements affecting eligibility. This will include income, household composition, health insurance coverage and citizenship status, listed in the case file, reported, and verified on the most recent application or review form, and verifications received from all electronic sources.

Information that is not subject to change, such as US citizenship, date of birth, SSN, etc., does not usually need to be reviewed. However, if questionable, the information needs to be verified. Passive Reviews: A Passive Review is the annual twelve-month review of eligibility. Information available in the case file is reviewed along with the available electronic verification sources. PASSES Reasonable Compatibility- If able to renew eligibility based on the information available, the case is processed, and the household must be notified of the eligibility determination and basis of eligibility The individual/household must inform the agency if any of the information contained in the notice is inaccurate. The individual is not required to sign and return such notice if all information in the notice is accurate. FAILS Reasonable Compatibility- A passive review verification notice and pre-populated review form needs to be sent. To complete the review, the pre-populated review form and required verifications must be returned. If both are not returned, eligibility will close the last day of the month in which the review is due The individual has 90 days after the termination to provide the pre-populated review form and verifications. Based on the information received, eligibility must be reconsidered back to the termination date. Ex Parte/Desk Reviews: A review completed when a zone office becomes aware of or has received information indicating a change. Examples: adding a household member, processing a change in level of care, adding Medicare Savings Program coverage, when an ineligible household member is requesting eligibility, when eligibility is lost under a category (e.g., SSI to non-SSI , Expansion to ABD coverage), aligning review dates with SNAP or TANF. When the zone office has all information needed to determine eligibility based on a change in circumstances, a review form does not have to be sent. When more information is needed to determine eligibility, a request for verification along with a pre-populated review form must be sent.

Additional information when completing a review:

A recipient has the same responsibility to furnish information during a review as an applicant has during an application. An online narrative must document the completion of the review A review must be completed within thirty days after a county agency has received information indicating a possible change in eligibility status. A review, using one of the forms identified, in acceptable review form section, is required to open a New Medicaid case for recipients who move from an existing case to their own case. (e.g. an 18-year-old attains age 19, moves out of the parental home, on other than a temporary basis.) Zone offices must accommodate any recipient requesting to have a face-to-face or telephone interview for their review. However, an interview is not required to complete a review Reviews must be completed and processed no later than the last working day of the month in which they are due. It is permissible to complete an early review of a child's eligibility for Medicaid and CHIP. However, the household may not be required to provide any information that is needed specifically for determining only the eligibility of the Medicaid and CHIP children who were determined to be continuously eligible. The family may voluntarily provide specific information but must not be required to do so.

If all factors of eligibility are reviewed:

If the child is found to be eligible for Medicaid (other than Medically Needy), eligibility must be authorized for Medicaid and the child will be given a new twelve-month continuous eligibility period. If the child is found to be NOT eligible for Medicaid (other than Medically Needy), the child may not be terminated at the time of the early review unless the child meets one of the state's exceptions to terminate continuous eligibility. They would remain eligible for the remainder of the original continuous eligibility period and a review would be required at that time.

Acceptable forms for completing a review:

A review received through the North Dakota Self Service Portal (SSP) for Medicaid System generated Review or "Monthly/Change Report"; SFN 642, "Title IV-E/Title XIX Redetermination- Foster Care" for children in Foster Care, or other confirmation from a state IV-E agency (in state or out of state) that verifies continued IV-E foster care eligibility; One of the previously identified applications; or When completing a review for children eligible for subsidized adoption assistance, receipt of one of the above review forms is not required. However, the following two criteria must be verified: The child remains a resident of North Dakota; and The child continues to be eligible for the subsidized adoption program In addition, contact should be made with the household to determine whether the child has obtained or lost insurance coverage.

(Revised 1/12/2023 ML #3696)

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(N.D.A.C. Section 75-02-02.1-10)

Current eligibility may be established from the first day of the month in which the signed application was received.

Retroactive eligibility may be established for as many as three calendar months prior to the month in which the signed application was received. Eligibility can be established if all factors of eligibility are met during each month of retroactive benefits. If a previous application has been taken and denied in the same month, eligibility for that entire month may be established based on the current application. Retroactive eligibility may be established even if there is no eligibility in the month of application.

All case records shall be documented to reflect eligibility or ineligibility for each individual month assistance is requested prior to and through the month in which the application is processed.

An individual determined eligible for part of a month is eligible for the entire calendar month unless a specific factor prevents eligibility during part of that month. Examples of specific factors include:

An individual is born in the month, in which case the date of birth is the first date of eligibility;

An individual enters the state, in which case the earliest date of eligibility is the date the individual entered the state unless still receiving Medicaid benefits from another state. Information regarding the date Medicaid benefits from the other state are no longer available should be established in order to determine the beginning date of eligibility in North Dakota; or

An individual is discharged from a public institution , in which case the earliest date of eligibility is the date of discharge.

A child cannot be eligible for Medicaid for the same period of time the child is covered under the Optional Children's Group.

For an ongoing Medicaid case, coverage may be added retroactively up to 12 months for a non-covered household member, provided the individual lived in the household during the months requested.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-02.1)

It is the responsibility of the applicant or recipient to provide information sufficient to establish the eligibility of each individual for whom assistance is requested, including, but not limited to, the furnishing of a social security number, and establishing age, identity, residence, citizenship, and financial eligibility in each of the months in which Medicaid benefits are requested.

Requesting information from an individual or household that is already available to the worker through other sources is prohibited.

No age, residence, citizenship, or other requirement that is prohibited by Title XIX of the Social Security Act will be imposed as a condition of eligibility.

(New 7/1/2014 ML #3404)

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All applicants for ACA Medicaid must be provided the "Application for Assistance Guidebook" or, in place of the guide book:

A brochure entitled " Medicaid " (376kb pdf) outlining the services available under the Medicaid Program;

A brochure entitled "Your Civil Rights" (152kb pdf);

A notice entitled " Notice of Privacy Practices " (18 kb pdf) (DN 900 which is available in E-Forms);

All households with individuals of childbearing age must be made aware of the opportunity they have to receive family planning services and must be given a brochure entitled "Family Planning-Choosing Your Family Size," or " Family Planning Program ";

All households with individuals under the age of twenty-one must be made aware of the availability of " North Dakota Health Tracks " (early and periodic screening, diagnosis and treatment services) and be given the brochure entitled "ND Health Tracks"; and

All households with pregnant, breast feeding or postpartum women, or children under age five, must be made aware of the availability of the WIC (Women, Infants, and Children) Program, and must be provided a " WIC " outreach brochure.

(Revised 2/21/2025 ML #3907 )

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CFR 431.210 - 431.214

(N.D.A.C. Section 75-02-02.1-03)

Applicants and recipients may choose the method by which they are notified of their eligibility status. They may choose paper, electronic, or through their ND Client portal account.

A decision as to eligibility will be made promptly on applications, by the forty-fifth day, except in unusual circumstances. When these time periods are exceeded, the case must contain documentation to substantiate the delay. Consideration must be given to weekends and holidays to ensure notices are sent by the appropriate timeframe. See #5 below for further information.

Following a determination of eligibility or ineligibility, an applicant must be notified of either approval or denial of Medicaid . The notice must address eligibility or ineligibility for each individual month requested including all prior months and through the processing month.

Section 1902 of the Social Security Act requires that Medicaid ID Cards and Health Care Coverage notices be made available to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address. To meet these federal regulations, when an individual applies for Health Care Coverage and does not have a residential or mailing address, or is unable to utilize a friend or relative’s address to receive their mailing, the County Social Service Office address must be used for the individual. Example: Applicant’s Name c/o XXXXX County Social Service Office 123 Main Street Any town, ND 58111 When an individual applies for Health Care Coverage, and does not have an address to receive his/her mail, the individual must be informed of the following: The individual will be required to pick up their mail at the county office on a weekly basis; and Failure to pick up their mail for three (3) consecutive weeks may result in their Health Care Coverage being closed. Since individuals who apply for Health Care Coverage are not required to complete a face to face interview: If the individual has a telephone contact number, the requirement to inform the individual will need to be done through a telephone call and this must be documented in the casefile. If the individual does not have a telephone contact number, all methods of informing the individual have been exhausted, and the individual does not stop by the county office for three (3) consecutive weeks, the case must be closed. When an individual fails to pick up their mail for three (3) consecutive weeks and the individual has not contacted the county social service office, the case must be closed for the reason of ‘Loss of Contact/ Whereabouts Unknown’. Remember to document this in the casefile narrative. Note: A ten-day Advance Notice is not required however, a notice containing the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested, must be mailed no later than the effective date of the action. If an applicant is denied, or is ineligible for any of the prior months or the processing month, the notice must include the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested.

Once a decision to deny eligibility is made on an application, a new application is needed to re-apply for assistance.

As specified below, a notice must be sent in all ongoing cases in which a proposed action adversely affects Medicaid eligibility. A notice must be mailed (as described in subsection 5) at least ten days in advance of any action to terminate or reduce benefits. The date of action is the date the change becomes effective.

This "Ten-Day Advance Notice" must include the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested. This gives the recipient an opportunity to discuss the situation with the county agency , obtain further explanation or clarification of the proposed action, or present facts to show that the planned action is incorrect. The recipient may appear on his own behalf or be represented by legal counsel, a relative, a friend, or any other spokesperson of their choice. When an individual is added to an eligible household and requests eligibility for a retroactive period, the addition of the member will NOT affect the eligibility for anyone already eligible for any prior month(s) or the current month. However, eligibility may change for future months provided the appropriate notice requirements can be met. Note : Eligibility for individuals within a Continuous Eligibility Period would not be changed. Example : A child eligible as ACA Medicaid cannot have eligibility changed to Optional Children's coverage without a 10-day advance notice, unless it meets one of the exceptions to the 10-day advance notice, as Optional Children's coverage is lower on the hierarchy chart. However, a child eligible as an ACA Transitional child can have eligibility changed to an ACA child without a 10-day advance notice as ACA child coverage is higher on hierarchy chart.

A "Ten-Day Advance Notice" is not required when information exists confirming the death of a recipient. Under the following circumstances a "Ten-Day Advance Notice" is not required; however, a notice containing the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested, must be mailed (as described in subsection 5) no later than the effective date of action:

The recipient provides a signed, clearly written statement providing information that requires a termination or reduction in benefits, and the recipient indicates that he or she understands that benefits will be reduced or terminated (changes reported on the change report form, the TANF monthly report, the review form, or via an applicant's or recipient's known email address meet this requirement);

The recipient provides a signed statement requesting termination of assistance (an oral request will also suffice if recorded in the casefile narrative and reflected on the adequate notice to terminate assistance. Termination may be effective as of the current date or a date in the future). An email from an applicant's or recipient's known email address is considered a signed statement for Medicaid;

The recipient has been admitted to an institution where he or she is ineligible for further services;

The recipient's whereabouts are unknown and mail directed to the client is returned by the post office indicating no known forwarding address;

There is factual information that responsibility for providing assistance has been accepted by another state or jurisdiction; or

The recipient has a change in the level of medical care prescribed by the individual's physician, such as the recipient begins or ceases to receive care in a specialized facility , an institution for mental diseases (IMD), a Psychiatric Residential Treatment Facility (PRTF), or nursing care services in a facility (LTC) or in the community (HCBS), or in an ICF-IID.

A "Ten-Day Advance Notice" is not required when probable fraud exists.

When the county agency obtains facts through objective collateral sources indicating the likely existence of fraud, an advance notice of proposed termination or reduction of benefits must be mailed only five days in advance of the date the action is to be taken. This shorter period allows for more prompt corrective action when probable fraud situations are uncovered.

System generated notices are dated and mailed on the next working day after the eligibility is authorized in the eligibility system. Consideration must be given to weekends and holidays to ensure notices are mailed no later than the effective date of the action.

Example: Eligibility is authorized on a Friday. The notice will be dated and mailed on the following Monday. If Monday is a holiday, the notice is dated and mailed on Tuesday. This may mean authorizing the eligibility 1 to 5 days prior to the effective date of the action.

Assistance may terminate at any time during the month. If, however, eligibility exists for at least one day of the month, eligibility generally exists for the entire month. Some exceptions to this rule are:

The date of death is the ending day of eligibility;

The last day of eligibility is the date of entry into a public institution .

Reminder: When eligibility is terminated due to death, the eligibility of other individuals in the case cannot be reduced or terminated without appropriate notice. Likewise, when a caretaker relative is no longer eligible because the last child entered foster care, or parental rights were terminated, the caretaker relative’s eligibility cannot be ended without a review of their eligibility.

Assistance cannot be terminated as of a past date except in case of death or if another state has assumed responsibility for providing assistance and then only if no assistance has been paid by North Dakota for the period in question.

Errors made by public officials and delays caused by the actions of public officials do not create eligibility or additional benefits for an applicant or recipient who is adversely affected.

(Revised 4/1/2020 ML #3576)

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All Medicaid cases in Vision or TECS must include electronic narratives in Lotus Notes. All Medicaid cases in SPACES must include an electronic narrative in SPACES. Narratives need to support eligibility, ineligibility, and other actions related to the case. The narrative must be detailed to permit a reviewer to determine the reasonableness and accuracy of the determination. Complete and accurate narratives include documenting the action taken; what the action was based on; sources of the information used; or if no action was taken, the reason for no action.

Narratives are also required to document contacts with the applicant, recipient, or other individuals regarding the case, regardless of whether the contact had an impact on the case.

(Revised 11/1/2020 ML #3600)

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(N.D.A.C. Chapter 75-01-03)

Applicants or recipients of Medicaid who are dissatisfied with a decision made by the county agency or the North Dakota Department of Human Services, or who have not had their application acted on with reasonable promptness, may appeal to the North Dakota Department of Human Services.

A request to appeal may be in writing, by telephone, internet, mail, in person or through other commonly available electronic means. The appeal must be filed no later than 30 days from the mail date on the notice of action. When an applicant or recipient requests a hearing by telephone without completing the SFN 162, Request for Hearing, the county must complete an SFN 162, Request for Hearing , based on the information available. When the county is completing the SFN 162, the form is not signed by the county.

When a recipient requests an appeal prior to the effective date of an adverse decision, the recipient's Medicaid eligibility may not be reduced or terminated until a decision is rendered after the appeal hearing unless it is determined that the sole issue is one of Federal or state law or policy. In these cases, the recipient must be informed in writing that eligibility will be reduced or terminated pending the final appeal decision. This applies even when a review of eligibility is due before the final appeal decision is made.

When assistance has continued pending an appeal decision and the county agency's decision to close the case or reduce benefits is upheld, the case must be closed, or the benefits reduced, immediately upon receipt of the notice of decision.

Refer to Service Chapter 448-01-30 for more information with regard to Hearings and Appeals.

(Revised 4/1/2026 Release 26.3 )

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(N.D.A.C. Section 75-02-02.1-05)

The following are the groups of individuals who can be covered under ACA Medicaid:

Categorically Needy Group

Parents and Caretaker/relatives of deprived children under age 18 (through the month they attain age 18) and their spouses up to 39% FPL (COE of M063);

Parents and Caretaker Relatives (and their spouses) of deprived children under age 18 (through the month they attain age 18) who were eligible under the Parents and Caretaker Relatives and their spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretakers lose coverage under the Parents and Caretaker Relatives and their spouses Category due to increased earned income or hours of employment, and their dependent children for up to 12 months (Transitional) (COE of M086 for Parents and Caretaker Relatives of deprived children and their spouses and M087 for children);

Exception: Children only become eligible under Transitional coverage when their Medicaid household income fails the respective children's group income level.

Parents and Caretaker Relatives (and their spouses) of deprived children under age 18 (through the month they attain age 18) who were eligible under the Parents and Caretaker Relative and their spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lose coverage under the Parents and Caretaker Relatives and their spouses Category due to increased alimony or spousal support and their dependent children for up to 4 months (Extended)(no budget test) (COE of M088 for Parents and Caretaker Relatives (and their spouses) of deprived children and M061 for Children);

Exception: Children only become eligible under Extended coverage when their Medicaid household income fails the respective children's group income level.

Pregnant Women up to 170% FPL (COE of M066);

Eligible pregnant women who applied for and were eligible for Medicaid during pregnancy continue to be eligible for twelve months, beginning on the last day of pregnancy, and through the last day of the twelfth month. (COE of M066);

Children born to pregnant women who applied for and were found eligible for Medicaid on or before the day of the child's birth, for one year, beginning on the day of the child's birth and for the remaining days of the month in which the twelfth month falls (COE of M67A);

Children ages 0 through 5 up to 147% FPL (COE of M067);

Children ages 6 through 18 up to 133% FPL (COE of M067);

Children ages 6 through 18 who become Medicaid eligible due to the increase in the Medicaid income levels. The income of these individuals falls between 111% and 133% of the Federal Poverty Level (FPL). (COE of M095)

Adults age 19 and 20 who are not pregnant, who pass the Adult Expansion Group but have income less than 90% FPL (M062);

Individuals ages 19 through 64 not eligible as parents, caretakers or pregnant women whose income does not exceed 133% FPL. This may include SSI recipients and other disabled individuals who fail the Medicaid asset limits, and individuals who are determined medically frail or disabled with a large client share (Adult Expansion Group) (COE of M076 or M76A)

Note: State Medicaid Policy may also assign COE’s M058, M059, M060 M065, M077 or M089, but must be determined ‘medically frail’.

Effective January 1, 2022, individuals age 19 to 20 determined eligible for Medically Frail will be covered under Traditional Medicaid (fee for service).

Individuals under age 19 who meet the non-financial requirements of the Children’s Category and who are residing in foster homes or private child care institutions licensed or approved by the Department , irrespective of financial arrangements, including children in a "free" foster home placement (non-IV-E Foster Care) (COE of M098);

Individuals who are not eligible as an ACA Medicaid Individual defined in a. thru h. above, who were in foster care, in any state ( Title IV-E , state-funded (non-IV-E) or tribal) in the month they turned age 18 must be covered through the month in which they turn age 26 with no budget test (COE of M091) .

Medically Needy Group

Pregnant Women who qualify and require medical services on the basis of insufficient income, but who do not meet pregnant women income requirements under ACA Medicaid (COE of 20F).

Children under age 21 who qualify and require medical services on the basis of insufficient income, but who do not meet income requirements under ACA Medicaid (COE of 03 or 09).

Parents and caretaker relatives of deprived children and their spouses who qualify and require medical services on the basis of insufficient income, but who do not meet the parents and caretaker relatives of deprived children and their spouses or the Medicaid Expansion income requirements under ACA Medicaid. (COE of 10C or 10P)

Optional Children's Group

Children age 0 through 18 (through the last day of the month in which child turns age 19) and has income between 152% and 205% of the FPL (COE of M078).

(Revised 5/1/2017 ML #3498)

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(N.D.A.C. Section 75-02-02.1-06)

An individual, who could establish eligibility under more than one category, such as between ACA Medicaid categories and Non-ACA Medicaid categories or within the ACA Medicaid categories may have eligibility determined under the category the individual selects. A hierarchy of these Categories of Eligibility has been established and can be found in the Reference Hard Card section of this manual at 510-03-105-05 .

Individuals eligible as QMBs and SLMBs are eligible as aged, blind or disabled for that coverage but may also establish eligibility under the ACA Medicaid categories as a caretaker/relative or pregnant woman. An individual who is not a caretaker relative who has Medicare coverage cannot chose to be covered under ACA Medicaid Expansion.

SSI recipients must first be tested for eligibility under Non-ACA Medicaid and only if they fail Non-ACA Medicaid (such as excess assets) may they be tested under ACA Medicaid. This also applies to SSI recipients who are pregnant women.

(Revised 4/1/2026 Release 26.3 )

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There are six (6) major Categories of Eligibility (COE), each of which have related categories that fall under them. The six major categories are:

Children Under age 21;

Optional Children's Group (CHIP);

Parents, caretaker relatives and their spouses ;

Pregnant Women;

Adults.

Former Foster Care Children

The following rules determine how to assign the COE for eligible individuals:

Children Under Age 21

COE COE Description Rule to Assign COE 61 Extended ACA Children The Child: Is under age 18 (through the month the child attains age 18) Is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent; Resides with one or both natural or adoptive parents, or one non-parent caretaker relative; Not eligible under the ACA Medicaid Children Poverty Levels; AND The child’s parent(s) or caretaker relative: Lost eligibility under the Parents and Caretaker Relative and their spouses Category due to increased alimony or spousal support; and Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category. 67 Children ages 0 thru 18 (including month turn age 19) -- other than MOE, Foster Care, Transitional, Extended, Med Needy or Optional Children's Group The Child: Is age 0 to 6 (including the month the child attains age 6); Was found eligible for ACA Medicaid with income at or below 152% of the Federal Poverty Level (FPL). OR Is age 6 (month following month attains age 6) thru age 18 (including the month the child attains age 19); Was found eligible for ACA Medicaid with income at or below 138% of the Federal Poverty Level (FPL). 67A Children ages 0 to 1(through the month prior to turning 1) – other than MOE, Foster Care, Transitional, Extended, Med Needy, or Optional Children’s Group The child’s mother is determined eligible for Medicaid as of the last day of pregnancy; The child is age 0 to 1 (through the month prior to turning 1) OR Who fail under ACA Categorically Needy Coverage Group and who have met the Client Share for the birth month under Medically Needy Group. 87 ACA Transitional Children The Child: Is under age 18 (through the month the child attains age 18) Resides with one or both natural or adoptive parents, or one non-parent caretaker relative; Not eligible under the ACA Medicaid Children Poverty Levels; AND The child's parent(s) or caretaker relative: Lost eligibility under the Parents and Caretaker Relative and their spouses category due to increased earned income or hours of employment; Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category. 95 Maintenance of Effort Child Absence Deprived (Age 6 to 19) The Child: Is age 6 to 19 (month following month attains age 6 through the end of the month the child attains age 19); Was found eligible for ACA Medicaid with income between 111% and 133% of the FPL. 98 State or Tribal Foster Care (Non-IV-E) The Child: Meets the definition of a Foster Care Child; Is eligible under regular Foster Care (non-Title IV-E, tribal or state-funded). 03 Child Age 0 to 21 (Medically Needy) The Child: Is age 0 to 21 (including the month the child attains age 21); Has income above 152% of the FPL; Has a medical need that exceeds the calculated Client Share (Recipient Liability); 09 Child Age 0 to 21 (Medically Needy) The Child is: Non-Deprived Is age 0 to 21 (including the month the child attains age 21); Has income above 152% of the FPL; Has a medical need that exceeds the calculated Client Share (Recipient Liability).

Optional Children's Group

COE COE Description Rule to Assign COE 78 Optional Children's Group The Child is: Age 0 through age 18 (through the last day of the month in which child turns age 19); Is not eligible for full Medicaid Coverage; Does not have current creditable health insurance coverage; Has income between 152% and 205% of the FPL

Parents, Caretakers and their Spouses

COE COE Description Rule to Assign COE 63 Parents, Caretaker Relatives (& their Spouses) of Deprived Children The Parent(s) or Caretaker: Is the natural or adoptive parent, or a caretaker/relative within the 5th degree of relationship to a child under age 18 (through the month the child attains age 18); Has a child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent; Has income below 39% of the FPL. 86 ACA Transitional Parents and Caretakers The Parent(s) or Caretaker relative: Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a child under age 18 (through the month the child attains age 18); Lost eligibility under the Parents and Caretaker Relative and their Spouses category due to increased earned income or hours of employment; and Was eligible under the Parent, Caretaker Relative and their Spouses category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category. 88 ACA Extended Parents, Caretaker Relatives (& their Spouses) of Deprived Children The Parent(s) or Caretaker: Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/underemployment of a child under age 18 (through the month the child attains age 18); Lost eligibility under the Parents and Caretaker Relative and their Spouses category as a result of the collection or increased collection of spousal support (alimony). Was eligible under the Parent, Caretaker Relative and their Spouses category in a least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category. 10C Parent/Caretaker Medically Needy Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/underemployment of a child under age 21 (through the month the child attains age 21); Meets the Caretaker Relatives policy. Meets the policy for Need; 10P Parent/Caretaker medically Needy Has at least one child residing with them who is non-deprived (intact household); Meets the Parent, Caretaker, and their Spouses category. Meets the policy for Need.

Pregnant Women

COE COE Description Rule to Assign COE 66 Pregnant Woman (Categorically Needy) A woman who is: Pregnant and through the end of the twelfth month post-partum period; Has income at or below 175% of the FPL. 20F Pregnant Woman (Medically Needy) A woman who is: Pregnant and through the end of the twelfth month post-partum period; Has income above 175% of the FPL; Has a medical need that exceeds the calculated Client Share (Recipient Liability).

Adults Adult Expansion

COE COE Description Rule to Assign COE 76 Adult Expansion Category Individual is: Age 21 through age 64 (month following the month attained age 21 and month prior to attaining age 65); Not eligible under the Parent/Caretaker or Pregnant Woman Category; Not eligible under the Adults age 19 and 20 Category; Not eligible as Medically Frail ; Has income at or below 138% of the FPL.

Adults age 19 and 20 COE COE Description Rule to Assign COE 62 Adult Age 19 and 20 The Adult: Must be age 19 or 20 (month following month attains age 19 through the month attains age 21); Is NOT pregnant; Pass the Adult Expansion Group BUT have income less than 90% of FPL 76A Adult Age 19 and 20 The Adult: Must be age 19 or 20 (month following month attains age 19 through the month attains age 21); Not eligible under Parent/Caretaker or Pregnant Woman Category; Not eligible under Adult Age 19-20 category with income less than 90% of the FPL; Not eligible as Medically Frail; Has income at or below the 138% of the FPL

Medically Frail COE COE Description Rule to Assign COE 58 Adults Medically Frail- Non-institutionalized The Individual is: Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65); Passes the Adult Expansion Group criteria; Determined Medically Frail; Not residing in an Institution; Income at or below 85% of FPL. 59 Adults Medically Frail- Non- Institutionalized Individual is: • Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65); Passes the Adult Expansion Group criteria; Determined Medically Frail; Not residing in an Institution; Income above 85% of FPL. 60 Adults Medically Frail- Institutionalized Individual is: Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65); Passes the Adult Expansion Group criteria; Determined Medically Frail; Residing in an Institution; Income at or below 85% of FPL. 65 Adults Medically Frail- Institutionalized Individual is: Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65); Passes the Adult Expansion Group criteria; Determined Medically Frail; Residing in an Institution; Income above 85% of FPL. 77 Adults Medically Frail- Non- Institutionalized Managed Care Individual is: Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65) for months prior to January 1, 2022; Age 21 through 64 (month following month attains age 21 through the month prior to the month attains 65) for months on or after January 1, 2022; Passes the Adult Expansion Group criteria; Determined Medically Frail; Not residing in an Institution; Income at or below 85% of FPL. 89 Adults Medically Frail- Non- Institutionalized Managed Care Individual is: Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65); for months prior to January 1, 2022; Age 21 through 64 (month following month attains age 21 through the month prior to the month attains 65) for months on or after January 1, 2022; Passes the Adult Expansion Group criteria; Determined Medically Frail; Not residing in an Institution; Income above 85% of FPL.

Former Foster Care Children

COE COE Description Rule to Assign COE 91 Former Foster Care Child The Child: Was in foster care (Title IV-E, state-funded (non IV-E or tribal) and on Medicaid, in any state, in the month they turned age 18. Is under age 26 (through the month attaining age 26); NOTE: An individual age 18 through 21 whom voluntarily sign him/herself back into Foster Care would also be assigned the COE of M091.

(Revised 1/12/2023 ML #3696)

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(N.D.A.C. Section 75-02-02.1-08)

Each eligible individual must have their ACA Medicaid Household determined separately based on whether the individual is a tax filer , a tax dependent , or an adult or child non-filer as well as the individual’s relationship to those with whom the individual resides.

NOTE: Under ACA-based Methodologies, individuals may no longer be opted out of a household. However, they can choose to not receive coverage.

Tax Filer Unit

If the person is a tax filer , that person’s Medicaid household includes:

The individual,

The spouse who lives with them, (regardless if they file jointly or separately),

Everyone the tax filer claims as a tax dependent, and

If any of these individuals are pregnant, include the number of unborn children.

Note : If the tax filer is also claimed as a tax dependent, follow the tax dependent rules.

Tax Dependent Unit

If a person is a tax dependent , that person’s Medicaid household includes:

The individual,

The spouse who lives with them, (regardless if they file jointly or separately)

Everyone in the tax filers household, UNLESS the tax dependent meets one of the following exceptions :

The individual is claimed as a dependent by someone other than a parent, adoptive parent, or step-parent, (example by a grandparent or older adult sibling) or

The individual is under age 19 and claimed as a dependent by an absent parent (example, child lives with Mom but absent Dad is claiming as a tax dependent), or

The individual is under age 19 and lives with both parents but the parents do not expect to file jointly (example—parents live together but are not married).

If any of these individuals are pregnant, include the number of unborn children.

If the tax dependent meets any of the above exceptions in 2.c., we must follow the non-filer rules in determining household size.

Non-Filer Unit

If a person is a non-filer , that person’s Medicaid household is determined based on whether or not the non-filer is an Adult (Age 19 and older) or a Child (Under age 19).

Non-filer Adult Household (age 19 or older) includes:

The non-filer adult, and Their spouse who lives with them, and Their natural, adopted or step-children under age 19 If any of these individuals are pregnant, include the number of unborn children.

Non-filer Child Household (under age 19) includes:

The non-filer child, The child’s natural, adopted or stepparents who lives with them, The child’s natural, adopted or step siblings under age 19 who lives with them, The child’s spouse, who lives with them, The child’s natural, adopted or step children under age 19 who lives with them. If any of these individuals are pregnant, include the number of unborn children.

Married couples, who file jointly , must be included in each other’s Medicaid households for budgeting purposes, even if not residing together.

Married couples, where one spouse is incarcerated, the incarcerated spouse must be included in other’s Medicaid households for budgeting purposes, IF-the spouses file their taxes jointly .

Note: The spouse who is incarcerated is not eligible for ACA Medicaid.

When both parents live in the household AND they are not married, only 1 parent may be eligible under the Parent, Caretaker Relatives and their Spouses group. The parent that claims to have primary responsibility over the child is the one that can be eligible under the parent/ caretaker group, provided they meet the parent/caretaker relative income limit. The other parent would have to be covered under the Adult Group, if eligible under that group.

If there is more than one child in the home, each parent could be eligible if each claimed primary responsibility over at least one child.

The parent that claims primary responsibility does not have to be the parent that claims the child on their taxes. The parent just has to indicate having primary responsibility for that child.

Example 1: Joe and Jill are the unmarried parents of Jessie, age 5. Jill claims to have primary responsibility for Jessie. No one has income at this time, so no one is filing taxes. Jill’s household will be Jill and Jessie. Jessie’s household will be Joe, Jill and Jessie. Joe’s household is Joe and Jessie. Jill is eligible under the parent/caretaker and their spouses group. Jessie is eligible under the children’s group. Joe is eligible under the Adult Group. Example 2: Mark and Mary are the unmarried parents of Mindy, age 15. Neither has claimed primary responsibility for Mindy. Mark is working and earns $2,000 per month. He also claims Mindy on his taxes. Mark’s household is Mark and Mindy. Mindy’s household is Mark, Mary and Mindy. Mary’s household is Mary and Mindy. Mark is not eligible because his income exceeds the Adult Group Income Level for 2. Mary is eligible under the adult group only since she is not claiming primary responsibility for Mindy. Mindy is Medicaid eligible as a child. (Note that if household comes back in and says that Mary has primary responsibility for Mindy, it would be a change in circumstance and would have to be acted upon. We accept client attestation for this.)

The following flowchart and examples will assist in determining the ACA Medicaid Household for each individual:

Examples:

Note : (In all of the following examples in this section, step, half, adoptive and natural parents, siblings and children are all treated the same.)

John is a single individual who is applying on his own. He does not plan to file income taxes. John is a non-filer and his household size is 1.

Joe is a single individual who is applying on his own. He plans to file income taxes. He is not claiming any dependents. Joe is a tax-filer and his household size is 1.

a. Tony is a single individual who is applying on his own. He plans to file income taxes and is claiming his 12 year old son, Jacob who resides with his mother, Claudia. Tony is a tax-filer and since he is claiming his son, his household size is 2.

b. Since Jacob resides with his mother, Claudia applies for herself and her son, Jacob. Claudia files taxes, but does not claim Jacob as his father does.

Jacob is considered a non-filer as he meets one of the exceptions in #2.c., Tax Dependent Unit rules, above. Therefore, his household size is 2. Since Jacob lives with his mother, she must be a part of Medicaid household. Claudia is considered a tax-filer and since Tony claims Jacob, her household size is 1.

Paul and Pam are married, live together, have no children and Pam is not pregnant. Paul plans to file taxes jointly with Pam. Paul and Pam are tax filer s and each has a household size of 2.

Paul and Pam are married and live together with their son Peter. Paul and Pam are filing jointly and claiming Peter as a tax dependent. Paul and Pam are tax filers and each has a household size of 3. Peter is a tax dependent and his household size of 3.

Paul and Pam are married and live together with their minor son, Peter. Paul and Pam plan to file taxes separately. Paul expects to claim their son, Peter, as his tax dependent. Paul is a tax filer and his household size of 3 as he is claiming his son. Pam is a tax filer and her household size of 2, as she is not claiming her son. Peter is a tax dependent but his parents are filing their taxes separately. Therefore, his household size is 3.

Paul and Pam are married and live together with their son Peter and Pam’s mother. They plan to file taxes together and claim their son and Pam’s mother as tax dependents. Paul and Pam are tax filers and each has a household size of 4. Peter is a tax dependent and his household size is 4. Pam’s mother is a non-filer and her household size is 1.

John and Julie are married. They have 2 children in common, Derik age 2 and Shawn age 10. Julie has a child from a previous relationship, Brynn, age 16. Mom and Step Dad file jointly and claim all the children on their taxes. John and Julie are tax filers and each has a household size of 5. Brynn, Shawn and Derik are tax dependents and each has a household size of 5.

Marty lives with his grandmother, who is widowed, and she expects to claim him as a tax dependent (even though Marty is a dependent someone other than a parent is claiming him so he is treated as a non-filer). Marty is a non-filer and his household size is 1. Grandmother is a tax filer and is claiming Marty. Grandmother’s household size is 2.

Marcy lives with both of her biological parents, Mary and Mark, who are married but expect to file separately. Marcy expects to be claimed as a tax dependent by Mary. Marcy is considered a non-filer as she meets one of the exceptions in #2.c., Tax Dependent Unit rules, above. Her household size is 3. Mary is a tax filer and is claiming her daughter and her household size is 3. Mark is a tax filer and is not claiming his child. His household size is 2.

Matt lives with his mother, Mary. Matt expects to be claimed as a tax dependent by his father, Mark who lives separately. Matt is considered a non-filer as he meets one of the exceptions in #2.c., Tax Dependent Unit rules, above. Therefore, his household size is 2. Mary is a tax filer and not claiming her son. Her household size is 1.

Carol and Bill reside together with their 2 children, Kyle and Sarah, and Carol’s nephew, Travis. Carol and Bill file their taxes jointly and claim their two children and Carol’s nephew. Kyle, Sarah and Travis are under age 18 and not required to file income taxes. Carol is considered a tax-filer and claims her two children and nephew. Her household size is 5. Bill is considered a tax-filer and claims his two children and Carol’s nephew. His household size is 5. Kyle is considered a tax dependent and his household is that of the tax filer (his parents). Therefore, his household size is 5. Sarah is considered a tax dependent and her household is that of the tax filer (her parents). Therefore, her household size is 5. Travis is considered a non-filer child. His household size is 1.

John lives with his girlfriend, Susan and Susan’s daughter, Mariah, age 3, who is not John’s biological, adopted, or step-daughter. He does not plan to file taxes. Susan will file taxes and claim her daughter only. John is a non-filer and his household size is 1. Susan is a tax-filer and her household size is 2. Mariah is a tax dependent and her household is 2.

Katie and Alex are married and file taxes separately. They have two children, Allan and Hannah, both under age 16. Alex claims them both on his taxes. Katie is a tax filer and her household size is 2. Alex is a tax filer and his household size is 4. Allan is a non-filer and his household size is 4. Hannah is a non-filer and her household size is 4.

Jack and Diane are married and file taxes together. They have two children in common, Quinn age 7 and Lucy age 9. They also have a Foster Child, Stephanie, age 14. They claim their children as well as the Foster Child on their taxes. Jack and Diane are tax filers and each has a household size of 5. Quinn and Lucy are tax dependents and each has a household size of 5. Stephanie is a non-filer and her household size is 1.

Tom and Francine are married and have 2 children, Garrett age 15 and Sonya age 19, who is living in a dorm attending college in another city. They file taxes jointly and claim both of the children on their taxes. Tom and Francine are tax filers and each has a household size of 4. Garret and Sonya are tax dependents and have a household size of 4. Tom and Francine are married and have 2 children, Garrett age 15 and Sonya age 19, who is living in a dorm attending college in another city. Sonya also works and will be required to file taxes on her own. However, her parents will be filing jointly and claiming both of the children on their taxes. Tom and Francine are tax filers and each has a household size of 4. Garret is a tax dependent and has a household size of 4. Sonya is a tax dependent and has a household size of 4. Note: Since Sonya is required to file taxes, her income is counted in all the households in which she is included.

Sharon is disabled and in receipt of SSI. She has 1 child, Ben, who is age 18. Sharon does not file taxes. Her son Ben is employed and earns sufficient income to require him to file taxes. Sharon is a non-filer and her household size is 2; herself and her son. Ben is a tax filer. His household size is 1. Note: If Ben claimed his mother, his household size would be 2.

Case consists of Sandy, her boyfriend Carl, and Sandy’s daughter Meghan, age 6 (who is not Carl’s daughter). Carl is employed and files taxes. He is claiming Sandy and her daughter. Carl is a tax filer and his household size is 3. Sandy is a non-filer and her household size is 2. Meghan is a non-filer and her household size is 2.

(New 7/1/2014 ML #3404)

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Deprivation must be established in order for an individual to be found eligible under the Parent, Caretaker Relative and their Spouse s categories or the ‘Absence’ and ‘Unemployment, or Underemployment of a Parent (UP)’ deprived children’s categories.

A child, under age 19 (including the month the child attains age 19) is considered deprived of a natural or adoptive parent’s support or care due to continued absence of a parent or inability of a parent to meet the child’s needs.

A child will be considered deprived under the following reasons:

Absence of a Parent Death of a parent; Divorce or legal annulment; Separation, legal or mutual, as long as there was no collusion between the parents to render the family eligible, or Note: A child will still be considered deprived when the absent parent was included in the household for budgeting purposes, due to spouses filing their taxes jointly. Imprisonment of one or both parents Note: A child will still be considered deprived when the imprisoned parent was included in the household for budgeting purposes due to spouses filing their taxes jointly.

To establish continued absence, the parent must be sentenced to a minimum of a thirty-day jail term. Any portion of a sentence actually suspended and not served does not count toward the thirty-day minimum. A parent who is permitted to live at home while serving a court-imposed sentence by performing unpaid public work or unpaid community service during the work day is not considered absent from the home;

Unmarried parenthood (when not residing together); Abandonment;

Disability, Incapacity or Age of a parent Disability of a parent (as defined in Service Chapter 510-05, Section 510-05-35-100, Blindness and Disability ); Incapacity of a parent; A parent is age sixty-five or older;

Unemployment, or underemployment, of a parent, if either parent is: Employed less than one hundred hours per month (based on pay stub hours, including holiday and sick pay hours; or if self-employed, in the absence of other credible information, by dividing the gross monthly income by minimum wage); or Employed more than one hundred hours in the current month, but employed less than one hundred hours in the previous month and is expected to be employed less than one hundred hours in the following month.

When the only means of income to a household is self-employment and both parents are actively involved in the business, consider both parents working more than 100 hours.

A parent’s contact with his or her child(ren) does not have to stop in order for continued absence to exist. A continuing relationship between an absent parent and child(ren), by itself, cannot be a basis for finding that continued absence does not exist. The continued absence of either parent from the home is established when a parent maintains and resides in a separate verified residence apart from the ACA Medicaid Household for reasons other than employment, education, training, medical care, or uniformed service. The parent is considered absent from the home and the absent parent’s functioning as a provider of maintenance, physical care, or guidance to the child(ren) is considered interrupted. (‘Uniformed service’ is defined to mean duty in the Army, Navy, Air Force, Marine Corps, Coast Guard, Environmental Sciences Services Administration, Public Health Service, and reserve duty.).

A parent temporarily living apart from the child(ren) due to employment, education, training, medical care, uniformed service, or any other temporary reason is not considered "Absent from the home" as long as the parent continues to function as a parent, even if the level of support or care is somewhat deficient. An exception is made when there is evidence that continued absence would have existed irrespective of the above reasons.

Divorce courts often award custody of children to both parents, however, legal custody orders have no bearing on whether or not a child is considered "deprived." It is the parent’s absence from the home and the child’s physical presence rather than legal custody that is relevant.

Deprivation of unemployment, underemployment, incapacity, or disability may be established on an unborn child only when the prospective parents are married and in the same ACA Medicaid household.

(Revised 4/1/2020 ML #3576)

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(N.D.A.C. Section 75-02-02.1-08.1)

Caretaker relatives may be eligible for Medicaid under the Parents and Caretakers of deprived children and their spouses category when: A child is residing with the caretaker/relative AND is eligible for Medicaid, or enrolled in a health insurance policy which includes the minimal essential coverage’s ; and The caretaker relative assumes primary responsibility for the child’s care (does not mean the caretaker relative must claim the child for tax purposes); and The caretaker relative is related within the 5th degree of relationship to the child; and The caretaker relative’s household has income at or below the parent/caretaker and their spouses’ category income level.

When the child is NOT eligible for Medicaid (with no ‘client share’), or enrolled in a health insurance policy that meets the minimal essential coverage criteria, the caretaker relative is not eligible for any coverage. This policy applies to coverage under Medicaid Expansion in the same way. However, this policy DOES NOT apply to the following:

A caretaker relative who is a pregnant woman

A caretaker relative who is eligible under Medically Needy coverage with a ‘client share’;

A caretaker relative who is eligible for coverage under Emergency Services only;

A caretaker relative who is eligible under the Breast and Cervical Cancer Early Detection (Women’s Way) Program as defined at 510-05-67;

A caretaker relative who has a child residing in the household and the child fails immigration/citizenship requirements;

Caretaker relative who is eligible under ACA Transitional Parent Caretaker coverage.

The following individuals may be considered a caretaker relative: A natural, adoptive, or stepparent; A grandparent (including a great, great-great, or great-great-great grandparent); A sibling, half-sibling, or step sibling (if age sixteen or older); An aunt or uncle (including a great or great-great aunt or great or great-great uncle); A niece or nephew (including a great or great-great niece or great or great-great nephew); A first cousin (an aunt or uncle’s child) or first cousin once removed (an aunt or uncle’s grandchild); A second cousin (a great aunt or great uncle’s child); A spouse of any of the above individuals even after the marriage is terminated by death or divorce.

A child is considered to be ‘living with’ a caretaker relative when away at school or when otherwise temporarily absent from the home.

A child is NOT considered to be living with a caretaker relative when either the child or the caretaker is residing in a nursing care facility, an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a specialized facility on other than a temporary basis.

A child may not be considered to be living with more than one caretaker relative in more than one Medicaid household for the same time period.

When the only child in common is an unborn and there is deprivation of unemployment/underemployment, incapacity, or disability, the prospective parents must be married in order for the father to be eligible as a caretaker relative under the Parents and Caretakers of deprived children and their spouses’ category.

Termination of parental rights removes all relationships and responsibilities between the parent and the child(ren). The parent becomes a "legal stranger" to the child(ren). However, for Medicaid purposes, the blood relatives of a parent whose parental rights have been terminated continue to be treated as relatives of the child(ren).

(New 7/1/2014 ML #3404)

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(N.D.A.C. Sections 75-02-02.1-25 and 75-02-02.1-34)

Each ACA Medicaid individual’s financial responsibility is determined in the same manner as their ACA Medicaid household defined in Section 510-03-35-05 , ACA Medicaid Household.

Income of all individuals included in the individual’s ACA Medicaid household must be counted unless disregarded as defined in Section 510-03-85-30 , Disregarded Income.

(Revised 5/1/2025 ML #3918 )

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(N.D.A.C. Section 75-02-02.1-11)

Need is a factor of eligibility. Need in this sense is not to be confused with the necessity for a particular medical service.

Need is automatically established for individuals who are determined to be categorically needy eligible under ACA Medicaid.

For a medically needy applicant or recipient, need is established when: The individual has applied for Medicaid; or There is no client share; or The individual has incurred or may incur medical expenses which the individual is responsible for after any third-party payments that equal or exceed client share.

If an individual does not utilize Medicaid for six months, their eligibility will end the following month.

Individuals may request their Medicaid coverage be terminated in writing or verbally. A verbal request must be recorded in the case file narrative and reflected on the closing notice. Follow policy at 510-03-25-25 notice requirements to determine proper closing time frame.

(Revised 1/1/2025 ML #3908 )

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(N.D.A.C. Section 75-02-02.1-12)

Caretaker relatives, are not subject to any age requirements for purposes of Medicaid eligibility.

In instances where only the year and not the exact date of birth can be established, use July 1 to designate the date of birth; or if the year and month can be established, use the year and first day of the month for purposes of Medicaid eligibility.

Identity must be established and documented as provided in this section. The following individuals are exempt from the identity verification requirements: SSI recipients who claim that they are US Citizens and that claim is not questionable (can prove using the SDX, NDVerify Other Benefits match); Medicare beneficiaries who claim that they are US Citizens and that claim is not questionable (can prove using the NDVerify Other Benefits match); Individuals receiving SSA disability insurance benefits based on their own disability; Individuals receiving Foster Care maintenance payments; Individuals receiving Subsidized Guardianship payments. Newborn children: A child, born to a woman who has applied for and been determined Medicaid eligible and is in receipt of Medicaid when the child is born, may be eligible without verifying identity. This provision also applies in instances where labor and delivery services were furnished prior to the date of the Medicaid application and covered based on retroactive eligibility.

This provision applies to all children whose Mother is eligible for Medicaid at the time of their birth, including those under the emergency services only provisions.

Children who are born to a woman who is here on a temporary basis and who is not eligible for Medicaid or emergency medical services must comply with the verification requirements if Medicaid is requested.

Reasonable Opportunity Period. Applicants who claim they are U.S. citizens or qualified non-citizens are entitled to a reasonable opportunity period to provide verification of citizenship, qualified non-citizen status, and identity. Medicaid is not permitted to deny, delay, reduce, or terminate eligibility while documentation is being gathered during the reasonable opportunity period. A reasonable opportunity period applies when all other information necessary to determine eligibility is available. If an individual is eligible for Medicaid and has met all other criteria except for citizenship or identity verification, that individual’s eligibility may not be pended for verification of either citizenship or identity, but must be approved. If the individual does not provide satisfactory documentation of citizenship and identity by the end of the reasonable opportunity period, the individual’s eligibility must be terminated with advance (10-day) notice and without regard to continuous eligibility provisions.

A ‘reasonable opportunity period’ is defined as 90 days from the date the application is submitted and for the remaining days of the month in which the 90th day falls. An extension of an additional 60 days from the 90th day may be granted if the individual has verifiable documented evidence they have been making a good faith effort to obtain the verifications, but still have not received them. An example of a good faith effort would be a letter from another state’s vital statistics office that the documentation was requested timely (no later than 10 days after the latter of the application date or the earliest date the verification was requested by the county or state agency), but there will be a delay in providing the documentation. Example: Mr. Brown applies for Medicaid on May 11, 2010. He has verification of citizenship; however he has nothing to prove identity. He does not meet any of the exemptions from the verification requirements that are listed in the manual. Mr. Brown is determined to be eligible for Medicaid and the application approved for the prior months of March and April, the application month of May, and the future month of June. Mr. Brown claims he is a member of a federally-recognized Indian tribe in California. The worker has assisted him in requesting identifying tribal documents from the tribe in California. The worker sets an alert to follow up in early August. The worker does not receive a response by August 20, so sends an advance notice to close. On August 23, Mr. Brown brings in a recent letter from the tribal enrollment office in California, acknowledging receipt of his request for his tribal enrollment verification, and stating that it will take another 6 weeks for them to process it. In this case, an additional 2 month period may be granted. The worker would set an alert for a secondary follow up for October 2010. If not received by October 20, 2010, advance notice to close must be sent.

A reasonable opportunity period is not limited to one. Example: If granted a reasonable opportunity period but the requested verifications are not received and eligibility is terminated, upon reapplication, if needed, a new reasonable opportunity period will be allowed. Primary and preferred verification of identity. A photocopy, facsimile, scanned or other copy of a document must be accepted to the same extent as the original document, unless information on the copy submitted is inconsistent with other information available, or there is reason to question the validity of the information in the document. A copy must be maintained in the case file.

These Documents Verify Both Citizenship and Identity: Explanatory Information US Passport or US Passport Card Issued since 2007 • Issued by the Department of State • Does not have to be currently valid, as long as it was issued without limitation; (any passport issued with a limitation cannot be used to verify citizenship, but CAN be used to verify identity). • Through 1980, spouses and children were often included on one passport; after that each person is issued his own passport. • The passport card is for frequent travelers by land or sea between the US and Canada, Mexico, the Caribbean and Bermuda. Certificate of Naturalization (DHS/INS Forms N-550 or N-570) • Department of Homeland Security or Immigration and Naturalization Service (INS) issues for naturalization. Certificate of US Citizenship (DHS/INS Forms N-560 or N-561) • Department of Homeland Security or INS issues certificates of citizenship to individuals who derive citizenship through a parent. Tribal Enrollment Card Certificate of Degree of Indian Blood OR other documents issued by a federally recognized Indian tribe that evidences membership or enrollment with such tribe • A Document issued by a federally recognized Indian tribe evidencing membership or enrollment or affiliation with, such tribe. See following table for acceptable verification from ND tribes. Citizenship verification received from using the “Other Benefits” inquiry in the NDVerify system or from the citizenship verification system available through the Federally Facilitated Marketplace (FFM) – as automated through the Streamlined application process. • Acceptable codes are: "Citizenship Verified" or "Verified with positive citizenship; Deceased."

Documents Issued by Recognized ND Tribes Sisseton-Wahpeton (Wahpeton—SE corner of ND) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood; Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal ID cards: Name, DOB, enrollment #, degree of Indian blood, SSN, photo and individual’s signature; Issued to enrolled members age 16 and older who request it; Issued by tribal enrollment office; Spirit Lake (Devils Lake) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood (may have more information); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal Photo ID: Photo ID including name, DOB, tribal enrollment #, and degree of Indian blood (may have more information); Issued by tribal motor vehicle office; Issued to enrolled members; Standing Rock Sioux Tribe (Fort Yates) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood, (may have more information); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal ID cards: Name, DOB, enrollment #, and degree of Indian blood, last 4 digits of SSN (may have more information); Issued to enrolled members age 14 and older who request it; Issued by tribal enrollment office; Three Affiliated Tribes (T. A. T.) (New Town) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal ID cards: Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo ( plastic card with hologram on back) (will enter SSN (non-verified) at individual’s request); Issued to any enrolled member who requests it; Issued by tribal enrollment office (Cost = $10; free to seniors); Expire every 4 years; Turtle Mountain Chippewa (Belcourt, Trenton) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood, (may have more information); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal Enrollment cards: Name, DOB, enrollment #, and degree of Indian blood (may have more information); Issued to enrolled members age 18 and older who request it; Issued by tribal enrollment office. Secondary verifications of identity may be accepted if primary verifications are not provided. Verification documents must be presented in their official and original form as received from the issuing agencies. Photocopies or notarized copies are not acceptable. Once an original document is presented, a photocopy must be made and maintained in the case file.

Secondary Verifications of Identity

(Level 2)

Acceptable Verifications: Explanatory Information Driver's license issued by a state or territory (DO NOT accept Canadian driver's license) • Must include a photograph of the applicant or recipient: or • Have other personal identifying information for the individual such as name, age, sex, race, height, weight, or eye color. Identification card issued by a US Federal, State or local government with the same information as a driver's license. • DO NOT accept a voter's registration card. School ID card • Must include a photograph of the applicant or recipient. U. S. military ID card or draft record Military dependent's identification card U. S. Coast Guard Merchant Mariner card

Third level verification of identity. These documents should only be used when documentation from levels one and two are unavailable.

Third Level Verifications of Identity

(Level 3)

Acceptable Verifications: Explanatory Information 3 or more documents that together reasonably corroborate the identity of an individual, provided such documents have not been used to establish the individual's citizenship AND the individual has submitted at least second or third level citizenship verification • Only to be used if no other evidence of identity is available. • Must contain the individual's name plus additional identifying information (employer ID cards, high school and college diplomas from accredited institutions, marriage certificates, death certificates, divorce decrees and property deeds/titles.).

Identity verifications for minor children. Exceptions identified in this section are allowed when a child does not have or cannot get any of the identity documents from the first three levels.

Identity Verifications for Children

(Level 4)

Acceptable Verifications: Explanatory Information School record • Must show child's date and place of birth and parents' name. Clinic, doctor, or hospital record • Must show child's date and place of birth and parent's name. Daycare or nursery school record showing date and place of birth • Eligibility worker must call and verify with the school that issued the record. An affidavit, signed under penalty of perjury, by the parent, guardian, or caretaker relative which states the date and place of birth of the child • Only one affidavit may be used to establish either citizenship or identity. If an affidavit is used to establish citizenship, then identity must be established using a different document from the identity list. • The affidavit is not required to be notarized. • May be used for a child aged 16 to 18 only when school identity cards and driver's licenses are not available to the individual in that area until that age. • SFN 691, "Affidavit of Identity for Children," has been created for convenience.

Identity verifications for disabled individuals in institutional care facilities. Exceptions identified in this section are allowed when a disabled individual in an institutional care facility does not have or cannot get any of the identity documents from the first three levels.

(Revised 8/1/2024 ML #3854)

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(N.D.A.C. Section 75-02-02.1-18)

As a condition of eligibility, applicants or recipients must be United States citizens, U.S. nationals, or certain lawfully present non-citizens. Verification of citizenship, naturalization, or lawful non-citizen status must be documented. This section addresses: Exceptions to verification of citizenship; Newborn children; Verification requirements; Acceptable documentation for US citizens and naturalized citizens; and Individuals born in Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, and Nationals from American Samoa.

For non-citizens, apply the appropriate policy identified in sections 510-03-35-50 through 510-03-35-70.

Exceptions to verification of citizenship. The following individuals are exempt from the citizenship verification requirements: SSI recipients who claim that they are US Citizens and that claim is not questionable (can prove using SDX or NDVerify SSI match); Medicare beneficiaries who claim that they are US Citizens and that claim is not questionable (can prove using NDVerify SSA match); Individuals receiving SSA disability insurance benefits based on their own disability; Individuals receiving Foster Care maintenance payments; Individuals receiving Subsidized Guardianship payments.

Newborn children. A child, born to a woman who has applied for and been determined Medicaid eligible and is in receipt of Medicaid when the child is born, may be eligible without verifying citizenship. This provision also applies in instances where labor and delivery services were furnished prior to the date of the Medicaid application and covered based on retroactive eligibility.

This provision applies to all children whose Mother is eligible for Medicaid at the time of their birth, including those under the emergency services only provisions. Children who are born to a woman who is not eligible for regular Medicaid must comply with the verification requirements if Medicaid is requested.

Verification Requirements: Applicants must provide satisfactory documentary evidence of citizenship or naturalization. A photocopy, facsimile, scanned or other copy of a document must be accepted to the same extent as the original document, unless information on the copy submitted is inconsistent with other information available, or there is reason to question the validity of the information in the document. A copy must be maintained in the casefile. Verifications may be accepted from another state agency that may have already verified citizenship, but a photocopy must be obtained for the casefile. Once an individual's citizenship is documented and recorded, subsequent changes in eligibility do not require repeating the documentation unless questionable, or there is no verification in the casefile. Example: John Doe applies for Medicaid and supplies his citizenship verifications and his case closes. If his casefile is purged after the three year retention period and he reapplies, he will need to again provide his verifications so that his casefile is complete. If an individual has made a good faith effort to obtain verifications, but cannot obtain them within the processing timeframes , or because the documents are not available, assistance must be provided to the individual in securing evidence of citizenship. Matches with other agencies may be used to assist the individual. Reasonable Opportunity Period. Applicants who claim they are U.S. Citizens or qualified non-citizens are entitled to a reasonable opportunity period to provide verification of citizenship, qualified non-citizen status, and identity. Medicaid is not permitted to deny, delay, reduce, or terminate eligibility while documentation is being gathered during the reasonable opportunity period. A reasonable opportunity period applies when all other information necessary to determine eligibility is available. If an individual is eligible for Medicaid and has met all other criteria except for citizenship or identity verification, that individual’s eligibility may not be pended for verification of either citizenship or identity, but must be approved. If the individual does not provide satisfactory documentation of citizenship and identity by the end of the reasonable opportunity period, the individual’s eligibility must be terminated with advance (10-day) notice and without regard to continuous eligibility provisions.

A ‘reasonable opportunity period’ is defined as 90 days from the date the application is submitted and for the remaining days of the month in which the 90th day falls. An extension of an additional 60 days from the 90th day may be granted if the individual has verifiable documented evidence they have been making a good faith effort to obtain the verifications, but still have not received them. A reasonable opportunity period is not limited to one. Example: If granted a reasonable opportunity period but the requested verifications are not received and eligibility is terminated, upon reapplication, if needed, a new reasonable opportunity period will be allowed.

Acceptable documentation for US citizens and naturalized citizens. The following documents may be accepted as proof of both citizenship and identity because either the US, a state, or Tribal government has established the citizenship and identity of the individual. These documents are considered to be the primary (Level 1) and preferred verification documents.

Primary Verifications

(Level 1)

These Documents Verify both Citizenship and Identity: Explanatory Information: US Passport or US Passport Card issued since 2007 • Issued by the Department of State. • Does not have to be currently valid, as long as it was issued without limitation; (any passport issued with a limitation cannot be used to verify citizenship, but CAN be used to verify identity). • Through 1980, spouses and children were often included on one passport; after that each person is issued his own passport. • The passport card is for frequent travelers by land or sea between the US and Canada, Mexico, the Caribbean and Bermuda. Certificate of Naturalization (DHS/INS Forms N-550 or N-570) • Department of Homeland Security or Immigration and Naturalization Service (INS) issues for naturalization. Certificate of US Citizenship (DHS/INS Forms N-560 or N-561) • Department of Homeland Security or INS issues certificates of citizenship to individuals who derive citizenship through a parent. Tribal Enrollment Card Certificate of Degree of Indian Blood; or Other documents issued by a federally recognized Indian tribe that evidences membership or enrollment with such tribe. • A document issued by a federally recognized Indian tribe evidencing membership or enrollment or affiliation with, such tribe. See following table for acceptable verifications from ND tribes. Citizenship verification received from using the “Other Benefits” inquiry in the NDVerify system or from the citizenship verification system available through the Federally Facilitated Marketplace (FFM) – as automated through the Streamlined application process. • Acceptable codes are: "Citizenship Verified" or "Verified with positive citizen; Deceased."

Documents Issued by Recognized ND Tribes

Tribe: Documents Sisseton-Wahpeton (Wahpeton—SE corner of ND) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood; Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal ID cards: Name, DOB, enrollment #, degree of Indian blood, SSN, photo and individual’s signature; Issued to enrolled members age 16 and older who request it; Issued by tribal enrollment office; Spirit Lake (Devils Lake) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood (may have more information); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal Photo ID: Photo ID including name, DOB, tribal enrollment #, and degree of Indian blood (may have more information); Issued by tribal motor vehicle office; Issued to enrolled members; Standing Rock Sioux Tribe (Fort Yates) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood, (may have more information); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal ID cards: Name, DOB, enrollment #, and degree of Indian blood, last 4 digits of SSN (may have more information); Issued to enrolled members age 14 and older who request it; Issued by tribal enrollment office; Three Affiliated Tribes (T. A. T.) (New Town) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal ID cards: Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo ( plastic card with hologram on back) (will enter SSN (non-verified) at individual’s request); Issued to any enrolled member who requests it; Issued by tribal enrollment office (Cost = $10; free to seniors); Expire every 4 years; Turtle Mountain Chippewa (Belcourt, Trenton) • Certificate of Degree of Indian Blood: Name, DOB, enrollment #, and degree of Indian blood, (may have more information); Issued to any enrolled member who requests it; Issued by tribal enrollment office; • Tribal Enrollment cards: Name, DOB, enrollment #, and degree of Indian blood (may have more information); Issued to enrolled members age 18 and older who request it; Issued by tribal enrollment office.

If an individual does not have one of the primary verifications, the individual must supply one document from one of the Citizenship lists (Levels 2, 3, or 4) and one document from the Identity lists (Levels 2, 3, or 4).

The verifications are listed in levels and the levels indicate the degree of reliability of the verifications. Level 1 has the highest reliability and is the preferred verification. Level 4 has the lowest reliability and those verifications should be used only when documents from levels 1-3 are not available. The verifications in level 1 must be requested prior to requesting those in level 2, those in level 2 must be requested prior to requesting those in level 3, and so on. Verification documents must be presented in their official and original form as received from the issuing agencies. Photocopies or notarized copies are not acceptable. Once an original document is presented, a photocopy must be made and maintained in the casefile.

Secondary Verification of Citizenship

(Level 2)

Acceptable Verifications: Explanatory Information: Certificate of Birth in the United States • Must have the embossed seal of the issuing agency. • North Dakota only issues certified copies. If it does not have the raised seal, it is not a certified copy - i.e. the old black and white prints. • The original must have been recorded before the person was 5 years of age. (For issuance date, use the "Date received by Local Registrar".) If recorded at or after 5 years of age, it is a 4th level verification. • Must show birth in one of the 50 states, or the District of Columbia. • Persons born to foreign diplomats are not citizens of the United States. • An electronic match with the ND vital statistics agency showing the individual's place of birth will suffice. Report of Birth Abroad of a Citizen of the United States (FS-240) aka Consular Report of a Birth Abroad of a Citizen of the United States • Prepared by the Department of State Consular office. • Can only be prepared at an American Consular office overseas while the child is under age 18. • Children born outside the US to US military personnel usually have one of these. Certificate of Birth Abroad (FS-545 or Form DS-1350) aka Certificate of Report of Birth or Certification of Birth Abroad • For those who were born outside the US and acquired US Citizenship at birth and is based on FS-240. • FS-545 issued prior to November 1, 1990. • DS-1350 issued on and after November 1, 1990. • Is issued only within the US. United States Citizen Identification Card (I-197 or I-179) • Issued by the Immigration and Naturalization Service from 1960-1973 as I-179; Issued to naturalized US Citizens living near the Canadian or Mexican border who needed it for frequent border crossings. • Issued as I-197 from 1973-1983. • No longer currently used, but still valid. American Indian Card (I-872) with the classification code "KIC" and a statement on the back • Issued by the Department of Homeland Security to identify US citizen members of the Texas Band of Kickapoos living near the US / Mexican border. Evidence of Civil Service Employment • Must show employment by the US Government prior to June 1, 1976. Official Military record of service • Including a DD-214. • Must show a US place of birth. A data verification with the Systematic Alien Verification for Entitlements (SAVE) Program for naturalized citizen • Determines if someone is a naturalized citizen. • May need to provide the individual's alien registration number. Adopted or biological children born outside the US may establish their automatic citizenship if verification is provided • Showing at least one parent is a US citizen by either birth or naturalization. • Child is under age 18. • Child is residing in the US in the legal and physical custody of the US citizen parent. • Child was admitted to the US for lawful permanent residence. • If adopted, the child must be a lawful permanent resident as an IR-3 (child adopted outside the US) or as IR-4 (child coming to the US to be adopted); with the final adoption having subsequently occurred.

Third Level Verification of Citizenship

(Level 3)

Acceptable Verifications: Explanatory Information: Extract of hospital record on hospital letterhead established at the time of birth and created at least 5 years prior to the Medicaid application • It must indicate a US place of birth. • A souvenir 'birth certificate' issued by the hospital cannot be accepted. • For children under 16 the document must have been created near the time of birth or 5 years prior to the Medicaid application. Life or health or other insurance record • Showing a US place of birth for the individual. • Created at least 5 years before the initial application date. Official religious record (recorded with the religious organization) recorded in the US within 3 months of birth • Must show a US place of birth. • Must show the individual's date of birth or age at the time the record was made. • In questionable cases, such as where the child's religious record was recorded near a US international border and the child may have been born outside the US, the worker must verify the religious record with the religious organization and verify that the mother was in the US at the time of birth. Early school record showing a US place of birth • Must show the name, date of birth, and US place of birth of the child. • Must show the date of school admission. • Must show the name(s) and place(s) of birth of the applicant's parents.

Fourth Level Verification of Citizenship

(Level 4)

Acceptable Verifications: Explanatory Information: Federal or state census record showing US citizenship or a US place of birth - (generally for persons born 1900-1950) • Must also show the applicant's age. • Census records from 1900 through 1950 contain citizenship information. • To obtain this information the applicant or recipient should complete a Form BC-600, "Application for Search of Census Records for Proof of Age", adding in the remarks portion, "US Citizenship data requested for Medicaid eligibility." This form can be obtained online at: http://www.census.gov/genealogy/www/bc-600.pdf. • A fee will be charged. Seneca Indian tribal census record • Must be created at least 5 years prior to initial Medicaid application; and • Must show a US place of birth. Bureau of Indian Affairs tribal census records of the Navajo Indians • Must be created at least 5 years prior to initial Medicaid application; and • Must show a US place of birth. US State Vital Statistic official notification of birth registration • Must be created at least 5 years prior to initial Medicaid application; and • Must show a US place of birth. Delayed US public birth record that is amended more than 5 years after the person's birth • Must be created at least 5 years prior to initial Medicaid application; and • Must show a US place of birth. Statement signed by the physician or midwife who was in attendance at the time of birth • Must be created at least 5 years prior to initial Medicaid application; and • Must show a US place of birth. Institutional admission papers from a nursing home, skilled care facility or other institution • Must be created at least 5 years prior to initial Medicaid application; and • Must show a US place of birth. Medical (clinic, doctor or hospital) record (An immunization record is NOT considered a medical record for establishing citizenship) • Must be created at least 5 years prior to initial Medicaid application (or near the time of birth, if a child under age 16 only); and • Must show Written affidavit, made under penalty of perjury, by at least two individuals--one of which is not a relative--showing they have personal knowledge of the event(s) establishing the applicant's claim of citizenship (date and place). These individuals must provide proof of their own citizenship and identity • It must also state a reasonable basis of personal knowledge that an applicant or recipient who cannot produce documentary evidence of citizenship is a citizen. SFN 707, "Affidavit of Citizenship," has been created for convenience. • A second affidavit from the applicant/recipient or other knowledgeable individual explaining why the information cannot be obtained must also be supplied. SFN 706, "Affidavit of Explanation why Citizenship Cannot be Supplied," has been created for convenience. • Use only in rare circumstances.

Individuals born in Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, and Nationals from American Samoa. For purposes of qualifying as a United States citizen, individuals born in Puerto Rico, Guam, the Virgin Island, the Northern Mariana Islands and Nationals from American Samoa may qualify as follows: Puerto Rico: Certificate of birth in Puerto Rico on or after January 13, 1941 (For applicants whose eligibility is determined for the first time on or after November 1, 2010, the birth certificate must have an issue date of on or after July 1, 2010, to be considered valid.) Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant's statement that he or she was residing in the US, a US possession, or Puerto Rico on January 13, 1941 (For applicants whose eligibility is determined for the first time on or after November 1, 2010, the birth certificate must have an issue date of on or after July 1, 2010, to be considered valid.) Evidence that the individual was a Puerto Rican citizen and the applicant's statement that he or she was residing in Puerto Rico on March 1, 1917, and that he or she did not take an oath of allegiance to Spain

Guam:

Evidence of birth in Guam on or after April 10, 1899

The US Virgin Islands:

Certificate of birth in the US Virgin Islands on or after January 17, 1917 Evidence of birth in the US Virgin Islands and the applicant's statement of residence in the US, a US possession, or the US Virgin Islands on February 25, 1927 The applicant's statement indicating residence in the US Virgin Islands as a Danish citizen on January 17, 1917 and residence in the US, a US possession, or the US Virgin Islands on February 25, 1927, and that he or she did not make a declaration to maintain Danish citizenship Evidence of birth in the US Virgin Islands and the applicant's statement indicating residence in the US, a US possession, or the Canal Zone on June 28, 1932

Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):

Certificate of birth in the Northern Mariana Islands after November 4, 1986. Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the US or a US territory or possession on November 3, 1986 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986. These individuals carry the Northern Mariana Identification Card (I-873). This form is no longer issued, but is still valid. Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981, voter registration prior to January 1, 1975, and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986. Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986. If the person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a US Citizen.

U.S. Nationals refers to individuals who were born in or having ties with "an outlying possession of the United States which, as of 2005, were American Samoa or Swain's Islands:

Certificate of birth in American Samoa or Swain's Islands after November 4, 1986 Persons born in American Samoa or Swain's Islands are treated as citizens for Medicaid purposes

Persons born to foreign diplomats while residing in one of the preceding jurisdictions of the US are not citizens of the United States.

The child's citizenship or non-citizen status follows that of the parent.

(Revised 8/1/2024 ML #3854)

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American Indians born in Canada who may freely enter and reside in the United States are considered to be lawfully admitted for permanent residence if at least one-half American Indian blood. This does not include a spouse or child of such an Indian nor a noncitizen whose membership in an Indian tribe or family is created by adoption, unless such person is of at least 50 percent or more Indian blood. These American Indians are qualified non-citizens and are considered to be lawful permanent residents.

Article III of the ‘Jay Treaty’ declared the right of “Indians” (“Native Americans”) to trade and travel between the United States and Canada, which was then a territory of Great Britain. As a result of the “Jay Treaty”, Native Indians born in Canada are entitled to enter the Unites States for the purpose of employment, study, retirement, investing, and/or immigration.

Verification of percentage of American Indian blood may be obtained from INS Form I-551 with the code 513, S1-3, or S-13, or an unexpired temporary I-551 stamp (with the code 513, S1-3, or S-13) in a Canadian passport or on Form I-94. If the individual does not have an INS document, satisfactory evidence of birth in Canada and a document indicating the percentage of American Indian blood must be provided. Documents, indicating the percentage of American Indian blood include a birth certificate issued by the Canadian reservation, or a Blood Quantum Letter, card, or other record issued by the tribe (each tribe provides some type of evidence). The Blood Quantum Letter may use the following verbiage: at least 50% Aboriginal blood, at least 50% Indigenous blood, at least 50% North American Indian blood, or at least 50% American Indian blood. Do not accept a Certificate of Indian Status card ("Band" card) issued by the Canadian Department of Indian Affairs, information from any internet sites, or any other document not directly issued by the individual’s tribe.

Note: The Blood Quantum Letter can be used to show that an individual possesses at least 50% blood of the American Indian Race, but cannot be used to show that an individual does not possess at least 50% blood of the American Indian Race. If the letter does not show an individual possesses at least 50% blood of the American Indian Race, additional verification may be warranted.

(Revised 5/5/2025 ML #3929 )

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(N.D.A.C. Section 75-02-02.1-18)

Some non-citizens may be lawfully admitted for a temporary or specified period of time and are not eligible for Medicaid. They have the following types of documentation: Form I-94, Arrival-Departure Record; DSP-150 Border Crossing Card and B-1/B-2 visitor visa; I-586 Mexican Border Crossing Card; Form I-95A, Crewman’s Landing Permit. These non-citizens are not eligible for Medicaid because of the temporary nature of their admission status. Ineligible non-citizens are eligible for coverage of emergency services. The following categories of individuals are ineligible non-citizens: Foreign government representatives on official business and their families and servants; Visitors for business or pleasure, including exchange visitors; Non-citizens in travel status while traveling directly through the U.S.; Crewman on shore leave; Treaty traders and investors and their families; Foreign students; International organization representation and personnel and their families and servants; Temporary workers including agricultural contract workers; and Members of foreign press, radio, film, or other information media and their families.

Illegal non-citizens who are not lawfully admitted for permanent residence in the United States are not eligible for Medicaid, except for emergency services. Ongoing eligibility does not exist.

(Revised 5/5/2025 ML #3929 )

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Qualified non-citizens are individuals that have been legally admitted and may be eligible for Medicaid if they meet all other Medicaid eligibility criteria. Some qualified non-citizens may be eligible under the Refugee Medical Assistance Program if they do not meet all other Medicaid eligibility criteria. The following categories of individuals are qualified non-citizens: (Forms indicated below are USCIS or Immigration and Naturalization Service (INS) forms and the sections refer to the Immigration and Nationality Act (INA).

Individuals with the documents described in subsections 2 through 14 below may be eligible for Medicaid from their date of arrival in North Dakota, without being subject to the five-year ban or required to meet the forty qualifying quarters of social security coverage, as long as they meet all other Medicaid criteria:

Non-citizens who are lawfully admitted for permanent residence (LPR) may be eligible as described in sections 510-03-35-60 and 510-03-35-65 .

Honorably discharged veterans, non-citizens on active duty in the United States’ armed forces, and the spouse or unmarried dependent child(ren) of such individuals with: Verification of honorable US military discharge (such as a DD214); Verification of relationship of family members.

Refugees who possess one of the following: Form I-94 (Arrival Departure Record) showing "207" or "REFUG" or codes RE1, RE2, RE3, RE4, or RE5; Form I-766 (Employment Authorization Document) with code A3; Form I-571 (Refugee Travel Document); Form I-551 or I-151 (Permanent Resident Card) with codes R8-6; RE6, RE7, RE8, RE9.

Asylees who have been granted asylum (not applicants for asylum) and posess one of the following: Form I-94 showing “208” or “asylee” and/or codes of AS1, AS2, or AS3); Form I-766 annotated A5; A grant letter from Asylum office of USCIS; An order from immigration judge granting asylum; Form I-571 or; Form I-551 or I-151 with codes AS6, AS7, AS8, AS9, GA-6 to GA-8.

Cuban and Haitian Entrants who possess one of the following: Form I-94 showing “Cuban/Haitian Entrant” or “parole” under Section 212(d)(5) or codes CU6, or CU7 or “OOE” or ”outstanding orders of exclusion”, Citation of INA 212(d)(5) or the word “Parole” Automated I-94 Codes CH, CP, HF, HR, HT, HQRAP, PARCIS; codes EQ1, AM2, AM3; Form I-151 or I-551 with National of Cuba or Haiti and codes CH6,CH7,CNP, CU0, CU-6, CU-7, CU-8, CU-9, CUP, HA-6 to HA-9; HB-6 to HB-9; HD-6 to HD-9; HE-6 to HE-9, or NC-6 to NC-9; Forms I-766 with code A04, A12, C08,C10,C11; Form I-327- Re-entry Permit; Form I-797 A and C- USCIS Notice of Action Receipt of Asylum Application; Form I-862- Notice to Appear; Form I-220A- Order of Release on Recognizance; Form I-797A- USCIS Notice of Action; Form I-589- Date stamped by the Executive Office for Immigration Review (EOIR); Form I-485- Date stamped by EOIR; Form Executive Office for Immigration Review (EOIR)-26; DHS forms: I-221, I-862, I-220A, I-122, I-221S; Other applications for relief that have been date stamped by EOIR or; Other documentation pertaining to an applicant's removal, exclusion, or deportation proceedings.

Victims of a severe form of trafficking and their families (non-citizens granted non-immigrant status under Section 101(a)(15)(T) of the Immigration and Nationality Act (INA) who have a pending application that sets forth a prima facie case for eligibility for that non-immigrant status) who possess one of the following: Form I-94 showing codes T-1 or T-2; Form I-94 or passport showing non-immigrant status under 101(a)(15)(T); Form I-766 showing 247a.12(a)(16), A16, 274a.12(c)(25) or C25; Other INS document showing non-immigrant status under Section101(a)(15)(T) of the INA or; Any verification from the INS or other authoritative documents showing non-immigrant status under Section 101(a)(15)(T) of the INA.

Non-citizens whose deportation was withheld under Section 243(h) of the Immigration and Naturalization Act (INA) who possess one of the following: Form I-94 or foreign passport showing “243(h)” or “241(b)(3)”; Form I-766 with code of “274a.12(a)(10) or A10; or Form I-571.

Non-citizens admitted as an Amerasian immigrant who possess one of the following: Form I-94 showing National of Vietnam and AM1, AM2, or AM3; or Form I-151 or I-551 showing National of Vietnam and AM-1, AM-2, AM-3, AM-6, AM-7; or AM-8.

American Indians born in Canada as described in 510-03-35-50 .

Non-citizens paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year who possess one of the following: Form I-94 showing “212(d)(5)” or “parolee” or “PIP”; Form I-766 with code such as 274a.12(a)(4), or A4, or 274a.12(c)(11);or Cuban-Haitian entrants with parole status.

Certain battered non-citizens; battered non-citizen children; and the parents of such children with a Form I-551 card showing B2-1, B2-3, B2-6, or B2-8.

Iraqi and Afghan Special Immigrants and their families who possess: Form I-94 with a stamp of “IV” and category SQ1, SQ2, SQ3, SQ4, SQ5, SI1, SI2 or SI3 and date of entry; COA of OAR, PAR, or DT; An Afghan or Iraqi passport with a stamp of “IV” and category CQ1, CQ2, CQ3, SQ1, SQ2, SQ3, SQ6, SQ7, SQ8, SI1, SI2 or SI3 and DHS stamp or notation on passport showing date of entry; COA of OAR, PAR, or DT with CBP PAROLED stamp and/or parole COA notation; Form I-551 showing national of Afghanistan or Iraq with “IV” code of CQ1, CQ2, CQ3, SQ1, SQ2, SQ3, SQ6, SQ7, SQ8, SQ9, SI6, SI7, SI9 or; Form I-766 with a stamp of ‘IV’ code of SQ4 and SQ5 with C11 Parolee category. COA of OAR, PAR, or DT with C11 Parolee category.

Non-citizens granted conditional entry under section 203(a)(7) of the INA in effect prior to April 1, 1980: Form I-94 or other document showing “conditional entrant”, “refugee conditional entry”, “seventh preference”; “section 203(a)(7)”; “P7” ; Form I-766 annotated “A3”; or Any verification from the INS or other authoritative document.

Individuals from the Federated States of Micronesia, the Marshall Islands or Palau, are permanent non-immigrants and must posses one of the following:

Form I-94 Arrival/Departure Record created electronically upon arrival to an air or sea port of entry. Paper versions can be obtained by logging on to U.S. Customs and Border Protection (CBP) at CBP’s I-94 website. Form I-94 will contain an admission stamp, but not an “admit until” date. Form I-94 printed from the CBP website will show an “admitted until” date of D/S (duration of status). D/S indicates that the individual is authorized to remain in the United States as long as they maintain a valid status.

A valid, unexpired passport from Federated States of Micronesia (FSM), Republic of Marshall Islands (RMI), or Republic of Palau (PAL).

Notations on passports will be CFA/PAL (Compact of Free Association/Palau); `CFA/FSM (Compact of Free Association/Micronesia) or CFA/MIS (older version would be RMI) (Compact of Free Association/Marshall Islands).

Form I-94 will have either an U.S. Citizenship and Immigration Services (USCIS) registration number (A-number) or an 11 alphanumeric-character admission/departure number.

(Revised 8/1/2024 ML #3854)

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(N.D.A.C. Section 75-02-02.1-18)

Non-citizens who lawfully entered the United States for permanent residence before August 22, 1996, and who meet all other Medicaid criteria may be eligible for Medicaid. These individuals have Forms I-551 or I-151 (Permanent Resident Cards) or a Foreign Passport stamped LPR or I-551.

(Revised 8/1/2024 ML #3854)

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(N.D.A.C. Section 75-02-02.1-18)

Non-citizens admitted for Lawful Permanent Residence (LPR) on or after August 22, 1996 are banned from Medicaid, for five years from the date they obtained LPR status. After the five-year ban, non-citizens who are lawful permanent residents who can be credited with forty qualifying quarters of social security coverage may be eligible for Medicaid.

Verifications of this status are:

Form I-551 or I-151 (Permanent Resident Card) (these are also known as ‘green cards’ but are not green); Foreign passport stamped LPR or I-551.

Note: If a qualified non-citizen's status has changed to LPR, the codes at 510-03-35-58 apply. If the code on the Permanent Resident Card is not in 510-03-35-58 , the individual is subject to the 5–year ban and forty qualifying quarter requirements.

Example: An asylee entered as an AS1 (which shows on his I-94 card). He has now become a LPR and his code on his I-551 is AS8. He is still an Asylee and a qualified non-citizen. If his LPR code had been issued as an SD6, which is not a qualified non-citizen code instead of the AS8, he is subject to the 5-year ban or the forty-quarter requirements.

Qualifying quarters of social security coverage, determined by the Social Security Administration, can be obtained using the Verification Interfaces/40 Quarters in the eligibility system.

When the interface returns a total of forty quarters or more, no further action is needed. If the interface returns less than forty quarters, but the alien claims to have 40 quarters work history, gather the information regarding the amount of earnings by quarter and contact the Medicaid Eligibility unit for further assistance. Note: When determining the number of qualifying quarters an individual has, count: All qualifying quarters the non-citizen has due to work; All qualifying quarters worked by the non-citizen's spouse during their marriage, if the non-citizen remains married to such spouse or the spouse is deceased; and All qualifying quarters worked by a natural, adoptive, or stepparent of such alien while the non-citizen was under age 18. Qualifying quarters of an adoptive parent count from the quarter of the adoption. Qualifying quarters of a stepparent count from the quarter of marriage to the non-citizen's parent. Earnings of some federal civilian employees hired before 1984, earnings of employees of some state and local governments, and certain agricultural and domestic earnings are not calculated by Social Security. Do not count or deem any qualifying quarters for any quarter in which an individual received TANF, SNAP, Medicaid, or SSI benefits (including benefits received in another state), for at least one month in the quarter, or from any parent whose parental rights have been terminated.

Adopted or biological children born outside the US may establish their automatic citizenship if verification is provided as described in the Secondary Verification of Citizenship table at 510-03-35-45 .

Pregnant women who are lawfully present in the United States and are otherwise eligible for medical assistance, are not subject to the 5 year waiting period/40 quarter requirement through the twelve month postpartum period.

(Revised 11/1/2025 Release 25.14 )

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(N.D.A.C. Section 75-02-02.1-18)

Ineligible non-citizens (identified in of 510-03-35-55 ), and qualified non-citizens, who are not eligible for Medicaid because of the time limitations or forty qualifying quarters of social security coverage requirement, may be eligible to receive emergency services that are not related to an organ transplant procedure, if all of the following conditions are met:

The non-citizen has a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Placing health in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part.

The non-citizen meets all other eligibility requirements for Medicaid except illegal non-citizens do not have to meet the requirements concerning furnishing social security numbers and verification of alien status; and

The non-citizen's need for the emergency service continues. Eligibility for Medicaid ends when the emergency service has been provided, and does not include coverage of follow-up care if the follow-up care is not an emergency service. A pregnant woman, who is not lawfully present in the United States, may be covered from the date she entered the hospital for labor and delivery through the date she was discharged. A pregnant woman who delivers a child and is covered under this provision is not eligible for the twelve month period of eligibility after pregnancy. Her child, however, is a citizen and may be eligible for twelve months of continuous coverage.

When an ineligible non-citizen is requesting coverage for 'Emergency Services' for reasons other than childbirth, a completed SFN 451, Eligibility Report on Disability/Incapacity and medical reports must be submitted to the State Review Team for a determination of whether the medical condition meets ALL the criteria listed in #1 above. Note: Remember to check the box in the upper right hand corner titled 'Emergency Services'.

Pregnant women who are lawfully present in the United States and are otherwise eligible for medical assistance are not subject to the five-year waiting period/ forty quarter requirement through the twelve month postpartum period.

When an ineligible non-citizen is requesting coverage for ‘Emergency Services’ for reasons other than childbirth, a completed SFN 451, Eligibility Report on Disability/Incapacity and medical reports must be submitted to the State Review Team for a determination of whether the medical condition meets ALL the criteria listed in #1 above.

Note: Remember to check the box in the upper right hand corner titled ‘Emergency Services’.

(Revised 11/1/2025 Release 25.14 )

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(N.D.A.C. Section 75-02-02.1-13)

A valid social security number (SSN), or verification of application for SSN, must be furnished as a condition of eligibility, for each individual requesting coverage.

Members of the Medicaid Household who are not seeking coverage may voluntarily provide their SSN; however, they are not required to do so. Individuals who do not have a number must be referred to the Social Security Administration to apply for one. The zone may assist the applicant as needed.

Examples of verification of application for an SSN includes but is not limited to:

A copy of the Parent Verification document the hospital submitted to Vital Records or written verification from the hospital. Refugee Global boarding letter Refugee travel document Any proof from the Social Security Administration

The following individuals are exempt and do not have to provide an SSN or verification of application for an SSN:

A newborn who is eligible during the birth month, beginning on the date of birth and through the last day of the twelfth month; Note: If a newborn is NOT eligible in the birth month, but is eligible for months following the birth month an SSN or Application for SSN is required. An individual who is currently eligible for Transitional or Extended Medicaid Benefits; An ineligible noncitizen (identified in 510-03-35-55 ) seeking emergency services. (See 510-03-35-70 for a description of emergency service.), and An individual who is determined eligible under Hospital Presumptive Eligibility (HPE).

When the exempt period ends, a social security number or verification of application for SSN must be provided to continue Medicaid coverage.

The Medicaid household must be informed, at the time of application that the agency will use the SSN in the administration of the Medicaid Program. The SSN will be used to verify income and asset information from the Social Security Administration, Internal Revenue Service, Job Service, Unemployment Compensation, SNAP, TANF Program, Child Support Enforcement, State Motor Vehicle, Department of Vital Statistics and other states.

The informing requirement is met by the appropriate language found on the Application for Assistance.

Social Security numbers are electronically verified through the NDVerify interface in SPACES for all individuals. When a number is reported as not valid, the individual must provide their valid SSN to continue to be eligible for Medicaid.

Refer to the Administrative Manual Section 448-01-50-15-60.

The eligibility system may be incorrect or the individual's record at SSA has incorrect information. The worker should check the information entered into the system for accuracy. If the worker is unable to determine if the information in the system is accurate, the worker must contact the household (via phone or notice) to determine the correct date of birth or gender and then correct the information in the system.

If the worker contacts the household by phone, the contact must be thoroughly documented in the narrative. The worker must document the request and give the household 10 days to provide the number.

If the household refuses to provide the SSN, or fails to respond to the request, that individual's coverage must be ended or denied. If the household requests additional time, another 10 days may be allowed. Household members who are not requesting coverage are not required to provide an SSN.

If the individual can only show a request date and not a number, they have until the next review to provide an SSN, or eligibility will end for that individual. Newborns may be eligible until the month of their first birthday with a request date, after that , an SSN must be provided.

Except for individuals exempt in Subsection 1, individuals who provided verification of application for an SSN must provide an SSN by the next review. If a child is within a continuous eligibility (CE) period when the case review is being completed, and the SSN is not provided, the child is eligible through the end of the current CE period. However, the child's SSN must be provided for eligibility to continue past the end of that CE period.

(Revised 10/1/2023 ML #3763)

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(N.D.A.C. Section 75-02-02.1-16)

An individual must be a resident of North Dakota to be eligible for Medicaid through this state. A resident of the state is an individual who is living in the state voluntarily with the intention to remain there permanently or for an indefinite period (not a temporary purpose), or is entering the state with a job commitment or seeking employment. Temporary absences from the state with subsequent returns to the state, or intent to return when the purpose of the absence has been accomplished, do not interrupt continuity of residence. Residence is retained until abandoned or established in another state.

For individuals entering the state, the earliest date of residency is the date of entry. Residence may not be established for individuals who claim residence in another state.

Note: Individuals in receipt of SSI who have residence address on SOLQ showing a North Dakota address, will be considered a North Dakota resident. If the residence address on SOLQ indicates an out of state address, the application will need to be pended for verification of residence address. In the pending notice, the client must be informed to contact SSA to report the move and update the residence address.

An individual’s Medicaid case may remain open in the other state for a period of time after the individual moves. However, most states will not cover out-of-state care. Eligibility may be determined as of the date the individual entered the state. When an individual leaves the state, eligibility is ended as soon as, and in accordance with, proper notice. North Dakota Medicaid will no longer extend coverage through the month in which an individual moves out of the state. This information must be documented in the case file.

Individuals under age twenty-one.

For any individual under age twenty-one who is living independently from their parents or who is married and capable of indicating intent, the state of residence is the state where the individual is living with the intention to remain. For any individual who is receiving foster care or adoption assistance payments, under Title IV-E , from another state and is living in North Dakota, North Dakota is the state of residence for Medicaid purposes. For children receiving non IV-E foster care assistance payments from another state, the state of residence for Medicaid is the state making the payment unless the Interstate Compact on the Placement of Children (ICPC) indicates which state will cover Medicaid. Children receiving non-IV-E adoption assistance payments from another state are considered residents of North Dakota for Medicaid purposes if there is an Interstate Compact on Adoption and Medical Assistance (ICAMA) agreement with a member state that indicates that the receiving state will cover the Medicaid. Likewise, children from North Dakota receiving non-IV-E adoption assistance payments who move to another member state may no longer be considered North Dakota residents if the ICAMA agreement indicates that the receiving state will cover the Medicaid. The Children and Family Services division provides zone agencies with information on whether a sending or receiving state is a member state and which state is responsible for the medical coverage per the agreement.

For any individual under age twenty-one not residing in an institution, whose Medicaid eligibility is based on blindness or disability , the state of residence is the state in which the individual is living. For any other non-insitutionalized individual under age twenty-one, the state of residence is the state in which the child is living with the child's parent or another caretaker relative on other than a temporary basis. A child is normally considered to be living in the state temporarily if:

The child comes to North Dakota to receive an education, special training or services in the Anne Carlsen School, maternity homes, vocational training centers, etc. If the intent is to return to the child's home state upon completion of the education or service; The child is placed by an out -of-state court into the home of relatives or foster parents in North Dakota on other than a permanent basis or on other than an indefinite period; or The child entered the state to participate in Job Corps or other specialized services if the intent is to return to the child's home state upon completion of the activity or service.

For any institutionalized individual under age twenty-one, who is neither married nor living independently, residence is that of the parents or legal guardians at the time of placement or the state of residence of the parent or legal guardian at the time of Medicaid application if the child is institutionalized in the same state. Only if the parental rights have been terminated, and a guardian or custodian be used. If the individual has been abandoned by their parents and does not have a guardian, the individual is a resident of the state in which the individuals lives.

For students entering the state to attend school full time and are between the ages of 18 and 22 (including the month the child attains age 22), who apply for Medicaid on their own behalf, are considered North Dakota residents if the individual intends to remain in North Dakota when their education has been completed. Individuals who do not intend to remain in North Dakota when their education has been completed are considered residing in the state temporarily and are not considered a resident of North Dakota. Individuals age twenty-one and over: For any individual not residing in an institution, the state of residence is the state where the individual is living with the intention to remain there permanently or for an indefinite period or is entering the state with a job commitment or seeking employment. The state of residence, for Medicaid purposes, of migrants and seasonal farm workers is the state in which they are living due to employment or seeking employment. For an institutionalized individual who became incapable of indicating intent before age twenty-one, the state of residence is that of the parent or guardian making application, at the time of placement or, if the individual is institutionalized in that state, at the time of application. If the individual has no guardian, the application is not made by either parent, and the placement was not made by another state, the state of residence is the state in which the individual is physically present. For any other institutionalized individual, the state of residence is the state where the individual is living with the intention to remain there permanently or for an indefinite period. An "individual incapable of indicating intent" means one who: Has an intelligence quotient of forty-nine or less, or a mental age of seven or less, based upon tests acceptable to the Division of Behavioral Health under the Department of Health and Human Services; Has been found by a court of competent jurisdiction to be an incapacitated person as defined in subsection 2 of North Dakota Century Code section 30.1-26-01; Has been found by a court of competent jurisdiction to be legally incompetent; or Is found incapable of indicating intent based on medical documentation obtained from a physician or surgeon, clinical psychologist, or other person licensed by the state in the field of mental retardation. Individuals placed in out-of-state institutions by a state agency retain residence in that state regardless of the individual's indicated intent or ability to indicate intent. State residence ends, however, when the competent individual leaves the facility in which the individual was placed by the state. Providing information about another state's Medicaid program or about the availability of health care services and facilities in another state, or assisting an individual in locating an institution in another state, does not constitute a state placement. State agencies include human service centers, the Division of Juvenile Services, special education, zone offices, and the Department of Health and Human Services. Tribal entities and hospital social workers or other staff are not state agencies. For any individual receiving a state supplemental payment, the state of residence is the state making the payment. If an interstate reciprocal residency agreement has been entered into between this state and another state pursuant to 42 CFR 435.403(k), the state of residence of the individual is the state determined under that agreement. North Dakota has an interstate reciprocal residency agreement with nine states. The agreement provides that individuals of any age institutionalized in one of these states are considered a resident of the state in which they are institutionalized. The states with whom we have the agreement are: California New Mexico Tennessee Kentucky Ohio Texas Wisconsin Pennsylvania North Dakota also has a specific agreement with the State of Minnesota. The agreement states that individuals who enter a nursing facility in the other state remain a resident of the state they were a resident of prior to admission into the nursing facility for 24 months following admission, and if the individual has a community spouse, they continue to be a resident of the state the community spouse lives in beyond the 24 month time limit. This agreement terminates at the point the individual is discharged from a nursing facility unless the individual is being transferred to a different nursing facility. When two or more states cannot agree which state is the individual's state of residence, the state of residence is the state in which the individual is physically present. North Dakota residents will be provided Medicaid outside the state when: It is a general practice for residents of a particular locality to use medical resources outside the state; The availability of medical resources requires an individual to use medical facilities outside the state for short or long periods. Prior approval from the Medical Services Division must be obtained when an individual is being referred for out-of-state medical services. Transportation for approved out-of-state medical services will be arranged jointly by the individual and the Customer Support Center. Individuals are absent from the state for a limited period of time to receive special services or training; It is an emergency situation; and Services are received during an eligible period by prior to application.

(Revised 1/1/2025 ML 3892 )

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(N.D.A.C. Section 75-02-02.1-17)

Medicaid applicants and beneficiaries are not required to apply for other benefits that they may be entitled to as a condition of Medicaid eligibility, including: Annuities Pensions Retirement benefits Disability benefits Unemployment benefits Example: Other benefits include, but are not limited to, Veterans’ Compensation and Pensions; Old Age, Survivors, and Disability Insurance Benefits; Railroad Retirement Benefits; and Unemployment Compensation.

Applicants and recipients are notified these benefits may be available to them to apply for.

Application for needs based payments (e.g. SSI, TANF , etc.) cannot be imposed as a condition of eligibility.

(Revised 1/1/2025 ML #3916 )

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(N.D.A.C. Section 75-02-02.1-19)

Incarceration status is not a condition of Medicaid eligibility and does not make an individual ineligible. An individual who is an “inmate” of a “public institution” who meets all eligibility factors for Medicaid is Medicaid eligible. Medicaid eligibility for individuals who are inmates of a public institution will be suspended. No medical services will be covered under the Medicaid program during the individual's stay in the public institution. Public Institutions in North Dakota include (but are not limited to): North Dakota Youth Correctional Center, Dakota Women’s Correctional Center in New England, North Dakota State Penitentiary, Bismarck Transition Center (BTC) Women’s Treatment Program (locked unit which is separate and distinct from the BTC transitional housing and work release unit), James River Correctional Center, Heart River Correctional Center, Missouri River Correctional Center City, county, and tribal jails. A transfer from a public institution to a hospital or another medical institution, for evaluation or treatment does not terminate inmate status. Example : A release from a public institution to a hospital for the birth of the inmate’s child will not terminate inmate status if the inmate is required to return to the public institution following discharge from the hospital.

The period of Medicaid eligibility suspension under this section begins the day after the day the individual enters the public institution and ends the day before the day the individual is discharged from the public institution. A Ten-Day Advance Notice is not needed when suspending benefits due to entry into the public institution. See Paragraph (4)(c)(iii) of 510-03-25-25 , "Decision and Notice," for further information.

(Revised 1/1/2025 ML #3916 )

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An individual's Medicaid coverage is suspended when he or she is incarcerated and is an inmate with the Department of Corrections and Rehabilitation (DOCR) or a county or tribal jail.

(Revised 1/1/2025 ML #3916 )

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For purposes of the Coverage for Inmates Receiving Inpatient Care in Certain Medical Institutions section:

Inpatient: A patient who has been admitted to a medical institution as an ‘inpatient’ on recommendation of a physician or dentist and: Receives room, board and professional services in the institution for a 24 hour period or longer, or Is expected by the institution to receive room, board and professional services in the institution for a 24 hour period or longer even though it later develops that the patient dies, is discharged or is transferred to another facility and does not actually stay in the institution for 24 hours.

NOTE : An inmate may be placed in a hospital under an 'observation' status, which is an 'outpatient category. These inmates are not considered receiving inpatient medical care and Medicaid eligibility would remain in suspended status.

Medical Institution means an institution that: Is organized to provide medical care, including nursing and convalescent care; Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards; Is authorized under State law to provide medical care; and Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include adequate and continual medical care and supervision by a physician; registered nurse or licensed practical nurse supervision and services and nurses' aid services, sufficient to meet nursing care needs; and a physician's guidance on the professional aspects of operating the institution.

Department of Corrections and Rehabilitation includes the ND State Penitentiary and Missouri River Correctional Center in Bismarck, Dakota Women’s Correctional and Rehabilitation Center in New England, James River Correctional Center in Jamestown, and the North Dakota Youth Correctional Center in Mandan.

County Jail means a place of confinement for persons held in lawful custody under the jurisdiction of a local government. A listing of county jails in North Dakota can be found at: http://www.nd.gov/docr/county/jails.html

Note : This does not include Tribal run jails.

(Revised 1/1/2025 ML #3916 )

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Inmates of a public institution for whom Medicaid eligibility is suspended are eligible for payment of their Medicaid-covered services received while an inpatient in one of the following Medical Institutions for a 24-hour period or longer:

A hospital,

A nursing facility (nursing home),

A Psychiatric Residential Treatment Facility (PRTF),

An Intermediate Care Facility for the Intellectually Disabled (ICF-ID),

The inmate must apply for and meet all other Medicaid factors of eligibility.

Individuals who are not aged or disabled will have their eligibility determined under this Chapter.

Individuals who are aged or disabled will have their eligibility determined based on Non-ACA Medicaid Policy defined in Manual Chapter 510-05.

Note#1 : Individuals who become incarcerated will have their Social Security and SSI benefits terminated by the Social Security Administration. However, these individuals continue to be considered disabled for Medicaid purposes.

Note #2 : Individuals who are under age 65, disabled, and do not have Medicare coverage, who fail the asset limits, can have their eligibility determined under ACA Medicaid.

Eligibility begins on the date the inmate is admitted as an inpatient in a medical institution and ends the day they are discharged from the medical institution. Any services received before the inmate is admitted or after the inmate is discharged from the medical institution will not be covered by Medicaid.

Individuals who are:

Greater than age 21 but less than age 65 will be assigned a COE of M072.

Pregnant, under age 21, or aged or disabled will be assigned a COE of M073.

Note : For individuals who are aged, blind or disabled, please refer to policy at 510-05-35-95-05-10.

Regardless of the COE assigned individuals eligible under this provision:

Will have their eligible inpatient care paid through the Traditional Medicaid Fee for Service benefit plan.

Will receive notification of their Medicaid ID Number from ND Health Enterprise MMIS;

Will not be issued a Medicaid ID Card;

(New 5/1/2017 ML #3498)

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There is no asset test for applicants and recipients whose eligibility is determined under ACA Medicaid . Asset provisions do not apply to these individuals.

The medically needy asset provisions defined in Service Chapter 510-05-70 apply to all aged, blind, and disabled applicants and recipients under this provision.

(New 5/1/2017 ML #3498)

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Income calculations for those eligible under ACA Medicaid are defined at 510-03-85 .

(New 5/1/2017 ML #3498)

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Income levels for those eligible under ACA Medicaid are defined at 510-03- 85-40.

(New 5/1/2017 ML #3498)

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Budgeting provisions for those eligible under ACA Medicaid are defined at 510-03-90 .

Refer to Section 510-03-110 , Policy Processing Appendix for information on how to process eligibility for these individuals.

(Revised 1/1/2025 ML #3916 )

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Inmates residing in state or local corrections-related supervised community residential facilities (whether operated by a governmental entity or a private entity) are eligible for Medicaid unless the inmate does not have the freedom of movement and association while residing at the facility. To meet this requirement, the facility must operate in such a way as to ensure that individuals living there have freedom of movement and association, and the inmate:

MUST be able to work outside the facility in employment available to individuals who are not under justice system supervision;

MUST be able to use community resources (libraries, grocery stores, recreation, education, etc.) “at will”; and

MUST be able to seek health care treatment in the broader community to the same or similar extent as other Medicaid enrollees in the state.

For this purpose, “at will” includes and is consistent with requirements related to operational “house rules” where, for example the residence may be closed or locked during certain hours or where inmates are required to report during certain times and sign in and out. Similarly, an inmate's supervisory requirements may restrict traveling to or frequenting certain locations that may be associated with high criminal activity.

Examples of (not limited to) corrections-related supervised community residential facilities that house inmates include:

Bismarck Transition Center Transitional Housing and Work Release Program

Centre Inc. in Mandan

Centre Inc. in Fargo

Centre Inc. in Grand Forks

Lake Region Residential Reentry Center

Note : These facilities also house individuals who are on parole and probation. Individuals on probation or parole are not considered inmates.

Federal inmates residing in supervised community residential facilities are not eligible for Medicaid coverage under this provision as the Department of Justice (DOJ) and/or Bureau of Prisons (BOP) retains responsibility for payment of health care services rendered to individuals in supervised community residential facilities.

If an inmate was incarcerated by another state and was sent to North Dakota for any reason, including the other state not having capacity to house the individual, the other state remains the state of residence. The inmate would retain residency for purposes of Medicaid eligibility in the other state and eligibility in North Dakota would be denied for ‘Not a Resident’.

Likewise, if an inmate was incarcerated by North Dakota and was sent to another State for any reason, including North Dakota not having capacity to house the individual, North Dakota remains the state of residence. The inmate would retain residency for purposes of Medicaid eligibility in North Dakota. When determining the Medicaid Unit for this individual under ACA, the household of the individual is determined based on their tax filing status. While the individual is considered NOT residing in the home, this may result in a spouse or child(ren) needing to be included in the ACA case.

Many of these individuals are allowed to work in the community. This income must be considered when determining eligibility.

Processing for these individuals can be found in the Processing Appendix at 510-03.

(Revised 1/1/2025 ML #3916 )

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Incarceration status is not a condition of Medicaid eligibility and does not make an individual ineligible. A person who applies for or is enrolled in Medicaid, and who is or becomes incarcerated, is eligible for Medicaid if they meet all Medicaid eligibility factors. If an inmate meets all eligibility factors for Medicaid, Medicaid will be suspended while the individual remains an inmate in the public institution. Medicaid will not pay for medical services for inmates in a public institution except for inpatient care per 510-03-35-95-05-15.

People who are incarcerated may apply for Medicaid at any time. The zone agency must accept Medicaid applications from, or on behalf of, inmates of public institutions at any time during their incarceration and process these applications promptly. They are not to be held for later processing (refer to 510-03-25-05 ).

If determined eligible for Medicaid while incarcerated, the individuals Medicaid will be placed in a suspended eligibility status.

Individuals who are incarcerated will continue to have Medicaid eligibility reviews while their eligibility is in suspend status. Passive reviews will be completed and if an incarcerated person fails reasonable compatibility, a review form will be mailed. Review forms received are not to be held for later processing.

Incarceration is not an exception to a child’s CE period. Therefore, if a child is released from the carceral setting before their CE period ends, benefits must be reinstated without conducting a redetermination of eligibility, unless the child has experienced an exception per Continuous Eligibility Periods 510-03-53-15 .

Example : Alex is 17 and his eligibility period is January 1, 2024 through December 31, 2024. Due to Alex’s age, he has 12 months of CE. Alex becomes incarcerated in May 2024, and is released on October 1, 2024. A Medicaid review prior to his release is not needed because Alex is released prior to the end of his current CE period.

Redetermination of eligibility is required for certain individuals prior to their release from a carceral setting. If a Medicaid determination was conducted while an individual was incarcerated and within 12 months of date of release, another redetermination upon release is not required.

Example: Sally is determined eligible for Medicaid in January, becomes incarcerated in March, and is released from incarceration in May. Sally's Medicaid eligibility determination, which was completed pre-incarceration in January, would not fulfill the pre-release redetermination because the eligibility determination was made before Sally was incarcerated in March. Therefore, Sally’s eligibility needs to be redetermined prior to Sally’s release.

Example: Sally is determined eligible for Medicaid in May 2024 and becomes incarcerated in January 2025. She had a passive review complete in May 2025, and was released in July 2025. Sally does not need a review upon release as she had one completed while incarcerated and within 12 months of last review.

(Revised 10/1/2025 Release 25.13 )

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An IMD is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases. A facility with 16 beds or less is not an IMD. An institution is classified as an IMD if its main purpose is for the care and treatment of mental diseases. An intermediate care facility for individuals with intellectual disabilities (ICF-IID) is not classified as an IMD.

Current listing of IMDs in North Dakota

Admission at an Institution for Mental Disease (IMD) does not make an individual ineligible for Medicaid . However, Medicaid will not pay for covered services for individuals under age 65 who reside at an IMD unless the individual:

Is 21 and under AND

Has a certificate of need AND

Receives inpatient psychiatric services.

For those who do not meet the criteria for Medicaid to pay for covered services, their Medicaid coverage will be suspended while they are residing at the IMD.

In Medicaid policy, “residing” in an Institution for Mental Disease (IMD) means that a person is admitted and staying overnight at the facility and is receiving inpatient or residential treatment. Individuals who are present at the IMD only for outpatient services or day treatment are not considered to be residing in the facility. Suspension of Medicaid eligibility does not apply to individuals receiving only outpatient or day services at an IMD.

Note : An individual who attains age 21 while receiving treatment, and who continues to receive treatment as an inpatient, may continue to receive Medicaid covered services through the month the individual attains the age of 22. An individual on conditional release or convalescent leave from an IMD is not considered to be a patient residing in that institution. However, such an individual who is under age 21 and has been receiving inpatient psychiatric services is considered to be a patient residing in the institution until unconditionally released or, if earlier, the last day of the month in which the individual reaches age 22. An individual on conditional release is an individual who is away from the institution, for trial placement in another setting or for other approved leave, but who is not discharged. An individual on "definite leave" from the state hospital is an individual on conditional release. The period of Medicaid suspension under this section begins the day after the day of entry and ends the day before the day of discharge of the individual from a public institution or IMD. A Ten-Day Advance Notice is not needed when terminating benefits due to entry into the public institution or IMD. See Paragraph (4)(c)(iii) of 510-03-25-25, "Decision and Notice," for further information.

(Revised 10/1/2025 Release 25.12 )

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(N.D.A.C. Section 75-02-02.1-14)

Under final rules for the Affordable Care Act published on July 15, 2013, individuals determined eligible under the Adult Expansion Group MUST be given the option to be covered under a broader coverage plan.

Note: All determinations for this coverage are done by HHS Medically Frail Determination Team.

Once eligibility under the Adult Expansion Group is determined, the approval notice includes information informing the recipient to provide verification of their disability and assets if they would like to receive broader coverage under the ‘medically frail’ provisions. It is Medical Services' obligation to screen for the disability.

Recipients, who request to be considered for coverage as ‘medically frail’ , MUST complete a self-assessment, using SFN 1598, and return the completed form to:

HHS Medical Services 600 E Boulevard Ave, Dept. 325 Bismarck ND 58505-0250 EMAIL: medicallyfrail@nd.gov

EXCEPTION #1 : If the individual is a Medicare beneficiary and not eligible under the Parents, Caretaker Relative’s and their Spouses Category, that individual must be tested under Non-ACA Medicaid .

EXCEPTION#2: If the individual is determined disabled by the Social Security Administration and is eligible under Non-ACA Medicaid or ACA Medicaid, other than the Adult Expansion Group, the ‘medically frail’ provisions do not need to be pursued for these individuals.

EXCEPTION #3: ‘Medically Frail’ provisions do not apply to individuals over age 65.

Individuals requesting coverage as Medically Frail, who complete the self-assessment:

If the self-assessment meets a threshold score set by the department , the individual shall schedule an appointment with a provider to review and validate the information on the self-assessment. After the individual attends a face-to-face appointment with the provider, the individual shall ensure that the provider provides documentation to the department that validates the diagnosis or medical condition and that includes a medication list.

Upon review of the information provided by the provider, the department shall determine whether the individual meets ‘medically frail’ eligibility requirements.

If the individual eligible under the Adult Expansion Group:

Is approved for eligibility as ‘medically frail’, prior to January 1, 2022, the individual may choose coverage through the Alternative Benefit Plan (ABP) or through the Medicaid State Plan fee-for-service .

Is approved for eligibility as 'medically frail' on or after January 1, 2022 and is age 21 through 64, the individual may choose coverage through the Alternative Benefit Plan (ABP).

Is approved for the eligibility on or after January 1, 2022 and is age 19 and 20, the individual will have coverage through the Medicaid State Plan fee-for-service.

Individuals determined ‘medically frail’ and who are requesting assistance for nursing care services are subject to the Disqualifying Transfer Provisions described in Service Chapter 510-05, Medicaid Eligibility Factors for Non-ACA Medicaid , Section 510-05-80 , Disqualifying Transfers.

If denied for eligibility as ‘medically frail’, the individual will remain eligible under the Adult Expansion Group.

Coverage of an individual approved as 'medically frail' may begin no earlier than the first of the month in which the self-assessment was received by the department.

If the individual who requested a ‘medically frail’ determination also applied for SSA Disability:

If the individual is found not disabled by State Review Team and/or SSA, we will continue coverage under the Adult Expansion group.

If the individual is determined disabled by the Social Security Administration or the State Review Team and is not eligible for Non-ACA Medicaid or ACA Medicaid other than the Adult Expansion Group, the individual will continue eligible under the Adult Expansion Group.

If the individual does not cooperate, does not provide verification of disability or assets, or refuses to do so, but is otherwise eligible for the Adult Expansion Group, coverage will continue under the Adult Expansion Group.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-15)

Incapacity should be pursued for parents who would meet the criteria defined under this section as these parents would receive coverage under Traditional Medicaid fee-for-service.

A child, if otherwise eligible for Medicaid benefits, is "deprived of parental support or care" when the child's parent, whether married or unmarried, has a physical or mental defect which is of such a debilitating nature as to reduce substantially or eliminate the parent’s capacity either to earn a livelihood (breadwinner) or to discharge the parent’s responsibilities as a homemaker and provider of child care (homemaker) for a period of thirty days or more. A parent may establish incapacity by demonstrating that the parent has reached age sixty-five. When the only child is an unborn, the prospective parents must be married, and in the same ACA Medicaid Household to claim incapacity.

If the incapacitated parent is a breadwinner, the incapacity must be such that it reduces substantially or eliminates employment in the parent’s usual occupation or another occupation to which the parent may be able to adapt. The fact that a breadwinner may have to change occupation or work location does not establish incapacity. It does not matter whether a parent was employed or fulfilled the role of homemaker prior to the onset of the asserted incapacity. Incapacity is established either when a parent is unable to earn a livelihood or to act as a homemaker. The county agency must, therefore, be alert in identifying persons with potential for vocational training so that referrals can be made promptly to Vocational Rehabilitation Services for rehabilitation services, or to Job Service of North Dakota for possible training, or other appropriate programs.

A determination that a parent is disabled or blind, made by the Social Security Administration, constitutes adequate substantiation of incapacity for purposes of this section. If the medical approval date is prior to the eligibility date for SSI, medical and social information must be submitted to the State Review Team for an incapacity or disability determination for the period prior to the SSI approval date. Likewise, incapacity is established upon attaining age sixty-five years without submitting medical or social information to the State Review Team. Such person, however, must be informed of the potential eligibility for SSI and that choosing SSI will likely yield a larger amount of total income for the family.

The county agency is responsible for determining all eligibility factors except for incapacity which is determined by the State Review Team. Since the State Review Team does not see the person, it must depend on the examining physician's medical report to document the individual's physical or mental condition. In addition, the State Review Team must rely on the county agency's report which is based on both observation and the applicant's or recipient's judgment of how the incapacity affects the family in terms of employment or ability to discharge homemaking and child care responsibilities. Pertinent information about the person's past employment or homemaking adjustments, type of housing, method of heating the home, the availability or lack of modern conveniences in the home, ability to manage personal needs and affairs, attitudes and behavior, motivation, etc., is invaluable to the State Review Team. This information, which is reported on SFN 451 , "Eligibility Report on Disability/Incapacity", is forwarded along with any other medical reports to the State Review Team for evaluation and decision.

Incapacity is periodically reviewed by the State Review Team. When an incapacity review is due within three months of the previous decision, a new SFN 451 does not need to be completed by the county agency. The county is only required to inform the State Review Team whether the individual continues to be eligible for Medicaid.

A parent continues to be incapacitated, for purposes of this section, if the incapacity is not reasonably subject to remediation, or if the parent makes reasonable progress towards remediation of the incapacity. For purposes of this section, "reasonable progress towards remediation of the incapacity" means cooperation with medical practitioners who prescribe a course of treatment intended to remediate or limit the effect of the incapacity, including, but not limited to, physical therapy, counseling, use of prosthesis, drug therapy and weight loss, cooperation with vocational practitioners, cooperation with vocational and functional capacity evaluations, and reasonable progress in a course of training or education intended to qualify the parent to perform an occupation which, with that training or education, the parent would have the capacity to perform.

A parent who engages in activities inconsistent with the claimed incapacity, may be determined to not be incapacitated.

The Department may require a parent to demonstrate reasonable progress towards remediation of the incapacity, and may set reasonable deadlines for the demonstrations.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-09)

As a condition of eligibility for a parent or caretaker, the parent or caretaker must cooperate with the Department and county agency in establishing paternity of any child under age eighteen in the ACA Medicaid Household. An exception to this provision exists when the child is a subsidized adoption child or the parent or caretaker is pregnant, within a continuous eligibility period for Medicaid, receiving Extended Medicaid Benefits, or receiving Transitional Medicaid Benefits. It is never a condition of a child’s eligibility that the parent or caretaker cooperates.

A child for whom "paternity has not been established" means a child who was born out of wedlock and for whom paternity has not been legally established. A child is not considered to be born out-of-wedlock if the child is born within three hundred (300) days after the marriage is terminated by death, annulment, declaration of invalidity, or divorce, or after a decree of separation is entered by a court. Paternity is not considered to be legally established unless adjudicated by a court of law, or the parents completed the process using the "North Dakota Acknowledgment of Paternity" form, SFN 8195, with a revision date of 4/98 or later.

An automated referral will be made to Child Support when paternity has not been legally established and a caretaker who is not excluded in subsection 1 is seeking eligibility, or when a child is eligible for foster care.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-09)

An assignment of rights to medical support from any absent parent of a child who is under age eighteen and who is deprived of parental support or care is automatic under North Dakota state law. (Refer to Section 510-03-35-10 for the description of deprivation.)

The assignment of rights to medical support from absent parents continues through the month in which the child reaches the age of eighteen or until the child’s eligibility for assistance ends, whichever occurs first.

An automated referral will be made to Child Support to pursue Medical Support for all children whose deprivation is based on the absence of a parent, except that no referral is made: For any Subsidized Adoption child; In any case in which the only eligible individuals are children; In any case in which the only eligible caretaker is pregnant; or In any case in which the only eligible caretakers are continuously eligible, receiving Extended Medicaid Benefits, or receiving Transitional Medicaid Benefits.

(Revised 2/12/2026 Release 26.2 )

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(N.D.A.C. Section 75-02-02.1-09)

All legally able parent/caretaker relatives of a child under 18 who has an absent parent must cooperate with Child Support to establish paternity and medical support, unless they meet one of the following exceptions: Pregnant women. May be exempt up to 12 months after the birth of a child. Recipients of Extended Medicaid Benefits and Transitional Medicaid Benefits. Parent/Carektaker relatives under age 19 who are in a continuous eligibility period. Parent/Caretaker relatives do not need to cooperate with Child Support for subsidized adoption children. Parent/Caretaker relatives of deprived children do not need to cooperate with Child Support if they are not requesting Medicaid for themselves. Parent/Caretaker relatives of deprived children where all the children in the household are eligible for services through Indian Health Services (IHS). Parent/Caretaker relatives who have a pending or approved “good cause” claim See 510-03-40-20 for more information on Good Cause.

A parent/caretaker relative is not eligible for Medicaid if they do not cooperate with child support. However, children in the Medicaid unit are eligible.

If a parent/caretaker relative is not eligible for Medicaid because they did not cooperate with Child Support, the income and allowable expenses of the parent/caretaker relative are counted in the Medicaid unit.

Absent parent information cannot be requested before a Medicaid eligibility determination. A ‘Request for Absent Parent’ form is sent to the parent/caretaker relative upon Medicaid approval, if the absent parent information was not provided.

If the parent/caretaker relative does not give the absent parent information or does not return the completed ‘Request for Absent Parent’ form within 10 days, they are non-cooperating, and their Medicaid eligibility ends. A 10-day advance notice must be sent. If the parent/caretaker relative gives the absent parent information or returns the completed ‘Request for Absent Parent form’ later, their Medicaid eligibility can restart the first day of the month when the absent parent information was received.

If the parent/caretaker relative gives the absent parent information with the application or Medicaid request, or within 10 days after Medicaid approval, a referral to Child Support is automatically sent when Medicaid is approved.

Once a referral is sent to Child Support, they decide if the parent/caretaker relative is cooperating. If the parent/caretaker relative is not cooperating, their Medicaid eligibility ends. A 10-day advance notice must be sent. Note: The parent/caretaker relative has the right to appeal the child support agency’s decision.

If Child Support decides that a parent/caretaker relative is not cooperating, the child support case may be closed. If the child support case is closed and the parent/caretaker relative later wants to cooperate, they must re-apply for child support and meet all child support requirements.

If Child Support decides that the parent/caretaker relative is now cooperating, they may qualify for Medicaid again. Medicaid coverage can start on the first day of the month in which cooperation began.

If a parent/caretaker relative did not cooperate and their Medicaid case is closed for everyone in the household, and they later apply again, the parent/caretaker relative may be approved for Medicaid. Coverage will continue until it is decided again that they are not cooperating.

(New 7/1/2014 ML #3404)

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(N.D.A.C. 75-02-02.1-09)

The requirement to cooperate may be waived when a legally responsible caretaker relative has "good cause" not to cooperate.

All legally responsible caretaker relatives must be given the opportunity to claim "good cause". Applicants are notified of their rights to claim good cause in the SFN 405, Application for Assistance, DN 405, the Application for Assistance Guidebook, and the SFN 1909, Application for Health Coverage and Help Paying Costs. Applicants can indicate their request to claim good cause in either application. Recipients who become subject to the cooperation requirements may be notified by providing each legally responsible caretaker with SFN 443 , "Notice of Right to Claim 'Good Cause'". The notice briefly summarizes the legislative intent of child support enforcement, defines the caretaker's responsibility to cooperate in the support enforcement effort, and advises them of their right to claim "good cause". The notice also describes circumstances under which cooperation may be "against the best interests" of the child or caretaker and cites the kinds of evidence needed to substantiate a claim.

A legally responsible caretaker wishing to claim "good cause" may do so by completing SFN 446 , "Request to Claim 'Good Cause'". If "good cause" is claimed, the caretaker relative can be eligible for Medicaid while the decision is pending.

The determination of whether there is "good cause" is made by the county agency . The county agency may waive the requirement to cooperate if it determines that cooperation is against the best interests of the child. A county agency may determine that cooperation is against the best interests of the child only if: The applicant’s or recipient’s cooperation in establishing paternity or securing medical support is reasonably anticipated to result in: (1) Physical harm to the child for whom support is to be sought; (2) Emotional harm to the child for whom support is to be sought; (3) Physical harm to the parent or caretaker relative with whom the child is living which reduces such person’s capacity to care for the child adequately; or (4) Emotional harm to the parent or caretaker relative with whom the child is living, of such nature or degree that it reduces such person’s capacity to care for the child adequately; or At least one of the following circumstances exists, and the county agency believes that because of the existence of that circumstance, in the particular case, proceeding to establish paternity or secure medical support would be detrimental to the child for whom support would be sought. (1) The child for whom support is sought was conceived as a result of incest or forcible rape; (2) Legal proceedings for the adoption of the child are pending before a court of competent jurisdiction; or (3) The applicant or recipient is currently being assisted by a public or licensed private social agency to resolve the issue of whether to keep or relinquish the child for adoption, and the discussions have not gone on for more than three months.

There must be evidence to substantiate a claim of "good cause." Exemptions on the basis of physical or emotional harm, either to the child or to the caretaker relative must be of a genuine and serious nature. Mere belief that cooperation might result in harm is not a sufficient basis for finding "good cause." Evidence upon which the county agency bases its finding must be supported by written statements and contained in the case record.

It is the caretaker relative’s responsibility to provide the county agency with the evidence needed to establish "good cause." The caretaker is normally given twenty days from the date of claim to collect the evidence. In exceptional cases, the county agency may grant reasonable additional time to allow for difficulty in obtaining proof. Records of law enforcement, social service, or adoption agencies may be readily available to document instances of rape, physical harm, or pending adoption, perhaps without requiring further investigation. Documentation of anticipated emotional harm to the child or caretaker, however, may be somewhat more elusive. Whenever the claim is based in whole or in part on anticipated emotional harm, the county agency must consider the following:

The present emotional state of the individual subject to emotional harm; The emotional health history of the individual subject to emotional harm; The intensity and probable duration of the emotional impairment; The degree of cooperation to be required; and The extent of involvement of the child in establishing paternity or health insurance coverage.

Upon request, the county agency is required to assist the caretaker in obtaining evidence necessary to support a "good cause" claim. This, however, is not intended to place an unreasonable burden on staff, shift the caretaker’s basic responsibility to produce evidence to support the claim, or to delay a final determination. The county agency must promptly notify the caretaker if additional evidence is necessary and actively assist in obtaining evidence when the individual is not reasonably able to obtain it.

The county agency is directly responsible for investigating a "good cause" claim when it believes that the caretaker's claim is authentic, even though confirming evidence may not be available. When the claim is based on a fear of serious physical harm and the claim is believed by county agency staff, investigation may be conducted without requiring corroborative evidence by the caretaker. It may involve a careful review of the case record, evaluation of the credibility of the caretaker’s statements, or a confidential interview with an observer who has good reasons for not giving a written statement. Based on such an investigation, and on professional judgment, the county agency may find that "good cause" exists without the availability of absolute corroborative evidence.

While conducting an investigation of a "good cause" claim, care must be taken to ensure that the location of the child is not revealed.

Except for extenuating circumstances, the "good cause" issue must be determined with the same degree of promptness as for the determination of other factors of eligibility (45 days). The county agency may not deny, delay, or discontinue assistance pending the resolution of the "good cause" claim. In the process of making a final determination, the county agency is required to give Child Support Enforcement staff the opportunity to review and comment on the findings and basis for the proposed decision. It is emphasized, however, that responsibility for the final determination rests with the county agency.

The claimant and the child support agency must be informed of the "good cause" decision. Claimants – The caretaker must be informed, in writing, of the county agency’s final decision that "good cause’ does or does not exist and the basis for the findings. A copy of this communication must be maintained in the case record. If "good cause" was determined not to exist, the communication must remind the caretaker of the obligation to cooperate with child support if he or she wishes to be eligible for Medicaid, of the right to appeal the decision, and of the right to withdraw the application or have the case closed. In the event the caretaker relative does appeal, Child Support must be advised to delay its activity until the results of the appeal are known. Child Support Enforcement – The automated referral process notifies Child Support of the status of all "good cause" claims by: (1) Informing them of all caretaker relatives who claim "good cause" exemptions which suspend child support activity pending a determination; (2) Informing them of all cases in which it has been determined that there is "good cause" for refusal to cooperate. Once the exemption is established, no child support activity may be pursued unless at a future time it is determined that "good cause" no longer exists; and (3) Informing them of all cases in which it has been determined that "good cause" for refusing to cooperate does not exists and that child support enforcement activity can begin or resume.

The county agency must review the "good cause" decision at least every twelve months. If "good cause" continues to exist, the caretaker must again be informed in writing. If circumstances have changed so "good cause" no longer exists, the caretaker must be informed, in writing, and given the opportunity to cooperate, terminate the caretaker’s assistance, close the case, or appeal the decision. When "good cause" no longer exists Child Support will commence its child support activity.

(Revised 8/1/2024 ML #3854)

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(N.D.A.C. Section 75-02-02.1-05)

Pregnant women who applied for Medicaid during pregnancy, and are determined to be eligible as of the last day of pregnancy, continue to be eligible for twelve (12) months, beginning on the last day of pregnancy, and through the last day of the twelfth month.

Note: Includes pregnant women who are lawfully present in the United States. Refer to Non-Citizens Lawfully admitted for Permanent Residence on or after August 22, 1996 510-03-35-65.

A pregnant woman is considered to be eligible for Medicaid as of the last day of pregnancy when she is eligible with no client share (recipient liability), or if there is a client share (recipient liability), when the full client share is incurred as of the last day of pregnancy.

This provision applies regardless of the reason the pregnancy was terminated, and without regard to changes in income or whether a review of eligibility is due during the free eligibility period.

If the Medicaid case closes for loss of residency during the extended period and the family returns to the state and reapplies while still in the extended period, eligibility may be reestablished for the remainder of the period.

For Budgeting Procedures for Pregnant Women, refer to section 510-03-90-25 .

(New 7/1/2014 ML #3404)

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Children born to pregnant women, who were determined to be eligible as of the last day of pregnancy, are eligible for Medicaid for one year, beginning on the date of birth, and for the remaining days of the month in which the twelfth month falls.

Children who are eligible for the extended eligibility period become continuously eligible for the 12 months.

If the Medicaid case closes for loss of residency during the extended period and the family returns to the state and reapplies while still in the extended period, eligibility may be reestablished for the remainder of the period.

Revised 1/12/2023 ML #3696)

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(N.D.A.C. Section 75-02-02.1-20)

A parent or caretaker relative who ceases to be eligible under the Parent/caretaker relative and their spouses category and who meets the requirements of this section may continue to be eligible for Medicaid benefits without making further application for Medicaid.

Note: Children eligible under one of the child categories, will remain eligible under that category when a parent or caretaker relative becomes Transitional Medicaid Eligible.

When at least one parent or caretaker relative, who was eligible under the Parent/caretaker (COE M063) category in at least three of the six months immediately preceding the month in which the individual became ineligible because of the caretaker relative's hours or earnings from employment, may continue eligible for Medicaid benefits for up to twelve months if: The household has a child living in the home that meets the children’s coverage age requirements; and The caretaker relative remains a resident of the state; and The caretaker relative remains employed or shows good cause for not being employed (In families with two caretaker relatives, as long as one of the caretaker relatives remains employed; the provision is met. If both caretaker relatives stop working, the good cause provision applies to the last one that was employed); and

A family becomes ineligible under the Parent/caretaker (COE M063) category because of the caretaker relative’s earned income when it is determined that the household would continue to be eligible under the Parent/caretaker (COE M063) category, if the caretaker relative’s earned income is not counted, but they fail when the earned income is counted.

An individual that seeks to demonstrate eligibility in at least three of the six months immediately preceding the month in which the household became ineligible must have been eligible in this state in the month immediately preceding the month in which the household became ineligible. Eligibility from another state may be substituted for the other two months. Verification of eligibility in another state is required.

Only recipients become eligible for Transitional Medicaid Benefits. Applicants who fail the Parent/caretaker (COE M063) category due to earned income must be eligible under the Parent/caretaker (COE M063) category for at least one month, including any of the three prior months, before considering whether they were eligible under the Parent/caretaker category in three of the past six months.

If a child loses eligibility under one of the child categories during the parent/caretakers 12 month Transitional Medicaid Period, and the reason for the child’s loss of eligibility is due to the parent/caretakers earned income, the child will be added to Transitional Medicaid for the remaining 12 month period of the parent/caretaker. Example 1: Household consists of mom and one child. Mom is eligible under the Parent/caretaker category in January and February. The entire case closes at the end of February per the family's request. In June, the family reapplies for Medicaid and requests assistance for the three prior months. When the application is processed, mom is NOT eligible under the Parent/caretaker category for March, but is in April. Mom fails under the Parent/caretaker category for May due to income.

Because mom received three months,(January, February and April), of coverage under the Parent/caretaker category in the past six months, mom became INELIGIBLE under the Parent/caretaker category due to earned income in May, and the mom was a recipient, Mom is eligible for Transitional Medicaid Benefits effective May 1.

If mom’s child is eligible under one of the child categories, the child remains eligible under that category and ONLY Mom becomes Transitional Medicaid Eligible. If mom’s child is no longer eligible under one of the child categories, the child will also become Transitional Medicaid eligible at the same time as Mom does. If mom’s child loses eligibility under one of the child categories during mom’s 12 month Transitional Medicaid Period, and the reason for the child’s loss of eligibility is due to mom’s earned income, the child will be added to Transitional Medicaid for the remaining 12 month period.

Example 2: Household consists of mom and 2 children. Mom is eligible under the Parent/caretaker category in January, February, and March.

The case closes at the end of March per the family's request. In June, the household reapplies for Medicaid and does NOT request, or is not eligible for, assistance for April and May. When the application is processed, mom is NOT eligible under the Parent/caretaker category for June due to earned income.

Even though mom received three months, (January, February and March) of coverage under the Parent/caretaker category in the past six months, she is an applicant and not a recipient (no approved months based on this application). This household is NOT eligible for Transitional Medicaid Benefits.

If an individual was included as eligible under the Parent/caretaker category the month eligibility ended under the Parent/caretaker category, the individual is included in the Transitional Medicaid Benefits.

The following individuals are also eligible for Transitional Medicaid Benefits:

Children, deprived or non-deprived

Who meet the age requirements under the Children category, and Who are born, adopted, or who enter the home of a caretaker relative during the twelve month period, and Who are not eligible under one of the children categories.

Parents who were absent from the household when the family became ineligible under the Parent/caretaker relative and their spouses category but who return during either period.

Example: Mom and her child are eligible under the Parent/caretaker relative and their spouses category from January through April. Dad moves in during the month of April, and is not eligible under the Parent/caretaker relative and their spouses category. His earnings make mom and Dad ineligible under the Parent/caretaker relative and their spouses category for May, so mom is eligible for Transitional Medicaid Benefits beginning May.

Note: Dad is NOT eligible for Transitional Medicaid Benefits because he was not covered under the Parent Caretaker relative and their spouses category in the month coverage under the Parent Caretaker relative and their spouses category ended.

Children who no longer meet the age requirements are not eligible for Transitional Medicaid Benefits.

If a Transitional Medicaid Benefits case closes for loss of state residency and the household returns to the state and reapplies while still in the twelve-month period, eligibility may be re-established for the remainder of the Transitional period.

Refer to Section 510-03-85-40 for the Transitional Medicaid Benefits income level.

(Revised 5/14/2024 ML #3832)

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(N.D.A.C. Section 75-02-02.1-20)

A Parent(s) or caretaker relative who ceases to be eligible under the Parent/caretaker for Family Coverage category and who meets the requirements of this section, may continue to be eligible for Medicaid benefits without making further application for Medicaid.

Note: Children eligible under one of the child categories, will remain eligible under that category when a parent or caretaker relative becomes Extended Medicaid Eligible.

When at least one parent or caretaker relative, who was eligible under the Parent/caretaker or Family Coverage categories in at least three of the six months immediately preceding the month in which the parent/ caretaker relative became ineligible as a result (wholly or partly) of the collection or increased collection of spousal support (alimony) continue eligible for Medicaid for four calendar months if: The household has a child living in the home that meets the children’s coverage age requirements; and The caretaker relative remains a resident of the state.

If an extended Medicaid Benefits case closes for loss of state residency and the household returns to the state and reapplies while still in the four-month period, eligibility may be re-established for the remainder of the period.

A household that seeks to demonstrate eligibility in the Parent/caretaker category in at least three of the six months immediately preceding the month in which the household became ineligible must have been eligible in this state in the month immediately preceding the month in which the household became ineligible. Eligibility from another state may be substituted for the other two months. Verification of eligibility in another state is required.

If a parent or caretaker relative was included as eligible in the Parent/caretaker category the month eligibility under the Parent/caretaker category ended, that individual is included in the Extended Medicaid Benefits. No individual may be added into Extended Medicaid benefits.

(New 7/1/2014 ML #3404)

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Continuous eligibility for children allows recipients under age 19 who have been determined eligible for Medicaid, other than Medically Needy, to be deemed eligible for a total of up to 12 months regardless of changes in circumstances other than attainment of age 19. This has an effective date of June 1, 2008.

(New 7/1/2014 ML #3404)

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An individual may be continuously eligible for Medicaid if he or she: Is under age 19 (including the month the individual turns age 19); and Is not eligible as medically needy.

Individuals under age 19 include children, caretaker relatives, and pregnant women.

Individuals eligible for Refugee Medical Assistance (RMA) or Emergency Services are NOT entitled to continuous eligibility.

(Revised 5/1/2017 ML #3498)

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Continuous eligibility may be established from the first day of: The application month; or The month after the application month in which the individual becomes eligible for Medicaid under a coverage group other than medically needy.

When eligibility is being determined for one of the three prior months or when any other retroactive eligibility is approved, the continuous eligibility period DOES NOT begin during any of the retroactive months. An individual may be Medicaid eligible during the retroactive months; however, their eligibility is based on their actual circumstances during those months. Example : A family applies for Medicaid on May 8 and requests coverage for the THMP period of February, March and April. When processing the application month and THMP months, the child is determined eligible as an ACA Child in February and March, Medically Needy with a ‘spend down’ in April and as an ACA child in May. The child becomes continuously eligible effective May 1.

Except as identified in subsection 4, once an individual becomes continuously eligible, they remain eligible for Medicaid without regard to changes in circumstances, until they have been on Medicaid for 12 consecutive months. They do not have to have been continuously eligible for the entire 12 months.

When a review of eligibility is completed an eligible individual may be determined to be eligible for a new continuous eligibility period.

Reviews must be completed at least annually, but may be scheduled earlier in order to align continuous eligibility periods within a case between children, or to align review dates with other programs.

If the individual’s previous continuous eligibility period ended, the individual must meet all eligibility criteria to continue eligible for Medicaid. If a review is being completed before the individual’s continuous eligibility period has ended, and the individual meets all Medicaid eligibility criteria, the individual begins a new continuous eligibility period. If a review is being completed before the individual’s continuous eligibility period has ended, and the individual fails to meet all Medicaid eligibility criteria, the individual remains eligible only until the end of their current continuous eligibility period. A new review of eligibility is required at that time to establish any further eligibility.

A continuous eligibility period must be ended earlier than when the review is due for any of the following reasons: The recipient turns age 19; The recipient loses state residency; The recipient requests that their coverage end; The recipient dies; The agency has lost contact with the family and the child's whereabouts are unknown; or The recipient has failed to provide verification of citizenship or identity within their reasonable opportunity period.

A continuous eligibility period must also be ended if it is determined that the recipient should not have become continuously eligible because the individual was approved in error; approval was based on fraudulent information; an appealed ending is upheld in favor of the agency.

(New 7/1/2014 ML #3404)

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When an individual who is continuously eligible for Medicaid moves out of the ACA Medicaid Household , that individual’s eligibility continues.

When a continuously eligible child leaves the ACA Medicaid Household and enters foster care, a new application is processed to determine the child’s ongoing eligibility. If the child meets all eligibility criteria, the child begins a new continuous eligibility period. If the child does not meet the eligibility criteria, or would be eligible as medically needy, the child must be approved and remains continuously eligible only until the end of their current continuous eligibility period. A new review of eligibility is required at that time to establish any further eligibility.

When a continuously eligible individual enters a long term care facility, the individual is still considered part of the ACA Medicaid Household; however, the post eligibility treatment of income ( 510-05-85-25 ) applies. Even though the individual is continuously eligible and remains eligible as other than medically needy, the individual’s income must be considered toward the cost of care, and he or she may have a client share (recipient liability). Once the individual’s continuous eligibility period ends, and a review is completed, the individual may become medically needy.

When a continuously eligible individual enters a specialized facility other than foster care, the individual is still considered part of the ACA Medicaid Household. The individual remains eligible as other than medically needy. Once the individual’s continuous eligibility period ends, and a review is completed, the individual may become medically needy.

When a continuously eligible individual elects to receive HCBS, the individual is still considered part of the ACA Medicaid Household. The individual remains eligible as other than medically needy. Once the individual’s continuous eligibility period ends, and a review is completed, the individual may become medically needy.

A continuously eligible individual is still considered part of the ACA Medicaid Household when the individual is considered ‘Living With’ the ACA Medicaid Household.

A continuously eligible individual may move from one case to another case. If the individual, through an application or review, meets all eligibility criteria to be continuously eligible in the new case, the individual begins a new continuous eligibility period. If the individual does not meet the eligibility criteria, or would be eligible as medically needy, the individual must be approved and remains eligible only until the end of their current continuous eligibility period. A new review of eligibility is required at that time to establish any further eligibility in the new case.

When a continuously eligible individual moves out of a household on other than a temporary basis, and is not being added to another case, the individual remains eligible in the case, but is no longer considered part of the ACA Medicaid Household. Accordingly, the individual’s income will no longer affect other members of the ACA Medicaid Household. Likewise, any caretaker relative remaining in the ACA Medicaid Household can no longer remain eligible if their eligibility is based on being a caretaker relative for the child that left the household. If the caretaker relative remains eligible because of other children still in the case, or because the caretaker relative is eligible in their own right, the caretaker relative is no longer required to cooperate with Child Support for the child that left the household. Once the child’s continuous eligibility period ends, the child’s eligibility ends in the case.

When a continuously eligible individual leaves the household to enter a public institution or IMD, the child remains continuously eligible through the end of their continuous eligibility period. Refer to 510-03-35-95 “Public Institutions and IMD’s” for information regarding whether a medical service will be covered by Medicaid.

(Revised 8/1/2024 ML #3854)

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For Medicaid purposes, a child is not considered to be in foster care unless the child is an Unaccompanied Refugee Minor (URM) in the legal guardianship of Agassiz Valley Human Service Zone Director OR for non-URM youth and all the following requirements are met:

There is a current foster care court order;

A public agency has care, custody, and control of the child;

The child is a foster care child in the state foster care system through the state's Children and Family Services unit, or a Tribal 638 Foster Care child.

Children who are placed on Trial Home Visits, including those who are placed on a Trial Home Visit during the month they attain age 18, will be considered ‘in Foster Care’. Therefore, these children will now meet the requirements to be eligible under the Former Foster Care Child group through the month they attain age 26, without requiring a budget test, if all other factors of eligibility are met.

Note : If a foster care child was on a trial home visit when the child attained age 18 prior to November 1, 2015, the child should now be considered to have been in ND foster care at that point in time for the purpose of determining current and future Medicaid eligibility for the former foster care eligibility group effective November 1, 2015.

A child who was previously found ineligible for coverage under the Former Foster Care group due to being placed on a Trial Home Visit may meet the requirement for eligibility beginning November 1, 2015. The child’s eligibility cannot be changed prior to November 1, 2015, including any THMP months prior to November 1, 2015.

Children who were determined eligible based on the Foster Care eligibility criteria and who no longer meet one of the criteria listed above are no longer considered Foster Care children. Eligibility must be determined based on non-Foster Care criteria.

Children who are removed from the parental home and placed directly into a Psychiatric Residential Treatment facility (PRTF) and meet the three (3) criteria listed above, or are an Unaccompanied Refugee Minor are considered a Foster Care child.

(Revised 3/7/2024 ML #3812)

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Individuals who were in foster care (Title IV-E, state-funded (non-IV-E) or tribal) and on Medicaid, in any state, in the month they turned age 18 must be covered through the month in which they turn age 26 with no budget test.

(New 7/1/2014 ML #3404)

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Children in the Volunteer Placement Program are not considered to be in foster care. The parents retain care, custody, and control of the child; and the income of the child and parents is considered. Eligibility for these individuals is determined under ACA Medicaid Policy.

The child could be placed in a facility that is not in-patient care including PATH and county foster families or facilities, i.e. Manchester House, Dakota Boys Ranch, Prairie learning Center, etc. For a child to qualify under this program, there must not be a delinquency, abuse and/or neglect issue.

The child must be Medicaid eligible to cover medical expenses and the cost of treatment. The Volunteer Placement Program pays the room and board for the child to the county foster home or to the facility. The Administrators of the Volunteer Placement Program, and Mental Health and Substance Abuse must approve any placement in the Volunteer Placement Program.

(New 7/1/2014 ML #3404)

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The Subsidized Guardianship Project is designed to serve North Dakota children who are in foster care, but who need a permanency alternative. The program was created in response to the Adoption and Safe Families Act of 1997.

Children in the Subsidized Guardianship Project are no longer foster care children, and the subsidy is not a foster care payment. The guardianship subsidy is paid to help meet the maintenance needs of the child and is considered the child’s income.

When determining Medicaid eligibility, the child’s income is considered, and parental income is not used unless the guardianship court order specifies that the parents are responsible for the child’s needs. Eligibility for these individuals is determined under ACA Medicaid Policy unless the child is eligible under Non-ACA Medicaid . In this instance, the assets of the child and parents are also considered.

The guardian is not included as part of the case and the guardian’s income and assets are not considered in determining the child’s Medicaid eligibility. An exception is in cases in which the guardian is a relative, and the relative becomes eligible for Medicaid because of the child. In such cases, the relative chooses to be an eligible caretaker.

Note: The Subsidized Guardianship Project is a North Dakota program. Occasionally, children come to North Dakota from states that have opted to cover children under a Title IV-E program called Kinship Guardianship program. This is not to be confused with either the ND Subsidized Guardianship Project or TANF ’s Kinship Program. Children who come from those states under the Title IV-E Kinship Guardianship program are categorically eligible.

(New 5/1/2017 ML #3498)

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The Affordable Care Act of 2010 requires states to implement policy and procedures to allow qualifying hospitals to make presumptive Medicaid eligibility determinations, also referred to as HPE. HPE offers a streamlined, expedited path to coverage for individuals in all states and allows clients to receive temporary Medicaid coverage while their eligibility is being determined for ongoing Medicaid.

Individuals do not need to be hospitalized to apply for HPE coverage. However, they can only apply for HPE coverage through qualifying hospitals approved to make HPE determinations.

(New 5/1/2017 ML #3498)

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A qualifying hospital must assist an individual who requests to apply for HPE coverage through the ND Self-Service Portal. The applicant need not be hospitalized in order to apply for HPE coverage. However, the applicant, an authorized representative or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant must sign the application. The ND SPACES system will make the HPE eligibility determination.

The applicant must provide all information the hospital needs to determine HPE eligibility. The HPE determination is based on the applicant’s declaration; no verifications are needed.

In order for coverage to continue beyond the month following the month the HPE coverage will end, the individual must complete and submit one of the prescribed applications defined in section 510-03-25-05. If a completed Medicaid application is not submitted by the last day of the final month of HPE eligibility, the HPE eligibility period ends on that date.

(New 5/1/2017 ML #3498)

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HPE may be determined for Medicaid only, for the following individuals:

Children under age 19 (through the month they attain age 19);

Former Foster Care Individual;

Parents and Caretaker/relatives;

Pregnant Women;

Medicaid Expansion Group ages 19 (month following the month they attain age 19) through 64 (month prior to the month in the individual attains age 65);

(New 5/1/2017 ML #3498)

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In order to be eligible for coverage under HPE, the following must be attested to for each household member who is requesting assistance:

US Citizen, US National, or Eligible Immigrant status; and

ND residency; and

Gross income amount; and

Whether or not each applicant is currently enrolled in Medicaid; and

Applicant(s) do not have any other health insurance coverage that meets the Minimal Essential Coverage definition.

(New 5/1/2017 ML #3498)

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Budgeting provisions for those eligible under HPE are defined at 510-03-90 .

(New 5/1/2017 ML #3498)

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HPE begins on the day the HPE eligibility determination is made and does not begin retroactive to the first of the month of the HPE Application. If determined eligible, the individual will remain eligible through the month following the month the HPE eligibility determination was made.

Example : Jane applies for and is found eligible for HPE coverage on January 10th. Jane’s HPE eligibility period will be authorized for January 10th through February 28th.

When an application for ongoing Medicaid coverage has not been submitted, HPE ends on the last day of the month following the month the HPE eligibility determination is made.

Example : Tyler applies for and is found eligible for HPE coverage on January 25th. His HPE eligibility period is authorized for January 25th through February 28th.

When an application for ongoing Medicaid coverage has been submitted, HPE ends on the date a full determination is made. If the individual requested eligibility for any of the THMP months based on the full application, eligibility must be determined for each month requested. In addition, if more time is needed to make a full determination of eligibility, the Eligibility Worker must grant a month by month extension of HPE coverage until the full determination is made.

If eligible, the individual’s eligibility may change from HPE to Traditional or Expansion Medicaid coverage.

If not eligible, the individual’s eligibility will remain unchanged.

Example #1 : Sophie applies for and is found eligible for HPE coverage on January 25th. Her HPE eligibility period is authorized for January 25th through February 28th.

On February 15th, an application is received at the county and a full determination is made. The determination results in Sophie being determined eligible for Medicaid for the application month and ongoing. In addition, Sophie requested and was found eligible for the THMP month of January.

For February and ongoing, Sophie’s eligibility will change from HPE to Traditional Medicaid.

For January, Sophie’s eligibility will change from HPE to Traditional Medicaid.

Example#2 : Mary applied for and was approved for HPE coverage on January 19th. Her HPE eligibility period was authorized for January 19th through February 28th.

On February 25th, a full application is received. The eligibility for the full application cannot be made in February as additional information is needed. Therefore, the worker must authorize an additional month of HPE eligibility. Thus the HPE eligibility end date changes from February 28th to March 31st.

On March 18th, the worker receives all of the information needed to make a full determination.

If eligible, Mary’s eligibility for March will change from HPE to Traditional Medicaid.

If not eligible, Mary’s HPE eligibility must end on March 18th.

Individuals are only eligible for one (1) period of HPE period per calendar year with the exception of an individual who is pregnant. Pregnant Women can receive HPE coverage once per pregnancy.

(New 5/1/2017 ML #3498)

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Individuals eligible under HPE will receive full coverage of medical expenses based on the North Dakota Medicaid State Plan with the exception of Pregnant Women. Pregnant Women are not eligible for inpatient hospital services.

(New 5/1/2017 ML #3498)

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Individuals applying for eligibility under HPE cannot request coverage for the three months prior period. In order to request coverage for the three prior months, the individual must submit a full application and request the three prior months on the full application.

(New 5/1/2017 ML #3498)

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The standard notice and appeal rights do not apply to HPE decisions.

(Revised 1/1/2023 ML #3696)

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Qualifying hospitals must be willing to abide by state policies and procedures to immediately enroll individuals who are likely eligible under a state’s Medicaid eligibility guidelines for a temporary period of time. Each qualifying hospital has the choice to make HPE determinations, and if they choose to, the qualifying hospital and their designee’s must:

Offer HPE to individuals without Medicaid or other health care coverage; and

Assure timely access to care while the HPE application and eligibility determination is made; and

Ensure all individuals designated to assist and complete HPE applications follow the regulations set forth for HPE; and

Provide the individual with the HPE determination notices; and

Inform individuals at the time of the HPE determination that in order to obtain Medicaid coverage beyond the HPE period they must file a full Medicaid Application.

Inform, recommend and assist individuals with completing and submitting a full application for Medicaid/Children’s Health Insurance Program (CHIP) or subsidized insurance through the Federally Facilitated Marketplace; and

Meet the Performance Standards as listed below; and

Ensure the individual responsible for managing the Hospital’s HPE and their designee’s (person’s assisting and completing HPE applications) attend all HPE Policy training provided by the Medicaid Eligibility Policy Unit of the North Dakota Department of Human Services and keep current with changes affecting HPE through various means of communication, including but not limited to the following: Participate in all in-person, telephone conference, webinar or computer-based HPE training sessions; Read all information provided regarding updates and changes to HPE.

Provide, upon request, verification that all members listed in #8 above have completed the training.

Effective September 1, 2016, all qualifying hospitals will be required to meet ongoing performance standards in order to remain a Qualified Hospital. These standards include:

Ninety-five percent (95%) of individuals that have an HPE determination made were not enrolled in Medicaid at the time the HPE determination was made.

Ninety percent (90%) of individuals determined presumptively eligible by the hospital submit a full application during the HPE period;

Eighty-five percent (85%) of individuals approved for Hospital Presumptive Eligibility, who submitted a full application during the HPE period, are subsequently determined eligible for Medicaid based on the full application.

Qualifying hospitals who do not meet the standards listed above for three (3) consecutive months will be required to participate in additional training and/or other reasonable corrective action measures provided by the North Dakota Department of Human Services. If after participation in the additional training or other reasonable corrective action measures the hospital continues to fail to meet the standards for two additional (2) consecutive months, action will be taken to disqualify the hospital under this section.

(Revised 6/1/2015 ML #3441)

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There is no asset test for applicants and recipients whose eligibility is determined under ACA Medicaid. Asset provisions do not apply to these individuals.

Note: Although assets are not a consideration for this coverage, individuals requesting long term care services under ACA Medicaid are subject to the disqualifying transfer provision as described in section 510-05-80 of the Non ACA Medicaid manual.

(Revised 6/1/2015 ML #3441)

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(N.D.A.C. Sections 75-02-02.1-28(1) and 75-02-02.1-34(8))

Income from ownership in a Partnership or Corporation is countable income for ACA Medicaid.

Partnerships

A partnership is a self-employment business set up as a partnership with two or more partners. A partner’s share of income, gain, loss, deductions or credits is determined by a partnership agreement.

An individual, who is an owner or part owner in a partnership, will be issued a Schedule K-1 (Form 1065) from the partnership, which lists the income they received. The information from the appropriate K-1 is carried over to the Form 1040.

Corporation

A company or group of people authorized to act as a single entity (legally a person) and recognized as such in law. Shareholders have the right to participate in the profits, through dividends and/or the appreciation of stock, but are not held personally liable for the company's debts.

The information from the Form 1099-DIV is used when the individual files their personal income taxes.

S –Corporation

An S-Corporation is a separate business entity with 1 to 100 shareholder(s) that passes through the net profit or loss to their shareholder(s). The business profits are taxed at individual tax rates on each individual shareholder’s income tax. The information from the appropriate K-1 is entered on the Schedule E of the individuals’ personal income tax forms. If the individual provides a copy of their income tax forms, the countable income from the K-1, 1099-DIV, or Schedule E would be carried over to the Form 1040. Therefore, the Schedule E amount from the Form 1040 would be used. If the individual does not file taxes, the net income from the individual’s schedule 1099-DIV or K-1 from the corporation or partnership, will be used, plus any wages paid to the individual in addition to the net income. If the 1099-DIV or K-1 is not prepared, ledgers must be provided.

(Revised 2/9/2026 Release 26.1 )

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(N.D.A.C. Sections 75-02-02.1-28(1) and 75-02-02.1-37(3))

Conservation Reserve Program (CRP) payments are counted as unearned income. They are included in the net income from Schedule C, E, F, or Form 1099 (if no tax forms are provided).

The income is treated as follows if tax forms are provided:

Subtract the CRP amount from countable income. The countable income would be carried over to the Form 1040 from the respective schedules. The allowable expenses are subtracted from the income prior to the income being carried over to the Form 1040. Therefore, do not allow more expenses.

The income will be treated as follows if tax forms are NOT provided:

Use the gross amount from Form 1099. Subtract the allowable expenses. The individual must provide ledgers of the expenses including property taxes, insurance and other expenses for the land.

(New 7/1/2014 ML #3404)

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Individuals who live communally (i.e. Hutterites, Mennonites, Amish, etc.) may or may not have a collective ownership of property and income. In determining eligibility, it will first be necessary to determine whether collective ownership of assets and income exists.

If the commune has collective ownership, also determine whether the commune is self-employed. Most communal colonies are self-employed in agricultural or manufacturing and are incorporated, or set up as a large partnership. Occasionally, some colonies are not self-employed, but may be working under contract for wages.

Income. Most colonies have collective ownership of income, which is often generated from their self-employment venture. When colonies have a collective ownership in income, a share attributable to each individual or family must be determined. Countable income is established as follows: If the colony is self-employed, calculate self-employment income based on the previous year of self-employment. From the colony’s corporate or partnership tax return: Divide the total amount of adjusted gross income by the number of members in the colony to establish each individual’s share of income. Multiply this amount by the number of individuals in the ACA Medicaid Household to determine the unit’s yearly share.

Example: There are 124 members in a colony that is engaged in farming. A family of six in the colony applies for Medicaid. The corporate tax return indicates $4,922,603 in adjusted gross earnings. Divide $4,922,603 by 124 members to arrive at each individual’s share of $39,698.41. Multiply $39,698.41 by six to arrive at the unit’s yearly income of $238,190.46.

Identify the income as belonging only to the adults in the ACA Medicaid Household, or older children who are actively engaged in the operation and are not students. If no individuals in the ACA Medicaid Household are actively engaged in the business, such as an aged or disabled individual, the income is considered to be unearned income; or

Example: An aged individual from a colony engaged in farming applies for Medicaid. The corporate tax return indicates $4,922,603 in adjusted gross earnings, which is divided by the 124 members in the colony to arrive at each individual’s share of $39,698.41. The income is shown as unearned income because the aged person is no longer actively engaged in the business.

If the colony is not self-employed, but is working under contract for wages:

Divide the total contract income by the number of members in the colony to establish each individual’s share of income. Multiply this amount by the number in the ACA Medicaid Household to determine the unit’s share; and Identify the income as belonging only to the adults in the ACA Medicaid Household, or older children who are actively engaged in the operation and are not students. If no individuals in the ACA Medicaid Household are actually engaged in the business, such as an aged or disabled individual, the income is considered to be unearned income.

For members who have other earned or unearned income, the income counts as income of the individual who receives it. Income is counted for the individual, even if the income has been given to the colony.

Adding or deleting individuals: Changes in the unit’s share of income must be changed when adding or deleting members to the unit and is based on the number of individuals in the unit. The share is not changed when adding an unborn child until the child is born.

Example: The individual share of income established for a colony, based on the colony’s self-employment, is $350 per individual per month. A family within the colony consists of 5 individuals so the ACA Medicaid Household’s total monthly income is $1,750 (5 x $350) or $21,000 per year. A child is born and added to the unit, so now the unit consists of 6 individuals, and monthly income is $2,100 (6 x $350), or $25,200 per year. If the unit had instead lost a member and reduced in size to 4, the income would have decreased to $1,400 (4 x $350), or $16,800 per year.

The individual’s share of income, which is based on the number of members in the colony, is normally determined when calculating annual income from self-employment for self-employed colonies, or for a new contract period for colonies working under a contract for wages. The number of members in the colony does not need to be changed in between these calculations, or when adding or deleting a member from the household. However, if the colony reports a change in the number of members, the individual share must be recalculated based on the new information.

Example 1: The individual share of income has been established for a colony at $350 per individual per month. This amount was originally calculated based on the number of members in the colony and the colony’s self-employment income. A child is born to a family. A new calculation does not have to be made because there may now be more members in the colony, but the $350 per person per month continues to be used as the individual share of income.

Example 2: The individual share of income has been established for a colony at $350 per individual per month, and was based on 124 members. A child is born to a family and reported. At the same time, new information is provided that the colony now has 118 members because a different family left the colony, and one member died. A new calculation must be made because a change in the actual membership number has been confirmed by the colony. The new individual share has now increased to $367.80 per person per month.

(Revised 6/1/2015 ML #3441)

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(N.D.A.C. Section 75-02-02.1-34)

Income is defined as any cash payment, which is considered available to an ACA Medicaid Household for current use. Income may be earned or unearned. It must be reasonably evaluated.

“Earned Income” is income that is currently received as wages, salaries, commissions, or profits from activities in which an individual or family is engaged through either employment or self-employment. Income is “earned” only if the individual or family contributes an appreciable amount of personal involvement and effort. “Earned income” shall be applied in the month in which it is normally received .

Note: If earnings from more than one month are received in a single payment, the payment must be prorated over the months for which it is intended.

MAGI income methodologies must be applied to all ACA Medicaid Households.

Current, point-in-time income must be used.

All income which is actually available must be considered. Income is actually available when it is at the disposal of an applicant, recipient, or responsible individual; when the applicant, recipient, or responsible individual has a legal interest in a liquidated sum and has the legal ability to make the sum available for support, maintenance, or medical care; or when the applicant, recipient, or responsible individual has the lawful power to make the income available or to cause the income to be made available.

An individual may have rights, authority, or powers that he or she does not wish to exercise. An example includes an individual who allows a relative to use excluded assets free or at a reduced rental. In such cases, a fair rental amount will be counted as available income whether the applicant or recipient actually receives the income. Income that is withheld because of garnishment or to pay a debt or other legal obligation is still considered available. Title II and SSI overpayments being deducted from Title II benefits, are normally considered to be available because the applicant or recipient can pursue a waiver of the overpayment. Only if the waiver has been denied after a good faith effort, can the Title II or SSI overpayment deductions be considered unavailable. Occasionally other delinquent debts owed to the federal government may be collected from an individual’s federal payment benefit (i.e. Title II, Civil Service, and Railroad Retirement). These other reductions of federal benefits are not allowed to reduce the countable benefit amount. The award amount of the federal benefit payment is counted as available except to the extent an undue hardship is approved for the individual. Requests for undue hardship exceptions must be submitted to the Medicaid Eligibility Unit where a determination will be made whether an undue hardship exists. An undue hardship may be determined to exist for all or a portion of the debt owed, or all or a portion of the reduction from the monthly income. An undue hardship will be determined to exist only if the individual shows all of the following conditions are met:

The debt is a debt owed to the Federal government; The deduction from the individual’s federal payment benefit was non-voluntary; The amount of the deduction exceeds the Medicaid income level(s) to which the individual and the individual’s spouse is subject; The individual has exhausted all lawful avenues to get the reduction waived, forgiven, or deferred; and The individual or their spouse does not own assets that can be used to pay for the debt.

Financial responsibility of any individual for any applicant or recipient is subject to their tax filing status as well as the individual’s relationship to those with whom the individual resides, as defined at 510-03-35-05 , “ACA Medicaid Household”.

Monthly income is considered available when determining eligibility for ACA Medicaid, however, an individual may die before their income is actually received for the month. An income payment received after death is no longer considered income, but an asset to the individual’s estate. In circumstances where the Department will pursue estate recovery, Medicaid eligibility can be re-determined counting only that income which was received prior to the individual’s death; resulting in the elimination or reduction of the client share (recipient liability).

When a Medicaid provider reports that a recipient’s current month client share (recipient liability) was not paid as of the date of death, determine whether the following conditions are met:

There is no surviving spouse; There is no surviving minor or disabled child; and Countable monthly income was not received prior to death.

If all conditions are met, refer the case to the Medicaid Eligibility Unit. Information regarding the date of death and the dates of the month in which each source of income is received must also be provided. The Medicaid Eligibility Unit will determine whether Medicaid estate recovery is being pursued and an adjustment to the client share (recipient liability) can be approved. If approved, the Medicaid Eligibility unit will process the adjustment.

Income may be received weekly, biweekly, monthly, intermittently, or annually. However income is received, a monthly income amount must be computed.

Many benefit programs deposit an individual’s monthly benefit onto a debit card. Examples of these benefit programs are TANF benefits, Unemployment Insurance Benefits (UIB), Child Support benefits, Workforce Safety and Insurance benefits (WSI), Social Security Administration benefits (SSA), and Supplemental Security Income benefits (SSI).

Individuals may also receive as gifts or bonuses such things as gift cards, debit cards, prepaid credit cards or ‘in-store credits’. Examples include bonus or commission payments, compensation for work performed, or Tribal Gaming Per Capita Distributions from gaming revenues etc.

Note: These benefits must be determined whether countable or disregarded based on ACA Medicaid policy.

Earnings paid under a contract must be prorated over the period the contract covers. Example: A teacher receives paychecks in August through May, however the contract covers 12 months and the contracted salary is $30,000. The annual salary is prorated over 12 months. Countable ACA Income is $2500 per month.

Occasionally, migrants or seasonal farm workers may receive an advance lump sum payment to reimburse or cover travel expenses. Such reimbursement is normally received prior to their arrival and is not considered earned income. An advance for wages, however, is counted as earned income and is prorated over the months it is intended to cover.

Example: Don is a migrant worker who received a reimbursement from his grower for traveling to North Dakota to work. This reimbursement is disregarded from income as a reimbursement. Don’s grower also gave him a wage advance of $900 in May for the months of June, July and August. The wage advance would be prorated over the months of June, July, and August as earned income.

In addition, migrants or seasonal farm workers may not receive an advance lump sum, but will be paid in a lump sum at the end of their employment or contract period. Such income is prorated over the period the payment is intended to cover.

Bonuses, profit sharing, and other similar payments are not considered lump sum earnings or wages received other than monthly, but an extra payment of earned income based on a productive period. These are considered income in the month received.

Individuals who lost a source of income (earned or unearned) in the month of application will not have income from that source annualized. The terminated source of income actually received in the application month will only be counted in the month terminated.

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-34(7)

In determining ownership of income from a document (e.g. a tax return for a self-employment business, or a rental agreement for rental property . . .), income must be considered available to each individual as provided in the document, or, in the absence of a specific provision in the document: If payment of income is made solely to one individual, the income shall be considered available only to that individual; and If payment of income is made to more than one individual, the income shall be considered available to each individual in proportion to their interest.

In the case of income available to a couple in which there is no document establishing ownership, one-half of the income shall be considered to be available to each spouse .

Except in the case of income from a trust, the rules for determining ownership of income are superseded to the extent that the applicant or recipient can establish that ownership interests are otherwise than as provided in those rules.

(Revised 1/1/2025 ML #3916 )

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The following income methodologies will be used in determining income eligibility for individuals eligible under ACA Medicaid:

Income is based on household composition, tax filer rules, and who resides with the individual.

Monthly income is used prospectively.

Current, point in time income is used—prospecting reasonable expected changes.

Married couples, who file their taxes jointly , must be included in each other’s households, even if they are not residing together. This includes situations where one of spouses is incarcerated.

Income of most children NOT expected to be required to file a federal income tax return is considered as follows:

A tax dependent CHILD’s income does not count in a tax filer’s parents or caretaker’s household if the child is not required to file a tax return.

A tax dependent CHILD’s income does not count in the child’s household, IF the tax filer parent or tax filer caretaker is in the child’s ACA Medicaid household .

If the tax filer parent or tax filer caretaker is NOT in the child’s ACA Medicaid household, the child’s income DOES count in the child’s household. (e.g. the child is in (non-IV-E) foster care).

If the child is not required to file a tax return, however, files a return in order to get a refund of taxes withheld, that child’s income is NOT counted in either the tax-filer’s or the child’s household.

If the child IS required to file a tax return, the child’s income is counted in all the households in which the child is included.

Filing requirements change every year and this information may be found in the instructions for Form 1040 at http://www.irs.gov.

In determining whether a child has to file income tax:

If a child has income other than SSA benefits, the child must file if their unearned income (excluding child support) exceeds $1250 annually.

The TAXABLE portion of the child’s Social Security (SSA) benefits must be considered. Normally, only 50% of the SSA benefit is subject to taxation.

SSA benefits are only taxable to the extent that 50% of the SSA benefit PLUS the individual’s other income exceeds $25,000. The child’s TOTAL yearly income minus half of the SSA income would have to be more than $25,000 to be taxable; and then only the excess over $25,000 would be taxable. If the child’s only income were SSA income, the monthly benefit would have to be over $4,166.67 per month to be countable, and over $4,333.33 to require filing a tax return.

Example: A child, age 17, receives $480 per month in Social Security survivor benefits. In addition, the 17 year old is employed and earns approximately $1000 per month. The child is claimed as a dependent on his parent’s tax return.

Based on the child’s earned income, he is required to file a tax return. However, his SSA benefits are not taxable as his earnings of $12,000 for the year plus 50% of the SSA benefits ($2,880) do not exceed $25,000.

Non-recurring and recurring lump sum payments of income not identified as Disregarded Income in section 510-03-85-30 , count only in the month received.

Qualified Lottery and Gambling Winnings

Winnings received from a sweepstakes, lottery, or pool from gambling.

Winnings equal or greater than $80,000 are counted as income over multiple months for the individual receiving the winnings. The lottery and gambling winnings are only counted in the month received in determining eligibility for the other household members.

Self-Attestation may be accepted before requesting documentation from the individual. Note: Non-cash prizes are not included and continue to be counted as a lump sum income in the month received. Undue Hardship The individual who has lost or is denied eligibility due to qualified lottery and gambling winnings may request an exemption for undue hardship. The department will apply a hardship exemption if the individual can demonstrate that counting the lottery or gambling winnings may deprive the individual of medical care to the extent that the individual's health or life would be endangered. The undue hardship request must be made within 90 days from the loss or denial of coverage. The request must be submitted to the Medicaid Eligibility Policy Unit who will review and determine if the undue hardship exists. If the request is denied, the individual may request an appeal to North Dakota Health and Human Services.

Calculating "self-employment" Income

The most recent income tax forms must be requested from individuals who are self-employed. If the individual provides their most recent income tax forms, the information will be used to determine their countable self-employment income IF it is indicative of what the income will be for the current year.

When a self-employed individual has not filed their taxes or the business is newly established, there are no federal income tax forms to use. In this situation, the household needs to submit copies of their ledgers, receipt books, etc. The county agency and self-employed individual will use the best information available to determine the countable income as defined in #1 through #8 below, minus allowable expenses identified in section 510-03-85-35 , Income Deductions.

Net earnings or losses from self-employment as considered for income tax purposes are counted for ACA Medicaid households .

NOTE: Losses from self-employment can be used to offset other countable income.

Using the amount from the line on the income tax forms titled ' Adjusted Gross Income (AGI)’;

Subtract any amount in the line titled ‘Wages, salaries, tips, etc.’, as current, point in time income is used.

Subtract the amount in the Capital Gain line, if Capital Gains are not expected to recur. (If they are expected to recur, do not subtract them).

Subtract the amount in the ‘Taxable refunds, credits, or offsets of state and local income taxes’ line as these are ONLY countable in the month received.

Subtract any scholarships, awards, or fellowship grants used for education purposes and not for living expenses, IF they are included in the ’Adjusted Gross Income’.

Add tax-exempt interest;

Add tax-exempt Social Security income (determined by subtracting the taxable amount of Social Security Benefits from the total amount.)

(Revised 7/1/2025 ML 3935 )

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(N.D.A.C. Section 75-02-02.1-37)

The following types of income are countable when determining eligibility for ACA Medicaid:

Gross taxable wages, salaries, tips ( must deduct pre-tax deductions ).

Interest income, including tax exempt.

Dividend income, including tax exempt.

Taxable refunds of state income taxes.

Alimony received when alimony agreements have been finalized on or before December 31, 2018.

Adjusted net income or loss from self-employment.

Net Capital Gains (capital gains minus capital losses), if expected to recur in the current year.

Taxable amounts of IRA distributions.

Taxable Amount of Pensions and annuities.

Net rents, royalties, lease, partnerships, S corporation or trust income.

Gross unemployment compensation.

Gross Social Security income.

Veteran’s Administration (VA) Retirement Pensions.

Gross foreign earned income.

Child’s income (See section 510-03-85-13 , ACA Income Methodologies regarding when to count a child’s income.)

Short Term Disability payments to replace income

The portion of educational scholarships, awards, and fellowship grants that is used for living expenses or other non-educational related expenses

Per Capita payments paid from tribal casino gambling proceeds. Exception : MHA (TAT) does not play out monies from casino gambling. See Disregarded Income 510-03-85-30 .

Value of prizes or awards

Gambling winnings

Winnings less than $80,000 are counted in the month received.

Qualified lottery and gambling winnings of $80,000 or more, which are received in a single payout are counted not only in the month received but over a period of 120 months for the individual who has won the Qualified Lottery and gambling winnings. See Reference Hard Cards 510-03-105 and ACA Income Methodologies 510-03-85-13.

Alaska Permanent Funds dividends.

Payments for work performed at sheltered workshops, (e.g. Minot Vocational Adjustment Workshop, etc.)

Work-Study Income reported as wages on the individuals tax return.

Payments from a trust fund, or from other countable sources deposited into a trust account for the client's benefit count as income of the client.

Jury duty pay not given to employer as reimbursement of wages.

Income from a life estate.

Value of cancelled debts.

Other taxable income.

(Revised 5/1/2017 ML #3498)

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For purposes of this section:

‘Biweekly’ is defined as receiving earnings every two weeks.

Example: Individual receives a paycheck every other Monday.

In cases where income, (both earned and unearned) is received either weekly or biweekly, income must be converted when determining the household's countable income.

To convert earnings received weekly, total the weekly checks and divide by the number of checks (4 or 5) to arrive at the weekly average. The weekly average is then multiplied by 4.3.

To convert biweekly earnings, total the biweekly checks and divide by the number of checks (2 or 3) to arrive at the biweekly average. The biweekly average is then multiplied by 2.15.

If tips, commissions, bonuses or incentives are paid or reported weekly or biweekly and are included in the gross income on the weekly or biweekly paycheck or pay stub, they are converted.

If tips, commissions, bonuses or incentives are paid or reported weekly or biweekly and are included on the paycheck or pay stub, but not in the gross income and the paychecks are received weekly or biweekly, they must be added to the gross income and converted.

If tips, commissions, bonuses or incentives are not paid weekly or biweekly, they are not converted. The tips, commissions, bonuses or incentives must be counted separately as earned income.

Cash tips received daily and reported monthly are not converted.

Tips paid in a separate check that is not paid weekly or biweekly are not converted.

Example #1 : A household reports June 20 that a member started a new job and received the first paycheck on June 25th and is paid every Wednesday. Income for the month of application is not converted (June) because the individual did not receive income each Wednesday in June. Actual anticipated income is used for June. Income is converted for July.

Example #2 : A household reports on May 10 that a household member lost their job on May 9 and will receive a final paycheck on May 16. When calculating eligibility for May, the income for this household member is not converted, as the individual will not receive income each week in May. No income can be anticipated from this job for June.

Effective with application received on or after February 1, 2016, when determining eligibility for Three Prior (THMP) months, income must be verified for each of the three prior months and actual, verified income must be used. Income is not converted in THMP months.

(Amended 5/3/2024 ML #3825)

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Background

Provisions in the Patient Protection and Affordable Care Act of 2010 (PPACA or ACA) require states to rely as much as possible on electronic data sources when verifying information provided by applicants or recipients. Federal regulations restrict states from requesting verification from applicants or recipients unless the verification cannot be obtained through an electronic data source, or information from the data source is not “reasonably compatible” with what the applicant or recipient has reported.

Available Electronic Verification Sources

The Centers for Medicare and Medicaid (CMS) have identified electronic verifications received from the following sources to be valid when determining reasonable compatibility for health care coverage (HCC) programs. Below is the list of electronic data sources in hierarchy order:

Federal Data Services Hub (FDSH) TALX or The Work Number Can only be used to determine HCC program eligibility FDSH (TALX or the Work Number) Employers are not required to provide payroll information.

Equifax Can only be used for combination cases (HCC and other programs such as SNAP, TANF, etc.)

SDX and Bendex

ND Job Service Unemployment Insurance Benefits

ND State Directory of New Hires

ND Job Service Wage Information, Quarterly Wage Verification

ND Child Support (FACSES)

PARIS Interface

Reasonable Compatibility

Income Compatibility is a comparison of the income in SPACES with electronic data sources against the income limit for the applicable HCC program.

Reasonable Compatibility exists when income information reported by an individual and available electronic data sources are compatible. When reasonable compatibility is determined no further verification is requested from the individual.

The combined income of all types must be used to determine reasonable compatibility.

Earned income Unearned income

Note: When determining 'reasonable compatibility' of income, the most recent verification of income from electronic sources must be used unless the household has provided more current information.

Verification of income CANNOT be requested from an applicant or recipient unless the information cannot be obtained through an electronic data source, or information from the data source is not "reasonably compatible" with what the applicant or recipient has reported.

Exception: 'Reasonable compatibility' does not apply to THMP months. Refer to policy at 510-03-90-60.

At the time of initial application or review for Medicaid and the individual also applies or submits a review for another program, check all data sources and compare the data received against the information received for the other programs to determine reasonable compatibility.

Scenarios for Reasonable Compatibility

If reported income and information obtained electronically through a data source are both above, at or below the applicable HCC program income standard, they are considered reasonably compatible.

1. When determining 'reasonable compatibility' for income other than self-employment:

If both the electronic data sources and the member-reported information results in the individual's income being below the individual's budget unit income level, the two data sources are "reasonably compatible" and further verification may be requested or required. Utilize the most current information available. The calculation must be narrated in the case file. Example #1 : Joe is age 25 and single with an income limit of $1,353.00 per month. At review, Joe reports that his earnings are $500 per month. ND Job Service Wage Match reports that his quarterly earnings are $2,569.72 To determine his monthly amount from the Job Service wage electronic data verification source, divide $2659.73 by 13 and multiply by 4.3. This results in verification of his monthly income of $818.37. Since both his reported income and the ND Job Service Wage Match electronic data source verified income are below his budget unit income level, his income is "reasonably compatible" and Joe is re-determined eligible for HCC. The Job Service wage electronic verification source will be used since it is the most current and additional verification cannot be requested. Example #2: A new application is received for Barb, who is age 31 and single with an income limit of $1,353.00 per month. Barb reports she is employed and earns $1,250 per month. Since Barb is a new applicant, a search of the electronic data sources did not return a response. Therefore, 'reasonable compatibility' cannot be determined and verification of wages must be requested from Barb. If both the electronic data source and the member-reported information results in the individual's total countable income being above the individual's budget unit income level, the two data sources are "reasonably compatible" and further verification may not be requested or required. Example #1: Melanie is age 27 and single with an income limit of $1,353.00 per month. The ND Job Service Wage Match reports that her quarterly earnings for the most recent quarter are $4,500. To determine her monthly amount from the Job Service wage electronic data verification source, divide $4,500 by 13 and multiple by 4. This results in a verification of her monthly income of $1,384.61. Melanie is determined not eligible for Medicaid and her case would be closed without requesting any further verification. Example #2: A new application is received for Brady, who is age 40 and single. Brady reports he is employed and earns $1,925 per month. Since Brady is a new applicant, a search of the Federal Data Services hub (FDSH) does not provide any response. Therefore, 'reasonable compatibility' cannot be determined, and verification of wages must be requested from Brady. If verification from the electronic source puts the individual's total countable income above the individual's budget unit income level, but the member-reported information puts the individual's total countable income below that level (or vice versa), the two sources are not "reasonably compatible" and further verification is required to determine eligibility. The calculation used to determine 'reasonable compatibility' MUST be narrated in the case file. Example #1: Lynn is age 34 and single with an income limit of $1,353.00 per month. At review, the member-reported information indicated his earnings are $1,100 per month. The Federal Data Services Hub (FDSH) reports that his earnings are $2, 066.95. Since there is a difference in the eligibility outcome, between the member-reported earnings and the FHSH data source, Lynn's reported information is not considered to be "reasonably compatible", and the agency must request additional verification from Lynn to determine eligibility. Example #2: Michelle applies for herself and her two children. She reports that she started a job last month and is earning $1,400 per month. Since this is a new application, the quarterly Job Service Wage verification is not available, and the reasonable compatibility test cannot be performed. Michelle will be required to verify her earnings. If the electronic source of Equifax received through the Federal Data Services Hub (FDSH) provided verification of Michelle's wages from Walmart "reasonable compatibility' must be used to determine Michelle's eligibility.

2. When determining 'reasonable compatibility' for unearned income:

If the source of the income reported matches the source verified through the available electronic sources and the amounts are considered "reasonably compatible", further verification cannot be requested from the applicant or recipient. If verification cannot be obtained through the electronic source, the individual must provide documentation of the unearned income. The calculation used to determine 'reasonable compatibility' MUST be narrated in the case file.

When determining 'reasonable compatibility' for self-employment income, the income must be verified based on current policy. See Policy at 510-03-85-13 or 501-05-85-20 (Non-ACA)

(Revised 7/1/2025 ML 3935 )

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The following income types are not reported on Form 1040 and are not countable income under ACA Medicaid:

Non-taxable income other than: Non-taxable foreign earned income, Non-taxable interest or dividend income; The non-taxable portion of Social Security Benefits

Supplemental Security Benefits (SSI)

Veteran’s Administration Disability Benefits Aid and attendance payments, Homebound benefits Reimbursements for unusual medical expenses

Child support income.

Temporary Assistance for Needy Families (TANF) benefit and support services payments made by the Department or another state.

Workforce Safety and Insurance (WSI) Benefits.

Proceeds from life, accident or health insurance.

Federal tax credits,(i.e. Child Tax credit and IETC (Earned Income Tax Credit) and federal income tax refunds.).

Gifts and Loans.

Inheritances.

Child’s income (See section 510-03-85-13, ACA Income Methodologies regarding when to count a child’s income.)

Tribal General Assistance Payments.

Subsidized Guardianship Project payments

Educational scholarships, awards, and fellowship grants used for educational expenses do not count as income. Count only the portion of educational income that is used for living expenses or other non-educational related expenses.

Certain distributions, payments and student financial assistance for American Indians/Alaska Natives can only be disregarded if they were initially counted as taxable income.

Non-recurring and recurring lump sum payments of disregarded earned or unearned income Veteran’s Administration Aid and attendance payments, Veteran’s Administration Homebound benefits Veteran’s Administration Reimbursements for unusual medical expenses Veteran’s Administration Dependents Indemnity Compensation; Insurance settlements for destroyed exempt property; Death benefits Health or long-term care insurance payments; Life Insurance proceeds Accident Insurance proceeds

Voluntary cash contributions from others.

Proceeds from a loan agreement, including reverse mortgages. However, if the person lending the money receives interest, the interest received is income.

Hostile Fire Pay when an individual is on active military duty serving in a combat zone, the full amount of the person's military pay can be excluded from taxable income.

Deposits to a joint checking account made by a non-household member.

Money payments made by the Department, another state, or tribal entities in connection with the State LTC Subsidy program, foster care, subsidized guardianship, or the subsidized adoption program.

Benefits received through the Low Income Home Energy Assistance Program.

Refugee cash assistance or grant payments.

County general assistance that may be issued on an intermittent basis to cover emergency type situations.

Payments from the Child and Adult Food Program for meals and snacks to licensed families who provide day care in their home.

Payments from the family subsidy program.

Income received as a housing allowance by programs sponsored by the United States Department of Housing and Urban Development and rent supplements or utility payments provided through the Housing Assistance Program.

Money received by Indians from the lease or sale of natural resources, and rent or lease income, resulting from the exercise of federally-protected rights on excluded Indian property, is considered an asset conversion and is therefore not considered as income (even if the money is taken out of the IIM account in the same month it was deposited into the account). This includes distributions of per capita judgment funds or property earnings held in trust for a tribe. This does not include local Tribal funds that a Tribe distributes to individuals on a per capita basis, but which have not been held in trust by the Secretary of Interior (e.g., tribally managed gaming revenues - which is countable income).

Income derived from sub marginal lands, conveyed to Indian tribes and held in trust by the United States, as required by Pub. L. 94-114.

Compensation received by volunteers participating in the ACTION program as stipulated in the Domestic Volunteer Service Act of 1973, including the National Senior Volunteer Corps, including Retired Senior Volunteer Program (RSVP), Foster Grandparents, and Senior Companion Program; National Volunteer Programs to Assist Small Businesses and Promote Volunteer Services by Persons with Business Experience; Volunteers in Service to America (VISTA) (now AmeriCorps*VISTA, not to be confused with AmeriCorps, a separate program), VISTA Literary Corps.

Payments made to recipients under title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.

All income, allowances, and bonuses received as a result of participation in the Job Corps Program.

Payments received for the repair or replacement of lost, damaged or stolen assets.

Homestead tax credits.

Training funds received from Vocational Rehabilitation.

Training allowances of up to thirty dollars per week provided through a tribal native employment works program, or the Job Opportunities and Basic Skills Training program.

Needs-based payments, support services, and relocation expenses provided through programs established under the Workforce Innovation and Opportunity Act (WIOA), and through the Job Opportunities and Basic Skills program.

Training stipends provided to victims of domestic violence by private, charitable organizations, such as the Seeds of Hope Gift Shop, or the Abused Adult Resource Center, for attending their educational programs.

Tax-exempt portions of payments made as a result of the Alaska Native Claims Settlement Act.

Payments to certain United States citizens of Japanese ancestry, resident Japanese non-citizens, and eligible Aleuts made under the Wartime Relocation of Civilians Reparations Act.

Agent Orange payments.

Crime Victims Reparation payments.

German reparation payments made to survivors of the holocaust, and reparation payments made under sections 500 through 506 of the Austrian General Social Insurance Act.

Assistance received under the Disaster Relief and Emergency Assistance Act of 1974 or some other federal statute, because of a presidentially declared major disaster (including disaster assistance unemployment compensation), and interest earned on that assistance. Comparable assistance received from a state or local government, or from a disaster assistance organization is also excluded.

Allowances paid to children of Vietnam veterans who are born with spina bifida, or to children of women Vietnam veterans who are born with certain covered birth defects.

Netherlands Reparation payments based on Nazi, but not Japanese, persecution during World War II, Public Law 103-286

Radiation Exposure Compensation, Public Law 101-426

The Medicare part B premium refunded by the Social Security Administration

Medicare Part D premiums, copayments, and deductibles refunded by prescription drug plans

Reimbursements from an employer, training agency, or other organization for past or future training, or volunteer related expenses are disregarded from income. Reimbursements must be specified for an identified expense, other than normal living expenses, and used for the purpose intended. Examples of disregarded reimbursements include: Reimbursements for job or training-related expenses such as travel, per diem, uniforms, and transportation to and from the job or training site Reimbursements for out-of-pocket expenses of volunteers incurred in the course of their work

The first $2,000 received by an individual age 19 and over as compensation for participation in a clinical trial for rare diseases or conditions meeting the requirements of Section 1612(b)(26) of the Act. This disregard is only allowed if approved by the Medicaid Eligibility Unit.

Monthly food coupons distributed to individuals age 55 and over from the Sisseton-Wahpeton Oyate Lake Traverse Reservation Food Distribution program.

Payments of flat rate insurance like a hospital plan that pays a daily rate to the client for each day in the hospital. These are usually referred to as an indemnity policy.

Any withdrawal made from a 529 plan is excluded as income if the funds are used for the intended purposes. If the funds are withdrawn and not used for their intended purpose, they become taxable income and must be counted.

Payments distributed by the Emergency Rent Assistance Program (ERAP).

Parent Mentor compensation of a parent or guardian of a Medicaid or CHIP eligible child who is 'trained to assist families with children who have no health insurance coverage with respect to improving the social determinants of the health of such child.

Alimony received when the alimony agreement is finalized or an existing alimony agreement is modified on or after January 1, 2019.

Discharged Student Loan Debt, normally included in MAGI-based income, for tax years 2018-2025 in cases of discharged debt on account of the death or permanent and total disability of a student. Debt is not included as income of the borrower.

Disbursements from The People’s Fund and General Disbursements to members of the Mandan, Hidatsa, Arikara (MHA) Nation also known as Three Affiliated Tribes (TAT) come from natural resources (oil and gas royalties), therefore are disregarded income.

(Revised 10/1/2024 ML #3861 )

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Instead of itemized disregards and deductions, a standard deduction equal to 5% of the Federal Poverty Level (FPL) is allowed under ACA Medicaid.

Note: This disregard is not deducted from income as the ACA Income Levels have been increased by 5% to allow for this disregard.

In addition, the following deductions can be allowed from income under ACA Medicaid:

Pre-tax deductions (from the gross pay listed on paystubs)

Adjusted Gross Income deductions from gross income that are used in determining the countable Adjusted Gross Income for tax purposes (Listed on the Form 1040 in the ‘Adjusted Gross Income’ section) Educator expenses Business expenses of reservist, performing artists and fee-basis government officials Health savings account deduction Moving expenses (only for active duty members of the military who are ordered to move or change duty station) Deductible portion of self-employment tax Contributions to self-employed SEP, SIMPLE and qualified plans Self-employed health insurance deduction Penalty on early withdrawal of savings Alimony paid when alimony agreements have been finalized on or before December 31,2018 Contributions to IRA Student loan interest deduction Domestic production activities deduction

When determining income using the Federal Income Tax forms, amounts for the above deductions can only be allowed IF they have not been allowed when determining the Adjusted Gross Income.

(Revised 4/1/2026 Release 26.3 )

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(N.D.A.C. Sections 75-02-02.1-40, 75-02-02.1-22(7), 75-02-02.1-24.2(8), and 75-02-02.1-24(5))

Following are the Income Levels for the various categories under ACA Medicaid Categorically Needy:

Parents and Caretakers of Deprived Children and their Spouses who are NOT eligible for Medicare, SSI or over age 65 – (ACA Equivalent to 1931 Levels).

The family size is increased for each unborn when determining the appropriate family size.

Income Levels for Parents and Caretakers of Deprived Children and their Spouses who are NOT eligible for Medicare, SSI or over age 65 Household Size Monthly Income Level Yearly Income Level 1 $517 $6,204 2 694 8,328 3 871 10,452 4 1048 12,576 5 1226 14,712 6 1403 16,836 7 1580 18,960 8 1757 21,084 9 1934 23,208 10 2111 25,332 Plus - 1 178 2,136 Effective January 1, 2014

Parents and Caretaker Relatives who ARE Medicare beneficiaries, SSI recipients or over age 65. (Parent and Caretaker Relative fixed dollar level listed in #1 above PLUS the 5% Federal Poverty Level disregard.)

The family size is increased for each unborn when determining the appropriate family size. Income Levels for Parents and Caretaker Relatives who ARE Medicare beneficiaries, SSI recipients or over age 65. Household Size Monthly Income Level Annual Income 1 $566 $6,792 2 760 9,120 3 955 11,460 4 1,149 13,788 5 1,344 16,128 6 1,539 18,468 7 1,733 20,796 8 1,927 23,124 9 2,122 25,464 10 2,316 27,792 Plus - 1 195 2,339 Effective April 1, 2015

Children ages 6 through 18 and Individuals eligible for the Adult Expansion Group - 133% + the 5% disregard or 138%.

The family size is increased for each unborn when determining the appropriate family size. Income Levels for Children ages 6 through 18 and Individuals eligible for the Adult Expansion Group - 133% + the 5% disregard or 138% Household Size Monthly Income Level Annual Income Level 1 $1,836 $22,025 2 $2,489 $29,864 3 $3,142 $37,702 4 $3,795 $45,540 5 $4,449 $53,379 6 $5,102 $61,217 7 $5,755 $69,056 8 $6,408 $76,894 9 $7,061 $84,732 10 $7,715 $92,571 Plus - 1 $654 $7,839 Effective April 1, 2026

Children ages 0 through 6 - 147% + the 5% disregard or 152%.

The family size is increased for each unborn when determining the appropriate family size.

Income Levels for Children ages 0 through 6 - 147% + the 5% disregard or 152% Household Size Monthly Income Level Annual Income Level 1 $2,022 $24,260 2 $2,742 $32,893 3 $3,451 $41,527 4 $4,180 $50,160 5 $4,900 $58,794 6 $5,619 $67,428 7 $6,339 $76,061 8 $7,058 $84,695 9 $7,778 $93,328 10 $8,497 $101,962 +1 $720 $8,634 Effective April 1, 2026

ACA Adults age 19 and 20 and Medically Needy Pregnant Women, Children and Parent/Caretaker relative - 90% of Poverty Level. See Non-ACA Medicaid Policy income considerations, income deductions and income disregards.

The family size is increased for each unborn when determining the appropriate family size. Income Levels for ACA Adults age 19 and 20 and Medically Needy Pregnant Women, Children and Parent/Caretaker relative - 90% of Poverty Level Household Size Monthly Income Level Yearly Income Level 1 $1,197 $14,364 2 $1,623 $19,476 3 $2,049 $24,588 4 $2,475 $29,700 5 $2,901 $34,812 6 $3,327 $39,924 7 $3,753 $45,036 8 $4,179 $50,148 9 $4,605 $55,260 10 $5,031 $60,372 +1 $426 $5,112 Effective April 1, 2026

Pregnant Women - 170% + 5% Disregard or 175% The family size is increased for each unborn when determining the appropriate family size.

Income Levels for Pregnant Women - 170% + 5% Disregard or 175% Household Size Monthly Income Level Yearly Income Level 1 $2,328 $27,930 2 $3,156 $37,870 3 $3,985 $47,810 4 $4,813 $57,750 5 $5,641 $67,690 6 $6,470 $77,630 7 $7,298 $87,570 8 $8,126 $97,510 9 $8,955 $107,450 10 $9,783 $117,390 +1 $829 $9,940 Effective April 1, 2026

Optional Targeted Low-Income Children (CHIP) - 200% + 5% Disregard or 205%. The family size is increased for each unborn when determining the appropriate family size.

Income Levels for 7. Optional Targeted Low-Income Children (CHIP) - 200% + 5% Disregard or 205% Household Size Monthly Income Level Yearly Income Level 1 $2,727 $32,718 2 $3,697 $44,362 3 $4,668 $56,006 4 $5,638 $67,650 5 $6,608 $79,294 6 $7,579 $90,938 7 $8,549 $102,582 8 $9,519 $114,226 9 $10,490 $125,870 10 $11,460 $137,514 +1 $971 $11,644 Effective April 1, 2026

ACA Maintenance of Effort – Medicaid – Children ages 6 through 18.

The family size is increased for each unborn when determining the appropriate family size. Income Levels for ACA Maintenance of Effort – Medicaid – Children ages 6 through 18 Household Size 111% FPL Monthly 111% FPL Annual 133% FPL Monthly 133% FPL Annual 1 $1,477 $17,716 $1,769 $21,227 2 $2,022 $24,021 $2,399 $28,782 3 $2,528 $30,326 $3,028 $36,336 4 $3,053 $36,630 $3,658 $43,890 5 $3,578 $42,935 $4,288 $51,445 6 $4,104 $49,240 $4,917 $58,999 7 $4,629 $55,545 $5,547 $66,554 8 $5,155 $61,850 $6,176 $74,108 9 $5,680 $68,154 $6,806 $81,662 10 $6,205 $74,459 $7,435 $89,217 +1 $526 $6,305 $630 $7,555 Effective April 1, 2026

(New 7/1/2014 ML #3404)

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(N.D.A.C. Section 75-02-02.1-41.2(1))

For purposes of this section: "Base month" means the calendar month prior to the processing month. "Benefit month" means the calendar month for which eligibility and client share (recipient liability) is being computed. "Best estimate" means an income, deductions, or circumstance prediction based on past amounts of income and deductions and known factual information concerning future circumstances which affect eligibility, deductions to be incurred; or income to be received in the benefit month. Factual information concerning future circumstances must be based on information by which the applicant or recipient demonstrates known changes or highly probable changes to the income, deductions, or circumstances which offset eligibility, from the base month to the benefit month. "Processing month" means the month between the base month and the benefit month. "Prospective budgeting" means computation of a household's eligibility and client share based on the best estimate of income, deductions, and circumstances for a benefit month.

(New 7/1/2014 ML #3404)

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The "10-10-10 Rule" means: The recipient has ten days from the date they become aware of a change to report that change to the county agency . The county agency has ten days in which to act on a reported change. The county agency must allow ten days for an advance notice before any adverse action can be taken on a case (unless the change is one of the exceptions to the Ten-Day Advance Notice as defined in section 510-03-25-25 , Decision and Notice).

The purpose of the 10-10-10 rule is to describe the ACA Medicaid Household 's responsibility to report changes and to determine when the county agency can or cannot act on changes. It can, and should be, used as a caseload management tool.

(New 7/1/2014 ML #3404)

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Use prospective budgeting to determine eligibility based on the countable income which is anticipated to be received and the allowable deductions that are anticipated to be incurred. Anticipated income and deductions are an estimate based on reasonable expectations and knowledge of past, current, and future events.

The following guidelines are offered to assist in this determination.

An employed individual who does not expect a significant change should have the previous month's earnings and employment deductions verified by pay stub or employer's statement. The previous month’s earnings serve as the basis for estimating the income likely to be received during the initial prospective month.

Example: A person applies for assistance on November 15 and reports there should be no significant change in income and deductions from the month of October. The October income should be verified and converted if paid weekly or bi-weekly, to anticipate the income and deductions likely to be available in November.

If the applicant or recipient indicates that he or she expects to begin working or that a material change in income is likely, the statement shall be documented as the basis for the "best estimate" of income to be received. The employer may be contacted, with the applicant's or recipient’s permission, to verify the statement that income will be reduced or increased during the prospective month, or the applicant or recipient may provide other documentation supporting the expected change.

If new income is expected during the prospective month, the worker needs to arrive at a "best estimate" of the income likely to be available. If the income is from employment in which "tips" are likely, these also need to be estimated.

When anticipating income, also anticipate bonuses, profit sharing, and other such additional income whenever possible. This type of income can be anticipated based on prior receipt of such income. The amount anticipated can be estimated based on amounts previously received, unless factual information suggests otherwise.

To summarize, the method(s) used to anticipate income will vary according to the circumstances in each case. It is the responsibility of the county agency to decide on the best approach. Whatever the method used, it is imperative that the rationale for arriving at estimated income be clearly and thoroughly documented in the case file .

(Revised 4/1/2025 ML #3919 )

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CFR 435.300 and 435.800

(N.D.A.C. 75-02-02.1-41.1)

As of January 1, 2024, the budgeting for Client Share (Recipient Liability) is under Non-ACA Medicaid policy. See 510-05-85-55 Client Share (Recipient Liability) in the Non-ACA Medicaid policy manual.

(Revised 4/1/2025 ML #3919 )

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(N.D.A.C. Section 75-02-02.1-41.1)

As of January 1, 2024, the budgeting for Client Share (Recipient Liability) is under Non-ACA Medicaid policy. See 510-05-90-20 Computing Client Share (Recipient Liability) in the Non-ACA Medicaid policy manual.

(New 7/1/2014 ML #3404)

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(N.D.A.C. 75-02-02.1-41.1)

Up to fifteen dollars per month of expenses for necessary medical or remedial care, incurred by a member of the ACA Medicaid Household, or a spouse or child they were legally responsible for, in a month prior to the month for which eligibility is being determined, may be subtracted from client share (recipient liability), other than client share created as a result of medical care payments, to determine remaining client share, provided that: The expense was incurred in a month during which the individual who received the medical or remedial care was not a Medicaid recipient or the expense was incurred in a month the individual was a Medicaid recipient, but was for a service not covered by Medicaid; The expense was not previously applied in determining eligibility for, or the amount of, Medicaid benefits for any Medicaid recipient; The medical or remedial care was provided by a medical practitioner licensed to furnish the care; The expense is not subject to payment by any third party, including Medicaid and Medicare; The expense was not incurred for swing bed services provided in a hospital, nursing facility services, or HCBS during a period of ineligibility because of a disqualifying transfer; Each expense claimed for subtraction is documented by the applicant or recipient in a manner which describes the service, the date of the service, the amount of the cost incurred, the amount of the cost remaining unpaid, the amount of the cost previously applied in determining Medicaid benefits for any Medicaid recipient, and the name of the service provider; and The ACA Medicaid Household is still obligated to pay the expense.

The ACA Medicaid Household must apply the remaining client share to expenses of necessary medical care incurred by a member of the ACA Medicaid Household in the month for which eligibility is being determined. The ACA Medicaid Household is eligible for Medicaid benefits to the extent the expenses of necessary medical care incurred in the month for which eligibility is being determined exceed remaining client share in that month.

(Revised 10/1/2023 ML #3747)

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(N.D.A.C. 75-02-02.1-21)

The Omnibus Budget Reconciliation Act of 1990 provided for extended eligibility for pregnant women effective July 1, 1991.

When a pregnant woman becomes eligible for Medicaid, including during the three month prior period (THMP), she continues to be eligible, without regard to any increase in income of the ACA Medicaid Household , for twelve months after the day her pregnancy ends, and through the last day of the twelfth month. Decreases in income, however, will be considered to further reduce any client share (recipient liability). All other Medicaid eligibility factors continue to apply.

Self-attestation of a single-birth or multi-fetus pregnancy is accepted unless it is questionable.

For determinations made after the birth of the baby, the child’s birth verification may be used as verification of pregnancy.

When a woman applies for coverage and is pregnant, if eligible, she must be enrolled in Medicaid coverage as a pregnant woman, rather than in the Adult Expansion Group .

When a woman is already enrolled in the Adult Expansion Group, and becomes pregnant after her enrollment, her coverage will move to the ACA Pregnant Women group. She may request to move to the Adult Expansion Group if within the income level.

If the woman chooses Medicaid coverage as a pregnant woman, during the final month of the twelve-month period of eligibility, a review must be completed to evaluate whether she will remain eligible for Medicaid under another coverage group, or be referred to the Marketplace to choose an insurance policy. This will ensure there is no loss of coverage.

For policy relating to Extended Eligibility for Pregnant Women, refer to 510-03-45-05 .

(Revised 5/1/2017 ML #3498)

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(N.D.A.C. 75-02-02.1-41.2(5) & (6))

When an individual is added to an ACA Medicaid Household , a review must be completed to process eligibility for the individual.

Individuals may be added to an eligible unit up to one year prior to the current month, provided The individual meets all eligibility criteria for Medicaid; The eligible unit was eligible in all of the months in which eligibility for the individual is established; and The individual was in the unit in the months with respect to which eligibility for that individual is sought.

Note: Individuals eligible under the Adult Expansion Group only, cannot be added as eligible prior to January 1, 2014.

When an individual is added to an eligible household and requests eligibility for a retroactive period, the addition of the member will NOT affect the eligibility for anyone already eligible for any prior month(s) or the current month. However, eligibility may change for future months provided the appropriate notice requirements can be met.

Note : Eligibility for individuals within a Continuous Eligibility Period would not be changed.

Client share (recipient liability) will be based on the unit's actual income and circumstances when adding each individual for retroactive periods. Client share must be based on the unit's income and circumstances from the base month, plus the best estimate of each individual's income and circumstances when adding each individual to the current or next month.

Client share for other individuals in the ACA Medicaid Household who were medically needy eligible may increase or decrease with the addition of the new member. Any client share, or lack of, applied to previously paid claims will be adjusted.

Other individuals in the ACA Medicaid Household who were previously determined to be poverty level eligible remain poverty level eligible, regardless of any income change, when adding an individual to the unit.

Budgeting procedures when deleting individuals from a case.

When a member of an existing unit is expected to leave the unit during the benefit month, that person may remain as a member of the unit until the end of the benefit month.

Refer to Manual Section 510-03-53-20 for policy regarding deleting individuals who are Continuously Eligible and move out of the ACA Medicaid Household.

(New 7/1/2014 ML #3404)

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SSI individuals must first be tested under the Non-ACA Medicaid methodologies and, if eligible, budgeted under the Non-ACA Medicaid rules Service Chapter 510-05 , Eligibility Factors for Non-ACA Medicaid

If the SSI recipient is not eligible under the Non-ACA Medicaid methodologies (excess assets), the individual may be eligible under one of the ACA Medicaid coverages. In those cases, ACA Medicaid budgeting methodologies applies.

(Revised 1/1/2024 ML #3776)

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Parents and caretaker relatives of deprived children, Pregnant Women and children under age 21 , who fail under the ACA Medicaid Categorically Needy Coverage Group, may be eligible under the Medicaid Medically Needy Coverage Group, provided they have a Medical Need as defined in 510-03-35-35 , Need. See Non-ACA Medicaid policy income considerations, income deductions and income disregards.

(Revised 3/1/2024 ML #3811)

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When a child becomes continuously eligible for Medicaid, that child continues to be eligible without regard to any changes in income and/or deductions of the ACA Medicaid Household until the next review.

For policy relating to Continuous Eligibility for Children, refer to 510-03-53 .

(Revised 1/12/2023 ML #3696)

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When establishing eligibility for the three calendar months prior to the month in which the signed application was received, all factors of eligibility must be met during each month of retroactive benefits.

Retroactive eligibility may be established even if there is no eligibility in the month of application.

Budgets must be calculated for each of the three prior months, based on actual, verified income.

All case records shall be documented to reflect eligibility or ineligibility for each individual month assistance is requested prior to and through the month in which the application is processed.

(Revised 1/12/2023 ML #3696)

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Recipients are required to report changes in income, household size, employment, residence, new tax filing status, etc., within 10 days of their knowledge of the change. Because every household’s circumstances are unique, all changes must be reported and reviewed, and it will depend on those circumstances whether it affects the recipient’s coverage.

Under ACA Medicaid, clients will no longer be required to monthly report, but are required to report changes that may affect their eligibility, such as those itemized above. A revised change report has been created, which is currently being generated electronically. This is for the client’s reporting convenience and does not require the individual to submit a form monthly.

We must not impose a threshold on what the household reports, or how often. In some cases, a $20 increase in income can make someone ineligible, in others; it may be a few thousand dollars. It all depends on the situation. Therefore, there is no dollar amount or percentage threshold, all changes must be reported.

Upon receipt of a reported change, the Eligibility Workers will determine whether a change in eligibility results and process the change based on the policy defined in section 510-03-10-25, Suspected Fraud.

Note : The 10-10-10 requirements defined in section 510-03-90-10 and the Notification requirements defined in section 510-03-25-25 must be adhered to when acting on reported changes.

(New 7/1/2014 ML #3404)

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There are other non-Medicaid programs that help meet the health needs of individuals and families. Some of these programs closely interact with Medicaid. Applicants who are ineligible for Medicaid may qualify for these other programs and should be referred accordingly.

(Revised 4/1/2020 ML #3576)

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The Refugee Medical Assistance Program (RMA) provides health care coverage for legally admitted refugees who are not eligible for Medicaid, including the optional children's group.

For Refugee Medical Assistance Program policy, please refer to Non-ACA Manual Section 510-05-95-20 .

(Revised 1/12/2023 ML #3696)

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Special Health Services provides services for children with special health care needs and their families. Services include coverage for diagnosis and treatment for children who have disabilities or chronic conditions. The program supports family-centered, community-based, coordinated services and systems of health care that meet the diverse needs of families. For information, contact the Special Health Services, North Dakota Department of Health, Division of Special Health Services (SHS), 600 East Boulevard Ave, Dept 301, Bismarck ND 58505-0200, or call 701-328-2436, 1-800-755-2714, or FAX: 701-328-1645.

(New 6/1/2015 ML #3441)

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North Dakota Medicaid's Coordinated Services Program (CSP) (formerly Lock-In program) helps individuals find healthcare services that match their medical needs. Individuals have one coordinated services medical provider and one pharmacy provider who will work regularly with them to understand their health care needs and coordinate your care. The coordinated services medical provider can also refer them to specialists who can help maintain and improve their health.

This program was developed to assist individuals eligible for Traditional Medicaid coverage who may be unintentionally misusing program benefits and to ensure the continuity and quality of care for recipients. When deciding if someone meets the criteria to be placed on the CSP, the following areas are examples of what is taken into consideration;

Use of multiple providers and clinics;

Early prescription refills;

Use of multiple pharmacies;

Trips to the emergency room (ER) for services other than emergent care. Examples of non-emergent care include, refills of medication, chronic pain, headaches including migraines, constipation, or menstrual cramps;

Use of multiple controlled drugs; and

Prescriptions obtained from multiple providers

The State is to inform the insurance vendor of individuals who were participating in the CSP Program while eligible for Traditional Medicaid coverage, when their coverage changes to Medicaid Expansion coverage. The Insurance vendor is required to apply a similar policy under the insurance coverage provided.

(Revised 1/1/2024 ML #3779)

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North Dakota Health Tracks (formerly EPSDT) is a preventive health benefit that is free for children age 0 to 21, who are eligible for Medicaid. Health Tracks pays for screenings, diagnosis, and treatment services to help prevent health problems from occurring or help keep health problems from becoming worse. Health Tracks also pays for orthodontics (teeth braces), glasses, hearing aids, vaccinations, counseling and other important health services. Some services require prior authorization so be sure to check with your screener about these requirements.

Federal legislation requires states to make available to all Medicaid-eligible children under age 21 comprehensive, periodic health assessment, dental, vision and hearing services, and “medically necessary” follow-up diagnostic and treatment service.

(New 7/1/2014 ML #3404)

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This information is available through the Department of Human Services.

Family Planning Program (pdf)

(New 7/1/2014 ML #3404)

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This information is available through the Department of Human Services.

WIC: Because You Care brochure (tif)

(New 7/1/2014 ML #3404)

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This brochure is available through the Department of Human Services.

DN 143, "Your Civil Rights Brochure" (33 kb pdf)

(New 7/1/2014 ML #3404)

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Medicaid Program Brochure (4,043 kb pdf)

Brochures are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(Revised 1/24/2024)

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These flyers are available through the Department of Health and Human Services.

DN 538 " Health Tracks/Well-Child Checks

Health Tracks/Well-Child Checks

(New 7/1/2014 ML #3404)

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This form is used by workers to report suspected provider or recipient related errors to the Surveillance Utilization Review (SURS) Unit who wish to request a hearing.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used by recipients who wish to request a hearing.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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The front of the form briefly summarizes the legislative intent of the IV-D Program and the applicant’s or recipient’s obligation to cooperate with Child Support. The back of the form describes in some detail the circumstances under which cooperation may be "against the best interests" of the child and provides examples of the kinds of evidence necessary to substantiate a claim.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (34 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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The form provides the caretaker with the opportunity to describe the circumstances which he/she believes will have a bearing on the claim.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (44 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form may be used by the county agency to submit social information to the State Review Team for the evaluation of disability or incapacity.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (180 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used to obtain the signature of someone legally able to assign benefits when the individuals who sign the application do not have the right to do so.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (42 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used to obtain information from the recipient if other sources of payment are available for recovery of Medicaid funds.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (42 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used by the parent, guardian, or caretaker relative to verify either citizenship or identity, but not both, for a child aged 16 to 18 only when school identity cards and driver's licenses are not available.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used by an applicant/recipient or other knowledgeable individual explaining why verification of citizenship cannot be obtained.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used when an applicant or recipient cannot produce documentary evidence of citizenship.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used by the county agency to refer Medicaid eligible cases with health insurance to the state Medicaid Eligibility unit to determine if the health insurance is cost-effective and can be paid by Medicaid.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (96 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(New 7/1/2014 ML #3404)

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This form is used by recipients who wish to request to be considered for coverage as ‘medically frail’.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

(Revised 1/18/2023 ML #3697)

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This Reference Hard Card explains the order in which eligibility is tested under ACA Health Care Coverage.

Coverage Hierarchy Order (Highest to Lowest) COEs DESCRIPTION COEs DESCRIPTION 1 M098 Non IV-E State or Tribal Foster Care Children 2 M091 ACA Former Foster Care Child 3 M067, M67A, M095 ACA Children 4 M066 ACA Pregnant Woman 5 M063 ACA Parent/Specified Caretaker Relative 6 M086 ACA Transitional Parent/Specified Caretaker Relative 7 M088 ACA Extended Parent/Specified Caretaker Relative 8 M087 ACA Transitional Children 9 M061 ACA Extended Children 10 M078 Optional Children's Group 11 M075, M069, M064 Medicaid Breast and Cervical Cancer Early Detection Program 12 M062, M76A ACA Adult 19 or 20 13 M058, M059, M077, M089, M060, M065 Adults Medically Frail 14 M076 ACA Adult Expansion 15 M081 Emergency Services

(Revised 5/15/2026 Release 26.4)

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This Reference Hard Card lists all of the living arrangements used when determining eligibility for ACA Health Care Coverage.

Medicaid Living Arrangement Reference Hard Card

DD Providers ICF-IID

DD Providers HCBS-SF

(New 10/1/2024 ML #3861 )

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From $ To $ # Months Counted for Medicaid 1 79,999 1 80,000 89,999 2 90,000 99,999 3 100,000 109,999 4 110,000 119,999 5 120,000 129,999 6 130,000 139,999 7 140,000 149,999 8 150,000 159,999 9 160,000 169,999 10 170,000 179,999 11 180,000 189,999 12 190,000 199,999 13 200,000 209,999 14 210,000 219,999 15 220,000 229,999 16 230,000 239,999 17 240,000 249,999 18 250,000 259,999 19 260,000 269,999 20 270,000 279,999 21 280,000 289,999 22 290,000 299,999 23 300,000 309,999 24 310,000 319,999 25 320,000 329,999 26 330,000 339,999 27 340,000 349,999 28 350,000 359,999 29 360,000 369,999 30 370,000 379,999 31 380,000 389,999 32 390,000 399,999 33 400,000 409,999 34 410,000 419,999 35 420,000 429,999 36 430,000 439,999 37 440,000 449,999 38 450,000 459,999 39 460,000 469,999 40 470,000 479,999 41 480,000 489,999 42 490,000 499,999 43 500,000 509,999 44 510,000 519,999 45 520,000 529,999 46 530,000 539,999 47 540,000 549,999 48 550,000 559,999 49 560,000 569,999 50 570,000 579,999 51 580,000 589,999 52 590,000 599,999 53 600,000 609,999 54 610,000 619,999 55 620,000 629,999 56 630,000 639,999 57 640,000 649,999 58 650,000 659,999 59 660,000 669,999 60 670,000 679,999 61 680,000 689,999 62 690,000 699,999 63 700,000 709,999 64 710,000 719,999 65 720,000 729,999 66 730,000 739,999 67 740,000 749,999 68 750,000 759,999 69 760,000 769,999 70 770,000 779,999 71 780,000 789,999 72 790,000 799,999 73 800,000 809,999 74 810,000 819,999 75 820,000 829,999 76 830,000 839,999 77 840,000 849,999 78 850,000 859,999 79 860,000 869,999 80 870,000 879,999 81 880,000 889,999 82 890,000 899,999 83 900,000 909,999 84 910,000 919,999 85 920,000 929,999 86 930,000 939,999 87 940,000 949,999 88 950,000 959,999 89 960,000 969,999 90 970,000 979,999 91 980,000 989,999 92 990,000 999,999 93 1,000,000 1,009,999 94 1,010,000 1,019,999 95 1,020,000 1,029,999 96 1,030,000 1,039,999 97 1,040,000 1,049,999 98 1,050,000 1,059,999 99 1,060,000 1,069,999 100 1,070,000 1,079,999 101 1,080,000 1,089,999 102 1,090,000 1,099,999 103 1,100,000 1,109,999 104 1,110,000 1,119,999 105 1,120,000 1,129,999 106 1,130,000 1,139,999 107 1,140,000 1,149,999 108 1,150,000 1,159,999 109 1,160,000 1,169,999 110 1,170,000 1,179,999 111 1,180,000 1,189,999 112 1,190,000 1,199,999 113 1,200,000 1,209,999 114 1,210,000 1,219,999 115 1,220,000 1,229,999 116 1,230,000 1,239,999 117 1,240,000 1,249,999 118 1,250,000 1,259,999 119 1,260,000 or higher 120

(Revised 3/1/2024 ML #3811)

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When an individual is determined eligible:

Enter the information in SPACES just like any other case with the following exceptions: Enter the address of the facility where the individual is residing for the individual’s address. Enter the Living Arrangement of ‘In Own Home’ with a date equal to the first day of the first month they began residing in one of the facilities. See Coverage for Inmates Residing in Corrections-related Supervised Community Residential Facilities 510-03-35-95-10 for a list of facilities.