Chapter 02-02.1. Eligibility for Medicaid

For the purposes of this chapter: 1. "Agency" means the North Dakota department of health and human services. 2. "Applicant" means an individual seeking health care coverage benefits. 3. "Asset" means any kind of property or property interest, whether real, personal, or mixed, wh…

1. Application. a. All individuals wishing to make application for Medicaid must have the opportunity to do so, without delay. b. An application is a written request made by an individual desiring assistance under the Medicaid program, or by an individual seeking such assistance …

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 furnishing of a social security number, and establishing age, identity, residence, citizenship, bli…

1. A decision as to eligibility must be made promptly on applications, by the forty-fifth day, or within ninety days in cases with a disability determination pending, except in unusual circumstances. 2. Following a determination of eligibility or ineligibility, an applicant must …

All applicants or recipients who seek nursing care services in nursing facilities, swing-bed facilities, or intermediate care facilities for individuals with intellectual disabilities, or who seek home and community-based services, must demonstrate a medical necessity for the ser…

1. Children under age twenty-one who seek services in an institution for mental disease must obtain certification of need in order to be eligible for Medicaid. 2. For an individual who attains age twenty-one while receiving treatment and continues to receive treatment as an inpat…

Within the limits of legislative appropriation, the department may provide benefits to coverage groups described in the approved Medicaid state plan in effect at the time those benefits are sought. These coverage groups do not define eligibility for benefits. Any individual who i…

An individual who could establish eligibility under more than one category may have eligibility determined under the category the individual selects. Except for qualified Medicare beneficiaries and special low-income Medicare beneficiaries, who may also establish eligibility as a…

Repealed effective December 1, 1991.

1. For individuals not subject to MAGI-based methodology, a Medicaid unit may be one individual, a married couple, or a family with children under twenty-one years of age or, if blind or disabled child, under age eighteen, whose income and assets are considered in determining eli…

1. A caretaker relative who is not a child's parent may be eligible for Medicaid as a caretaker relative only if: a. Age sixteen or older; b. Actually living in the same home as the dependent child; and c. The dependent child is not only temporarily absent from the home of the ch…

1. The applicant and each individual for whom assistance is requested must, as a condition of eligibility, assign rights to payment or benefits from any third party or private insurer and cooperate in obtaining medical payments and benefits. This assignment of rights to payment o…

1. Current eligibility may be established from the first day of the month in which the application was received. This subsection does not apply to qualified Medicare beneficiaries. 2. Retroactive eligibility may be established for as many as three calendar months prior to the mon…

Need is a factor of eligibility. Need in this sense is not to be confused with the necessity for a particular medical service. 1. Need is established for individuals who are determined to be categorically needy, optionally categorically needy, or poverty level eligible. 2. For a …

1. An eligible categorically or medically needy aged applicant or recipient is eligible for Medicaid for the entire calendar month in which that individual reaches age sixty-five. 2. An individual who attains age twenty-one while receiving treatment and continues to receive treat…

1. For purposes of this section: a. "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. 17 b. "Health plan" means any plan un…

A social security number must be furnished as a condition of eligibility, for each individual for whom Medicaid benefits are sought, except for: 1. A newborn child who is eligible during the birth month, for sixty days after the date of birth beginning on the date of birth and fo…

1. In any instance in which a determination is to be made as to whether any individual is disabled, each medical report form and social history shall be reviewed by a review team consisting of technically competent individuals, not less than a physician and an individual qualifie…

1. For the purpose of this section, "medically frail" means an individual who is eligible for or enrolled with Medicaid expansion and has been deemed to meet the status of medically frail which upon a review and determination may include an individual with any of the following: s…

1. A child, if otherwise eligible for Medicaid benefits, is "deprived of parental support or care" when the child's parent has a physical or mental defect, supported by current competent medical testimony, of such a debilitating nature as to reduce substantially or eliminate the …

A resident of the state is an individual who is living in the state voluntarily and not for a temporary purpose. 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 con…

Repealed effective January 1, 2025.

1. An applicant or recipient must be a United States citizen or an alien lawfully admitted for permanent residence. Acceptable documents to establish United States citizenship and naturalized citizen status are defined in 42 CFR 435.407. 2. For purposes of qualifying as a United …

1. 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 eligible. Medicaid eligibility for individuals who are inmates o…

1. Parents and caretaker relatives, and their spouses, who meet the medically needy technical requirements and the requirements of this section are eligible under the parent and caretaker relative group. 2. Parents and caretaker relatives eligible under the parent and caretaker r…

1. An institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases. 2. An institution for mental disease consists of more than sixteen beds. 3. Fede…

Families that cease to be eligible under the parent and caretaker relative group and who meet the requirements of this section may continue to be eligible for Medicaid benefits without making further application for Medicaid. 1. Families that include at least one individual who w…

When a pregnant woman, whose pregnancy has been confirmed, becomes eligible for Medicaid, she continues eligible, without regard to any increase in income of the Medicaid unit, while pregnant, for twelve months beginning on the last day of pregnancy, and through the end of the mo…

1. Qualified Medicare beneficiaries are entitled only to Medicare cost-sharing benefits described in subsection 19 of section 75-02-02.1-01, beginning in the month following the month in which the individual is determined eligible. 2. Special low-income Medicare beneficiaries are…

1. Qualified disabled and working individuals are entitled only to Medicare cost-sharing benefits described in paragraph 1 of subdivision a of subsection 19 of section 75-02-02.1-01. 2. No person may be found to be a qualified disabled and working individual unless the total valu…

1. For purposes of this section: a. "Community spouse" means the spouse of an institutionalized spouse or the spouse of a home and community-based services spouse. b. "Family member" means only a minor or dependent child, dependent parent, or dependent sibling of the institutiona…

The breast and cervical cancer early detection group consists of individuals under age sixty-five who: 1. Are uninsured and not otherwise eligible for Medicaid; 2. Have been screened for breast and cervical cancer under the centers for disease control and prevention's national br…

1. An individual shall be enrolled as a member of the workers with disabilities coverage if that individual: a. Is gainfully employed; b. Is at least sixteen, but less than sixty-five, years of age; c. Is disabled as determined by the social security administration or the state r…

1. A child must be enrolled as a member of the children with disabilities coverage if that child: a. Is under age nineteen, including the month the child turns age nineteen; b. Is disabled; c. Meets the requirements of this section; and d. Is not in receipt of any other Medicaid …

1. For purposes of this section, "qualified hospital" means a hospital or hospital-owned physician practice or clinic that: a. Is a Medicaid provider; b. Notifies the department of its election to make presumptive eligibility determinations; and c. Has been approved by the depart…

Except as otherwise provided in this chapter, this section applies to all aged, blind, and disabled applicants and recipients of Medicaid. 1. All actually available assets must be considered in establishing eligibility for Medicaid. Assets are actually available when at the dispo…

In all instances, including determinations of equity, property must be realistically evaluated in accord with current fair market value. No one subject to an asset limit may be found eligible for Medicaid unless the combined equity value of the Medicaid unit's assets of whatever …

Repealed effective April 1, 2012.

Except as provided in section 75-02-02.1-28.1, the following types of assets will be excluded in determining if the available assets of an applicant or recipient exceed asset limits: 1. The home occupied by the Medicaid unit, including trailer homes being used as living quarters.…

working individuals, and spousal impoverishment prevention. 1. An asset may be excluded for purposes of Medicare savings programs, qualified disabled and working individuals, and spousal impoverishment prevention only if this section provides for the exclusion. An asset may be ex…

1. Ownership of real or personal property or liquid assets can take various forms. The first basic consideration is the distinction between real and personal property. Real property relates to land and those things, such as houses, barns, and office buildings, which are more or l…

1. An applicant or recipient may own contractual rights to receive money payments. Such contractual rights are available assets subject to the asset limits. If the applicant or recipient has sold property and received in return a promise of payments of money at a later date, usua…

Repealed pursuant to North Dakota Century Code section 28-32-18.1, effective July 16, 2003.

1. A trust is an arrangement whereby a person known as the "grantor" or "trustor" gives assets to another person known as the "trustee" with instructions to use the assets for the benefit of a third person known as the "beneficiary". The assets placed in trust are called the "pri…

August 10, 1993. 1. For purposes of determining an individual's eligibility under this chapter, subject to subsection 4, this section applies to a trust established by the individual after August 10, 1993. Subsections 1, 2, and 3 of section 75-02-02.1-31 apply to this section. 2.…

It is not always possible to determine the value of assets with absolute certainty, but it is necessary to determine a value in order to determine eligibility. The valuation must be based on reasonably reliable information. It is the responsibility of the applicant or recipient, …

Repealed effective February 1, 1996.

Repealed effective January 1, 2024.

1. This section applies to transfers of income or assets made on or after February 8, 2006. 2. Except as provided in subsections 7 and 16, an individual is ineligible for skilled nursing care, swing-bed, or home and community-based benefits if the individual or the individual's s…

1. All income that is actually available shall be considered. Income is actually available when it is at the disposal of an applicant, recipient, or responsible relative; when the applicant, recipient, or responsible relative has a legal interest in a liquidated sum and has the l…