Definitions 510-05-05
(Revised 10/1/13 ML #3390)
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(N.D.A.C. Section 75-02-02.1-01)
For the purpose of this chapter:
The amount at the bottom line of the front page of IRS Form 1040. This is also a line on the 1040A
Advance payments of the Premium Tax Credit (APTC)
Individuals who are not eligible for Medicaid or Healthy Steps under the Affordable Care Act may be eligible for tax credits for the health care insurance premiums they pay out of pocket.
Individuals age 19 through 64 and who are not eligible for Medicaid under other categories. As of 01-01-2014, North Dakota Medicaid is expanded to cover these individuals. These individuals will be covered under an Alternative Benefit Plan.
The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010, as amended by the Three Percent Withholding Repeal and Job Creation Act. Also known as Healthcare Reform.
Alternative Benefit Plan (ABP)
Formerly known as Medicaid Benchmark or Benchmark Equivalent Plans, Alternative Benefit Plans must cover the 10 Essential Health Benefits (EHB) described in section 1302(b) of the Affordable Care Act. Individuals in the new adult eligibility (Expansion) group will receive benefits through an Alternative Benefit Plan unless they are determined to be medically frail.
Has the same meaning as the term has when used by the social security administration in determining blindness for Titles II and XVI.
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.
The county social service board.
The North Dakota Department of Human Services.
Has the same meaning as the term has when used by the Social Security Administration in determining disability for Titles II and XVI.
A disabled or blind person over the age of twenty-one who became blind or disabled before age twenty-two.
A set of health care service categories that must be covered by certain plans, starting in 2014. Essential health benefits must include items and services within at least 10 specified categories. Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace and all Medicaid state plans must cover these services.
Federally Facilitated Marketplace (FFM)
The web portal through which Americans may choose a qualified health plan, and be assessed for possible eligibility for Medicaid, Healthy Steps or Advance Premium Tax Credits (APTC).
The most common method of Medicaid payments under which Medicaid pays providers directly for their services. It is a specific dollar limit that Medicaid pays for a specific service.
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.
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, in the following manner:
- To any co-owner, joint owner, possessor, or occupier of the property, and, if no buyer is thereby secured;
- To the regular market for such property, if any regular market exists, or, if no regular market exists (a realtor is considered the regular market for real estate, including mobile homes);
- 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 the selling price, a plain and accurate description of the property and the name, address, and telephone number of a person who will answer inquiries and receive offers.
An insurance program, for children up to age 19, administered under North Dakota Century Code Chapter 50-29 and Title XXI (CHIP).
Home and community based services
Services, provided under a waiver secured from the United States Department of Health and Human Services, that are:
- Not otherwise available under Medicaid; and
- 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 the intellectually disabled (ICF-ID).
An individual who is an inpatient in a nursing facility, an ICF/ID, the State Hospital, the Prairie at St. John's center, the Stadter Psychiatric Center, an out-of-state institution for mental disease (IMD), the Anne Carlsen facility, a Psychiatric Residential Treatment Facility (PRTF), or who receives swing bed care in a hospital.
In reference to a single individual under the age of twenty-one, or if blind or disabled under age eighteen, a status which arises in any of the following circumstances:
- 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.
- 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.
- The individual has lived separately and apart from both parents for at least three consecutive full calendar months after the date the individual left the 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. Periods in which a child is included in the parent's Medicaid unit are deemed to be periods in which the parents are providing support. Providing health insurance coverage or paying court ordered child support payments for a child is not considered to be providing support or assistance. For purposes of this paragraph, periods when the individual is attending an educational or training facility, receiving care in a specialized facility, or is an institutionalized person are deemed to be periods when the individual was living with a parent, unless the individual had already established that the individual was living independently.
- The individual has left foster care and established a living arrangement separate and apart from either parent and received no support or assistance from either parent. Providing health insurance coverage or paying court ordered child support payments for a child is not considered to be providing support or assistance.
- The individual lives separately and apart from both parents due to incest, continues to live separately and apart from both parents, and receives no support or assistance from either parent while living separately and apart. Providing health insurance coverage for a child is not considered to be providing support or assistance.
Refers to services received in a nursing facility, the State Hospital, the Anne Carlson facility, the Prairie at St. John's center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for the intellectually disabled (ICF-ID), or a swing bed when the individual in the facility is screened or certified as requiring the services provided in the facility.
The method of determining eligibility for Medicaid and Healthy Steps that generally follows Modified Adjusted Gross Income rules. It is not a line on a tax return, rather a combination of household and income rules.
A household required to be budgeted using MAGI methodologies. This includes the Adult Expansion Group, Parents, Caretaker Relatives, and their Spouses, Children, and Pregnant Women.
A program implemented pursuant to North Dakota Century Code chapter 50-24.1 and title XIX of the Act.
Under the Affordable Care Act, anyone claiming to be disabled must be considered to be medically frail and provided coverage similar to that in the Medicaid state plan if covered through the adult expansion group.
Refers to the following costs:
- Medicare part A premiums (hospital); and Medicare part B premiums (doctor);
- Medicare coinsurance (Including coinsurance amounts for certain services and the remaining 20% after Medicare pays 80% on the approved amount of the bill.); and
- Medicare deductibles.
The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Ace. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP (Healthy Steps), TRICARE and certain other coverage.
Modified Adjusted Gross Income (MAGI)
Income calculated using the same financial methodologies used to determine modified adjusted gross income as defined in Section 36B(d)(2)(B) of the Internal Revenue Code, with exceptions. Adjusted Gross Income from Form 1040 plus tax-exempt interest, tax-exempt Social Security Benefits, and any foreign earned income excluded from taxes.
The federal mandate that allows individuals to apply for Medicaid through any means, may be through the Federal Facilitated Marketplace, the State eligibility portal, by telephone, through the OASYS application, by FAX or in-person.
An individual who neither files an income tax return nor is claimed as a dependent by another tax filer unless:
- They are claimed as a tax dependent by someone other than a spouse, or natural, adoptive or stepparent;
- They are a child under age 19 living with both parents but the parents do not file a joint return; or
- A child under age 19 who expects to be claimed by a non-custodial parent.
Households required to be budgeted using original Medicaid methodologies. Such households include aged individuals, disabled individuals qualifying as disabled under original Medicaid requirements, MEDICARE recipients who choose to be treated as disabled, individuals who request or are eligible for coverage under the Medicare Savings Programs, SSI individuals who pass the Medicaid asset test, Title IV-E sub-adopt, foster care and kinship guardianship children.
Care provided in a medical institution, a nursing facility, a swing bed, the state hospital, the Anne Carlson facility, the Prairie at St. John's center, the Stadter Psychiatric Center, a Psychiatric Residential Treatment Facility (PRTF), an intermediate care facility for the intellectually disabled (ICF-ID), or a home and community based services setting.
An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
An insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (deductibles, copayments and out-of-pocket maximums) and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.
Those services, provided in specialized facilities, which produce the maximum reduction of physical or mental disability and restoration of the residents to the best possible level of functioning. Remedial services do not include room and board expenses.
Refers to individuals who are physically present, individuals who are temporarily absent, or individuals attending educational facilities.
Supplemental Nutrition Assistance Program (SNAP)
Previously known as the Food Stamp Program, SNAP is a uniform nationwide program intended to promote the general welfare and safeguard the health and well being of the nation's population by raising the levels of nutrition among low-income households.
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. Examples of a specialized facility include the School for the Blind, School for the Deaf, and Svee Home.
A person of the opposite sex who is a husband or a wife. One man and one woman can become husband and wife through marriage (a legal union). North Dakota Medicaid does not consider members of a civil union or same-sex marriage as spouses.
- A Common law marriage from another state is valid in North Dakota only if it can be verified that the marriage is recognized by the other state.
- A non-traditional marriage from another country is valid in North Dakota only if it can be verified that the union is declared valid by the other country.
- In polygamy situations, the first marriage is the valid marriage in North Dakota. Any additional spouses are considered non-relatives.
A program under Section 1843 of the Social Security Act in which Medicaid eligible recipients who are in receipt of Supplemental Security income (SSI) benefits and who are eligible for Medicare Part B, are eligible for the state to pay the monthly Medicare Part B premium.
The North Dakota Department of Human Services.
An individual who regularly attends and makes satisfactory progress in elementary or secondary school, General Equivalency Diploma (GED) classes, a home-school program recognized or supervised by the student’s state or local school district, college, university, or vocational training, including summer vacation periods if the individual intends to return to school in the fall. A full-time student is a person who attends school on a schedule equal to a full curriculum.
(TANF) Temporary Assistance For Needy Families
A program administered under North Dakota Century Code Chapter 50-09 and Title IV-A of the Social Security Act. References to TANF include TANF Kinship Care Assistance, Diversion Assistance, and Transition Assistance.
An individual for whom another individual claims a deduction for a personal exemption under section 151 of the Internal Revenue Code for a taxable year.
Title II of the Social Security Act (Social Security benefits).
Title IV-D of the Social Security Act (Child Support).
Title IV-E of the Social Security Act (Foster Care and Adoption Assistance).
Title XVI of the Social Security Act (Supplemental Security Income (SSI)).
Title XIX of the Social Security Act (Medicaid).
Title XXI of the Social Security Act (Healthy Steps).
