Groups Covered under ACA Medicaid 510-03-30-05

(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).