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Bismarck, North Dakota	MANUAL LETTER #3227	August 1, 2010

Par. 1.	Material Transmitted and Purpose – Transmitted with this Manual Letter are changes to Service Chapter 510-05 Medicaid Eligibility Factors.  This manual letter includes and supersedes IM’s 5033, 5087, 5092, 5099 and 5100.

Definitions 510-05-05
A definition for SNAP is included due to the change in the name of the Food Stamp Program.
Supplemental Nutrition Assistance Program (SNAP)
Previously known as the Food Stamp Program, SNAP is a uniform nationwide program intended to promote the general welfare and safeguard the health and well being of the nation's population by raising the levels of nutrition among low-income households.

Application and Redetermination 510-05-25-05
A new paragraph “xi” has been added to the list of acceptable application forms in subsection 1 to allow for coverage of subsidized adoption children from other states who have come to North Dakota through the Interstate Compact on Adoption and Medical Assistance (ICAMA).  This is a change in policy.  Also, language was added to subsection b of subsection 2 to allow confirmation of continued IV-E eligibility for foster care or subsidized adoption in place of a redetermination form.  This addition incorporates information from FYI 10-008.
1.	Application.
a.	All individuals wishing to make application for Medicaid must have the opportunity to do so, without delay.
b.	A relative or other interested party may file an application in behalf of a deceased individual to cover medical costs incurred prior to the deceased individual's death.
c.	An application is a request for assistance on:
i.	SFN 405, "Application for Economic Assistance Programs";
ii.	SFN 502, "Application for HealthCare Coverage for Children, Families, and Pregnant Women";
iii.	SFN 641, "Title IV-E/Title XIX Application-Foster Care";
iv.	SFN 1803, "Subsidized Adoption Agreement";
v.	SFN 958, "Health Care Application for the Elderly and Disabled";
vi.	The Department’s system generated "Statement of Facts";
vii.	The Department's online "Application for Economic Assistance Programs";
viii.	The Low Income Subsidy file from SSA;
ix.	If within one calendar month of when an applicant's Medicaid case was closed, one of the prescribed redetermination forms (see subsection 2(b); ~~or~~
x.	Applications provided by disproportionate share hospitals or federally qualified health centers are SFN 405 with "HOSPITAL" stamped on the front page~~.~~; or
xi.	ICAMA (Interstate Compact on Adoption and Medical Assistance) form 6.01 “Notice of Medicaid Eligibility/Case Activation” stating North Dakota is responsible for the Medicaid coverage of the specified child.
2.	Redetermination.
a.	A recipient has the same responsibility to furnish information during a redetermination as an applicant has during an application.
b.	A redetermination must be completed at least annually using the Department's:
i.	System generated "Monthly Report";
ii.	System generated "Redetermination of Eligibility;"
iii.	SFN 407, "Redetermination for Healthcare Coverage";
iv.	SFN 642, "Title IV-E/Title XIX Redetermination-Foster Care" for children in Foster Care, or other confirmation from a state IV-E agency (in state or out of state) that verifies continued IV-E foster care  eligibility;
v.	SFN 856, "Adoption Subsidy Agreement - Annual Review" for subsidized adoption, or other confirmation from a state IV-E agency (in state or out of state) that verifies continued IV-E subsidized adoption  eligibility; or
vi.	One of the previously identified applications completed to apply for another program.

Medicaid Unit 510-05-35-05
Verbiage was added to this section to clarify that once a child is age 18 and disabled, that child will be set to out in the parent’s case and a new case will need to be entered for the 18 year old, unless the 18 year old chooses to be treated as a child instead of as a disabled individual.
1.	A Medicaid unit may be one individual, a married couple, or a family with children under twenty-one years of age, or if blind or disabled under age eighteen, whose income and assets are considered in determining eligibility for any member of that unit, without regard to whether the members of the unit all physically reside in the same location.   
A single 18 year old disabled individual is included in the parental Medicaid unit if choosing to be treated as a child, or in a separate case and not included in the parental Medicaid unit if choosing to be eligible as a disabled individual.

Screening for Nursing Care, ICF-MR or HCBS Recipients 510-05-35-25
Verbiage has been changed and a new paragraph added to clarify the treatment of individuals in an IMD.

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.

This screening allows payment to providers for eligible recipients from the effective date of the screening. A new screening is required whenever there is a change in provider or a reentry into a facility following a discharge from that facility. A new screening is not required on a reapplication for Medicaid if there has been no change in the living arrangement of the applicant since the initial screening was completed and screening has not since ended. An annual rescreening is required only for recipients requiring care in an ICF-MR or through HCBS.

Applicants or recipients age 65 or older who seek nursing care services in the state hospital, the Prairie at St. John’s center, the Stadter Psychiatric Center, or any other institution for mental disease (IMD) are not required to be screened.  Applicants and recipients age 22 to 65 who are residing in the state hospital, the Prairie at St. John’s center, the Stadter Psychiatric Center, or any other IMD, are not eligible for Medicaid.  Children under age 22 who have obtained a certification of need may be eligible as described in 05-35-30.

Age and Identity 510-05-35-40
New subsection 5(c) has been added to include a change in policy mandated by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to allow individuals a reasonable opportunity period to provide the mandatory verifications for Identity.  The remainder of subsection 5 is renumbered.  Also, a new sentence was added to the Tribal documents line of the Primary Verifications table at subsection 5(d) referring individuals to a new table that addresses acceptable documents from North Dakota tribes.  This is a clarification in policy.
5. Identity must be established and documented as provided in this section.
	c.	Reasonable Opportunity Period.  Applicants who claim they are U.S. citizens or qualified aliens are entitled to a reasonable opportunity period to provide verification of citizenship, qualified alien status, and identity.  Medicaid is not permitted to deny, delay, reduce, or terminate eligibility while documentation is being gathered during the reasonable opportunity period.  A reasonable opportunity period applies when all other information necessary to determine eligibility is available.  If an individual is eligible for Medicaid and has met all other criteria except for citizenship or identity verification, that individual’s eligibility may not be pended for verification of either citizenship or identity, but must be approved. If the individual does not provide satisfactory documentation of citizenship and identity by the end of the reasonable opportunity period, the individual’s eligibility must be terminated with advance (10-day) notice and without regard to continuous eligibility provisions.
		A ‘reasonable opportunity period’ is defined as 90 days from the date the application is submitted and for the remaining days of the month in which the 90^th day falls.  An extension of an additional 60 days from the 90^th day may be granted if the individual has verifiable documented evidence they have been making a good faith effort to obtain the verifications, but still have not received them.  
		An example of a good faith effort would be a letter from another state’s vital statistics office that the documentation was requested timely (no later than 10 days after the latter of the application date or the earliest date the verification was requested by the county or state agency), but there will be a delay in providing the documentation.
Example: Mr. Brown applies for Medicaid on May 11, 2010.  He has verification of citizenship; however he has nothing to prove identity. He does not meet any of the exemptions from the verification requirements that are listed in the manual.  Mr. Brown is determined to be eligible for Medicaid and the application approved for the prior months of March and April, the application month of May, and the future month of June.   Mr. Brown claims he is a member of a federally-recognized Indian tribe in California.  The worker has assisted him in requesting identifying tribal documents from the tribe in California.  The worker sets an alert to follow up in early August.  The worker does not receive a response by August 20, so sends an advance notice to close.  On August 23, Mr. Brown brings in a recent letter from the tribal enrollment office in California, acknowledging receipt of his request for his tribal enrollment verification, and stating that it will take another 6 weeks for them to process it.  In this case, an additional 2 month period may be granted.  The worker would set an alert for a secondary follow up for October 2010.  If not received by October 20, 2010, advance notice to close must be sent.  
A reasonable opportunity can only be allowed once for any individual.  If granted a reasonable opportunity period but the requested verifications are not received and eligibility is terminated, a second reasonable opportunity period is not allowed at a later application.
d.~~c.~~	Primary and preferred verification of identity.  Verification documents must be presented in their official and original form as received from the issuing agencies.  Photocopies or notarized copies are not acceptable.  Once an original document is presented, a photocopy must be made and maintained in the casefile.

Primary Verifications of Identity
(Level One)
These Documents Verify Both Citizenship and Identity: | Explanatory Information:

US Passport
or US Passport Card Issued since 2007

•	Issued by the Department of State
•	Does not have to be currently valid, as long as it was issued without limitation; (any passport issued with a limitation cannot be used to verify citizenship, but CAN be used to verify identity).
•	Through 1980, spouses and children were often included on one passport; after that each person is issued his own passport.
•	The passport card is for frequent travelers by land or sea between the US and Canada, Mexico, the Caribbean and Bermuda.

Certificate of Naturalization (DHS/INS Forms N-550 or N-570) | •	Department of Homeland Security or Immigration and Naturalization Service (INS) issues for naturalization.
Certificate of US Citizenship (DHS/INS Forms N-560 or N-561) | •	Department of Homeland Security or INS issues certificates of citizenship to individuals who derive citizenship through a parent.

Tribal Enrollment Card
 
Certificate of Degree of Indian Blood
 
Or other documents issued by a federally recognized Indian tribe that evidences membership or enrollment with such tribe

•	A Document issued by a federally recognized Indian tribe evidencing membership or enrollment or affiliation with, such tribe.  See following table for acceptable verifications from ND tribes.

Documents Issued by Recognized ND Tribes
Tribe: | Documents:

Sisseton-Wahpeton
(Wahpeton—SE corner of ND)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood;
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal ID cards:
o	Name, DOB, enrollment #, degree of Indian blood, SSN, photo and individual’s signature;
o	Issued to enrolled members age 16 and older who request it;
o	Issued by tribal enrollment office;

Spirit Lake 
(Devils Lake)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood (may have more information);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal Photo ID:
o	Photo ID including name, DOB,  tribal enrollment #, and degree of Indian blood (may have more information);
o	Issued by tribal motor vehicle office;
o	Issued to enrolled members;

Standing Rock Sioux Tribe
(Fort Yates)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood, (may have more information);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal ID cards:
o	Name, DOB, enrollment #, and degree of Indian blood, last 4 digits of SSN (may have more information);
o	Issued to enrolled members age 14 and older who request it;
o	Issued by tribal enrollment office;

Three Affiliated Tribes (T. A. T.)
(New Town)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo); 
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal ID cards:
o	Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo ( plastic card with hologram on back) (will enter SSN (non-verified) at individual’s request);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office  (Cost = $10; free to seniors);
o	Expire every 4 years;

Turtle Mountain Chippewa
(Belcourt, Trenton)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood, (may have more information);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal Enrollment cards:
o	Name, DOB, enrollment #, and degree of Indian blood (may have more information);
o	Issued to enrolled members age 18 and older who request it;
o	Issued by tribal enrollment office.

Citizenship and Alienage 510-05-35-45
New subsection 4(e) has been added to include a change in policy mandated by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to allow individuals a reasonable opportunity period to provide the mandatory verifications for Citizenship.  Also, a new sentence was added to the Tribal documents line of the Primary Verifications table at subsection 5(a) referring individuals to a new table that addresses acceptable documents from North Dakota tribes.  This is a clarification in policy.  Finally, a change in policy is added to subsection 6(a) regarding birth certificates from Puerto Rico and a correction of a typo in that subsection.  Due to a change in law, effective October 1, 2010, all Puerto Rican birth certificates issued prior to July 1, 2010 will be invalid.  Only birth certificates from Puerto Rico that are “issued” (or reissued) on or after July 1, 2010 are acceptable.  This change is effective October 1, 2010.
4.	Verification Requirements:  Applicants must provide satisfactory documentary evidence of citizenship or naturalization.   
d.	If an individual has made a good faith effort to obtain verifications, but cannot obtain them within the processing timeframes , or because the documents are not available, assistance must be provided to the individual in securing evidence of citizenship.  Matches with other agencies may be used to assist the individual.
e.	Reasonable Opportunity Period.  Applicants who claim they are U.S. Citizens or qualified aliens are entitled to a reasonable opportunity period to provide verification of citizenship, qualified alien status, and identity.  Medicaid is not permitted to deny, delay, reduce, or terminate eligibility while documentation is being gathered during the reasonable opportunity period.  A reasonable opportunity period applies when all other information necessary to determine eligibility is available.  If an individual is eligible for Medicaid and has met all other criteria except for citizenship or identity verification, that individual’s eligibility may not be pended for verification of either citizenship or identity, but must be approved. If the individual does not provide satisfactory documentation of citizenship and identity by the end of the reasonable opportunity period, the individual’s eligibility must be terminated with advance (10-day) notice and without regard to continuous eligibility provisions.
A ‘reasonable opportunity period’ is defined as 90 days from the date the application is submitted and for the remaining days of the month in which the 90^th day falls.  An extension of an additional 60 days from the 90^th day may be granted if the individual has verifiable documented evidence they have been making a good faith effort to obtain the verifications, but still have not received them.  
An example of a good faith effort would be a letter from another state’s vital statistics office that the documentation was requested timely (no later than 10 days after the latter of the application date or the earliest date the verification was requested by the county or state agency), but there will be a delay in providing the documentation.
Example:  Mr. Brown applies for Medicaid on May 11, 2010.  He claims he was born in California.  He does not meet any of the exemptions from the verification requirements that are listed in the manual.  Mr. Brown is determined to be eligible for Medicaid and the application approved for the prior months of March and April, the application month of May, and the future month of June.  The worker has assisted him in requesting birth verification from California.  The worker sets an alert to follow up in early August.  The worker does not receive a response by August 20, so sends an advance notice to close.  On August 23, Mr. Brown brings in a recent letter from the State of California, acknowledging receipt of his request for a birth certificate, and stating that it will take another 6 weeks for them to process it.  In this case, an additional 2 month period may be granted.  The worker would set an alert for a secondary follow up for October, 2010.  If not received by October 20, 2010, advance notice to close must be sent.  
A reasonable opportunity can only be allowed once for any individual.  If granted a reasonable opportunity period but the requested verifications are not received and eligibility is terminated, a second reasonable opportunity period is not allowed at a later application.
5.	Acceptable documentation for US citizens and naturalized citizens.
a.	There are ~~three~~ four documents that may be accepted as proof of both citizenship and identity because each contains a photograph of the individual named in the document and either the US or a state government has established the citizenship and identity of the individual.  These ~~three~~ four are considered to be the primary (Level 1) and preferred verification documents.

Primary Verifications of Identity
(Level One)
These Documents Verify Both Citizenship and Identity: | Explanatory Information:

US Passport
or US Passport Card Issued since 2007

•	Issued by the Department of State
•	Does not have to be currently valid, as long as it was issued without limitation; (any passport issued with a limitation cannot be used to verify citizenship, but CAN be used to verify identity).
•	Through 1980, spouses and children were often included on one passport; after that each person is issued his own passport.
•	The passport card is for frequent travelers by land or sea between the US and Canada, Mexico, the Caribbean and Bermuda.

Certificate of Naturalization (DHS/INS Forms N-550 or N-570) | •	Department of Homeland Security or Immigration and Naturalization Service (INS) issues for naturalization.
Certificate of US Citizenship (DHS/INS Forms N-560 or N-561) | •	Department of Homeland Security or INS issues certificates of citizenship to individuals who derive citizenship through a parent.

Tribal Enrollment Card
 
Certificate of Degree of Indian Blood
 
Or other documents issued by a federally recognized Indian tribe that evidences membership or enrollment with such tribe

•	A Document issued by a federally recognized Indian tribe evidencing membership or enrollment or affiliation with, such tribe.  See following table for acceptable verifications from ND tribes.

Documents Issued by Recognized ND Tribes
Tribe: | Documents:

Sisseton-Wahpeton
(Wahpeton—SE corner of ND)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood;
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal ID cards:
o	Name, DOB, enrollment #, degree of Indian blood, SSN, photo and individual’s signature;
o	Issued to enrolled members age 16 and older who request it;
o	Issued by tribal enrollment office;

Spirit Lake 
(Devils Lake)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood (may have more information);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal Photo ID:
o	Photo ID including name, DOB,  tribal enrollment #, and degree of Indian blood (may have more information);
o	Issued by tribal motor vehicle office;
o	Issued to enrolled members;

Standing Rock Sioux Tribe
(Fort Yates)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood, (may have more information);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal ID cards:
o	Name, DOB, enrollment #, and degree of Indian blood, last 4 digits of SSN (may have more information);
o	Issued to enrolled members age 14 and older who request it;
o	Issued by tribal enrollment office;

Three Affiliated Tribes (T. A. T.)
(New Town)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo); 
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal ID cards:
o	Name, DOB, enrollment #, and degree of Indian blood, mailing address, physical address, photo (plastic card with hologram on back) (will enter SSN (non-verified) at individual’s request);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office  (Cost = $10; free to seniors);
o	Expire every 4 years;

Turtle Mountain Chippewa
(Belcourt, Trenton)

•	Certificate of Degree of Indian Blood:
o	Name, DOB, enrollment #, and degree of Indian blood, (may have more information);
o	Issued to any enrolled member who requests it;
o	Issued by tribal enrollment office;
•	Tribal Enrollment cards:
o	Name, DOB, enrollment #, and degree of Indian blood (may have more information);
o	Issued to enrolled members age 18 and older who request it;
o	Issued by tribal enrollment office.

6.	Individuals born in Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, and Nationals from American Samoa. For purposes of qualifying as a United States citizen, individuals born in Puerto Rico, Guam, the Virgin Island, the Northern Marian Islands and Nationals from American Samoa may qualify as follows:
a.	Puerto Rico:
•	Certificate of birth in Puerto Rico on or after January ~~31~~ 13, 1941 (to be considered a valid birth certificate, it must have an issue date of on or after July 1, 2010)
•	Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant's statement that he or she was residing in the US, a US possession, or Puerto Rico on January 13, 1941 (If a birth certificate is provided, it must have an issue date of on or after July 1, 2010)
•	Evidence that the individual was a Puerto Rican citizen and the applicant's statement that he or she was residing in Puerto Rico on March 1, 1917, and that he or she did not take an oath of allegiance to Spain

American Indians Born in Canada 510-05-35-50
Additional verbiage was added to subsection one to incorporate information regarding the Jay Treaty.  Additional INS codes were added to subsection 2 to clarify the forms of verification that may be used in determining whether an individual meets this criterion.  Verbiage was also added to subsection 2 to clarify that while a quantum letter can prove an individual has at least 50% or more of Indian blood, it does NOT prove that the individual does NOT have  at least 50% or more Indian blood, and if the individual claims they do, additional verification will be required.

1.	American Indians born in Canada who may freely enter and reside in the United States are considered to be lawfully admitted for permanent residence if at least one-half American Indian blood. This does not include a spouse or child of such an Indian nor a noncitizen whose membership in an Indian tribe or family is created by adoption, unless such person is of at least 50 percent or more Indian blood. These American Indians are qualified aliens and are considered to be lawful permanent residents.
Article III of the ‘Jay Treaty’ declared the right of “Indians” (“Native Americans”) to trade and travel between the United States and Canada, which was then a territory of Great Britain.   As a result of the “Jay Treaty”, Native Indians born in Canada are entitled to enter the Unites States for the purpose of employment, study, retirement, investing, and/or immigration.

2.	Verification of percentage of American Indian blood may be obtained from INS Form I-551 with the code 513, S1-3, or S-13, or an unexpired temporary I-551 stamp (with the code 513, S1-3, or S-13) in a Canadian passport or on Form I-94. If the individual does not have an INS document, satisfactory evidence of birth in Canada and a document indicating the percentage of American Indian blood must be provided. Documents, indicating the percentage of American Indian blood include a birth certificate issued by the Canadian reservation, or a Blood Quantum Letter, card, or other record issued by the tribe (each tribe provides some type of evidence). The Blood Quantum Letter may use the following verbiage: at least 50% Aboriginal blood, at least 50% Indigenous blood, at least 50% North American Indian blood, or at least 50% American Indian blood. Do not accept a Certificate of Indian Status card ("Band" card) issued by the Canadian Department of Indian Affairs, information from any internet sites, or any other document not directly issued by the individual’s tribe.
Note:  The Blood Quantum Letter can be used to show that an individual possesses at least 50% blood of the American Indian Race, but cannot be used to show that an individual does not possess at least 50% blood of the American Indian Race.  If the letter does not show an individual possesses at least 50% blood of the American Indian Race, additional verification may be warranted.

Qualified Aliens 510-05-35-58
This is a new section to incorporate the changes in policy as explained in IM 5092 and IM 5099.  This will assist workers in determining an alien’s status and eligibility for Medicaid.

Qualified aliens are aliens that have been legally admitted and may be eligible for Medicaid if they meet all other Medicaid eligibility criteria.  The following categories of individuals are qualified aliens:   (Forms indicated below are USCIS or INS forms and the sections refer to the Immigration and Nationality Act (INA):

1.	Aliens who are lawfully admitted for permanent residence (LPR) may be eligible as described in sections 510-05-35-60 and 510-05-35-65.
2.	Honorably discharged veterans, aliens on active duty in the United States’ armed forces, and the spouse or unmarried dependent child(ren) of such individuals:
a.	Verification of honorable  US military discharge (such as a DD214);
b.	Verification of relationship of family members.
3.	Refugees:
a.	Form I-94 (Arrival Departure Record) showing “207” or “REFUG” or codes RE1, RE2, RE3, RE4; or RE5;
b.	Form I-688B (Temporary Resident Card) annotated 274a.12(a)(3);
c.	Form I-766 (Employment Authorization Document) with code A3;
d.	Form I-571 (Refugee Travel Document); 
e.	Form I-551 or I-151 (Permanent Resident Card) with codes R8-6; RE6, RE7, RE8, RE9.
4.	Asylees who have been granted asylum (not applicants for asylum):
a.	Form I-94 showing “208” or “asylee” and/or codes of AS1, AS2, or AS3);
b.	Form I-688B annotated 274.a12(a)(5);
c.	Form I-766 annotated A5;
d.	Grant letter from Asylum office of USCIS;
e.	Order from immigration judge granting asylum;
f.	Form I-571;
g.	Form I-551 or I-151 with codes AS6, AS7, AS8, AS9, GA-6 to GA-8.
5.	Cuban and Haitian Entrants:
a.	Form I-94 showing “Cuban/Haitian Entrant”  or “parole” under Section 212(d)(5) or codes CU6, or CU7 or “OOE” or ”outstanding orders of exclusion”;
b.	Form I-151 or I-551 with National of Cuba or Haiti and codes CH6, CNP, CU0, CU-6, CU-7, CU-8, CU-9, CUP, HA-6 to HA-9; HB-6 to HB-9; HD-6 to HD-9; HE-6 to HE-9, or  NC-6 to NC-9.
6.	Victims of a severe form of trafficking:
a.	I-94 showing codes T-1 or T-2;
b.	I-688B or I-766 showing 247a.12(a)(16), A16, 274a.12(c)(25) or C25.
7.	Aliens whose deportation was withheld under Section 243(h) of the Immigration and Naturalization Act (INA):
a.	I-94 or foreign passport showing “243(h)” or “241(b)(3)”;
b.	I-688B or I-766 with code of “274a.12(a)(10)  or A10;
c.	I-571.
8.	Aliens admitted as an Amerasian immigrant:
a.		I-94 showing National of Vietnam and AM1, AM2, or AM3;
b.	I-151 or I-551 showing National of Vietnam and AM-1, AM-2, AM-3, AM-6, AM-7; or AM-8.
9.	American Indians born in Canada as described in 510-05-35-50.
10.	Aliens paroled into the United States under Section 212(d)(5) of the Immigration and Nationality Act for a period of at least 1 year: 
a.	I-94 showing “212(d)(5)” or “parolee” or “PIP”;
b.	Form I-688B or I-766 with code such as 274a.12(a)(4), or A4, or 274a.12(c)(11);
c.	Cuban-Haitian entrants with parole status are considered Cuban-Haitian entrants.
11.	Certain battered aliens; battered alien children; and the parents of such children with an I-551 card showing B2-1, B2-3, B2-6, or B2-8.
12.	Iraqi and Afghan Special Immigrants and their families:
a.	I-94 with a stamp of “IV” and category SQ1, SQ2, SQ3, SI1, SI2 or SI3 and date of entry;
b.	Afghan  or Iraqi passport with a stamp of “IV” and category SQ1, SQ2, SQ3, SI1, SI2 or SI3 and DHS stamp or notation on passport showing date of entry;
c.	I-551 showing national of Afghanistan or Iraq with “IV” code of SQ6, SQ7, SQ9, SI6, SI7, SI9.

Aliens Lawfully Admitted for Permanent Residence Before August 22, 1996 510-05-35-60
 This section was updated to clarify which documents will verify this alien status.
Aliens who lawfully entered the United States for permanent residence before August 22, 1996, and who meet all other Medicaid criteria may be eligible for Medicaid.  These individuals have Forms I-551 or I-151 (Resident Alien Cards) or a Foreign Passport stamped LPR or I-551.

Aliens Lawfully Admitted for Permanent Residence on or After August 22, 1996 510-05-35-65
This section was updated to reflect the changes in policy from IM 5092 and IM 5099 and to include the appropriate documents that may be used to verify this status.

~~Aliens who entered the United States for permanent residence on or after August 22, 1996, and who meet all other Medicaid criteria may be eligible for Medicaid as qualified aliens.~~
 
~~1.~~	~~The following qualified aliens may be eligible at any time:~~
~~a.~~	~~Honorably discharged veterans, aliens on active duty in the United States’ armed forces, and the spouse or unmarried dependent child (ren) of such individuals;~~
~~b.~~	~~Refugees;~~
~~c.~~	~~Asylees, who have been granted asylum (not applicants for asylum);~~ 
~~d.~~	~~Cuban and Haitian Entrants;~~ 
~~e.~~	~~Victims of a severe form of trafficking;~~ 
~~f.~~	~~Aliens whose deportation was withheld under Section 243(h) of the Immigration and Naturalization Act (INA); and~~ 
~~g.~~	~~Aliens admitted as an Amerasion immigrant; and~~
~~h.~~	~~American Indians born in Canada as described in 510-05-35-50.~~ 
~~i.~~	~~Iraqi and Afghan aliens and family members who claim special immigrant status, and can provide verification that they have been admitted under section 101(a)(27) of the INA, may be eligible for Medicaid for the first eight months after their entry into the United States.~~  
~~After the eight month period of initial entry, Iraqi and Afghan Special Immigrants and their families may only qualify for Medicaid coverage of emergency services until such time that they satisfy the 5-year ban and can be credited with forty qualifying quarters of social security coverage.~~
~~Iraqi and Afghan immigrants who are determined ineligible for Medicaid may be eligible for Refugee Medical Assistance (RMA) but only for coverage during the eight month period after entry.~~
~~All other aliens are banned from Medicaid, except for emergency services, for five years from the date they entered the United States. After the five-year ban, aliens who are lawful permanent residents who can be credited with forty qualifying quarters of social security coverage may be eligible for Medicaid.~~

1.~~2~~.  Aliens admitted for Lawful Permanent Residence (LPR) on or after August 22, 1996 are banned from Medicaid~~,~~ for five years from the date they entered the United States. After the five-year ban, aliens who are lawful permanent residents who can be credited with forty qualifying quarters of social security coverage may be eligible for Medicaid.
	Verifications of this status are:
a.	Form I-551 or I-151 (Resident Alien Card) (these are also known as ‘green cards’ but are not green);
b.	Foreign passport stamped LPR or I-551.
Note:	If a refugee’s status has changed to LPR, the codes at 510-05-35-58 apply.  
2.~~3.~~ Qualifying quarters of social security coverage determined by Social Security can be obtained using the Third Party Query (TPQY) information system. Earnings of some federal civilian employees hired before 1984, earnings of employees of some state and local governments, and certain agricultural and domestic earnings are not calculated by Social Security. These earnings count in establishing qualifying quarters of social security coverage and must be determined using the same process used by Social Security. If an alien claims to have work history that may qualify, but that the TPQY does not support, gather the information regarding the amount of earnings by quarter and contact the Medicaid Eligibility unit for further assistance.
a.	When determining the number of qualifying quarters an individual has, count:
i.		All qualifying quarters the alien has due to work; 
ii.		All qualifying quarters worked by the alien’s spouse during their marriage, if the alien remains married to such spouse or the spouse is deceased; and 
iii.		All qualifying quarters worked by a natural, adoptive, or stepparent of such alien while the alien was under age 18. Qualifying quarters of an adoptive parent count from the quarter of the adoption. Qualifying quarters of a stepparent count from the quarter of marriage to the alien’s parent.
b.	Do not count qualifying quarters for any quarter in which TANF, ~~Food Stamps~~ SNAP, Medicaid, Healthy Steps, or SSI benefits were received (including benefits received in another state), or from any parent whose parental rights have been terminated.

Social Security Numbers 510-05-35-80
Subsection 4 is updated to reflect the name change from Food Stamps to Supplemental Nutritional Assistance Program. 
4.	The Medicaid household must be informed, at the time of application and yearly thereafter, that the agency will use the SSN in the administration of the Medicaid Program. The SSN will be used to verify income and asset information from the Social Security Administration, Internal Revenue Service, Job Service, Unemployment Compensation, SNAP ~~Food Stamp~~, TANF Program, Child Support Enforcement, State Motor Vehicle, Department of Vital Statistics and other states.

Application for Other Benefits 510-05-35-90
Verbiage has been added to clarify that a spouse and financially responsible parents are subject to the requirements under this section.
 
1.	As a condition of eligibility, applicants and recipients (including spouses and financially responsible absent parents) must take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits, to which they are entitled, unless they can show good cause for not doing so. Annuities, pensions, retirement, and disability benefits include, but are not limited to, veterans' compensation and pensions; old age, survivors, and disability insurance benefits; railroad retirement benefits; and unemployment compensation.

Blindness and Disability 510-05-35-100
Subsection 4(b) is updated to clarify when medical and social information is required to be submitted to the State Review Team.
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 and Title II (SSA) has not made a disability determination;
b.	The applicant is not eligible for SSI because of the SSI income and resource levels; or, if a Medicaid recipient  and the individual has had a non-pay SSI reason of “N01” or “N04” for one year;
Note: If the individual is “N01” AND is 1619(b) eligible, the individual is still disabled and no evaluation by the State review Team is required.
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;
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.

Paternity 510-05-40-05

Subsection 1 is updated to incorporate the policy change made by IM 5033 which stops child support referrals for Subsidized Adoption Children.  This supersedes IM 5033.  Medicaid no longer makes child support referrals in any non-foster care case in which the only eligible individuals are children or in which the eligible caretaker(s) are not required to cooperate.  Language has been added to subsection 3 for this change.  The change in subsection 3 is effective July 1, 2010.

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 child is a subsidized adoption child or 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.
2.	A child for whom "paternity has not been established" means a child who was born out of wedlock and for whom paternity has not been legally established. A child is not considered to be born out-of-wedlock if the child is born within three hundred (300) days after the marriage is terminated by death, annulment, declaration of invalidity, or divorce, or after a decree of separation is entered by a court. Paternity is not considered to be legally established unless adjudicated by a court of law, or the parents completed the process using the "North Dakota Acknowledgment of Paternity" form, SFN 8195, with a revision date of 4/98 or later.
~~3.~~	~~In cases where paternity has not been established an automated referral will be made to Child Support to establish legal paternity~~
3.  An automated referral will be made to Child Support when paternity has not been legally established and a caretaker who is not excluded in subsection 1 is seeking eligibility, or when a child is eligible for foster care.

Medical Support 510-05-40-10
Medicaid no longer makes child support referrals in any non-foster care case in which the only eligible individuals are children or in which the eligible caretaker(s) are not required to cooperate.  Language has been added to subsection for this change.  The change in subsection 3 is effective July 1, 2010.
3.	An automated referral will be made to Child Support to pursue Medical Support for all children whose deprivation is based on the absence of a parent, except that no referral is made:
~~a.~~	~~when a~~ For any Subsidized Adoption child ~~enters Foster Care~~.;
b.	In any case in which the only eligible individuals are children;
c.	In any case in which the only eligible caretaker is pregnant; or
d.	In any case in which the only eligible caretakers are continuously eligible, receiving Extended Medicaid Benefits, or receiving Transitional Medicaid Benefits.

Continuous Eligibility Periods 510-05-53-15
The second paragraph of subsection 5 is deleted as it is now obsolete.  A new subsection 5(f) was added to include the change in policy that we must close a continuously eligible child that has not submitted citizenship or identity verifications within their reasonable opportunity period.
5.	A continuous eligibility period must be ended earlier than redetermination for any of 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 family and the child's whereabouts are unknown~~.~~: or
f.	The recipient has failed to provide verification of citizenship or identity within their reasonable opportunity period.
~~Afghan and Iraqi immigrant children who become continuously eligible are only entitled to Medicaid for the first eight months they are in the country, and not for the normal 12-month period.  Their continuous period must be ended at the end of the eight month period.  Note:  It will be necessary to contact the Helpdesk to do a data change to shorten the period.~~

Institutionalized Spouse or Home and Community Based Services (HCBS) Spouse Asset Limit 510-05-65-15
Due to a change in the interpretation of federal statute relating to transfers between spouses in spousal impoverishment situations, policy is changed to provide no limits on transfers between spouses.  The previous interpretation limited such transfers to the community spouse asset allowance.  With this change (in subsection 3), interspousal transfers are not disqualifying as long as the couple’s total countable assets are within the combined asset allowance at the time that eligibility is determined.  This change is effective immediately for any determination (including retroactive determinations) made after the issuance of this policy.
3.	After eligibility has been established, the institutionalized or HCBS spouse must reduce his or her countable assets (solely or jointly owned) to be within the medically needy asset limit ($3,000) not later than the next regularly scheduled redetermination.
If the assets are not reduced to the asset limit by the next regularly scheduled redetermination, the individual's case must be closed. Verification of the reduction in assets must be provided.
When an eligible institutionalized or HCBS spouse exceeds the asset limit due to an increase in the value of, a change in the exclusion of, or the receipt of assets, a new period, until the next regularly scheduled redetermination, may be allowed in order to transfer the excess assets to the community spouse. The amount of assets to which this new period applies is an amount equal to the difference between the current community spouse's asset allowance and the value of assets owned by the community spouse at the time eligibility was established, less the value of assets transferred to the community spouse.
 
Example:  The community spouse has an asset allowance of $70,000.  At the time eligibility was established, the community spouse owned $30,000 and the institutionalized spouse transferred $25,000 to the community spouse by the first redetermination.  If the institutionalized spouse received new assets in excess of the $3,000 asset limit, the institutionalized spouse is allowed until the next regularly scheduled redetermination to transfer up to $15,000 to the community spouse ($70,000 less $30,000 owned by community spouse less $25,000 previously transferred to community spouse equals $15,000 that can still be transferred).
This new period is not allowed ~~and additional transfers of countable assets are not allowed~~ if:
a.	The community spouse had assets equal to the community spouse asset allowance at the time the institutionalized or HCBS spouse became eligible; or
b.	The community spouse has since received assets from the institutionalized or HCBS spouse up to the community spouse asset allowance.
The following examples illustrate:
 
Example 1:  The community spouse had an asset allowance of $90,000.  At the time of eligibility, the community spouse owned all $90,000 in countable assets.  No new period is allowed to transfer additional assets ~~may be transferred~~ to the community spouse.
 
Example 2:  The community spouse had an asset allowance of $80,000. At the time of eligibility the community spouse owned $50,000 in countable assets.  The institutionalized spouse has since transferred an additional $30,000 to the community spouse.  The community spouse has received assets up to the community spouse asset allowance so no new period is allowed to transfer additional assets ~~may be transferred~~ to the community spouse.  

Excluded Assets 510-05-70-30
Subsection 2(c) has been updated to clarify that workers should wait until the third month after the month in which a good faith effort to sell has begun to determine whether property is non-saleable.  Subsection 17 was added to include the change in policy to exclude certain Indian assets.  This supersedes IM 5100.

2.	Property that is not saleable without working an undue hardship. Property that is not saleable without working an undue hardship means property which the owner has made a good faith effort to sell which has produced no buyer willing to pay an amount equaling or exceeding seventy-five percent of the property's fair market value, and which is continuously for sale. Property may not be included within this definition at any time earlier than the first day of the first month in which a good faith effort to sell is begun.
Refer to 05-05 for the definition of "good faith effort to sell" to determine the method and order in which an attempt to sell property must be made.
c.	When making a good faith effort to sell real property, wait to determine ~~eligibility~~ that it is non-saleable until the third month after the month in which the good faith effort began.  This provides a reasonable amount of time for offers to be received without loss of potential months of eligibility for an applicant.  If the property is determined to be non-saleable without working an undue hardship, the property must remain continuously for sale, and any offers received must be reported.  
17.	Property connected to the political relationship between Indian Tribes and the Federal government:
a.	Any Indian trust or restricted land, or any other property under the supervision of the Secretary of the Interior located on a federally-recognized Indian reservation, including any federally-recognized Indian Tribe’s, pueblo, or colony, and including Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior.  This exclusion includes Individual Indian Monies (IIM) accounts, which are under the supervision of the Secretary of the Interior. 
b.	Property located within the most recent boundaries of a prior Federal reservation, including former reservations in Oklahoma and Alaska Native regions established by the Alaska Native Claims Settlement Act.  The Tribe, through the Department of the Interior, can provide verification to identify such property.
c.	Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally-protected rights. Monies received from the lease or sale of these natural resources remain excluded while in an IIM account, however, if taken out of the account, they are considered as a countable asset. 
d.	Property with unique Indian significance such as ownership interests in or usage rights to items not covered by paragraphs (a) through (c) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable Tribal law or custom.
While the above identified assets are excluded in determining eligibility, if the assets are converted to a non-excluded asset, they become countable.  For instance, money in an IIM account is excluded, however, once the money is removed from the IIM account it becomes a countable asset.

Contractual Rights to Receive Money Payments 510-05-70-40
Language is added to subsection 2 to add clarification that contractual rights to receive money payments that are still owned after a penalty has been imposed due to a disqualifying transfer are considered to be an available asset.
2.	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).   When the penalty period is finished, and the applicant or recipient still owns the contractual right to receive the money payments, the contractual right is considered an available asset. 

Annuities Purchased or Changed on or After February 8, 2006 510-05-70-45-30
Changes to annuity policy are made to subsections 3 and 4 to reflect treatment of annuities as identified in ND statute, and to add clarification.  The changes are self-explanatory.
3.	 The annuity is counted as an available asset in the asset test unless:
b.	  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 principal and interest within the annuitant’s life expectancy 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 $2739 effective January 2009 ($2610 for 2008) and, when combined with the annuitant’s and the annuitant’s spouse’s other income at the time of application for Medicaid, does not exceed $4109 effective January 2009 ($3915 for 2008); and
~~vi.~~	~~If the applicant for Medicaid is age 55 or older, the~~ 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 community 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.
~~NOTE:  This subsection applies to determining whether an annuity is a countable asset.  The provision in paragraph (vi) above allows a community spouse to name an institutionalized spouse (IS) or HCBS spouse as the primary beneficiary ahead of the Department.  If the annuity, however, was purchased or changed within the individual’s or the individual’s spouse’s look back period, ONLY a community spouse (not an IS or HCBS spouse) can be named ahead of the Department to avoid a disqualifying transfer as discussed in subsection 4 below.~~
 
Example:  Mr. White, who is in LTC, has an annuity that meets the criteria above and names Mrs. White, the community spouse, as the primary beneficiary and the Department as the secondary beneficiary.  The annuity is excluded as an asset and is not considered a disqualifying transfer because Mrs. White is a community spouse.
 Mrs. White also has an annuity that meets the criteria above and names Mr. White as the primary beneficiary and the Department as the secondary beneficiary.  The annuity is not excluded as an asset. It ~~because it meets the criteria above, however, it~~ may be considered a disqualifying transfer because Mr. White is not a community spouse.  It is necessary to determine whether Mrs. White’s annuity was purchased or changed within Mr. or Mrs. White’s look back period.  If it was, then her annuity is a disqualifying transfer equal to the annuity value.  If the annuity was last changed prior to their look back periods, then it is not ~~an issue~~ a disqualifying transfer.
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's, or the individual’s spouse’s look back date;
b.	The annuity is a qualified employee benefit annuity, 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:
i.	The annuity meets all of the requirements in (3)(c)(i) through (3)(c)~~(v)~~(iii) above;  ~~and~~ 
ii.	The annuity will return the full principal and interest within the annuitant’s life expectancy; and
~~iii.~~	~~the~~ 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; ~~and~~ or
d.	The annuity is a third party annuity.

Valuation of Assets 510-05-70-60
Subsection 3(a) has been updated to reflect the change in the valuation of mineral interests.
3.	Real property:
a.	With respect to mineral interests: ~~appraisers, specializing in minerals, mineral buyers, geologists.~~      
i.	If determining current value (for sale or pending transfer):
1)	Fair market value is the value established by good faith effort to sell. The best offer received establishes the value.
2)	A good faith effort to sell means offering the mineral interests to at least three companies purchasing mineral rights in the area, or by offering for bids through public advertisement.
ii.	If determining a previous value for mineral rights sold or transferred in the past, fair market value is:
1)	If producing, three times the annual royalty income.
a)	Based on actual royalty income from the 36 months following the
transfer; or
b)	If 36 months have not yet passed, based on actual royalty income for
the months that have already passed, and an estimate for the
remainder of the 36 month period.
2)	If not producing, but mineral rights are leased, two times the lease amount
(based on the actual lease and not the yearly lease amount).
3)	If not leased, the greater of two times the estimated lease amount or the
potential sale value of the mineral rights, as determined by a geologist,
mineral broker, or mineral appraiser.
iii.	In determining current or previous value, an applicant or recipient may provide persuasive evidence that the value established using the above process is not accurate. Likewise, if an established value is questionable, the Department may require additional evidence be provided to establish estimated fair market value.

Definitions 510-05-80-05
Subsection 9 was updated with the 2010 average cost of nursing facility care.  This supersedes IM 5087.
9.	The average cost of nursing facility care is:
 
Year | Daily Rate | Monthly Rate
2010 | 195.55 | 5948

Exceptions to Disqualifying Transfer Provision 510-05-80-25
Due to a change in the interpretation of federal statute relating to transfers between spouses in spousal impoverishment situations, policy is changed to provide no limits on transfers between spouses.  The previous interpretation limited such transfers to the community spouse asset allowance.  With this change (in subsection 3), interspousal transfers are not disqualifying,  The institutionalized or HCBS spouse can become eligible if the couple’s total countable assets are within the combined asset allowance at the time that eligibility is determined.  This change is effective immediately for any determination (including retroactive determinations) made after the issuance of this policy.
3.	A transfer is not disqualifying to the extent the income or assets were transferred:
a.	To the individual's spouse or to another for the sole benefit of the individual's spouse. ~~, except that transfers to a community spouse may not exceed the limits identified in section 05-65-15, Institutionalized Spouse or HCBS Spouse Asset Limit (the value of the home or residence is not included in the limit on assets that can be transferred to a community spouse, but the limit only applies to other assets);~~
b.	From the individual's spouse to another for the sole benefit of the individual's spouse;
c.	To, or to a trust established solely for the benefit of, the individual's child who is blind or disabled; or
d.	To a trust established solely for the benefit of an individual under sixty-five years of age who is disabled.

Unearned Income 510-05-85-15
Subsection 5 (a) was updated to clarify that Veteran Assistance Vocational Rehabilitation Subsistence Payments are countable unearned income.  Subsection 5(f) was updated to clarify that Medicaid does not allow books, tuition and fees to reduce amounts specifically earmarked for housing or personal needs, nor from VA vocational rehabilitation subsistence payments.  Subsection 5 (p) was deleted in accordance with IM 5100.
5.	Types of unearned income include but are not limited to:
a.	Income from pension and benefit programs, such as Social Security, Railroad Retirement, veteran’s pension or compensation, veteran’s vocational rehabilitation subsistence payments, unemployment compensation (including disaster assistance unemployment compensation), employee or individual pension plans and annuities, union compensation during strikes, Workforce Safety & Insurance, etc.
f.	Student income received from the Veterans Administration through the GI Bill or Reserve Education Assistance Program (REAP), except that verified out of pocket school expenses (tuition, books and fees) may be deducted~~;~~ .  Such expenses may not be deducted from benefits specifically earmarked for housing or personal needs or from Veteran’s vocational rehabilitation subsistence payments;
~~p.~~	~~Payments, not otherwise disregarded in section 05-85-30 (relates to income from leases and trust or restricted funds for non-LTC and Medicare Savings Programs), that are deposited in Individual Indian Monies (IIM) accounts by the Bureau of Indian Affairs (BIA).~~
~~Payments received in either the past twelve months or in the most recent four full calendar quarters may be used to estimate the current IIM payments. If the applicant or recipient demonstrates, by furnishing lease documents or reports, that the deposit amount will be substantially different, current payments must be determined by totaling all payments likely to be made in the twelve-month period beginning with the month in which the lease arrangement changed.~~
~~When new source income is deposited into an individual’s IIM account, the countable amount is determined using the IIM account verification from either the past twelve months or the most recent four full calendar quarters, less deposits that cannot be counted as IIM income, such as inheritances, VA, SSA, SSI, gaming profits, etc. The new source income from the most current month, or an average if received for multiple months, is multiplied by twelve and added to the countable deposits for the twelve-month period (excluding the new source income deposited into the IIM account).  The $2000 disregard is subtracted, and the remaining balance is divided by twelve to determine the monthly countable unearned income.~~   
~~Because the first $2000 per year of income received from leasing of privately owned or restricted Indian lands is disregarded as income for individuals who are not residing in LTC facilities, Client statement is acceptable verification of the amount in the IIM account unless one of the following applies:~~
~~i.~~	~~The balance of the account is more than $2000;~~
~~ii.~~	~~The client statement information is questionable;~~
~~iii.~~	~~The deposits include countable income such as inheritances, bonuses, or any other income that is not derived from leases, and trust or restricted lands; or~~
~~iv.~~	~~The individual resides in a LTC facility.~~
~~When additional verification is necessary, the following three options are available:~~
~~i.~~	~~A request for verification, using SFN 413, Individual Indian Monies Account.  The form must be notarized before it will be accepted by the BIA, and is valid for one year.~~
~~ii.~~	~~Individuals with IIM accounts receive quarterly statements.  A copy of the statement can be requested from the individual.~~
~~iii.~~	~~The individual may obtain a statement of the individual's IIM account directly from the Office of Trust Funds Management through the BIA by requesting the information in person or by making a telephone request.  The individual will need to know the account number and provide at least two forms of identification.~~
~~IIM account ledgers have columns for:~~
~~i.~~	~~Debit, which is amounts paid out of the account and which do not affect eligibility;~~ 
~~ii.~~	~~Credit, which is amounts put into the account. This column is used to establish the amount of countable IIM for the year. Consider all deposits for the twelve-month period being looked at and subtract any per capita payments or judgment funds distributed by the Secretary of the Interior, subtract per capita payments distributed by the local tribe, and subtract other non-lease moneys deposited in the accounts. The remaining balance is the lease payments to which the $2,000 disregard is applied; and~~ 
~~iii.~~	~~Balance, which is the amount still in the account. This amount is what is currently in the account and is considered an asset. (This balance may not be available to children under age 18 if they cannot access the account.)~~ 

Earned Income 510-05-85-20
Subsection 3(f) is updated to clarify that while sick leave is considered earned income, disability payments are not.
3.	Types of earned income include:
f.	Sick leave pay or loss of time private insurance paid for the loss of employment due to illness (but does not include public or private disability payments);

Post Eligibility Treatment of Income 510-05-85-25
Language is added to subsection 3(c)(i) to clarify that if a medical expense was incurred as recipient liability, it may not be allowed as a current expense.
3.	In establishing the application of income to the cost of care, the following deductions are allowed in the following order:

c.	Medical expenses for necessary medical or remedial care. Each medical or remedial care expense claimed for deduction must be documented in a manner, which describes the service, the date of the service, the amount of cost incurred, and the name of the service provider. An expense may be deducted only if it is:
i.	Incurred in the month for which eligibility is being determined, or was incurred in a prior month but was actually paid in the month for which eligibility is being determined and was not a previous month’s recipient liability or was not previously allowed as a deduction or offset of recipient liability;

Disregarded Income 510-05-85-30
Subsection 9 was rewritten to incorporate IM 5100 which changes the treatment of certain distributions of tribal monies from income to assets, thereby excluding them from income.  This is effective July 1, 2009.  Subsection 26 was updated to clarify that Medicaid does not allow books, tuition and fees to reduce amounts specifically earmarked for housing or personal needs, nor from VA vocational rehabilitation subsistence payments.  Subsection 41 was deleted as it is no longer applicable and the following subsections renumbered. 
~~9.~~	~~Per capita judgment funds paid to members of any Indian tribe under Pub. L. 92-254, Pub. L. 93-134, or Pub. L. 97-403;~~ 
9.	Money received by Indians from the lease or sale of natural resources, and rent or lease income, resulting from the exercise of federally-protected rights on excluded Indian property, is considered an asset conversion and is therefore not considered as income (even if the money is taken out of the IIM account in the same month it was deposited into the account).  This includes distributions of per capita judgment funds or property earnings held in trust for a tribe. This does not include local Tribal funds that a Tribe distributes to individuals on a per capita basis, but which have not been held in trust by the Secretary of Interior (e.g., tribally managed gaming revenues - which is countable income);

26.	Educational loans, scholarships, grants, awards, Workforce Safety & Insurance vocational rehabilitation payments, and work study received by a student~~;~~. See 510-05-85-15 (Unearned income) for treatment of student income received from the Veteran’s Administration;

~~41.~~	~~The first $2,000 per year of lease payments deposited in IIM accounts;~~

Income Deductions 510-05-85-35
Subsection 2(a) was changed to clarify that if a medical expense is incurred as recipient liability, it may not be allowed as an expense.

2.	Except in determining eligibility for the Medicare Savings Programs, medical expenses for necessary medical or remedial care claimed for deduction must be documented in a manner which describes the service, the date of the service, the amount of cost incurred, and the name of the service provider. A medical expense may be deducted only if it is:
a.	Incurred:
i.	By a member of a Medicaid unit in the month for which eligibility is being determined; or
ii.	By a member of the Medicaid unit (or a spouse or child they were legally responsible for) in a prior month, but was actually paid in the month for which eligibility is being determined, and was not a previous month’s recipient liability, or was not previously allowed as a deduction or offset of recipient liability;

Income Levels 510-05-85-40
Subsection 2(b) had verbiage added to recognize the name change from Prairie Psychiatric Center to the Prairie at St. John’s Center.
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, the state hospital, the Prairie ~~Psychiatric~~ at Saint John’s Center, the Stadter 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
Subsection 4 had verbiage added to clarify that to receive the nursing home level of care in a facility; the individual must be screened as requiring that level of care.

4.	During a month in which an individual with eligible family members in the home enters or leaves a Psychiatric Residential Treatment Facility (PRTF); an Intermediate Care Facility for the Mentally Retarded (ICF-MR), 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), an Intermediate Care Facility for the Mentally Retarded (ICF-MR), or a nursing facility will be allowed the appropriate nursing care or Intermediate Care Facility for the Mentally Retarded (ICF-MR) income level to meet their maintenance needs during all full calendar months in which the individual resides in the facility and is screened as needing that level of care. 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 level for one during all full calendar months in which the individual resides in the facility.  

Budgeting Procedures for SSI Recipients 510-05-90-45
Subsection 2 had verbiage added to recognize the name change from Prairie Psychiatric Center to the Prairie at St. John’s Center.
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~~ at Saint John’s Center, the Stadter 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. Also see State LTC Subsidy Program 510-05-95-45.
Parental and spousal income is not considered available to the recipient.  
Individuals between the ages of 21 and 65 are not eligible for Medicaid in the state hospital.

Budget Procedures for Medically Needy and Poverty Level 510-05-90-55
Subsection 2 had verbiage added to clarify that to receive the nursing home level of care in a facility, the individual must be screened as requiring that level of care; and to recognize the name change from Prairie Psychiatric Center to the Prairie at St. John’s Center.
 2.  Recipients ~~residing~~ screened for and receiving services in a nursing facility, the state hospital, the Anne Carlsen facility, the Prairie ~~Psychiatric~~ at Saint John’s Center, the Stadter 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.

Budgeting Procedures for Continuous Eligibility for Children Under Age 19 510-05-90-75
Subsection 2 had verbiage added to recognize the name change from Prairie Psychiatric Center to the Prairie at St. John’s Center.

2.	For a continuously eligible child residing in a nursing facility, the state hospital, the Anne Carlsen facility, the Prairie ~~Psychiatric~~ at Saint John’s Center, the Stadter 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.
Recipients residing in an intermediate care facility for the mentally retarded (ICF-MR): The recipient is allowed the $85 ICF-MR income level.
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, (or $85, if the individuals is in an ICF-MR) to meet the maintenance needs of the individual.
NOTE:  The premium calculation for Children/Workers with Disabilities is still required.

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PCP

Primary Care Physician
Manual 510-06

Primary Care Physician

Primary Care Physician
Manual 510-06

Par. 2.  Effective Date -- This manual letter is effective for the benefit month of August 2010 except as indicated.

Carol K. Olson, Executive Director		Manual Letter #3227
North Dakota Department of Human Services	Page  of  Pages