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

Bismarck, North Dakota	MANUAL LETTER #3127	March 1, 2008

Par.1.	Material Transmitted and Purpose – Transmitted with this Manual Letter are changes to Service Chapter 510-05 – Medicaid Eligibility Factors, to add policy for the new Children with Disabilities Coverage.  Also, the 2008 average cost of nursing home figures have been added to the Disqualifying Transfer section of the manual. IM 5026, and Amended IM 5026 were incorporated into the manual sections.

510-05-30-05.   Groups Covered Under Medicaid

Language was added as subdivision f. in subsection 2 to list the Children with Disabilities coverage.

2.	The optional categorically needy group includes:
f.	Children with Disabilities under age 19 (including the month attaining age 19) who meet medically needy nonfinancial criteria, have income at or below 200% of the poverty level, and are not eligible for full Medicaid benefits under any other provision.  Effective March 2008.

510-05-35-100.   Blindness and Disability

Language was added to subsection 4 to identify another situation where SSA will not make a disability determination.  The State Review Team will need to make a disability determination for these individuals.

4.	The county agency will need to obtain and submit medical and social information to the State Review Team for their evaluation if:
a.	The applicant is requesting assistance for a month prior to the SSI application;
b.	The applicant is not eligible for SSI because of the SSI income and resource levels;
c.	The applicant refuses to apply for SSI;
d.	The applicant is not eligible for SSA disability due to not being insured;
e.	The applicant is applying for Workers with Disabilities coverage and is not eligible for SSA disability due to substantial gainful activity;
f.	The applicant has applied for SSA disability and a determination is not made within 45 days of the Medicaid application; ~~or~~
g.	The applicant is within six months of reaching full retirement age; or
h.	The applicant is requesting assistance under the Children with Disabilities coverage and has not been determined disabled by SSA.
The medical and social information is generally submitted along with SFN 451, "Eligibility Report on Disability/Incapacity" (05-100-40), and if the individual is applying for Workers with Disabilities coverage, SFN 228, "Workers with Disability Report Part II" (05-100-41).  

510-05-58.   Children with Disabilities
This is new policy relating to eligibility for Children with Disabilities.  The new sections added are:

510-05-58-05.   General Information
The Children with Disabilities coverage allows options to families of children with disabilities under age 19, who are not eligible for Medicaid or who are eligible for Medicaid and have a recipient liability, to buy into Medicaid. This coverage became effective in North Dakota on March 1, 2008.

All medically needy technical and financial eligibility factors apply to the Children with Disabilities coverage except as identified in sections 05-58-10 through 05-58-35.

510-05-58-10.   Individuals Covered (Children with Disabilities) 
1.	An individual may be enrolled under the Children with Disabilities coverage if he or she:
a.	Is under age 19 (including month individual turns age 19);
b.	Is disabled; and
c.	Except for Qualified Medicare Beneficiary or Special Low-income Medicare Beneficiary coverage, is not in receipt of any other Medicaid benefits under this chapter. 
2.	The Social Security Administration may refuse to determine disability for a new applicant when the family has excess assets or income.  In these situations, the State Review Team will make a medical determination of disability.  This disability determination is valid for all Medicaid coverages; however, these individuals will likely remain eligible for Medicaid under the Children with Disabilities coverage.  
3.	Applicants or recipients who are eligible under this coverage, but who may also be eligible as medically needy, may choose which coverage they want, and will likely be based on which is more cost-effective for them.  Once a recipient has been authorized as eligible for a current or past benefit month under one coverage, and the eligibility cannot be unauthorized, the recipient cannot switch coverages for that benefit month.   A recipient can switch between coverages prospectively. 

510-05-58-15.   Employer Based Insurance
As a condition of eligibility for Children with Disabilities coverage, a child must be enrolled in a health insurance policy if:
1.	The family has an employer based health insurance available to them; and
2.	The employer pays at least 50% of the premium (excluding separate dental and vision coverage).

510-05-58-20.   Income Considerations for Children with Disabilities
Income calculations must consider income in the manner provided for in the Medically Needy income considerations; ownership of income; unearned income; earned income; disregarded income; and income deductions; except:
1.	Income disregards in 05-85-30 and income deductions in 05-85-35 are allowed regardless of the individuals living arrangement; and
2.	The cost of any Children with Disabilities premium is not allowed as a deduction in the Children with Disabilities budget calculation.

510-05-58-25.   Income Levels for Children with Disabilities

Refer to Section 05-85-40 for the Children with Disabilities income levels.

510-05-58-30.   Premium Calculation for Children with Disabilities
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.
2.	The Children with Disabilities premium is offset by any premium amount the family pays toward a family health insurance policy in which the disabled child is covered. 
3.	Prior to authorizing initial eligibility for any month(s) prior to the future benefit month, the individual is required to pay any premiums due for those benefit months. Premium payments received by the county must be submitted to the department's Fiscal Administration unit using the Medicaid credit form, SFN 828. Premiums for future benefit months are due on the tenth day of the future month.
4.	When rebudgeting an eligible month of Children with Disabilities coverage, and the individual remains eligible, a previously established premium is not changed unless it can be changed prospectively with a ten-day advance notice, or if the original premium notice has not been mailed.
5.	Monthly premium notifications will be sent informing eligible individuals of any premium amount(s) due. The notice will include a self-addressed envelope for the individual to send the premium payment directly to the Fiscal Administration unit. 
Any excess monies received by the Fiscal Administration unit will not be immediately refunded, but will be held as credit, and will be applied to future premiums due. When an individual becomes ineligible for Children with Disabilities coverage for a period of more than 30 days, Fiscal Administration will return any credit balance to the individual in the form of a refund.
If a premium payment by check is returned due to non-sufficient funds, the premium will be considered unpaid.
6.	Any individual who fails to pay the premium established under this section for three consecutive months shall be disenrolled and may not be reenrolled thereafter without first reestablishing eligibility under this section and paying all outstanding premiums. Any month in which no premium is due shall not be counted as a month in which the individual failed to pay a premium.
Payments received by the Department from an individual claiming eligibility under this section shall be credited to the oldest unpaid premium. The Department shall credit payments on the day received, provided that credit for any payment made by an instrument that is not honored shall be reversed. The Department may require any individual who has attempted payment by a dishonored instrument to make subsequent payments in a specified manner.

510-05-80-05.   Definitions 
Subsection 9 of the Definitions Section under Disqualifying Transfers has been updated to include the 2008 average cost of nursing facility care. This change is effective January 1, 2008.
9.	The average cost of nursing facility care is:
 
Year | Daily Rate | Monthly Rate
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
1996 | 85.00 | 2562
1995 | 80.00 | 2419
1994 | 74.00 | 2339
 
510-05-85-30.   Disregarded Income 
Language was added to the first paragraph to indicate that the income disregards also apply to the Children with Disabilities coverage. 
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 and Children with Disabilities coverages. 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).

510-05-85-35.   Income Deductions

Language was added to the first paragraph to indicate that the income deductions also apply to the Children with Disabilities coverage.   Language was also added to subsection one to indicate that the Children with Disabilities premium is allowed deductions from income when determining eligibility for other family members in other coverages, but is not allowed as a deduction when establishing Children 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 to the Workers with Disabilities and Children with Disabilities coverages, 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.
 
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 as well as the Children with Disabilities coverage premium are ~~is an~~ allowed deductions except the Workers with Disabilities premium is not allowed when determining eligibility for the Workers with Disabilities coverage and the Children with Disabilities premium is not allowed when determining eligibility for the Children 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:

510-05-85-40.   Income Levels 

3.	Poverty income levels
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 | $1702
2 | 2282
3 | 2862
4 | 3442
5 | 4022
6 | 4602
7 | 5182
8 | 5762
Effective March 1, 2008
For each person in the Medicaid unit above eight, add $580 to the monthly amount.

510-05-85-45.   Determining the Appropriate Income Level in Special Circumstances

Language was added to subsections 3 and 4 to identify that the 200% of poverty income level applies when determining eligibility for Children 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 and Children with Disabilities coverages, individuals in a specialized facility will be allowed the appropriate Workers with Disabilities or Children 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 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 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 and Children with Disabilities coverages, individuals in a nursing facility, or in receipt of HCBS, will be allowed the appropriate Workers with Disabilities or Children with Disabilities ~~income~~ level for one during all full calendar months in which the individual resides in the facility.

510-05-85-50.   Deeming of Income
A new subsection 6 was added to indicate that income may be deemed to members of the Medicaid unit at the 200% of poverty income level for the purpose of establishing Children with Disabilities eligibility.

6.	For purposes of determining eligibility for Children 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 Children with Disabilities income level.

510-05-90-70.   Budgeting Procedures for Children with Disabilities 

This new section was added to summarize the budgeting procedures for the Children with Disabilities coverage.
All income of the applicant or recipient and other members of the Medicaid unit 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 200% of the poverty level can be eligible under the Children with Disabilities coverage.  

If the family passes the 200% eligibility test, the premium required to obtain the coverage is equal to 5% of the family’s gross countable income. The Children with Disabilities premium is offset by any premium amount the family pays toward a family health insurance policy in which the disabled child is covered. 

Par. 2.   Effective Date – This manual letter is effective for the benefit month of March 2008, unless otherwise indicated.

Carol K. Olson, Executive Director	Manual Letter #3127
North Dakota Department of Human Services	Page  of