Groups Covered Under Medicaid 510-05-30-05

(Revised 03/01/2024 ML #3811)

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

Groups Covered Under Medicaid on or after January 1, 2014:

Categorically Needy Group:

Children for whom adoption assistance maintenance payments are made under title IV-E or non-IV-E.

Children for whom foster care maintenance payments are made under title IV-E.

Children who are living in North Dakota and are receiving title IV-E adoption assistance payments from another state.

Children in a foster care placement in North Dakota and receiving a title IV-E foster care payment from another state.

Note: Medicaid eligibility for all regular foster care (non-Title IV_E) children is determined under ACA Medicaid policies.

Children who are living in North Dakota and are receiving title IV-E kinship guardianship assistance payments from another state.

Children who were in foster care at age 18 up through the month they turn 26.

Aged, blind, or disabled individuals who are receiving SSI payments or who appear on ND Verify – Other Benefits as zero payment as a result of SSI’s recovery of an overpayment or who are suspended because the individuals do not have a protective payee, provided that the more restrictive Medicaid criteria is met.

Individuals under age 21 who have been approved for SSI may be categorically eligible beginning with the month of the SSI application.

Individuals age 21 or older who have been approved for SSI may be categorically eligible beginning the month following the month of SSI application. (If disabled in the month of SSI application, the individual age 21 or older may be medically needy eligible for that month.) Individuals who qualify under this category who are also eligible for Medicare Part B are also eligible for coverage of their Medicare Part B premium (SSI Buy-In).

Individuals who meet the more restrictive requirements of the Medicaid program and qualify for SSI benefits under section 1619(a) or 1619(b) of the Act.

Section 1619 of the Social Security Act provides continued Medicaid eligibility for certain disabled or blind persons who lose SSI benefits because they are performing substantial gainful activity. These benefits may continue beyond the age of sixty-five.

Section 1619a: These individuals continue to receive a special SSI payment, and may continue to be eligible for Medicaid as categorically needy if all other eligibility factors are met. They also will continue to be eligible for coverage of their Medicare Part B premium (SSI Buy-In).

Section 1619b: These are blind and disabled individuals who lose SSI benefits because of their earnings, and whose ability to continue employment or self-employment would be seriously impaired by termination of Medicaid and whose earnings are insufficient to provide the reasonable equivalent of the cash payments and Medicaid benefits (and in the case of determinations made under this law before October 1, 1981, Title XX Social Services) which would be available to them in the absence of such earnings. These individuals will not receive any cash assistance but may continue to be eligible for Medicaid as categorically needy if all other eligibility factors are met. They also will continue to be eligible for coverage of their Medicare Part B premium (SSI Buy-In).

Optional Categorically Needy Group:

Uninsured individuals under age 65, who have been screened for breast and cervical cancer under the Department of Health Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program and need treatment for breast or cervical cancer, including a pre-cancerous condition of the breast or cervix, and whose family income is at or below 200% of the poverty level. Effective July 1, 2001. (Medicaid Breast and Cervical Cancer Early Detection Program),

Workers with Disabilities (Gainfully employed individuals with disabilities) ages sixteen through sixty-four who meet medically needy non-financial criteria, have countable assets within the medically needy asset levels + $10,000, have income at or below 225% of the poverty level, and are not eligible for Medicaid under any other provision other than as a Qualified Medicare Beneficiary or a Special Low-income Medicare Beneficiary. Effective June 1, 2004.

Children with Disabilities under age 19 (including the month attaining age 19) who meet medically needy non-financial criteria, have income at or below 250% of the poverty level, and are not eligible for full Medicaid benefits under any other provision. Effective April 2008.

Medically Needy Group:

Pregnant women who qualify on the basis of financial eligibility.

Self-attestation of a single-birth or multi-fetus pregnancy is accepted unless it is questionable. For determination made after the birth of the baby, the child's birth verification may be used as verification of pregnancy.

Eligible pregnant women who applied for Medicaid during pregnancy, and for whom client share (recipient liability) for the month was met no later than on the date each pregnancy ends, continue to be eligible without regard to financial circumstances, for twelve months, beginning on the last of pregnancy and through the last day of the twelfth month.

Children born to eligible pregnant women under age 19 who have applied for and been 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.

Aged, blind, or disabled individuals who are not in receipt of SSI benefits.

Individuals under age twenty-one who have been certified as needing the service, or age sixty-five and over in the state hospital who qualify on the basis of financial eligibility.

Individuals who are screened as and receiving Home and Community Based Services at home or in a specialized facility.

The poverty level group includes:

Qualified Medicare Beneficiaries (QMB), who are entitled to Medicare part A benefits regardless of age or disability status, and who meet the medically needy non-financial criteria, have assets no greater than the limit established for the Medicare part D Low Income Subsidy, and have income at or below one hundred percent of the poverty level. Effective January 1, 1991 (90% of the poverty level from April 1, 1990, through December 31, 1990).

Qualified Disabled and Working Individuals (QDWI), who are individuals entitled to enroll in Medicare part A under section 1818a of the Social Security Act, and who have income no greater than two hundred percent of the poverty level, have assets no greater than twice the SSI resource standard, and who are not eligible for Medicaid under any other provision. The SSI program income and asset methodologies must be used and none of the more restrictive 209b criteria may be applied. (The eligibility determination for this group will temporarily be done by the Medicaid Eligibility Division of the North Dakota Department of Human Services.) Coverage for this group began July 1, 1990.

Special Low-Income Medicare Beneficiaries (SLMB), who are entitled to Medicare Part A benefits regardless of age or disability status, who meet the medically needy non-financial criteria, have assets no greater than the limit established for the Medicare Part D Low Income Subsidy, and have income above one hundred percent of the poverty level but not in excess of one hundred twenty percent of the poverty level. Effective January 1, 1993.

Qualifying Individuals (QI-1), who are entitled to Medicare Part A benefits regardless of age or disability status, who meet the medically needy non-financial criteria, have assets no greater than the limit established for the Medicare Part D Low Income Subsidy, have income above 120% of the poverty level, but not in excess of 135% of the poverty level, and are not eligible for Medicaid under any other provision. Effective January 1, 1998.