Material Transmitted and Purpose – Transmitted with this Manual Letter are changes to Service Chapter 510-05 – Medicaid Eligibility Factors.  This manual letter supersedes IM #4996 Failure to Provide Verification of Identity and Amended IM# 4998 Average Cost of Nursing Facility Care.  In addition, there are miscellaneous updates to clarify policy as well as to integrate the Federal Poverty Levels for 2007.  Effective April 1, 2007.

Definitions 510-05-05

The definition of Living Independently has been updated to clarify that a blind or disabled individual eighteen years of age or older is not subject to the living independently provisions.  It has also been updated to clarify that 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. The definition of Temporary Assistance for Needy Families has been updated to include Diversion Assistance.

For the purpose of this chapter:
Living independently
In reference to a single individual under the age of twenty-one, or if 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.

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 and Diversion Assistance.

Nondiscrimination in Federally Assisted Programs 510-05-10-10

This section has been updated to include the telephone and TDD numbers for those who wish to file a discrimination complaint.

The Department of Human Services makes available all services and assistance without regard to race, color, religion, national origin, age, sex, political beliefs, disability, or status with respect to marriage or public assistance, in accordance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990, and the North Dakota Human Rights Act of 1983. Persons who contract with or receive funds to provide services for the North Dakota Department of Human Services are obligated to abide by the provisions of these laws. The Department of Human Services makes its programs accessible to persons with disabilities. Persons needing accommodation or who have questions or complaints regarding the provisions of services according to these Acts may contact the Civil Rights Officer, North Dakota Department of Human Services, Judicial Wing, State Capitol, 600 E. Boulevard, Bismarck, ND 58505 or the US Department of Health and Human Services, Office for Civil Rights, Region VIII, Federal Office Building, 1961 Stout Street, Suite 1426, Denver, Colorado 80294. or call 1-800-368-1018 or 303-844-2024 (voice) or 303-844-3439 (TDD).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

Home and Community Based Services (HCBS) 
510-05-15-05
Subsections (4) and (5) have been deleted and a new subsection (4) added to reflect the merger of the Waiver for the Aged and Disabled and the Waiver for the Traumatic Brain Injured into the new Medicaid Waiver for Home and Community Based Services.
 
The Medicaid program provides home and community based services (HCBS) to eligible individuals who have been screened as requiring nursing care services but who choose to receive those services in the community. Eligibility for individuals with an ineligible community spouse may be determined using the Spousal Impoverishment Provision found at 05-65. Services may be provided through one of the following waivers:
1.	Waiver for Developmentally Disabled:  Services are provided to individuals who meet the developmental disability criteria and who are screened intermediate care-mentally retarded. These individuals generally meet the disability criteria of the Social Security Administration; however, the few who do not may still be eligible for these wavered services. (Began in 1981.)
2.	Waiver for Self Directed Supports for Families:  Allows families or individuals, where at least one individual, age 3 to age 21, meets the developmental disability criteria and requires long-term supports and services, to direct their own care and financial resources so the individual may remain in the home.  (Began July 1, 2006.)
3.	Waiver for Self Directed Supports for Adults:  Allows individuals, age 21 or over, who meet the developmental disability criteria and require long-term supports and services, to direct their own care and financial resources so the individual may remain in their own home.  (Began July 1, 2006.)
4.	Waiver for the Aged or Disabled: Services are provided to individuals who, from birth to age sixty-five meet the disability criteria of the Social Security Administration and to individuals sixty-five years of age and over. These individuals must be screened as requiring care in a nursing facility but choose to receive services in the community. (Began October 1, 1983.)      Medicaid Waiver for Home and Community Based Services:  Services are provided to individuals who meet the disability criteria of the Social Security Administration, or are at least 65 years of age who are screened as requiring care in a nursing facility, but choose to receive services in the community. As of April 1, 2007, this waiver merged the Waiver for the Aged or Disabled (which began October 1, 1983) and the Waiver for the Traumatic Brain Injured (which began in 1994).
5.	Waiver for the Traumatic Brain Injured: Services are provided to individuals between the ages of 18 and 65 who meet the criteria for traumatic Brain Injury and who are screened as requiring care in a nursing facility but choose to receive services in the community. These individuals must meet the disability criteria of the Social Security Administration. (Began in 1994.)

Groups Covered Under Medicaid 510-05-30-05
This section has been updated to include the requirement under Section 6065 of the Deficit Reduction Act as it applies to certain SSI beneficiaries.

1.	The categorically needy group includes:
j.	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 under age 21 who have been approved for SSI may be included beginning with the month of the SSI application. Individuals age 21 or older who have been approved for SSI may be included beginning the month following the month of SSI application.

Medicaid Unit 510-05-35-05

Subsections (2)(b) and (2)(e) were updated to reflect the policy change per IM 4996 "Failure to Provide Verification of Identity".
2.	An applicant or recipient who is also a caretaker of children under twenty-one years of age may select the children who will be included in the Medicaid unit. Anyone whose needs are included in the unit for any month is subject to all Medicaid requirements which may affect the unit. The financial responsibility of relatives must be considered with respect to all members of the assistance unit.
When a child is included in the Medicaid unit eligibility is pursued for the child unless:
a.	The child is eligible under the Healthy Steps Program;
b.	The child is an ineligible alien or the child's US citizenship has not been verified;          
c.	The child is ineligible due to no medical need (recipient liability exceeds need); or
d.	The child is receiving services in a Psychiatric Residential Treatment Facility (PRTF), or the state hospital, the Prairie at St. John's center, the Stadter Psychiatric Center, or any other institution for mental disease (IMD), and has not obtained certification of need for services in that facility; or
e.	The child's identity has not been verified.

Asset Considerations 510-05-70-10

Subsection 6 was added to include the policy regarding the treatment of assets transferred by someone with a fiduciary responsibility. Such assets must be considered an available asset and not as a disqualifying transfer. 
 
6.   Transfers of an applicant or recipient’s property made by someone with a confidential relationship, whether to themselves or to a third party, for which 100% of fair market value was not received, are not considered to be transfers without adequate compensation when an applicant or recipient is not competent, or if competent, does not approve.  In these situations, the uncompensated value is considered to be available to the applicant or recipient because the person who made the transfer must account for and replace any amounts lost by the applicant or recipient. 

See the definition for "Someone in a Confidential Relationship," 510-05-80-05, for additional information.
 
Treatment of Conservation Reserve Program Property and Payments 510-05-75-10

Subsection (4) (b) has been updated to reflect the change in how the amount of a disqualifying transfer is calculated for CRP due to the Deficit Reduction Act.  The changes to this section were inadvertently omitted in Manual Letter 3047.

4.	Disqualifying transfer of CRP income.

b.	If it is determined that a disqualifying transfer of income did occur, the amount of the disqualifying transfer is calculated by establishing the value of the payments transferred.  and determining the discounted value of those payments. A request for a discounted value, accompanied by the contract document and information regarding the amount of the transfer, may be sent to the Legal Advisory Unit. Following is an example showing how a disqualifying transfer would be applied.
Example: Property was put into a CRP contract within the look back period. A tenant was farming the property in the year before the contract was signed. The contract pays $10,000 per year and the tenant receives 50% of the payment. There is nothing showing that the tenant should receive more than 10% of the payment and the landlord is applying for Medicaid. The tenant receives $5000 of the payment each year, but should only receive $1000. The amount of the disqualifying transfer, which occurred when the contract was signed is $4000 multiplied by the number of years (10) in the contract, for a total of $40,000. This amount is discounted giving an actual transfer amount of $22,400.   

Disqualifying Transfers 510-05-80
Definitions 510-05-80-05
This subsection (9) has been updated to include the 2007 average cost of Nursing Home Care.  This supersedes Amended IM 4998.
9. 	The average cost of nursing facility care is:
 
Year	Daily Rate	Monthly Rate	
2007	159.96	4865	
 
Disregarded Income 510-05-85-30
This section has been updated to delete the reference to Diversion Assistance payments. Since Diversion Assistance has been added to the definition of TANF, the reference here is redundant.
2.	Temporary Assistance for Needy Families (TANF) benefit and support services payments, or Diversion Assistance payments made by the Department or another state; 

Income Levels 510-05-85-40

The income levels have been changed to reflect the increases in the Federal Poverty Level effective April 2007.
2.	Medically needy income levels.
d.	Family member income level. The income level for each ineligible family member in a spousal impoverishment case is $550 $571 effective April 2007    2006 ($534 $550 effective April 2006). 2005).   
3.	Poverty income levels.
a.	Qualified Medicare Beneficiaries and Children age six to nineteen. The income level is equal to one hundred percent of the poverty level applicable to a family of the size involved.
 
Number of Persons	Monthly Income Level	
1	 $ 817  $ 851	
2	   1100  1141	
3	   1384  1431	
4	   1667  1721	
5	   1950  2011	
6	   2234  2301	
7	   2517  2591	
8	   2800  2881	
Effective April 1, 2006    2007	

For each person in the Medicaid unit above eight, add $284 290 to the monthly amount.
b.	Specified Low-Income Medicare Beneficiaries. The income level is equal to one hundred twenty percent of the poverty level applicable to a family of the size involved. This is the maximum income level for SLMBs. Applicants or recipients who have income at or below one hundred percent of the poverty level are not eligible as a SLMB, but must be a QMB. These income levels apply regardless of living arrangements (i.e., in home or in a nursing facility. . .).

Number of Persons	Monthly Income Levels	
1	 $ 980  $ 1021	
2	   1320   1369	
3	   1660    1717	
4	   2000   2065	
5	   2340   2413	
6	   2680   2761	
7	   3020   3109	
8	   3360   3457	
Effective April 1, 2006   2007	
For each person in the Medicaid unit above eight, add $340 348 to the monthly amount.
c.	Pregnant women and children under age six. The income level is equal to one hundred and thirty-three percent of the poverty level, applicable to a family of the size involved. The family size is increased for each unborn when determining the appropriate family size.
Number of Persons	Monthly Income Level	
1	 $1087  $1132	
2	 1463   1518	
3	 1840   1903	
4	 2217   2289	
5	 2594   2675	
6	 2971   3061	
7	 3348   3446	
8	 3724  3832	
Effective April 1, 2006  2007	
 
For each person in the Medicaid unit above eight, add $377 386 to the monthly amount.
d.	Qualifying Individuals. The income level is equal to 135% of the poverty level applicable to a family of the size involved. This is the maximum income level for QIs. Applicants or recipients who have income at or below 120% of the poverty level are not eligible as a QI, but may be eligible as a SLMB or QMB. These income levels apply regardless of living arrangements (i.e., in home or in a nursing facility...).
 
Number of Persons	Monthly Income Level	
1	 $ 1103   $1149	
2	   1485    1541	
3	   1868    1932	
4	   2250    2324	
5	   2633   2715	
6	   3015    3107	
7	   3398    3498	
8	   3780    3890	
Effective April 1, 2006  2007	
For each person in the Medicaid unit above eight, add $383 392 to the monthly amount.

e.	Transitional Medicaid Benefits. The income level is equal to one hundred and eighty-five percent of the poverty level applicable to a family of the size involved.
Number of Persons	Monthly Income Level	
1	 $1511     1575	
2	   2035    2111	
3	   2560    2648	
4	   3084    3184	
5	   3608    3721	
6	   4132    4257	
7	   4656    4794	
8	   5180    5330	
Effective April 1, 2006    2007	
For each person in the Medicaid unit above eight, add $525 $537 to the monthly amount.

f.	Workers with Disabilities.  The income level is equal to two hundred and twenty-five percent of the poverty level applicable to a family of the size involved.

Number of Persons	Monthly Income Level	
1	 $1837   $1914	
2	   2475    2566	
3	   3112     3219	
4	   3750    3871	
5	   4387    4524	
6	   5025    5176	
7	   5662   5829	
8	   6300    6481	
Effective April 1, 2006   2007	
For each person in the Medicaid unit above eight, add $637 $652 to the monthly amount.

Budgeting Procedures for SSI Recipients 510-05-90-45
This section has been updated to include the requirement under Section 6065 of the Deficit Reduction Act as it applies to certain SSI beneficiaries.

For aged, blind, or disabled individuals who are receiving SSI beneficiaries, including those receiving SSI benefits as 1619a or 1619b, categorically needy SSI beneficiaries, the following procedures apply: