N.D. Admin Code 75-02-02.1-01 - Definitions

Current through Supplement No. 382, October, 2021

For the purposes of this chapter:

1. "Agency" means the North Dakota department of 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 services.
10. "Department" means the North Dakota department of human services.
11. "Deprived child" means a child who is deprived of parental support or care because one or both parents are deceased, incapacitated, disabled, aged, or maintains and resides in a separate verified residence for reasons other than employment, education, training, medical care, or uniformed service.
12. "Disabled" has the same meaning as the term has when used by the social security administration in determining disability for title II or XVI of the Act.
13. "Disabled adult child" means a disabled or blind individual over the age of twenty-one who became blind or disabled before age twenty-two.
14. "Full calendar month" means the period which begins at midnight on the last day of the previous month and ends at midnight on the last day of the month under consideration.
15. "Good-faith effort to sell" means an honest effort to sell in a manner which is reasonably calculated to induce a willing buyer to believe that the property offered for sale is actually for sale at a fair price. A good-faith effort to sell includes, at a minimum, making the offer at a price based on an appraisal, a market analysis by a realtor, or another method which produces an accurate reflection of fair market value or, with respect to a determination of qualified disabled and working individual benefits under section 75-02-02.1-23, sixty-six and two-thirds percent of fair market value, in the following manner:
a. To any co-owner, joint owner, possessor, or occupier of the property, and, if no buyer is thereby secured;
b. To the regular market for such property, if any regular market exists, or, if no regular market exists;
c. By public advertisement for sale in a newspaper of general circulation, the circulation area of which includes the location of any property resource offered for sale, which advertisement was published successively for two weeks if the newspaper is a weekly publication and for one week if the newspaper is a daily publication, and which includes a plain and accurate description of the property, the selling price, and the name, address, and telephone number of a person who will answer inquiries and receive offers.
16. "Home" includes, when used in the phrase "the home occupied by the Medicaid unit", the land on which the home is located, provided that the acreage [hectarage] does not exceed one hundred sixty contiguous acres [64.75 hectares] if rural or two acres [.81 hectares] if located within the established boundaries of a city.
17. "Home and community-based services" means services, provided under a waiver secured from the United States department of health and human services, which are:
a. Not otherwise available under Medicaid; and
b. Furnished only to individuals who, but for the provision of such services, would require the level of care provided in a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities.
18. "Institutionalized individual" means an individual who is an inpatient in a nursing facility, an intermediate care facility for individuals with intellectual disabilities, the state hospital, a psychiatric residential treatment facility, an institution for mental disease, or who receives swing-bed care in a hospital.
19. "Living independently" means, in reference to an individual under the age of twenty-one, a status which arises in any of the following circumstances:
a. The individual has served a tour of active duty with the armed services of the United States and lives separately and apart from the parent.
b. The individual has married, even though that marriage may have ended through divorce or separation. A marriage ended by legal annulment is treated as if the marriage never occurred.
c. The individual has lived separately and apart from both parents for at least three consecutive full calendar months after the date the individual left a parental home, continues to live separately and apart from both parents, and has received no support or assistance from either parent while living separately and apart. For purposes of this subsection:
(1) Periods when the individual is attending an educational or training facility, receiving care in a specialized facility, or is an institutionalized individual are deemed to be periods when the individual is living with a parent unless the individual first established that the individual was living independently; and
(2) Health insurance coverage and court-ordered child support payments are not "assistance or support".
d. The individual is a former foster care recipient who has established a living arrangement separate and apart from either parent and received no support or assistance from either parent.
e. The individual lives separately and apart from both parents due to incest and receives no support or assistance from either parent.
20. "Long-term care" means the services received by an individual when the individual is screened or certified as requiring long-term care services.
21. "MAGI-based methodology" means the method of determining eligibility for Medicaid that generally follows modified adjusted gross income rules.
22. "Medicaid" means a program implemented pursuant to North Dakota Century Code chapter 50-24.1 and title XIX of the Act [ 42 U.S.C. 1396 et seq.].
23. "Medicare cost sharing" means the following costs:
a.
(1) Medicare part A premiums; and
(2) Medicare part B premiums;
b. Medicare coinsurance;
c. Medicare deductibles; and
d. Twenty percent of the allowed cost for Medicare covered services where Medicare covers only eighty percent of the allowed costs.
24. "Nursing care services" means nursing care provided in a medical institution, a nursing facility, a swing-bed, the state hospital, or a home and community-based services setting.
25. "Occupied" means, when used in the phrase "the home occupied by the Medicaid unit", the home the Medicaid unit is living in or, if temporarily absent from, possessed with an intention to return and the capability of returning within a reasonable length of time. Property is not occupied if the right to occupy has been given up through a rental or lease agreement, whether or not that rental or lease agreement is written. Property is not occupied by an individual in long-term care or the state hospital, with no spouse, disabled adult child, or child under age twenty-one at home, unless a physician has certified that the individual is likely to return home within six months.
26. "Poverty level" means the income official poverty line, as defined by the United States office of management and budget, and as revised annually in accordance with 42 U.S.C. 9902(2).
27. "Property that is essential to earning a livelihood" means property that a member of a Medicaid unit owns, and which the Medicaid unit is actively engaged in using to earn income, and where the total benefit of such income is derived for the Medicaid unit's needs. A member of a Medicaid unit is actively engaged in using the property if a member of the unit contributes significant current personal labor in using the property for income-producing purposes. The payment of social security taxes on the income from such current personal labor is an indicator of the active use of the property.
28. "Property that is not saleable without working an undue hardship" means property which the owner has made a good-faith effort to sell which has produced no buyer willing to pay an amount equaling or exceeding seventy-five percent of the property's fair market value, or sixty-six and two-thirds percent of the property's fair market value with respect to determination of qualified disabled and working individual benefits under section 75-02-02.1-23, and which is continuously for sale. Property may not be included within this definition at any time earlier than the first day of the first month in which a good-faith effort to sell is begun or if a bona fide offer is received by the third month after the month in which the good-faith effort to sell is begun.
29. "Recipient" means an individual approved as eligible for health care coverage.
30. "Regulation", as used in 42 CFR 431.210, 431.244, and 435.912, includes any written statement of federal or state law or policy, including, but not limited to, federal and state constitutions, statutes, regulations, rules, policy manuals or directives, policy letters or instructions, and relevant controlling decisions of federal or state courts.
31. "Remedial services" means those services, provided in specialized facilities, which produce the maximum reduction of physical or mental disability and restoration of the facilities' residents to the residents' best possible level of functioning.
32. "Residing in the home" refers to individuals who are physically present, individuals who are temporarily absent, or individuals attending educational facilities.
33. "Specialized facility" means a residential facility, including a basic care facility, a licensed family foster care home for children or adults, a licensed group foster care home for children or adults, a transitional living facility, a facility established to provide quarters to clients of a sheltered workshop, and any other facility determined by the department to be a provider of remedial services, but does not mean an acute care facility or a nursing facility.
34. "State agency" means the North Dakota department of human services.
35. "Student" means an individual who regularly attends and makes satisfactory progress in elementary or secondary school, general educational development classes, college, university, vocational training, including summer vacation periods if the individual intends to return to school in the fall, or a home school program recognized or supervised by the student's state or local school district. A full-time student is an individual who attends school on a schedule equal to a full curriculum.
36. "Supplemental security income" means a program administered under title XVI of the Social Security Act [ 42 U.S.C. 1381 et seq.].
37. "Temporary assistance for needy families" means a program administered under North Dakota Century Code chapter 50-09 and title IV-A of the Act [ 42 U.S.C. 601 et seq.].
38. "The Act" means the Social Security Act [ 42 U.S.C. 301 et seq.].
39. "Title II" means title II of the Social Security Act [ 42 U.S.C. 401 et seq.].
40. "Title IV-E" means title IV-E of the Social Security Act [ 42 U.S.C. 670 et seq.].
41. "Title XIX" means title XIX of the Social Security Act [ 42 U.S.C. 1396 et seq.].
42. "Title XXI" means title XXI of the Social Security Act [ 42 U.S.C. 1397aa et seq.].

Notes

N.D. Admin Code 75-02-02.1-01
Amended by Administrative Rules Supplement 2014-352, April 2014, effective April 1, 2014. . Amended by Administrative Rules Supplement 2014-353, July 2014, effective January 1, 2014. . Amended byAdministrative Rules Supplement 375, January 2020, effectiveJanuary 1, 2020

General Authority: NDCC 50-06-16, 50-24.1-04

Law Implemented: NDCC 50-24.1-01, 50-24.1-37; 42 USC 1396a(e)

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