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Medicaid (ages 6-18)
Medicaid is a health insurance program for some North Dakotans with lower incomes.  It is usually a free program, although there may be some small costs (co-pays).  Medicaid is administered by the North Dakota Department of Human Services.
  1. What is Medicaid?
  2. Who can get Medicaid?
  3. How does Medicaid work?
  4. Can I go to any doctor that I choose?
  5. Which services are covered on Medicaid?
  6. Do I have to be a U.S. citizen to get Medicaid?
  7. Does it matter how long I have lived in North Dakota?
  8. Do I have to cooperate with the child support office to get Medicaid?
  9. How do I get an application?
  10. Do I have to go in person to apply?
  11. Are there income and asset limits for Medicaid?
  12. What do I have to do to stay on the program?
  13. How often do I need to renew coverage for Medicaid?
  14. What is a co-pay?
  15. Are there co-payments (co-pays)?
  16. What is a recipient liability?

1. What is Medicaid?
It is a health insurance program for some North Dakotans with lower incomes.  It is usually a free program, although there may be some small costs (co-pays).  Medicaid is administered by the North Dakota Department of Human Services.

2. Who can get Medicaid?
If you are a pregnant woman or a member of a family with children under age 21, you may be eligible for Medicaid. (Adults who do not have children living in their household cannot get Medicaid unless they are elderly, blind or disabled.) You have to live in North Dakota. You also have to be a U.S. citizen or a legal immigrant (with an acceptable immigration status) to get Medicaid.

Depending on the amount of your net income, individuals may be eligible for full Medicaid benefits or may be responsible for a portion of their medical bills which is called their recipient liability. Children who are not eligible for full Medicaid benefits may be eligible for Healthy Steps or the Caring for Children Program. Medicaid looks at a family's total countable income and subtracts allowed expenses to establish net income.

Some of the more common allowable deductions are taxes and other work related expenses, health insurance premiums, dependent care expenses, and child support paid to a non household member.  Other deductions also may apply.

NOTE: The rest of this document is written for pregnant women or members of a family with children under age 21 who want to get help from Medicaid. It does not talk about how Medicaid works for other people, such as those who are elderly, blind or disabled.

3. How does Medicaid work?
Eligible persons will select a primary care provider.  You also will receive a Medicaid ID Card.  You will need to show your Medicaid ID Card every time you receive health care services or have a prescription filled or refilled. 

4. Can I go to any doctor that I choose?
Families with children are required to choose a primary care physician who will be responsible for all of their health care and who will make referrals to specialty physicians if needed.  If your primary care physician is not able to provide a service, a referral will be made to a doctor who can give you the care you need.

5. Which services are covered on Medicaid?
Medicaid covers a specific list of medical services. Some covered services have limitations or restrictions. It is a recipient's responsibility to ask a medical provider whether a particular service being provided is covered by Medicaid. Non-covered medical services are the recipient's responsibility.

The services listed below are a general listing.  Some covered services have limitations or restrictions.

Hospital Inpatient: Covers room and board, regular nursing services, supplies and equipment, operating and delivery room, X-rays, lab and therapy.

Hospital Outpatient: Covers emergency room services and supplies, lab, X-ray, therapies, drugs and biologicals, and outpatient surgery.

Clinics, Rural Health Clinics: Covers outpatient medical services and supplies furnished under the direction of a doctor.

Hospice: Provides health care and support services to terminally ill individuals and their families.

Physicians: Covers medical and surgical services performed by a doctor; supplies and drugs given at the doctor's office; and X-rays and laboratory tests needed for diagnosis and treatment.

Prescription Drugs: Covers a wide range of, but not all, prescription drugs, insulin, family planning prescriptions, supplies, and devices. Requires a prescription from a doctor. Pharmacists can tell you if a particular drug is covered by Medicaid.

Chiropractor: Covers X-rays and manual manipulation of the spine for certain diagnosis.

Health Tracks (EPDST): Covers screening and diagnostic services to determine physical and mental status, and treatment to correct or eliminate defects or chronic conditions and help prevent health problems from occurring for children under 21. Also covers orthodontia and vaccinations.

Home Health: Covers nursing care, therapy and medical supplies when provided in a recipient's home. Care must be ordered by a physician and provided by a home health agency.

Durable Medical Equipment and Supplies: Covers medical supplies such as oxygen and catheters and reusable equipment that is primarily medical in nature. Items must be medically necessary and do not include exercise equipment, personal comfort or environmental control equipment.

Dental: Covers exams, X-rays, cleaning, fillings, surgery, extractions, crowns, root canals, dentures (partial and full) and anesthesia.

Family Planning: Covers diagnosis and treatment, drugs, supplies, devices, procedures and counseling for persons of child bearing age.

Sterilization: Covers sterilization procedures if: (1) The recipient is at least 21 years old; (2) The recipient is legally competent; (3) The recipient signs an informed consent form; and (4) At least 30 days but not more than 180 days have passed between the signing of the consent form and the sterilization.

Podiatry: Covers office visits, supplies, X-rays, glucose and culture checks, and surgery procedures.

Mental Health: Covers psychiatric and psychological evaluations, inpatient services in a psychiatric unit of a hospital, individual-group-family psychotherapy, partial hospitalization services, and inpatient psychiatric and residential treatment centers services for individuals under 21 for the care and treatment of mental illness or disorders.

Ambulance: Covers ground and air ambulance trips, attendant, oxygen, and mileage when medically necessary to transport a recipient to the closest health care facility meeting his/her needs.

Transportation: Covers non-emergency transportation services to and from the recipient's home to the closest medical provider capable of providing a medically necessary examination or treatment.

Vision: Covers exam, glasses, frames and some hard contact lenses for the correction of certain conditions. Replacement eyeglasses may only be provided after a minimum of 12 months for children under 21 or 36 months for adults if a lens change is medically necessary. An exception to the replacement limitation may be made if new eyeglasses are required for a significant change in correction and the eyeglasses are prior approved. Lost or broken glasses for individuals over 21 will not be replaced within the first three years.

Therapies: Covers physical and occupational therapy and speech and language pathology.

Out-of-State Services: Medically necessary covered services may be provided outside of North Dakota if the services are not available within North Dakota and have been prior approved by the department or if the services are provided in an emergency situation.

NOTE: Additional services are available for eligible children with medically fraglie needs.  To see more about this program, click here.

6. Do I have to be a U.S. citizen to get Medicaid?
No.  Legal immigrants with an acceptable immigration status can also get Medicaid.  Proof of alien status and identity must be provided to be eligible for North Dakota Medicaid.  Undocumented immigrants cannot get Medicaid, unless they are pregnant.   

  • A new federal law requires some Medicaid applicants and enrollees to prove that they are U.S. citizens and give proof of their identity when they apply for or renew their coverage. This includes U.S. nationals from American Samoa and Swains Island.
  • You do not have to show proof if you are getting Medicare benefits or getting Supplemental Security Income (SSI) or Social Security disability benefits based on your own disability.

7. Does it matter how long I have lived in North Dakota?
No. But you must be a North Dakota resident and plan to stay in North Dakota to get Medicaid.

8. Do I have to cooperate with the child support office to get Medicaid?
For most people, yes. If you do not cooperate, you will not be able to get Medicaid. But your children can get Medicaid even if you do not cooperate with the child support office. However, if you have a good reason for not wanting to cooperate (for example, if you fear physical or emotional harm to you or your child), you may not have to cooperate. If this applies to you, you have to tell your worker that you want to claim “good cause.” You will have to fill out a form to explain your situation.

9. How do I get an application?
You can get an application at your county social services office or you may call your county social service office and request to have an application mailed to you. To locate your county social services office, click here. You may also get applications by clicking on the information in the next question or
you may complete an online application which will be electronically sent to your county social service office, who will determine your qualification for programs.

10. Do I have to go in person to apply?
No. You can apply for Medicaid by sending your application and documents of proof in the mail to your county social services office.  You can also take the application to your county social services office and turn it in or you may complete an online application which will be electronically sent to your county social service office, who will determine your qualification for programs.

11. Are there income and asset limits for Medicaid?
Asset limits do not apply to families with children.  Eligibility is based on income.

12. What do I have to do to stay on the program?
You have to tell your county social services worker about any changes in your household within 10 days of them happening. Things you must report include births, deaths, moving, income or job changes, and people moving in or out of your household. You also have to renew your coverage by mail. This means telling your county social services worker updated information about you to make sure that you can still get Medicaid. 

Most children can become continuously eligible for 12 months of coverage.  For children up to age 19 who become continuously eligible, only the following need to be reported during the 12 month period: when your child leaves home, if you change addresses, if you intend to move out of state, or if your household has access to or obtains health insurance coverage.

13. How often do I need to renew coverage for Medicaid?
Once per year, you will have to renew your coverage. You will get a “Renewal Form” in the mail that asks you questions. Fill it out and mail it back right away so that you can keep getting your Medicaid. If you move, be sure to let a Medicaid worker know your new address so that you will get this letter.

14. What is a co-pay?
It is a small amount of the total bill that you have to pay when you get some services (get a prescription, get eyeglasses, etc.).

15. Are there co-payments (co-pays)?
Some people are required to pay co-payments for services received, and some may also be required to pay a recipient liability. Individuals DO NOT have to pay co-payments if they are younger than age 21, or are pregnant, or need emergency services, or receive family planning services, or if Medicare pays for part of the service, or if they are living in a nursing facility, swing bed, intermediate care facility for the mentally retarded, the state hospital, or the Anne Carlsen School.

Co-pays include:

Chiropractic visit - $1 each visit

Doctor office visit - $2 each visit (This includes all medical doctors, nurse practitioners, and physician assistant certified)

Inpatient hospital stay - $75 each stay

Dental office visits - $2 each visit

Prescriptions brand name - $3 each

Outpatient speech therapy - $1 each visit

Outpatient physical therapy - $2 each visit

Outpatient occupational therapy - $2 each visit

Optometry appointment - $2 each visit

Outpatient psychological appt - $2 each visit

Hearing test visit - $2 each visit

Hearing aid supplied - $3 each

Rural Health Clinic or Federally Qualified Health Center Appt - $3 each visit

Podiatry office appt - $3 each visit

Emergency room visit that is not an emergency - $6 each visit

16. What is a recipient liability?
Recipient liability is the amount you are responsible to pay toward your medical expenses for the month. It is based on your monthly income, and is similar to the deductible amount in an insurance policy.