Determining the Appropriate Income Level in Special Circumstances 510-05-85-45

(Revised 8/1/2024 ML #3851)

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(N.D.A.C. Sections 75-02-02.1-40 and 75-02-02.1-24.2)

This section applies to individuals who are subject to the Non-ACA Medicaid policies.

A child who is away at school is not treated as l iving independently , but is allowed the appropriate income level for one during all full calendar months . This is in addition to the income level applicable for the Medicaid Unit remaining at home.

A child who is living outside of the parental home, but who is not living independently; or a spouse who is temporarily living outside of the home to attend training or college, to secure medical treatment, because of temporary work relocation required by an employer, or for other reasons beyond the control of the spouse, is allowed a separate income level during all full calendar months during which the child or spouse lives outside the home.

This does not apply to situations where an individual simply decides to live separately.

During a month in which an individual enters a specialized facility , or leaves one to return home, the individual will be included in the Medicaid Unit in the home for the purpose of determining the Medicaid Unit and the appropriate income level. Individuals in a specialized facility will be allowed the medically needy income level for one during all full calendar months in which the individual resides in the facility. In determining eligibility for Workers with Disabilities and Children with Disabilities coverages, individuals in a nursing facility, or in receipt of HCBS, will be allowed the appropriate Workers with Disabilities or Children with Disabilities income level for one during all full calendar months in which the individual resides in the facility.

During a month in which an individual with eligible family members in the home enters or leaves a Psychiatric Residential Treatment Facility (PRTF); an Intermediate Care Facility for the intellectually disabled (ICF-ID), or a nursing facility to return home, or elects to receive HCBS or terminates that election, the individual will be included in the Medicaid Unit in the home for the purpose of determining the Medicaid Unit and the appropriate medically needy income level. Individuals in a Psychiatric Residential Treatment Facility (PRTF), an Intermediate Care Facility for the intellectually disabled (ICF-ID), or a nursing facility will be allowed the appropriate nursing care or Intermediate Care Facility for the intellectually disabled (ICF-ID) income level to meet their maintenance needs during all full calendar months in which the individual resides in the facility and is screened as needing that level of care. Recipients of HCBS will be allowed the medically needy income level for one during all full calendar months in which the individual receives HCBS. In determining eligibility for Workers with Disabilities and Children with Disabilities coverages, individuals in a nursing facility, or in receipt of HCBS, will be allowed the appropriate Workers with Disabilities or Children with Disabilities level for one during all full calendar months in which the individual resides in the facility.

For an institutionalized spouse with an ineligible community spouse the $100 income level is effective in the month of entry, during full calendar months, and in the month of discharge. The ineligible community spouse, and any other family members, remaining in the home must be given the community spouse and family member income levels.

For a spouse electing to receive HCBS who has an ineligible community spouse, the medically needy income level for one is effective in the month the HCBS services begin, during full calendar months, and in the month the HCBS are terminated. The ineligible community spouse, and any other family members, remaining in the home must be given the community spouse and family member income levels.

An individual who enters a nursing facility may receive the medically needy income level for one if a physician certifies that the individual is likely to return to the individual's home within six months. The six-month period begins with the first full calendar month the individual is in the nursing facility. If, at any time during the six-month period, the individual’s status changes and the stay in the nursing facility is expected to exceed the six months, the individual is only allowed the $100 nursing care income level beginning in the month following the month of the status change.

For a married couple, budget one spouse at the medically needy income level and the other as permanent long-term care when:

Both spouses are admitted to a nursing facility for temporary stays, or

One spouse is permanently in a nursing facility and the other spouse requires temporary nursing care level services.

Only one six-month period is allowed per period of institutionalization. If an individual is discharged, then readmitted to the nursing facility, there must be a break of at least one full calendar month between the periods of institutionalization for the new stay to be considered a new period of institutionalization.

An individual who is residing in a Psychiatric Residential Treatment Facility (PRTF) or a nursing facility but who is not certified or screened as needing that level of care is allowed the medically needy income level. If the individual appeals the certification or screening and wins, the nursing care income level applies to all full calendar months the appeal covers.

An individual’s living arrangement or income level does not change when the individual enters a hospital for a temporary stay unless the individual receives nursing care/swing bed services in the hospital.