North Dakota Administrative Code
Title 75 - Department of Human Services
Article 75-02 - Economic Assistance
Chapter 75-02-02 - Medical Services
Section 75-02-02-08 - Amount, duration, and scope of Medicaid and children's health insurance program
Universal Citation: ND Admin Code ยง 75-02-02-08
Current through Supplement No. 394, October, 2024
1. Within any limitations which may be established by rule, regulation, or statute and within the limits of legislative appropriations, eligible recipients may obtain the medically necessary medical and remedial care and services which are described in the approved Medicaid and children's health insurance program state plan in effect at the time the service is rendered by providers. Services may include:
a.
(1)
Inpatient hospital services. "Inpatient hospital services" means those items
and services ordinarily furnished by the hospital for the care and treatment of
inpatients provided under the direction of a physician or dentist in an
institution maintained primarily for treatment and care of patients with
disorders other than tuberculosis or mental diseases and which is licensed or
formally approved as a hospital by an officially designated state
standard-setting authority and is qualified to participate under title XVIII of
the Social Security Act, or is determined currently to meet the requirements
for such participation; and which has in effect a hospital utilization review
plan applicable to all patients who receive Medicaid or children's health
insurance program.
(2) Inpatient
prospective payment system hospitals that are reimbursed by a
diagnostic-related group will follow Medicare guidelines for supplies and
services included and excluded as outlined in
42 CFR
409.10.
b. Outpatient hospital services. "Outpatient
hospital services" means those preventive, diagnostic, therapeutic,
rehabilitative, or palliative items or services furnished by or under the
direction of a physician or dentist to an outpatient by an institution which is
licensed or formally approved as a hospital by an officially designated state
standard-setting authority and is qualified to participate under title XVIII of
the Social Security Act, or is determined currently to meet the requirements
for such participation and emergency hospital services which are necessary to
prevent the death or serious impairment of the health of the individual and
which, because of the threat to the life or health of the individual,
necessitate the use of the most accessible hospital available that is equipped
to furnish such services, even though the hospital does not currently meet the
conditions for participation under title XVIII of the Social Security
Act.
c. Other laboratory and x-ray
services. "Other laboratory and x-ray services" means professional and
technical laboratory and radiological services ordered by a physician or other
licensed practitioner of the healing arts within the scope of the physician's
or practitioner's practice as defined by state law, and provided to a recipient
by, or under the direction of, a physician or licensed practitioner, in an
office or similar facility other than a hospital outpatient department or a
clinic, and provided to a recipient by a laboratory that is qualified to
participate under title XVIII of the Social Security Act, or is determined
currently to meet the requirements for such participation.
d. Nursing facility services. "Nursing
facility services" does not include services in an institution for mental
diseases and means those items and services furnished by a licensed and
otherwise eligible nursing facility or swing-bed hospital maintained primarily
for the care and treatment which are provided under the direction of a
physician or other licensed practitioner of the healing arts within the scope
of the physician's or practitioner's practice as defined by state law for
individuals who need or needed on a daily basis nursing care, provided directly
or requiring the supervision of nursing personnel, or other rehabilitation
services which, as a practical matter, may only be provided in a nursing
facility on an inpatient basis.
e.
Intermediate care facility for individuals with intellectual disabilities
services. "Intermediate care" means those items and services which are provided
under the direction of a physician or other licensed practitioner of the
healing arts within the scope of the physician's or practitioner's practice as
defined by state law. "Intermediate care facility for individuals with
intellectual disabilities" has the same meaning as provided in
chapter
75-04-01.
f. Early and periodic screening, diagnosis,
and treatment of individuals. "Early and periodic screening, diagnosis, and
treatment" means the services provided to ensure that individuals under age
twenty-one who are eligible under the plan receive appropriate, preventative,
mental health developmental, and specialty services to correct or ameliorate
medical conditions.
g. Physician's
services. "Physician's services" whether furnished in the office, the
recipient's home, a hospital, nursing facility, or elsewhere means those
services provided, within the scope of practice of the physician's profession
as defined by state law, by or under the personal supervision of an individual
licensed under state law to practice medicine or osteopathy.
h. Medical care and any other type of
remedial care other than physician's services recognized under state law and
furnished by licensed practitioners within the scope of their practice as
defined by state law.
i. Home
health care services. "Home health care services", is in addition to the
services of physicians, dentists, physical therapists, and other services and
items available to recipients in their homes and described elsewhere in this
section, means any of the following items and services when they are provided,
based on physician order, medical necessity, and a written plan of care, to a
recipient in the recipient's place of residence, excluding a residence that is
a hospital or a skilled nursing facility:
(1)
Intermittent or part-time skilled nursing services furnished by a home health
agency;
(2) Intermittent or
part-time nursing services of a registered nurse, or a licensed practical
nurse, or which are provided under the direction of a physician and under the
supervision of a registered nurse, when a home health agency is not available
to provide nursing services;
(3)
Medical supplies, equipment, and appliances ordered or prescribed by the
physician as required in the care of the patient and suitable for use in the
home; and
(4) Services of a home
health aide provided to a patient in accordance with the plan of treatment
outlined for the patient by the attending physician and in collaboration with
the home health agency.
j. Hospice care. "Hospice care" means the
care described in 42 CFR
418 furnished to an individual who is
terminally ill and who has voluntarily elected to have hospice care. Hospice
care may be provided to an individual while the individual is a resident of a
nursing facility, but only the hospice care payment may be made. An
individual's voluntary election must be made in accordance with procedures
established by the department.
k.
Private duty nursing services. "Private duty nursing services" means nursing
services for recipients who require more individual and continuous care than is
available from a visiting nurse or is routinely provided by the nursing staff
of a medical facility. Services are provided by a registered nurse or a
licensed practical nurse under the direction of and ordered by a
physician.
l. Dental services.
"Dental services" means any diagnostic, preventive, or corrective procedures
administered by or under the supervision of a dentist in the practice of the
dentist's profession and not excluded from coverage. Dental services include
treatment of the teeth and associated structures of the oral cavity, and of
disease, injury, or impairment which may affect the oral or general health of
the individual. Dental services reimbursed under
42 C.F.R.
440.90 may only be reimbursed if provided
through a public or private nonprofit entity that provides dental
services.
m. Physical therapy.
"Physical therapy" means those services prescribed by a physician or other
licensed practitioner of the healing arts within the scope of that individual's
practice under state law and provided to a recipient by or under the
supervision of a qualified physical therapist.
n. Occupational therapy. "Occupational
therapy" means those services prescribed by a physician or other licensed
practitioner of the healing arts within the scope of that individual's practice
under state law and provided to a recipient and given by or under the
supervision of a qualified occupational therapist.
o. Services for individuals with speech,
hearing, and language disorders. "Services for individuals with speech,
hearing, and language disorders" means those diagnostic, screening, preventive,
or corrective services provided by or under the supervision of a speech
pathologist or audiologist in the scope of practice of the speech pathologist's
or audiologist's profession for which a recipient is referred by a physician or
other licensed practitioner of the healing arts within the scope of the
practitioner's practice under state law.
p. Prescribed drugs. "Prescribed drugs" means
any simple or compounded substance or mixture of substances prescribed as such
or in other acceptable dosage forms for the cure, mitigation, or prevention of
disease, or for health maintenance, by a physician or other licensed
practitioner of the healing arts within the scope of the physician's or
practitioner's professional practice as defined and limited by federal and
state law.
q. Durable medical
equipment and supplies. "Durable medical equipment and supplies" means those
medically necessary items that are primarily and customarily used to serve a
medical purpose and are suitable for use in the home and used to treat disease,
to promote healing, to restore bodily functioning to as near normal as
possible, or to prevent further deterioration, debilitation, or injury which
are provided under the direction of a physician or other licensed practitioner
of the healing arts within the scope of the physician's or practitioner's
practice as defined by state law. Durable medical equipment includes prosthetic
and orthotic devices, eyeglasses, and hearing aids. For purposes of this
subdivision:
(1) "Eyeglasses" means lenses,
including frames when necessary, and other aids to vision prescribed by a
physician skilled in diseases of the eye, or by an optometrist, whichever the
recipient may select, to aid or improve vision;
(2) "Hearing aid" means a specialized
orthotic device individually prescribed and fitted to correct or ameliorate a
hearing disorder; and
(3)
"Prosthetic and orthotic devices" means replacement, corrective, or supportive
devices prescribed for a recipient by a physician or other licensed
practitioner of the healing arts within the scope of the physician's or
practitioner's practice as defined by state law for the purpose of artificially
replacing a missing portion of the body, or to prevent or correct physical
deformity or malfunction, or to support a weak or deformed portion of the
body.
r. Other
diagnostic, screening, preventive, and rehabilitative services.
(1) "Diagnostic services", other than those
for which provision is made elsewhere in these definitions, includes any
medical procedures or supplies recommended for a recipient by the recipient's
physician or other licensed practitioner of the healing arts within the scope
of the physician's or practitioner's practice as defined by state law, as
necessary to enable the physician or practitioner to identify the existence,
nature, or extent of illness, injury, or other health deviation in the
recipient.
(2) "Preventive
services" means those recommended by a physician or other licensed practitioner
of the healing arts, within the scope of authorized practice as defined by
state law, to prevent illness, disease, disability, and other health conditions
or their progression, prolong life, and promote physical and mental health and
efficiency.
(3) "Rehabilitative
services", in addition to those for which provision is made elsewhere in these
definitions, includes any medical or remedial items or services prescribed for
a recipient by the recipient's physician or other licensed practitioner of the
healing arts, within the scope of the physician's or practitioner's practice as
defined by state law, for the purpose of maximum reduction of physical or
mental disability and restoration of the recipient to the recipient's best
possible functional level.
(4)
"Screening services" consists of the use of standardized tests performed under
medical direction in the mass examination of a designated population to detect
the existence of one or more particular diseases or health deviations, to
identify suspects for more definitive studies, or identify individuals
suspected of having certain diseases.
s. Inpatient psychiatric services for
individuals under age twenty-one, as defined in
42 CFR
440.160, provided consistent with the
requirements of 42 CFR part 441 and section
75-02-02-10.
t. Services provided to individuals age
sixty-five and older in an institution for mental diseases, as defined in
42 U.S.C.
1396d(i).
u. Personal care services. "Personal care
services" means those services that assist an individual with activities of
daily living and instrumental activities of daily living in order to maintain
independence and self-reliance to the greatest degree possible.
v. Any other medical care and any other type
of remedial care recognized under state law and specified by the secretary of
the United States' department of health and human services, including:
(1) Nonemergency medical transportation,
including expenses for transportation and other related travel expenses,
necessary to securing medical examinations or treatment when determined by the
department to be medically necessary.
(2) Family planning services, including
drugs, supplies, and devices, when such services are under the medical
direction of a physician or licensed practitioner of the healing arts within
the scope of their practices as defined by state law. There must be freedom
from coercion or pressure of mind and conscience and freedom of choice of
method, so that individuals may choose in accordance with the dictates of their
consciences.
(3) Whole blood,
including items and services required in collection, storage, and
administration, when it has been recommended by a physician or licensed
practitioner and when it is not available to the recipient from other
sources.
w. A community
paramedic service. "Community paramedic service" means a Medicaid-covered
service rendered by a community paramedic, advanced emergency medical
technician, or emergency medical technician. The care must be provided under
the supervision of a physician or advanced practice registered nurse.
x. Interpreter services. "Interpreter
services" means services that assist recipients with sign or oral language
interpreter services for assistance in providing covered health care services
to a recipient of medical assistance who has limited English proficiency or who
has hearing loss and uses interpreter services.
2. The following limitations apply to medical and remedial care and services covered or provided under the Medicaid program and children's health insurance program:
a.
Coverage may not be extended and payment may not be made for an exercise
program or a weight loss program prescribed for eligible recipients.
b. Coverage may not be extended and payment
may not be made for alcoholic beverages prescribed for eligible
recipients.
c. Coverage may not be
extended and payment may not be made for orthodontia prescribed for eligible
recipients, except for orthodontia necessary to correct serious functional
problems.
d. Coverage may not be
extended and payment may not be made for any service provided to increase
fertility or to evaluate or treat fertility.
e. Coverage and payment for eye examinations
and eyeglasses for eligible recipients are limited to, and payment will only be
made for, examinations and eyeglass replacements necessitated because of visual
impairment.
f.
(1) Coverage may not be extended to and
payment may not be made for any physician-administered drugs in an outpatient
setting if the drug does not meet the requirements for a covered outpatient
drug as outlined in section 1927 of the Social Security Act [42 U.S.C.
1396r-8] .
(2) Payment for any physician-administered
drugs in an outpatient setting will be the lesser of the provider's submitted
charge, the Medicare allowed amount, or the pharmacy services allowed amount
described in subdivision n.
g. Coverage and payment for home health care
services and private duty nursing services are limited to no more, on an
average monthly basis, to the equivalent of one hundred seventy-five visits.
The limit for private duty nursing is in combination with the limit for home
health services.
(1) This limit may be
exceeded in cases where it is determined there is a medical necessity for
exceeding the limit and the department has approved a prior treatment
authorization request.
(2) The
prior authorization request must describe the medical necessity of the home
health care services or private duty nursing services, and explain why less
costly alternative treatment does not afford necessary medical care.
(3) At the time of initial ordering of home
health services, a physician or other licensed practitioner shall document that
a face-to-face encounter related to the primary reason the recipient requires
home health services occurred no more than ninety days before or thirty days
after the start of home health services.
h. Coverage may not be extended and payment
may not be made for transportation services except as provided in sections
75-02-02-13.1 and
75-02-02-13.2.
i. Coverage may not be extended and payment
may not be made for any abortion except when necessary to save the life of the
individual who is pregnant or when the pregnancy is the result of an act of
rape or incest.
j. After
consideration of North Dakota Century Code section 50-24.1-15, coverage for
ambulance services must be in response to a medical emergency and may not be
extended and payment may not be made for ambulance services that are not
medically necessary, as determined by the department.
k. Coverage for an emergency room must be
made in response to a medical emergency and may not be extended and payment may
not be made for emergency room services that are not medically necessary, as
determined by the department under section
75-02-02-12.
l. Coverage may not be extended and payment
may not be made for medically necessary chiropractic services exceeding twelve
treatments for spinal manipulation services and two radiologic examinations per
year, per recipient, unless the provider requests and receives prior
authorization from the department.
m. Coverage and payment for personal care
services:
(1) May not be made unless prior
authorization is granted, and the recipient meets the criteria established in
subsection 1 of section
75-02-02-09.5; and
(2) May be approved for:
(a) Up to one hundred twenty hours per month,
or at a daily rate;
(b) Up to two
hundred forty hours per month if the recipient meets the medical necessity
criteria for nursing facility level of care described in section
75-02-02-09 or intermediate care
facility for individuals with intellectual disabilities level of care;
or
(c) Up to three hundred hours
per month if the recipient is determined to be impaired in at least five of the
activities of daily living of bathing, dressing, eating, incontinence,
mobility, toileting, and transferring; meets the medical necessity criteria for
nursing facility level of care described in section
75-02-02-09 or intermediate care
facility for individuals with intellectual disabilities level of care; and none
of the three hundred hours approved for personal care services are allocated to
the tasks of laundry, shopping, or housekeeping.
n. Coverage and payment for
pharmacy services are limited to the coverage and methodology approved by the
centers for Medicare and Medicaid services in the current North Dakota Medicaid
state plan.
3.
a. Except as provided in subdivision b,
remedial services are covered services.
b. Remedial services provided by residential
facilities such as licensed basic care facilities, licensed foster care homes
or qualified residential treatment programs, and specialized facilities are not
covered services, but expenses incurred in securing such services must be
deducted from countable income in determining financial eligibility.
4.
a. The department may refuse payment for any
covered service or procedure for which a prior treatment authorization request
is required but not secured.
b. The
department may consider making payment if the provider demonstrates good cause
for the failure to secure the required prior treatment authorization request.
Provider requests for good cause consideration must be received within twelve
months of the date the services or procedures were furnished and any related
claims must be filed within timely claims submission requirements.
c. The department may refuse payment for any
covered service or procedure provided to an individual eligible for both
Medicaid and third-party coverage if the third-party coverage denies payment
because of the failure of the provider or recipient to comply with the
requirements of the third-party coverage.
5. A provider who renders a covered service except for personal care, but fails to receive payment due to the requirements of subsection 4, may not bill the recipient. A provider who attempts to collect from the eligible recipient or the eligible recipient's responsible relatives any amounts which would have been paid by the department but for the requirements of subsection 4, has by so doing breached the terms of their Medicaid provider agreement.
6. Community paramedic services are limited to vaccinations, immunizations, and immunization administration.
General Authority: NDCC 50-24.1-04
Law Implemented: NDCC 50-24.1-04; 42 USC 1396n(b)(1); 42 CFR 431.53; 42 CFR 431.110; 42 CFR 435.1009; 42 CFR Part 440 ; 42 CFR Part 441 , subparts A, B, D
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