North Dakota Administrative Code

No payment will be made for inpatient rehabilitation services provided to a recipient age twenty-one or older, in a distinct part unit of a hospital, except for the first thirty days of each admission. History: Effective January 1, 1997. General Authority: NDCC 50-24.1-04 Law Imp…

1. No payment will be made for single crowns on posterior teeth for individuals twenty-one years of age and older except for stainless steel crowns. Payment for other crowns may be allowed by the department for the anterior portion of the mouth for adults if the crown is necessar…

1. Covered medical or remedial services or supplies are medically necessary when determined so by the medical provider unless the department has: a. Denied a prior treatment authorization request to provide the service; 13 b. Imposed a limit that has been exceeded; c. Imposed a c…

1. No payment for personal care services may be made unless an assessment of the recipient is made by the department or the department's designee and the recipient is determined to be impaired in at least one of the activities of daily living of bathing, dressing, eating, inconti…

twenty-one. 1. Inpatient psychiatric services for individuals under age twenty-one must be provided: a. Under the direction of a physician; b. By a psychiatric hospital or an inpatient psychiatric program in a hospital, accredited by the joint commission on accreditation of healt…

Repealed effective January 1, 2022.

1. For purposes of this section: a. "Clinically managed high-intensity residential care" means services for treatment of substance use disorder as prescribed in chapters 75-09.1-03 and 75-09.1-03.1. b. "Clinically managed low-intensity residential care" means services for treatme…

1. For purposes of this section: a. "Level A" means an intense level of partial hospitalization psychiatric services which provide treatment for an individual by at least three licensed health care professionals under the supervision of a licensed physician for at least four hour…

1. For purposes of this section: a. "Coordinated services" means the process used to limit a recipient's medical care and treatment to a single physician or other provider to prevent the continued misutilization of services. b. "Coordinated services provider" means a physician, n…

1. For purposes of this section, "screening" means the initial evaluation of an individual, intended to determine suitability for a particular medical treatment modality. 2. The provider of emergency services shall assure that a recipient is referred to the appropriate health del…

1. For purposes of this section: a. "Out-of-state care" means care or services furnished by any individual, entity, or facility, pursuant to a provider agreement with the department, at a site located more than fifty statute miles [80.45 kilometers] from the nearest North Dakota …

1. For purposes of this section, "travel expenses" means fares, mileage, meals, lodging, and driver and attendant care. 2. General requirements. a. A transportation service provider shall be enrolled as a provider in the Medicaid program and children's health insurance program an…

Limitations. 1. For purposes of this section: 24 a. "Long-term care facility" means a nursing facility, intermediate care facility for individuals with intellectual disabilities, or swing-bed facility; and b. "Medical center city" means Bismarck, Devils Lake, Dickinson, Fargo, Gr…

Repealed effective April 1, 2020. 25

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed. 26

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

Repealed effective December 1, 1991, unless chapter 75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and is not affirmed.

1. Prior authorization means a process requiring the prescriber or the dispenser to verify with the department or the department's contractor that proposed medical use of a particular drug for a Medicaid program or children's health insurance program recipient meets predetermined…

1. The department shall implement a prospective and retrospective drug use review program for outpatient prescription drugs and determine which drugs shall be subject to prior authorization before payment will be approved. The department shall consider the advice and recommendati…

Repealed effective January 1, 2024. 30

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…