Eligibility Factors for ACA (Affordable Care Act) Medicaid 510-03
Definitions 510-03-05
(Revised 3/7/2024 ML #3812)
N.D.A.C. Section 75-02-02.1-01)
For the purpose of this chapter:
ACA
Affordable Care Act, also known as the Patient Protection and Affordable Care Act of 2010, which was signed into law by President Obama on March 23, 2010.
ACA (Affordable Care Act) Medicaid
The Medicaid policies and procedures used to determine eligibility for individuals covered under the Affordable Care Act of 2010, which became effective January 1, 2014.
ACA Individual
An individual required to be budgeted using MAGI methodologies as defined in Service Chapter 510-03, Eligibility Factors for ACA (Affordable Care Act) Medicaid. Individuals include:
- Parents and Caretaker/relatives of deprived children up to age 18 (through the month the child attains age 18) and their spouses;
- Parents and Caretaker Relatives of deprived children and their spouses 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);
- Parents and Caretaker Relatives of deprived children and their spouses 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);
- Pregnant Women;
- 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.
- 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;
- Children Ages 0 through 18 (through the month the child turns 19);
- Adults ages 19 through 64 (Adult Expansion Group)
Note: This may include SSI recipients and other disabled individuals who fail the Medicaid asset limits and individuals who are disabled with a large client share;
- Individuals under age 19 who meet the 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);
- Individuals who are not eligible as an ACA Individual defined in #’s 1 thru 7 above, who were in North Dakota foster care (Title IV-E, state-funded non-IV-E) tribal or Unaccompanied Refugee Minor and on Medicaid, in any state, in the month they turned age 18 must be covered through the month in which they turn age 26 with no budget test.
ACA Medicaid Household
One or more individuals, whose countable income and allowable expense are used to determine eligibility under ACA Medicaid.
- Each eligible individual must have their ACA Medicaid Household determined based on whether the individual is a tax filer, a tax dependent, or an adult or child non-filer as well as the individual’s relationship to those with whom the individual resides.
The amount that displays on the bottom line of the front page of IRS Form 1040. This is also a line on the 1040A.
Individuals age 19 through 64 and who are not eligible for Medicare or Medicaid under other categories. As of January 1, 2014, North Dakota Medicaid is expanded to cover these individuals. Some individuals, including individuals found to be medically frail, will be covered under an Alternative Benefit Plan (ABP).
Advance Payments of the Premium Tax Credit (APTC)
Individuals who are not eligible for Medicaid under the Affordable Care Act, may be eligible for tax credits for the health care insurance premiums they pay out of pocket.
Alternative Benefit Plan (ABP)
Formerly known as Medicaid Benchmark or Benchmark Equivalent Plans, Alternative Benefit Plans must cover the 10 Essential Health Benefits (EHB) described in section 1302(b) of the Affordable Care Act. Individuals in the new adult eligibility (Expansion) group will receive benefits through an Alternative Benefit Plan unless they are determined to be medically frail.
The county social service board.
The North Dakota Department of Human Services.
Starting in 2014, a set of health care service categories that must be covered by insurance policies in order to be certified and offered in the Health Insurance Marketplace by States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid. Essential health benefits must include items and services within at least 10 specified categories. The 10 categories are:
- Ambulatory patient services;
- Emergency services;
- Hospitalization;
- Maternity and newborn care;
- Mental health and substance use disorder services, including behavioral health treatment;
- Prescription drugs;
- Rehabilitative and habilitative services and devices;
- Laboratory services;
- Preventive and wellness services and chronic disease management; and
- Pediatric services, including oral and vision care.
Federally Facilitated marketplace (FFM)
The web portal through which Americans may choose a qualified health plan, and be assessed for possible eligibility for Medicaid, or Advance Premium Tax Credits (APTC).
The most common method of Medicaid payments under which Medicaid pays providers directly for their services. Medicaid pays a specific dollar limit for a specific service.
The period which begins at midnight on the last day of the previous month and ends at midnight on the last day of the month under consideration.
An individual who is an inpatient in a nursing facility, an ICF/IID, the State Hospital, an intermediate care facility for mental disease (IMD), a Psychiatric Residential Treatment Facility (PRTF), or who receives swing bed care in a hospital.
‘Living with’ means those individuals who reside together as one household. Individuals who are out of the household temporarily for health, educational, training or employment purposes are considered to be ‘living with’ the household.
- Other than the above, individuals who have moved away with the intent not to return to live in the household are not considered to be ‘living with’ the household. This includes a child, who moved away with the intent not to return, who remains on their parents’ health insurance coverage or whose parents are paying court ordered child support.
Refers to services received in a nursing facility, the State Hospital, an intermediate care facility for mental disease (IMD), a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a swing bed when the individual in the facility is screened or certified as requiring the services provided in the facility.
The method of determining eligibility for Medicaid that generally follows Modified Adjusted Gross Income rules. It is not a line on a tax return, rather a combination of household and income rules.
A program implemented pursuant to North Dakota Century Code chapter 50-24.1 and Title XIX of the Act.
Under the Affordable Care Act, recipients covered under the Adult Expansion Group, who request to be considered for coverage as ‘medically frail’ and have the choice to be provided coverage similar to that in the Medicaid state plan.
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act (ACA). This includes individual market policies, job-based coverage, Medicare, Medicaid, TRICARE and certain other coverage.
Modified Adjusted Gross Income (MAGI)
Income calculated using the same financial methodologies used to determine modified adjusted gross income as defined in Section 36B(d)(2)(B) of the Internal Revenue Code, with exceptions. Adjusted Gross Income from Form 1040 plus tax-exempt interest, tax-exempt Social Security Benefits, and any foreign earned income excluded from taxes.
The federal mandate that allows individuals to apply for Medicaid through any means, may be through the Federal Facilitated Marketplace, the State eligibility portal, by telephone, through the OASYS application, by FAX or in-person.
Individuals who are required to be budgeted using Non-ACA methodologies as defined in Service Chapter 510-05, Eligibility Factors for Non-ACA Medicaid. These include:
- Aged, blind and disabled individuals who choose to be treated as aged or disabled, including individuals eligible for Workers with Disabilities and Children with Disabilities;
- Individuals qualifying as disabled under original Medicaid requirements
- Individuals receiving HCBS or Waivered Services
- Workers with Disabilities
- Children with Disabilities;
- MEDICARE recipients who choose to be treated as aged, blind or disabled;
- Individuals who request or are eligible for coverage under the Medicare Savings Programs;
- Individuals who request eligibility under Spousal Impoverishment;
- SSI individuals who pass the Medicaid asset test;
- Individuals who are eligible under the Medicaid Breast and Cervical Cancer Early Detection Program;
Note: If eligible for Medicaid Expansion, the individual may choose coverage under Traditional Medicaid or through North Dakota’s insurance policy vendor. This would include individuals who are not eligible as Pregnant Women, Parent Caretaker, or as a disabled person.
- Individuals who are eligible under Refugee Medical Assistance;
- Individuals who are eligible under Title IV-E and Non IV-E Subsidized Adoption Program;
- Individuals who are eligible under Title IV-E foster care;
- Individuals who are eligible under Title IV-E Kinship Guardianship Program.
The Medicaid policies and procedures used to determine eligibility for individuals whose eligibility cannot be determined based on methodologies of the Affordable Care Act. These Medicaid policies can be found in Service Chapter 510-05.
An individual who neither files an income tax return nor is claimed as a dependent by another tax filer unless:
- They are claimed as a tax dependent by someone other than a spouse, or natural, adoptive or stepparent;
- They are a child under age 19 living with both parents but the parents do not file a joint return; or
- A child under age 19 who expects to be claimed by a non-custodial parent.
Care provided in a medical institution, a nursing facility, a swing bed, the state hospital, an intermediate care facility for mental disease (IMD), a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a home and community based services setting.
Coverage for children up to age 19 who do not have other health insurance coverage.
An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. (e.g. School for the Blind, School for the Deaf, North Dakota Youth Correctional Center, Women’s Correctional Center in New England, North Dakota State Penitentiary, Bismarck Transition Center, and city, county, or tribal jails.)
An insurance plan that is certified by the Health Insurance Marketplace which provides essential health benefits, follows established limits on cost-sharing (deductibles, copayments and out-of-pocket maximums) and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.
A residential facility, including a basic care facility, a licensed family foster care home for children or adults, a licensed group foster care home for children or adults, a transitional living facility, a facility established to provide quarters to clients of a sheltered workshop, and any other facility determined by the Department to be a provider of remedial services, but does not mean an acute care facility or a nursing facility. Examples of a specialized facility include a foster care bed at the Dakota Boys Ranch, Home on the Range, and Manchester House.
A spouse is a person who is legally married to another person.
For a marriage performed in North Dakota to be considered valid in North Dakota, couples are required to obtain a marriage license through the County Recorder’s Office.
Marriages that occur outside of North Dakota are considered valid in North Dakota if:
- The Marriage was legally performed in another state;
- The marriage is a common law marriage that occurred in another state and was considered a valid marriage in that state (the couple would be required to provide documentation verifying that the common-law marriage was considered valid by the state in which it took place);
- The marriage occurred in another country and the marriage was considered valid according to the law of the country were the marriage was contracted, unless the marriage violates the strong public policy of North Dakota.
- Polygamous marriages violate the strong public policy of North Dakota. In situations where polygamy has occurred, the first marriage is considered valid in North Dakota if the marriage meets the criteria in #1, 2 or 3 above. Any additional spouse (s) claimed after the first marriage are considered non-relatives.
The North Dakota Department of Human Services.
Supplemental Nutrition Assistance Program (SNAP)
Previously known as the Food Stamp Program, SNAP is a uniform nationwide program intended to promote the general welfare and safeguard the health and well-being of the nation's population by raising the levels of nutrition among low-income households.
An individual for whom another individual claims a deduction for a personal exemption under section 151 of the Internal Revenue Code for a taxable year.
An individual who is required to file, or who is not required to file but chooses to file a Federal Income Taxes based on IRS Regulations.
Temporary Assistance for Needy Families (TANF)
A program administered under North Dakota Century Code Chapter 50-09 and Title IV-A of the Social Security Act. References to TANF include TANF Kinship Care Assistance, Diversion Assistance, and Transition Assistance.
Title II of the Social Security Act (Social Security benefits).
Title IV-D of the Social Security Act (Child Support).
Title IV-E of the Social Security Act (Foster Care and Adoption Assistance).
Title XVI of the Social Security Act (Supplemental Security Income (SSI)).
Title XIX of the Social Security Act (Medicaid).
For eligibility months prior to January 1, 2020, Title XXI of the Social Security Act (Healthy Steps).
For eligibility months on or after January 1, 2020, Title XXI of the Social Security Act (Optional Children's Group).
