Title: Par
Author: Michele Gee
Last saved by: raddington
Company: DHS

Bismarck, North Dakota	MANUAL LETTER #3047	November 1, 2006

Par. 1.  Material Transmitted and Purpose --Transmitted with this Manual Letter are changes to Service Chapter 510-05, Medicaid Eligibility Factors.  This Manual Letter supersedes IM’s 4985 (original and amended) Psychiatric Residential Treatment Facilities (PRTF’s) and 4989 Effect of TANF Diversion Assistance on Other Programs. Outstanding IM 4988 (original and amended) Verification Requirements, has not been included in this manual update due to potential changes.

Definitions. 510-05-05
The definition for LTC was updated to include PRTFs (from IM 4985), and the definition for nursing care services was moved here from the Transfer definition section as it is used throughout the manual.  This definition was also updated to include all facilities in which nursing care services are provided. 
 Long term care, (LTC)
Refers to services received in a nursing facility, the State Hospital, the Anne Carlson facility, the Prairie at St. John's center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for the mentally retarded (ICF-MR), or a swing bed when the individual in the facility is screened or certified as requiring the services provided in the facility.
Nursing care services
Care provided in a medical institution, a nursing facility, a swing bed, the state hospital, the Anne Carlson facility, the Prairie at St. John's center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for the mentally retarded (ICF-MR), or a home and community based services setting.

Home and Community Based Services (HCBS). 510-05-15-05
The two new HCBS waivers were added. This change is effective July 1, 2006.

2.  Waiver for Self Directed Supports for Families:  Allows families or individuals, where at least one individual, age 3 to age 21, meets the developmental disability criteria and requires long-term supports and services, to direct their own care and financial resources so the individual may remain in the home.  (Began July  1, 2006.)

3.  Waiver for Self Directed Supports for Adults:  Allows individuals, age 21 or over, who meet the developmental disability criteria and require long-term supports and services, to direct their own care and financial resources so the individual may remain in their own home.  (Began July 1, 2006.)

Decision and Notice. 510-05-25-25
Subsection 4(c)(vi), relating to when an adequate notice is allowed, was updated to include when an individual enters or leaves a PRTF (IM 4985).
4.	As specified below, a notice must be sent in all ongoing cases in which a proposed action adversely affects Medicaid eligibility.
…
c.	Under the following circumstances a "Ten-Day Advance Notice" is not required; … 
…
vi. 	The recipient has a change in the level of medical care prescribed by the individual's physician, such as the recipient begins or ceases to receive care in a specialized facility, an institution for mental diseases (IMD), a Psychiatric Residential Treatment Facility (PRTF), or nursing care services in a facility (LTC) or in the community (HCBS).

Medicaid Unit. 510-05-35-05
Subsection 2(d) was updated with the PRTF policy from IM 4985.  
 	   2.	An applicant or recipient who is also a caretaker of children under twenty-one years of age may select the children who will be included in the Medicaid unit. Anyone whose needs are included in the unit for any month is subject to all Medicaid requirements which may affect the unit. The financial responsibility of relatives must be considered with respect to all members of the assistance unit.
When a child is included in the Medicaid unit eligibility is pursued for the child unless:
a.	…
d.	The child is receiving services in a Psychiatric Residential Treatment Facility (PRTF), or the state hospital, the Prairie at St. John's center, the Stadter Psychiatric Center, or any other institution for mental disease (IMD), and has not obtained certification of need for services in that facility.

Screening for Nursing Care, ICF-MR or HCBS Recipients. 510-05-35-25
Language was added to clarify that the screening provision applies to individuals seeking “nursing care” services.
 
All applicants or recipients who seek nursing care services in nursing facilities, swing bed facilities, institutions for mental disease (IMD), or intermediate care facilities for the mentally retarded (ICF-MR), or who seek home and community-based services, must be screened to establish the medical necessity for these services.

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, and the title, regarding who requires a certification of need, was updated with the PRTF policy from IM 4985.

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. . . .

Need. 510-05-35-35
Language was added to subsection 2 to clarify that medical expenses are considered incurred when the applicant or recipient is responsible for the costs and the costs are not covered by third party payments. 
 
2.	For a medically needy applicant or recipient, need is established when there is no recipient liability when the applicant or recipient has incurred medical expenses for which the applicant or recipient is responsible (after any third party payments) that equal or exceed the recipient liability. If there is no need, there is no eligibility, and the application must be denied or the case must be closed.

Age and Identity. 510-05-35-40
Subsection 2, which allows recipients receiving inpatient services in a PRTF to remain eligible until age 22, was updated with the PRTF policy from IM 4985.
 
2.	An individual who is eligible upon reaching age twenty-one remains eligible for Medicaid through the month in which the individual reaches that age. An exception to this general rule permits eligibility to continue for a person who attains age twenty-one while receiving treatment and continues to receive treatment as an inpatient in a Psychiatric Residential Treatment Facility (PRTF), or the state hospital, the Prairie at St. John's center, or the Stadter Psychiatric Center. Eligibility may continue through the month the individual attains the age of twenty-two.

Aliens Lawfully Admitted for Permanent Residence on or After August 22, 1996. 510-05-35-65
Language was added to clarify that “asylees” refers to individuals who have been granted asylum.

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;
b.	Refugees;
c.	Asylees who have been granted asylum (not applicants for asylum);

Foster Care. 510-05-55-05
Subsection 4 was updated to clarify that a PRTF is not a licensed foster care facility, and subsection 5 was updated to clarify that Tribal 638 Foster Care children are considered foster care.
 
For Medicaid purposes, a child is not considered to be in foster care unless all of the following requirements are met:
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
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 children ~~are not in the state foster care system~~.~~)~~

Premiums for Workers with Disabilities. 510-05-57-35
Language was added to clarify that the premium is based only on countable income. 
 
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.

Definitions for Spousal Impoverishment. 510-05-65-10
Language was added to identify when an asset assessment can be completed for an individual who requires nursing care services and opts to receive HCBS.  

5.	"First continuous period" means the first period in which:
a.	An institutionalized spouse requires care in, and enters a medical institution, a nursing facility, or a swing bed, or when a HCBS spouse begins receiving HCBS, and the institutionalized or HCBS spouse is expected to continue to receive that level of care for at least 30 consecutive days~~.~~; or  
b.	The date on which a medical doctor, a physician’s assistant, a nurse practitioner, or Dual Diagnosis Management has determined that a spouse requires nursing care services for at least 30 consecutive days and the community spouse or a private HCBS agency provides those services.

Exempt Assets. 510-05-70-25
Language was changed in subsection 1 to follow terminology used by the Deficit Reduction Act and to reference a new section that addresses home equity.  
 
The following assets are exempt from consideration in determining Medicaid eligibility:
1.	The home occupied by the Medicaid unit, including trailer homes being used as living quarters.
The home occupied by the Medicaid unit includes the land on which it is located, provided that the acreage does not exceed one hundred sixty contiguous acres if rural or two acres if located within the established boundaries of a city.
The home is considered occupied by the Medicaid unit when it is the home the Medicaid unit is living in or, if temporarily absent from, possesses with an intention to return and the capability of returning within a reasonable length of time. Property is not occupied if the right to occupy has been given up through a rental or lease agreement, whether or not that rental or lease agreement is written. Property is not occupied by an individual in long-term care or the state hospital, with no spouse, or son or daughter who is under age twenty-one, or blind or disabled (any age) ~~adult child~~, ~~or child under age twenty-one~~ at home, unless a physician has certified that the individual is likely to return home within six months.  (See 510-05-70-27 for home equity limit for exempt home during six month period and for single HCBS applicants and recipients.)

Home Equity Limit. 510-05-70-27
This is a new section that limits coverage of nursing care services for certain individuals with excess home equity.  This policy change is effective February 8, 2006.

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 $500,000.  The applicant or recipient may, however, be eligible for other Medicaid benefits.

This provision does not apply if one of the following individuals lives in the home:
1.	A spouse;
2.	A son or daughter who is under age twenty-one; or 
3.	A son or daughter of any age who is blind or disabled.  

Excluded Assets. 510-05-70-30
Minor wording changes were made in subsections 1 and 2.  New references were made in subsection 16 to coincide with the new annuity sections.  

1.	Property ~~which~~ that is essential to earning a livelihood. Property ~~which~~ that is essential to earning a livelihood means property that a member of a Medicaid unit owns, and which the Medicaid unit is actively engaged in using to earn income, and where the total benefit of such income is derived for the Medicaid unit's needs…
2.	Property ~~which~~ that is not saleable without working an undue  hardship. Property ~~which~~ 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…
16.	An ~~employee benefit~~ annuity~~, or an annuity purchased by a community spouse, as long as the annuity~~ ~~meets the requirements specified in 05-70-45 that allow that annuity to be~~ that is excluded per annuity sections 05-70-45-20, 05-70-45-25, or 05-70-45-30.

Contractual Rights to Receive Money Payments. 510-05-70-40
This section has been rewritten and reorganized for clarification and includes new policy.  Key policy changes are found in subsection 3(a) and (b), which addresses how contracts are valued, and subsection 4, which addresses two different ways contracts can be disqualifying transfers.  Contracts that are not in default will no longer need to be sent to the Legal Advisory Unit for a discounted value.  This policy change is effective April 1, 2006.
 
1.	For various reasons, but usually because an applicant or recipient has sold property with a contract to receive a series of payments, rather than one payment, an applicant or recipient may own contractual rights to receive money payments. ~~Such contractual rights are available assets subject to the asset limits.~~ If the applicant or recipient has sold property, and received in return a promise of payments of money at a later date, usually to be made periodically, and an attendant promise to return the property if the payments are not made, the arrangement is usually called a "contract for deed". The essential feature of the contract for deed is the right to receive future payments, usually coupled with a right to get the property back if the payments are not made. Contractual rights to receive money payments also arise out of other types of transactions. The valuable contract document may be called a note, accounts receivable, mortgage, or by some other name.
Some contractual rights may be written so the lender has the right to demand payment at any time. If so, the note is considered a demand note and can be called in at any time. If a note is written so the lender does not have the right to demand payment but the note is in default, it also becomes a demand note. Contractual rights may or may not have collateral or security to guarantee payment.
~~2.~~	~~Some contracts may have been entered into when interest rates were lower, or because a low interest rate or no interest may have been charged in a transaction between relatives. The contract may not be saleable or negotiable at face value.~~ ~~A proper valuation may be made by a process called "discounting", which will take into account the changes in the interest rates. The discounted value may be determined through a formula described in 75-02-02.1-32(5)(b)(1) or~~ A contractual right to receive money payments is considered an available asset, subject to the asset limits, unless the Medicaid unit is requesting coverage of nursing care services and the contract itself must be considered a disqualifying transfer (see subsection 4). 
3. Contract values.
a.  The value of a contract in which payments are current is equal to the total of all outstanding payments of principle and interest required to be made by the contract.  
b.  The value of a contract in which payments are not current is an amount equal to the greater of the total of all outstanding payments of principle and interest required to be made by the contract, or the current fair market value of the property subject to the contract ~~a request for a valuation, accompanied by the contract documents, may be sent to the Legal Advisory Unit~~. SFN 880, "Contractual Right to Receive Money Payments Valuation Request" (05-100-95) ~~should~~ may be used ~~when~~ to request~~ing~~ a valuation from the Legal Advisory unit when ~~. The request must indicate~~ ~~if the payments on the contract are current.  If the~~ payments are not current.  The request must indicate the amount of each payment made and time each such payment was made.
c. 	In situations where the contractual right to receive money payments is not collectable and is not secured, the debt has no collectable value, and thus no countable asset value. An applicant or recipient can establish that a note has no collectable value if:
i.	The debtor is judgment proof. A debtor is judgment proof when money judgments have been secured and not satisfied. An applicant or recipient may show a debt has no value as long as a money judgment obtained by any creditor (including the applicant or recipient) has been on file in a county in which the debtor lives, or owns property, for at least 60 days and has not been satisfied; or
ii.	The applicant or recipient verifies the debt is uncollectible due to a statute of limitations. A satisfactory verification includes an attorney’s letter identifying the statute and facts that make a debt uncollectible due to a statute of limitations.
Applicants and recipients should be encouraged not to forgive debts that have been determined to be uncollectible. Such debts could have a future value if the debtor ever accrues assets. At each annual redetermination, determine whether the judgments are still on file or whether the debtor has any change in assets.

~~3.~~	~~In some cases, the price and terms of a contract for deed may, in combination, be extremely favorable to the buyer. If the sale is made with a minimal down payment, low interest rates, a long payment period, or a combination of any of those factors, the effect may be a transfer for less than adequate consideration. In such cases, the valuation must also indicate the fair market value of the property sold as of the date of sale and the value of the contractual rights immediately after the sale.~~  
4.	The purchase or establishment of a contract may be a disqualifying transfer if the owner, or the owner’s spouse, is requesting coverage for nursing care services and the contract was purchased or established on or after the look-back date (as defined in 05-80-10).
a.	A disqualifying transfer will be determined to have occurred if the value of the contract at the time it was purchased or established, plus any compensation received at that time, was less than the value of the property exchanged for the contract.  The difference is the amount of the transfer.

Example:   Mr. Green sells land to his children on a contract for deed.  The land has a fair market value of $100,000.  The contract required a $5,000 down payment and the value of the remaining payments adds up to $60,000.  $100,000 less $60,000 (value of contract), and less $5,000 (down payment), leaves a difference of $35,000.  Mr. Green made a $35,000 disqualifying transfer when he established the contract.
b.	The contract itself is also a disqualifying transfer unless:
i.	All payments due on the contract are expected to be made within the owners life expectancy as established using the tables at 05-100-75;
ii.	The contract provides for equal payments and does not provide for a balloon or deferred payment; and
iii.	The contract cannot be cancelled, or the payments diminished, upon the lender’s death.
The uncompensated value of a contract that is considered a disqualifying transfer is an amount equal to the remaining payments due from the contract.
Example:   When Mr. Green sold his land to his children on a contract for deed, the contract included a clause that no further payments would be due on the contract when he passed away.  Because of this clause, the contract is considered a disqualifying transfer.  $55,000 is still due on the contract, so the amount of the transfer is $55,000. 

As is shown in the above two examples, Mr. Green made two transfers.  The first transfer was because he did not receive fair market value for the property, thus he made a $35,000 transfer.  The second transfer was because of the cancellation clause, which results in a $55,000 transfer.  These two transfers are combined for a total transfer of $90,000.
If the entire contract itself is considered a disqualifying transfer that results in a penalty period, the contract is not also considered an available asset.
~~4.~~5. There is a presumption that the holder’s interest in contractual rights to receive money payments is saleable without working an undue hardship. This presumption may be rebutted by evidence demonstrating that the contractual rights are not saleable without working an undue hardship.
When offering contractual rights for sale, they must first be offered to co-owners, joint owners, or occupiers. If no buyer is secured, the contract must be offered for sale by public advertisement. The following content is acceptable as a means of demonstrating a good faith effort to sell a contract for deed:
Example 1: Offered at 75% of value.
For Sale: Seller’s interest in contract for deed. Secured by W ½ of Sec. 65-13-120. Remaining ~~principal~~ payments of $18,000~~, plus interest at 5.5%, is~~ are due in annual installments on Nov. 1, ~~2000~~ 2006 through ~~2004~~ 2010. Will consider offers which exceed $~~12,250~~ 13,500. Call 555-3333 or write Box 12, Tampa Gazette, Tampa, ND 58990.
Example 2: Offered at 100% of value.
For Sale: Seller’s interest in contract for deed. Secured by W ½ of Sec. 65-13-120. Remaining ~~principal~~ payments of $18,000~~, plus interest at 5.5%, is~~ are due in annual installments on Nov. 1, ~~2000~~ 2006 through ~~2004~~ 2010. ~~This seller’s interest is offered at $16,334.~~ Call 555-3333 or write Box 12, Tampa Gazette, Tampa, ND 58990.
~~5.~~6. If an asset is sold in exchange for a contractual right to receive money payments, the principal payments received constitute a converted asset. (The interest portion of the payments is considered unearned income.)
~~6.  Some contractual rights may be written so the lender has the right to demand payment at any time. If so, the note is considered a demand note and can be called in at any time. If a note is written so the lender does not have the right to demand payment but the note is in default, it also becomes a demand note. Contractual rights may or may not have collateral or security to guarantee payment.~~
~~While the lender may have the right to demand payment, there are situations where the debt is not collectable and is not secured. In these situations, the debt has no collectable value. An applicant or recipient can establish that a note has no collectable value because:~~
~~a.~~	~~The debtor is judgment proof. A debtor is judgment proof when money judgments have been secured and not satisfied. An applicant or recipient may show a debt has no value as long as a money judgment obtained by any creditor (including the applicant or recipient) has been on file in a county in which the debtor lives, or owns property, for at least 60 days and has not been satisfied; or~~
~~b.~~	~~The applicant or recipient verifies the debt is uncollectable due to a statute of limitations. A satisfactory verification includes an attorney’s letter identifying the statute and facts that make a debt uncollectable due to a statute of limitations.~~
~~Applicants and recipients should be encouraged not to forgive debts that have been determined to be uncollectible. Such debts could have a future value if the debtor ever accrues assets. At each annual redetermination, determine whether the judgments are still on file or whether the debtor has any change in assets.~~

General Information (Annuities). 510-05-70-45-05
The annuity section has been reorganized into six different sections for simplification. This first section includes general annuity information regardless of when an annuity was purchased.

1.	An annuity is a financial instrument, identified as such, that is established to provide periodic income payments over a defined period of time (see "annuity").  Most annuities are sold by organizations such as insurance companies (see "issuing entity"), though individuals sometimes assume the responsibility to pay annuity contracts. An annuity may be purchased with a single lump sum payment or through periodic payments.  Annuities have long been used as a means of creating retirement income, and many established retirement plans involve the use of annuities. Annuities are also used in an attempt to convert countable assets into income so as to avoid consideration of those assets in eligibility determinations.  
~~2.~~	~~This~~ The following annuity sections describe~~s~~ the effect of any annuity on any application for Medicaid benefits. ~~This~~ These sections ~~identifies~~ identify annuities that are not countable assets; annuities that are countable assets, ~~and~~ how to establish the~~ir~~ value of an annuity; and how to determine if the purchase, ~~or~~ annuitization, or change to ~~of~~ an annuity is a disqualifying transfer, and if so, how to determine the amount of the disqualifying transfer. ~~This~~ These sections takes into consideration ~~the requirements of North Dakota law, including~~ asset considerations (510-05-70-10), valuation of assets (510-05-70-60), and federal and state (N.D.C.C. 50-24.1-02.8) annuity provisions, which govern~~s~~ transfers ~~involving annuities~~ and purchases of annuities ~~by community spouses~~. ~~This~~ These sections recognize~~s~~ the extent to which annuities may be returned to the issuing entity for a cash settlement, transferred to another individual as payee, or have the payee’s rights to income sold to another without the permission, or even the knowledge, of the issuing entity.
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.

Definitions for Annuities. 510-05-70-45-10
This section includes definitions that are common to all of the annuity sections.  The definitions for community spouse, HCBS spouse, and institutionalized spouse were removed as they no longer apply to the annuity sections.  A new definition for “third party annuity” was added.  This change is effective February 8, 2006.
	For purposes of ~~this~~ the annuity sections:
1.	“Annuitant” means the individual whose life is considered in determining the price and payment schedule of an annuity, and who is usually the payee of the annuity;
2.	“Annuitized annuity” means an annuity subject to a contractually established schedule of payments to be made by the issuing entity, other than an immediate lump sum payment of all of the annuity’s value;
3. 	“Annuity” means a policy, certificate, contract, or other arrangement between two or more parties whereby one party pays money or other valuable consideration to the other party in return for the right to receive payments in the future for a fixed period of time;
~~“Community spouse” has the same meaning as in 05-65-10, Definitions for Spousal Impoverishment.~~
~~“Home and community based services spouse” has the same meaning as in 05-65-10, Definitions for Spousal Impoverishment.~~
~~“Institutionalized spouse” has the same meaning as in 05-65-10, Definitions for Spousal Impoverishment.~~
4.	“Issuing entity” means the individual or entity that issues and undertakes a promise to make payments provided in an annuity;
5.	“Level monthly payments” means substantially equal monthly payments such that the total annual payment in any year varies by five percent or less from the total annual payment of the previous year and does not provide for a balloon or deferred payment of principal or interest;
6.	“Life expectancy” means the anticipated lifetimes of individuals of a given age and sex according to the appropriate life expectancy table at 05-100-75.  
7.	“Third party annuity” means an annuity that is purchased and owned by a third party, but in which a Medicaid applicant, recipient, or their spouse, is the annuitant (i.e. an accident settlement annuity).

Valuation of Annuities.  510-05-70-45-15
This section includes information on how annuities are valued and is common to all of the annuity sections.  New policy identifies how annuities are valued. This policy change is effective February 8, 2006.
1.  The value of a countable annuity is:
a.    If the annuity may be surrendered to its issuing entity for a refund or payment of a specified amount or provides an available lump-sum settlement option, an amount equal to the total available proceeds from that refund, surrender, or settlement; and
b.    ~~If the~~ For any other annuity ~~may be assigned~~, an amount equal to either:
i.	~~its~~ Its value as a contractual right to receive money payments (value of outstanding payments due); ~~and~~ or
ii.    Following a good faith effort to sell the annuity,
~~c.~~  	~~If the annuity may not be surrendered or assigned,~~ an amount equal to the highest amount offered by a buyer ready and able to complete the purchase of the annuity or the right to receive a stream of income consisting of the payments yet to come due under the terms of the annuity. (An annuity in which a payment option was selected before August 1, 2005 may indicate that it is non-assignable and irrevocable, however, the income stream from the annuity may still be sold.  An annuity in which a payment option is selected on or after August 1, 2005 is considered assignable by state law unless the annuity meets all of the requirements of 05-70-45-25(2)(c), or 05-70-45-30(3)(c).  This state law provision applies even if the annuity indicates that it is non-assignable.) 

2.    The owner of an annuity may demonstrate a good faith effort to sell the annuity or the right to receive the payments from the annuity by making an offer to sell to the regular market for such property.
~~i.~~ a. "Receivables" are the legal right to be paid money due under the terms of a contract. The income stream produced by an annuity is such a receivable. Any person may purchase the right to this income stream.
~~ii.~~ b. A "factor" is someone who buys receivables at a discount.
~~iii.~~c. The "factors' market" is one place that an annuity's income stream may be sold. Companies and individuals nationwide will pay a lump sum in return for the right to receive the remaining annuity payments. This income stream may be sold regardless of whether the annuity is irrevocable or not assignable. Several offers must be sought in order to establish the fair market value of the annuity.
3.    A good faith effort to sell must include an honest effort to sell the annuity that is reasonably calculated to induce a willing buyer to believe the annuity or income stream offered for sale is actually for sale ~~at a reasonable price~~. An offer to sell an annuity or its payments includes making an offer ~~in writing and submitting it~~ to potential purchasers. The offer must include, at a minimum:
~~i.~~  a.  	~~A statement~~ That the annuity owner is willing to take all necessary steps to sell the annuity or relinquish the payments under it in exchange for a lump sum payment including but not limited to providing an irrevocable power of attorney, change of beneficiary, payee, or address;
~~ii.~~  b. 	~~A statement of~~ The amount of payments;
~~iii.~~ c.  	A description of the term of the payments (how long they will last); and
~~iv.~~ d. 	The name, address, and telephone number of a person who will answer inquiries and receive offers.
4.  An annuity may not be excluded from consideration as an asset on the basis that it is not saleable without working an undue hardship.

Annuities Purchased Before August 1, 2005. 510-05-70-45-20
This section addresses annuities purchased before August 1, 2005.  Such annuities are countable assets unless they meet the requirements in subsection 2.  Subsection 4 identifies when the annuity is considered a disqualifying transfer, and subsection 5 identifies the amount of the transfer.  The primary policy changes are an expansion of what is considered an employee benefit annuity, and that annuities can belong to anyone (not just a community spouse) and still be excluded under subsection 2.  This change is effective February 8, 2006.
1.	Any payment received from the annuity is income, regardless whether the annuity itself is countable as an asset or is considered a disqualifying transfer.
2. 	An annuity ~~purchased for a community spouse~~ in which the payment option was selected before August 1, 2005 is ~~not countable~~ counted as an available asset ~~for purposes of making an assessment or determining eligibility but any payment derived from that annuity is income if~~ in the asset test unless:
a.	The annuity must be considered a disqualifying transfer; 
b.    The annuity constitutes an employee benefit that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue Code of 1986 (These annuities are considered “qualified” annuities); or
c.    The annuity meets all of the following conditions:
i.     The annuity is irrevocable and cannot be assigned to another person;
ii. 	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii. 	The annuity provides for level monthly payments;
iv.	The annuity will return the full purchase price and interest within the purchaser’s life expectancy; and
v. 	Unless specifically ordered otherwise by a court of competent jurisdiction acting to increase the amount of spousal support paid on behalf of a community spouse by an institutionalized spouse or a home and community based services (HCBS) spouse, the monthly payments from the annuity do not exceed $2488 effective January 2006 ($2378 effective August 2005).
3.    An annuity purchased ~~for a community spouse~~ before August 1, 2005, but for which the payment option is selected ~~on or after~~ from August 1, 2005, through February 7, 2006, is ~~not excluded under this provision~~ counted as an available asset.  ~~To meet the requirements under this subsection, the annuity cannot be assignable, however, an~~ State law considers any annuity in which a payment option is selected on or after August 1, 2005 ~~is considered~~ as assignable ~~(subsection 3, subdivision b)~~ unless it meets ~~all of~~ the requirements ~~Under subsection 7~~ in 05-70-45-25(2)(c).  ~~Annuities excluded under subsection 7 must be~~ To meet those requirements, the annuity would have to have been purchased on or after August 1, 2005.  
4.   The annuity is considered a disqualifying transfer unless:
a.  	The payment option was selected prior to the individual’s, or the individual’s spouse’s look back date;
b.	The annuity is a qualified employee benefit annuity, as described in (2)(b);
c.	The annuity meets all of the requirements in (2)(c) above; or
d.	The annuity is a third party annuity.
5.    The uncompensated value of an annuity that is considered a disqualifying transfer is an amount equal to the remaining payments due from the annuity.

Annuities Purchased From August 1, 2005 Through February 7, 2006.  510-05-70-45-25
This section addresses annuities purchased from August 1, 2005 through February 7, 2006.  Such annuities are countable assets unless they meet the requirements in subsection 2.  Subsection 3 identifies when the annuity is considered a disqualifying transfer, and subsection 4 identifies the amount of the transfer.  The primary policy changes are an expansion of what is considered an employee benefit annuity, and that annuities can belong to anyone (not just a community spouse) and still be excluded under subsection 2.  This change is effective February 8, 2006.

1.	Any payment received from an annuity is income, regardless whether the annuity itself is countable as an asset or is considered a disqualifying transfer.
2.  	The annuity is counted as an available asset in the asset test unless:
a.    The annuity must be considered a disqualifying transfer; 
b.    The annuity constitutes an employee benefit that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue Code of 1986 (These annuities are considered “qualified” annuities); or
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.   The annuity provides for level monthly payments;
iv    The annuity will return the full principle and has a guaranteed period that is equal to at least 85% of the annuitant’s life expectancy;
v.    The monthly payments from all annuities that meet the requirements of this subsection do not exceed $2488 and, when combined with the annuitant’s other income at the time of application for Medicaid, does not exceed $3732; and
vi.	If the applicant for Medicaid is age 55 or older, the Department of Human Services is irrevocably named as the primary beneficiary of the annuity following the death of the applicant and the applicant’s spouse, not to exceed the amount of benefits paid by Medicaid.  If a minor child who resided and was supported financially by the applicant or spouse, or disabled child, survives the applicant and spouse, any payments from the annuity will be provided to those individuals.
3.    The annuity is considered a disqualifying transfer unless:
a.  	The payment option was selected prior to the individual’s, or the individual’s spouse’s look back date;
b.    The annuity is a qualified employee benefit annuity, as described in (2)(b);
c.    The annuity meets all of the requirements in (2)(c) above; or
d.    The annuity is a third party annuity.
4.    The uncompensated value of an annuity that is considered a disqualifying transfer is an amount equal to the remaining payments due from the annuity.

Annuities Purchased Or Changed On Or After February 8, 2006.  510-05-70-45-30
This section addresses annuities purchased or changed on or after February 8, 2006.  This is new policy. Subsection 2 identifies when an annuity is considered to be changed.  Such annuities are countable assets unless they meet the requirements in subsection 3.  Subsection 4 identifies when the annuity is considered a disqualifying transfer, and subsection 5 identifies the amount of the transfer.  Subsection 6 identifies a notice that must be sent to the annuity company when the Department is the primary or secondary beneficiary.  This policy change is effective February 8, 2006.

1.	Any payment received from the annuity is income, regardless whether the annuity itself is countable as an asset or is considered a disqualifying transfer.
2.    An annuity is considered changed on or after February 8, 2006 if any action is taken on or after that date that changes the course of payments or the treatment of the income or principle of the annuity.  These actions include additions of principle to the annuity, elective withdrawals, requests to change the distribution of the annuity, elections to annuitize the contract, or similar actions.
3.	The annuity is counted as an available asset in the asset test unless:
a.	The annuity must be considered a disqualifying transfer; 
b.	The annuity constitutes an employee benefit that is an individual retirement annuity or is an annuity that was purchased with the proceeds from an individual retirement account (IRA), a Roth IRA, a simplified employee pension, an employer or employee association retirement account, or an employer simple retirement account, as described in section 408 of the Internal Revenue Code of 1986 (These annuities are considered “qualified” annuities); or
c.    The annuity meets all of the following conditions:
i.     The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full principle and has a guaranteed period that is equal to at least 85% of the annuitant’s life expectancy;
v.	The monthly payments from all annuities that meet the requirements of this subsection do not exceed $2488 and, when combined with the annuitant’s other income at the time of application for Medicaid, does not exceed $3732; and
vi.	If the applicant for Medicaid is age 55 or older, the Department of Human Services is irrevocably named as the primary beneficiary of the annuity following the death of the applicant and the applicant’s spouse, not to exceed the amount of benefits paid by Medicaid.  If a minor child who resided and was supported financially by the applicant or spouse, or disabled child, survives the applicant and spouse, any payments from the annuity will be provided to those individuals.
4.    The annuity is considered a disqualifying transfer unless:
a.    The payment option was selected, or the latest change to the annuity was made, prior to the individual, or the individual’s spouse’s look back date;
b.	The annuity is a qualified employee benefit annuity, as described in (3)(b) above and the department is named as the remainder beneficiary in the first position for at least the total amount of Medicaid paid on behalf of the annuitant or the annuitant’s spouse.  The department may be named as the remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or child disposes of any such remainder for less than fair market value;
c.	The annuity meets all of the requirements in (3)(c)(i) through (3)(c)(v) above and the department is named as the remainder beneficiary in the first position for at least the total amount of Medicaid paid on behalf of the annuitant or the annuitant’s spouse.  The department may be named as the remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if such spouse or child disposes of any such remainder for less than fair market value; or
d.	The annuity is a third party annuity.
5.    The uncompensated value of an annuity that is considered a disqualifying transfer is an amount equal to the remaining payments due from the annuity.
6.	When the Department is entitled to be the remainder beneficiary of an annuity purchased or changed on or after February 8, 2006, the “Notice To Insurer Of Annuity” (SFN----) (05-100-96) must be sent to the company that issued the annuity.  The notice must be sent when the Medicaid application is approved, or if an ongoing case, when the annuity is reported.

Valuation of Assets. 510-05-70-60
This policy change is adopted because of the new method of determining the value of contractual rights to receive money payments.  
2.	With respect to personal property other than liquid assets:
e.	With respect to contractual rights to receive money payments: If payments are current, the contract, and if payments are not current, the Legal Advisory Unit of the Department (see 05-70-40).  

Definitions. (Transfer provision) 510-05-80-05
The definition of nursing care services was moved to the beginning of the manual, and the remaining definitions were renumbered. 

~~3.~~	~~"Nursing care services" means nursing care provided in a medical institution, a nursing facility, a swing bed, the state hospital, or a home and community based services setting.~~

Disqualifying Transfer Provisions. 510-05-80-10
This section has been updated to reflect the 5-year look-back date for transfers made on or after February 8, 2006.  This policy change is effective February 8, 2006.
1.	…
2.	The look-back date for income or asset transfers made before February 8, 2006 (other than for transfers to or from a trust ~~described in subsection 3~~) is a date that is thirty-six months before the date on which the individual is both receiving nursing care services and has applied for benefits under this chapter, without regard to the action taken on the application.
3.	The look-back date for income or assets transferred on or after February 8, 2006 or transferred to an irrevocable trust, or from a revocable or irrevocable trust, established by an applicant, a recipient, their spouse, or any one acting on their behalf, other than by will, is a date that is 60 months before the date on which the individual is both receiving nursing care services and has applied for benefits under this chapter, without regard to the action taken on the application.

Penalty Periods. 510-05-80-15
This section includes policy changes relating to when the penalty period starts (subsection 3) for transfers made on or after February 8, 2006, and identifies when an individual is “otherwise eligible” for Medicaid (subsection 4).  The “otherwise eligible” determination is needed to determine when a penalty period can begin.  Subsection 6 has been added to address notice requirements and to identify when penalty periods can be imposed.  This policy change is effective February 8, 2006.

2.	For transfers made before February 8, 2006:
a.	The period of ineligibility begins the first day of the month in which the income or assets were transferred for less than fair market value, or if that day is within any other period of ineligibility under this chapter, the first day thereafter that is not in such a period of ineligibility.
For Example: Mr. Smith made a disqualifying transfer in January ~~of last year~~ 2005 that resulted in a ten-month period of ineligibility. The period begins the first day of the month of transfer, January 2005, and goes through October 2005. In July ~~of last year~~ 2005, he made a second disqualifying transfer that resulted in a 12-month period of ineligibility. Because the month of transfer, July 2005, was already within a period of ineligibility, the 12-month period from the second transfer only begins in November 2005, and goes through October ~~of this year~~2006.
b.	Separate transfers made within the same month may be combined as one transfer.  Separate penalty periods must be established for transfers made in separate months.
3.	For transfers made on or after February 8, 2006:
a.	 The period of ineligibility begins on the latest of:
i.   The first day of the month in which the income or assets were transferred for less than fair market value; 
ii.  The first day on which the individual is receiving nursing care services and is “otherwise eligible” for Medicaid (per subsection 4); or 
iii. The first day thereafter which is not in such a period of ineligibility.
b. Separate transfers for which a penalty period has not yet been created, regardless of whether made in separate months, may be combined into one larger transfer for processing purposes.
4.	When determining if an individual is “otherwise eligible” for Medicaid:
a.	The individual must have applied for Medicaid and must meet all nonfinancial eligibility criteria;
b.	Countable assets must be within appropriate Medicaid asset levels; and 
c.	The monthly cost of nursing care and other medical care the individual is responsible for must be equal to or greater than the individual’s recipient liability.
This “otherwise eligible” determination is used to establish whether an individual would be eligible for Medicaid if they were not subject to a penalty period.  If so, the “otherwise eligible” determination is used to establish the penalty period start.  
An applicant who is determined to be “otherwise eligible” does not mean that the applicant is actually eligible for Medicaid.  Since Medicaid is prohibited from paying any nursing care services during a penalty period, these nursing care expenses are not allowed as a deduction in the Post Eligibility Treatment of Income (510-05-85-25(3)).  As a result, an individual who made a disqualifying transfer may be “otherwise eligible” for penalty period start purposes, but the individual is not approved for Medicaid because there is no medical need per 510-05-35-35.

Example 1:  Mr. Brown made a disqualifying transfer in March 2006 that results in a 6-month penalty period.  He entered the nursing home in May 2006 and used his remaining assets to cover his cost of care.  In September 2006 his assets were under $3000 and he applied for Medicaid.  In determining when Mr. Brown’s penalty period begins it is necessary to establish when he is “otherwise eligible” for Medicaid.  First, he meets all nonfinancial criteria.  Second, his assets are within the appropriate level beginning September 2006.  Third, he has income of $900 per month; he is allowed the $50 income level; and he pays a Medicare premium of $88.50 per month.  This leaves him with a recipient liability of $761.50 per month.  He has actual nursing care costs of $4820 per month and other medical expenses of $150 per month for total medical costs of $4970 per month.  These medical costs exceed his recipient liability.  He meets all of the criteria to be “otherwise eligible” so his penalty period starts September 1, 2006.
His application for Medicaid is still denied because in determining medical need, his other medical expenses of $150, excluding the nursing care costs, do not exceed his recipient liability.
Example 2:  Mr. White made a disqualifying transfer in March 2006, entered the nursing home in May 2006, and used his remaining assets to cover his cost of care.  In September 2006 his assets were under $3000 and he applied for Medicaid.  In determining whether Mr. White is “otherwise eligible” for Medicaid, it is first established that he meets all nonfinancial criteria.  Second, his assets are within the appropriate level beginning September 2006.  Third, he has income of $1500 per month; he is allowed the $50 income level; and he pays a Medicare premium of $88.50 per month.  This leaves him with a recipient liability of $1361.50 per month.  He has actual nursing care costs of $3520 per month, and he has nursing home insurance that pays $75 per day ($2250 in a 30-day month).  As a result, the nursing care costs that he is responsible for ($1270) does NOT exceed his recipient liability, and he is not “otherwise eligible.”  His penalty period would not start and his application for Medicaid is denied for no medical need.  
If at a later date his nursing care costs increase, or his insurance ends, causing his nursing care costs to exceed his recipient liability, he would become “otherwise eligible,” and his penalty period would only start at that time.

~~3.~~ 5.	If a transfer results in a period of ineligibility for an individual receiving nursing care services, and the individual’s spouse begins receiving nursing care services and is “otherwise eligible” (per subsection 4) for Medicaid, the remaining period of ineligibility shall be apportioned equally between the spouses if the transfer was made on or after the individual's spouse's look-back date. Any months remaining in the period of ineligibility must be assigned or reassigned to the spouse who continues to receive the nursing care services if one spouse dies or stops receiving nursing care services.

6.	As with any adverse action, proper notice is required before the adverse action can be taken.  On an application, proper notice is given in the approval or denial notice.  In an ongoing case, even though the penalty period should have already begun, it cannot be imposed until an advance notice is provided to the recipient.  For the period of time from when the penalty period should have started through the date it is imposed following advance notice, an overpayment must be processed (manually).

Example:  Ms. Green is a current Medicaid recipient receiving HCBS.  On November 2 she made a disqualifying transfer of her home and reported it to the county on December 5.  The county determines a penalty period from November 1 through September 15 of the next year.  An advance notice is sent to Ms. Green informing her that Medicaid will stop paying her HCBS services from December 16 through September 15 of next year.  A manual overpayment is established for HCBS payments made by Medicaid for the period of November 1 through December 15.

Hardship Provision. 510-05-80-20
The hardship provision has been completely rewritten to identify the new policy (all of the previous policy has been removed).  Individuals, and nursing facilities (with the individual’s consent), can request a hardship exception through the county, and must follow the requirements identified in the policy.  The Medicaid Eligibility Unit will determine whether a hardship waiver will be granted.  This policy change is effective February 8, 2006.
 
1.	A disqualifying transfer penalty period is not imposed on an individual to the extent the individual makes a satisfactory showing that an undue hardship exists for the individual.  

2.	Upon imposition of a penalty period because of a transfer of assets or income, an individual must be provided notification of the right to request an undue hardship exception.  An individual may apply for an exception to the transfer of asset penalty if the individual claims that the penalty period will cause an undue hardship to the individual and provides sufficient documentation to support that claim within 90 days of notification of the transfer penalty, or within 90 days after the circumstances upon which the claim of hardship is made known, or reasonably should have been known, to the affected individual or the person acting on behalf of the individual if incompetent.  

The facility in which the person resides may apply for an exception to the transfer penalty on behalf of the individual if they have the individual’s, or their personal representative’s, consent.

3.   Requests for undue hardship exceptions must be submitted to the Medicaid Eligibility Unit.  Upon receipt of a request for a hardship exception, the Medicaid Eligibility Unit will determine whether an undue hardship exists.  The determination of hardship made by the Medicaid Eligibility Unit will state the date upon which the hardship exception begins, and, if applicable, when it ends.   

4.   An undue hardship exists only if the individual shows that all of the following conditions are met:

a.	Application of the penalty period would deprive the individual of food, clothing, shelter, or other necessities of life, or medical care such that the individual’s health or life would be endangered;

b.	The individual, the individual’s spouse, or anyone acting on behalf of either, has not made the transfer after a previous request for a hardship exception;

c.	The individual who transferred the assets or income, or on whose behalf the assets or income were transferred, has exhausted all lawful means to recover the transferred assets or income, or the value of the transferred assets or income, from the transferee, a fiduciary, or any insuror;

d.	A person who would otherwise provide care would have no cause of action, or has exhausted all causes of action, against the transferee of the assets or income of the individual or the individual’s spouse under North Dakota Century Code chapter 13-02.1, the Uniform Fraudulent Transfers Act, or any substantially similar law of another jurisdiction; and 

e.	The individual’s remaining available assets, and the remaining assets of the individual’s spouse, if any, are less than the asset limit applicable to a Medicaid eligible unit that would include the individual, the individual’s spouse, if any, and the individual’s minor children, if any, counting the value of all assets except:

i.	The home, but not if the individual, or the individual’s spouse, if any, have equity in the home in excess of $200,000;

ii.	Exempt personal effects, wearing apparel, household goods, and furniture;

iii.	One motor vehicle, if the primary purpose of the vehicle is to serve the needs of members of the Medicaid unit; and

iv.	Funds for burial of $5,000 or less for the individual and the individual’s spouse.

5.	If a request for an undue hardship exception is denied, the applicant or recipient may request an appeal to the North Dakota Department of Human Services.

6.	A hardship determination approved by the Medicaid eligibility unit, or through the appeal process, may be terminated, or adjusted if:

a.	New information is received that would have affected the original determination;

b.	Circumstances change;

c.	The individual, the individual’s spouse, or anyone with authority to transfer income or assets of the individual or the individual’s spouse, makes a subsequent transfer of income or assets; or

d.	The individual, the individual’s spouse, or anyone with authority to manage the income or assets of the individual or the individual’s spouse, converts any income or assets to a form that is exempt or excluded.

Exceptions to Disqualifying Transfer Provision. 510-05-80-25
Subsection 5 has been updated to remove the reference to community spouse and to provide references to the new annuity sections.  Individuals other than just community spouses are allowed to have excluded annuities, and the purchase of such an annuity is not a disqualifying transfer.

5.	A transfer is not disqualifying to the extent that the asset was used to acquire an annuity ~~for a community spouse~~ if the annuity meets the requirements in annuity ~~sub~~sections ~~6 and 7 of 05-70-45~~ 05-70-45-20, 05-70-45-25, or 05-70-45-30.

Post Eligibility Treatment of Income. 510-05-85-25
This section has been updated with the PRTF policy from IM 4985.
 
This section prescribes specific financial requirements for determining the treatment of income and application of income to the cost of care for individuals with a certification of need or who are screened as requiring nursing care services, and who are residing in nursing facilities, the state hospital, the Anne Carlsen facility, the Prairie at St. John's center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), intermediate care facilities for the mentally retarded (ICF-MR), and individuals receiving swing bed care in hospitals.

Disregarded Income. 510-05-85-30
This section has been updated with the PRTF policy from IM 4985 and TANF Diversion Assistance from IM 4989. The update also excludes foster care, subsidized guardianship, or subsidized adoption payments from another state, or from tribal entities.  This policy recognizes the recent change in which Tribal 638 Foster Care children are considered foster care by Children and Family Services.

This section applies to an individual residing in his or her own home or in a specialized facility, to the Medicare Savings Programs, and to the Workers with Disabilities coverage.  It does not apply to Transitional Medicaid Benefits (refer to 05-50-05), or to an individual receiving psychiatric or 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, a Psychiatric Residential Treatment Facility (PRTF), 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 types of income must be disregarded in determining Medicaid eligibility:
1.	Money payments made by the Department, another state, or tribal entities in connection with foster care, subsidized guardianship, or the subsidized adoption program (This does not include Casey Family~~, Tribal,~~ or other private foster care payments);
2.	Temporary Assistance for Needy Families (TANF) benefit and support services payments, or Diversion Assistance payments made by the Department or another state;

Income Deductions. 510-05-85-35
This section has been updated with the PRTF policy from IM 4985.
 
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 psychiatric or 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, a Psychiatric Residential Treatment Facility (PRTF), 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.

Income Levels. 510-05-85-40
This section has been updated with the PRTF policy from IM 4985.
  
2.	Medically needy income levels.
b.	Nursing care income level. The nursing care income level is fifty dollars per month and must be applied to residents receiving psychiatric or nursing care services in nursing facilities, intermediate care facilities for the mentally retarded (ICF-MR), the state hospital, the Prairie Psychiatric Center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), the Anne Carlsen facility, or receiving swing bed care in a hospital.

Determining the Appropriate Income Level in Special Circumstances. 510-05-85-45
This section has been updated with the PRTF policy from IM 4985.

4.	During a month in which an individual with eligible family members in the home enters or leaves a Psychiatric Residential Treatment Facility (PRTF) or 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 Psychiatric Residential Treatment Facility (PRTF) or 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.
…
8.	An individual who is residing in a Psychiatric Residential Treatment Facility (PRTF) or a nursing facility but who is not certified or screened as needing that level of care is allowed the medically needy income level. If the individual appeals the certification or screening and wins, the nursing care income level applies to all full calendar months the appeal covers.

Deeming of Income. 510-05-85-50
This section has been updated with the PRTF policy from IM 4985.

4.	The excess income of a spouse or parent(s) cannot be deemed to a recipient to meet medical expenses during any full calendar month in which the recipient receives psychiatric or nursing care services in a nursing facility, an intermediate care facility for the mentally retarded (ICF-MR), the state hospital, the Anne Carlsen facility, the Prairie at St. John's center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), or receives swing bed care in a hospital or HCBS. Income of the eligible spouse or parent(s), however, may be deemed to bring the individual to the appropriate income level when the individual is ineligible for SSI.

Budgeting Procedures for SSI Recipients. 510-05-90-45
This section has been updated with the PRTF policy from IM 4985.
 
2.	SSI recipients residing in a nursing facility, an intermediate care facility for the mentally retarded (ICF-MR), the state hospital, the Anne Carlsen facility, the Prairie Psychiatric Center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), or receiving swing bed care in a hospital: The SSI recipient is allowed the nursing care income level.
~~For a single SSI recipient under age 18, p~~Parental and spousal income is not considered available to the recipient. ~~Likewise, for a married SSI recipient, the income of the spouse is not considered available.~~

Budget Procedures for Medically Needy and Poverty Level. 510-05-90-55
This section has been updated with the PRTF policy from IM 4985.
 
2.	Recipients residing in a nursing facility, an intermediate care facility for the mentally retarded (ICF-MR), the state hospital, the Anne Carlsen facility, the Prairie Psychiatric Center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), or receiving swing bed care in a hospital: The recipient is allowed the $50 nursing care income level.

Life Expectancy Table. 510-05-100-75
A new life expectancy table applies beginning February 8, 2006.  The previous table still applies for dates prior.
 
 1.   The following life expectancy table is effective prior to February 8, 2006.
Age | Life Expectancy – Male | Life Expectancy – Female
55 | 22.21 | 27.00
		…
99 | 2.34 | 2.64
100 | 2.22 | 2.48

2.    The following life expectancy table is effective February 8, 2006.

Period Life Table
Age | Male | Female
| | | Life expectancy | | | Life expectancy
0 | | | 74.14 | | | 79.45
1 | | | 73.70 | | | 78.94
…
119 | | | 0.56 | | | 0.56

SFN 1186, “Notice To Insurer Of Annuity.” 510-05-100-96
This section identifies a new notice that must be sent to annuity insurers for annuities purchased or changed on or after February 8, 2006, in which the Department is entitled to be a remainder beneficiary.  This change is effective February 8, 2006. 

Other Sections Changed
This manual letter includes other typographical corrections and administrative code changes that are not identified above.

Par. 2.  Effective Date  -- This manual letter is effective for the benefit month of November 2006, unless otherwise indicated.

Carol K. Olson, Executive Director	Manual Letter #3047
North Dakota Department of Human Services	Page  of  Pages