North Dakota Medicaid Eligibility Analysis, 2009

Eligibility Pathways for Medicaid and Long-Term Care

This table shows the eligibility groups and other rules selected for calendar year 2009.

Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010.

Traditional Benefits: North Dakota is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government's SSI thresholds. Individuals with disabilities may qualify under the state's Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state's medically needy threshold.

Institutional LTC: The SSI-related: 209(b), Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,267 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly.

HCBS Waiver: For HCBS waiver services, individuals can qualify through the SSI-related: 209(b), Buy-In, and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $750 in an MMNA.

Other pathway: The Katie Beckett pathway is not available. The hospice only eligibility pathway is available.

Upper Income Threshold for Non-Working Aged and Disabled Medicaid Applicants

Below, the aged and disabled are divided into two groups: (1) applicants who are non-working regardless of whether they require LTSS and (2) applicants with higher income who apply to Medicaid for LTSS and require the level-of-care offered in an institution.²⁵ The following analysis looks at the highest income thresholds available in each state for both groups. Decisions states make about these thresholds often reflect the amount of state revenue they want to dedicate toward Medicaid for aged and disabled populations in general and LTSS in particular.

Table 2 summarizes the highest level of income, in 2009, that non-working elderly or disabled applicants could have and qualify for Medicaid by state. Specifically, it includes the upper income threshold, as a percent of the federal poverty level, for the SSI-related, 100% FPL, and medically needy pathways. (Table 2 does not describe the upper threshold for applicants applying to Medicaid because they require LTSS. These pathways are described in Table 3.)

Thirty-one states (30 used medically needy rules and 1 used spend-down rules) had no limit on the amount of income an aged or disabled individual (or individual with high medical expenses) could have to qualify for Medicaid. In these states, applicants could access Medicaid with higher income levels than in other states. Benefit packages for those who qualify for Medicaid through the SSI-related and 100% FPL pathways are generally more comprehensive than the benefit packages offered to medically needy individuals.

Among the 21 states with income caps for the non-working elderly and disabled applicants, 4 states (Arizona, Massachusetts, Utah, and Vermont) allowed applicants to qualify with income up to 100% FPL while the remaining states set thresholds at lower levels.

Source: CRS Analysis of CRS/AARP State Survey, 2009.

Table excludes eligibility for LTSS through the Special Income Rule and the Medicaid Buy-In pathway. Table shows the maximum threshold for individuals. In 2009, the federal poverty level (100% FPL) in the lower 48 states and the District of Columbia was $10,830 for an individual; in Hawaii it was $12,460; and in Alaska it was $13,330. See, Federal Poverty Guidelines for 2009 at http://aspe.hhs.gov/poverty/09poverty.shtml. Under the medically needy pathway, aged or disabled individuals qualify when their medical expenses (on such things as nursing home (NH) care, prescription drugs, etc.) deplete, or "spend down," their income and assets to specified Medicaid thresholds.

Upper Income Threshold for Applicants Meeting the State's Level-of-Care Criteria for Institutional LTSS

Table 3 summarizes the upper income threshold for applicants applying to Medicaid because they require LTSS and meet the state's criteria for institutional care. LTSS in Table 3 is divided into two service types: nursing homes and states' largest HCBS waivers. By showing the upper income thresholds for both service types, one can begin to evaluate the extent to which parity exists between these services. However, to fully evaluate parity, additional information is needed about the number of waiver slots a state offers compared to demand as well as the amount of income an individual is allowed to retain to pay for living expenses in a home and community-based setting (i.e., MMNA). The latter of these measures is presented in Table 4.

Although states have many rules for determining eligibility, 45 states had no maximum income limit for accessing nursing home care in their state (see Table 3). In addition, 39 states had no income limit for accessing their states' largest HCBS waiver program. In general, a state's use of either the medically needy pathway or miller trust, in conjunction with the special income rule, results in No upper income limit. This shows that at least six states (Connecticut, Louisiana, Massachusetts, Michigan, New Jersey, and Washington) allow applicants with higher income to access nursing home care, while limiting access to HCBS waiver services to individuals with lower income levels. Parity between nursing home and HCBS waivers was not as great in these states as in others.

Source: CRS Analysis of CRS/AARP State Survey, 2009.

Notes: Table shows the maximum threshold for individuals. In 2009, the federal poverty level (100% FPL) in the lower 48 states and the District of Columbia was $10,830 for an individual; in Hawaii it was $12,460; and in Alaska it was $13,330. See, Federal Poverty Guidelines for 2009 at http://aspe.hhs.gov/poverty/09poverty.shtml States with no upper income limit either use the medically needy pathway, in which medical expenses (on such things as nursing home (NH) care, prescription drugs, etc.) deplete, or "spend down," income and assets to specified Medicaid thresholds, or the special income rule with a Miller Trust, for eligibility purposes.

Monthly Maintenance of Need Allowance (MMNA) for Enrollees in Home and Community-Based Waiver Services

Table 4 shows each state's monthly maintenance of need allowance (MMNA). The MMNA is the maximum amount of income an individual enrolled in the state's HCBS wavier program may retain for living expenses; amounts above the MMNA are applied toward the cost of the beneficiary's care. Waiver enrollees use these funds to pay for living expenses, including housing, food, transportation, clothing, personal care products, among others.²⁶

Higher MMNAs allow Medicaid beneficiaries more income to live in their homes or community setting while accessing Medicaid. Lower MMNAs leave individuals less income to reside in home and community-based settings, increasing the likelihood that individuals will seek institutional care to meet their LTSS and housing needs. Fifteen states have MMNAs of less than $1,000 for all or some beneficiaries while the remainder of states have MMNAs of higher than $1,000. Although the information provided in Table 4 is useful for comparative purposes, it is not adjusted for differences in the cost of living across states.

Source: CRS Analysis of CRS/AARP State Survey, 2009.

Analysis of Selected Survey Findings

The survey looked at states' criteria for access to Medicaid for people aged 65 and over and certain people with disabilities. Questions concerning the income and asset thresholds associated with each eligibility pathway available in each state were among the many issues surveyed. In general, states' responses helped to measure the level of generosity or restrictiveness of a states' eligibility rules. States with higher income thresholds, for example, allow people with higher income levels to access Medicaid, while states with lower thresholds are more restrictive.

Medicaid Enrollment by State and Basis of Eligibility for Aged and Disabled

Although information on income thresholds is useful for comparative purposes, it does not tell the entire picture. To more accurately measure a state's generosity or restrictiveness for eligibility purposes, the wealth status of the state, the size of its population, and its demands on Medicaid enrollment should be considered. For example, a poorer state may have lower income thresholds than a richer state but have higher enrollment. Simultaneously, a richer state may have higher thresholds and have comparable, or even lower, enrollment numbers. Although an analysis of this complexity is not included in this report, Table 1 shows state-by-state enrollment numbers for the aged and disabled. The survey was conducted in calendar year (CY) 2009; the most recent enrollment data available are for FY2008.

Source: Medicaid and CHIP Payment and Access Commission (MACPAC), Report to Congress on Medicaid and CHIP, Washington, DC, March 2011, Table 2.

Notes: Numbers reflect individuals ever enrolled during the year, even if for a single month.

¹ Components do not sum to totals due to a small number of enrollees with unknown status.

View PDF of entire report: Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities: 2009 State Profiles.

Next: Medicaid resource rules.

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