Title: Removal and replace pages
Subject: Revised chapter
Author: MANAGEMENT
Last saved by: raddington
Company: DHS

Bismarck, North Dakota	MANUAL LETTER #2925	June 1, 2004

Par. 1.  Material Transmitted and Purpose --Transmitted with this Manual Letter are changes to Service Chapter 510-05, Medicaid Eligibility Factors:

05-30-05.    Groups Covered

Language was added as subdivision e in subsection 2 to list the Workers with Disabilities coverage.

2.	 The optional categorically needy group includes:
e.	Gainfully employed individuals with disabilities age eighteen to sixty-five who meet medically needy nonfinancial criteria, have countable assets within the medically needy asset levels, have income below 225% of the poverty level, and are not eligible for Medicaid under any other provision other than as a Qualified Medicare Beneficiary or a Special low-income Medicare Beneficiary.  Effective June 1, 2004.

05-30-10.  Applicant's Choice of Category 
 Language was changed to clarify and accuracy.  The categories are 1) aged, blind and disabled, and 2) children and family.  QMBs and SLMBs are aged, blind or disabled for that coverage, but could also choose to be eligible under the children and family category for other Medicaid benefits.
An individual who could establish eligibility under more than one category, such as between aged, blind, or disabled categories and family coverage categories, may have eligibility determined under the category the individual selects. An individual may establish eligibility under only one category except for QMBs and SLMBs~~,~~. ~~who may also establish eligibility~~ Individuals eligible as QMBs and SLMBs are eligible as aged, blind or disabled for that coverage but may also establish eligibility under the children and family category.

05-35-65.   Aliens Lawfully Admitted for Permanent Residence on or After August  22, 1996 
 
This is a policy change.  Beginning June 1, 2004, the seven-year limitation that applied to refugees, asylees, or aliens whose deportation was withheld has been eliminated.  Additional categories of qualified aliens were also added.
Aliens who entered the United States for permanent residence on or after August 22, 1996, and who meet all other Medicaid criteria may be eligible for Medicaid as qualified aliens.
1.	The following qualified aliens may be eligible at any time: 
a.	Honorably discharged veterans, aliens on active duty in the United States’ armed forces, and the spouse or unmarried dependent child(ren) of such individuals; ~~may be eligible at any time.~~ 
b.	Refugees;
c.	Asylees;
d.	Cuban and Haitian Entrants;
e.	Victims of a severe form of trafficking;
f.	Aliens whose deportation was withheld under Section 243(h) of the Immigration and Naturalization Act (INA); and
g.	Aliens admitted as an Amerasion immigrant.
~~2. Refugees and Asylees may be eligible~~ ~~for seven years from the date they entered the United States. After the seven year period, continued eligibility, other than emergency services, is allowed if the individual has been credited with forty qualifying quarters of social security coverage.~~
~~3. Aliens whose deportation was withheld under Section 243(h) of the Immigration and Naturalization Act (INA) may be eligible~~ ~~for seven years from the date they were granted withholding. After the seven-year period, continued eligibility, other than emergency services, is allowed if the individual has been credited with forty qualifying quarters of social security coverage.~~  

05-35-100.  Blindness and Disability

Language was added to subsection 4 to identify another situation where SSA will not make a SSA disability determination.  The State Review Team will need to make a disability determination for these individuals. 
4.	If the applicant is requesting assistance for a month prior to the SSI application, if the applicant is not eligible for SSI because of the SSI income and resource levels, if the applicant refuses to apply for SSI, if the applicant is not eligible for SSA disability due to not being insured, if the applicant is applying for Workers with Disabilities coverage and is not eligible for SSA disability due to substantial gainful activity, or the applicant is within six months of reaching age 65, the county agency will need to obtain and submit medical and social information to the State Review Team for their evaluation.  The medical and social information is generally submitted along with SFN 451, "Eligibility Report on Disability/Incapacity" (Appendix H).  An individual refusing to apply for SSI should be informed of potential eligibility for SSI and that receipt of SSI may yield a larger amount of total income for the family.

05-57.  Workers with Disabilities
This is new policy relating to eligibility for Workers with Disabilities.  The new sections added are:
05-57-05. General Information
05-57-10. Individuals Covered
05-57-15.	Gainful Employment
05-57-20. Assets which are Excluded for Workers with Disabilities
05-57-25. Income Considerations for Workers with Disabilities
05-57-30. Income Levels for Workers with Disabilities
05-57-35. Premium Calculation for Workers with Disabilities

05-70-30.  Excluded Assets
Subsection 8, relating to crime victims compensation, was deleted as such payments are already excluded in subsection 7.

~~8.~~	~~Payments from a fund established by a state as compensation for expenses incurred or losses suffered as a result of a crime. This asset must be identifiable and not commingled with other assets.~~

05-80-25.  Exceptions to Disqualifying Transfer Provision

Language was added to subdivision d of subsection 4 for clarification.  The change was made to clarify that a return of property to undo a transfer applies to each transfer individually.  For example, on a new application, if two separate transfers were made in April, and all was returned for one of them, then there would only be one transfer remaining.  All would not have to be returned for both transfers to be able to eliminate one of them.
4.	A transfer is not disqualifying to the extent the individual makes a satisfactory showing that:
d.	All income or assets transferred for less than market value have been returned to the individual.  If all of the income or assets of a particular transfer are returned at the time of application, and no periods of eligibility have been established for that transfer after the date of the original transfer, process the application as if the original transfer never occurred. If all of the income and assets of a particular transfer are returned after Medicaid eligibility has already been established (for a period after the date of the original transfer), the period of ineligibility for that transfer ends as of the date the income or assets are returned, but only if the returned assets do not cause the community spouse to have total countable assets in excess of the community spouse countable asset allowance allowed at the time the institutionalized or HCBS spouse became eligible. In establishing whether all of the income or assets have been returned, the income or assets transferred, or their equivalent value, must be returned.

05-85-30.  Disregarded Income

Language was added to the first paragraph to indicate that the income disregards also apply to the Workers with Disabilities coverage. 

This section applies to individuals residing in their own home or in a specialized facility, and to the Medicare Savings Programs~~,~~ and Workers with Disabilities coverage, but does not apply to Transitional Medicaid Benefits. For individuals receiving nursing care services in a nursing facility, the state hospital, the Anne Carlsen facility, the Prairie at St. John's center, the Stadter Psychiatric Center, an intermediate care facility for the mentally retarded (ICF-MR), or receiving swing-bed care in a hospital, refer to the Post Eligibility Treatment of income, Section 05-85-25.

05-85-35.  Income Deductions
 
Language was added to the first paragraph to indicate that the income deductions also apply to the Workers with Disabilities coverage.   Language was also added to subsection one to indicate that the Workers with Disabilities enrollment fee and the premium are allowed deductions from income when determining eligibility for other family members in other coverages, but is not allowed as a deduction when establishing Workers with Disability eligibility.
 
This section applies to individuals residing in their own home or in a specialized facility, and to the Medicare Savings Programs~~,~~ and Workers with Disabilities coverage, but does not apply to Transitional Medicaid Benefits. For individuals receiving nursing care services in a nursing facility, the state hospital, the Anne Carlsen facility, the Prairie at St. John's center, the Stadter Psychiatric Center, an intermediate care facility for the mentally retarded (ICF-MR), or receiving swing-bed care in a hospital, refer to the Post Eligibility Treatment of Income, Section 05-85-25.
The following income deductions are allowed in determining Medicaid eligibility:
1.	Except in determining eligibility for the Medicare Savings Programs, the cost of premiums for health insurance may be deducted from income in the month the premium is paid or prorated and deducted from income in the months for which the premium affords coverage. The Workers with Disabilities coverage enrollment fee and premium is an allowed deduction except when determining eligibility for the Workers with Disabilities coverage.  For purposes of this deduction, premiums for health insurance include payments made for insurance, health care plans, or nonprofit health service plan contracts which provide benefits for hospital, surgical, and medical care, but do not include payments made for coverage which is:
a.	Limited to disability or income protection coverage;
b.	Automobile medical payment coverage;
c.	Supplemental to liability insurance;
d.	Designed solely to provide payments on a per diem basis, daily indemnity, or nonexpense-incurred basis; or
e.	Credit accident and health insurance.

05-85-40.  Income Levels

The Workers with Disabilities income level of 225% of poverty was added as subdivision f in subsection 3.
3.	Poverty income levels.
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 | $1745
2 | 2341
3 | 2938
4 | 3534
5 | 4130
6 | 4726
7 | 5323
8 | 5919
9 | 6515
10 | 7111
Effective June 1, 2004
For each person in the Medicaid unit above ten, add $596 to the monthly amount.

05-85-45.  Determining the Appropriate Income Level in Special Circumstances 
 
Language was added to subsections 3 and 4 to identify that the 225% of poverty income level applies when determining eligibility for Workers with Disabilities even if the individual is residing in a specialized facility, in a nursing facility, or if receiving HCBS for the full month.  During partial months the applicant or recipient would be included in the same budget unit as other family members.  
3.	During a month in which an individual enters a specialized facility, or leaves one to return home, the individual will be included in the family unit in the home for the purpose of determining the family size and the appropriate income level. Individuals in a specialized facility will be allowed the medically needy income level for one during all full calendar months in which the individual resides in the facility.  In determining eligibility for Workers with Disabilities coverage, individuals in a specialized facility will be allowed the Workers with Disabilities income level for one during all full calendar months in which the individual resides in the facility.  
4.	During a month in which an individual with eligible family members in the home enters or leaves a nursing facility to return home, or elects to receive HCBS or terminates that election, the individual will be included in the family unit in the home for the purpose of determining the family size and the appropriate medically needy income level. Individuals in a nursing facility will be allowed fifty dollars to meet their maintenance needs during all full calendar months in which the individual resides in the nursing facility. Recipients of HCBS will be allowed the medically needy income level for one during all full calendar months in which the individual receives HCBS.  In determining eligibility for Workers with Disabilities coverage, individuals in a nursing facility, or in receipt of HCBS, will be allowed the Workers with Disabilities income level for one during all full calendar months in which the individual resides in the facility.  

05-85-50.  Deeming of Income
A new subsection 5 was added to indicate that income may be deemed to members of the Medicaid unit at the 225% of poverty income level for the purpose of establishing Workers with Disabilities eligibility.
5.	For purposes of determining eligibility for Workers with Disabilities coverage, income of a spouse or parent may be deemed to a non-SSI spouse or child, who is in the Medicaid unit, but who is not residing with the applicant or recipient, to bring their income up to the Workers with Disabilities income level.

05-90-05.  Definitions (Budgeting)

The budgeting month known as the “recipient liability month,” has had a name change to “benefit month”.  The name “recipient liability month” did not really fit with some Medicaid coverages and caused confusion.  The Workers with Disabilities coverage made the need to change the name more evident.
 
1.	For purposes of this section:
a.	"Base month" means the calendar month prior to the processing month.
b.	"Best estimate" means an income, expense, or circumstance prediction based on past amounts of income and expenses and known factual information concerning future circumstances which affect eligibility, expenses to be incurred; or income to be received in the ~~recipient liability~~ benefit month. Factual information concerning future circumstances must be based on information by which the applicant or recipient demonstrates known changes or highly probable changes to the income, expense, or circumstances which offset eligibility, from the base month to the ~~recipient liability~~ benefit month.
c.	"Processing month" means the month between the base month and the ~~recipient liability~~ benefit month.
d.	"Prospective budgeting" means computation of a household's eligibility and recipient liability based on the best estimate of income, expenses, and circumstances for a ~~recipient liability~~ benefit month.
e.	"~~Recipient liability~~ Benefit month" means the calendar month for which eligibility and recipient liability is being computed.

05-90-30.  Budgeting Procedures When Adding and Deleting Individuals 

The name change from “recipient liability month” to “benefit month” was made to this section to coincide with the previously identified changes.

2.	Budgeting procedures when deleting individuals from a case. When a member of an existing unit is expected to leave the unit during the ~~recipient liability~~ benefit month, that person may remain as a member of the unit until the end of the ~~recipient liability~~ benefit month.

05-90-40.  Budgeting Procedures for Unmarried Parents with Children 

Language was changed to correct the written policy.  Income and, if appropriate, assets of a newborns father are considered beginning with the month of birth.  If the child is eligible for the 60 free days, the father’s income or assets will not affect that eligibility, but will prevent a child support referral.  
 
When budgeting for children whose parents are living together, but are not married:
1.	If paternity has not been legally established, but the father's name is on the birth certificate or he has signed the "North Dakota Acknowledgment of Paternity" form, SFN 8195, with a revision date of 4/98 or later, the income of the father must be used to determine Medicaid eligibility. The assets of the father must also be used if the child is eligible as a disabled individual.
For the month of birth a child’s eligibility follows that of the mother. If the ~~child~~ mother is eligible for the 60 free days after birth, the child is too.  T~~t~~he father's income and, if appropriate, assets are used beginning ~~in~~ with the month ~~following~~ of birth, however, if they would cause Medicaid ineligibility for the child, the child will remain eligible through the month in which the 60th day falls.

05-90-65.  Budgeting Procedures for Workers with Disabilities

This new section was added to summarize the budgeting procedures for the Workers with Disabilities coverage.

All income of the applicant or recipient and other members of the Medicaid unit who are living with the applicant or recipient must be considered.
 
The same budgeting applies regardless of whether the individual lives in the individual’s own home, a specialized facility, or a nursing facility.
 
Recipients with family income at or below 225% of the poverty level can be eligible under the Workers with Disabilities coverage.  

If the 225% eligibility test is passed, the premium required to obtain the coverage is equal to 5% of the eligible individual’s gross income. If more than one individual in the case is eligible for Workers with Disabilities coverage, each individual’s premium is determined separately based on their own income.

Par. 2.  Effective Date -- June 2004

Par. 3.  Manual Maintenance -- Please remove the following sections from Service Chapter 510-05:

05-30-05.   Groups Covered
05-30-10.   Applicant’s choice of Category
05-35-65.   Aliens Lawfully Admitted for Permanent Residence on or After August 22, 1996
05-35-100. Blindness and Disability
05-70-30.   Excluded Assets
05-80-25.   Exceptions to disqualifying Transfer Provision
05-85-30.   Disregarded Income
05-85-35.   Income Deductions
05-85-40.   Income Levels
05-85-45.   Determining the Appropriate Income Level in Special Circumstances
05-85-50.   Deeming of Income
05-90-05.   Definitions (Budgeting)
05-90-30.   Budgeting procedures When Adding and Deleting Individuals
05-90-40.   Budgeting Procedures for Unmarried Parents with Children

Par. 4.  Check List of Pages Transmitted -- Attached are the following sections to be placed in Service Chapter 510-05:

05-30-05.   Groups Covered
05-30-10.   Applicant’s choice of Category
05-35-65.   Aliens Lawfully Admitted for Permanent Residence on or After August 22, 1996
05-35-100. Blindness and Disability  
05-57-05.   General Information (Workers with Disabilities) (NEW)
05-57-10.   Individuals Covered (Workers with Disabilities) (NEW)
05-57-15.   Gainful Employment (NEW)
05-57-20.   Assets which are Excluded for Workers with Disabilities (NEW)
05-57-25.    Income Considerations for Workers with Disabilities (NEW)
05-57-30.   Income Levels for Workers with Disabilities (NEW)
05-57-35.   Premium Calculation for Workers with Disabilities (NEW)
05-70-30.   Excluded Assets
05-80-25.   Exceptions to disqualifying Transfer Provision
05-85-30.   Disregarded Income
05-85-35.   Income Deductions
05-85-40.   Income Levels
05-85-45.   Determining the Appropriate Income Level in Special Circumstances
05-85-50.   Deeming of Income
05-90-05.   Definitions (Budgeting)
05-90-30.   Budgeting procedures When Adding and Deleting Individuals
05-90-40.   Budgeting Procedures for Unmarried Parents with Children
05-90-65.   Budget Procedures for Workers with Disabilities (NEW)

Carol K. Olson, Executive Director		Manual Letter #2925
North Dakota Department of Human Services	Page  of  Page