reglab/statecodes huggingface dataset:
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-10.3 - Partial hospitalization psychiatric services

Current through Supplement No. 393, July, 2024
1. For purposes of
				this section:
a. "Level A" means an intense
				level of partial hospitalization psychiatric services which provide treatment
				for an individual by at least three licensed health care professionals under
				the supervision of a licensed physician for at least four hours and no more
				than eleven hours per day for at least three days per week.
b. "Level B" means an intermediate level of
				partial hospitalization psychiatric services which provide treatment for an
				individual by at least three licensed health care professionals under the
				supervision of a licensed physician for three hours per day for at least two
				days per week.
c. "Partial
				hospitalization psychiatric services" means level A or level B services
				provided to an individual with an impairment resulting from a psychiatric,
				emotional, or behavior disorder which are provided by a multidisciplinary team
				of health care professionals and are designed to stabilize the health of the
				individual with the intent to avert inpatient hospitalization or to reduce the
				length of a hospital stay.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-11 - Coordinated services

Current through Supplement No. 393, July, 2024
1. For purposes of
				this section:
a. "Coordinated services" means
				the process used to limit a recipient's medical care and treatment to a single
				physician or other provider to prevent the continued misutilization of
				services.
b. "Coordinated services
				provider" means a physician, nurse practitioner, physician assistant, or Indian
				health service or tribal health facility or clinic selected by the coordinated
				services recipient to provide care and treatment to the recipient. The selected
				coordinated services provider is subject to approval by the
				department.
c. "Misutilization"
				means the incorrect, improper, or excessive utilization of medical services
				which may increase the possibility of adverse effects to a recipient's health
				or may result in a decrease in the overall quality of care.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-12 - Limitations on emergency room services

Current through Supplement No. 393, July, 2024
1.
				For purposes of this section, "screening" means the initial evaluation of an
				individual, intended to determine suitability for a particular medical
				treatment modality.
2. The provider
				of emergency services shall assure that a recipient is referred to the
				appropriate health delivery setting, including the recipient's enrolled
				in-state provider, when emergency room services are not judged to be
				appropriate.
3. Payment for
				emergency room services.
a. Claims for
				payment, and documentation in support of those claims, must be submitted on
				forms prescribed by the department. The claim must contain sufficient
				documentation to indicate that a medical emergency required emergency room
				diagnostic services and treatment.
b. Except as provided in subsection 4,
				providers must be paid for any medically necessary services.
c. Except as provided in subsection 4,
				providers must be paid for screening or examination services
				rendered.
d. Providers must be paid
				for services rendered to recipients who reside outside of the provider's
				regular service area and who do not normally utilize the provider's
				services.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-13 - Limitations on out-of-state care

Current through Supplement No. 393, July, 2024
1. For
				purposes of this section:
a. "Out-of-state
				care" means care or services furnished by any individual, entity, or facility,
				pursuant to a provider agreement with the department, at a site located more
				than fifty statute miles [80.45 kilometers] from the nearest North Dakota
				border.
b. "Out-of-state provider"
				means a provider of care or services that is located more than fifty statute
				miles [80.45 kilometers] outside of North Dakota. An out-of-state provider may
				be an individual or a facility but may not be located outside of the United
				States.
c. "Specialist" means a
				physician board certified in the required medical specialty who regularly
				practices within North Dakota or at a site within fifty statute miles [80.45
				kilometers] from the nearest North Dakota border.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-13.1 - Travel expenses for medical purposes - Limitations

Current through Supplement No. 393, July, 2024
1. For purposes of this section, "travel
				expenses" means fares, mileage, meals, lodging, and driver and attendant
				care.
2. General requirements.
a. A transportation service provider shall be
				enrolled as a provider in the Medicaid program and children's health insurance
				program and may be an individual, a taxi, a bus, a food service provider, a
				lodging provider, an airline service provider, a travel agency, or another
				commercial form of transportation.
b. The department or human service zone may
				determine and authorize the most efficient, economical, and appropriate means
				of travel to meet the medical needs of the recipient.
c. The cost of travel provided by a parent,
				spouse, or any other member of the recipient's Medicaid unit, as defined in
				section 75-02-02.1-08, may be allowed as
				an expense of necessary medical or remedial care for recipient liability
				purposes, unless the parent, spouse, or any other member of the recipient's
				Medicaid unit is enrolled as a transportation provider. A parent, spouse,
				friend, household member, or family member of the recipient may be paid as an
				enrolled provider for transportation for that recipient. An individual who
				provides foster care, kinship, or guardianship may enroll as a transportation
				provider and is eligible for reimbursement to transport a Medicaid-eligible
				child to and from Medicaid-eligible medical appointments in situations in which
				the Medicaid-eligible child's medical needs exceed ordinary, typical, and
				routine levels. A guardian of a vulnerable adult may enroll as a transportation
				provider and is eligible for reimbursement to transport a Medicaid-eligible
				adult, for whom the guardian has been court-ordered to provide guardianship
				services, to and from Medicaid-covered medical appointments.
d. Emergency transport by ambulance is a
				covered service when provided in response to a medical emergency.
e. Nonemergency transportation by ambulance
				is a covered service only when medically necessary and ordered by the attending
				licensed provider.
f. A recipient
				may choose to obtain medical services outside the recipient's community. If
				similar medical services are available within the community and the recipient
				chooses to seek medical services elsewhere, travel expenses are not covered
				services and are the responsibility of the recipient.
g. If a provider refers a recipient to a
				facility or provider that is not located at the closest medical center, travel
				expenses may not be covered services and are the responsibility of the
				recipient, unless special circumstances apply and prior authorization is
				secured.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-13.2 - Travel expenses for medical purposes - Individuals in an institution - Limitations

Current through Supplement No. 393, July, 2024
1. For purposes of
				this section:
a. "Long-term care facility"
				means a nursing facility, intermediate care facility for individuals with
				intellectual disabilities, or swing-bed facility; and
b. "Medical center city" means Bismarck,
				Devils Lake, Dickinson, Fargo, Grand Forks, Jamestown, Minot, and Williston,
				and includes any city that shares a common boundary with any of those
				cities.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-15 - Groups covered

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-16 - Basic eligibility factors

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-17 - Blindness and disability

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-18 - Financial eligibility

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-19 - Income and resource considerations

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-20 - Income levels and application

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-21 - Property resource limits

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-22 - Exempt property resources

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-23 - Excluded property resources

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-24 - Contractual rights to receive money payments

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-25 - Disqualifying transfers

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-26 - Eligibility under 1972 state plan

Current through Supplement No. 393, July, 2024
Repealed effective December 1, 1991, unless chapter
				  75-02-02.1 is appealed pursuant to section 27 of 1991 House Bill No. 1194 and
				  is not affirmed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-27 - Scope of drug benefits - Prior authorization

Current through Supplement No. 393, July, 2024
1. Prior authorization means a process
				requiring the prescriber or the dispenser to verify with the department or the
				department's contractor that proposed medical use of a particular drug for a
				Medicaid program or children's health insurance program recipient meets
				predetermined criteria for coverage by the Medicaid program or children's
				health insurance program.
2. A
				prescriber or a dispenser must secure prior authorization from the department
				or its designee as a condition of payment for those drugs subject to prior
				authorization.
3. A prescriber or a
				dispenser must provide to the department or its designee in the format required
				by the department the data necessary for the department or its designee to make
				a decision regarding prior authorization. The department shall deny a claim for
				coverage of a drug requiring prior authorization if the prescription was
				dispensed prior to authorization or if the required information regarding the
				prior authorization is not provided by the prescriber or the
				dispenser.
4. A prescriber or
				dispenser must submit a request for prior authorization to the department or
				its designee by telephone, facsimile, electronic mail, or in any other format
				designated by the department. The department or its designee must respond to a
				prior authorization request within twenty-four hours of receipt of a complete
				request that contains all of the data necessary for the department to make a
				determination.
5. Emergency supply.
a. If a recipient needs a drug before a
				prescriber or dispenser can secure prior authorization from the department, the
				department shall provide coverage of the lesser of a five-day supply of a drug
				or the amount prescribed if it is not feasible to dispense a five-day supply
				because the drug is packaged in such a way that it is not intended to be
				further divided.
b. The department
				will not provide further coverage of the drug beyond the five-day supply unless
				the prescriber or dispenser first secures prior authorization from the
				department.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-28 - Drug use review board and appeals

Current through Supplement No. 393, July, 2024
1.
				The department shall implement a prospective and retrospective drug use review
				program for outpatient prescription drugs and determine which drugs shall be
				subject to prior authorization before payment will be approved. The department
				shall consider the advice and recommendations of the drug use review board
				before requiring prior authorization of any drug.
2. The drug use review board shall:
a. Cooperate with the department to implement
				a drug use review program;
b.
				Receive and consider information regarding the drug use review process which is
				provided by the department and interested parties, including prescribers who
				treat significant numbers of recipients;
c. Review and make recommendations to the
				department regarding drugs to be included on prior authorization
				status;
d. Review no less than once
				each year the status of the drugs that have been deemed to require prior
				authorization and make recommendations to the department regarding any
				suggested changes;
e. Review and
				approve the prior authorization program process used by the department,
				including the process to accommodate the provision of a drug benefit in an
				emergency situation;
f. Advise and
				make recommendations to the department regarding any rule proposed for adoption
				by the department to implement the provisions of state and federal law related
				to drug use review; and
g. Propose
				remedial strategies to improve the quality of care and to promote effective use
				of Medicaid program and children's health insurance program funds or recipient
				expenditures.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02 - Medical Services › Section 75-02-02-29

Current through Supplement No. 393, July, 2024
General Authority:
NDCC 50-24.1-04,
					 50-24.1-41
Law Implemented:
NDCC 50-24.1-32, 50-24.1-41;
					 42 USC
					 1396u-2
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-01 - Definitions

Current through Supplement No. 393, July, 2024
For the purposes of this chapter:
1. "Agency" means the North Dakota department
				of health and human services.
2.
				"Applicant" means an individual seeking health care coverage
				benefits.
3. "Asset" means any kind
				of property or property interest, whether real, personal, or mixed, whether
				liquid or illiquid, and whether or not presently vested with possessory
				rights.
4. "Blind" has the same
				meaning as the term has when used by the social security administration in
				determining blindness for title II or XVI of the Act.
5. "Child" means an individual, under
				twenty-one, or, if blind or disabled, under age eighteen, who is not living
				independently.
6. "Children's
				health insurance program" means the North Dakota children's health insurance
				program implemented pursuant to North Dakota Century Code chapter 50-29 and
				42 U.S.C.
				1397aa et seq. to furnish health assistance
				to low-income children funded through title XXI of the Social Security Act
				[42 U.S.C.
				1397aa et seq.].
7. "Contiguous" means real property which is
				not separated by other real property owned by others. Roads and other public
				rights of way which run through the property, even if owned by others, do not
				affect the property's contiguity.
8. "County agency" means the human service
				zone.
9. "Creditable health
				insurance coverage" means a health benefit plan which includes coverage for
				hospital, medical, or major medical. The following are not considered
				creditable health insurance coverage:
a.
				Coverage only for accident or disability income insurance;
b. Coverage issued as a supplement to
				automobile liability insurance;
c.
				Liability insurance, including general liability insurance and automobile
				liability insurance;
d. Workforce
				safety and insurance or similar insurance;
e. Automobile medical payment
				insurance;
f.  Credit-only
				insurance;
g. Coverage for onsite
				medical clinics;
h. Other similar
				insurance coverage specified in federal regulations under which benefits for
				medical care are secondary or incidental to other insurance;
i. Coverage for dental or vision;
j. Coverage for long-term care, nursing home
				care, home health care, or community-based care;
k. Coverage only for specified disease or
				illness;
l. Hospital indemnity or
				other fixed indemnity insurance; and
m. Coverage provided through Indian health
				service.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-02 - Application and redetermination

Current through Supplement No. 393, July, 2024
1.
Application.
a. All individuals
				wishing to make application for Medicaid must have the opportunity to do so,
				without delay.
b. An application is
				a written request made by an individual desiring assistance under the Medicaid
				program, or by an individual seeking such assistance on behalf of another
				individual, to a county agency, the department, a disproportionate share
				hospital, as defined in section 1923(a)(1)(A) of the Act [
				42
				U.S.C. 1396r-4(a)(1)(A) ],
				or a federally qualified health center, as described in section 1905(I)(2)(B)
				of the Act [
				42
				U.S.C. 1396d(I)(2)(B)
				].
c. A prescribed application form
				must be signed by the applicant or by someone acting responsibly for an
				incapacitated applicant.
d.
				Information concerning eligibility requirements, available services, and the
				rights and responsibilities of applicants and recipients must be furnished to
				all who require it.
e. A relative
				or other interested party may file an application on behalf of a deceased
				individual to cover medical costs incurred prior to the deceased individual's
				death.
f. The date of application
				is the date an application, signed by an appropriate individual, is received at
				a county agency, the department, a disproportionate share hospital, or a
				federally qualified health center.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-02.1 - Duty to establish eligibility

Current through Supplement No. 393, July, 2024
It is the responsibility of the applicant or recipient to
				  provide information sufficient to establish the eligibility of each individual
				  for whom assistance is requested, including furnishing of a social security
				  number, and establishing age, identity, residence, citizenship, blindness,
				  disability, and financial eligibility in each of the months in which benefits
				  are requested.
General Authority:
NDCC 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-03 - Decision and notice

Current through Supplement No. 393, July, 2024
1. A decision as to
				eligibility will be made promptly on applications, within forty-five days, or
				within ninety days in cases with a disability determination pending, except in
				unusual circumstances.
2. Following
				a determination of eligibility or ineligibility, an applicant must be notified
				of either approval or denial of benefits.
3. Notice must be sent at the time, and in
				the manner, required by 42 CFR 431.210 through 431.214.
4. Errors made by public officials and delays
				caused by the actions of public officials do not create eligibility or
				additional benefits for an applicant or recipient who is adversely affected.
General Authority:
NDCC 50-06-16, 50-24.1-04
Law Implemented:
NDCC 50-24.1-02
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-04 - Screening of recipients of certain services

Current through Supplement No. 393, July, 2024
All applicants or recipients who seek nursing care services
				  in nursing facilities, swing-bed facilities, or intermediate care facilities
				  for individuals with intellectual disabilities, or who seek home and
				  community-based services, must demonstrate a medical necessity for the service
				  sought on or prior to admission to a facility, upon application for medicaid
				  while in a facility, or upon request for home and community-based services.
				  That demonstration must be through the department's established screening
				  process.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-04.1 - Certification of need for children in an institution for mental disease

Current through Supplement No. 393, July, 2024
1. Children under age twenty-one who seek
				services in an institution for mental disease must obtain certification of need
				in order to be eligible for medicaid.
2. For an individual who attains age
				twenty-one while receiving treatment and continues to receive treatment as an
				inpatient, eligibility may continue through the month the individual attains
				the age of twenty-two.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-06 - Applicant's choice of aid category

Current through Supplement No. 393, July, 2024
An individual who could establish eligibility under more than
				  one category may have eligibility determined under the category the individual
				  selects. Except for qualified medicare beneficiaries and special low-income
				  medicare beneficiaries, who may also establish eligibility as aged, blind, or
				  disabled, an individual may establish eligibility under only one
				  category.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-08.1 - Caretaker relatives

Current through Supplement No. 393, July, 2024
1. A caretaker
				relative who is not a child's parent may be eligible for medicaid as a
				caretaker relative only if:
a. Age sixteen or
				older;
b. Actually living in the
				same home as the dependent child; and
c. The dependent child is not only
				temporarily absent from the home of the child's parent.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-09 - Assignment of rights to medical payments and benefits

Current through Supplement No. 393, July, 2024
1. The applicant
				and each individual for whom assistance is requested must, as a condition of
				eligibility, assign rights to payment or benefits from any third party or
				private insurer and cooperate in obtaining medical payments and benefits. This
				assignment of rights to payment or benefits is automatic under North Dakota
				Century Code sections 50-24.1-02 and 50-24.1-02.1. As a condition of
				eligibility, the applicant or recipient may be required to execute a written
				assignment whenever appropriate to facilitate establishment of liability of a
				third party or private insurer.
a. The
				department and county agency shall take reasonable measures to obtain, from an
				applicant or recipient, health coverage information and other necessary
				information to determine the liability of third parties and private
				insurers.
b. For purposes of this
				subsection:
(1) "Private insurer" includes
				any commercial insurance company offering health or casualty insurance to
				individuals or groups, including both experience-related insurance contract and
				indemnity contracts; any profit or nonprofit prepaid plan offering either
				medical services or full or partial payment for services covered by the
				Medicaid program; and any organization administering health or casualty
				insurance plans for professional associations, employer-employee benefit plans,
				or any similar organization offering these payments or services, including
				self-insured and self-funded plans.
(2) "Third party" means any individual,
				entity, or program that is or may be liable to pay all or a part of the
				expenditures for services furnished under Medicaid, including a parent or other
				person who owes a duty to provide medical support to or on behalf of a child
				for whom Medicaid benefits are sought.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-10 - Eligibility - Current and retroactive

Current through Supplement No. 393, July, 2024
1.
				Current eligibility may be established from the first day of the month in which
				the application was received. This subsection does not apply to qualified
				Medicare beneficiaries.
2.
				Retroactive eligibility may be established for as many as three calendar months
				prior to the month in which the application was received. Eligibility can be
				established in each of those months for which benefits are sought and if all
				factors of eligibility are met during each such month. If a previous
				application has been taken and denied in the same month, eligibility for that
				entire month may be established based on the current application. Retroactive
				eligibility may be established even if there is no eligibility in the month of
				application. This subsection does not apply to qualified Medicare
				beneficiaries.
3. An individual
				determined eligible for part of a month is eligible for the entire calendar
				month unless a specific factor prevents eligibility during part of that month.
				Specific factors include:
a. An individual is
				born in the month, in which case the date of birth is the first date of
				eligibility;
b. An individual
				entering the state is eligible for Medicaid as of the date the individual
				entered the state; or
c. An
				individual is discharged from a public institution, in which case the date of
				eligibility is the date of discharge.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-11 - Need

Current through Supplement No. 393, July, 2024
Need is a factor of eligibility. Need in this sense is not to
				  be confused with the necessity for a particular medical service.
1. Need is established for individuals who
				are determined to be categorically needy, optionally categorically needy, or
				poverty level eligible.
2. For a
				medically needy applicant or recipient, need is established when there is no
				recipient liability or when the applicant or recipient has incurred current
				medical expenses for which the applicant or recipient is responsible after any
				third-party payments, which equal or exceed current recipient liability. If
				there is no need, there is no eligibility, and the application must be denied
				or the case must be closed.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-12 - Age and identity

Current through Supplement No. 393, July, 2024
1. An
				eligible categorically or medically needy aged applicant or recipient is
				eligible for medicaid for the entire calendar month in which that individual
				reaches age sixty-five.
2. An
				individual who attains age twenty-one while receiving treatment and continues
				to receive treatment as an inpatient in an institution for mental diseases
				remains eligible through the month the individual reaches age
				twenty-two.
3. Blind individuals,
				disabled individuals, and caretaker relatives are not subject to any age
				requirements for purposes of medicaid eligibility.
4. The identity of each applicant must be
				established and documented.
5.
				Citizenship status of each applicant must be established and
				documented.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01,
					 50-24.1-37
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-12.1 - Cost-effective health insurance coverage

Current through Supplement No. 393, July, 2024
1.
				For purposes of this section:
a. "Cost
				effective" means that medicaid payments for a set of medicaid-covered services
				are likely to exceed the cost of paying the health plan premium, coinsurance
				charges, and deductibles for those services.
b. "Health plan" means any plan under which a
				third party is obligated by contract to pay for health care provided to an
				applicant for or recipient of medicaid.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-13 - Social security numbers

Current through Supplement No. 393, July, 2024
A social security number must be furnished as a condition of
				  eligibility, for each individual for whom medicaid benefits are sought, except
				  for:
1. A newborn child who is
				eligible during the birth month, for sixty days after the date of birth
				beginning on the date of birth and for the remaining days of the month in which
				the sixtieth day falls or, if the newborn is continuously eligible, for the
				remaining days of the newborn's first eligibility period;
2. Coverage of emergency services provided to
				illegal aliens; and
3. Individuals
				who have applied for, but not yet received, social security numbers.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-14 - Blindness and disability

Current through Supplement No. 393, July, 2024
1. In any
				instance in which a determination is to be made as to whether any individual is
				disabled, each medical report form and social history shall be reviewed by a
				review team consisting of technically competent individuals, not less than a
				physician and an individual qualified by professional training and pertinent
				experience, acting cooperatively, who shall determine if the applicant meets
				the appropriate definitions of disability.
2. 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, who shall prepare and submit an eye
				examination report. The state review team shall review and compare that report
				with the state's definition of blindness and determine:
a. Whether the individual meets the
				definition of blindness; and
b.
				Whether and when reexaminations are necessary for periodic redeterminations of
				eligibility.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-14.1 - Eligibility for medically frail Medicaid expansion enrollees

Current through Supplement No. 393, July, 2024
1. For the purpose
				of this section, "medically frail" means an individual who is eligible for or
				enrolled with Medicaid expansion and has been deemed to meet the status of
				medically frail which upon a review and determination may include an individual
				with any of the following: serious or complex medical conditions; disabling
				mental disorders; chronic substance use disorders; or physical, intellectual,
				or developmental disability that significantly impairs one's ability to perform
				one or more activities of daily living.
2. A Medicaid expansion enrollee interested
				in applying for a medically frail determination shall complete a
				self-assessment and return the completed form to the department.
3. In any instance in which a determination
				is to be made as to whether any individual is medically frail, documentation
				that validates the diagnosis or medical condition along with any other
				supporting documentation must be submitted to the department. The
				self-assessment form and documentation submitted shall be reviewed by a medical
				professional with professional training and pertinent experience, and who shall
				determine if the applicant meets medically frail eligibility
				requirements.
4. If the Medicaid
				expansion enrollee is approved for eligibility as medically frail, the enrollee
				may choose coverage through a managed care organization or through the Medicaid
				state plan services, except for individuals ages nineteen and twenty as their
				coverage will be determined under the Medicaid state plan services.
5. Coverage of an enrollee as medically frail
				may begin no earlier than the first of the month in which the self-assessment
				was received by the department.
General Authority:
NDCC 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC 50-24.1-01, 50-24.1-37;
					 42 CFR 440.315(f)
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-15 - Incapacity of a parent

Current through Supplement No. 393, July, 2024
1. A child, if
				otherwise eligible for medicaid benefits, is "deprived of parental support or
				care" when the child's parent has a physical or mental defect, supported by
				current competent medical testimony, of such a debilitating nature as to reduce
				substantially or eliminate the parent's capacity either to earn a livelihood or
				to discharge the parent's responsibilities as a homemaker and provider of child
				care for a period of thirty days or more. In making a determination of capacity
				to earn a livelihood, the department takes into account the limited employment
				opportunities of disabled parents.
2. The incapacity must be such that it
				reduces substantially or eliminates employment in the parent's usual
				occupation. It does not matter whether a parent was employed or fulfilled the
				role of homemaker prior to the onset of the asserted incapacity. Incapacity is
				established either when the parent is unable to earn a livelihood or to act as
				a homemaker. A parent may also establish incapacity by demonstrating that the
				parent has reached age sixty-five.
3. A determination that a parent is disabled
				or blind, made by the social security administration, constitutes adequate
				substantiation of incapacity for purposes of this section.
4. A parent continues to be incapacitated,
				for purposes of this section, if the incapacity is not reasonably subject to
				remediation, or if the parent makes reasonable progress towards remediation of
				the incapacity. For purposes of this section, "reasonable progress towards
				remediation of the incapacity" means cooperation with medical practitioners who
				prescribe a course of treatment intended to remediate or limit the effect of
				the incapacity, including physical therapy, counseling, use of prosthesis, drug
				therapy and weight loss, cooperation with vocational practitioners, cooperation
				with vocational and functional capacity evaluations, and reasonable progress in
				a course of training or education intended to qualify the parent to perform an
				occupation which, with that training or education, the parent would have the
				capacity to perform.
5. A parent
				who engages in activities inconsistent with the claimed incapacity may be
				determined to not be incapacitated.
6. The department may require a parent to
				demonstrate reasonable progress towards remediation of the incapacity, and may
				set reasonable deadlines for the demonstrations.
General Authority:
NDCC
					 50-06-16,
					 50-24.1-04
Law Implemented:
NDCC
					 50-24.1-01
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-17 - Application for other benefits

Current through Supplement No. 393, July, 2024
1. Applicants and
				recipients, including spouses and financially responsible parents, must take
				all necessary steps to obtain any annuities, pensions, retirement, and
				disability benefits to which they are entitled, unless they can show good cause
				for not doing so. Annuities, pensions, retirement, and disability benefits
				include veterans' compensation and pensions; old age, survivors, and disability
				insurance benefits; railroad retirement benefits; and unemployment
				compensation, but do not include needs-based payments.
2. Good cause under this section exists if :
a. Receipt of the annuity, pension,
				retirement, or disability benefit would result in a loss of health insurance
				coverage;
b. An employed or
				self-employed individual has not met the individual's full retirement age and
				chooses not to apply for social security early retirement or widows benefits;
				or
c. An employed individual whose
				retirement benefits are through the individual's current employer and the
				individual is not allowed to access them while employed.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-18 - Citizenship and alienage

Current through Supplement No. 393, July, 2024
1. An
				applicant or recipient must be a United States citizen or an alien lawfully
				admitted for permanent residence. Acceptable documents to establish United
				States citizenship and naturalized citizen status are defined in
				42 CFR
				435.407.
2. For purposes of qualifying as a United
				States citizen, the United States includes the fifty states, the District of
				Columbia, Puerto Rico, Guam, the United States Virgin Islands, and the Northern
				Mariana Islands. Nationals from American Samoa or Swain's Island are also
				regarded as United States citizens for purposes of Medicaid.
3. American Indians born in Canada, who may
				freely enter and reside in the United States, are considered to be lawfully
				admitted for permanent residence if at least one-half American Indian blood. A
				spouse or child of such an Indian, or a noncitizen individual whose membership
				in an Indian tribe or family is created by adoption, may not be considered to
				be lawfully admitted under this subsection unless the individual is of at least
				one-half American Indian blood by birth.
4. The following categories of aliens, while
				lawfully admitted for a temporary or specified period of time, are not eligible
				for Medicaid, except for emergency services, because of the temporary nature of
				their admission status:
a. Foreign government
				representatives on official business and their families and servants;
b. Visitors for business or pleasure,
				including exchange visitors;
c.
				Aliens in travel status while traveling directly through the United
				States;
d. Crewmen on shore
				leave;
e. Treaty traders and
				investors and their families;
f.
				Foreign students;
g. International
				organization representatives and personnel and their families and
				servants;
h. Temporary workers,
				including agricultural contract workers; and
i. Members of foreign press, radio, film, or
				other information media and their families.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-19 - Inmates of public institutions

Current through Supplement No. 393, July, 2024
1. An
				inmate of a public institution is not eligible for medicaid unless the
				individual is:
a. Over age sixty-five and a
				patient in an institution for mental diseases;
b. Under age twenty-one, is a patient in an
				institution for mental diseases, and is receiving inpatient psychiatric
				services consistent with the requirements of
				42 CFR
				440.160 and 42 CFR part 441, subpart D, or,
				with respect to a patient who is eligible for medicaid and is receiving
				services in the institution when the patient reaches age twenty-one, inpatient
				psychiatric services under 42 CFR 440.160 may continue until
				age twenty-two; or
c. Receiving
				care as an inpatient in one of the following facilities:
(1) A hospital as defined in
				42 CFR
				440.140;
(2) A nursing facility as defined in
				42 CFR
				440.140 and
				42 U.S.C.
				1396 r(a);
(3) A psychiatric residential treatment
				facility as defined in 42
				CFR 440.160; or
(4) An intermediate care facility for the
				intellectually disabled as defined in
				42 CFR
				440.140 and
				440.150.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-19.1 - Family coverage group

Current through Supplement No. 393, July, 2024
1. Parents
				and caretaker relatives, and their spouses, who meet the medically needy
				technical requirements and the requirements of this section are eligible under
				the parent and caretaker relative group.
2. Parents and caretaker relatives eligible
				under the parent and caretaker relative group must be living with a child who
				is deprived of a biological or adoptive parent's support or care. The child
				described in this subsection must be under age eighteen.
3. A family may establish deprivation, for
				purposes of the parent or caretaker relative group, if the family's countable
				income is within the parent or caretaker relative group income levels and at
				least one of the caretaker relatives is:
a.
				Employed less than one hundred hours per month; or
b. Employed more than one hundred hours in
				the current month, but was employed less than one hundred hours in the previous
				month and is expected to be employed less than one hundred hours in the
				following month.
North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-02.1 - Eligibility for Medicaid › Section 75-02-02.1-20 - Transitional and extended Medicaid benefits

Current through Supplement No. 393, July, 2024
Families that cease to be eligible under the parent and
				  caretaker relative group and who meet the requirements of this section may
				  continue to be eligible for Medicaid benefits without making further
				  application for Medicaid.
1. Families
				that include at least one individual who was eligible under the parent and
				caretaker relative group in at least three of the six months immediately
				preceding the month in which the family became ineligible because of the
				relative's earned income may continue to be eligible for transitional Medicaid
				benefits for up to twelve months if:
a. The
				family has a child living in the home who meets the children's coverage group
				age requirements;
b. The caretaker
				relative remains a resident of the state; and
c. At least one member of the family remains
				employed or shows good cause for not being employed; or