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

Bismarck, North Dakota	MANUAL LETTER #3146	June 1, 2008

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

510-05-30-05 Groups Covered Under Medicaid

Language has been changed in Subsection 3 (a) to reflect that caretaker relatives under age 19 can be eligible for continuous eligibility.

3.	The medically needy group includes:
a.	Eligible caretaker relatives and individuals ~~under age~~ ages nineteen to twenty-one in families with deprived children who do not meet income or age Family Coverage group requirements, but meet medically needy income standards.

510-05-35-95 Inmates of Public Institutions 

Language has been added to Subsection 2 to identify that a child who has continuous eligibility and enters a public institution stays eligible for Medicaid but no claims for services are covered.

2.	An inmate of a public institution is not eligible for Medicaid unless:
a.	The individual is attending school at the North Dakota School for the Blind in Grand Forks, or North Dakota School for the Deaf in Devils Lake;
b.	The eligible individual is residing in the ICF/MR at the State Developmental Center, or is in long term care in the North Dakota Veteran’s Home;
c.	The individual is in a public institution for a temporary period pending other arrangements appropriate to the individual's needs (i.e., Juvenile Detention Center, Fargo);
d.	The individual is over age sixty-five and a patient in the state hospital; or
e.	The individual is under age twenty-one, in the state hospital receiving inpatient psychiatric services, and who meets the certificate of need for admission. A person who attains age twenty-one while receiving treatment, and who continues to receive treatment as an inpatient, may continue to be eligible through the month the individual attains the age of twenty-two.
f.	The individual is under the age of 19 and is determined to be continuously eligible for Medicaid.  While the individual remains eligible for Medicaid no medical services will be covered during the stay in the public institution.

510-05-40-05 – Paternity 

Language has been added to include a continuously eligible caretaker as an exception for cooperating in establishing paternity.

1.	As a condition of eligibility for a parent or caretaker, the parent or caretaker must cooperate with the Department and county agency in establishing paternity of any child under age eighteen in the Medicaid unit. An exception to this provision exists when the parent or caretaker is pregnant, within a continuous eligibility period for Medicaid, receiving Extended Medicaid Benefits, or receiving Transitional Medicaid Benefits. It is never a condition of a child’s eligibility that the parent or caretaker cooperates.

510-05-40-15 Cooperation -- Child Support 

Subsection 3 has been added to identify continuously eligible caretaker relatives as an exception for cooperating with child support enforcement.

3.	Caretaker relatives under age 19 who are within a continuous eligibility period are not required to cooperate with Child Support and remain eligible for Medicaid.

The current Subsection 3 will become Subsection 4.

510-05-57-35 Premiums for Workers with Disabilities 

Language has been added to Subsection 5 to identify what will happen in a situation where a Worker with Disabilities who has continuous eligibility fails to pay premiums for 3 consecutive months.

5.	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 enrollment fees and 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.
An individual who is under age 19 and is continuously eligible for Medicaid who fails to pay the premium for 3 consecutive months cannot be disenrolled prior to the end of their continuous eligibility period.  They may not be reenrolled thereafter without first reestablishing eligibility under this section and paying all outstanding enrollment fees and premiums.  
Payments received by the Department from an individual claiming eligibility under this section shall be credited first to unpaid enrollment fees and then 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.

510-05-58-30 Premium Calculation for Children with Disabilities

Language has been added to Subsection 6 to identify what will happen in a situation where a child with Children with Disabilities coverage who has continuous eligibility fails to pay premiums for 3 consecutive months.

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.
An individual who is under age 19 and is continuously eligible for Medicaid who fails to pay the premium for 3 consecutive months cannot be disenrolled prior to the end of their continuous eligibility period.  They may not be reenrolled thereafter without first reestablishing eligibility under this section and paying all outstanding premiums. 
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.

510-05-53  Continuous Eligibility for Children 
This is new policy relating to Continuous Eligibility for children.  The new sections added are:

510-05-53-05 General Statement
Continuous eligibility for children allows recipients under age 19 who have been determined eligible for Medicaid, other than Medically Needy, to be deemed eligible for a total of up to 12 months regardless of changes in circumstances other than attainment of age 19.  This has an effective date of June 1, 2008.

510-05-53-10 Individuals Covered 

1.	An individual may be continuously eligible for Medicaid if he or she:
a.	Is under age 19 (including the month the individual turns age 19); and
b.	Is not eligible as medically needy.
2.	Individuals under age 19 include children, caretaker relatives, and pregnant women.  
3.	Individuals eligible for Refugee Medical Assistance (RMA) or Emergency Services are NOT entitled to continuous eligibility.

510-05-53-15 Continuous Eligibility Periods

1.	Continuous eligibility may be established from the first day of the application month, or if later, the first day that the individual becomes eligible for Medicaid under a coverage group other than medically needy.  
Example 1:  A child applies for Medicaid on June 8 and is determined to be poverty level eligible.  The child becomes continuously eligible effective June 1.
Example 2:  A child is eligible for Medicaid as medically needy.  When determining eligibility for August, the family’s income decreased so the child becomes poverty level eligible for August. The child becomes continuously eligible effective August 1.
2.	If retroactive eligibility is approved for an applicant, the continuous eligibility period does not begin during any of the retroactive months. An individual may be Medicaid eligible during the retroactive months; however, their eligibility is based on their actual circumstances during those months.
Example:  A family with children applies for Medicaid on October 9 and requests Medicaid for the three prior months.  The application is processed and it is determined that the children are poverty level eligible for October, and they are eligible for the three prior months.  The children become continuously eligible effective October 1 regardless of their coverage group status during the three prior months.
3.	Except as identified in subsection 5, once an individual becomes continuously eligible, they remain eligible for Medicaid without regard to changes in circumstances, until they have been on Medicaid for 12 consecutive months.  They do not have to have been continuously eligible for the entire 12 months.  
4.	When a redetermination of eligibility is completed an eligible individual may be determined to be eligible for a new continuous eligibility period.  Redeterminations must be completed at least annually, but may be scheduled earlier in order to align continuous eligibility periods within a case between children, or to align redetermination dates with other programs.
a.	If the individual’s previous continuous eligibility period ended, the individual must meet all eligibility criteria to continue eligible for Medicaid.  
b.	If a redetermination is being completed before the individual’s continuous eligibility period has ended, and the individual meets all Medicaid eligibility criteria, the individual begins a new continuous eligibility period.
c.	If a redetermination is being completed before the individual’s continuous eligibility period has ended, and the individual fails to meet all Medicaid eligibility criteria, the individual remains eligible only until the end of their current continuous eligibility period.  A new redetermination of eligibility is required at that time to establish any further eligibility.
5.	A continuous eligibility period can be ended earlier than redetermination only for the following reasons:
a.	The recipient turns age 19;
b.	The recipient loses state residency;
c.	The recipient requests that their coverage end;
d.	The recipient dies; or
e.	The agency has lost contact with the recipient.
A continuous eligibility period may also be ended if it is determined that the recipient should not have become continuously eligible because the individual was approved in error; approval was based on fraudulent information; an appealed ending is upheld in favor of the agency.

510-05-53-20 Continuously Eligible Individuals Moving Out of the Medicaid Unit

When an individual who is continuously eligible for Medicaid moves out of the Medicaid unit, that individual’s eligibility continues.  
1.	When a continuously eligible child leaves the Medicaid unit and enters foster care, a new application is processed to determine the child’s ongoing eligibility. If the child meets all eligibility criteria, the child begins a new continuous eligibility period.  If the child does not meet the eligibility criteria, or would be eligible as medically needy, the child must be approved and remains continuously eligible only until the end of their current continuous eligibility period. A new redetermination of eligibility is required at that time to establish any further eligibility.
2.	When a continuously eligible individual enters a long term care facility, the individual is still considered part of the Medicaid unit; however, the post eligibility treatment of income (05-85-25) applies. Even though the individual is continuously eligible and remains eligible as other than medically needy, the individual’s income must be considered toward the cost of care, and he or she may have a recipient liability. Once the individual’s continuous eligibility period ends, and a redetermination is completed, the individual may become medically needy.  
3.	When a continuously eligible individual enters a specialized facility other than foster care, the individual is still considered part of the Medicaid unit. The individual remains eligible as other than medically needy. Once the individual’s continuous eligibility period ends, and a redetermination is completed, the individual may become medically needy.  
4.	When a continuously eligible individual elects to receive HCBS, the individual is still considered part of the Medicaid unit.  The individual remains eligible as other than medically needy.  Once the individual’s continuous eligibility period ends, and a redetermination is completed, the individual may become medically needy.  
5.	When a continuously eligible individual is away at school or training; is living outside the home to secure medical treatment; or is a child living outside of the parental home and is not living independently, the individual is still considered part of the Medicaid unit.  
6.	A continuously eligible individual may move from one case to another case. If the individual, through an application or redetermination, meets all eligibility criteria to be continuously eligible in the new case, the individual begins a new continuous eligibility period. If the individual does not meet the eligibility criteria, or would be eligible as medically needy, the individual must be approved and remains eligible only until the end of their current continuous eligibility period. A new redetermination of eligibility is required at that time to establish any further eligibility in the new case.  
7.	When a continuously eligible individual moves out of a household on other than a temporary basis, and is not being added to another case, the individual remains eligible in the case, but is no longer considered part of the Medicaid unit. Accordingly, the individual’s income will no longer affect other members of the Medicaid unit, nor can income be deemed from the Medicaid unit to the individual. Likewise, any caretaker relative remaining in the Medicaid unit can no longer remain eligible if their eligibility is based on being a caretaker relative for the child that left the household. If the caretaker relative remains eligible because of other children still in the case, or because the caretaker relative is eligible in their own right, the caretaker relative is no longer required to cooperate with Child Support for the child that left the household.  Once the child’s continuous eligibility period ends, the child’s eligibility ends in the case.

510-05-90-75 Budgeting Procedures for Continuous Eligibility for Children under Age 19 
1.	When a child becomes continuously eligible for Medicaid, that child continues to be eligible without regard to any changes in income and/or expenses of the Medicaid unit until the next redetermination. Likewise, a continuously eligible child can move from one coverage type to another (e.g. Foster Care to Poverty Level); however, if PL eligible and income increases to above PL, the child remains PL eligible until the end of their continuous eligibility period.
2.	For a continuously eligible child 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 and excess income becomes recipient liability.
For a single individual under age 19, parental income is not considered available during any full calendar month the recipient is in the facility. 
If the individual has no source of income, and is ineligible for SSI, the income of the parents may be deemed in the amount of $50 to meet the maintenance needs of the individual.
NOTE:  The premium calculation for Children/Workers with Disabilities is still required.

Par. 2.   Effective Date – This manual letter is effective June 1, 2008.

Carol K. Olson, Executive Director	Manual Letter #3146
North Dakota Department of Human Services	Page  of  Pages