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Financial help for North Dakota Medicare enrollees

Medicaid estate recovery does not apply to Medicaid managed care plans in North Dakota, including Medicaid expansion coverage

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As a Medicare beneficiary, where you live – meaning your state of residence – can have a significant impact on the care that you receive and how you pay for that care during your “golden years.” This page explains how North Dakota’s regulations and policies are likely to affect your bottom line.

Does North Dakota help with my Medicare premiums?

Many Medicare beneficiaries who struggle to afford the cost of Medicare coverage are eligible for help through a Medicare Savings Program (MSP). In North Dakota, these programs pay for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.

  • Qualified Medicare Beneficiary (QMB): The income limit is $1,063 a month if single and $1,437 a month if married. QMB pays for Part A and B cost sharing, Part B premiums, and – if a beneficiary owes them – it also pays their Part A premiums.
  • Specified Low-Income Medicare Beneficiary (SLMB):  The income limit is from QMB levels up to $1,276 a month if single and $1,724 a month if married. SLMB pays for Part B premiums.
  • Qualified Individuals (QI): The income limit is from SLMB levels up to $1,436 a month if single and $1,940 a month if married. QI pays for Part B premiums.

MSP asset limits: The asset limits for QMB, SLMB and QI are $7,860 if single and $11,800.

Who's eligible for Medicaid for the aged, blind and disabled in North Dakota?

Medicare covers a great number services – including hospitalization, physician services, and prescription drugs – but Original Medicare doesn’t cover important services like vision and dental benefits.

Medicare can also leave its beneficiaries with significant cost sharing obligations. Some beneficiaries – those whose incomes make them eligible for Medicaid – can receive coverage for those Medicare cost sharing and some Medicaid-covered services if they’re enrolled in Medicaid for the aged, blind and disabled (ABD).

Income eligibility: The income limit is $883 a month if single and $1,193 a month if married.

Asset limits: The asset limit is $3,000 if single and $6,000 if married.

North Dakota’s Medicaid spend-down for regular Medicaid for the aged, blind and disabled benefits and LTSS

In North Dakota, applicants whose incomes are too high to qualify for Medicaid for the aged, blind and disabled can enroll in the Medicaid spend-down. This program allows applicants to qualify for Medicaid by subtracting medical expenses from the amount of an applicant’s income counted toward the Medicaid eligibility limit.

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When an applicant is approved for the spend-down, Medicaid calculates the portion of their monthly income above the program’s income limit – which is known as “excess income.” Enrollees activate their spend-down coverage by submitting medical bills equal to this amount.

North Dakota usually approves spend-down benefits in 1 month increments – with additional coverage requiring the submission of new medical expenses.

In North Dakota, the Medicaid spend-down covers Long Term Services and Supports (LTSS).

Income eligibility: The income limit is $883 a month if single and $1,193 a month if married.

Asset limits: The asset limit is $3,000 if single and $6,000 if married.

How does North Dakota regulate long-term services and supports (LTSS)?

Medicare beneficiaries increasingly rely on long-term services and supports (LTSS) – or long-term care – which is mostly not covered by Medicare. In fact, 20 percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015. Medicaid fills this gap in Medicare coverage for long-term care, but its complex eligibility rules can make qualifying for benefits difficult. What’s more – eligibility rules vary significantly from state to state.

Medicaid nursing home coverage

Income limits: There is no income limit for this coverage in North Dakota. However, nursing home enrollees must pay nearly all their income toward their care, other than a small personal needs allowance (of $65 a month if single) and money to pay for health insurance premiums (such as Medicare Part B and Medigap).

When only one spouse needs nursing home care, only the applying spouse’s income is considered (when determining the amount that must be paid toward care).

Assets limits: The asset limit is $3,000 if single and $6,000 if married (and both spouses are applying). If only one spouse has Medicaid, the other spouse can keep up to $128,640.

Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car. Medicaid nursing home recipients can’t have more than $595,000 in home equity.

Home and Community Based Services (HCBS) waivers

Every state’s Medicaid program covers community-based long-term care, which is provided in an enrollee’s home, adult day care center, assisted living facility, or another location in the community. These are called Home and Community Based Services (HCBS) services because recipients continue living in the community, rather than entering a nursing home. In North Dakota, HCBS recipients must require a nursing home level of care.

Income limits: The income limit is $883 a month if single and $1,193 a month if married.
If only one spouse needs HCBS, the income limit for single applicants is used – and usually only the applying spouse’s income is counted toward the eligibility limit.

Assets limits: The asset limit is $3,000 if single and $6,000 if married (and both spouses are applying). If only one spouse has Medicaid, the other spouse can keep up to $128,640. HCBS recipients can’t have more than $595,000 in home equity.

Spousal impoverishment protections in North Dakota

Eligibility rules for Medicaid LTSS programs differ from other Medicaid benefits when only one spouse is applying. When this occurs, only the applying spouse’s income is counted. (Normally with Medicaid benefits, the income of both spouses is counted – regardless of who is applying.)

Spousal impoverishment rules allow the spouses of Medicaid LTSS recipients to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s income, as well as a resource allowance. These rules apply when one spouse receives Medicaid coverage for LTSS, and the other spouse doesn’t have Medicaid.
In North Dakota in 2020, these spousal impoverishment rules allow these ‘community spouses’ to keep:

Medicaid home equity limit in North Dakota

Applicants for Medicaid nursing home and HCBS benefits are not eligible if they have significant home equity. In 2020, states set a Medicaid home equity limit based on a federal minimum of $595,000 and maximum of $893,000.

North Dakota uses the federal minimum home equity limit – meaning applicants with more than $595,000 in home equity are not eligible for LTSS programs.

Penalties for transferring assets in North Dakota

Because long-term care is expensive, individuals can have an incentive to give away or transfer assets to make themselves eligible for Medicaid LTSS. To curb these asset transfers, federal law requires states to institute a penalty period for Medicaid nursing home applicants who give away or transfer assets for less than their value. States also had the option of using a penalty period for HCBS.

North Dakota has an asset transfer penalty for both nursing home care and HCBS, which is based on a 60-month lookback period when asset transfers and gifts are not allowed. The penalty’s length is calculated by dividing the amount transferred or given away by the monthly cost of nursing home care (about $9,217 in North Dakota in 2020).

Estate recovery in North Dakota

A state’s Medicaid agency is required to recover what it paid for long-term care related costs while an enrollee was 55 or older. States can choose to also pursue estate recovery for all other Medicaid benefits, and for enrollees who did not receive long-term care.

North Dakota has chosen to recover the cost of all Medicaid benefits after an enrollee’s death.

But North Dakota does not use estate recovery when the person was enrolled in Medicaid managed care (i.e., Medicaid coverage provided by a private health insurance carrier). Since Medicaid expansion in North Dakota is provided by private health insurance carriers, Medicaid expansion enrollees in the state are not subject to Medicaid estate recovery. Once a person turns 65 or becomes eligible for Medicare (if this happens before that age), they could no longer be eligible under the Medicaid expansion, and estate recovery could apply to them.

Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, although Medicaid could attempt to recover MSP benefits paid through that date.

Where can Medicare beneficiaries get help in North Dakota?

State Health Insurance Counseling Program (SHIC)

You can access free Medicare counseling through the State Health Insurance Counseling Program (SHIC) at 1-888-575-6611.

The SHIC can help beneficiaries enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. SHIC counselors may also be able to provide referrals for home care agencies or long-term care services. This website has more information about services the SHIC offers.

Elder law attorneys

Elder law attorneys can help individuals plan for Medicaid long-term care benefits. You can use this search feature from the National Academy of Elder Law Attorneys (NAELA) to find an elder attorney in your area.

Where can I apply for Medicaid in North Dakota?

Medicaid is administered by the State Department of Human Services (NDDHS) in North Dakota. You can apply for Medicaid ABD or an MSP using this website in North Dakota.


Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare technical assistance contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He has also held consulting roles, including at Sachs Policy Group, where he worked with hospital, insurer and technology clients.

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