Section 75-02-02.1-41.2 - Budgeting1.Definitions. For purposes of this section: a. "Base month" means the calendar month prior to the processing month.b. "Benefit month" means the calendar month for which eligibility and recipient liability is being computed.c. "Best estimate" means an income, expense, or circumstance prediction based on past amounts of income and expenses and known factual information concerning future circumstances which affect eligibility, expenses to be incurred; or income to be received in the benefit month. Factual information concerning future circumstances must be based on information by which the applicant or recipient demonstrates known changes or highly probable changes to the income, expenses, or circumstances which offset eligibility, from the base month to the benefit month.d. "Processing month" means the month between the base month and the benefit month.e. "Prospective budgeting" means computation of a household's eligibility and recipient liability based on the best estimate of income, expenses, and circumstances for a benefit month.2.Computing recipient liability for previous month. Compute the amount of recipient liability by use of actual verified information, rather than best estimate, in each of the previous months for which eligibility is sought.3.Computing recipient liability for the current month and next month at time of approval of the application. Compute the amount of the recipient liability prospectively for the current month and the next month. The income received or best estimate of income to be received during the current month must be used to compute the recipient liability for the current month. The best estimates of income to be received during the next month must be used to compute the recipient liability for the next month.4.Computing recipient liability for ongoing cases.a. For cases with fluctuating income, compute the recipient liability using verified income, expenses, and circumstances which existed during the base month, unless factual information concerning future circumstances is available. Recipients must report their income, expenses, and other circumstances on a monthly basis to determine continued eligibility.b. For cases with stable income, compute the recipient liability using the best estimate of income, expenses, and circumstances. Recipients with stable income must report changes in income, expenses, and other circumstances within ten days of the day the recipients became aware of the change. A determination of continued eligibility, after a change is reported and demonstrated, is based on a revised best estimate which takes the changes into consideration.5.Budgeting procedures used when adding individuals to an eligible unit. Individuals may be added to an eligible unit up to one year prior to the current month, provided the individual meets all eligibility criteria for Medicaid, the eligible unit was eligible in all of the months in which eligibility for the individual is established, and the individual was in the unit in the months with respect to which eligibility for that individual is sought unless the individual would have been eligible under the adult group. Recipient liability will be based on the unit's actual income and circumstances when adding each individual for retroactive periods. Recipient liability must be based on the unit's income and circumstances from the base month, plus the best estimate of each individual's income and circumstances when adding each individual to the current or next month, unless the individual would have been eligible under the adult group.6.Budgeting procedures when deleting individuals from a case. When a member of an existing unit is expected to leave the unit during the benefit month, that person may remain as a member of the unit until the end of the benefit month.7.Budgeting procedures when determining overpayments. When a household fails to report a change that results in a decrease in coverage, the maximum amount of the overpayment is: a. The difference between the correct amount of recipient liability and the actual recipient liability paid by the Medicaid household;b. The amount paid in error for all months the individual should not have been eligible under a fee-for-service benefit plan; orc. The amount paid for a premium under a managed care benefit plan.N.D. Admin Code 75-02-02.1-41.2
Amended by Administrative Rules Supplement 2014-353, July 2014, effective January 1, 2014. .Amended by Administrative Rules Supplement 368, April 2018, effective 4/1/2018.General Authority: NDCC 50-06-16, 50-24.1-04
Law Implemented: NDCC 50-24.1-02, 50-24.1-37