Par. 1.	Material Transmitted and Purpose – Transmitted with this Manual Letter are changes to Service Chapter 510-05 Medicaid Eligibility Factors.  New language is in red and underlined and removed language has been struck through.  This manual letter supersedes IM 5102 “Premium and Enrollment Fees for Children with Disabilities and Workers with Disabilities Coverages”, IM 5104 “Children’s Hospice Program”; IM 5109 “Asset Limits for the Medicare Savings Programs”; and IM 5110 and AMENDED IM 5110 “Average Cost of Nursing Facility Care”. 

Definitions 510-05-05
The definition of the SSI Buy-in has been added to this section.  The definition of a Good faith effort to sell had language added to clarify that, for real estate and mobile homes, a realtor is considered the regular market.

Good faith effort to sell
An honest effort to sell in a manner which is reasonably calculated to induce a willing buyer to believe that the property offered for sale is actually for sale at a fair price. A good faith effort to sell includes, at a minimum, making the offer at a price based on an appraisal, a market analysis by a realtor, or another method which produces an accurate reflection of fair market value, in the following manner:
1.	To any co-owner, joint owner, possessor, or occupier of the property, and, if no buyer is thereby secured;
2.	To the regular market for such property, if any regular market exists, or, if no regular market exists (a realtor is considered the regular market for real estate, including mobile homes);
3.	By public advertisement for sale in a newspaper of general circulation, the circulation area of which includes the location of any property resource offered for sale, which advertisement was published successively for two weeks if the newspaper is a weekly publication and for one week if the newspaper is a daily publication, and which includes the selling price, a plain and accurate description of the property and the name, address, and telephone number of a person who will answer inquiries and receive offers.

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

Improper Payments and Suspected Recipient Fraud 510-05-10-25
This section has been reworded and language added to identify what constitutes a recipient error, to clarify that actual income is used in determining the correct amount of recipient liability when determining an overpayment, to reflect the change in policy that now requires all recipient errors to be sent to the Surveillance Utilization Review (SURS) unit (instead of to the States Attorney) and that SFN20 be used. 

Improper payments can result from agency errors, recipient errors, and provider errors.  All reasonable and practical steps must be taken on all errors to prevent further overpayments, waste, or abuse. 
1.	Agency caused errors do not result in an overpayment that the recipient is responsible to repay, however, the error must be corrected to prevent further overpayments from occurring.
2.	Suspected provider related errors must be reported to the Surveillance Utilization Review (SURS) Unit in the Medical Services Division using SFN 20, “SURS Referral Form.” SFN 20 may be sent to SURS as described in 6 below.  The SURS unit will be responsible for recoupment from any provider. 
3.	Recipient errors may occur as a result of:
a.	Assistance granted pending a fair hearing decision subsequently made in favor of the county agency;
b.	Payment that was provided as a result of a medical expense or increased medical need for a given time period (i.e. medical care payments);
c.	Failure to report income or disclose assets;
d.	Failure to report other changes that affect eligibility or benefits, such as a change in household member composition, etc;
e.	Recipient misunderstanding;
f.	Disqualifying transfers; and 
g.	Medicaid ID card sharing.
4.	Any currently discovered overpayment, whether resulting from a recipient error, from assistance granted pending a fair hearing decision subsequently made in favor of the county agency, or from payment that was provided as a result of a medical expense or increased medical need for a given time period, is subject to recovery. No distinction is made between willful and nonwillful withholding of or failure to report information that affects eligibility. Overpayments are established on recipient errors in which Medicaid funds were misspent regardless of the reason the error occurred.
5.	The amount of a recipient error is determined as follows:
1a.	For ineligible cases resulting from excess assets, the amount of the overpayment is the lesser of:
a.i.	The amount of Medicaid payments paid in error on behalf of the Medicaid unit; or
b.ii.	The difference between the actual amount of excess assets and the Medicaid asset limit.
2b.	For overpayments resulting from errors related to incorrect recipient liability, the amount of the overpayment is the lesser of:
a.i.	The amount of Medicaid payments paid in error on behalf of the Medicaid unit; or
b.ii.	The difference between the correct amount of recipient liability (using actual income) and the amount of the recipient liability met by the Medicaid unit.
3c.	For overpayments resulting from any other error, the amount of the overpayment is the amount of Medicaid payments paid in error on behalf of the Medicaid unit.
 
6.	The county agency must promptly take all reasonable and practical steps to correct the overpayment. All recipient errors in which there is an overpayment or suspected fraud (regardless of overpayment) must be referred to the Surveillance Utilization Review (SURS) Unit in the Medical Services Division using SFN 20, “SURS Referral Form.” SFN 20 may be sent to SURS by:
a.	Mail: SURS, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505; 
b.	Fax: 701-328-1544; or 
c.	Email: medicaidfraud@nd.gov.  

A copy of SFN 20 must also be sent to the Estate Recovery Unit when the error includes an overpayment.  SFN 20 may be sent to the Estate Recovery Unit by: 
a.	Mail: Estate Recovery Unit, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505; 
b.	Fax: 701-328-1060; or 
c.	Email: dhseap@nd.gov.  

states attorney’s office with copies to the regional representative and the Estate Recovery Unit at the Department. Refer to Service Chapter 449-35-05 for additional information regarding referrals and follow-up on suspected fraud.
 
7.	Any repayment of an overpayment received at the county agency must be submitted to the Fiscal Administration unit using SFN 828, "Credit Form" (05-100-55). 

Liens and Recoveries 510-05-10-30
Language was added to subsection 2 to clarify that an outstanding overpayment due to recipient error that is not repaid during the recipient’s lifetime is subject to estate recovery regardless of the recipient’s age or whether or not there is a surviving spouse.

2.	A recovery of Medicaid correctly paid will be made from the estate of an individual who was 55 years of age or older when the recipient received such assistance. Recovery is pursued only after the death of the recipient's spouse, if any, and only at a time when the recipient has no surviving child who is under age 21, or who is age 21 or older and who is blind or permanently and totally disabled as defined by the Social Security Administration. The recovery of Medicaid paid for individuals under age 65 is only for assistance paid on or after October 1, 1993. Medicaid benefits incorrectly paid because of a recipient error can be recovered regardless of the individual’s age at the time the assistance was received.  Overpayments due to recipient errors that are still outstanding are subject to recovery upon the individual’s death without regard to whether or not there is a surviving spouse.  

Home and Community Based Services (HCBS) 510-05-15-05
Subsection 7 was amended to reflect the policy change for the Money Follows the Person Grant, the individual needs to have resided in the institutional setting for only 3 months rather than the 6 months previously indicated.   Subsection 9 was added to this section to include information on the Children’s Hospice Program, a waivered service effective July 1, 2010.  This addition in policy supersedes IM 5104.  Subsection 10 was added to include information on the Autism Spectrum Disorders Waiver for Birth Through Age 4 Program, a waivered service effective November 1, 2010.  
 
7.	Money Follows the Person Grant:  This Grant program assists recipients who are residing in a nursing facility or an ICF/MR who want to transition from an institutional care setting to a HCBS setting. Recipients must have been residing in the institutional setting for a period of 63 consecutive months or more, be screened as requiring care in a nursing facility or ICF/MR, and be Medicaid eligible for at least 30 days immediately prior to transition. (Began June 20, 2008.)

9.	Children’s Hospice Program:  Provides multiple services to children from birth to their 22nd birthday who have been screened as needing Nursing Home level of care and who have less than a year of life expectancy.  The services are designed to assist the family in dealing with the diagnosis and emotions a family needs to deal with when preparing for the possible death of their child.  This waiver allows a family to continue to explore curative measures at the same time they are utilizing hospice services.  The waiver is limited to 30 recipients in a 12-month period. (Began July 1, 2010.)
10.	Autism Spectrum Disorders Waiver for Birth Through Age 4:   Provides multiple services to a family with a child from birth to their 5th birthday who are eligible for Developmentally Disabled Program Management, have a confirmed diagnosis on the   Autism Spectrum , meet the ICF/MR level of care, and are eligible for Medicaid.  These services build on existing services available in North Dakota.  Families will also receive training, help in coordinating services, and access to in-home support staff to help provide structured activities that focus on communication, behavior, and other individual needs.  The waiver also provides financial help with the cost of equipment, supplies, and environmental modifications.  The waiver is limited to 30 recipients in a 12-month period.  (Began November 1, 2010.)

Application and Redetermination 510-05-25-05
Language was added to clarify when a redetermination form is not required, and when available information should not again be requested.

2.	Redetermination.
a.	A recipient has the same responsibility to furnish information during a redetermination as an applicant has during an application.
b.	A redetermination must be completed at least annually using the Department's:
i.	System generated "Monthly Report";
ii.	System generated "Redetermination of Eligibility;"
iii.	SFN 407, "Redetermination for Healthcare Coverage";
iv.	SFN 642, "Title IV-E/Title XIX Redetermination-Foster Care" for children in Foster Care, or other confirmation from  a state IV-E agency (in state or out of state) that verifies continued IV-E foster care eligibility;
v.	SFN 856, "Adoption Subsidy Agreement - Annual Review" for subsidized adoption, or other confirmation from a state IV-E agency (in state or out of state) that verifies continued IV-E subsidized adoption  eligibility; or
vi.	One of the previously identified applications completed to apply for another program.
In circumstances where a desk review is appropriate, such as when adding a child, moving to Transitional Medicaid Benefits, processing a change in the level of care, aligning redetermination dates with Healthy Steps, SNAP, or TANF, or adding Medicare Savings Programs coverage; to an existing case and in which the county agency has all information needed to complete a redetermination, eligibility may be established without a redetermination form. In unique circumstances, when the county agency has all information needed to complete a redetermination, and circumstances prevent a recipient or their representative from timely returning the redetermination form, continued eligibility may be established without a completed form.  In circumstances in which information needed to complete a redetermination is available through Healthy Steps, SNAP or TANF, that information should be used to redetermine eligibility without again requiring that information from the individual or family.  If all needed information is available, a redetermination can be completed without requiring a redetermination form.  Care must be used to ensure all needed information is on hand.

Groups Covered Under Medicaid 510-05-30-05
Language was added to subsections 1(j) and (k) to clarify that individuals eligible under these sections who are also eligible for Medicare Part B are eligible for the SSI Buy-In.

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 categorically eligible beginning with the month of the SSI application. Individuals age 21 or older who have been approved for SSI may be categorically eligible beginning the month following the month of SSI application. (If disabled in the month of SSI application, the individual age 21 or older may be medically needy eligible for that month.)  Individuals who qualify under this category who are also eligible for Medicare Part B are also eligible for coverage of their Medicare Part B premium (SSI Buy-In).
k.	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.  They also will continue to be eligible for coverage of their Medicare Part B premium (SSI Buy-In).
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 (SSI Buy-In).

Caretaker Relatives 510-05-35-15
Language was rearranged in subsection 1 to clarify when a caretaker relative may be eligible for Medicaid.

1.	Caretaker relatives may be eligible for Medicaid when they have a deprived child living with them. Caretaker relatives who are not a natural or adoptive parent, however, can only be eligible if the child is actually "living" with them, and is not just temporarily absent from the parental home, and if the caretaker relative is unmarried or married and not residing with their spouse or is an unmarried individual. The following individuals may be considered a caretaker relative:
a.	A natural or adoptive parent;
b.	A grandparent (including a great, great-great, or great-great-great- grandparent);
c.	A sibling (if age sixteen or older);
d.	An aunt or uncle (including a great or great-great aunt or great or great-great uncle);
e.	A niece or nephew (including a great or great-great niece or great or great-great nephew);
f.	A first cousin (an aunt or uncle’s child) or first cousin once removed (an aunt or uncle’s grandchild);
g.	A second cousin (a great aunt or great uncle’s child);
h.	A stepparent (if natural or adoptive parent is not in the home);
i.	A stepbrother or stepsister; or
j.	A spouse of any of the above individuals even after the marriage is terminated by death or divorce.

Certification of Need for Children in a Psychiatric Residential Treatment Facility (PRTF) or an Institution for Mental Diseases (IMD) 510-05-35-30
This section was renumbered and subsection 2 added to clarify that when a worker gets a long-term care alert, the worker needs to check the screening in the system.  If the screening shows the individual in an IMD or PRTF, the worker needs to make the appropriate changes to the client’s living arrangement.  If the screening is for psychiatric services in a general hospital, such as St. Alexius or Trinity, however, the worker may simply delete the alert and should make no change to the individual’s living arrangement.  Subsection 3 was also added to clarify that Medicaid only pays for the psychiatric services when a child is in an IMD and will not pay for services outside the facility.

1.	Children under age twenty-one who seek 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 IMD must obtain certification of need in order to be eligible for Medicaid. The certification of need must demonstrate:
1. a.	Necessity of treatment on an inpatient basis;
2. b.	That all community resources have been explored prior to admission; and
3. c.	The treatment to be provided can reasonably be expected to improve the condition.
For a person who attains age twenty-one while receiving treatment and continues to receive treatment as an inpatient, eligibility may continue through the month the individual attains the age of twenty-two.
2.	When a child enters a psychiatric unit in a general hospital or similar facility the child is not in an IMD and the child’s living arrangement is not changed.  A certification of need may be created for payment purposes only and will indicate what facility the child is in, so the certification of need must be reviewed to determine if the child’s eligibility is affected.
3.	A child who is residing in an IMD and who is certified as needing that level of care, is only eligible for coverage of the psychiatric services, and is not eligible for services outside of the facility.

Citizenship and Alienage 510-05-35-45
Language was added to Subsection 6(a) to include the change in Puerto Rico’s policy that the Puerto Rico birth certificate requirements apply only to applicants whose eligibility is determined for the first time on or after November 1, 2010.

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 13, 1941 (For applicants whose eligibility is determined for the first time on or after November 1, 2010, the birth certificate to be considered a valid birth certificate, it must have an issue date of on or after July 1, 2010, to be considered valid.)  
•	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 (For applicants whose eligibility is determined for the first time on or after November 1, 2010, the birth certificate must have an issue date of on or after July 1, 2010, to be considered valid. ,If a birth certificate is provided, it must have an issue date of on or after July 1, 2010)
•	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

Qualified Aliens 510-05-35-58
Language has been added to Subsection 6 to clarify that families of victims of trafficking may also be qualified aliens and the required documentation. Subsection 13 adds another type of qualified alien.  This is a change in policy.

6.	Victims of a severe form of trafficking and their families (aliens granted nonimmigrant status under 101(a)(15)(T) of the Immigration and Nationality Act who have a pending application that sets forth a prima facie case for eligibility for that nonimmigrant status):
a.	I-94 showing codes T-1 or T-2;
b.	I-94 or passport showing non-immigrant status under 101(a)(15)(T);
c.	I-688B or I-766 showing 247a.12(a)(16), A16, 274a.12(c)(25) or C25;
d.	Other INS document showing nonimmigrant status under 101(a)(15)(T); 
e.	Any verification from the INS or other authoritative documents showing non-immigrant status under 101(a)(15)(T).

13.	Aliens granted conditional entry under section 203(a)(7) of the Immigration and Nationality Act in effect prior to April 1, 1980:
a.	I-94 or other document showing “conditional entrant”, “refugee conditional entry”, “seventh preference”; “section 203(a)(7)”; “P7” ;
	b.	I-688B annotated “274a.12(a)(3);
	c.	I-766 annotated “A3”; or
d.	Any verification from the INS or other authoritative document.

Aliens Lawfully Admitted for Permanent Residence on or After August 22, 1996 510-05-35-65
Language was changed to the note under subsection 1 to clarify that if a qualified alien  that has been admitted as a Lawful Permanent Resident (LPR), has the codes indicated in Section 510-05-35-58 on their Permanent Resident Card (I-151 or I-551), that individual retains that status.  If the code on the Permanent Resident Card is not that same status, then the individual is subject to the 5–yr ban or forty qualifying quarter requirements. (Example, an asylee entered as an AS1 (which shows on his I-94 card).  He has now become a LPR and his code on his I-551 is AS8.  He is still an Asylee and a qualified alien.  If his LPR code had been issued as an SD6, which is not a qualified alien code instead of the AS8, he is subject to the 5-year ban or the forty-quarter requirements). 
 
1.	Aliens admitted for Lawful Permanent Residence (LPR) on or after August 22, 1996 are banned from Medicaid, for five years from the date they entered the United States. After the five-year ban, aliens who are lawful permanent residents who can be credited with forty qualifying quarters of social security coverage may be eligible for Medicaid.
Verifications of this status are:
a.	Form I-551 or I-151 (Resident Alien Card) (these are also known as ‘green cards’ but are not green);
b.	Foreign passport stamped LPR or I-551.
Note: If a refugee’s qualified alien’s status has changed to LPR, the codes at 510-05-35-58 apply.  If the code on the Permanent Resident Card is not in 510-05-35-58, the individual is subject to the 5–yr ban and forty qualifying quarter requirements.
Example, an asylee entered as an AS1 (which shows on his I-94 card).  He has now become a LPR and his code on his I-551 is AS8.  He is still an Asylee and a qualified alien.  If his LPR code had been issued as an SD6, which is not a qualified alien code instead of the AS8, he is subject to the 5-year ban or the forty-quarter requirements.

Emergency Services for Non-Citizens 510-05-35-70
Language was added to subsection 3 to clarify the time period for which eligibility under this coverage would be allowed for a pregnant woman at time of delivery.

Illegal aliens, permanent non-immigrants (identified in subsection 3 of 05-35-55), and qualified aliens, who are not eligible for Medicaid because of the time limitations or forty qualifying quarters of social security coverage requirement, may be eligible to receive emergency services that are not related to an organ transplant procedure, if all of the following conditions are met:
1.	The alien has a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
a.	Placing health in serious jeopardy;
b.	Serious impairment to bodily functions; or
c.	Serious dysfunction of any bodily organ or part.
2.	The alien meets all other eligibility requirements for Medicaid except illegal aliens do not have to meet the requirements concerning furnishing social security numbers and verification of alien status; and
3.	The alien’s need for the emergency service continues. Eligibility for Medicaid ends when the emergency service has been provided, and does not include coverage of follow-up care if the follow-up care is not an emergency service. A pregnant woman may be covered from the date she entered the hospital for labor and delivery through the date she was discharged.  A pregnant woman who delivers a child and is covered under this provision is not eligible for the sixty-day period of eligibility after pregnancy. Her child, however, is a citizen and may be eligible for the sixty-day period.  

State Residence 510-05-35-85
Language has been added to the introductory paragraph and subsection 1 to clarify that when an individual moves here from another state, they are considered a resident of ND as of the date of arrival and can become eligible for Medicaid as of that date, even if the individual is covered for the rest of that month in the other state, (unless the worker is aware that the previous state is covering the care in ND).  Language was added to subsection 8 to clarify that the Minnesota reciprocity agreement is specific to individuals who are institutionalized in another state.  

An individual must be a resident of North Dakota to be eligible for Medicaid through this state.  A resident of the state is an individual who is living in the state voluntarily and not for a temporary purpose. Temporary absences from the state with subsequent returns to the state, or intent to return when the purpose of the absence has been accomplished, do not interrupt continuity of residence. Residence is retained until abandoned or established in another state.

1.	For individuals entering the state, the earliest date of eligibility residency is the date of entry.  Residence may not be established for individuals who claim residence in another state.
An individual’s Medicaid case may remain open in the other state for a period of time after the individual moves, however, most states will not cover out-of-state care so eligibility may be determined as of the date the individual entered the state.   If it is known that the other state will pay for the care in North Dakota, wait to open the case until the other state stops the coverage.  Likewise, when an individual leaves the state, eligibility is ended as soon as, and in accordance with, proper notice.  North Dakota Medicaid will no longer extend coverage through the month in which an individual moves out of the state.  
8.	If an interstate reciprocal residency agreement has been entered into between this state and another state pursuant to 42 CFR 435.403(k), the state of residence of an affected individual is the state determined under that agreement.
North Dakota has an interstate reciprocal residency agreement with nine states. The agreement provides that individuals of any age institutionalized in one of these states are considered a resident of the state in which they are institutionalized.
The states with whom we have the agreement are:
California	New Mexico	Tennessee	
Florida	Ohio	Texas	
Kentucky	Pennsylvania	Wisconsin	
 
North Dakota also has a specific agreement with the State of Minnesota. The agreement states that individuals who enter a nursing facility in the other state remain a resident of the state they were a resident of prior to admission into the nursing facility for 24 months following admission, and if the individual has a community spouse, they continue to be a resident of the state the community spouse lives in beyond the 24 month time limit. This agreement terminates at the point the individual is discharged from a nursing facility unless the individual is being transferred to a different nursing facility.

Inmates of Public Institutions 510-05-35-95
An example was added to Subsection 3 to clarify treatment of an inmate who is released to a hospital to deliver her baby.  Language has also been added to include information from FYI 07-024 to clarify treatment of individuals who are in the Bismarck Transitional Assessment Center.  

3.	Individuals who are committed under the penal system to a public institution are not eligible for Medicaid even though they may be receiving care in a medical facility. For example, a release from a penal institution to a hospital for the birth of the inmate’s child will not terminate inmate status if the inmate is required to return to the penal institution following discharge from the hospital.  Inmate status at a penal facility (correctional) begins at the time of confinement. 
Residence in the institution is terminated by parole, discharge, release on bond, or whenever the individual is allowed to return and reside in their home. A transfer from a penal facility to the state hospital or another facility, for evaluation or treatment does not terminate inmate status. 
The Bismarck Transition Center (BTC) is a comprehensive, community-based correctional program designed to help eligible, non-violent offenders transition back into the community. 
a.	Individuals entering this facility on a voluntary basis while on probation are not inmates.  
b.	Individuals entering this facility as inmates who are sent to the facility for assessment purposes are committed under the penal system and will be arrested if they leave.  Such individuals are inmates and not eligible for Medicaid.  

"Good Cause" -- Child Support 510-05-40-20
Language is added in subsection 1 to recognize that applicants are provided the notice and opportunity to claim “good cause” for non-cooperation with child support on the application forms, and to clarify that the SFN 443 must still be used to inform other caretakers of their right to claim good cause.  The second paragraph of subsection 5 has been changed to remove reference to contacting the absent parent in determining whether there is good cause.
 
The requirement to cooperate may be waived when a legally responsible caretaker relative has "good cause" not to cooperate.
1.	All legally responsible caretaker relatives must be given the opportunity to claim "good cause".   Applicants are notified of their rights to claim good cause in the SFN 405, Application for Assistance, DN 405, the Application for Assistance Guidebook, and the SFN 502, Application for Health Care Coverage for Children, Families and Pregnant Women.  Applicants can indicate their request to claim good cause in either application.   Recipients who become subject to the cooperation requirements may be notified This is accomplished by providing each legally responsible caretaker with SFN 443, "Notice of Right to Claim 'Good Cause'" (05-100-45). The notice briefly summarizes the legislative intent of child support enforcement, defines the caretaker's responsibility to cooperate in the support enforcement effort, and advises them of their right to claim "good cause". The notice also describes circumstances under which cooperation may be "against the best interests" of the child or caretaker and cites the kinds of evidence needed to substantiate a claim.
A legally responsible caretaker wishing to claim "good cause" may do so by completing SFN 446, "Request to Claim 'Good Cause'" (05-100-50).
If "good cause" is claimed, the caretaker relative can be eligible for Medicaid while the decision is pending.
5.	The county agency is directly responsible for investigating a "good cause" claim when it believes that the caretaker's claim is authentic, even though confirming evidence may not be available. When the claim is based on a fear of serious physical harm and the claim is believed by county agency staff, investigation may be conducted without requiring corroborative evidence by the caretaker. It may involve a careful review of the case record, evaluation of the credibility of the caretaker’s statements, or a confidential interview with an observer who has good reasons for not giving a written statement. Based on such an investigation, and on professional judgment, the county agency may find that "good cause" exists without the availability of absolute corroborative evidence.
While conducting an investigation of a "good cause" claim, care must be taken to ensure that the location of the child is not revealed. In some circumstances, contact with the absent parent or alleged father may be deemed necessary to establish the claim. Before doing so, however, the caretaker must be notified of this in order to be afforded the opportunity to present additional information that makes contact with the absent parent unnecessary, to withdraw the application or have the case closed, or to have the "good cause" claim denied.
Except for extenuating circumstances, the "good cause" issue must be determined with the same degree of promptness as for the determination of other factors of eligibility (45 days). The county agency may not deny, delay, or discontinue assistance pending the resolution of the "good cause" claim. In the process of making a final determination, the county agency is required to give Child Support Enforcement staff the opportunity to review and comment on the findings and basis for the proposed decision. It is emphasized, however, that responsibility for the final determination rests with the county agency.

Transitional Medicaid Benefits 510-05-50-05
Language has been added to subsection 7(b) to clarify that, in the month 7 and 10 budgeting, we look only at the earned income and childcare expenses of the individuals in the Transitional Medicaid Unit plus the income of any ineligible natural parents, adoptive parents, or stepparents. Items were also added to clarify when children are not included in the budget unit.

7.	Budgeting in the second six-month period:
a.	The county agency must send a notice to the recipient in months six and nine, informing the recipient to report earnings and child care expenses. The recipient must report and verify income and child care expenses for the fourth, fifth, and sixth months by the twenty-first day of the seventh month, and for the seventh, eighth, and ninth months by the twenty-first day of the tenth month. Verification of earnings is required.

b.	All earned income of the eligible individuals in the eligible for   Transitional Medicaid benefits unit must be considered in determining eligibility for the second six month period, plus earned income of ineligible natural parents, adoptive parents, or stepparents.

A child who is not eligible for Transitional Medicaid benefits is not included in the family size and the earned income and child care expenses of the child are not considered.

Unborn children do not increase the family size.
In determining the amount of countable earned income, the medically needy income disregards (including the extra check disregard) and the self-employment percentage disregards do not apply.

Foster Care 510-05-55-05
Subsection 3 is removed and the rest of this section renumbered to implement the change in policy that a permanency plan is no longer required for a child to be considered in foster care for Medicaid purposes.  CFS confirmed there is a new rule to have a permanency plan in place within 30 days or before a child can leave foster care, as it is not always possible to have one in writing at the onset.

 For Medicaid purposes, a child is not considered to be in foster care unless all of the following requirements are met:
1.	There is a current foster care court order;
2.	A public agency has care, custody, and control of the child;
3.	There is a service plan (permanency plan) in place for the child;
3.4.	The child is residing in an approved licensed foster care home or facility (a Psychiatric Residential Treatment Facility (PRTF) is not a licensed foster care facility); and
4. 5.	The child is a foster care child in the state foster care system through the state's Children and Family Services unit, or a Tribal 638 Foster Care child.  

Volunteer Placement Program 510-05-55-15
The second paragraph of this section has been changed to recognize the change in the agency responsible for approving these placements.

The child must be Medicaid eligible to cover medical expenses and the cost of treatment. The Volunteer Placement Program pays the room and board for the child to the county foster home or to the facility. The Administrators of the Volunteer Placement Program, Children and Families Services, and Juvenile Court  and Mental Health and Substance Abuse must approve any placement in the Volunteer Placement Program.

Individuals Covered (Workers with Disabilities) 510-05-57-10
Language added to subsection 1(e) includes the American Recovery and Reinvestment Act (ARRA) of 2009 mandate that an Indian can no longer be charged enrollment fees.  This supersedes IM 5102 and is effective July 1, 2009.

1.	An individual may be enrolled under the Workers with Disabilities coverage if he or she:
a.	Is gainfully employed;
b.	Is at least sixteen, but less than sixty-five, years of age;
c.	Is disabled;
d.	Is not in receipt of any other Medicaid benefits under this chapter other than coverage as a QMB or SLMB; and 
e.	Pays a one-time, per lifetime, enrollment fee of $100.  Indians who are enrolled members of a Federally-recognized Indian tribe are exempt from this requirement.

Premiums for Workers with Disabilities 510-05-57-35
Language added to subsection 1 includes the American Recovery and Reinvestment Act (ARRA) of 2009 mandate that an Indian can no longer be charged premiums.   This supersedes IM 5102 and is effective July 1, 2009.  

1.	Individuals eligible under the Workers with Disabilities coverage are required to pay a monthly premium amount equal to 5% of the individual’s gross countable income. Premiums are computed on a monthly basis and are rounded to the nearest dollar.  Indians who are enrolled members of a Federally-recognized Indian tribe are exempt from this requirement.

Premium Calculation for Children with Disabilities 510-05-58-30
Language added to subsection 1 includes the American Recovery and Reinvestment Act (ARRA) of 2009 mandate that an Indian can no longer be charged premiums.  This supersedes IM 5102 and is effective July 1, 2009.  

1.	Individuals eligible under the Children with Disabilities coverage are required to pay a monthly premium amount equal to 5% of the family’s gross countable income. Premiums are computed on a monthly basis and are rounded to the nearest dollar.  Indians who are enrolled members of a Federally-recognized Indian tribe are exempt from this requirement.

Individuals Covered and Benefits 510-05-60-10
A new lead-in paragraph has been added to this section to clarify that the SSI Buy-In is the primary coverage for those who could qualify under either the SSI Buy-In or the Medicare Savings Programs.

Individuals who are eligible under the SSI Buy-In program are not eligible to be covered under the Medicare Savings Programs for the same time period.  The SSI Buy-In program is the primary coverage for individuals who could qualify under both programs.  
Exception: For individuals whose fluctuating income causes them to ‘bounce’ off and on SSI, the preferred coverage is under the Medicare Savings Program during the period of fluctuating income.

Asset Limits for the Medicare Savings Program 510-05-60-20
This section is updated to reflect the increase in the asset limits effective January 1, 2011 for the Medicare Savings Programs.   This is per the requirements of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and supersedes IM 5109.
 
No person may be found eligible for the Medicare Savings Programs unless the total value of all non-excluded assets does not exceed the limit established for the Medicare Part D Low Income Subsidy.  This amount changes annually. Effective with the benefit month of January 2011 2010, the limits are:
 
1.	$6,680 $6,600 for a one-person unit ($6,600 in 2010 $4,000 in 2009); or
2.	$10,160 $9,910 for a two-person unit ($9,910  in 2010$6,000 in 2009):.

Definitions for Spousal Impoverishment 510-05-65-10
Item (c) has been added to subsection 1 to clarify that if a Community Spouse requires care in a medical institution, a nursing facility, a swing bed, or in the state hospital, and the total length of the stay is anticipated to be more than a full calendar month, they are no longer treated as a community spouse and the case can no longer be processed under the spousal impoverishment provisions.

For purposes of the spousal impoverishment sections:
1.	"Community spouse," means the spouse of an institutionalized spouse or the spouse of a Home and Community Based Services (HCBS) spouse who is:
a.	Not financially responsible for a child who is in receipt of Medicaid; and
b.	Not in receipt of Medicaid other than coverage under the Medicare Savings Programs. ; and
c.	Not requiring care in a medical institution, a nursing facility, a swing bed, or in the state hospital, unless the total length of the stay is anticipated to be less than a full calendar month.

Institutionalized Spouse or Home and Community Based Services (HCBS) Spouse Asset Limit 510-05-65-15
Example 3 has been added under subsection 3 (b) to clarify what occurs in the situation where the Institutionalized spouse receives an amount that exceeds the amount that will allow a new period to transfer assets.
 
3.	After eligibility has been established, the institutionalized or HCBS spouse must reduce his or her countable assets (solely or jointly owned) to be within the medically needy asset limit ($3,000) not later than the next regularly scheduled redetermination.
If the assets are not reduced to the asset limit by the next regularly scheduled redetermination, the individual's case must be closed. Verification of the reduction in assets must be provided.
When an eligible institutionalized or HCBS spouse exceeds the asset limit due to an increase in the value of, a change in the exclusion of, or the receipt of assets, a new period, until the next regularly scheduled redetermination, may be allowed in order to transfer the excess assets to the community spouse. The amount of assets to which this new period applies is an amount equal to the difference between the current community spouse's asset allowance and the value of assets owned by the community spouse at the time eligibility was established, less the value of assets transferred to the community spouse. 
Example:  The community spouse has an asset allowance of $70,000. At the time eligibility was established, the community spouse owned $30,000 and the institutionalized spouse transferred $25,000 to the community spouse by the first redetermination.  If the institutionalized spouse received new assets in excess of the $3,000 asset limit, the institutionalized spouse is allowed until the next regularly scheduled redetermination to transfer up to $15,000 to the community spouse ($70,000 less $30,000 owned by community spouse less $25,000 previously transferred to community spouse equals $15,000 that can still be transferred).
This new period is not allowed if: 
a.	The community spouse had assets equal to the community spouse asset allowance at the time the institutionalized or HCBS spouse became eligible; or
b.	The community spouse has since received assets from the institutionalized or HCBS spouse up to the community spouse asset allowance.
The following examples illustrate:
Example 1:  The community spouse had an asset allowance of $90,000. At the time of eligibility, the community spouse owned all $90,000 in countable assets. No new period is allowed to transfer additional assets to the community spouse.
Example 2:  The community spouse had an asset allowance of $80,000. At the time of eligibility, the community spouse owned $50,000 in countable assets.  The institutionalized spouse has since transferred an additional $30,000 to the community spouse. The community spouse has received assets up to the community spouse asset allowance so no new period is allowed to transfer additional assets to the community spouse.  
Example 3:  The community spouse had an asset allowance of $25,000.  At application, the couple has $12,000 in countable assets and they have until the next redetermination to transfer at least $9,000 to the community spouse, which they do.  Several months later, the institutionalized spouse inherits $12,000. Because the community spouse still may receive an additional $16,000 and the institutionalized spouse has only $12,000 over his $3,000 asset limit, the institutionalized spouse can have until the next redetermination to transfer at least $12,000 to the community spouse.  The transfer is made, bringing the community spouse’s total countable/received assets up to $21,000.  The institutionalized spouse inherits another $10,000.  The community spouse has already received $21,000 of the $25,000 asset allowance.  Because the amount that the institutionalized spouse’s asset limit is exceeded is greater than the amount that would allow for another transfer period, no new transfer period is allowed.  Unless the institutionalized spouse transfers the excess amount to the community spouse in the month it was received, his case must be closed for excess assets.

Breast and Cervical Cancer Early Detection Program 510-05-67
General Information 510-05-67-05
Language was added to Subsection 1 to clarify that women who are eligible for Medicaid as a medically needy individual with a recipient liability who also meet the other criteria for the Women’s Way program have a choice as to which coverage they prefer.  

The breast and cervical cancer early detection group consists of women under age sixty-five who:
1.	Are uninsured and not otherwise eligible for Medicaid.  (If otherwise eligible for Medicaid with a recipient liability, the woman can choose coverage  as Medically Needy with a recipient liability or through the Women’s Way program);
2.	Have been screened for breast and cervical cancer through the Women's Way Screening Program under the Centers for Disease Control and Prevention's breast and cervical cancer early detection program and have been found to require treatment for breast cancer, cervical cancer, or a precancerous condition relating to breast cancer or cervical cancer; 
3.	Have family income below 200% of the poverty level; and
4.	Meet the residence citizenship, social security number, and inmates of public institutions requirements.
 
The earliest date of eligibility is the month of diagnosis, but not more than three months prior to the month of application. Eligibility can continue until the woman reaches age 65, is no longer a state resident, is admitted to a public institution, is eligible for Medicaid through a different category, becomes insured, or no longer needs treatment for breast or cervical cancer. 
 
Eligibility for this group is will be determined by the Women’s Way program of the North Dakota Department of Health and the Medicaid Eligibility unit of the Department. Coverage for this group began July 1, 2001.

General Information 510-05-70-05
Language was added to the second paragraph of this section to clarify that there is no asset test for children who are eligible under the Children with Disabilities coverage.

These medically needy asset provisions apply to all aged, blind, and disabled applicants and recipients of Medicaid unless otherwise specified in this chapter.

There is no asset test for applicants and recipients who are applying, or are eligible, under the children and family categories, or the Children with Disabilities coverage, so the asset provisions do not apply to those individuals.
 
Asset Considerations 510-05-70-10
Language is added to subsection 4(b) to clarify that when a disabled child is living with only one parent, consider the assets of the parent with whom the child resides, but not the absent parent.

4.	All parental assets are considered actually available to a disabled child under age eighteen unless the child is living:
a.	Independently; or
b.	With a parent who is separated from the child's other parent, with or without court order, if the parents did not separate for the purpose of securing Medicaid benefits.  Only the assets of the parent the child is residing with must be considered.

Home Equity Limit 510-05-70-27
Paragraph 2 was updated to reflect the change in the Home Equity Limit as dictated by the Deficit Reduction Act to increase by the percentage increase in the Consumer Price Index-Urban as prescribed by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

The Deficit Reduction Act of 2005 established limits on the home equity an individual may have and still qualify for coverage of nursing care services through Medicaid.  

Applicants or recipients who apply for Medicaid coverage on or after January 1, 2006 are not eligible for coverage of nursing care services (which include HCBS) if the individual’s equity interest in the individual’s home exceeds $506,000 ($500,000 prior to January 1, 2011).  The applicant or recipient may, however, be eligible for other Medicaid benefits.
 
Excluded Assets 510-05-70-30
Language was added to subsection 2 to clarify that the good faith effort to sell rules apply to mobile homes the same as to real property and that a real estate agent is considered the regular market.  Subsection 3 (c) was reworded to clarify the amount to be used when a life insurance policy is designated for burial.  Subsection 17 was renumbered to subsection 18 and a new subsection 17 was added to be in compliance with Attachment 2.6-A of the ND State Medicaid plan.

2.	Property that is not saleable without working an undue hardship. Property that is not saleable without working an undue hardship means property which the owner has made a good faith effort to sell which has produced no buyer willing to pay an amount equaling or exceeding seventy-five percent of the property's fair market value, and which is continuously for sale. Property may not be included within this definition at any time earlier than the first day of the first month in which a good faith effort to sell is begun.
c.	When making a good faith effort to sell real property or a mobile home, wait to determine that it is non-saleable until the third month after the month in which the good faith effort began.  This provides a reasonable amount of time for offers to be received without loss of potential months of eligibility for an applicant.  If the property is determined to be non-saleable without working an undue hardship, the property must remain continuously for sale, and any offers received must be reported.  The three calendar months must include a good faith effort to sell through the regular market for the three calendar months.  For purposes of this provision, an offer to the regular market for real estate is made by listing the property with a professional real estate agent when the property is located in an area serviced by a professional real estate agent.
d.	When making a good faith effort to sell property other than real property, a mobile home, or an annuity, wait to determine eligibility until at least 30 days after the good faith effort has been made to determine if any offers are received. If the property is determined to be non-saleable without working an undue hardship, the property must remain continuously for sale, and any offers received must be reported. 
3.c.	Normally a life insurance policy is a countable asset valued at its cash surrender value, however, when a whole life insurance policy or an annuity is designated for burial, the prepayments on the life insurance policy or annuity are the total premiums that have been paid less amounts paid for any riders and less any withdrawals of premiums paid. They are identified as the "remaining cost basis." Premium payments made by insurance dividends or disability insurance plans do not increase the remaining cost basis.
If the life insurance policy or annuity has a cash surrender value that exceeds the remaining cost basis, the excess cash surrender value is considered accrued earnings and are excluded. The following are two examples showing how remaining cost basis and cash surrender value are applied to the burial provision:
Example 1: An applicant has a life insurance policy with a face value of $5000. The policy remaining cost basis is $2400 and the cash surrender value is $2900. The $2400 remaining cost basis is considered to be the designated burial. The excess cash surrender value of $500 is considered accrued earnings and is excluded. 
Example 2: An applicant has an annuity with a face value of $7000. The annuity remaining cost basis is $6200 and the surrender value is $6500. Only $6000 of the remaining cost basis is excluded for burial. The remaining $200 is counted toward the asset limit. The excess surrender value of $300 is considered accrued earnings and is excluded.
In these two examples, if the cash surrender value had been less than the remaining cost basis, there would be no earnings exclusion.
Withdrawals from life insurance policies that reduce the face value of the life insurance also reduce the remaining cost basis and cash surrender value of the policy. Some applicants may make withdrawals to reduce the value of the insurance policy in order to qualify for Medicaid. Such withdrawals do not affect the designation of the insurance for burial. 
Example: An applicant has a life insurance policy with a remaining cost basis of $7500 and a cash surrender value of $9000. The applicant intended the policy for his burial expenses. When the applicant applied for Medicaid, he withdrew (not borrowed) $3000 from the policy, and spent it down, so he could be asset eligible. By withdrawing $3000, the policy’s face value was reduced, the remaining cost basis was reduced to $4500, and the cash surrender value was reduced to $6000. The applicant’s current designated burial is $4500 with $1500 in earnings.
17.	Funds held in employer-sponsored retirement plans, but not private retirement plans.
18. 17.  Property connected to the political relationship between Indian Tribes and the Federal government:

General Information 510-05-70-45-05
Language is added to subsection 3 to identify the location of the annuity review cover sheet as well as the annuity checklists.

3.	Annuities may be submitted to the Medicaid Eligibility unit for assistance in determining whether the annuity is countable as an asset or whether a disqualifying transfer occurred. A copy of the entire annuity policy, the date of birth of the annuitant, and verification of the annuity purchase price and, if applicable, date of annuitization must be secured and submitted with the inquiry.  A review cover sheet is available on the DHS County Intranet web site under the “Medicaid-Healthy Steps/Hard Cards/Annuity Information” folder for those wishing to submit an annuity to the Medicaid Eligibility Unit.  Annuity checklists are also available in that folder for those workers wishing to make the determinations on their own.  There is a separate checklist depending on when the annuity was last purchased or changed.

Trusts 510-05-70-50
A new subsection f is added to subsection 3 to clarify that workers need to include the “Trust Review Document” along with the trust information that is submitted to the Legal Advisory Unit to ensure Legal has the information they need up front, and to avoid delays.

3.	Trusts may, or may not, make income or assets available to an applicant or recipient. Also, when an applicant or recipient creates a trust, assets put into the trust may be a disqualifying transfer. A thorough review of each trust is necessary to determine its effect, if any, on eligibility. Send trusts to the Legal Advisory Unit for review. When trusts are submitted for review, include all appropriate information so the trust may be reviewed in a timely manner.  When requesting a review of a trust document:
a.	Send the complete trust agreement (signed, dated, and notarized) and all pages and attachments; 
b.	If the trust is unwritten, describe the circumstances that you believe created the trust in a letter; 
c.	Provide verification of the value of each asset owned by the trust, when each asset was transferred to the trust, and who transferred the assets to the trust;
d.	Identify who is applying for which benefits (e.g. Medicaid nursing care, Medicaid no-nursing care, etc.); and
e.	Provide any other documents or information you think may be relevant (like schedules, powers of attorney, financial statements, etc.); and.
f.	Complete and include the Trust Review Document available on the DHS County Intranet website under the “Medicaid-Healthy Steps/Hard Cards/Trust” folder.

Valuation of Assets 510-05-70-60
A comma is added to subsection 3(a)(3) to clarify that it is the greater of two times the lease amount or the potential sale value of the mineral right, not 2 times the potential sale value.

3.	Real property:
a.	With respect to mineral interests:
i.	If determining current value (for sale or pending transfer):
1) Fair market value is the value established by good faith effort to sell. The best offer received establishes the value.
2) A good faith effort to sell means offering the mineral interests to at least three companies mineral rights in the area, or by offering for bids through public advertisement.
ii.	If determining a previous value for mineral rights sold or transferred in the past, fair market value is:
1) If producing, three times the annual royalty income.
a) Based on actual royalty income from the 36 months following the transfer; or
b) If 36 months have not yet passed, based on actual royalty income for the months that have already passed, and an estimate for the remainder of the 36 month period.
2) If not producing, but mineral rights are leased, two times the lease amount (based on the actual lease and not the yearly lease amount).
3) If not leased, the greater of two times the estimated lease amount, or the potential sale value the mineral rights, as determined by a geologist, mineral broker, or mineral appraiser.

Definitions 510-05-80-05
Subsection 9 has been updated to reflect the 2011 average cost of nursing facility care effective January 1, 2011.  This supersedes revised IM 5110 and AMENDED IM 5110.

9.	The average cost of nursing facility care is:
 
Year	Daily Rate	Monthly Rate	
2011	205.07	6238	
2010	195.55	5948	
2009	179.27	5453	
2008	165.59	5037	
2007	159.96	4865	
2006	152.33	4633	
2005	144.48	4395	
2004	137.59	4185	
2003	129.71	3945	
2002	127.05	3864	
July-Dec 2001	120.08	3652	
Jan-June 2001	109.98	3345	
2000	104.94	3192	
1999	97.68	2971	
1998	94.31	2869	
1997	89.00	2713	

Disqualifying Transfer Provisions 510-05-80-10
Language was added to subsection 1 to clarify that transfers by a parent of the parent’s assets will not affect a child’s coverage in a long-term care facility, nor will a child’s transfer of the child’s assets affect their parent’s coverage in a long term care facility, however, a parent’s transfer of a child’s assets may affect that child’s coverage in a long-term care facility, likewise a child’s transfer of a parent’s assets will affect their parent’s coverage in a long-term care facility.

1.	An individual is ineligible for nursing care services if the individual or the spouse of the individual disposes of assets or income for less than fair market value on or after the look-back date. (Transfers by a parent of the parent’s assets do not affect a child’s coverage of nursing facility services and vice versa transfers by a child of the child’s assets do not affect the parent’s coverage.)

Income Considerations 510-05-85-05
Language has been added to subsection 1 to include the change in policy allowing a hardship exception in certain circumstances when a delinquent debt owed to the federal government is being deducted from the individual’s title II (SSA) or SSI benefits.  The last paragraph in this section has been moved to the second paragraph in further clarification.

1.	All income which is actually available must be considered. Income is actually available when it is at the disposal of an applicant, recipient, or responsible relative; when the applicant, recipient, or responsible relative has a legal interest in a liquidated sum and has the legal ability to make the sum available for support, maintenance, or medical care; or when the applicant, recipient, or responsible relative has the lawful power to make the income available or to cause the income to be made available. 
An individual may have rights, authority, or powers that he or she does not wish to exercise. An example includes an individual who allows a relative to use excluded or exempted assets free or at a reduced rental. In such cases, a fair rental amount will be counted as available income whether the applicant or recipient actually receives the income.
Income that is withheld because of garnishment or to pay a debt or other legal obligation is still considered available.
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 debts owed to the federal government may be collected from an individual’s Title II benefit. These other reductions of Title II benefits are generally not allowed to reduce the countable benefit amount. The award amount of the Title II benefit is counted as available. except to the extent an undue hardship is approved for the individual.  
Requests for undue hardship exceptions must be submitted to the Medicaid Eligibility Unit where a determination will be made whether an undue hardship exists.  An undue hardship may be determined to exist for all or a portion of the debt owed, or all or a portion of the reduction from the monthly income.
An undue hardship will be determined to exist only if the individual shows all of the following conditions are met:
a.	The debt is a debt owed to the Federal government;
b.	The deduction from the individual’s Title II benefit was non-voluntary;
c.	The amount of the deduction exceeds the Medicaid income level(s) to which the individual and the individual’s spouse is subject;
d.	The individual has exhausted all lawful avenues to get the reduction waived, forgiven, or deferred; and
e.	The individual or their spouse do not own assets that can be used to pay for the debt. 
An individual may have rights, authority, or powers that he or she does not wish to exercise. An example includes an individual who allows a relative to use excluded or exempted assets free or at a reduced rental. In such cases, a fair rental amount will be counted as available income whether or not the applicant or recipient actually receives the income.

Unearned Income 510-05-85-15
Language is added to Subsection 2 to clarify that the additional amounts of the adjusted SSA payments received towards the end of the year are considered  non-recurring lump sums.  Language is added to Subsection 5(a) to clarify that sick pay or disability payments paid to an individual are considered unearned income.

2.	All nonrecurring unearned lump sum payments, except health or long-term care insurance payments, Veteran's Administration aid and attendance, Veteran's Administration reimbursements for unusual medical expenses, and Veteran’s Administration homebound benefits intended for medical expenses, must be considered as income in the month received and assets thereafter.  
Lump sum retroactive adjustment payments from the SSA due to changes in the individual’s earning record are considered nonrecurring lump sums.

5.	Types of unearned income include but are not limited to:
a.	Income from pension and benefit programs, such as Social Security, Railroad Retirement, veteran’s pension or compensation, veteran's vocational rehabilitation subsistence payments, unemployment compensation (including disaster assistance unemployment compensation), employee or individual pension plans and annuities, union compensation during strikes, Workforce Safety & Insurance, public or private disability payments for an individual, etc.

Earned Income 510-05-85-20
Language was added under subsections 4(b) and (d) to clarify that labor or wages included under cost of goods sold on the individual’s self-employment schedules must be deducted from the cost of goods sold before deducting cost of goods sold from the gross receipts of the activity.  New subsection 4 (j) was added to clarify that each household member that is involved in a self-employment activity must have their share of the self-employment income calculated.
4.	Calculating "self-employment" income:
b.	Self-employed persons whose business requires the purchase of goods for resale. Examples of this type of business enterprise include Avon, Tupperware, Amway, Mary Kay Cosmetics, etc. 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. In these instances, subtract the cost of the goods (if cost of goods sold includes any labor or wage amounts, those amounts must be deducted from the cost of goods sold amount before subtracting the cost of goods sold from the gross receipts) from the gross monthly or annual receipts to arrive at the adjusted gross income. When the tax return is used, one twelfth of the annual adjusted gross income is monthly earnings. The first 25% of the adjusted gross income shall be disregarded to offset the costs of producing the income and will cover such things as sample kits, demonstrations, supplies, etc. Seventy-five percent of the adjusted gross income will be the monthly income to which the appropriate earned income deductions are applied to arrive at monthly net income.
d.	Self-employed persons in a service business requiring purchase of goods or parts for repair or replacement. These include mechanics, TV repairmen, beauty salons, restaurants, etc. 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. In this instance, subtract the cost of goods or parts (if cost of goods sold includes any labor or wage amounts, those amounts must be deducted from the cost of goods sold amount before subtracting the cost of goods sold from the gross receipts) from the gross monthly or annual receipts to arrive at the adjusted gross income. When the tax return is used, one-twelfth of the annual adjusted gross income is monthly earnings. The first 75% of the adjusted gross monthly income shall be disregarded to offset the cost of expenses such as heat, lights, phone, rent, or building, etc. The remaining 25% of the adjusted gross income will be the monthly income to which the appropriate earned income deductions are applied to arrive at monthly net income.
j.	Once self-employment income is caluculated, it is divided by the number of individuals listed on the self-employment schedules.

Disregarded Income 510-05-85-30
Language is added to subsection 12 to clarify that the extra check disregard is applied only to earned and unearned income, not self-employment. 

12.	Extra checks received by individuals who are paid weekly or bi-weekly. The check may be from earned (but not self-employment) or unearned income. The last check received in the month is always considered the extra check. For individuals paid weekly, it is the fifth check and for individuals paid bi-weekly, it is the third check. Bonus checks, or checks for any other reason, are not considered extra checks; 

Income Levels 510-05-85-40
This section is updated to reflect the change in the Federal Poverty Levels effective 04-01-11.

2.	Medically needy income levels.
Number of Persons	Monthly Income Level	
1	 $750  754	
2	 1008  1018 	
3	 1267  1282	
4	 1526  1546	
5	 1784  1811	
6	 2043  2075	
7	 2302  2339	
8	 2560  2603	
Effective July 1, 2009  April 1, 2011	
For each person in the medically needy unit above eight, add $259 $265 to the monthly amount.

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	 $ 903  908	
2	   1215  1226	
3	   1526  1545	
4	   1838  1863	
5	   2150  2181	
6	   2461  2500	
7	   2773  2818	
8	   3085  3136	
Effective April 1, 2009  2011	
For each person in the Medicaid unit above eight, add $312 319 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 Level	
1	 $1083  1089	
2	   1457  1471	
3	   1831  1853	
4	   2205  2235	
5	   2579  2617	
6	   2953  2999	
7	   3327  3381	
8	   3701  3763	
Effective April 1, 2009  2011	
For each person in the Medicaid unit above eight, add $374 382 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	$1201  1207	
2	1615  1631	
3	2030  2054	
4	2444  2478	
5	2859  2901	
6	3273  3324	
7	3688  3748	
8	4102  4171	
Effective April 1, 2009 2011	
For each person in the Medicaid unit above eight, add $415 424 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	 $ 1219  1226	
2	   1640  1655	
3	   2060  2085	
4	   2481  2515	
5	   2902  2945	
6	   3323  3374	
7	   3743  3804	
8	   4164  4234	
Effective April 1, 2009 2011	
For each person in the Medicaid unit above eight, add $421 430 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	 $1670  1679	
2	   2247  2268	
3	   2823  2857	
4	   3400  3446	
5	   3976  4035	
6	   4553  4624	
7	   5130  5213	
8	   5706  5802	
Effective April 1, 2009 2011	
For each person in the Medicaid unit above eight, add $577 589 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	 $2031  2042	
2	   2732  2759	
3	   3434  3475	
4	   4135  4191	
5	   4836  4907	
6	   5537  5624	
7	   6239  6340	
8	   6940  7056	
Effective April 1, 2009  2011	
For each person in the Medicaid unit above eight, add $702 717 to the monthly amount.
g.	Children with Disabilities. The income level is equal to two hundred percent of the poverty level applicable to a family of the size involved.

Number of Persons	Monthly Income Level	
1	 $1805  1815	
2	   2429  2452	
3	   3052  3089	
4	   3675  3725	
5	   4299  4362	
6	   4922  4999	
7	   5545  5635	
8	   6169  6272	
Effective April 1, 2009 2011	
For each person in the Medicaid unit above eight, add $624 637 to the monthly amount.

SFN 880, "Contractual Right to Receive Money Payments Valuation Request" 510-05-100-95
This section is being deleted from the manual as it is no longer applicable.   These requests are no longer submitted to the Legal Advisory Unit and SFN 880 is no longer available on E-forms.  
 
This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (64 kb pdf).

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader.  If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

North Dakota Health Tracks 
This is a new section added to clarify the policy and procedures for administering the Health Tracks program.
General Information 
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program was created by Congress in 1967 as part of the Medicaid program. In North Dakota, EPSDT is known as the Health Tracks Program. Federal legislation requires states to make available to all Medicaid-eligible children under age 21 comprehensive, periodic health assessment, dental, vision and hearing services, and “medically necessary”* follow-up diagnostic and treatment service (see definition below). The program’s emphasis is on preventive and primary care, with the overall goal of preventing childhood illnesses or disabilities and identifying children’s and young adult’s problems early on, before they become severe and disabling. Early identification and treatment improves children’s outcomes and enables families to access important resources that will improve family functioning and outcomes.

* “Medically necessary”: A covered service or item can be defined as “medically necessary” if it will do, or is reasonably expected to do, one or more of the following: 
a.	Arrive at a correct medical diagnosis;
b.	Prevent the onset of an illness, condition or injury or disability in the individual or in covered relatives, as appropriate;
c.	Reduce, correct, or ameliorate the physical, mental, developmental, or behavioral effects of an illness, condition, injury or disability;
d.	Assist the individual to achieve or maintain sufficient functional capacity to perform age appropriate or developmentally appropriate daily activities.

Persons Eligible for Health Tracks 
There are three groups of individuals who may be eligible for Health Tracks:
1.	Children and adolescents under age 21 who are eligible for Medicaid 

2.	TANF children – Temporary Assistance for Needy Families children are those who qualify based on criteria for assistance to low-income families

3.	Foster children – Foster children are those who are placed in protective services because they cannot remain at home. These children may have experienced neglect or abuse in the home and are generally placed with a substitute family.

Health Tracks Procedures – Informing  
Informing eligibles is done by the individual’s eligibility worker and/or the service worker.
The SFN 502 and SFN 405 forms have information regarding Health Tracks and inform the client up-front of the availability of the Health Tracks program for those applying for Medicaid and TANF
FORMS 
1.	SFN 502 – Healthcare Coverage Application
2.	SFN 405 – Application for Assistance
HEALTH TRACKS BROCHURE
PROCEDURES
1.	Worker informs ALL Medicaid eligible individuals (or their families) about the Health Tracks program providing a combination of written and oral methods.
2.	Route all Health Tracks referrals to the designated Health Tracks services worker within 3 days of determination date.

Health Tracks Procedures – Intake 
The service worker or other staff assigned by the county director do intake.
FORMS 
1.	SFN 710 --  Health Tracks Referral
2.	SFN 1818 – Health Record – Initial request for screening
3.	SFN 1059 – Authorization to Disclose Information * if   appropriate
4.	Appointment Log
Procedures
1.	Contact the parent/recipient as soon as possible, must be within 60 days of the receipt of the Health Tracks Referral. May use the referral as a documentation form to note progress.
a.	Explain what Health Tracks offers
b.	Set up a time to complete the Health Record, either by phone, mail, or personal appointment. May want to schedule actual screening appointment immediately and arrange to have health record completed at the screening site; or have recipient mail or bring to screening.
c.	Request immunization records for children prior to screening if parent/guardian is unable to secure records by the screening appointment.
*Screening appointment must be completed within a 90-day time frame. If the time limit is exceeded, the reason must be noted on the Health Tracks Referral.
2.	If the parent/recipient, upon contact, verbally indicates they are no longer interested in the screening, service worker documents on the Health Tracks Referral and destroys the form after one year.
3.	For TANF Participants: Discuss the choice of screening provider with participant; verify if the child’s (ren’s) primary care physician (PCP) is a Health Track screening provider. The family has a choice to schedule a screening appointment with their PCP or local Public Health screener. The participant is responsible for completing screening within the prescribed time frame. Document on the TANF referral if the time limit was not met due to a scheduling problem with the chosen provider.
4.	For Medicaid only families -- if contact cannot be made after at least 2 attempts (one written), document the attempts on the referral; keep referral for one year.

Health Tracks Procedures – Prior to the scheduled Screening – Public Health Screener 
1.	Complete the Health Record within 90 days of receipt of referral. Obtain health record information from the natural parent(s) whenever possible. If the child’s caretaker does not have legal custody, attempts should be made to reach the legal custodian or natural parents for the information and signatures. 
2.	Discuss transportation needs and document on the Health Tracks Referral.
3.	Arrange a screening appointment and complete the screening within 90 days of the receipt of the referral.
4.	Complete an appointment slip and/or call or mail a reminder to the parent/recipient.
5.	Route the following to the regional coordinator five business days prior to the screening:
a.	Appointment Log
b.	Health Record
c.	Attached Immunization Record, if available
*ReminderS:
•	One to three days prior to screening appointment, verify current eligibility status of recipient scheduled for screening. (Verify Eligibility Phone #: 1-800-428-4140)
•	Remind parent/recipient of screening appointment.

Health Tracks Procedures –Follow-up Diagnosis and Treatment Follow-up Diagnosis and treatment is done by the Social Worker or other staff, as assigned by the county Director.
Forms:
1.	SFN 1059 – Authorization to Disclose Information
2.	SFN 1819 – MCH/Health Tracks Assessment
3.	SFN 710 – Referral and Request for Information
Procedures after screening:
1.	Upon receipt of SFN 1819 – Results of screening received from the regional coordinator or completion by worker and nurse, review the diagnosis and treatment referral plan.
2.	Initiate follow-up of referrals as soon as possible by:
Sending SFN 710 – If not previously completed, Referral and Request for Information should be sent to providers with whom an appointment has been made. If possible, this should be done prior to the appointment.
*Reminder: It is essential to know if the case is currently open. This prevents non-eligibles from being referred for treatment.
3.	Update the SFN 1059 - Authorization to Disclose, adding new non-medical providers who will receive the SFN 710 (Referral and Request for Information).
4.	Follow-up with short (ear infection) and long-term (orthodontics) diagnosis and treatment referrals to insure initial appointments are completed, generally within 60 days of screening date.
5.	Document all case activity on the Health Tracks Referral Form or other method.
6.	Cases are never “closed” unless recipient becomes ineligible for the Medicaid program. Discontinuation of follow up of referrals may end after the verification of the initial follow-up appointment.
7.	Transfer copies of pertinent screening information to other counties within the state, if the service worker is asked by the recipient or other county personnel to transfer records. All screening results are considered confidential medical records and may not be released unless the recipient gives permission. Dates and place of a screening may be released without permission of the recipient.
8.	Frequency of Screenings:
Suggested Schedule of Screenings:
Bright Futures Guidelines	
Newborn     
2 to 5 days 
1 Month	1 Year 
15 Months
18 Months	6 Years 
7 Years
8 Years	13 Years
14 Years 
15 Years	
2 Months	2 Years	9 Years 	16 Years	
4 Months	3 Years	10 Years	17 Years	
6 Months	4 Years	11 Years	18 Years	
9 Months	5 Years	12 Years	19 Years	
			20 Years

9.	Records Retention
a.	Retain in office for one year, then dispose:
i.	EPSDT General Correspondence
ii.	Meeting Minutes
b.	Retain in office for two years, then dispose:
i.	Monthly Reports
c.	Follow individual agency policies on record retention and destruction:
   Public Health and County Social Services

Par. 2.  Effective Date -- This manual letter is effective for the benefit month of February 2011 except as indicated.