Coverage Groups 510-05-30

Groups Covered Under Medicaid 510-05-30-05

(Revised 2/04 ML #2900)

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(N.D.A.C. Section 75-02-02.1-05)

1. The categorically needy group includes:

• Children for whom adoption assistance maintenance payments are made under title IV-E.
• Children for whom foster care maintenance payments are made under title IV-E.
• Children who are living in North Dakota and are receiving title IV-E adoption assistance payments from another state.
• Children in a foster care placement in North Dakota and receiving a title IV-E foster care payment from another state.
• Caretakers, pregnant women, and children who meet the Family Coverage (section 1931 of the Act) eligibility criteria.
• Families who were eligible under the Family Coverage group in at least three of the six months immediately preceding the month in which the family became ineligible because of the caretaker relative’s hours or earnings from employment.
• Families who were eligible under the Family Coverage group in at least three of the six months immediately preceding the month in which they became ineligible as a result, wholly or partly, of the collection or increased collection of child or spousal support continue eligible for Medicaid for four calendar months.
• Eligible pregnant women who applied for and were categorically needy eligible for Medicaid during pregnancy continue to be eligible for sixty days, beginning on the last day of pregnancy, and for the remaining days of the month in which the sixtieth day falls.
• Children born to categorically needy eligible pregnant women who applied for and were found eligible for Medicaid on or before the day of the child's birth, for sixty days, beginning on the day of the child's birth and for the remaining days of the month in which the sixtieth day falls.
• Aged, blind, or disabled individuals who are receiving SSI payments or who appear on the state data exchange (SDX) as zero payment as a result of SSI’s recovery of an overpayment or who are suspended because the individuals do not have a protective payee, provided that the more restrictive Medicaid criteria is met.  
• Individuals who meet the more restrictive requirements of the Medicaid program and qualify for SSI benefits under section 1619(a) or 1619(b) of the Act.

Section 1619 of the Social Security Act provides continued Medicaid eligibility for certain disabled or blind persons who lose SSI benefits because they are performing substantial gainful activity. These benefits may continue beyond the age of sixty-five.

Section 1619a: These individuals continue to receive a special SSI payment, and may continue to be eligible for Medicaid as categorically needy if all other eligibility factors are met.

Section 1619b: These are blind and disabled individuals who lose SSI benefits because of their earnings, and whose ability to continue employment or self-employment would be seriously impaired by termination of Medicaid and whose earnings are insufficient to provide the reasonable equivalent of the cash payments and Medicaid benefits (and in the case of determinations made under this law before October 1, 1981, Title XX Social Services) which would be available to them in the absence of such earnings. These individuals will not receive any cash assistance but may continue to be eligible for Medicaid as categorically needy if all other eligibility factors are met. They also will continue to be eligible for coverage of their Medicare Part B premium (Buy-In).

2. The optional categorically needy group includes:

• Individuals under age twenty-one whose income is within the Family Coverage group levels, but who are not otherwise eligible under the Family Coverage group.
• Individuals under age twenty-one who are residing in adoptive homes and who have been determined under the state-subsidized adoption program to be eligible as provided in state law and in accordance with the requirements of the department.
• Individuals under age twenty-one who meet the financial requirements of the Family Coverage 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.
• Uninsured women under age 65, who are not otherwise eligible for Medicaid, who have been screened for breast and cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program and need treatment for breast or cervical cancer, including a pre-cancerous condition of the breast or cervix, and whose family income is at or below 200% of the poverty level. Effective July 1, 2001.

3. The medically needy group includes:

• Eligible caretaker relatives and individuals under age twenty-one in families with deprived children who do not meet income or age Family Coverage group requirements, but meet medically needy income standards.
• Individuals under the age of twenty-one who qualify for and require medical services on the basis of insufficient income, but who do not qualify as categorically needy including children in common in stepparent families who are ineligible under the Family Coverage group and foster care children who do not qualify as categorically needy or optional categorically needy.
• Pregnant women whose pregnancy has been medically verified and who qualify on the basis of financial eligibility.
• Eligible pregnant women who applied for Medicaid during pregnancy, and for whom recipient liability for the month was met no later than on the date each pregnancy ends, continue to be eligible without regard to financial circumstances, for sixty days, beginning on the last day of pregnancy, and for the remaining days of the month in which the sixtieth day falls.
• Children born to eligible pregnant women who have applied for and been found eligible for Medicaid on or before the day of the child's birth, for sixty days, beginning on the day of the child's birth and for the remaining days of the month in which the sixtieth day falls.
• Aged, blind, or disabled individuals who are not in receipt of SSI benefits.
• Individuals under age twenty-one who have been certified as needing the service, or age sixty-five and over in the state hospital who qualify on the basis of financial eligibility.

4. The poverty level group includes:

• Pregnant women whose pregnancy has been medically verified and who meet the nonfinancial requirements of the Medicaid program and whose family income is at or below one hundred thirty-three percent of the poverty level. Effective April 1, 1990 (75% of the poverty level from July 1, 1988, through March 31, 1990).
• Eligible pregnant women who applied for and were poverty level eligible for Medicaid during their pregnancy continue to be eligible for sixty days, beginning on the last day of pregnancy, and for the remaining days of the month in which the sixtieth day falls.
• Children under the age of six who meet the nonfinancial requirements of the Medicaid program and whose family income is at or below one hundred thirty-three percent of the poverty level. Effective April 1, 1990 (75% of the poverty level from July 1, 1988, through March 31, 1990, for children up to the age of one).
• Children, age six to nineteen, who meet the nonfinancial requirements of the Medicaid program and whose family income is at or below one hundred percent of the poverty level. Effective July 1, 1991.
• Qualified Medicare Beneficiaries (QMB), who are aged, blind, or disabled individuals entitled to Medicare part A benefits, and who meet the medically needy nonfinancial criteria, have assets no greater than twice the SSI resource standards, and have income at or below one hundred percent of the poverty level. Effective January 1, 1991 (90% of the poverty level from April 1, 1990, through December 31, 1990).
• Qualified Disabled and Working Individuals (QDWI), who are individuals entitled to enroll in Medicare part A under section 1818a of the Social Security Act, and who have income no greater than two hundred percent of the poverty level, have assets no greater than twice the SSI resource standard, and who are not eligible for Medicaid under any other provision. The SSI program income and asset methodologies must be used and none of the more restrictive 209b criteria may be applied. (The eligibility determination for this group will temporarily be done by the Medicaid Eligibility Division of the North Dakota Department of Human Services.) Coverage for this group began July 1, 1990.
• Special Low-Income Medicare Beneficiaries (SLMB), who are aged, blind, or disabled individuals entitled to Medicare Part A benefits, who meet the medically needy nonfinancial criteria, have assets no greater than twice the SSI resource standards, and have income above one hundred percent of the poverty level but not in excess of one hundred twenty percent of the poverty level. Effective January 1, 1993.
• Qualifying Individuals (QI-1), who are aged, blind, or disabled individuals entitled to Medicare Part A benefits, who meet the medically needy nonfinancial criteria, have assets no greater than twice the SSI resource standards, have income above 120% of the poverty level, but not in excess of 135% of the poverty level, and are not eligible for Medicaid under any other provision. Effective January 1, 1998.