Eligibility Factors 510-05

Definitions 510-05-05

(Revised 1/1/2025 ML #3916)

(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 Individual

An individual required to be budgeted using ACA MAGI-based methodologies as defined in Service Chapter 510-03, Eligibility Factors for ACA (Affordable Care Act) Medicaid. Individuals include:

1. Parents and Caretakers of deprived children and their spouses

2. Parents and Caretaker Relatives of deprived children and their spouses who were eligible under the Parents and Caretaker Relatives and their spouses group 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 group due to increased earned income or hours of employment, and their dependent children for up to 12 months (Transitional);

3. Parents and Caretaker Relatives of deprived children and their spouses who were eligible under the Parents and Caretaker Relative and their spouses group 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 group due to increased alimony or spousal support and their dependent children for up to 4 months (Extended)(no budget test);

4. Pregnant Women

5. Pregnant women who applied for and were eligible for Medicaid during pregnancy continue to be eligible for twelve (12) months, beginning on the last day of the pregnancy, and through the last day of the twelfth month;

6. 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;

7. Children Ages 0 through 18 (through the month the child turns 19)

8. Single adults ages 19 through 64 not eligible for Medicare (Adult Expansion group)

Note: This may include SSI recipients who fail eligibility under Non-ACA Medicaid, other disabled individuals who fail the Medicaid asset limits and individuals who are disabled with a large client share.

9. Individuals under age 19 who meet the financial requirements of the Children’s group 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).

10. Individuals who are not eligible as an ACA individual defined in #’s 1 thru 7 above, who were in North Dakota foster care and receiving Medicaid (Title IV-E, state-funded (non-IV-E, tribal or Unaccompanied Refugee Minor) and on ND Medicaid in the month they turned age 18 must be covered through the month in which they turn age 26 with no budget test.

Attorney in Fact

An agent authorized to act on behalf of another person, but not necessarily authorized to practice law, e.g. a person authorized to act by a power of attorney. An attorney in fact is a fiduciary.

Blind

Has the same meaning as the term has when used by the social security administration in determining blindness for Titles II and XVI.

Contiguous

Real property, which is not separated by other real property owned by others. Roads and other public rights-of-way, which run through the property, even if owned by others, do not affect the property's contiguity.

County agency

The county social service board.

Department

The North Dakota Department Health and Human Services.

Disabled

Has the same meaning as the term has when used by the Social Security Administration in determining disability for Titles II and XVI.

Disabled adult child

A disabled or blind person over the age of twenty-one who became blind or disabled before age twenty-two.

Fee for Service

The most common method of Medicaid payments under which Medicaid pays providers directly for their services. It is a specific dollar limit that Medicaid pays for a specific service.

Full calendar month

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.

Good faith effort to sell

An honest effort to sell in a manner which is reasonably calculated to induce a willing buyer to believe that the property offered for sale is actually for sale at a fair price. A good faith effort to sell includes, at a minimum, making the offer at a price based on an appraisal, a market analysis by a realtor, or another method which produces an accurate reflection of fair market value, in the following manner:

1. To any co-owner, joint owner, possessor, or occupier of the property, and, if no buyer is thereby secured;
2. To the regular market for such property, if any regular market exists, or, if no regular market exists (a realtor is considered the regular market for real estate, including mobile homes);
3. By public advertisement for sale in a newspaper of general circulation, the circulation area of which includes the location of any property resource offered for sale, which advertisement was published successively for two weeks if the newspaper is a weekly publication and for one week if the newspaper is a daily publication, and which includes the selling price, a plain and accurate description of the property and the name, address, and telephone number of a person who will answer inquiries and receive offers.

Home and community based services

Services, provided under a waiver secured from the United States Department of Health and Human Services, that are:

1. Not otherwise available under Medicaid; and
2. Furnished only to individuals who, but for the provision of such services, would require the level of care provided in a hospital, nursing facility, or intermediate care facility for the intellectually disabled (ICF-ID).

Inmate

A person who has been sentenced, placed, committed, admitted, or otherwise required or allowed to live in a public institution, and who has not subsequently been unconditionally released or discharged from the institution.

Institutionalized individual

An individual who is an inpatient in a nursing facility, an ICF/ID, 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.

Irrevocable Itemized Funeral Contract

A fully executed document between two or more parties that has been signed and dated. The document must contain an itemized listing of funerary components agreed upon between the parties. Terms and conditions must be irrevocable and cannot be changed, except for the ability to transfer to another licensed funeral establishment or cemetery association.

Living independently

In reference to a single individual who is blind or disabled under age eighteen, a status which arises in any of the following circumstances:

1. The individual has served a tour of active duty with the armed services of the United States and lives separately and apart from the parent.
2. The individual has married, even though that marriage may have ended through divorce or separation. A marriage ended by legal annulment is treated as if the marriage never occurred.
3. The individual has lived separately and apart from both parents for at least three consecutive full calendar months after the date the individual left the parental home, continues to live separately and apart from both parents, and has received no support or assistance from either parent while living separately and apart. Periods in which a child is included in the parent's Medicaid unit are deemed to be periods in which the parents are providing support.  Providing health insurance coverage or paying court ordered child support payments for a child is not considered to be providing support or assistance. For purposes of this paragraph, periods when the individual is attending an educational or training facility, receiving care in a specialized facility, or is an institutionalized person are deemed to be periods when the individual was living with a parent, unless the individual had already established that the individual was living independently.
4. The individual has left foster care and established a living arrangement separate and apart from either parent and received no support or assistance from either parent. Providing health insurance coverage or paying court ordered child support payments for a child is not considered to be providing support or assistance.
5. The individual lives separately and apart from both parents due to incest, continues to live separately and apart from both parents, and receives no support or assistance from either parent while living separately and apart. Providing health insurance coverage for a child is not considered to be providing support or assistance.

Long term care, (LTC)/ Nursing Care Services

Refers to care provided in a medical institution, a nursing facility, the State Hospital, an Intermediate Care Facility (IMD), a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for the intellectually disabled (ICF-ID), a swing bed, or in a home and community based setting.

MAGI Household

A household required to be budgeted using MAGI methodologies. This includes the Adult Expansion Group, Parents, Caretaker Relatives, and their Spouses, Children, and Pregnant Women.

Medicaid

A program implemented pursuant to North Dakota Century Code chapter 50-24.1 and title XIX of the Act.

Medicare cost sharing

Refers to the following costs:

1. Medicare part A premiums (hospital); and Medicare part B premiums (doctor);
2. Medicare coinsurance (Including coinsurance amounts for certain services and the remaining 20% after Medicare pays 80% on the approved amount of the bill.); and
3. Medicare deductibles.

Medicare Part A Conditional Enrollment

Medicare Part A Conditional Enrollment Medicare Part A conditional enrollment allows an individual to apply for premium-Medicare Part A at Social Security on the condition he/she only wants coverage if the State approves their QMB application. Medicare Part A start date will be the date the State can start paying the Medicare Part A.

No Wrong Door

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.

Non-ACA Individual

Individuals who are required to be budgeted using Non-ACA Medicaid methodologies as defined in Service Chapter 510-05, Eligibility Factors for Non-ACA Medicaid. Such Individuals include:

1. Aged and disabled individuals who choose to be treated as aged or disabled, including individuals eligible for Workers with Disabilities and Children with Disabilities

2. Individuals eligible for:
   1. HCBS or Waivered Services
   2. Workers with Disabilities
   3. Children with Disabilities

3. MEDICARE recipients who choose to be treated as aged or disabled,

4. Individuals who request or are eligible for coverage under the Medicare Savings Programs,

5. Individuals who request eligibility under Spousal Impoverishment,

6. SSI individuals who pass the Medicaid asset test,

7. Individuals who are eligible under the Breast and Cervical Cancer Early Detection.

8. Individuals who are eligible under Refugee Medical Assistance.

9. Individuals who are eligible under Title IV-E and Non IV-E Subsidized Adoption Program

10. Individuals who are eligible under Title IV-E foster care,

11. Individuals who are eligible under Title IV-E Kinship Guardianship Program.

Non-ACA Medicaid

The Medicaid policies and procedures used to determine eligibility for individuals whose eligibility cannot be determined based on methodologies of the Affordable Care Act (ACA).

Optional Children's Group

Coverage for children up to age 19 who do not have other health insurance coverage.

Public institution

An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. The term “public institution” does not include:

1. A medical institution as defined in 42 CFR §435.1010;

2. An intermediate care facility as defined in 42 CFR §§440.140 and 440.150;

3. A publicly operated community residence that serves no more than 16 residents, as defined in 20 CFR §416.231 (b)(6)(i); or

4. A child-care institution as defined in 42 CFR §435.1010 with respect to:

   1. Children for whom foster care maintenance payments are made under title IV- E of the Act; and

   2. Children receiving AFDC—foster care under title IV-A of the Act.

Remedial services

Those services, provided in specialized facilities, which produce the maximum reduction of physical or mental disability and restoration of the residents to the best possible level of functioning. Remedial services do not include room and board expenses.

Residing in the home

Refers to individuals who are physically present, individuals who are temporarily absent, or individuals attending educational facilities.

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.

Specialized facility

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.

Spouse

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:

1. The Marriage was legally performed in another state;
2. 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);
3. The marriage occurred in another country and the marriage was considered valid according to the law of the country were the marriage took place.
4. Polygamous marriages are not recognized in 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.

SSI Buy-In

A program under Section 1843 of the Social Security Act in which Medicaid eligible recipients who are in receipt of Supplemental Security income (SSI) benefits and who are eligible for Medicare Part B, are eligible for the state to pay the monthly Medicare Part B premium.

State agency

The North Dakota Department of Health and Human Services.

Student

An individual who regularly attends and makes satisfactory progress in elementary or secondary school, General Equivalency Diploma (GED) classes, a home-school program recognized or supervised by the student’s state or local school district, college, university, or vocational training, including summer vacation periods if the individual intends to return to school in the fall. A full-time student is a person who attends school on a schedule equal to a full curriculum.

(TANF) Temporary Assistance For Needy Families

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

Title II of the Social Security Act (Social Security benefits).

Title IV-D

Title IV-D of the Social Security Act (Child Support).

Title IV-E

Title IV-E of the Social Security Act (Foster Care and Adoption Assistance).

Title XVI

Title XVI of the Social Security Act (Supplemental Security Income (SSI)).

Title XIX

Title XIX of the Social Security Act (Medicaid).

Title XXI

For eligibility months prior to January 1, 2020. Title XXI of 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).

Unconditionally Released

Unconditionally released means released, discharged, or otherwise allowed or required to leave the institution under circumstances such that a return to the institution cannot be required by the operator of the institution.