Author: Masad, Deb R.
Last saved by: raddington
Company: NDDHS

Bismarck, North Dakota	MANUAL LETTER #3312	March 1, 2012

Par. 1.	Material Transmitted and Purpose – Transmitted with this Manual Letter are changes to Service Chapter 510-05 Medicaid Eligibility Factors.  New language is in red and underlined and removed language has been struck through.  This supersedes IM 5126, Amended IM 5126, and Second Amended IM 5126 “Disaster Unemployment Insurance Benefits,” IM 5130, “IIM Monies and Health Care,” IM  5132  “2012 Home Equity Limits,” IM  5133  “2012 Community Spouse Asset Allowance and Annuity Income Limits,” IM 5134 “2012 Medicare Savings Programs Asset Limit Update,” and IM 5135 “2012 Average Cost of Nursing Facility Care”.  Technical corrections that do not affect policy have also been made.

Cooperation - Third Party Liability 510-05-12-05 
A new subsection d is added to subsection 2 to clarify that SFN 566 may be used when requesting third party payment information, and to identify that recipients must cooperate.   The rest of subsection 2 is renumbered.   A link to SFN566 is also created.

2.	As a condition of eligibility, legally able applicants or recipients and their spouses must cooperate with the Department and county agency in identifying and providing information to assist Medicaid in pursuing third parties who may be liable to pay for care or services, unless there is good cause not to cooperate.  
This policy is not intended to place an unreasonable burden on applicants or recipients, or to shift the state's responsibility to pursue third parties. If Department and county staff have the ability to obtain the information, it cannot be shown that an applicant or recipient is not cooperating. If the necessary information cannot be obtained without the applicant or recipient’s cooperation, and the applicant or recipient has the ability to assist, this provision applies. As part of cooperation, the Department or agency may require an individual to:
a.	Appear at a state or local office designated by the Department or county agency to provide verbal or written information or evidence relevant to the case;
b.	Appear as a witness at a court or other proceeding;
c.	Provide information, or attest to lack of information, under penalty of perjury;
d.	Complete SFN566 “Medicaid Questionnaire and Assignment” (which is available on eforms.)  
~~d.~~e.	Pay to the agency any medical payments received that are covered by the assignment of benefits; and
~~e.~~f.	Take any other reasonable steps to assist the state in securing third party payments and in identifying information to assist the state in pursuing any liable third party.

Application and Redetermination 510-05-25-05
Language is added to subsection (1)(e) to clarify that applications, regardless of how received MUST be registered in the system as soon as possible upon receipt in the county.  A new subsection (2)(f) is added to clarify that the Redetermination and all verifications must be received and processed no later than the last day of the month in which it is due.

1.	Application.
e.	The date of application is the date an application, signed by an appropriate person, is received at a county agency, the Medical Services Division, a disproportionate share hospital, or a federally qualified health center. The date received must be documented. Applications must be registered in the eligibility system as soon as possible upon receipt, but no later than the fifth day following receipt.
2.	Redetermination.
f.	Redeterminations must be completed and processed no later than the last working day of the month in which they are due.

Groups Covered Under Medicaid 510-05-30-05
Subsections 1(i) and 3(e) were amended to show the change in policy that extends Medicaid coverage to eligible newborns for one year after birth.  Language is added to subsections 4(e), 4(g) and 4(h) to clarify that an individual does not need to be aged or disabled to qualify for the Medicare Savings Programs.

1.	The categorically needy group includes:
i.	Children born to categorically needy eligible pregnant women who applied for and were found eligible for Medicaid on or before the day of the child's birth, for one year ~~sixty days~~, beginning on the day of the child's birth and for the remaining days of the month in which the ~~sixtieth day~~ twelfth month falls.
3.	The medically needy group includes:
e.	Children born to eligible pregnant women who have applied for and been found eligible for Medicaid on or before the day of the child's birth, for one year ~~sixty days~~, beginning on the day of the child's birth and for the remaining days of the month in which the ~~sixtieth day~~ twelfth month falls.

4.	The poverty level group includes:
e.	Qualified Medicare Beneficiaries (QMB), who are entitled to Medicare part A benefits regardless of age or disability status, and who meet the medically needy non-financial criteria have assets no greater than the limit established for the Medicare part D Low Income Subsidy, and have income at or below one hundred percent of the poverty level. Effective January 1, 1991 (90% of the poverty level from April 1, 1990, through December 31, 1990).
g.	Special Low-Income Medicare Beneficiaries (SLMB), who are entitled to Medicare Part A benefits regardless of age or disability status, who meet the medically needy non-financial criteria, have assets no greater than the limit established for the Medicare Part D Low Income Subsidy, and have income above one hundred percent of the poverty level but not in excess of one hundred twenty percent of the poverty level. Effective January 1, 1993.
h.	Qualifying Individuals (QI-1), who are entitled to Medicare Part A benefits regardless of age or disability status, who meet the medically needy nonfinancial criteria, have assets no greater than the limit established for the Medicare Part D Low Income Subsidy, have income above 120% of the poverty level, but not in excess of 135% of the poverty level, and are not eligible for Medicaid under any other provision. Effective January 1, 1998.

Screening for Nursing Care, ICF-ID or HCBS Recipients 
510-05-35-25
Language is added to the last paragraph of this section to clarify processing of individuals age 65 and over that enter an IMD.   This section is also renumbered.
 
1.	All applicants or recipients who seek nursing care services in nursing facilities, swing bed facilities, or intermediate care facilities for the intellectually disabled (ICF-ID), or who seek home and community-based services, must be screened to establish the medical necessity for these services.   
 
2.	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-ID or through HCBS.

3.	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) and who are: 
~~a.~~	~~Applicants and recipients a~~ Age 65 or older are not required to be screened.   
~~b.~~	~~Applicants and recipients a~~ Age 22 to 65 are not eligible for Medicaid.  
~~c.~~	~~Children u~~ Under age 22 who have obtained a certification of need may be eligible as described in 05-35-30.
  
Qualified Aliens 510-05-35-58
Language is added to the first paragraph, with a link to the Refugee Medical Assistance Program Section, to clarify that some aliens may be covered under that program.

Qualified aliens are aliens that have been legally admitted and may be eligible for Medicaid if they meet all other Medicaid eligibility criteria.  Some qualified aliens may be eligible under the Refugee Medical Assistance Program 510-05-95-20 if they do not 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):

~~Sixty Days Free~~ Extended Medicaid for Pregnant Women and Newborns 510-05-35-110
This section was renamed as pregnant women only get the 60-free days of Medicaid coverage, the newborn gets one year.  Subsection 2 is reworded to clarify that children born to pregnant women who applied for Medicaid during pregnancy and who were determined eligible as of the last day of pregnancy remain continuously eligible for Medicaid for 12 months.

2.	Children born to pregnant women ~~who applied for Medicaid during pregnancy, and~~ who were determined to be eligible as of the last day of pregnancy, are ~~also~~ eligible for Medicaid for ~~60 days~~ one year, beginning on the date of birth, and for the remaining days of the month in which the ~~60th day~~ twelfth month falls.
Children who ~~become~~ are eligible for the ~~free~~ extended eligibility period ~~remain eligible without regard to income, whether a redetermination of eligibility is due during the free eligibility period, or whether the child’s mother was an alien receiving emergency services~~ become continuously eligible for the 12 months.
3.	If the Medicaid case closes for loss of residency during the ~~60-day~~ ~~free~~ extended period and the family returns to the state and reapplies while still in the ~~60-day~~ ~~free~~ extended period, eligibility may be reestablished for the remainder of the period.  

Cooperation -- Child Support 510-05-40-15
Subsection 4 has been rewritten to incorporate the policy change as it applies to non-cooperating caretakers.

4.	Cooperation with Child Support is required for all other legally responsible caretaker relatives (including aged and disabled caretakers) for the purpose of establishing paternity and securing medical support. This requirement may be waived for "good cause" as described in 510-40-20
The determination of whether a legally responsible caretaker relative is cooperating is made by the Child Support Agency. The caretaker has the right to appeal that decision.
Legally responsible caretaker relatives who do not cooperate with Child Support will not be eligible for Medicaid. Children in the Medicaid unit, however, remain eligible.
When a legally responsible caretaker relative is not eligible because of non-cooperation, the earned and unearned income of that ineligible caretaker must be considered in determining eligibility for the child(ren).
~~For an ongoing case, if~~ If a previously non-cooperating legally responsible caretaker relative ~~cooperates~~ begins cooperating in an open Medicaid case, and the caretaker is otherwise eligible, ~~during a benefit month,~~ that caretaker’s eligibility  may be ~~eligible for Medicaid effective the first day of the month of cooperation, if otherwise eligible for Medicaid.~~ reestablished.  The caretaker must demonstrate that they are cooperating with Child Support before Medicaid coverage can be reestablished.  When the caretaker previously stopped cooperating, the automated referral to Child Support ended.  
a.	If the Child Support Enforcement case also closed, the caretaker must apply for Child Support services and fulfill the cooperation requirements as determined by the Child Support program (parents or other legal custodians/guardians can apply online at www.childsupportnd.com or mail a completed application to a Child Support office.  Applications can be printed from the web or requested directly from a Child Support office).
b.	If the Child Support Enforcement case did not also close, the caretaker may begin to cooperate with Child Support without application and confirmation of such can be secured by contacting the Child Support worker.
When Child Support has confirmed that the caretaker is cooperating, Medicaid coverage for that caretaker can be reestablished beginning with the first day of the month in which the caretaker began cooperating.  (Confirmation of cooperation must be secured by communicating with the Child Support worker; confirmation of cooperation may not be determined based on the Cooperation indicator on the Fully Automated Child Support Enforcement System (FACSES).)  Child Support has 20 days to process an application for services.  However, typically, applications are processed more quickly than 20 days and Child Support can be contacted as soon as an open case can be viewed in FACSES.
If a previously non-cooperating legally responsible caretaker relative reapplies for Medicaid after the Medicaid case closed, the caretaker relative is eligible for Medicaid until it is again determined that the caretaker relative is not cooperating.

Continuous Eligibility Periods 510-05-53-15
Language is added in subsections 1 and 2 to clarify continuous eligibility for newborn children.
 
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. Continuous eligibility periods cannot be established when re-working a prior month~~.~~ except when adding a newborn child to a prior month and the newborn child is eligible.
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.
Example 3: An application was taken for the month of September and the child was determined medically needy for September and October. When determining eligibility for November, the family’s income decreased so the child becomes poverty level eligible for November. The child becomes continuously eligible effective November 1 and their continuous eligibility period end date would be equal to the redetermination due date of August 31. In November the parents provide verification of decreased income for October and when re-working the month of October the child is now poverty level eligible. The child’s continuous eligibility period would remain November thru August.
Example 4:  An application was taken in October.  The household consists of a woman who gave birth in August and is requesting coverage of her labor and delivery costs.  The woman was poverty level eligible in August.  The newborn became continuously eligible for Medicaid beginning in August and the continuous eligibility period runs through the month of its first birthday.  The woman is not entitled to 60 days of extended coverage because she applied after the birth.  
2.	Except for newborn children, i~~I~~f 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.

Asset Limits for the Medicare Savings Program 510-05-60-20
This section is updated to reflect the increase in the asset limits effective January 1, 2012 for the Medicare Savings Programs.   This is per the requirements of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).  This supersedes IM 5134.
 
No person may be found eligible for the Medicare Savings Programs unless the total value of all non-excluded assets does not exceed the limit established for the Medicare Part D Low Income Subsidy.  This amount changes annually. Effective with the benefit month of January 2012 ~~2011~~, the limits are:
1.	$6,940~~$6,680~~ for a one-person unit ($6,680 in 2011 ~~$6600 in 2010~~); or
2.	$10,410~~$10,160~~ for a two-person unit ($10,160 in 2011 ~~$9910 in 2010~~).

Assets Which are Excluded for the Medicare Savings Programs 510-05-60-25
Language is added to subsection 3(b) to clarify that “Property Essential to Self-Support” is different from “Property Essential to Earning a Livelihood”.
3.	The following additional assets are excluded:
b.	Property essential to self-support~~;~~ is property that a member of the Medicaid unit owns, but which the Medicaid unit is not actively engaged in using to earn income.  It is non-business property that may or may not produce unearned income.

Definitions for Spousal Impoverishment 510-05-65-10
Language is added to subsection 1 (a) to clarify that for the purposes of spousal impoverishment protection, “a child who is in receipt of Medicaid” does not include a child who is enrolled in Healthy Steps.

For purposes of the spousal impoverishment sections:

1.	"Community spouse," means the spouse of an institutionalized spouse or the spouse of a Home and Community Based Services (HCBS) spouse who is:
a.	Not financially responsible for a child who is in receipt of Medicaid (the child may be eligible for Healthy Steps,);
b.	Not in receipt of Medicaid other than coverage under the Medicare Savings Programs; and
c.	Not requiring care in a medical institution, a nursing facility, a swing bed, or in the state hospital, unless the total length of the stay is anticipated to be less than a full calendar month.

Community Spouse Asset Allowance 510-05-65-20
Subsection 2 is updated to reflect the 2012 minimum and maximum amounts the Community Spouse may have in assets under the Spousal Impoverishment provisions.  This supersedes IM 5133.

2.	The community spouse asset allowance is determined by first establishing a spousal share.  The spousal share is an amount equal to one half of the total value of all countable assets owned (individually or jointly) by the institutionalized, HCBS, or community spouse.
Example:
If the couple's countable assets are: | The community spouse share is:
$25,000 | $12,500
$90,000 | $45,000
$250,000 | $125,000
From the spousal share, the community spouse asset allowance is established, and is an amount that is equal to the community spouse share, but not less than $22,728 ~~$21,912~~, and not more than $113,640 ~~$109,560~~, effective January 20~~09~~12 ($21,912 ~~$20,880~~ and $109,560 ~~$104,400~~ effective January 200~~8~~9).

Example:
If_the_spousal share is: | The community spouse asset allowance is:
$12,500 | $~~21,912~~22,728 (at least the minimum)
$45,000 | $45,000
$125,000 | $~~109,560~~113,640 (one-half is more than the maximum allowed, so the community spouse gets the maximum)
 
The community spouse asset allowance may be adjusted by any additional amount transferred under a court order or established through a fair hearing.
Adjustments in the minimum and maximum allowed for a community spouse may also adjust the community spouse asset allowance.

Assets Which are Excluded for Spousal Impoverishment 510-05-65-25
Language is added to subsection 1 to clarify that, for spousal impoverishment, a residence occupied by the person’s dependent relative is excluded, just as when the community spouse lives there.  Language is added to subsection 3(b) to clarify that “Property Essential to Self-Support” is different from “Property Essential to Earning a Livelihood”.
The medically needy exempt and excluded assets are excluded with the following exceptions:
 
1.	Instead of the home, a residence occupied by the community spouse or the person’s dependent relative may be excluded. The residence may be owned by either spouse or jointly.
The residence includes all contiguous lands, including mineral interests, upon which it is located. The residence may include a mobile home suitable for use, and being used, as a principle place of residence. The residence remains excluded during temporary absence of the individual from the residence, so long as the individual intends to return. Renting or leasing part of the residence to a third party does not affect this definition. Terms used in this subsection have the following meaning:
a.	"Relative" means a child, stepchild, grandchild, parent, stepparent, grandparent, aunt, uncle, niece, nephew, brother, sister, stepbrother, stepsister, half brother, half sister, first cousin, or in-law.
b.	"Dependent" means an individual who relies on another for financial, medical, and other forms of support, provided that an individual is financially dependent only when another individual may lawfully claim the financially dependent individual as a dependent for federal income tax purposes.

3.	The following additional assets are excluded:
b.	Property essential to self-support~~;~~ is property that a member of the Medicaid unit owns, but which the Medicaid unit is not actively engaged in using to earn income.  It is non-business property that may or may not produce unearned income.

Asset Considerations 510-05-70-10
Language is added to subsection (1)(e) to clarify that a reverse mortgage is a loan that must be repaid, and proceeds from said loan are an excluded asset.

1.	All assets which are actually available must be considered in establishing eligibility for Medicaid. Assets are actually available when at the disposal of an applicant, recipient, or responsible relative; when the applicant, recipient, or responsible relative has a legal interest in a liquidated sum and has the legal ability to make the sum available for support, maintenance, or medical care; or when the applicant, recipient, or responsible relative has the lawful power to make the asset available, or to cause the asset to be made available. Asset availability is also as follows:
e.	Funds from a loan that must be repaid,  including a reverse mortgage, and that the applicant or recipient demonstrates are for a purpose unrelated to achieving Medicaid eligibility, are not considered to be available assets if identifiable as a loan and if not commingled with other assets.

Home Equity Limit 510-05-70-27
Paragraph 2 was updated to reflect the change in the Home Equity Limit as dictated by the Deficit Reduction Act to increase by the percentage increase in the Consumer Price Index-Urban as prescribed by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).  This supersedes IM 5132.

The Deficit Reduction Act of 2005 established limits on the home equity an individual may have and still qualify for coverage of nursing care services through Medicaid.  

Applicants or recipients who apply for Medicaid coverage on or after January 1, 2006 are not eligible for coverage of nursing care services (which include HCBS) if the individual’s equity interest in the individual’s home exceeds $525,000 effective January 1, 2012 ($506,000 effective January 2011) ~~($500,000 prior to January 1, 2011)~~.  The applicant or recipient may, however, be eligible for other Medicaid benefits.

Excluded Assets 510-05-70-30
The last paragraph of subsection 23 has language added to clarify that, as a general rule, clients may not be asked to provide IIM account information. This supersedes IM 5130.

23.	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.  As a general rule, workers may not request IIM information.

Annuities Purchased Before August 1, 2005 510-05-70-45-20
Subsection (2)(c)(v) is updated to reflect the 2012 limit for the monthly payment from annuities purchased prior to August 1, 2005.  The monthly payment cannot exceed $2841 effective January 2012 in order to meet the exclusions at 510-05-70-45-20(2)(c)(i-v).  This supersedes IM 5133.

2.	An annuity in which a payment option was selected before August 1, 2005 is counted as an available asset in the asset test unless:
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full purchase price and interest within the purchaser's life expectancy; and
v.	Unless specifically ordered otherwise by a court of competent jurisdiction acting to increase the amount of spousal support paid on behalf of a community spouse by an institutionalized spouse or a home and community based services (HCBS) spouse, the monthly payments from the annuity do not exceed $2841 ~~$2739~~ effective January 2012 ~~2009~~ ($~~2610~~2739 ~~for~~ effective 200~~8~~9).

Annuities Purchased from August 1, 2005 Through February 7, 2006 510-05-70-45-25
Subsection (2)(c)(v) is updated to reflect the 2012 limits for the monthly payments from all annuities purchased between August 1,2005 and February 7, 2006.  The limit is $2841, and when combined with the annuitant’s other income at the time of application for Medicaid, cannot exceed $4261. This supersedes IM 5133.

2.	The annuity is counted as an available asset in the asset test unless:
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full principal 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 $~~2739~~ 2841 effective January 20~~09~~12 ($~~2610~~2739 ~~for~~ effective 200~~8~~9) and, when combined with the annuitant’s other income at the time of application for Medicaid, does not exceed $~~4109~~ 4261 effective January 20~~09~~12 ($~~3915~~ 4109 ~~for~~ effective 200~~8~~9); and

Annuities Purchased or Changed on or After February 8, 2006 510-05-70-45-30
Subsection (3)(c)(v) is updated to reflect the 2012 limits for the monthly payments from all annuities purchased or changed on or after February 8,  2006.  The limit is $2841, and when combined with the annuitant’s and the annuitant’s spouse’s other income at the time of application for Medicaid, cannot exceed $4261.    This supersedes IM 5133.

3.	The annuity is counted as an available asset in the asset test unless:
c.	The annuity meets all of the following conditions:
i.	The annuity is irrevocable and cannot be assigned to another person;
ii.	The issuing entity is an insurance company or other commercial company that sells annuities as part of the normal course of business;
iii.	The annuity provides for level monthly payments;
iv.	The annuity will return the full 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 $~~2739~~ 2841 effective January 20~~09~~12 ($~~2610~~ 2739 ~~for~~ effective 200~~8~~9)  and, when combined with the annuitant’s and the annuitant's spouses's other income at the time of application for Medicaid, does not exceed $~~4109~~ 4261 effective January 20~~09~~12 ($~~3915~~ 4109 ~~for~~ effective 200~~8~~9); and

Definitions 510-05-80-05 (Disqualifying Transfers)
Subsection 9 has been updated to reflect the 2012 average cost of nursing facility care effective January 1, 2012.  This supersedes IM 5135.

9.	The average cost of nursing facility care is:
Year | Daily Rate | Monthly Rate
2012 | 213.82 | 6504
2011 | 205.07 | 6238
2010 | 195.55 | 5948
2009 | 179.27 | 5453
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

Income Considerations 510-05-85-05
A new subsection 5 has been added to include a change in policy that will allow for the proper treatment of income payments received after death if specific circumstances are met.

5.      Monthly income is considered available when determining eligibility for Medicaid, however, an individual may die before their income is actually received for the month.  An income payment received after death is no longer considered income, but an asset to the individual’s estate.  In circumstances where the Department will pursue estate recovery, Medicaid eligibility can be redetermined counting only that income which was received prior to the individual’s death; resulting in the elimination or reduction of the recipient liability.
When a Medicaid provider reports that a recipient’s current month recipient liability was not paid as of the date of death, determine whether the following conditions are met:
a.	There is no surviving spouse;
b.	There is no surviving minor or disabled child; and
c.	Countable monthly income was not received prior to death.
If all conditions are met, refer the case to the Medicaid Eligibility Unit.  Information regarding the date of death and the dates of the month in which each source of income is received must also be provided.  The Medicaid Eligibility Unit will determine whether Medicaid estate recovery is being pursued and an adjustment to recipient liability can be approved.  If approved, the Medicaid Eligibility unit will process the adjustment.
~~5.~~	6.	Income may be received weekly, biweekly, monthly, intermittently, or annually. However income is received, a monthly income amount must be computed.

Unearned Income 510-05-85-15
Language was changed in subsection 5(a) to include the change in policy that disaster unemployment benefits are no longer counted as income.  This supersedes IM 5126, Amended IM 5126, and Second Amended IM 5126.  Language is added to subsection 5(c) to clarify that any fees deducted from child support received by the State Disbursement Unit are not considered available income.  This supersedes FYI 07-034.    Language is added to subsection 5(i) to clarify that the production taxes withheld are not included as royalty income; however any other withholdings are.

Unearned income is income that is not earned. Unearned income which is received in a fixed amount each month shall be applied in the month in which it is normally received. For example, Social Security benefits received in January will be applied against January need.
 
Child Support payments made via Direct Deposit or Electronic Payment Card are considered received on the third (3rd) working day from the 'Check Date' field on the FACSES ledger, unless the applicant or recipient verifies that the payment is received otherwise. The 'Check Date' will be considered the first day when determining the three (3) working days.  Any fees deducted from child support received by the State Disbursement Unit are not counted as child support income (nor may it be subtracted from the child support paid amount when determining the allowable child support deduction).
 
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, public or private disability payments for an individual, etc.
These benefits are to be considered in the full amount awarded within the Medicaid unit. However, when a mandatory deduction for taxes is withheld, the benefit is reduced by those deductions (see 05-85-05(1) for policy on how to treat Social Security overpayments);
c.	The net amount of c~~C~~ourt ordered or voluntary support payments and alimony.  The net amount of the payment is the amount after fees are deducted from child support payments received by the State Disbursement Unit;
i.	Royalty income less mandatory production taxes withheld prior to distribution (income taxes withheld are not allowed to reduce the royalty payment);

Earned Income 510-05-85-20
The example in subsection 1 is changed to clarify the treatment of expenses for a contractual employee.  A new subsection 4 (g) is added, and the rest of subsection 4 renumbered, to clarify that disaster payments received by a self-employed business are excluded income and must be deducted from the gross in determining the self-employment income

1.	If earnings from more than one month are received in a lump sum payment, the payment must be divided by the number of months in which the income was earned, and the resulting monthly amounts are attributed to each of the months with respect to which the earnings were received.
Similarly, earnings paid under a contract must be prorated over the period the contract covers. ~~For example, a teacher receives paychecks in August through May, however, the teacher's contract covers 12 months. The teacher’s pay and employment expenses are annualized and prorated over the 12-month period.~~
Example:  A teacher receives paychecks in August through May, however the contract covers 12 months and the contracted salary is $30,000.  The annual salary is prorated over 12 months for $2500 per month.  The paystubs show that from the August through May monthly checks, $350 per month is withheld.  To annualize the withholdings, take the 10 months of withholdings, (10 X $350 = $3500) and divide by 12 ($3500/12) = $291.67 to establish the monthly allowable withholdings.
4.	Calculating "self-employment" income:
g.	Disaster agricultural payments and other disaster payments made to a self-employment entity due to a disaster must be deducted from the gross income on the tax schedules as this is disregarded income.

Post Eligibility Treatment of Income 510-05-85-25
Three examples and ‘CRP’are added to subsection (1)(i) to clarify how to determine the real estate taxes deduction.
i.	From annual countable gross CRP and rental income, an amount equal to the real estate taxes for CRP and rental property that the recipient is responsible for paying on that property.
Example 1:  Ed is in the nursing home.  He receives rental income on farmland in the amount of $24,000.  Ed is responsible to pay the property taxes.   The most current tax statement verifies that Ed is responsible for property taxes of $3600.  $24,000 - $3600 is his annualized adjusted rental income of $20,400; divided by 12 equals $1700 per month unearned income to Ed.
Example 2:  Ralph and Edna are married.  Edna is in the nursing home, Ralph is in the community.  Their farmstead is leased out in both of their names.  They receive annual gross rent of $30,000 and the property taxes for which both are responsible is $6,000.  Since they both own and are entitled to the income, it is divided, so each has gross rental income of $15,000.  Likewise, the property tax is split between them.  When determining Edna’s income, the $15,000 - $3,000, or $12,000 is prorated over the year for $1000 per month.  When determining Ralph’s income, the $15,000 is prorated over the year, giving him countable income of $1250 per month.  Because only Edna is in a long term care facility, only she is allowed the property tax disregard.

Example 3:  Pete is in the nursing home.  He receives land rental income of $12,000 in April and $12,000 in October.  His most recent tax statement verifies his responsibility of $4,000 in property taxes.  Taking his annual rental income of $24,000 minus his property tax liability of $4000 equals $20,000 countable annual rental income.  Dividing this by 12 months gives us a prorated countable monthly unearned rental income of $1,666.67.  This would be reviewed in March of the following year to determine if the income or the liability has changed.  If they apply after the April payment was received, but prior to receipt of the October payment, only the $12,000 October payment minus half of the allowed property tax liability would be prorated up to the next payment the following April.

Disregarded Income 510-05-85-30
Language is added to subsection 22 to clarify that reverse mortgages are treated the same as any other loan requiring repayment.  Language was changed in subsection 37 to include the change in policy that disaster unemployment benefits are no longer counted as income.  This supersedes IM 5126, Amended IM 5126, and Second Amended IM 5126.

22.	A loan from any source that is subject to a written agreement requiring repayment by the recipient (which includes a reverse mortgage payment);
37.	Assistance received under the Disaster Relief and Emergency Assistance Act of 1974 or some other federal statute, because of a presidentially declared major disaster (~~but not~~ including disaster assistance unemployment compensation), and interest earned on that assistance.~~;~~ Comparable assistance received from a state or local government, or from a disaster assistance organization is also excluded;

Income Deductions 510-05-85-35
Subsection 2(e) has been revised to clarify that bed hold days and transportation for out of state medical care that has not been prior approved may not be used to reduce recipient liability.

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;
b.	Provided by a medical practitioner licensed to furnish the care;
c.	Not subject to payment by any third party, including Medicaid and Medicare;
d.	Not incurred for nursing facility services, swing bed services, or HCBS during a period of ineligibility because of a disqualifying transfer; and
e.	Claimed.
Examples of expenses that cannot be used to reduce countable income and affect recipient liability:
i.	Extra amounts paid on glasses, such as more expensive frames, tint, etc.;
ii.	Expenses that are considered medically necessary, but are applied to recipient liability;
iii.	Costs for Lifeline;
iv.	Over the counter medications and supplies that Medicaid does not pay for, even if prescribed*;
v.	Other medications and services that Medicaid does not pay for, such as DESI drugs, such as Midrin (for Migraines), Tigan (for nausea).  (DESI drugs -- Drug Efficacy Study Implementation --are determined by the federal government to be safe but less than effective);
vi.	Expenses from visiting a provider who is not the individual's Coordinated Services Program (CSP) "lock-in" provider; ~~or~~
vii.	Drugs from Canada prescribed by someone other than a United States physician; 
viii.	Transportation costs for out of state medical care provided to recipients that have not been prior approved; or 
ix.	Up to 15 bed-hold days in a long term care facility that neither Medicare nor Medicaid will cover.

Guidelines for Anticipating Income 510-05-90-15
Language is added to this section to clarify that the guidelines for anticipating income also apply to anticipating expenses.  

Use prospective budgeting to determine eligibility based on the income which is anticipated to be received and the expenses that are anticipated to be incurred. Anticipated income and expenses ~~is~~ are an estimate based on reasonable expectations and knowledge of past, current, and future events. The following guidelines are offered to assist in this determination.
 
An employed individual who does not expect a significant change ~~in income~~ should have the previous month's earnings and employment deductions verified by pay stub or employer's statement. The previous month’s earnings serve as the basis for estimating the income likely to be received during the initial prospective month. To illustrate, a person applies for assistance on November 15 and reports there should be no significant change in income and deductions from the month of October. The October income should be verified to anticipate the income and deductions likely to be available in November.

Budget Procedures for Medically Needy and Poverty Level 510-05-90-55
Language has been added to subsection 2 of this section to clarify the treatment of individuals age 65 and over who have entered an IMD.

2.	Recipients screened for and receiving services in a nursing facility, the state hospital, the Prairie 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.  Individuals age 65 and over who have entered an IMD do not require a screening.  Those admitted for a temporary stay keep the same living arrangement they had prior to being admitted to the IMD and remain at the same income level for that living arrangement.  Those admitted for an indefinite stay are allowed the $50 nursing care level for one. 
Recipients residing in an intermediate care facility for the intellectually disabled (ICF-ID) (including the Anne Carlsen facility): The recipient is allowed the $85 ICF-ID income level.  
For a single individual under age 21, or if blind or disabled under age 18, parental income is not considered available during any full calendar month the recipient is in the facility. Likewise, for a married recipient, income of the spouse is not considered available during any full calendar month, or when the community spouse is ineligible for Medicaid (spousal impoverishment case), during any full or partial month.
If the individual has no source of income, and is ineligible for SSI, the income of the spouse or parents may be deemed in the amount of $50 (or $85 if the individual is in an ICF-ID) to meet the maintenance needs of the individual.
Individuals between the ages of 21 and 65 are not eligible for Medicaid in the state hospital.

Children's Special Health Services 510-05-95-40
This section is updated to reflect the most recent contact information for Children’s Special Health Services. 

Children's Special Health Services provides services for children with special health care needs and their families. Services include coverage for diagnosis and treatment for children who have disabilities or chronic conditions.  The program supports family-centered, community-based, coordinated services and systems of health care that meet the diverse needs of families.  For information, contact the Children’s Special Health Services Program, North Dakota Department of Health, Division of Maternal and Child Health, 600 East Boulevard Ave, Dept 301, Bismarck ND 58505-0200, or call 701-328-2436,  1-800-~~472-2286~~755-2714 or FAX: 701-328-1645.  

Technical corrections that do not affect policy have also been made.

Par. 2.  Effective Date -- This manual letter is effective for the benefit month of March 2012 except as indicated.

Carol K. Olson, Executive Director	                                                               Manual Letter #3312
North Dakota Department of Human Services	Page  of  Pages