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

Bismarck, North Dakota	MANUAL LETTER #3321	April 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 manual letter includes changes in Medicaid terminology from “redetermination” to “review” and “recipient liability” to “client share” as well as the increase in the federal poverty income levels effective April 1, 2012.

Improper Payments and Suspected Fraud 510-05-10-25
Language is added to subsection 5 to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.  Language requiring workers to send a copy of the SFN 20 to the Estate Recovery Unit is removed from subsection 6 to document the change in policy that the SURS unit is now responsible for doing this.

5.	The amount of a recipient error is determined as follows:
a.	For ineligible cases resulting from excess assets, the amount of the overpayment is the lesser of:
i.	The amount of Medicaid payments paid in error on behalf of the Medicaid unit; or
ii.	The difference between the actual amount of excess assets and the Medicaid asset limit.
b.	For overpayments resulting from errors related to incorrect client share (recipient liability), the amount of the overpayment is the lesser of:
i.	The amount of Medicaid payments paid in error on behalf of the Medicaid unit; or
ii.	The difference between the correct amount of client share ~~recipient liability~~ (using actual income) and the amount of the client share ~~recipient liability~~ met by the Medicaid unit.
c.	For overpayments resulting from any other error, the amount of the overpayment is the amount of Medicaid payments paid in error on behalf of the Medicaid unit.
6.	All recipient errors in which there is an overpayment or suspected fraud (regardless of overpayment) must be referred to the Surveillance Utilization Review (SURS) Unit in the Medical Services Division using SFN 20, “SURS Referral Form.” SFN 20 may be sent to SURS by:
a.	Mail: SURS, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505;
b.	Fax: 701-328-1544; or
c.	Email: medicaidfraud@nd.gov.  
~~A copy of SFN 20 must also be sent to the Estate Recovery Unit when the error includes an overpayment. SFN 20 may be sent to the Estate Recovery Unit by:~~
~~a.~~	~~Mail: Estate Recovery Unit, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505;~~
~~b.~~	~~Fax: 701-328-1060; or~~
~~c.~~	~~Email: dhseap@nd.gov.~~  

Cost-effectiveness Determination 510-05-20-20
Language is added to subsection 5(f) to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

5.	The following health plans are usually not considered to be cost-effective.
a.	Medicare supplement policies for individuals with routine medical needs (the exceptions are recipients with higher medical needs and the recipient's covered costs exceed the premium);
b.	Hospital indemnity policies if the recipient is not currently collecting benefits;
c.	Policies where the absent parent is the policy holder;
d.	Specific illness policies (i.e. cancer ins.) if the individual covered does not have the illness;
e.	Accident insurance policies, if the recipient is not currently collecting benefits; or
f.	Policies where all of the members of the Medicaid unit, who are covered by the health plan, have a client share (recipient liability).
If the cost-effectiveness of any of these policies is questionable, the policy should be submitted to the Medicaid Eligibility Division for a formal determination.

Application and Review ~~Redetermination~~ 510-05-25-05
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

1.	Application.

c.	An application is a request for assistance on:

ix.	If within one calendar month of when an applicant's Medicaid case was closed, one of the prescribed review ~~redetermination~~ forms (see subsection 2(b);
2.	Review ~~Redetermination~~.
a.	A recipient has the same responsibility to furnish information during a review ~~redetermination~~ as an applicant has during an application.
b.	A review ~~redetermination~~ must be completed at least annually using the Department's:
i.	System generated "Monthly Report";
ii.	System generated " Review ~~Redetermination~~ of Eligibility;"
iii.	SFN 407, " Review ~~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.
Ex Parte Reviews ~~Redeterminations~~: In circumstances where a desk review is appropriate, such as when adding a child, moving to Transitional Medicaid Benefits, processing a change in the level of care, aligning review r~~edetermination~~ dates with Healthy Steps, SNAP, or TANF, or adding Medicare Savings Programs coverage; and in which the county agency has all information needed to complete a review r~~edetermination~~, eligibility may be established without a review r~~edetermination~~ form. In unique circumstances, when the county agency has all information needed to complete a review r~~edetermination~~, and circumstances prevent a recipient or their representative from timely returning the review r~~edetermination~~ form, continued eligibility may be established without a completed form. In circumstances in which information needed to complete a review r~~edetermination~~ is available through Healthy Steps, SNAP or TANF, that information should be used ~~to redetermine eligibility~~ without again requiring that information from the individual or family. If all needed information is available, review r~~edetermination~~ can be completed without requiring a review r~~edetermination~~ form. Care must be used to ensure all needed information is on hand. An online narrative must document the completion of the Ex Parte review r~~edetermination~~.
c.	A  review r~~edetermination~~ must be completed within thirty days after a county agency has received information indicating a possible change in eligibility status, when eligibility is lost under a category (e.g. Transitional Medicaid Benefits), or when adding an individual to an existing Medicaid case. When the county agency has all information needed to ~~re~~determine eligibility based on a change in circumstances, a review r~~edetermination~~ form does not have to be completed. When additional information is needed one of the forms identified in b. must be used.
d.	A review r~~edetermination~~, using one of the forms identified in b, is required to open a new Medicaid case for recipients (other than children who are adopted through the state subsidized adoption program, which requires an application) who move from an existing case to their own case (e.g. an 18 year old caretaker moves to her own case; a disabled child turns age 18; or a child goes into foster care).
e.	A recipient may choose to have a face-to-face or telephone interview for their review r~~edetermination~~; however, none are required in order to complete a review r~~edetermination~~.
f.	Reviews~~Redeterminations~~ must be completed and processed no later than the last working day of the month in which they are due.

Decision and Notice 510-05-25-25
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

4.	As specified below, a notice must be sent in all ongoing cases in which a proposed action adversely affects Medicaid eligibility.
c.	Under the following circumstances a "Ten-Day Advance Notice" is not required; however, a notice containing the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested, must be mailed (as described in subsection 5) no later than the effective date of action:
i.	The recipient provides a signed, clearly written statement providing information that requires a termination or reduction in benefits, and the recipient indicates that he or she understands that benefits will be reduced or terminated (changes reported on the change report form, the TANF monthly report, the review r~~edetermination~~ form, or via an applicant's or recipient's known email address  meet this requirement);

Groups Covered Under Medicaid 510-05-30-05
Language is added to subsection 3(d) to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

3.	The medically needy group includes:
a.	Eligible caretaker relatives and individuals under age twenty-one in families with deprived children who qualify and require medical services on the basis of insufficient income, but who do not meet income or age Family Coverage group requirements, or who do not qualify as optional categorically needy or poverty level.
b.	Individuals under the age of twenty-one who qualify for and require medical services on the basis of insufficient income, but who do not qualify as categorically needy, optional categorically needy, or poverty level, including children in common in stepparent families who are ineligible under the Family Coverage group and foster care children who do not qualify as categorically needy or optional categorically needy.
c.	Pregnant women whose pregnancy has been medically confirmed and who qualify on the basis of financial eligibility.
d.	Eligible pregnant women who applied for Medicaid during pregnancy, and for whom client share (recipient liability) for the month was met no later than on the date each pregnancy ends, continue to be eligible without regard to financial circumstances, for sixty days, beginning on the last day of pregnancy, and for the remaining days of the month in which the sixtieth day falls.
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, beginning on the day of the child's birth and for the remaining days of the month in which the twelfth month falls.
f.	Aged, blind, or disabled individuals who are not in receipt of SSI benefits.
g.	Individuals under age twenty-one who have been certified as needing the service, or age sixty-five and over in the state hospital who qualify on the basis of financial eligibility.

Medicaid Unit 510-05-35-05
Language is added to subsection 2(c) to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

2.	An applicant or recipient who is also a caretaker of children under twenty-one years of age may select the children who will be included in the Medicaid unit. Anyone whose needs are included in the unit for any month is subject to all Medicaid requirements which may affect the unit. The financial responsibility of relatives must be considered with respect to all members of the assistance unit.
When a child is included in the Medicaid unit eligibility is pursued for the child unless:
a.	The child is eligible under the Healthy Steps Program;
b.	The child is an ineligible alien or the child's US citizenship has not been verified;
c.	The child is ineligible due to no medical need (client share (recipient liability) exceeds need);
d.	The child is receiving services in a Psychiatric Residential Treatment Facility (PRTF), or the state hospital, the Prairie at St. John's center, the Stadter Psychiatric Center, or any other institution for mental disease (IMD), and has not obtained certification of need for services in that facility; or
e.	The child's identity has not been verified.

Need 510-05-35-35
Language is added to subsections 2 and 3 to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

2.	For a medically needy applicant or recipient, need is established when there is no client share (recipient liability) or when the applicant or recipient has incurred medical expenses for which the applicant or recipient is responsible (after any third party payments) that equal or exceed the client share ~~recipient liability~~. If there is no need, there is no eligibility, and the application must be denied or the case must be closed.
3.	When financially eligible individuals (individuals in subsection 1 or those in subsection 2 with no client share ~~recipient liability~~) are not utilizing the program, assistance may be terminated if a written request is obtained from the recipient. An oral request will also suffice if recorded in the case file narrative and reflected on the closing notice, which must be mailed to the recipient.

Aliens Lawfully Admitted for Permanent Residence on or After August 22, 1996 510-05-35-65
Subsection 3 is added to clarify that adopted or biological children born outside the US may establish automatic citizenship if specific conditions are met.

3.  	Adopted or biological children born outside the US may establish their automatic citizenship if verification is provided as described in the Secondary Verification of Citizenship table at 510-05-35-45.

Social Security Numbers 510-05-35-80
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

6.	Except for recipients excused in Subsection 1, recipients who provide verification of application for a SSN must provide a SSN by the next review ~~redetermination~~. If a child is within a continuous eligibility (CE) period when the case review ~~redetermination~~ is being completed, and the SSN is not provided, the child is eligible through the end of the current CE period; however, the child's SSN must be provided for eligibility to continue past the end of that CE period.

Blindness and Disability 510-05-35-100
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

4.	The county agency will need to obtain and submit medical and social information to the State Review Team for their evaluation if:
The State Review Team will use the following in determining blindness or disability:
a.	DETERMINATION OF BLINDNESS:  In any instance in which a determination is to be made whether an individual is blind, the individual shall be examined by a physician skilled in the diseases of the eye, or by an optometrist, whichever the individual may select. The State Review Team shall review and compare that report with the state's definition of blindness and determine:
(1) Whether the individual meets the definition of blindness; and
(2) Whether and when reexaminations are necessary for periodic reviews r~~edeterminations~~ of eligibility.
Reviews R~~edeterminations~~ of blindness are established at the recommendation of the State Review Team, or at such time that activity or behavior on the part of a blind recipient raises doubts about his visual status. The same procedure is utilized in reviews r~~edeterminations~~ of blindness as in the original determination.

Extended Medicaid for Pregnant Women and Newborns 510-05-35-110
This section documents the changes in Medicaid terminology from ‘redetermination’ to ‘review’ and ‘recipient liability’ to ‘client share’.

1.	Pregnant women who applied for Medicaid during pregnancy, and are determined to be eligible as of the last day of pregnancy, continue eligible for Medicaid for 60 days, beginning on the last day of pregnancy, and for the remaining days of the month in which the 60th day falls.
A pregnant woman is considered to be eligible for Medicaid as of the last day of pregnancy when she is eligible with no client share (recipient liability), or if there is a client share ~~recipient liability~~, when the full client share ~~recipient liability~~ is incurred as of the last day of pregnancy.
This provision applies regardless of the reason the pregnancy was terminated, and without regard to changes in income or whether a review ~~redetermination~~ of eligibility is due during the free eligibility period.
This provision is only available to women who are eligible for Medicaid under one of the pregnant women coverages in the family category, but is not available to women who are aliens covered by Medicaid for emergency services.

Continuous Eligibility Periods 510-05-53-15
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’. Subsection 1, Example 4, is reworded to clarify policy.  

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.  
 
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 review r~~edetermination~~ 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 July 31, the end of the month prior to the month of its first birthday. The woman is not entitled to 60 days of extended coverage because she applied after the birth.
4.	When a review r~~edetermination~~ of eligibility is completed an eligible individual may be determined to be eligible for a new continuous eligibility period.  Reviews R~~edeterminations~~ must be completed at least annually, but may be scheduled earlier in order to align continuous eligibility periods within a case between children, or to align review r~~edetermination~~ dates with other programs.
a.	If the individual’s previous continuous eligibility period ended, the individual must meet all eligibility criteria to continue eligible for Medicaid.  
b.	If a review r~~edetermination~~ is being completed before the individual’s continuous eligibility period has ended, and the individual meets all Medicaid eligibility criteria, the individual begins a new continuous eligibility period.
c.	If a review r~~edetermination~~ is being completed before the individual’s continuous eligibility period has ended, and the individual fails to meet all Medicaid eligibility criteria, the individual remains eligible only until the end of their current continuous eligibility period.  A new review r~~edetermination~~ of eligibility is required at that time to establish any further eligibility.
5.	A continuous eligibility period must be ended earlier than when the review is due r~~edetermination~~ for any of the following reasons:

Continuously Eligible Individuals Moving Out of the Medicaid Unit 510-05-53-20
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.  Subsection 2 is changed to document the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

1.	When a continuously eligible child leaves the Medicaid unit and enters foster care, a new application is processed to determine the child’s ongoing eligibility. If the child meets all eligibility criteria, the child begins a new continuous eligibility period. If the child does not meet the eligibility criteria, or would be eligible as medically needy, the child must be approved and remains continuously eligible only until the end of their current continuous eligibility period. A new review r~~edetermination~~ of eligibility is required at that time to establish any further eligibility.
2.	When a continuously eligible individual enters a long term care facility, the individual is still considered part of the Medicaid unit; however, the post eligibility treatment of income (05-85-25) applies. Even though the individual is continuously eligible and remains eligible as other than medically needy, the individual’s income must be considered toward the cost of care, and he or she may have a client share (recipient liability). 

Once the individual’s continuous eligibility period ends, and a review r~~edetermination~~ is completed, the individual may become medically needy.  
3.	When a continuously eligible individual enters a specialized facility other than foster care, the individual is still considered part of the Medicaid unit. The individual remains eligible as other than medically needy. Once the individual’s continuous eligibility period ends, and a review r~~edetermination~~ is completed, the individual may become medically needy.  
4.	When a continuously eligible individual elects to receive HCBS, the individual is still considered part of the Medicaid unit. The individual remains eligible as other than medically needy. Once the individual’s continuous eligibility period ends, and a review r~~edetermination~~ is completed, the individual may become medically needy.  
5.	When a continuously eligible individual is away at school or training; is living outside the home to secure medical treatment; or is a child living outside of the parental home and is not living independently, the individual is still considered part of the Medicaid unit.  
6.	A continuously eligible individual may move from one case to another case. If the individual, through an application or review r~~edetermination~~, meets all eligibility criteria to be continuously eligible in the new case, the individual begins a new continuous eligibility period. If the individual does not meet the eligibility criteria, or would be eligible as medically needy, the individual must be approved and remains eligible only until the end of their current continuous eligibility period. A new review ~~redetermination~~ of eligibility is required at that time to establish any further eligibility in the new case.  

Children with Disabilities 510-05-58
General Information 510-05-58-05
Language is added this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

The Children with Disabilities coverage allows options to families of children with disabilities under age 19, who are not eligible for Medicaid or who are eligible for Medicaid and have a client share (recipient liability), to buy into Medicaid. This coverage became effective in North Dakota on April 1, 2008.

Individuals Covered and Benefits 510-05-60-10
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

3.	Qualifying Individuals are entitled only to payment of their Medicare Part B premium. Eligibility may be established for as many as three calendar months prior to the month in which the application was received or the date the Social Security Administration received the Low Income Subsidy application. A review r~~edetermination~~ of eligibility is required in December of each year to establish continued eligibility for the coming year.

Institutionalized Spouse or Home and Community Based Services (HCBS) Spouse Asset Limit 510-05-65-15
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

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 review r~~edetermination~~.
If the assets are not reduced to the asset limit by the next regularly scheduled review r~~edetermination~~, 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 review r~~edetermination~~, 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 review r~~edetermination~~.  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 review r~~edetermination~~ 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).
Example 3: The community spouse had an asset allowance of $25,000. At application, the couple has $12,000 in countable assets and they have until the next review r~~edetermination~~ to transfer at least $9,000 to the community spouse, which they do. Several months later, the institutionalized spouse inherits $12,000. Because the community spouse still may receive an additional $16,000 and the institutionalized spouse has only $12,000 over his $3,000 asset limit, the institutionalized spouse can have until the next review r~~edetermination~~ to transfer at least $12,000 to the community spouse. The transfer is made, bringing the community spouse’s total countable/received assets up to $21,000. The institutionalized spouse inherits another $10,000. The community spouse has already received $21,000 of the $25,000 asset allowance. Because the amount that the institutionalized spouse’s asset limit is exceeded is greater than the amount that would allow for another transfer period, no new transfer period is allowed. Unless the institutionalized spouse transfers the excess amount to the community spouse in the month it was received, his case must be closed for excess assets.

Breast and Cervical Cancer Early Detection Program 510-05-67
General Information 510-05-67-05
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

The breast and cervical cancer early detection group consists of women under age sixty-five who:
1.	Are uninsured and not otherwise eligible for Medicaid (If otherwise eligible for Medicaid with a client share (recipient liability), the woman can choose coverage  as Medically Needy with a client share ~~recipient liability~~ or through the Women’s Way program);

Excluded Assets 510-05-70-30
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

Subsection 7
i.	It is expected that a "good faith effort to sell" will normally generate a sale. If no offer for at least 75% of the established fair market value has been received on the property as of the annual review r~~edetermination~~, the county agency must review the previous efforts and determine if they truly reflect a good faith effort to sell, and may require a re-evaluation of the property value, or other appropriate action likely to produce a sale.

Contractual Rights to Receive Money Payments 510-05-70-40
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’.

Subsection 3(c)
Applicants and recipients should be encouraged not to forgive debts that have been determined to be uncollectible. Such debts could have a future value if the debtor ever accrues assets. At each annual review r~~edetermination~~, determine whether the judgments are still on file or whether the debtor has any change in assets.

Penalty Periods 510-05-80-15
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

4.	When determining if an individual is “otherwise eligible” for Medicaid:
a.	The individual must have applied for Medicaid and must meet all nonfinancial eligibility criteria;
b.	Countable assets must be within appropriate Medicaid asset levels; and
c.	The monthly cost of nursing care and other medical care the individual is responsible for must be equal to or greater than the individual’s client share (recipient liability).
This “otherwise eligible” determination is used to establish whether an individual would be eligible for Medicaid if they were not subject to a penalty period.  If so, the “otherwise eligible” determination is used to establish the penalty period start.  
 
An applicant who is determined to be “otherwise eligible” does not mean that the applicant is actually eligible for Medicaid.  Since Medicaid is prohibited from paying any nursing care services during a penalty period, these nursing care expenses are not allowed as a deduction in the Post Eligibility Treatment of Income (510-05-85-25(3)).  As a result, an individual who made a disqualifying transfer may be “otherwise eligible” for penalty period start purposes, but the individual is not approved for Medicaid because there is no medical need per 510-05-35-35.
 
Example 1:  Mr. Brown made a disqualifying transfer in March 2006 that results in a 6-month penalty period.  He entered the nursing home in May 2006 and used his remaining assets to cover his cost of care. In September 2006 his assets were under $3000 and he applied for Medicaid.  In determining when Mr. Brown’s penalty period begins it is necessary to establish when he is “otherwise eligible” for Medicaid.  First, he meets all nonfinancial criteria.  Second, his assets are within the appropriate level beginning September 2006.  Third, he has income of $900 per month; he is allowed the $50 income level; and he pays a Medicare premium of $88.50 per month.  This leaves him with a client share ~~recipient liability~~ of $761.50 per month.  He has actual nursing care costs of $4820 per month and other medical expenses of $150 per month for total medical costs of $4970 per month. These medical costs exceed his client share ~~recipient liability~~. He meets all of the criteria to be “otherwise eligible” so his penalty period starts September 1, 2006.
 
His application for Medicaid is still denied because in determining medical need, his other medical expenses of $150, excluding the nursing care costs, do not exceed his client share ~~recipient liability~~.
 
Example 2:  Mr. White made a disqualifying transfer in March 2006, entered the nursing home in May 2006, and used his remaining assets to cover his cost of care.  In September 2006 his assets were under $3000 and he applied for Medicaid.  In determining whether Mr. White is “otherwise eligible” for Medicaid, it is first established that he meets all nonfinancial criteria.  Second, his assets are within the appropriate level beginning September 2006.  Third, he has income of $1500 per month; he is allowed the $50 income level; and he pays a Medicare premium of $88.50 per month.  This leaves him with a client share ~~recipient liability~~ of $1361.50 per month.  He has actual nursing care costs of $3520 per month, and he has nursing home insurance that pays $75 per day ($2250 in a 30-day month). As a result, the nursing care costs that he is responsible for ($1270) does NOT exceed his client share ~~recipient liability~~, and he is not “otherwise eligible.”  His penalty period would not start and his application for Medicaid is denied for no medical need.  
 
If at a later date his nursing care costs increase, or his insurance ends, causing his nursing care costs to exceed his client share ~~recipient liability~~, he would become “otherwise eligible,” and his penalty period would only start at that time.
 
Income Considerations 510-05-85-05
Language is added to Subsection 1 to clarify that the gross amount of a federal benefit may be reduced in specific cases of undue hardship.
1.	All income which is actually available must be considered. Income is actually available when it is 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 income available or to cause the income to be made available.
An individual may have rights, authority, or powers that he or she does not wish to exercise. An example includes an individual who allows a relative to use excluded or exempted assets free or at a reduced rental. In such cases, a fair rental amount will be counted as available income whether the applicant or recipient actually receives the income.
Income that is withheld because of garnishment or to pay a debt or other legal obligation is still considered available.
Title II and SSI overpayments being deducted from Title II benefits are normally considered to be available because the applicant or recipient can pursue a waiver of the overpayment. Only if the waiver has been denied after a good faith effort, can the Title II or SSI overpayment deductions be considered unavailable. ~~Occasionally other delinquent debts owed to the federal government may be collected from an individual’s Title II benefit. These other reductions of Title II benefits are generally not allowed to reduce the countable benefit amount. The award amount of the Title II benefit is counted as available except to the extent an undue hardship is approved for the individual.~~
Occasionally other delinquent debts owed to the federal government may be collected from an individual’s federal payment benefit (i.e. Title II, Civil Service, and Railroad Retirement). These other reductions of federal benefits are not allowed to reduce the countable benefit amount.  The award amount of the federal payment benefit is counted as available except to the extent an undue hardship is approved for the individual.
Requests for undue hardship exceptions must be submitted to the Medicaid Eligibility Unit where a determination will be made whether an undue hardship exists.  An undue hardship may be determined to exist for all or a portion of the debt owed, or all or a portion of the reduction from the monthly income.
An undue hardship will be determined to exist only if the individual shows all of the following conditions are met:
a.	The debt is a debt owed to the Federal government;
b.	The deduction from the individual’s ~~Title II~~ federal payment benefit was non-voluntary;
c.	The amount of the deduction exceeds the Medicaid income level(s) to which the individual and the individual’s spouse is subject;
d.	The individual has exhausted all lawful avenues to get the reduction waived, forgiven, or deferred; and
e.	The individual or their spouse do not own assets that can be used to pay for the debt.

Earned Income 510-05-85-20
Language is added this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

4.	Calculating "self-employment" income:
a.	Self-employed individuals whose business does not require the purchase of goods for resale. Examples of this type of business include persons who provide childcare services in their own home, or qualified service providers (QSP's) (who are not employees of a home health agency) who provide HCBS. For example, those QSP's who receive payments from the Department. Such income may be accounted for on a monthly basis, or the income tax return from the previous year may be used if it reflects a full year’s operation. When the tax return is used, one-twelfth of the annual gross income is monthly earnings. The first 25% of the gross monthly earnings shall be disregarded to offset the cost of producing the income and will cover such things as additional food, utilities, supplies, etc. The remaining 75% of gross monthly earnings is the figure to which the appropriate earned income deductions are applied to arrive at monthly net income.
QSP rates change each July, and per policy at 510-05-85-05(1), all income which is available to a unit must be considered. The annual increase in the rate paid is a known increase, so must be taken into consideration when determining income. The daily rate the QSP is paid should be used.  It is important also to note that income tax returns filed by QSPs who are providing services to a family member may only include the income they are paid by the Department, and not the client share (recipient liability) amount that is applied toward the QSP bill (because they did not collect the client share ~~recipient liability~~ from their family member).  The client share ~~recipient liability~~ due the QSP is income they are paid in addition to that from the Department. The available income to the QSP must include the higher rate and any client share ~~recipient liability~~ amounts due them. The self-employment percentage disregard and earned income deductions can then be allowed from this total amount. As a result, all available income will be correctly counted. Following is an example:

Post Eligibility Treatment of Income 510-05-85-25
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

3.	In establishing the application of income to the cost of care, the following deductions are allowed in the following order:
a.	The appropriate nursing care or ICF-ID income level;
b.	Amounts provided to a spouse or family member for maintenance needs (this is the appropriate Medicaid income level for the spouse or family member, NOT alimony or child support);
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 client share (recipient liability) or was not previously allowed as a deduction or offset of client share ~~recipient liability~~;
ii.	Provided by a medical practitioner licensed to furnish the care;
iii.	Not subject to payment by any third party, including Medicaid and Medicare;
iv.	Not incurred for nursing facility services, swing bed services, or HCBS during a period of ineligibility because of a disqualifying transfer; and
v.	Claimed.
d.	The cost of Medicare and health insurance premiums. A health insurance premium may be deducted from income in the month the premium is paid or may be prorated and deducted from income in the months for which the premium affords coverage. For purposes of this deduction, premiums for health insurance include payments made for insurance, health care plans, or nonprofit health service plan contracts which provide benefits for hospital, surgical, and medical care, but do not include payments made for coverage which is:
i.	Limited to disability or income protection coverage;
ii.	Automobile medical payment coverage;
iii.	Supplemental to liability insurance;
iv.	Designed solely to provide payments on a per diem basis, daily indemnity, or nonexpense-incurred basis; or
v.	Credit accident and health insurance.
e.	The cost of long term care insurance premiums, for insurance carried by the recipient or the recipient’s spouse. The premium may be deducted from income in the month the premium is paid or prorated and deducted from income in the months for which the premium affords coverage.
f.	A deduction of payments made for services of a guardian or conservator may be made, up to a maximum deduction equal to five percent of countable gross monthly income excluding nonrecurring lump sum payments.
4.	Payments from any source, which are or may be received as a result of a medical expense or increased medical need, such as health or long-term care insurance payments, VA Aid and Attendance, VA homebound benefits intended for medical expenses, or VA reimbursements for unusual medical expenses, must be added to the remaining income to determine client share ~~recipient liability~~. 

Disregarded Income 510-05-85-30
Subsection 46 is added to reflect the change in policy to disregard the first $2,000 received by an individual age 19 and over as compensation for participation in some clinical trials meeting the requirements of Section 1612(b)(26) of the Social Security Act.

The following types of income must be disregarded in determining Medicaid eligibility:
46.    The first $2,000 received by an individual age 19 and over as compensation for participation in a clinical trial for rare diseases or conditions meeting the requirements of Section 1612(b)(26) of the Act.  This disregard is only allowed if approved by the Medicaid Eligibility Unit and will expire on October 5, 2015.

Income Deductions 510-05-85-35
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

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 client share (recipient liability), or was not previously allowed as a deduction or offset of client share ~~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 client share ~~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 client share ~~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.

Examples of expenses that can be used to reduce countable income and affect client share ~~recipient liability~~:
i.	Medications and services Medicaid does not pay for only because the provider is not enrolled;
ii.	*Over-the-counter medications that Medicaid does cover, such as Antacids (for stomach acid), analgesics (for pain), iron supplements (for anemia), artificial tears (for severe dry eye diseases).  Also, those payable because of rebates, such as Maalox and Advil. (Non-payable are Mylanta and CVS generics).  Medicaid covers drugs with a NDC code on the bottom of the bottle label.  (http://nddrug.rxexplorer.com/ND Dept. of Human Services is a website that workers may use to inquire whether ND Medicaid covers a specified drug.);
iii.	Other over-the-counter supplies that Medicaid covers, such as diabetic supplies;
iv.	Nicoderm patches;
v.	Drugs from Canada when prescribed by a US physician;
vi.	Co-pays; or
vii.	Transportation costs:
(a) Lodging up to the limit.  Hotels can bill the difference to the client if they stay at a hotel that charges more. (As with meals, we pay per diem and client can eat where they want.)
(b)  Allow the difference to reduce client share ~~recipient liability~~ if reasonable.  (If they choose to stay in a penthouse suite when other less costly rooms are available, not reasonable.)
(c) Transportation costs are not paid or allowed as a deduction if the medical services are available locally but client travels elsewhere, even if referred by a physician. The provider must be within the nearest service area, client has choice of providers.

Income Levels 510-05-85-40
This section is updated to reflect the change in the Federal Poverty Levels effective 04-01-12.

2.	Medically needy income levels.
Number of Persons | Monthly Income Level
1 | $ ~~754~~ 773
2 | ~~1018~~ 1047
3 | ~~1282~~ 1321
4 | ~~1546~~ 1595
5 | ~~1811~~ 1869
6 | ~~2075~~ 2143
7 | ~~2339~~ 2416
8 | ~~2603~~ 2690
9 | ~~2867~~ 2964
10 | ~~3132~~ 3238
Effective April 1, 2012 ~~2011~~
For each person in the medically needy unit above ten, add $274 ~~$265~~ to the monthly amount.
e.	Family member income level. The income level for each ineligible family member in a spousal impoverishment case is $~~613~~ 630 effective April 2012 ~~2011~~ ($613 effective April 2011 ~~$607 effective April 2009~~).

3.	Poverty income levels.
a.	Qualified Medicare Beneficiaries and Children age six to nineteen. The income level is equal to one hundred percent of the poverty level applicable to a family of the size involved.

Number of Persons | Monthly Income Level
1 | $  ~~908~~ 931
2 | ~~1226~~ 1261
3 | ~~1545~~ 1591
4 | ~~1863~~ 1921
5 | ~~2181~~ 2251
6 | ~~2500~~ 2581
7 | ~~2818~~ 2911
8 | ~~3136~~ 3241
9 | ~~3455~~ 3571
10 | ~~3773~~ 3901
Effective April 1, ~~2011~~  2012
For each person in the Medicaid unit above ten, add $ 330~~319~~ to the monthly amount.
b.	Specified Low-Income Medicare Beneficiaries. The income level is equal to one hundred twenty percent of the poverty level applicable to a family of the size involved. This is the maximum income level for SLMBs. Applicants or recipients who have income at or below one hundred percent of the poverty level are not eligible as a SLMB, but must be a QMB. These income levels apply regardless of living arrangements (i.e., in home or in a nursing facility. . .).
 
Number of Persons | Monthly Income Level
1 | $ ~~1089~~ 1117
2 | ~~1471~~ 1513
3 | ~~1853~~ 1909
4 | ~~2235~~ 2305
5 | ~~2617~~ 2701
6 | ~~2999~~ 3097
7 | ~~3381~~ 3493
8 | ~~3763~~ 3889
9 | ~~4145~~ 4285
10 | ~~4527~~ 4681
Effective April 1, 2012  ~~2011~~
For each person in the Medicaid unit above ten, add $ 396 ~~382~~ to the monthly amount.
c.	Pregnant women and children under age six. The income level is equal to one hundred and thirty-three percent of the poverty level, applicable to a family of the size involved. The family size is increased for each unborn when determining the appropriate family size.
Number of Persons | Monthly Income Level
1 | $ ~~1207~~ 1238
2 | ~~1631~~ 1677
3 | ~~2054~~ 2116
4 | ~~2478~~ 2555
5 | ~~2901~~ 2994
6 | ~~3324~~ 3433
7 | ~~3748~~ 3871
8 | ~~4171~~ 4311
9 | ~~4595~~ 4750
10 | ~~5018~~ 5189
Effective April 1, ~~2011~~ 2012
For each person in the Medicaid unit above ten, add $ 439 ~~424~~ to the monthly amount.
d.	Qualifying Individuals. The income level is equal to 135% of the poverty level applicable to a family of the size involved. This is the maximum income level for QIs. Applicants or recipients who have income at or below 120% of the poverty level are not eligible as a QI, but may be eligible as a SLMB or QMB. These income levels apply regardless of living arrangements (i.e., in home or in a nursing facility...).

Number of Persons | Monthly Income Level
1 | $  ~~1226~~ 1257
2 | ~~1655~~ 1703
3 | ~~2085~~ 2148
4 | ~~2515~~ 2594
5 | ~~2945~~ 3039
6 | ~~3374~~ 3485
7 | ~~3804~~ 3930
8 | ~~4234~~ 4376
9 | ~~4664~~ 4821
10 | ~~5093~~ 5267
Effective April 1, ~~2011~~ 2012
For each person in the Medicaid unit above ten, add $ 446 ~~430~~ to the monthly amount.
e.	
Transitional Medicaid Benefits. The income level is equal to one hundred and eighty-five percent of the poverty level applicable to a family of the size involved.

Number of Persons | Monthly Income Level
1 | $  ~~1679~~ 1723
2 | ~~2268~~ 2333
3 | ~~2857~~ 2944
4 | ~~3446~~ 3554
5 | ~~4035~~ 4165
6 | ~~4624~~ 4775
7 | ~~5213~~ 5386
8 | ~~5802~~ 5996
9 | ~~6391~~ 6607
10 | ~~6980~~ 7217
Effective April 1, ~~2011~~ 2012
For each person in the Medicaid unit above ten, add $ 611 ~~589~~ to the monthly amount.
f.	Workers with Disabilities.  The income level is equal to two hundred and twenty-five percent of the poverty level applicable to a family of the size involved.

Number of Persons | Monthly Income Level
1 | $  ~~2042~~ 2095
2 | ~~2759~~ 2837
3 | ~~3475~~ 3580
4 | ~~4191~~ 4322
5 | ~~4907~~ 5065
6 | ~~5624~~ 5807
7 | ~~6340~~ 6550
8 | ~~7056~~ 7292
9 | ~~7772~~ 8035
10 | ~~8489~~ 8777
Effective April 1, ~~2011~~  2012
For each person in the Medicaid unit above ten, add $ 743 ~~717~~ to the monthly amount.
g.	Children with Disabilities. The income level is equal to two hundred percent of the poverty level applicable to a family of the size involved.

Number of Persons | Monthly Income Level
1 | $ ~~1815~~ 1862
2 | ~~2452~~ 2522
3 | ~~3089~~ 3182
4 | ~~3725~~ 3842
5 | ~~4362~~ 4502
6 | ~~4999~~ 5162
7 | ~~5635~~ 5822
8 | ~~6272~~ 6482
9 | ~~6909~~ 7142
10 | ~~7545~~ 7802
Effective April 1, ~~2011~~ 2012
For each person in the Medicaid unit above ten, add $ 660 ~~637~~ to the monthly amount.

Deeming of Income 510-05-85-50
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

1.	An ineligible Medicaid unit in the home is allowed a disregard of seventy-five percent of their excess income when determining client share (recipient liability) for an eligible recipient residing in a specialized facility. The excess income may be deemed to a non-SSI recipient in a specialized facility to bring the individual’s income up to the medically needy income level for one. Any remaining income becomes client share ~~recipient liability~~ for the individual in the specialized facility. The 75% disregard applies during any full calendar month in which the recipient resides in a specialized facility.
Excess income of an eligible Medicaid unit in the home may be deemed to a non-SSI recipient in a specialized facility to bring the individual’s income up to the medically needy income level for one. Any remaining income becomes client share ~~recipient liability~~ for the individual in the specialized facility and becomes client share ~~recipient liability~~ for any other medically needy recipients in the Medicaid unit.
Refer to subsection 3 of 05-85-45 for instructions for the month the individual enters or leaves the facility.

Client Share (Recipient Liability) 510-05-85-55
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

Client Share (Recipient Liability)is the amount of monthly net income remaining after all appropriate deductions, disregards, and Medicaid income levels have been allowed. All such income must be considered to be available for payment of medical services provided to the eligible individual or family.

Offset of Client Share (Recipient Liability) 510-05-85-60
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

1.	Up to fifteen dollars per month of expenses for necessary medical or remedial care, incurred by a member of the Medicaid unit, or a spouse or child they were legally responsible for, in a month prior to the month for which eligibility is being determined, may be subtracted from client share (recipient liability), other than client share ~~recipient liability~~ created as a result of medical care payments, to determine remaining client share ~~recipient liability~~, provided that:
a.	The expense was incurred in a month during which the individual who received the medical or remedial care was not a Medicaid recipient or the expense was incurred in a month the individual was a Medicaid recipient, but was for a service not covered by Medicaid;
b.	The expense was not previously applied in determining eligibility for, or the amount of, Medicaid benefits for any Medicaid recipient;
c.	The medical or remedial care was provided by a medical practitioner licensed to furnish the care;
d.	The expense is not subject to payment by any third party, including Medicaid and Medicare;
e.	The expense was not incurred for swing bed services provided in a hospital, nursing facility services, or HCBS during a period of ineligibility because of a disqualifying transfer;
f.	Each expense claimed for subtraction is documented by the applicant or recipient in a manner which describes the service, the date of the service, the amount of the cost incurred, the amount of the cost remaining unpaid, the amount of the cost previously applied in determining Medicaid benefits for any Medicaid recipient, and the name of the service provider; and
g.	The Medicaid unit is still obligated to pay the expense.
2.	The Medicaid unit must apply the remaining client share ~~recipient liability~~ to expenses of necessary medical care incurred by a member of the Medicaid unit in the month for which eligibility is being determined. The Medicaid unit is eligible for Medicaid benefits to the extent the expenses of necessary medical care incurred in the month for which eligibility is being determined exceed remaining client share ~~recipient liability~~ in that month.
 
Budgeting 510-05-90
Definitions 510-05-90-05
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

1.	For purposes of this section:
a.	"Base month" means the calendar month prior to the processing month.
b.	"Benefit month" means the calendar month for which eligibility and client share (recipient liability) is being computed.
c.	"Best estimate" means an income, expense, or circumstance prediction based on past amounts of income and expenses and known factual information concerning future circumstances which affect eligibility, expenses to be incurred; or income to be received in the benefit month. Factual information concerning future circumstances must be based on information by which the applicant or recipient demonstrates known changes or highly probable changes to the income, expense, or circumstances which offset eligibility, from the base month to the benefit month.
d.	"Processing month" means the month between the base month and the benefit month.
e.	"Prospective budgeting" means computation of a household's eligibility and client share ~~recipient liability~~ based on the best estimate of income, expenses, and circumstances for a benefit month.

Computing Client Share (Recipient Liability) 510-05-90-20
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

1.	Computing client share (recipient liability) for previous month. Compute the amount of client share ~~recipient liability~~ by use of actual verified information, rather than best estimate, in each of the previous months for which eligibility is sought.
2.	Computing client share ~~recipient liability~~ for the current month and next month at time of approval of the application. Compute the amount of the client share ~~recipient liability~~ prospectively for the current month and the next month. The income received or best estimate of income to be received during the current month must be used to compute the client share ~~recipient liability~~ for the current month. The best estimates of income to be received during the next month must be used to compute the client share ~~recipient liability~~ for the next month.
3.	Computing client share ~~recipient liability~~ for ongoing cases.
a.	For cases with fluctuating income (monthly reporting), compute the client share ~~recipient liability~~ using verified income, expenses, and circumstances which existed during the base month, unless factual information concerning future circumstances is available. Recipients must report their income, expenses, and other circumstances on a monthly basis to determine continued eligibility.
When a case is required to report monthly, there is no requirement to use a specific reporting form. A report form, however, will be sent to the recipient each month as a tool and reminder for them to report. The county agency has the flexibility to determine whether a case must report monthly.
b.	For cases with stable income (non-monthly reporting), compute the client share ~~recipient liability~~ using the best estimate of income, expenses, and circumstances. Recipients with stable income must report changes in income, expenses, and other circumstances within ten days of the day they became aware of the change. A determination of continued eligibility, after a change is reported and demonstrated, is based on a revised best estimate, which takes the changes into consideration.
Non-monthly reporting cases may be given a change report form that they can use to report changes. This form is not required to be used by the client but is provided as a tool.
 
Budgeting Procedures for Financially Responsible Absent Parents 510-05-90-23
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

3.	If the parent's unit fails the poverty level budget, compute a medically needy budget. All excess income (client share (recipient liability)) from the medically needy budget is considered unearned income for the child and is used in the child's budget.

Budgeting Procedures for Pregnant Women 510-05-90-25
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

When a pregnant woman, whose pregnancy has been medically confirmed, becomes eligible for Medicaid, she continues eligible, without regard to any increase in income of the Medicaid unit, for sixty days after the day her pregnancy ends, and for the remaining days of the month in which the sixtieth day falls. Decreases in income, however, will be considered to further reduce any client share (recipient liability). Likewise, a pregnant woman can move from one coverage type to another (e.g. from Family Coverage to poverty level); however, if poverty level eligible and income increases, the pregnant woman remains poverty level eligible. All other Medicaid eligibility factors continue to apply.
 
Budgeting Procedures When Adding and Deleting Individuals 510-05-90-30
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

1.	Budgeting procedures used when adding individuals to an eligible unit. Individuals may be added to an eligible unit up to one year prior to the current month, provided the individual meets all eligibility criteria for Medicaid, the eligible unit was eligible in all of the months in which eligibility for the individual is established, and the individual was in the unit in the months with respect to which eligibility for that individual is sought. Client share (recipient liability) will be based on the unit's actual income and circumstances when adding each individual for retroactive periods.   Client share ~~recipient liability~~ must be based on the unit's income and circumstances from the base month, plus the best estimate of each individual's income and circumstances when adding each individual to the current or next month.
Cient share ~~recipient liability~~ for other individuals in the Medicaid unit who were medically needy eligible may increase or decrease with the addition of the new member. Any client share ~~recipient liability~~, or lack of, applied to previously paid claims will not be adjusted; however, the new client share ~~recipient liability~~  will be applied to any claims billed in the future. 
Other individuals in the Medicaid unit who were previously determined to be poverty level eligible remain poverty level eligible, regardless of any income change, when adding an individual to the unit.

Budgeting Procedures for Stepparents 510-05-90-35
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

Under North Dakota law, a stepparent has no legally enforceable obligation to support stepchildren. Therefore, the stepparent's own personal income and assets cannot be considered available in determining Medicaid eligibility for the stepchildren. The natural parent, however, is legally responsible for supporting the children. The income of the natural parent cannot be first applied to the children if by doing so other members of the family are deprived of basic necessities. To determine eligibility when both the stepparent and natural parent have income, the county agency must first apply the stepparent's net income against the appropriate income level for the stepparent, spouse and the stepparent's children or children born of this marriage. If the stepparent's income is adequate to meet their needs, the natural parent's net income may then be considered in relation to the needs of the children for whom application is being made. If the stepparent has no income, or if it is sufficient to meet only a portion of the needs of those for whom he is legally responsible, the natural parent's net income shall first be allocated to the remaining unmet needs of those persons (that he or she is legally responsible for) before being considered available to the children in determining client share (recipient liability).

Budgeting Procedures for SSI Recipients 510-05-90-45
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

3.	SSI recipients living in a specialized facility: All income is normally considered by the Social Security Administration in determining the SSI benefit amount.  There are situations, however, when the Social Security Administration may be unaware of income.  In such cases, the county agency must take the necessary steps to insure that the individual is eligible for SSI if all income is considered before certifying the individual as categorically eligible for Medicaid.
If the individual is under 18 years of age and enters the specialized facility from a public institution or the parental home, consider the income of the individual and parents. If the Medicaid unit in the home is not receiving Medicaid, 75% of the excess income shall be disregarded in determining client share (recipient liability).
If the individual is married, the income of the individual and of the spouse must be considered. If the Medicaid unit in the home is ineligible, a disregard of 75% of the excess income is allowed in determining client share ~~recipient liability~~.

Budget Procedures for Medically Needy and Poverty Level 
510-05-90-55
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.

3.	Recipients living in a specialized facility: The recipient is allowed the medically needy income level for one. The members of the Medicaid unit remaining in the home are allowed the appropriate income level.
If the individual is under age 21, or if blind or disabled under age 18, and enters the specialized facility from a public institution or the parental home, consider the income of the individual and parents.
If the individual is married, the income of the individual and of the spouse must be considered. If the Medicaid unit in the home is not receiving Medicaid, 75% of the excess income shall be disregarded in determining client share (recipient liability).
If the individual in the specialized facility is eligible for SSI, do not deem income from the Medicaid unit at home to the individual because the maintenance needs are considered to be met.
If the individual in the specialized facility is not eligible for SSI and has no source of income or insufficient income, the family at home may deem income to the individual up to the medically needy income level for one.
Remedial services provided in a specialized facility cannot be paid through Medicaid, but can be allowed as a deduction. Remedial services are determined by subtracting the medically needy income level for one from the recipient’s remedial cost of care at the specialized facility. The resulting amount is deducted from the individual's income to determine client share ~~recipient liability~~. If the actual remedial expense is less than the calculated amount, use the actual amount.

Budgeting Procedures for Continuous Eligibility for Children Under Age 19 510-05-90-75
This section documents the change in Medicaid terminology from ‘redetermination’ to ‘review’ and from ‘recipient liability’ to ‘client share’.

1.	When a child becomes continuously eligible for Medicaid, that child continues to be eligible without regard to any changes in income and/or expenses of the Medicaid unit until the next review r~~edetermination~~. Likewise, a continuously eligible child can move from one coverage category to another (e.g. Foster Care to Poverty Level); however, if PL eligible and income increases to above PL, the child remains PL eligible until the end of their continuous eligibility period.

2.	For a continuously eligible child residing in a nursing facility, 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 and excess income becomes client share (recipient liability).

Refugee Medical Assistance Program 510-05-95-20
Language is added to this section to recognize the change in Medicaid terminology from ‘recipient liability’ to ‘client share’.
	
1.	The Refugee Medical Assistance Program is a program designed to cover Medical expenses for unaccompanied minors and other legally admitted refugees who are not eligible for Medicaid or Healthy Steps. Medicaid receives 100% federal funding for Refugee Medical Assistance (RMA).
2.	Refugees and unaccompanied minors who meet all Medicaid eligibility criteria, including need, must be enrolled in Medicaid instead of the Refugee Medical Assistance Program. Similarly, refugee children and unaccompanied minors who are eligible for Healthy Steps are processed under that program prior to considering Refugee Medical Assistance.
When a refugee or unaccompanied minor does not meet the technical requirements to be eligible for Medicaid and has no medical "need" which equals or exceeds client share (recipient liability), and is not eligible for Healthy Steps the individual can be enrolled in Refugee Medical Assistance.
3.	Refugee Medical Assistance is available during the first eight months a refugee is in this country , the first eight months after an asylee has been granted asylum, or longer if an unaccompanied minor.  
a.	Unaccompanied minors are not limited to the eight-month refugee time limit, but can remain eligible under the unaccompanied minor coverage until age 21. Children age 18-21 must be attending school full time.
b.	The date an asylee is granted asylum (regardless of the actual date of entry) is considered the date the asylee entered the country and is the first month of the eight-month period.
c.	When any other refugee has been in this country for eight months, Refugee Medical Assistance ends. Refugees who want continued medical coverage must have their eligibility determined under the Medicaid or Healthy Steps programs.
4.	Eligibility for Refugee Medical Assistance is determined using medically needy income and asset methodologies and limits, except:
a.	Refugees who receive a refugee cash assistance payment (currently administered through Lutheran Social Services) and are not eligible for traditional Medicaid or Healthy Steps are eligible for Refugee Medical Assistance without regard to any other eligibility tests;
b.	Refugees who become eligible for Refugee Medical Assistance continue eligible without regard to increases in earned income until the end of the eight-month period; and
c.	Refugees who lose Medicaid during the first eight months in the country due to increased earnings are transferred to Refugee Medical Assistance without an eligibility test. Their earned income will not affect their Refugee Medical Assistance for the remainder of the 8-month period.
5.	A refugee who has income above the medically needy income level will have a client share ~~recipient liability~~.  Because increases in income do not affect eligibility, the client share ~~recipient liability~~ will remain the same for the duration of the Refugee Medical Assistance coverage, except that the client share ~~recipient liability~~ can decrease if income decreases or expenses increase.  

North Dakota Health Tracks
Sections under the North Dakota Health Tracks subsection are updated as indicated in red as follows:

General Information
The definition of ‘Medically necessary’ is reworded to provide clarification.

* “Medically necessary” is defined as ~~: A~~  acovered service or item ~~can be defined as “medically necessary”~~ if it will do, or is reasonably expected to do, one or more of the following:

~~Persons~~ Categories of Eligibles ~~for Health Tracks~~
This subsection is renamed and punctuation is added as appropriate.

There are three groups of individuals who may be eligible for Health Tracks:
1.	Children and adolescents under age 21 who are eligible for Medicaid.
~~2.~~	~~TANF children –~~ Temporary Assistance for Needy Families (TANF) children are those who qualify based on criteria for assistance to low-income families.
~~3.~~	~~Foster children –~~ Foster children are those who are placed in alternative care ~~protective services~~ because they cannot remain at home. These children may have experienced neglect or abuse in the home and are generally placed with a substitute family.
 
The following section has been moved from another section.

Frequency of Screenings:
 
SUGGESTED SCHEDULE OF SCREENINGS:
BRIGHT FUTURES GUIDELINES
 
| Newborn | 1 Year | 6 Years | 13 Years
| 2 to 5 days | 15 Months | 7 Years | 14 Years
| 1 Month | 18 Months | 8 Years | 15 Years
| 2 Months | 2 Years | 9 Years | 16 Years
| 4 Months | 3 Years | 10 Years | 17 Years
| 6 Months | 4 Years | 11 Years | 18 Years
| 9 Months | 5 Years | 12 Years | 19 Years
| | | | 20 Years

Forms have been combined and identified as required or as needed.

REQUIRED FORMS

1.	ND Health Tracks (Healthy Children Right from the Start) Brochure – used by eligibility staff – for outreach
2.	SFN 1818 – MCH/Health Tracks Health History (Regional & County)
3.	SFN 1819 – MCH/Health Tracks Pediatric Assessment (Regional)
4.	SFN 871 – Health Tracks Results (for parents) (Regional)
5.	SFN 710 – Referral and Request for Information (Regional and County)

“AS NEEDED” FORMS

1.	SFN 1059 – Authorization to Disclose Information 
2.	SFN 705 – Appointment Slip
3.	Appointment Log (Developed by each County)

Click on the links to access the forms. 
The Health Tracks Procedures subsections have been rewritten as follows:
~~Health Tracks Procedures – Informing~~
~~Informing eligibles is done by the individual’s eligibility worker and/or the service worker.~~
 
~~The SFN 502 and SFN 405 forms have information regarding Health Tracks and inform the client up-front of the availability of the Health Tracks program for those applying for Medicaid and TANF.~~
 
~~FORMS~~
~~1.~~	~~SFN 502 – Healthcare Coverage Application~~
~~2.~~	~~SFN 405 – Application for Assistance~~
 
~~HEALTH TRACKS BROCHURE~~
 
~~PROCEDURES~~
~~1.~~	~~Worker informs ALL Medicaid eligible individuals (or their families) about the Health Tracks program providing a combination of written and oral methods.~~
~~2.~~	~~Route all Health Tracks referrals to the designated Health Tracks services worker within 3 days of determination date.~~
Procedures

I.	INFORMING – ELIGIBILITY WORKER AND / OR SERVICE WORKER
MUST occur at intital application and at annual review.
A.	PROCEDURES
1.	The Health Tracks information window must be set to ‘yes’ at initial application and again at annual review.
2.	Worker must print off the Health Tracks referral sheet at initial application and at the annual review.
3.	Route all Health Tracks referrals to the designated Health Tracks services worker within three days of determination date. 
4.	Worker must inform ALL Medicaid eligible individuals (or their families) about the Health Tracks program.
5.	Oral communication must occur between the worker and the individual (or their families) about the Health Tracks program. This communication may include phone calls or during a face to face interview, if applicable.
6.	Contact the parent/recipient as soon as possible; this contact must be within 60 days of the receipt of the Health Tracks Referral. The worker may use the referral as a documentation form to note progress.
a.	During this contact the worker should explain the benefits of Health Tracks:
i.	Immunizations
ii.	Vision – glasses
iii.	Dental
iv.	Orthodontia (teeth braces)
v.	Mental health screening
vi.	Lead screening
vii.	Hearing aids
viii.	Developmental screening
ix.	Fluoride varnish
x.	Maternal Depression Screening for mothers of newborns.
b.	If the family wishes to schedule a Health Tracks screening, schedule immediately or inform families of other local Health Tracks screening sites in the area.  
i.	local public health
ii.	Primary Care Providers 
iii.	Clinics
iv.	Hospitals

c.	Complete the screening within 90 days of the receipt of the referral.  The worker should document on the Health Tracks referral form if the time limit was NOT met and the reason.

d.	If the family requests assistance, the worker should set up a time to complete the Health History SFN 1818, either by phone, mail, or personal appointment.  If the family does not request assistance with filling out the Health History, encourage them to have the form completed prior to the appointment and remind them to bring the form with them to their Health Tracks appointment.  If the child’s caretaker does not have legal custody, attempts should be made to reach the legal custodian or natural parents for the information and signatures required. 
 
e.	Remind families to bring immunization records with for their children, especially those who have moved here from another state.
7.	If the parent/recipient, upon contact, verbally indicates they are no longer interested in the screening, the worker should document this on the Health Tracks Referral and destroy the form after one year.  The parent/recipient must indicate each year if they are interested in a Health Tracks screening.
8.	For TANF participants: Discuss the choice of screening provider with participant; verify if the child’s (ren’s) primary care provider (PCP) is a Health Track screening provider. The family has a choice to schedule a screening appointment with their PCP or local Public Health screener. The participant is responsible for completing a screening within the prescribed time frame.  The worker should document on the TANF referral if the time limit was not met due to a scheduling problem with the chosen provider.
9.	For Medicaid only families - if contact cannot be made after at least two attempts (one written and one oral), the worker should document the attempts on the referral and keep the referral for one year.
B.	Materials that must be given to the applicant: 
1.	SFN 405 – Application for Assistance Guidebook
2.	Health Tracks Brochure

II.	PROCEDURES PRIOR TO THE SCHEDULED SCREENING APPOINTMENT

A.	Discuss transportation needs and document on the Health Tracks Referral.  If transportation is needed, assist parent with arranging for public transit or other methods.
B.	If county schedules Health tracks screenings, Complete an appointment slip and/or call or mail a reminder to the parent/recipient, unless this process is completed by the provider.
C.	Five days prior to the screening appointment, verify the current eligibility status of the scheduled recipient for screening, if requested by the provider. (Always verify eligibility in the month the screening occurs.)
D.	Route the following to the regional coordinator five business days prior to the screening:
1.	Appointment Log, if completed by county worker
2.	Health History, if available
3.	Immunization Record, if available

III.	Follow-up FOR Diagnosis and Treatment Procedures
Follow-up is a very important part of the health tracks program.
COMPLETED by Social Worker or other staff, as assigned by the county director.
A.	Procedures after screening:
1.	Upon receipt of MCH/Health Tracks Pediatric Assessment SFN 1819 – The results of the screening received from the regional coordinator or completed by the worker and nurse, should be reviewed for a diagnosis and treatment referral plan.
2.	Initiate follow-up of referrals as soon as possible by:
a.	Sending SFN 710 – If this is not previously completed, the Referral and Request for Information form should be sent to providers with whom an appointment has been made. If possible, this should be done prior to the appointment.
*Reminder: It is essential to know if the case is currently open. This prevents non-eligible recipients from being referred for treatment.
3.	Update the SFN 1059 - Authorization to Disclose, adding new non-medical providers who will receive the SFN 710 (Referral and Request for Information).
4.	Follow-up with the short (ear infection) and long-term (orthodontics) diagnosis and treatment referrals to insure initial appointments are completed, generally within 60 days of screening date.
5.	Document all case activity on the Health Tracks Referral form or by some other method of reporting.
6.	Cases are never “closed” unless recipient becomes ineligible for the Medicaid program. Discontinuation of follow up of referrals may end after the verification of the initial follow-up appointment.
7.	Transfer copies of the pertinent screening information to other counties within the state, if the service worker is asked by the recipient or other county personnel to transfer records. All screening results are considered confidential medical records and may not be released unless the recipient gives permission by using the Authorization to Disclose Information form. 

8.	Records Retention
a.	Retain records in office for one year, then dispose:
i.	EPSDT General Correspondence
ii.	Meeting Minutes
b.	Retain records in office for two years, then dispose:
i.	Monthly Reports
c.	Follow individual agency policies on record retention and destruction:
i.	Public Health and County Social Services

~~Health Tracks Procedures – Intake~~
~~The service worker or other staff assigned by the county director do intake.~~
 
~~FORMS~~
~~1.~~	~~SFN 710 --  Health Tracks Referral~~
~~2.~~	~~SFN 1818 – Health Record – Initial request for screening~~
~~3.~~	~~SFN 1059 – Authorization to Disclose Information * if   appropriate~~
~~4.~~	~~Appointment Log~~
 
~~PROCEDURES~~
~~1.~~	~~Contact the parent/recipient as soon as possible, must be within 60 days of the receipt of the Health Tracks Referral. May use the referral as a documentation form to note progress.~~
~~a.~~	~~Explain what Health Tracks offers~~
~~b.~~	~~Set up a time to complete the Health Record, either by phone, mail, or personal appointment. May want to schedule actual screening appointment immediately and arrange to have health record completed at the screening site; or have recipient mail or bring to screening.~~
~~c.~~	~~Request immunization records for children prior to screening if parent/guardian is unable to secure records by the screening appointment.~~
~~*Screening appointment must be completed within a 90-day time frame. If the time limit is exceeded, the reason must be noted on the Health Tracks Referral.~~
~~2.~~	~~If the parent/recipient, upon contact, verbally indicates they are no longer interested in the screening, service worker documents on the Health Tracks Referral and destroys the form after one year.~~
~~3.~~	~~For TANF Participants: Discuss the choice of screening provider with participant; verify if the child’s (ren’s) primary care physician (PCP) is a Health Track screening provider. The family has a choice to schedule a screening appointment with their PCP or local Public Health screener. The participant is responsible for completing screening within the prescribed time frame. Document on the TANF referral if the time limit was not met due to a scheduling problem with the chosen provider.~~
~~4.~~	~~For Medicaid only families -- if contact cannot be made after at least 2 attempts (one written), document the attempts on the referral; keep referral for one year.~~
 
~~Health Tracks Procedures – Prior to the scheduled Screening – Public Health Screener~~
~~1.~~	~~COMPLETE THE HEALTH RECORD within 90 days of receipt of referral. Obtain health record information from the natural parent(s) whenever possible. If the child’s caretaker does not have legal custody, attempts should be made to reach the legal custodian or natural parents for the information and signatures.~~
~~2.~~	~~DISCUSS TRANSPORTATION NEEDS AND DOCUMENT on the Health Tracks Referral.~~
~~3.~~	~~ARRANGE A SCREENING APPOINTMENT and complete the screening within 90 days of the receipt of the referral.~~
~~4.~~	~~COMPLETE AN APPOINTMENT SLIP and/or call or mail a reminder to the parent/recipient.~~
~~5.~~	~~ROUTE THE FOLLOWING TO THE REGIONAL COORDINATOR five business days prior to the screening:~~
~~a.~~	~~Appointment Log~~
~~b.~~	~~Health Record~~
~~c.~~	~~Attached Immunization Record, if available~~
 
~~*REMINDERS:~~
~~•~~	~~One to three days prior to screening appointment, verify current eligibility status of recipient scheduled for screening. (Verify Eligibility Phone #: 1-800-428-4140)~~
~~•~~	~~Remind parent/recipient of screening appointment.~~
 
~~Health Tracks Procedures –Follow-up Diagnosis and Treatment~~
~~Follow-up Diagnosis and treatment is done by the Social Worker or other staff, as assigned by the county Director.~~
 
~~FORMS:~~
~~1.~~	~~SFN 1059 – Authorization to Disclose Information~~
~~2.~~	~~SFN 1819 – MCH/Health Tracks Assessment~~
~~3.~~	~~SFN 710 – Referral and Request for Information~~
 
~~PROCEDURES AFTER SCREENING:~~
~~1.~~	~~Upon receipt of SFN 1819 – Results of screening received from the regional coordinator or completion by worker and nurse, review the diagnosis and treatment referral plan.~~
~~2.~~	~~Initiate follow-up of referrals as soon as possible by:~~
~~Sending SFN 710 – If not previously completed, Referral and Request for Information should be sent to providers with whom an appointment has been made. If possible, this should be done prior to the appointment.~~
 
~~*REMINDER: It is essential to know if the case is currently open. This prevents non-eligibles from being referred for treatment.~~
~~3.~~	~~Update the SFN 1059 - Authorization to Disclose, adding new non-medical providers who will receive the SFN 710 (Referral and Request for Information).~~
~~4.~~	~~Follow-up with short (ear infection) and long-term (orthodontics) diagnosis and treatment referrals to insure initial appointments are completed, generally within 60 days of screening date.~~
~~5.~~	~~Document all case activity on the Health Tracks Referral Form or other method.~~
~~6.~~	~~Cases are never “closed” unless recipient becomes ineligible for the Medicaid program. Discontinuation of follow up of referrals may end after the verification of the initial follow-up appointment.~~
~~7.~~	~~Transfer copies of pertinent screening information to other counties within the state, if the service worker is asked by the recipient or other county personnel to transfer records. All screening results are considered confidential medical records and may not be released unless the recipient gives permission. Dates and place of a screening may be released without permission of the recipient.~~
~~3.~~	~~Frequency of Screenings:~~
 
~~SUGGESTED SCHEDULE OF SCREENINGS:~~
~~BRIGHT FUTURES GUIDELINES~~
 
| ~~Newborn~~ | ~~1 Year~~ | ~~6 Years~~ | ~~13 Years~~
| ~~2 to 5 days~~ | ~~15 Months~~ | ~~7 Years~~ | ~~14 Years~~
| ~~1 Month~~ | ~~18 Months~~ | ~~8 Years~~ | ~~15 Years~~
| ~~2 Months~~ | ~~2 Years~~ | ~~9 Years~~ | ~~16 Years~~
| ~~4 Months~~ | ~~3 Years~~ | ~~10 Years~~ | ~~17 Years~~
| ~~6 Months~~ | ~~4 Years~~ | ~~11 Years~~ | ~~18 Years~~
| ~~9 Months~~ | ~~5 Years~~ | ~~12 Years~~ | ~~19 Years~~
| | | | ~~20 Years~~

Par. 2.  Effective Date -- This manual letter is effective for the benefit month of April 2012.

Carol K. Olson, Executive Director	                                                              Manual Letter # 3321
North Dakota Department of Human Services	Page  of  Pages