North Dakota Medicaid Application Packet (Long-Term Care, Aged/Blind/Disabled, Aged & Disabled Waiver)

NORTH DAKOTA MEDICAID APPLICATION PACKET — LONG-TERM CARE / AGED, BLIND, DISABLED / AGED & DISABLED WAIVER

TABLE OF CONTENTS

1. Cover Letter to Human Service Zone
2. Applicant and Household Identification
3. Program Election and Effective-Date Request
4. Categorical Eligibility — Aged, Blind, or Disabled
5. Income Statement and Six-Month Spend-Down Election
6. Resource (Asset) Statement
7. Spousal Impoverishment — Asset Assessment and Allowances
8. Primary Residence and Home-Equity Affidavit
9. Five-Year Transfer Disclosure and Look-Back Schedule
10. Trust, Annuity, Promissory Note, and Life-Estate Disclosure
11. Insurance, Burial, and Pre-Need Disclosures
12. Level-of-Care Documentation (Nursing Facility / HCBS Waiver)
13. Authorized Representative and Release of Information
14. Estate-Recovery Notice and Acknowledgment
15. Document Checklist and Verification Inventory
16. Applicant Signature, Penalty-of-Perjury, and Date
17. North Dakota Practice Notes
18. Sources and References

1. COVER LETTER TO HUMAN SERVICE ZONE

Date: [__/__/____]

To: [HUMAN SERVICE ZONE NAME] Human Service Zone
[STREET ADDRESS]
[CITY], North Dakota [ZIP]

Re: Medicaid Application — [APPLICANT NAME] — Program: ☐ Nursing Home Medicaid ☐ Aged & Disabled Waiver (HCBS) ☐ Medicaid for the Aged, Blind, and Disabled (ABD) ☐ Medically Needy / Spend-Down

To the Eligibility Worker:

Enclosed please find the application of [APPLICANT NAME] for North Dakota Medicaid benefits under the program(s) checked above. This packet contains: (a) the completed SFN 958 (Health Care Application for the Elderly and Disabled) or SFN 405 (Application for Assistance); (b) supporting verifications; (c) where applicable, SFN 1571 (Asset Assessment) and level-of-care documentation; and (d) the disclosures required by N.D.A.C. art. 75-02-02.1 and DHHS Eligibility Policy Manual 510-05.

The applicant requests an eligibility determination effective [__/__/____] and, pursuant to N.D.A.C. § 75-02-02.1-22, requests three (3) months of retroactive coverage to [__/__/____].

Direct all eligibility correspondence to the authorized representative identified in Section 13.

Respectfully,

[ATTORNEY OR APPLICANT/AR NAME]
[FIRM, IF ANY]
[STREET ADDRESS]
[PHONE] / [EMAIL]

2. APPLICANT AND HOUSEHOLD IDENTIFICATION

Community Spouse (if applicable):

Other household members: [________________________________]

3. PROGRAM ELECTION AND EFFECTIVE-DATE REQUEST

The applicant elects:

☐ Nursing Home Medicaid (institutional LTC; 60-month look-back; income-cap not used — ND post-eligibility income calculation under 42 C.F.R. § 435.725 with personal-needs allowance, MMMNA to community spouse, and Medicare/insurance premiums).

☐ Aged & Disabled Medicaid Waiver (Home and Community-Based Services; 60-month look-back; nursing-facility level of care required; services include personal care, adult day, home-delivered meals, respite, environmental modifications).

☐ Aged, Blind, and Disabled Medicaid (ABD / Regular Medicaid) (community-based; income limit $1,197/month single, $1,623/month married couple, eff. 4/1/26–3/31/27 — VERIFY).

☐ Medically Needy / Spend-Down (income above categorical limit; six-month certification period under N.D.A.C. § 75-02-02.1-39).

Coverage start date requested: [__/__/____]

Three-month retroactive coverage requested back to: [__/__/____]

4. CATEGORICAL ELIGIBILITY — AGED, BLIND, OR DISABLED

Applicant qualifies under (check all that apply):

• ☐ Aged — age 65 or older. Date of birth: [__/__/____].
• ☐ Blind — meets SSA blindness criteria. Verification: ☐ SSA award letter ☐ ND Medical Review Team determination.
• ☐ Disabled — meets SSA disability criteria. Verification: ☐ SSA disability award ☐ ND State Review Team determination pending.

Note (209(b) state): SSI receipt does not automatically confer Medicaid eligibility in North Dakota. SSI status is documented for reference only.

5. INCOME STATEMENT AND SIX-MONTH SPEND-DOWN ELECTION

A. Monthly gross income (applicant):

B. Community spouse income (if married): $[____]/month

C. Spend-down (medically needy) election:

☐ Applicant elects six-month spend-down period beginning [__/__/____].

Excess income above the medically needy income level (MNIL: $1,197/single, $1,623/couple — VERIFY) for the six-month period is $[____]. Applicant will document incurred medical expenses (Medicare premiums, prescription co-pays, nursing-home billing, home-health, etc.) sufficient to meet spend-down. Bills supporting initial spend-down are attached at Exhibit [____].

D. Post-eligibility income (institutional applicants):

After eligibility, monthly income is applied per 42 C.F.R. § 435.725 in this order: (1) personal-needs allowance — $[____] (ND PNA — VERIFY); (2) community-spouse MMMNA up to $[____] ($2,644 eff. 7/1/25–6/30/26 — VERIFY); (3) family allowance for dependent children/parents; (4) health-insurance premiums (Medicare Parts A/B/D, Medigap); (5) incurred non-covered medical; (6) remainder paid to facility as patient liability.

6. RESOURCE (ASSET) STATEMENT

Asset limit (single applicant): $3,000. Asset limit (married, both applying): $6,000. Asset limit (married, one applying — applicant share): $3,000 (community spouse retains CSRA — see Section 7). VERIFY current limits.

Excluded resources claimed (cite each): ☐ Homestead (Section 8) ☐ One vehicle of any value ☐ Household goods ☐ Term life ☐ Burial space and funds up to $1,500 (or irrevocable burial contract of any value) ☐ Other [________]

7. SPOUSAL IMPOVERISHMENT — ASSET ASSESSMENT AND ALLOWANCES

(Complete only if applicant is married and one spouse needs LTC.)

A. Snapshot date (first day of first continuous 30-day institutionalization or waiver enrollment): [__/__/____]

B. Combined countable resources at snapshot: $[____]

C. Community-Spouse Resource Allowance (CSRA):

• One-half of combined countable resources: $[____]
• Subject to floor of $32,532 and ceiling of $162,660 (CY 2026 — VERIFY)
• CSRA awarded to community spouse: $[____]

D. Monthly Maintenance Needs Allowance (MMMNA) for community spouse:

• Standard MMMNA (eff. 7/1/25–6/30/26): $2,644/month (VERIFY)
• Excess shelter allowance: $[____]
• Total MMMNA requested: $[____]

E. Asset Assessment form filed: ☐ SFN 1571 attached (may be requested separately at any time after first continuous 30-day institutionalization)

F. Right to fair hearing on CSRA / MMMNA: Applicant or community spouse preserves right to request a fair hearing under N.D.A.C. art. 75-01-03 to expand CSRA / MMMNA based on income shortfall or exceptional expenses. ☐ Hearing reserved.

8. PRIMARY RESIDENCE AND HOME-EQUITY AFFIDAVIT

Property address: [________________________________]

Title held by: [________________________________]

Equity value (FMV less encumbrances): $[____]

Home-equity limit (2026): $752,000 (VERIFY annually).

Exclusion claim: ☐ Applicant resides there ☐ Spouse resides there ☐ Minor child resides there ☐ Blind or disabled child resides there ☐ Sibling with equity interest who resided there ≥ 1 year before institutionalization

Intent to return home (institutional applicants): ☐ Applicant declares subjective intent to return home for purposes of homestead exclusion under N.D.A.C. § 75-02-02.1-31 and 42 U.S.C. § 1396p(c)(2)(B). Signature confirms.

Estate-recovery exposure note: The homestead, although excluded for eligibility, is subject to TEFRA estate recovery under N.D.C.C. ch. 50-24.4 and 42 U.S.C. § 1396p(b). Applicant has been advised. ☐

9. FIVE-YEAR TRANSFER DISCLOSURE AND LOOK-BACK SCHEDULE

Look-back period: 60 months preceding the later of (a) date of LTC application or (b) date applicant becomes otherwise eligible. Per 42 U.S.C. § 1396p(c) and N.D.A.C. § 75-02-02.1-33.1.

Have any assets been transferred for less than fair market value during the look-back? ☐ No ☐ Yes — list below.

Penalty calculation (if non-exempt transfer):

Uncompensated value $[____] ÷ ND penalty divisor (statewide average private-pay nursing-facility rate; CONFIRM current figure with Human Service Zone — published annually in DHHS Manual 510-05-85-30) $[____] = [____] months of penalty, beginning the date applicant is otherwise eligible and would receive LTC services but for the transfer.

Exemptions asserted (cite each): ☐ Spousal transfer ☐ Disabled-child transfer ☐ Caretaker-child homestead transfer (resided ≥ 2 years and provided care delaying institutionalization) ☐ Sibling-with-equity homestead transfer ☐ Sole-benefit-of-disabled-individual trust under 42 U.S.C. § 1396p(c)(2)(B)(iv) ☐ Hardship waiver requested ☐ Return of transferred asset (cure)

10. TRUST, ANNUITY, PROMISSORY NOTE, AND LIFE-ESTATE DISCLOSURE

A. Trusts (any trust in which applicant or spouse is grantor, trustee, or beneficiary):

Copies of all trust instruments and amendments are attached at Exhibit [____].

B. Annuities owned by applicant or spouse:

Note: To avoid transfer penalty, an annuity must be (i) irrevocable, (ii) non-assignable, (iii) actuarially sound, (iv) provide equal periodic payments with no balloon, and (v) name the State of North Dakota as remainder beneficiary up to the amount of medical assistance paid. 42 U.S.C. § 1396p(c)(1)(F)–(G).

C. Promissory notes / loans / mortgages held by applicant:

D. Life estates and remainder interests: [____]

11. INSURANCE, BURIAL, AND PRE-NEED DISCLOSURES

12. LEVEL-OF-CARE DOCUMENTATION (NURSING FACILITY / HCBS WAIVER)

Required for Nursing Home Medicaid and Aged & Disabled Waiver.

• ☐ MDS 3.0 (nursing facility) attached
• ☐ ND Functional Assessment / SFN 405A attached
• ☐ Physician's certification of need for nursing-facility level of care attached
• ☐ Pre-Admission Screening and Resident Review (PASRR) Level I, and Level II if indicated
• ☐ Plan of care (waiver applicants)
• ☐ Case-management contact: [Name / phone]

13. AUTHORIZED REPRESENTATIVE AND RELEASE OF INFORMATION

The applicant designates the following authorized representative under 42 C.F.R. § 435.923 and N.D.A.C. § 75-02-02.1-12:

Release of information: The applicant authorizes DHHS, the Human Service Zone, and the State Review Team to obtain records from financial institutions, employers, the Social Security Administration, the IRS, the VA, Medicare contractors, insurers, and health-care providers necessary to determine eligibility. Signature in Section 16 constitutes the release. This authorization remains in effect for the duration of the eligibility period and any redetermination.

14. ESTATE-RECOVERY NOTICE AND ACKNOWLEDGMENT

Pursuant to 42 U.S.C. § 1396p(b) and N.D.C.C. ch. 50-24.4, North Dakota will recover from the estate of a deceased Medicaid recipient (age 55+ or any age if institutionalized) the cost of medical assistance paid, including services provided in nursing facilities, HCBS waivers, hospital, and prescription drug services. Recovery is deferred while a surviving spouse is living, while a child under 21 survives, and while a blind or disabled child of any age survives.

The applicant acknowledges receipt of this notice. ☐

15. DOCUMENT CHECKLIST AND VERIFICATION INVENTORY

• ☐ SFN 958 (or SFN 405) — signed
• ☐ Photo ID and proof of citizenship/immigration
• ☐ SSN card (or verification)
• ☐ Medicare card (front and back)
• ☐ Marriage certificate / divorce decree / death certificate of spouse
• ☐ Bank statements — all accounts — last 60 months (LTC/waiver) or 3 months (ABD)
• ☐ Brokerage / retirement account statements — last 60 months
• ☐ Life insurance policies and most recent cash-value statements
• ☐ Burial / pre-need contracts (irrevocability rider)
• ☐ Vehicle titles
• ☐ Real-estate deeds, mortgage statements, recent property-tax assessment
• ☐ Trust instruments and amendments
• ☐ Annuity contracts
• ☐ Promissory notes / loan documents
• ☐ Tax returns — last 5 years
• ☐ Income verification (SSA-1099, pension award, VA letter, pay stubs)
• ☐ Health-insurance / LTC-insurance policies
• ☐ Medical records supporting level of care
• ☐ Power of attorney / guardianship documents
• ☐ SFN 1571 (Asset Assessment) — if married
• ☐ Documentation of all transfers within look-back

16. APPLICANT SIGNATURE, PENALTY-OF-PERJURY, AND DATE

I declare under penalty of perjury under the laws of the State of North Dakota and the United States that the information in this application and its exhibits is true, correct, and complete to the best of my knowledge. I understand that providing false information may result in denial of benefits, recovery of benefits paid, civil penalties, and criminal prosecution under N.D.C.C. § 50-24.1-26 and 42 U.S.C. § 1320a-7b.

I authorize DHHS and the Human Service Zone to verify all statements and to obtain documentation from third parties as set forth in Section 13.

17. NORTH DAKOTA PRACTICE NOTES

1. 209(b) state. North Dakota retains the option under § 209(b) of the 1972 Social Security Amendments to apply more restrictive Medicaid criteria than SSI. SSI receipt is not automatic Medicaid. Confirm at filing.
2. Medically needy / spend-down. ND offers a six-month spend-down for individuals whose income exceeds the categorical limit but who incur sufficient medical expenses. Track and submit bills monthly.
3. No income cap. Unlike "income-cap" states (e.g., Texas), ND has no Miller-trust mechanism for nursing-home applicants — post-eligibility income is applied to patient liability.
4. Asset Assessment (SFN 1571). Available to married couples beginning the first continuous 30-day institutionalization, even if the institutionalized spouse has not yet applied. Locks in CSRA snapshot.
5. Penalty divisor. ND publishes annually. Verify the current figure with the Human Service Zone before advising on transfers — divisor changes the timing of any penalty.
6. Caretaker-child / sibling-with-equity exceptions to homestead transfer penalty are documentation-heavy. Begin assembling proof (caregiving logs, medical records showing institutionalization delayed, proof of co-residence) early.
7. Annuities require strict compliance with 42 U.S.C. § 1396p(c)(1)(F)–(G); irrevocability, non-assignability, actuarial soundness, equal periodic payments, and ND as primary remainder beneficiary up to benefits paid.
8. Estate recovery in ND can include long-term care, hospital, and prescription benefits paid for persons aged 55+. Consider TEFRA-lien and probate-avoidance planning before death.
9. Fair-hearing rights. A denial, reduction, or termination triggers a 30-day window to request a fair hearing under N.D.A.C. art. 75-01-03; benefits continue pending hearing if the request is filed within 10 days.
10. Tribal applicants. Members of federally recognized tribes who reside on or near reservations may have enhanced protections; coordinate with Tribal Health and ND Indian Affairs.

18. SOURCES AND REFERENCES

• ND Health & Human Services — Medicaid Eligibility: https://www.hhs.nd.gov/healthcare/medicaid/eligibility
• ND HHS — Long-Term Care Services: https://www.hhs.nd.gov/healthcare/medicaid/provider/long-term-care-services
• ND HHS — Apply for Help: https://www.hhs.nd.gov/applyforhelp
• ND HHS — Ways to Apply (Medicaid): https://www.hhs.nd.gov/healthcare/medicaid/apply
• ND HHS Eligibility Policy Manual 510-05 (Groups Covered): https://www.nd.gov/dhs/policymanuals/51005/510_05_30_05.htm
• N.D.C.C. ch. 50-24.1 (Medical Assistance for Needy Persons): https://ndlegis.gov/cencode/t50c24-1.pdf
• N.D.C.C. ch. 50-24.4 (Medical Assistance Recipient Estate Recovery): https://ndlegis.gov/cencode/t50c24-4.pdf
• N.D.C.C. ch. 50-24.5 (Long-Term Care Continuum): https://ndlegis.gov/cencode/t50c24-5.pdf
• N.D.A.C. art. 75-02-02.1 (Medical Assistance Eligibility): https://ndlegis.gov/information/acdata/html/75-02-02.1.html
• 42 U.S.C. § 1396p (transfers/look-back/estate recovery): https://www.law.cornell.edu/uscode/text/42/1396p
• 42 U.S.C. § 1396r-5 (spousal impoverishment): https://www.law.cornell.edu/uscode/text/42/1396r-5
• SFN 958 (Health Care Application for the Elderly and Disabled): https://www.nd.gov/eforms/doc/sfn00958.pdf
• ND HCBS Waiver overview (Medicaid Planning Assistance): https://www.medicaidplanningassistance.org/north-dakota-hcbs-medicaid-waiver/
• 209(b) state list (CMS / Social Security Administration): https://www.ssa.gov/ssi/text-eligibility-ussi.htm