Overview of ND’s Home and Community Based Services Waiver
North Dakota’s Medicaid Waiver for Home and Community Based Services, also called the Home and Community Based Services (HCBS) Waiver, provides long-term services and supports for state residents who are aged and disabled. Intended to prevent unnecessary nursing home admissions, the benefits received vary based on the needs and circumstances of the program participant. For a senior who lives alone, home modifications for safety and accessibility, a personal emergency response system, and home delivered meals might serve them well. In contrast, an individual with an informal family caregiver might benefit from adult day care and respite care.
Program participants can live in a variety of settings. This includes their private home, that of a loved one, an adult foster care home, an assisted living residence, or a residential care home.
While many long-term care Medicaid programs allow program participants a self-directed / participant-directed option that enables them to hire, train, and manage their own caregivers, the HCBS Waiver does not. This program does, however, allow program participants to choose among a list of qualified service providers. Furthermore, a unique benefit called family personal care is available. This allows a family member, such as a spouse, an adult child, or an adult grandchild, who lives with the program participant to be paid to provide care. The caregiver must enroll as a Qualified Service Provider with ND’s Department of Human Services (DHS).
North Dakota’s Waiver for Home and Community Based Services is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. Informally, it may be called the Aged and Disabled Waiver. It is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. The number of participant enrollment slots are limited, and when they are full, a waiting list for program participation forms.
Benefits of the Home and Community Based Services Waiver
Follows is a list of long-term care services and supports available via the HCBS Waiver. An individualized care plan determines which benefits a program participant receives.
– Adult Day Care / Adult Day Health
– Adult Foster Care Services
– Adult Residential Care Services – for persons with memory loss and brain injuries
– Case Management
– Chore Services
– Community Support Service
– Community Transition Services – to assist persons in relocating to the community from a nursing home
– Companionship Service
– Emergency Response Systems
– Extended Personal Care – hands-on medical care, which may include skilled or nursing care
– Family Personal Care – allows live-in family members, including spouses and adult children, to be paid to provide care
– Home Delivered Meals
– Home Modifications – i.e., wheelchair ramps, grab bars, widening of doorways
– Homemaker Services – i.e., light housecleaning, meal preparation, laundry
– Residential Habilitation
– Respite Care – in-home and out-of-home care to relieve a primary caregiver
– Specialized Equipment / Assistive Technology / Supplies
– Supervision
– Supported Employment Services
– Transitional Living Service – supervision / training to develop independent living skills
– Transportation Services (Non-Medical)
– Waiver Personal Care – hands-on-assistance and cueing for daily living activities
While program participants can live in an adult family foster care home, an assisted living residence, or a residential care home, the HCBS Waiver does not cover the cost of room and board.
Eligibility Requirements for Home and Community Based Services Waiver
The HCBS Waiver is for North Dakota residents who are seniors (65+ years old) or 18+ years old and disabled. Additional eligibility criteria are as follows below.
Financial Criteria: Income, Assets & Home Ownership
Income
Effective 4/1/24 – 3/31/25, an individual applicant can have up to $1,130 / month in income. When both spouses of a married couple are applicants, there is a couple income limit of $1,533. When only one spouse is an applicant, the individual applicant income limit of $1,130 / month applies and the income of the non-applicant spouse is disregarded. In other words, their income is not counted towards the income eligibility of their spouse. However, in some cases, income can be allocated to the non-applicant spouse from the applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance (MMNA).
Effective 7/1/24 – 6/30/25, the maximum amount of income that can be transferred to the non-applicant spouse is $2,555 / month. This is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. To be clear, this allowance is intended to bring a non-applicant’s monthly income up to $2,555. If a non-applicant’s own income is equal to or greater than this amount, they are not entitled to a Spousal Income Allowance.
Assets
In 2024, the asset limit is $3,000 for an individual applicant. For married couples, with both spouses as applicants, the asset limit is $6,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can have $3,000 in assets, while the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment.
In 2024, the CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If 50% of the couple’s assets falls under $30,828, the non-applicant spouse can keep all of the couple’s assets, up to this amount.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.
Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for eligibility purposes, Medicaid in ND considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $713,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child (under 21 years old) living in the home.
– The applicant has a blind or disabled child (of any age) living in the home.
While one’s home is generally safe from Medicaid’s asset limit, it is not necessarily safe from Medicaid’s Estate Recovery Program.
Medical Criteria: Functional Need
An applicant must require a Nursing Facility Level of Care (NFLOC). For the HCBS Waiver, the Level of Care (LOC) Determination form is completed by a nurse to determine if this level of care need is met. An applicant’s ability / inability to independently complete their Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) is assessed. These activities include bathing, dressing, transferring, toileting, eating, laundry, and housework. Deficits in cognition, such as memory, planning, and comprehension, which are commonly seen in persons with Alzheimer’s disease and related dementias, is also considered. While persons with dementia might meet the functional need for care, a diagnosis of dementia in and of itself does not equate to a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for ND Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
North Dakota has a Medically Needy Pathway to eligibility for Medicaid applicants who have high medical expenses relative to their income. Also known as a Spend-Down Program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet the income limit. The amount that must be “spent down” can be thought of as a deductible. Once one’s “deductible” has been met, the HCBS Waiver will pay for services and supports for the remainder of the spend down period.
When persons have assets over the limit, Irrevocable Funeral Trusts (IFTs) are an option. They are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts (MAPTs), which must be implemented well in advance of the need for care, are trusts that protect assets from Medicaid and Medicaid’s Estate Recovery Program. There are additional planning strategies available when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in North Dakota to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of the strategies violate Medicaid’s 60-month Look-Back Rule, and therefore, should only be implemented with careful planning. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.
How to Apply for the Home and Community Based Services Waiver
Before You Apply
Prior to submitting an application for the HCBS Waiver, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, bank statements up to 60-months prior to application, and proof of income. A common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
Since North Dakota’s HCBS Waiver is not an entitlement program, there may be a waiting list for program participation. This waiver is approved for a maximum of approximately 854 beneficiaries per year. In the case of a waiting list, an applicant’s access to a participant slot is based on the date of Medicaid application.
Application Process
Persons can apply for the HCBS Waiver online or by contacting their local Human Service Zone (previously County Social Services) for a paper application. Furthermore, a Health Care Application for the Elderly and Disabled form can be downloaded from this webpage. For persons who want or require application assistance, ND Navigators are available for free assistance by calling 1-800-233-1737.
Though not intended for a consumer audience, one can learn more about the HCBS Waiver here. Persons can also contact the Aging and Disability Resource Link at 855-462-5465 or their local Human Service Zone.
The Medicaid Home and Community Based Services Waiver is administered by the North Dakota Department of Human Services’ Aging Services Division.
Approval Process & Timing
The North Dakota Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as a waiting list may exist, approved applicants may spend many months waiting to receive benefits.