Par. 1.  Material Transmitted and Purpose – Transmitted with this Manual Letter are changes to Service Chapter 510-05 – Medicaid Eligibility Factors.  These include policy changes and policy updates as indicated, and miscellaneous spelling, grammar, punctuation and spacing corrections.  This also supersedes Amended IM 4988, and IM 4988, "Verification Requirements - Deficit Reduction Act of 2005"; Amended IM 5016, and IM 5016, "Temporary Assistance for Needy Families (TANF) Transition Assistance"; IM 4824, "Medicaid and Refugee Medical Assistance"; and IM 5020, "Acceptable forms of Verification for Canadian Indians".

510-05-05.  Definitions 

The definition of an "institutionalized individual' has been updated to include residents in a Psychiatric Residential Treatment Facility.   The definition of "Temporary Assistance for Needy Families" has been updated to include Transition Assistance per IM 5016.

Institutionalized individual
An individual who is an inpatient in a nursing facility, an ICF/MR, the State Hospital, the Prairie at St. John's center, the Stadter Psychiatric Center, an out-of-state institution for mental disease (IMD), the Anne Carlsen facility, a Psychiatric Residential Treatment Facility (PRTF), or who receives swing bed care in a hospital.

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 and Transition Assistance.

510-05-25-25.  Decision and Notice 

In Subsection 4(c), the word "mailed" is bolded and language has been added to emphasize that an adequate notice must be mailed no later than the date of action.

Subsection 4 (c) 

c.	Under the following circumstances a "Ten-Day Advance Notice" is not required; however, a notice containing the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested, must be mailed no later than the date of action (this may mean creating and sending the notice 1 to 5 days prior to the date of action):

510-05-35-40.  Age and Identity 
This section has been updated and rearranged to include the final rules regarding verification of identity as required by the Deficit Reduction Act.  Changes that were made since Amended IM 4988 include:
•	Under Secondary Verifications of Identity, the criterion, 'Native American Tribal Document' was deleted from the table by the final rule
•	A Third Level Verifications of Identity has been created--3 or more documents that together corroborate the identity -- to be used only as a last resort
•	Under Identity Verifications for Minor Children, clinic, doctor or hospital record has been added back to the listing of acceptable verifications
•	A new criterion which allows a residential care facility director or administrator to sign an affidavit for a disabled individual in an institutional care facility has been created
•	The identity affidavits have been made into SFN's and will soon be available on the eforms website
	
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 is eligible upon reaching age twenty-one remains eligible for Medicaid through the month in which the individual reaches that age. An exception to this general rule permits eligibility to continue for a person who attains age twenty-one while receiving treatment and continues to receive treatment as an inpatient in a Psychiatric Residential Treatment Facility (PRTF), or the state hospital, the Prairie at St. John's center, or the Stadter Psychiatric Center. Eligibility may continue through the month the individual attains the age of twenty-two.
3.	Blind individuals, disabled individuals, and caretaker relatives, are not subject to any age requirements for purposes of Medicaid eligibility.
4.	In instances where only the year and not the exact date of birth can be established, use July 1 to designate the date of birth; or if the year and month can be established, use the year and first day of the month for purposes of Medicaid eligibility.
5.	Identity must be established and documented as provided in this section.  for each applicant.  
	
	a. 	The following individuals are exempt from the identity verification requirements:

i.	SSI recipients who claim that they are US Citizens and that claim is not questionable (can prove using the SDX or TPQY SSI match);
ii.	Medicare beneficiaries who claim that they are US Citizens and that claim is not questionable (can prove using the TPQY SSA match);
iii.	Individuals receiving SSA disability insurance benefits based on their own disability;
iv.	Individuals receiving Foster Care maintenance payments;
v.	Individuals receiving Subsidized Adoption payments.

b.	Newborn children:  A child, born to a woman who has applied for and been determined Medicaid eligible and is in receipt of Medicaid when the child is born, may be eligible without verifying identity for up to one year as long as the Mother is eligible or would remain eligible if she were pregnant and as long as the child remains in the Mother's household.  Identity verification for the child must be supplied at the next redetermination of eligibility.  This provision also applies in instances where labor and delivery services were furnished prior to the date of the Medicaid application and covered based on retroactive eligibility.

This exception applies to all children whose birth is covered by Medicaid, including those under the emergency services only provisions as long as the child remains in the Mother's household.

Children who are born to a woman who is here on a temporary basis and who is not eligible for Medicaid or emergency medical services must comply with the verification requirements if Medicaid is requested.

c.	Primary and preferred verification of identity.  Verification documents must be presented in their official and original form as received from the issuing agencies.  Photocopies or notarized copies are not acceptable.  Once an original document is presented, a photocopy must be made and maintained in the case file.

Primary Verifications of Identity

(Level One)

These Documents Verify Both Citizenship and Identity:	Explanatory Information:	
US Passport	•	Issued by the Department of State
•	Does not have to be currently valid, as long as it was issued without limitation; (any passport issued with a limitation cannot be used to verify citizenship, but CAN be used to verify identity)
•	Through 1980, spouses and children were often included on one passport; after that each person is issued their own passport.	
Certificate of Naturalization (DHS/INS Forms N-550 or N-570)	•	Department of Homeland Security or Immigration and Naturalization Service (INS) issues for naturalization.	
Certificate of US Citizenship (DHS/INS Forms N-560 or N-561)	•	Department of Homeland Security or INS issues certificates of citizenship to individuals who derive citizenship through a parent.	
	
d.	Secondary verifications of identity may be accepted if primary verifications are not provided. Verification documents must be presented in their official and original form as received from the issuing agencies.  Photocopies or notarized copies are not acceptable.  Once an original document is presented, a photocopy must be made and maintained in the case file.

Secondary Verifications of Identity

(Level 2)

Acceptable Verifications of Identity:	Explanatory Information:	
Certificate of Degree of Indian Blood, or other U. S. American Indian / Alaska Native tribal document	•	Must include a photograph of the applicant or recipient; or
•	Have other personal identifying information for the individual such as name, age, sex, race, height, weight, or eye color	
Driver's license issued by a state or territory 
(DO NOT accept Canadian driver's license)	•	Must include a photograph of the applicant or recipient: or
•	Have other personal identifying information for the individual such as name, age, sex, race, height, weight, or eye color	
Identification card issued by a US Federal, State or local government with the same information as a driver's license.	•	DO NOT accept a voter's registration card	
School ID card	•	Must include a photograph of the applicant or recipient 	
U. S. military ID card or draft record		
Military dependent's identification card		
U. S. Coast Guard Merchant Mariner card		

e.	Third level verification of identity.  These documents should ONLY be used when documentation from levels one and two are unavailable.

Third Level Verifications of Identity

(Level 3)

Acceptable Verifications of Identity:	Explanatory Information:	
3 or more documents that together reasonably corroborate the identity of an individual, provided such documents have not been used to establish the individual's citizenship AND the individual has submitted at least second or third level citizenship verification	•	Only to be used if no other evidence of identity is available.
•	Must contain the individual's name plus additional identifying information (employer ID cards, high school and college diplomas from accredited institutions, marriage certificates, death certificates, divorce decrees and property deeds/titles.)	

f.	Identity verifications for minor children.  Exceptions identified in this section are allowed when a child does not have or cannot get any of the identity documents from the first three levels.

Identity Verifications for Children

(Level 4)

Acceptable Verifications of Identity:	Explanatory Information:	
School record	•	Must show child's date and place of birth and parents' name	
Clinic, doctor, or hospital record	•	Must show child's date and place of birth and parent's name	
Daycare or nursery school record showing date and place of birth	•	Eligibility worker must call and verify with the school that issued the record	
An affidavit, signed under penalty of perjury, by the parent, guardian, or caretaker relative which states the date and place of birth of the child	•	Only one affidavit may be used to establish either citizenship or identity.  If an affidavit is used to establish citizenship, then identity must be established using a different document from the identity list.
•	The affidavit is not required to be notarized
•	May be used for a child aged 16 to 18 only when school identity cards and driver's licenses are not available to the individual in that area until that age, 
•	SFN  691, "Affidavit of Identity for Children," has been created for convenience. 	

g.	Identity verifications for disabled individuals in institutional care facilities.  Exceptions identified in this section are allowed when a disabled individual in an institutional care facility does not have or cannot get any of the identity documents from the first three levels.

Identity Verifications for Disabled Individuals in 
Institutional Care Facilities

(Level 4)

Acceptable Verification of Identity:	Explanatory Information:	
An affidavit signed under penalty of perjury by a residential care facility director or administrator	•	Is not required to be notarized
•	Should be used only as a last resort
•	SFN 690, "Affidavit of Identity for Disabled Individual in Facility," has been created for convenience	

510-05-35-45.  Citizenship and Alienage 
This section has been rearranged and updated to include the final rules regarding verification of citizenship as required by the Deficit Reduction Act.
Changes that were made since Amended IM 4988 include:
•	Under the Secondary Verifications of Citizenship:
o	Certificate of Birth in the United States-- the 3rd bullet--the final rules changed the wording from 'the original must have been issued ' to the 'the original must have been recorded'
o	A new criterion of a data verification with the Systematic Alien Verification for Entitlements (SAVE) program has been added as an acceptable verification for naturalized citizens
o	A new criterion allowing adopted or biological children born outside the US to establish automatic citizenship
•	Under the Third Level Verifications of Citizenship:
o	A new criterion allowing an official religious record had been added
o	A new criterion allowing an early school record showing a US place of birth has been added
•	Under the Fourth Level Verifications of Citizenship:
o	A new criterion allowing a Bureau of Indian Affairs Roll of Alaska Natives
o	The wording was changed from "Amended US public birth record that is amended more than 5 years after the person's birth" to "Delayed US public birth record...."
o	The affidavits for citizenship forms have been made into SFN's and will soon be available on the eforms website
1.	As a condition of eligibility, applicants or recipients must be a United States citizen or an alien lawfully admitted for permanent residence.  Verification of citizenship, naturalization, or lawful alien status must be documented.  This section addresses:
a.	Exceptions to verification of citizenship;
b.	Newborn children;
c.	Verification requirements;
d.	Acceptable documentation for US citizens and naturalized citizens; and
e.	Individuals born in Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, and Nationals from American Samoa.
For aliens, apply the appropriate policy identified in sections 510-05-35-50 through 510-05-35-70.
2.	For purposes of qualifying as a United States citizen, the United States as defined in the Immigration and Nationality Act includes the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, and the Northern Mariana Islands. Nationals from American Samoa or Swain’s Island are also regarded as United States citizens for purposes of Medicaid.
3.	With the exception of the children of certain diplomats, all persons born in the United States and it’s territories acquire U.S. citizenship at birth.
Individuals born abroad to U.S. citizen parent(s) may automatically be U.S. citizens at birth. Whether a person born abroad with at least one U.S. citizen parent became a citizen at birth depends on the law in effect at the time the person was born. Generally one parent (or in some cases, a grandparent) must have resided in the U.S. for a specific period of time prior to the person’s birth.
A child who has been adopted by a U.S. citizen and who has been admitted to the U.S. as a lawful permanent resident may automatically acquire U.S. citizenship. Likewise, children under age 18 may automatically become citizens as a result of the naturalization of one or both parents (if that parent has custody of the children). This process is known as "derivative naturalization." The law governing derivative naturalization has been changed many times, and the specific requirements differ depending upon the law in effect at the time the parent(s) naturalized. 
When citizenship is questionable, a record of birth abroad to U.S. citizen parent(s), if registered with a U.S. Consulate or embassy, is proof of citizenship. The individual may also have a passport on which his or her citizenship will be identified. If an individual needs additional proof of citizenship, the individual may file an "Application for Certificate of Citizenship" (Form N-600) with INS to get a Certificate of Citizenship.
4.	In the absence of evidence that an individual is a citizen or lawfully admitted alien, lawful admission can be presumed if the individual can be proven to have resided in the United States continuously since January 1, 1972, and such proof is documented and entered in the case record. Questions regarding the alien status of an individual should be directed to the nearest office of the Immigration and Naturalization Service.
5.	The Social Security Administration has already verified citizenship or qualified alien status for individuals receiving SSI, therefore, it will be unnecessary for the county agency to reestablish citizenship status. For Title II beneficiaries who applied for Title II benefits after December 1, 1996, (Title II beneficiaries with a date of entitlement after December 1, 1996, can be assumed to have applied after December 1, 1996) the Social Security Administration has verified that the individual is either a United States citizen or a lawfully admitted alien. 
2.	Exceptions to verification of citizenship. The following individuals are exempt from the citizenship verification requirements:

a.	SSI recipients who claim that they are US Citizens and that claim is not questionable (can prove using SDX or TPQY SSI match);
b.	Medicare beneficiaries who claim that they are US Citizens and that claim is not questionable (can prove using TPQY SSA match);
c.	Individuals receiving SSA disability insurance benefits based on their own disability;
d.	Individuals receiving Foster Care maintenance payments;
e.	Individuals receiving Subsidized Adoption payments. 

3.	Newborn children.  A child, born to a woman who has applied for and been determined Medicaid eligible and is in receipt of Medicaid when the child is born, may be eligible without verifying citizenship for up to one year as long as the Mother is eligible or would remain eligible if she were pregnant and as long as the child remains in the mother's household.  Citizenship verification for the child must be supplied at the next redetermination of eligibility.  This provision also applies in instances where labor and delivery services were furnished prior to the date of the Medicaid application and covered based on retroactive eligibility.

Children who are born to a woman who is not eligible for regular Medicaid must comply with the verification requirements if Medicaid is requested.
4.	Verification Requirements:  Applicants must provide satisfactory documentary evidence of citizenship or naturalization.   

a.	The only acceptable verifications from individuals must be either originals or copies certified by the issuing agency.  Photocopies or notarized copies may not be accepted; however, a photocopy of the original document must be maintained in the casefile. 

b.	Verifications may be accepted from another state agency that may have already verified citizenship, but a photocopy must be obtained for the casefile.

c.	Once an individual's citizenship is documented and recorded, subsequent changes in eligibility do not require repeating the documentation unless questionable, or there is no verification in the casefile.

Example:  John Doe applies for Medicaid and supplies his citizenship verifications and his case closes.  If his casefile is purged after the three year retention period and he reapplies, he will need to again provide his verifications so that his casefile is complete.

d.	If an individual has made a good faith effort to obtain verifications, but cannot obtain them within the processing timeframes , or because the documents are not available, assistance must be provided to the individual in securing evidence of citizenship.  Matches with other agencies may be used to assist the individual.

5.	Acceptable documentation for US citizens and naturalized citizens.

a.	There are three documents that may be accepted as proof of both citizenship and identity because each contains a photograph of the individual named in the document and either the US or a state government has established the citizenship and identity of the individual.  These three documents are considered to be the primary (Level 1) and preferred verification documents. 

Primary Verifications

(Level 1)

These Documents Verify Both Citizenship and Identity:	Explanatory Information:	
US Passport	•	Issued by the Department of State
•	Does not have to be currently valid, as long as it was issued without limitation; (any passport issued with a limitation cannot be used to verify citizenship, but CAN be used to verify identity)
•	Through 1980, spouses and children were often included on one passport; after that each person is issued his own passport.	
Certificate of Naturalization (DHS/INS Forms N-550 or N-570)	•	Department of Homeland Security or Immigration and Naturalization Service (INS) issues for naturalization	
Certificate of US Citizenship (DHS/INS Forms N-560 or N-561)	•	Department of Homeland Security or INS issues certificates of citizenship to individuals who derive citizenship through a parent	

b.	If an individual does not have one of the primary verifications, the individual must supply one document from one of the Citizenship lists (Levels 2, 3, or 4) and one document from the Identity lists (Levels 2 ,3 or 4).

The verifications are listed in levels and the levels indicate the degree of reliability of the verifications.  Level 1 has the highest reliability and is the preferred verification.  Level 4 has the lowest reliability and those verifications should be used only when documents from levels 1-3 are not available.  The verifications in level 1 must be requested prior to requesting those in level 2, those in level 2 must be requested prior to requesting those in level 3, and so on.

Verification documents must be presented in their official and original form as received from the issuing agencies.  Photocopies or notarized copies are not acceptable.  Once an original document is presented, a photocopy must be made and maintained in the casefile.

Secondary Verification of Citizenship

(Level 2)

Acceptable Verifications: 
	Explanatory Information:	
Certificate of Birth in the United States 	•	Must have the embossed seal of the issuing agency
•	North Dakota only issues certified copies.  If it does not have the raised seal, it is not a certified copy--i.e. the old black and white prints
•	The original must have been recorded before the person was 5 years of age.  (For issuance date, use the "Date received by Local Registrar".)  If recorded at or after 5 years of age, it is a 4th level verification.
•	Must show birth in one of the 50 states, or the District of Columbia
•	Persons born to foreign diplomats are not citizens of the United States
•	An electronic match with the ND vital statistics agency showing the individual's place of birth will suffice 	
Report of Birth Abroad of a Citizen of the United States (FS-240) aka Consular Report of a Birth Abroad of a Citizen of the United States	•	Prepared by the Department of State Consular office
•	Can only be prepared at an American Consular office overseas while the child is under age 18
•	Children born outside the US to US military personnel usually have one of these	
Certificate of Birth Abroad (FS-545 or Form DS-1350) aka Certificate of Report of Birth or Certification of Birth Abroad	•	For those who were born outside the US and acquired US Citizenship at birth and is based on FS-240
•	FS-545 issued prior to November 1, 1990
•	DS-1350 issued on and after November 1, 1990
•	Is issued only within the US	
United States Citizen Identification Card (I-197 or I-179)	•	Issued by the Immigration and Naturalization Service from 1960-1973 as I-179; Issued to naturalized US Citizens living near the Canadian or Mexican border who needed it for frequent border crossings
•	Issued as I-197 from 1973-1983
•	No longer currently used, but still valid	
American Indian Card (I-872) with the classification code "KIC" and a statement on the back 	•	Issued by the Department of Homeland Security to identify US citizen members of the Texas Band of Kickapoos living near the US / Mexican border	
Evidence of Civil Service Employment 	•	Must show employment by the US Government prior to June 1, 1976	
Official Military record of service 	•	Including a DD-214
•	Must show a US place of birth	
A data verification with the Systematic Alien Verification for Entitlements (SAVE) Program for naturalized citizens	•	Determines if someone is a naturalized citizen
•	May need to provide the individual's alien registration number	
Adopted or biological children born outside the US may establish their automatic citizenship if verification is provided	•	Showing at least one parent is a US citizen by either birth or naturalization
•	Child is under age 18
•	Child is residing in the US in the legal and physical custody of the US citizen parent
•	Child was admitted to the US for lawful permanent residence
•	If adopted, the child must be a lawful permanent resident as an IR-3 (child adopted outside the US) or as IR-4 (child coming to the US to be adopted); with the final adoption having subsequently occurred.	

Third Level Verification of Citizenship

(Level 3)

Acceptable Verifications:	Explanatory Information:	
Extract of hospital record on hospital letterhead established at the time of birth and created at least 5 years prior to the Medicaid application 	•	It must indicate a US place of birth
•	A souvenir 'birth certificate' issued by the hospital cannot be accepted
•	For children under 16 the document must have been created near the time of birth or 5 years prior to the Medicaid application.	
Life or health or other insurance record	•	Showing a US place of birth for the individual
•	Created at least 5 years before the initial application date	
Official religious record (recorded with the religious organization) recorded in the US within 3 months of birth	•	Must show a US place of birth
•	Must show the individual's date of birth or age at the time the record was made
•	In questionable cases, such as where the child's religious record was recorded near a US international border and the child may have been born outside the US, the worker must verify the religious record with the religious organization and verify that the mother was in the US at the time of birth	
Early school record showing a US place of birth	•	Must show the name, date of birth, and US place of birth of the child
•	Must show the date of school admission
•	Must show the name(s) and place(s) of birth of the applicant's parents	

Fourth Level Verification of Citizenship

(Level 4)

Acceptable Verifications:	Explanatory Information:	
Federal or state census record showing US citizenship or a US place of birth—(generally for persons born 1900-1950)	•	Must also show the applicant's age
•	Census records from 1900 through 1950 contain citizenship information
•	To obtain this information the applicant or recipient should complete a Form BC-600, "Application for Search of Census Records for Proof of Age", adding in the remarks portion, "US Citizenship data requested for Medicaid eligibility."  This form can be obtained online at:
 http://www.census.gov/genealogy/www/bc-600.pdf 
•	A fee will be charged	
Seneca Indian tribal census record	•	Must be created at least 5 years prior to initial Medicaid application; and
•	Must show a US place of birth	
Bureau of Indian Affairs tribal census records of the Navajo Indians	•	Must be created at least 5 years prior to initial Medicaid application; and
•	Must show a US place of birth	
US State Vital Statistics official notification of birth registration	•	Must be created at least 5 years prior to initial Medicaid application; and
•	Must show a US place of birth	
Delayed US public birth record that is amended more than 5 years after the person's birth 	•	Must be recorded at least 5 years prior to initial Medicaid application; and
•	Must show a US place of birth	
Statement signed by the physician or midwife who was in attendance at the time of birth	•	Must be created at least 5 years prior to initial Medicaid application; and
•	Must show a US place of birth	
Institutional admission papers from a nursing home, skilled care facility or other institution	•	Must be created at least 5 years prior to initial Medicaid application; and
•	Must show a US place of birth	
Medical (clinic, doctor or hospital) record (An immunization record is NOT considered a medical record for establishing citizenship)	•	Must be created at least 5 years prior to initial Medicaid application (or near the time of birth, if a child under age 16 only); and
•	Must show a US place of birth	
Written affidavit, made under penalty of perjury, by at least two individuals--one of which is not a relative--showing they have personal knowledge of the event(s) establishing the applicant's claim of citizenship (date and place). These individuals must provide proof of their own citizenship and identity	•	It must also state a reasonable basis of personal knowledge that an applicant or recipient who cannot produce documentary evidence of citizenship is a citizen.  SFN 707, "Affidavit of Citizenship" has been created for convenience.  
•	A second affidavit from the applicant/recipient or other knowledgeable individual explaining why the information cannot be obtained must also be supplied.  SFN 706, "Affidavit of Explanation why Citizenship Cannot be Supplied", has been created for convenience.  
•	Use only in rare circumstances	

6.	Individuals born in Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, and Nationals from American Samoa.  For purposes of qualifying as a United States citizen, individuals born in Puerto Rico, Guam, the Virgin Island, the Northern Marian Islands and Nationals from American Samoa may qualify as follows:

a.	Puerto Rico:

•	Certificate of birth in Puerto Rico on or after January 31, 1941
•	Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant's statement that he or she was residing in the US, a US possession, or Puerto Rico on January 13, 1941
•	Evidence that the individual was a Puerto Rican citizen and the applicant's statement that he or she was residing in Puerto Rico on March 1, 1917, and that he or she did not take an oath of allegiance to Spain
b.	Guam:
•	Evidence of birth in Guam on or after April 10, 1899

c.	The US Virgin Islands:

•	Certificate of birth in the US Virgin Islands on or after January 17, 1917
•	Evidence of birth in the US Virgin Islands and the applicant's statement of residence in the US, a US possession, or the US Virgin Islands on February 25, 1927
•	The applicant's statement indicating residence in the US Virgin Islands as a Danish citizen on January 17, 1917 and residence in the US, a US possession, or the US Virgin Islands on February 25, 1927, and that he or she did not make a declaration to maintain Danish citizenship
•	Evidence of birth in the US Virgin Islands and the applicant's statement indicating residence in the US, a US possession, or the Canal Zone on June 28, 1932

d.	Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):

•	Certificate of birth in the Northern Mariana Islands after November 4, 1986.
•	Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the US or a US territory or possession on November 3, 1986 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986. These individuals carry the Northern Mariana Identification Care (I-873).  This form is no longer issued, but is still valid.
•	Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981, voter registration prior to January 1, 1975, and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986.
•	Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant's statement that he or she did not owe allegiance to a foreign state on November 4, 1986.
•	If the person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a US Citizen.

e.	Nationals from American Samoa or Swain's Islands:

•	Certificate of birth in American Samoa or Swain's Islands after November 4, 1986
•	Persons born in American Samoa or Swain's Islands are treated as citizens for Medicaid purposes

f.	Persons born to foreign diplomats while residing in one of the preceding jurisdictions of the US are not citizens of the United States.  

•	The child's citizenship or alien status follows that of the parent.

510-05-35-50.  American Indians Born in Canada 
Subsection 2 has been updated to include information regarding the Blood Quantum Letter and supersedes IM 5020.
1.	American Indians born in Canada who may freely enter and reside in the United States and are considered to be lawfully admitted for permanent residence if at least one-half American Indian blood. This does not include a spouse or child of such an Indian nor a noncitizen whose membership in an Indian tribe or family is created by adoption, unless such person is of at least 50 percent or more Indian blood. These American Indians are qualified aliens and are considered to be lawful permanent residents.
2.	Verification of percentage of American Indian blood may be obtained from INS Form I-551 with the code 513, or an unexpired temporary I-551 stamp (with the code 513) in a Canadian passport or on Form I-94. If the individual does not have an INS document, satisfactory evidence of birth in Canada and a document indicating the percentage of American Indian blood must be provided. Documents, indicating the percentage of American Indian blood include a birth certificate issued by the Canadian reservation, or a Blood Quantum Lletter, card, or other record issued by the tribe (each tribe provides some type of evidence).  The Blood Quantum Letter may use the following verbiage: at least 50% Aboriginal blood, at least 50% Indigenous blood, at least 50% North American Indian blood, or at least 50% American Indian blood.  Do not accept a Certificate of Indian Status card ("Band" card) issued by the Canadian Department of Indian Affairs, information from any internet sites, or any other document not directly issued by the individual’s tribe.

510-05-35-95.  Inmates of Public Institutions 
Language was added to Subsection 5 to clarify that a ten-day notice is not required when an individual is no longer eligible due to entering an institution.

5.	The period of ineligibility under this section begins the day after the day of entry and ends the day before the day of discharge of the individual from such an institution.  A Ten-Day Advance Notice is not needed when terminating benefits due to entry into the institution.  See Paragraph (4)(c)(iii) of 510-05-25-25 "Decision and Notice" for further information.  

510-05-40-15.  Cooperation -- Child Support 
Language has been added to Subsection 3 to clarify that if a previously non-cooperating caretaker cooperates with child support in an ongoing case, that caretaker may be eligible for Medicaid starting the first of the month in which the individual started cooperating.
3.	Cooperation with Child Support is required for all other legally responsible caretaker relatives (including aged and disabled caretakers) for the purpose of establishing paternity and securing medical support. This requirement may be waived for "good cause" as described in 510-40-20.
The determination of whether a legally responsible caretaker relative is cooperating is made by the Child Support Agency. The caretaker has the right to appeal that decision.
Legally responsible caretaker relatives who do not cooperate with Child Support will not be eligible for Medicaid. Children in the Medicaid unit, however, remain eligible.
When a legally responsible caretaker relative is not eligible because of non-cooperation, the earned and unearned income of that ineligible caretaker must be considered in determining eligibility for the child(ren).
For an ongoing case, if a previously non-cooperating legally responsible caretaker relative cooperates during a benefit month, that caretaker may be eligible for Medicaid effective the first day of the month of cooperation, if otherwise eligible for Medicaid.

510-05-45-15.  Family Composition 
Language was added to Subsection 1 to clarify that a Family Coverage case must include an eligible child unless the child is an SSI recipient.

Language was added to Subsection 3 to clarify the treatment of teenage parents.

1.	Families eligible under the Family Coverage group must contain a child, which can include an unborn, that is eligible under this section, or is in receipt of SSI, and that is deprived of a natural or adoptive parent’s support or care. Deprivation is described at 05-35-10 and includes deprivation due to unemployment or underemployment of a parent.
3.	The parents of a caretaker who is at least age 18, or if under age 18 is married or is not residing with the parent(s), may not be included in the same family unit as the caretaker.
If a teenage parent under age 18 moves out of the parental home of the teenage parent other than temporarily, the teenage parent and  child(ren) must have their own case if they are eligible under the Family Coverage Group.  (Living independently rules do not apply.)  
If the teenage parent and children fail Family Coverage, the living independently rules do apply.

510-05-65-20.  Community Spouse Asset Allowance 
Language was added to Subsection 1 to clarify that for the community spouse we consider the assets as of the date the institutionalized spouse enters a nursing facility or begins receiving the nursing home level of care. 

In Subsection 2, the paragraph below the example was broken into two paragraphs to clarify that the situation indicated is an exception to the rule.   Also, Subsection 2 has been updated to show the 2008 community spouse minimum and maximum asset allowances.
1.	The community spouse asset allowance is computed considering the assets as of the first continuous period of institutionalization of the institutionalized spouse, or as of the beginning of the first continuous period of receipt of HCBS by a HCBS spouse.

Subsection 2--Below the example:
Example:
If the couple's countable assets are:	The community spouse share is:	
$25,000	$12,500	
$90,000	$45,000	
$250,000	$125,000	

From the spousal share, the community spouse asset allowance is established, and is an amount that is equal to the community spouse share, but not less than $20,880 $20,328, and not more than $104,400, $101,640, effective January 2008 2007 ($20,328 $19,908 and $101,640 $99,540 effective January 2007 2006).

Example:
If the spousal share is:	The community spouse asset allowance is:	
$12,500	$20,880 $20,328 (at least the minimum)	
$45,000	$45,000	
$125,000	$104,400 $101,640 (one-half is more than the maximum allowed, so the community spouse gets the maximum)	
 
The community spouse asset allowance may be adjusted by any additional amount transferred under a court order or established through a fair hearing.  
Adjustments in the minimum and maximum allowed for a community spouse may also adjust the community spouse asset allowance.

510-05-70-10.  Asset Considerations 

Language was added to Subsection 6 to clarify that when a transfer is made by someone who has a confidential relationship with the applicant or recipient, the disqualifying transfer look-back period does not apply, and the transferred property is still considered available to the applicant or recipient.

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, regardless of when the transfer was made, 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.

510-05-70-25.  Exempt Assets 

In Subsection 3, the word "purpose" was changed to "use" to clarify that the vehicle is for the use of the Medicaid unit.

3.	One motor vehicle, if the primary purpose use of the vehicle is to serve the needs of members of the Medicaid unit. If the vehicle is used primarily by someone who is not in the Medicaid unit, it does not meet this exemption.

510-05-70-30.  Excluded Assets 
Language was added to Subsection 11 to clarify that an income tax refund, or earned income credit must be kept separate and not commingled in order to be excluded as an asset.
11.	For nine months beginning after the month of receipt, any income tax refund, any earned income tax credit refund or any advance payments of earned income tax credit.  This asset must be identifiable and not commingled with other assets.

510-05-70-45-10.  Definitions for Annuities 

The definition of an "Employee Benefit Annuity" was modified and moved to this section (as Subsection 4) and the rest of the definitions renumbered.

For purposes of the annuity sections:

4.	"Employee benefit annuity" means: 
a.	An annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue code of 1986 (IRC) ;
b.	An individual retirement annuity under Section 408(b) of the IRC (not to be confused with an individual retirement account); or
c.	An annuity described in any of the following IRC Sections:
i.	Employer plan under 401(a);
ii.	Trust under 501(a);
iii.	Annuity plan under 403(a) or 403 (b); or
iv.	Deferred compensation plan under 457(b).
(These annuities are considered "qualified" annuities.);

510-05-70-45-20.  Annuities Purchased Before August 1, 2005 

Language has been added to Subsections 2, 3, and 4 to clarify when an annuity that was considered a disqualifying transfer can also be a countable asset, and language describing an employee benefit annuity was removed as it is now covered in the annuity definitions section.  Language was added to allow for different value for transfer purposes.  Subsection 6 was also added to identify the date of the transfer for annuities considered to be a disqualifying transfer.
2.	An annuity in which a payment option was selected before August 1, 2005 is counted as an available asset in the asset test unless:
a.	The annuity must be considered a disqualifying transfer; and the penalty period is not finished (if the penalty period is finished and the applicant or recipient still owns the annuity, the annuity may be considered an available asset);
b.	The annuity has been annuitized and constitutes an employee benefit annuity that cannot be surrendered; or that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue code of 1986 (These annuities are considered "qualified" annuities); or
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full purchase price and interest within the purchaser's life expectancy; and
v.	Unless specifically ordered otherwise by a court of competent jurisdiction acting to increase the amount of spousal support paid on behalf of a community spouse by an institutionalized spouse or a home and community based services (HCBS) spouse, the monthly payments from the annuity do not exceed $2610 $2541 effective January 2008 2007 ($2541 $2488 for 2006  2007).
3.	An annuity purchased before August 1, 2005, but for which the payment option is selected from August 1 2005, through February 7, 2006, is counted as an available asset unless the annuity is considered a disqualifying transfer and the penalty period is not finished, or the annuity is a qualified employee benefit that cannot be surrendered.  State law considers any annuity in which a payment option is selected on or after August 1, 2005, as assignable unless it meets the requirements in 05-70-45-25(2)(c). To meet those requirements, the annuity would have to have been purchased on or after August 1, 2005. 
4.	The annuity is considered a disqualifying transfer unless:
a.	The payment option was selected prior to the individual's, or the individual’s spouse’s look back date;
b.	The annuity is a qualified employee benefit annuity, as described in (2)(b);
c.	The annuity meets all of the requirements in (2)(c) above; or
d.	The annuity is a third party annuity.
5.	The uncompensated value of an annuity that is considered a disqualifying transfer is an amount equal to the remaining payments due from the annuity (or the applicant or recipient can show the outstanding principal amounts due, if that information can be attained).  
6.	The date of the disqualifying transfer is the date the payment option was selected on the annuity, or if later, the date the annuity was changed so the annuity could no longer be surrendered.

510-05-70-45-25.  Annuities Purchased from August 1, 2005 Through February 7, 2006 

Language has been added to this section to clarify the treatment of annuities.  The changes are the same as those made in 510-05-70-45-20 for annuities purchased before August 1, 2005.
2.	The annuity is counted as an available asset in the asset test unless:
a.	The annuity must be considered a disqualifying transfer; and the penalty period is not finished (if the penalty period is finished and the applicant or recipient still owns the annuity, the annuity may be considered an available asset);
b.	The annuity has been annuitized and constitutes an employee benefit annuity that cannot be surrendered; or that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue code of 1986 (These annuities are considered "qualified" annuities); or
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full principle principal and has a guaranteed period that is equal to at least 85% of the annuitant’s life expectancy;
v.	The monthly payments from all annuities that meet the requirements of this Subsection do not exceed $2610 $2541 effective January 2008 2007 ($2541 $2488 for 2006  2007),  and, when combined with the annuitant’s other income at the time of application for Medicaid, does not exceed $3915 $3811 effective January 2008 2007 ($3811 $3732 for 2007 2006); and
vi.	If the applicant for Medicaid is age 55 or older, the Department of Human Services is irrevocably named as the primary beneficiary of the annuity following the death of the applicant and the applicant’s spouse, not to exceed the amount of benefits paid by Medicaid.  If a minor child who resided and was supported financially by the applicant or spouse, or disabled child, survives the applicant and spouse, any payments from the annuity will be provided to those individuals.

3.	The annuity is considered a disqualifying transfer unless:
a.	The payment option was selected prior to the individual's, or the individual’s spouse’s look back date;
b.	The annuity is a qualified employee benefit annuity, as described in (2)(b);
c.	The annuity meets all of the requirements in (2)(c) above; or
d.	The annuity is a third party annuity.
4.	The uncompensated value of an annuity that is considered a disqualifying transfer is an amount equal to the remaining payments due from the annuity (or the applicant or recipient can show the outstanding principal amounts due, if that information can be attained).  
5.	The date of the disqualifying transfer is the date the payment option was selected on the annuity, or if later, the date the annuity was changed so the annuity could no longer be surrendered.

510-05-70-45-30.  Annuities Purchased or Changed on or After February 8, 2006 

Language has been added to this section to clarify the treatment of annuities and to remove unnecessary duplicate language from Subsection 4.  The changes are the same as those made in 05-70-45-20 for annuities purchased before August 1, 2005.

3.	The annuity is counted as an available asset in the asset test unless:
a.	The annuity must be considered a disqualifying transfer; and the penalty period is not finished (if the penalty period is finished and the applicant or recipient still owns the annuity, the annuity may be considered an available asset);
b.	The annuity has been annuitized and constitutes an employee benefit annuity that cannot be surrendered; or that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue code of 1986 (These annuities are considered "qualified" annuities); or
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full principle  principal and has a guaranteed period that is equal to at least 85% of the annuitant’s life expectancy;
v.	The monthly payments from all annuities that meet the requirements of this Subsection do not exceed $2610 $2541 effective January 2008 2007 ($2541 $2488 for 2006  2007), and, when combined with the annuitant’s other income at the time of application for Medicaid, does not exceed $3915 $3811 effective January 2008 2007 ($3811 $3732 for 2007 2006); and
vi.	If the applicant for Medicaid is age 55 or older, the Department of Human Services is irrevocably named as the primary beneficiary of the annuity following the death of the applicant and the applicant’s spouse, not to exceed the amount of benefits paid by Medicaid.  If a minor child who resided and was supported financially by the applicant or spouse, or disabled child, survives the applicant and spouse, any payments from the annuity will be provided to those individuals.
4.	The annuity is considered a disqualifying transfer unless:
a.	The payment option was selected, or the latest change to the annuity was made, prior to the individual's, or the individual’s spouse’s look back date;
b.	The annuity is a qualified employee benefit annuity, as described in (3)(b) above and the Department is named as the remainder beneficiary in the first position for at least the total amount of Medicaid paid on behalf of the annuitant or the annuitant’s spouse. The Department may be named as the remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or child disposes of any such remainder for less than fair market value;
c.	The annuity meets all of the requirements in (3)(c)(i) through (3)(c)(v) above and the Department is named as the remainder beneficiary in the first position for at least the total amount of Medicaid paid on behalf of the annuitant or the annuitant’s spouse. The Department may be named as the remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or child disposes of any such remainder for less than fair market value;
d.	The annuity is a third party annuity;
e.	The monthly payments from all annuities that meet the requirements of this subsection do not exceed $2488 and, when combined with the annuitant’s other income at the time of application for Medicaid, does not exceed $3732; and
f.	If the applicant for Medicaid is age 55 or older, the Department of Human Services is irrevocably named as the primary beneficiary of the annuity following the death of the applicant and the applicant’s spouse, not to exceed the amount of benefits paid by Medicaid.  If a minor child who resided and was supported financially by the applicant or spouse, or disabled child, survives the applicant and spouse, any payments from the annuity will be provided to those individuals.
5.	The uncompensated value of an annuity that is considered a disqualifying transfer is an amount equal to the remaining payments due from the annuity (or the applicant or recipient can show the outstanding principal amounts due, if that information can be attained).  
6.	The date of the disqualifying transfer is the date the payment option was selected on the annuity, or if later, the date the annuity was changed so the annuity could no longer be surrendered.

510-05-80-05.  Definitions 
Language was changed to clarify how the treatment of transfers made by someone in a confidential relationship affects an applicant or recipient.
4.	"Someone in a confidential relationship" includes an applicant or recipient’s power of attorney, guardian, conservator, legal custodian, caretaker, trustee, attorney, accountant, or agent, and may include a relative or other person with a close and trusted relationship to the individual.
State law prohibits individuals with a confidential relationship from personally benefiting from transactions involving the applicant or recipient’s income or assets. 
North Dakota state law provides that any transaction between an applicant or recipient and someone who has a confidential relationship with that individual in which the individual who has a confidential relationship gains any advantage over the applicant or recipient is presumed to be entered into without sufficient consideration and under undue influence.  
They also Someone with a confidential relationship who can exercise control over an applicant's or recipient's income or assets has have a duty to act in the highest good faith and not obtain any advantage over the applicant or recipient; to not use or deal with an applicant or recipient's property for their own profit; to refrain from transactions adverse to the applicant or recipient; and to refrain from using undue influence to obtain any advantage from the applicant or recipient.
Accordingly, transfers of an applicant or recipient's real or personal property made by an applicant or recipient to the person with the confidential relationship must be at 100% of estimated fair market value. Transfers for less than 100% of fair market value may be subject to the disqualifying transfer provisions.
Transfers of an applicant or recipient’s property made by someone with a confidential relationship, 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.  The individual may require return of the assets, which may include legal proceedings if necessary.  There is no time limit that applies to these transfers (i. e. the disqualifying transfer look back date is not applicable).

510-05-80-20.  Hardship Provision
The home equity limit under Subsection 4(e)(1) was corrected to $125,000 to be excluded under the hardship provisions.  The word "purpose" under Subsection (4)(e)(iii) was changed to "use" to clarify policy.
Subsection 4
e.	The individual’s remaining available assets, and the remaining assets of the individual’s spouse, if any, are less than the asset limit applicable to a Medicaid eligible unit that would include the individual, the individual’s spouse, if any, and the individual’s minor children, if any, counting the value of all assets except:
i.	The home, but not if the individual, or the individual's spouse, if any, have equity in the home in excess of $200,000 125,000;
ii.	Exempt personal effects, wearing apparel, household goods, and furniture;
iii.	One motor vehicle, if the primary purpose use of the vehicle is to serve the needs of members of the Medicaid unit; and
iv.	Funds for burial of $5,000 or less for the individual and the individual's spouse.

510-05-85-05.  Income Considerations 

The words "non tax" were deleted from Subsection 1 to clarify and simplify this policy.

Subsection 1:
Title II and SSI overpayments being deducted from Title II benefits are normally considered to be available because the applicant or recipient can pursue a waiver of the overpayment. Only if the waiver has been denied after a good faith effort, can the Title II or SSI overpayment deductions be considered unavailable. Occasionally other delinquent non-tax debts owed to the federal government may be collected from an individual’s Title II benefit. These other reductions of Title II benefits are not allowed to reduce the countable benefit amount. The award amount of the Title II benefit is counted as available.

510-05-85-15.  Unearned Income 

Language was added to Subsection 5(f) to include the Reserve Education Assistance Program as countable income; and to Subsection 5(h) to clarify treatment of lease income, when received as a lump sum or when recurring.

Subsection 5:

f.	Student income received from the Veterans Administration through the GI Bill or Reserve Education Assistance Program (REAP), except that verified school expenses (tuition, books and fees) may be deducted;
h.	Mineral lease income (If a lump sum, count as income in the month received.  If recurring, prorate over the period it is to cover);

510-05-85-20.  Earned Income 

Language was added to Subsection 4(a) to clarify that payments by the Department to a qualified service provider are treated as self-employment income.  Language was added to Subsection 4(g) to clarify that all gains and losses are counted when considering actual income; and which forms to use when this income is considered.

Subsection 4:
a.	Self-employed individuals whose business does not require the purchase of goods for resale. Examples of this type of business include persons who provide childcare services in their own home, or qualified service providers (QSP's) (who are not employees of a home health agency) who provide HCBS.  For example, those QSP's who receive payments from the Department.  Such income may be accounted for on a monthly basis, or the income tax return from the previous year may be used if it reflects a full year’s operation. When the tax return is used, one-twelfth of the annual gross income is monthly earnings. The first 25% of the gross monthly earnings shall be disregarded to offset the cost of producing the income and will cover such things as additional food, utilities, supplies, etc. The remaining 75% of gross monthly earnings is the figure to which the appropriate earned income deductions are applied to arrive at monthly net income.

Subsection 4(g):
Example:
Gross annual income
(from federal tax return)	
$16,500.00	
Net annual income
(25% of $16,500)	    4,125.00	
Capital and other ordinary gains	     1,200.00	
Monthly income
(yearly income divided by 12)	       443.75	

Capital and other gains and losses are always counted when considering actual income for a prior period. When using the prior income to estimate income for a prospective period, however, use capital gains and losses that are reasonably expected to occur in the prospective period.
Capital gains, short term and long term, and ordinary other gains are found on the federal tax form as follows:
i.	Short term Ccapital gains-Schedule D, Part I; and 
ii.	Long term capital Other gains-Schedule D, Part II Form 4797; and
iii.	Ordinary gains-Form 1040-Supplemental gains or losses.

510-05-85-30.  Disregarded Income 

Subsection 45 was added to clarify when reimbursements for certain work or training-related expenses may be disregarded for Medicaid purposes.

45.	Reimbursements from an employer, training agency or other organization for past or future training, or volunteer related expenses are disregarded from income.  Reimbursements must be specified for an identified expense, other than normal living expenses, and used for the purpose intended.  Reimbursements for normal household living expenses or maintenance such as rent or mortgage, clothing or food, are a gain or benefit and are not disregarded.

Examples of disregarded reimbursements include: 

a.	Reimbursements for job or training-related expenses such as travel, per diem, uniforms, and transportation to and from the job or training site.
b.	Reimbursements for out-of -pocket expenses of volunteers incurred in the course of their work.

510-05-85-35.  Income Deductions 

Examples of expenses that may and may not be used to reduce recipient liability were added to Subsection 2.

Language was added to Subsection 8 to clarify that a child care deduction may only be allowed from the income of the child or a responsible caretaker such as a parent.

Unnecessary language was deleted from Subsection 14 to clarify policy.

2.	Except in determining eligibility for the Medicare Savings Programs, medical expenses for necessary medical or remedial care claimed for deduction must be documented in a manner which describes the service, the date of the service, the amount of cost incurred, and the name of the service provider. A medical expense may be deducted only if it is:
e.	Claimed.
Examples of expenses that cannot be used to reduce countable income and affect recipient liability:
i.	Extra amounts paid on glasses, such as more expensive frames, tint, etc.;
ii.	Expenses that are considered medically necessary, but are applied to recipient liability;
iii.	Costs for Lifeline;
iv.	Over the counter medications and supplies that Medicaid does not pay for, even if prescribed*;
v.	Other medications and services that Medicaid does not pay for, such as DESI drugs, such as Midrin (for Migraines), Tigan (for nausea).  (DESI drugs -- Drug Efficacy Study Implementation --are determined by the federal government to be safe but less than effective);
vi.	Expenses from visiting a provider who is not the individual's Coordinated Services Program (CSP) "lock-in" provider; or
vii.	Drugs from Canada prescribed by someone other than a United States physician.

Examples of expenses that can be used to reduce countable income and affect recipient liability:
i.	Medications and services Medicaid does not pay for only because the provider is not enrolled;
ii.	*Over-the-counter medications that Medicaid does cover, such as Antacids (for stomach acid), analgesics (for pain), iron supplements (for anemia), artificial tears (for severe dry eye diseases).  Also, those payable because of rebates, such as Maalox and Advil.  (Non-payable are Mylanta and CVS generics).  Medicaid covers drugs with a NDC code on the bottom of the bottle label.  (http://nddrug.rxexplorer.com/ND Dept. of Human Services is a website that workers may use to inquire whether ND Medicaid covers a specified drug.);
iii.	Other over-the-counter supplies that Medicaid covers, such as diabetic supplies;
iv.	Nicoderm patches;
v.	Drugs from Canada when prescribed by a US physician;
vi.	Co-pays; or
vii.	Transportation costs:
a.	Lodging up to the limit.  Hotels can bill the difference to the client if they stay at a hotel that charges more.  (As with meals, we pay per diem and client can eat where they want.)
b.	Allow the difference to reduce recipient liability if reasonable. (If they choose to stay in a penthouse suite when other less costly rooms are available, not reasonable.)
c.	Transportation costs are not paid or allowed as a deduction if the medical services are available locally but client travels elsewhere, even if referred by a physician.  The provider must be within the nearest service area, client has choice of providers.
8.	Reasonable child care expenses, not otherwise reimbursed, that the Medicaid unit is responsible to pay, may be deducted if necessary to engage in employment or training. The child must be a member of the Medicaid unit for the deduction to be allowed.  This expense may only be allowed as a deduction from the income of the child or those individuals who are responsible for the child, such as a parent or caretaker.

14.	The deductions described in this Subsection may be allowed only on earned income.
b.	For all aged, blind, or disabled applicants or recipients, sixty-five dollars plus one-half of the remaining monthly gross earned income; provided that, when more than one aged, blind, or disabled person lives together, no more than sixty-five dollars, plus one-half of the remaining combined earned income, may be deducted. This provision applies separately to the coverage, medically needy or the Medicare Savings Programs, for which eligibility is being determined.

510-05-95-20.  Refugee Medical Assistance Program 

This section has been changed to include the criteria for the Refugee Medical Assistance Program that used to be included in Service Chapter 400-12 and to incorporate IM 4824.

1.	The Refugee Medical Assistance Program is a program designed to cover Medical expenses for unaccompanied minors and other legally admitted refugees. Information and eligibility criteria can be found in Service Chapter 400-12.  who are not eligible for Medicaid or Healthy Steps.  Medicaid receives 100% federal funding for Refugee Medical Assistance (RMA).

2.	Refugees and unaccompanied minors who meet all Medicaid eligibility criteria, including need, must be enrolled in Medicaid instead of the Refugee Medical Assistance Program.  Similarly, refugee children and unaccompanied minors who are eligible for Healthy Steps are processed under that program prior to considering Refugee Medical Assistance.

When a refugee or unaccompanied minor meets the technical requirements to be eligible for Medicaid, but has no medical "need" which equals or exceeds recipient liability, and is not eligible for Healthy Steps the individual can be enrolled in Refugee Medical Assistance.

3.	Refugee Medical Assistance is available during the first eight months a refugee is in this country or longer if an unaccompanied minor.  

a.	Unaccompanied minors are not limited to the eight-month refugee time limit, but can remain eligible under the unaccompanied minor coverage until age 21.  Children age 18-21 must be attending school full time.

b.	When any other refugee has been in this country for eight months, Refugee Medical Assistance ends.  Refugees who want continued medical coverage must have their eligibility determined under the Medicaid or Healthy Steps programs.

4.	Eligibility for Refugee Medical Assistance is determined using medically needy income and asset methodologies and limits, except:

a.	Refugees who receive a refugee cash assistance payment (currently administered through Lutheran Social Services) and are not eligible for traditional Medicaid or Healthy Steps are  eligible for Refugee Medical Assistance  without regard to any other eligibility tests;

b.	Refugees who become eligible for Refugee Medical Assistance continue eligible without regard to increases in earned income until the end of the eight-month period; and

c.	Refugees who lose Medicaid during the first eight months in the country due to increased earnings are transferred to Refugee Medical Assistance without an eligibility test.  Their earned income will not affect their Refugee Medical Assistance for the remainder of the 8-month period.

5.	There are several groups of individuals who enter the US and are included under the 'Refugee' Category. These individuals may be eligible for Refugee Medical Assistance (RMA) for the first 8 months upon entry to the US.  The month of US Entry is considered month 1 of the 8 month period.  The following table identifies who these individuals are and provides information that may be obtained to identify them:

Type of Individual	How to Identify	
Alien Granted status as a refugee under Section 207 of the Act	Use of SAVE, or obtain Form I-94 annotated with stamp showing admission under section 207 of the INA.  Derive the date of admission from the date of inspection on the Form I-94 refugee stamp.  
Note: If the date is missing, must obtain further verification.
(These are the individuals we usually see and deal with in North Dakota.) 	
Alien Paroled as a Refugee or Asylee* under section 212(d)(5) of the Act	Use of SAVE, or obtain a valid I-94 card which will indicate they have been paroled pursuant to section 212(d)(5) of the INA, with an expiration date of at least 1 year from the date issued, or indefinite.  	
Alien Granted status as an Asylee* under Section 208 of the Act	Use of SAVE, or obtain either a Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA, or a grant letter from the Asylum office, or an order of an immigration judge.  Derive the date status granted from the date on Form I-94, the grant letter, or the date of the court order.
Note:  If the date is missing from Form I-94, request the grant letter from the alien.  If it is not available, must obtain further verification.	
Alien Granted parole status as a Cuban/Haitian Entrant	Use of SAVE, or if the individual cannot provide documentation of status, refer him/her to the Department of Homeland Security for evidence of current immigration status.
	
Certain Amerasians from Vietnam Admitted to the US as immigrants	Use of SAVE, or obtain the immigrant's Form I-551 with the code AM1, AM2, or AM3 or passport stamped with an unexpired temporary I-551 showing a code AM6, AM7, or AM8.  Derive the date of admission as an Amerasian immigrant from the I-551, or the date of inspection on the stamp on Form I-94.  
Note:  If the date is missing on the I-94, verify status with the Department of Homeland Security.	

Individuals Admitted for permanent residence, provided the individual previously held one of the statuses above.	If the individual held one of the previous statuses above, they will more than likely have been in the US more than 8 months and thus cannot be eligible for Refugee Medical Assistance.  	
* For Asylee's, individuals that enter the US and have not been granted Asylum by INS are considered an 'Applicant for Asylum'.  Federal Law prohibits 'Applicants for Asylum' from being eligible for Medicaid or Refugee Medical Assistance.  Therefore, they must be granted Asylum during the first 8 months of residing in the US in order to be eligible for Medicaid or Refugee Medical Assistance under the 'Refugee Category'.  In most situations, an alien who applies for asylum (Applicant for Asylum), is not actually granted asylum until after residing in the US for 8 months and thus most would not be eligible for Medicaid or Refugee Medicaid Assistance. 

Other changes:  Typographical and format changes were made to other sections of the manual but are not identified here.

Par. 2.  Effective Date:  This manual letter is effective for the benefit month of December 2007, unless otherwise indicated.