North Dakota Medicaid Guide 2026: 209(b) Spend-Down

North Dakota Medicaid covers long-term care for seniors with a $3,000 asset limit and a spend-down pathway for higher-income applicants, all processed through county Human Service Zones.

North Dakota Medicaid is administered by North Dakota Health and Human Services (ND HHS) and processed locally through county Human Service Zones. North Dakota is one of eight states operating under Section 209(b) of the Social Security Act: it uses at least one eligibility criterion more restrictive than SSI, may not use standards more restrictive than those in effect on January 1, 1972, and must let applicants spend down excess income on incurred medical expenses. For older adults, that means a distinct spend-down pathway and asset rules that differ from what most national guides describe. This guide maps the key rules and links to the dedicated articles that cover each topic in depth.1

What North Dakota Medicaid Covers

North Dakota Medicaid covers the federal Medicaid benefit floor plus state-elected optional services:

• Hospital care: Inpatient and outpatient
• Physician, clinic, and specialist visits
• Prescription drugs through the state pharmacy benefit
• Behavioral health: Mental health and substance use disorder services
• Home health: Skilled nursing and home health aide services
• Long-term care: Nursing facility care and HCBS waiver services for people meeting the clinical level-of-care standard
• Medicare Savings Programs (MSPs): Premium and cost-sharing assistance for dual-eligible beneficiaries
• Non-emergency medical transportation (NEMT)

For seniors, the long-term care benefit is the most financially significant. In North Dakota, a semi-private nursing home room runs about $138,335 per year and a private room about $147,643 per year, each priced on 365 days of care, according to the CareScout 2025 Cost of Care Survey. Medicaid covers that cost once a person is financially and clinically eligible.2

Who Qualifies for North Dakota Medicaid

North Dakota Medicaid Eligibility Overview

For seniors and people with disabilities, eligibility runs through the aged, blind, and disabled categories under North Dakota's 209(b) rules. The state applies its own resource and income standards set in the North Dakota Administrative Code (N.D.A.C. 75-02-02.1) rather than following SSI rules directly. Key 2026 figures:1

• Asset limit: $3,000 for a one-person unit; $6,000 for a two-person unit, with $25 added for each additional member (N.D.A.C. 75-02-02.1-26). That is higher than the $2,000 federal SSI resource standard for an individual ($3,000 for a couple). Countable assets exclude the home, one motor vehicle, household goods and furniture, wearing apparel and personal effects, and irrevocable burial plans. A prepaid burial arrangement that can still be revoked is not on that exclusion list.
• Income approach: North Dakota does not use a hard income cap for nursing facility or waiver coverage. ND HHS publishes an aged, blind and disabled monthly income level of $1,197 for a household of one, $1,623 for two, $2,049 for three, and $2,475 for four, plus $426 for each additional person, set at 90% of the federal poverty level and effective April 1, 2026. Someone above that limit who has a medical need can still get coverage with a "client share," incurring medical and care costs to bring net income down to the applicable level. Separate nursing care income levels apply to residents of a nursing facility or other institution.
• No hard income cap, so no income ceiling to plan around: Eligibility turns on spending down excess income against incurred medical expenses, which section 209(b) requires North Dakota to allow, not on getting under a single income ceiling. That is a real difference from income-cap states, where an applicant over the cap has to route income through a Qualified Income Trust (often called a Miller Trust) to qualify at all. No North Dakota rule we have been able to source addresses Miller Trusts by name, so treat that contrast as background and confirm your own situation with your Human Service Zone before building a plan on it.1
• Home equity limit: The home is an excluded asset, but an applicant is ineligible for skilled nursing, swing-bed, or home and community-based coverage if their equity interest in the home is too high. ND HHS applies a limit of $752,000 to anyone applying on or after January 1, 2026, up from $730,000 in 2025; the figure is indexed each year to the consumer price index for all urban consumers, all items, U.S. city average (N.D.A.C. 75-02-02.1-28). The limit does not apply at all if the applicant's spouse, or a child under 21 or a blind or disabled child, lawfully lives in the home.1,3 Beginning January 1, 2028, a 2025 federal law (the One Big Beautiful Bill Act, Public Law 119-21) will replace the indexed figure with a flat $1,000,000 ceiling for homes that are not on a lot zoned for agricultural use, so for those homes the limit is scheduled to stop rising with inflation; a home on an agriculturally zoned lot stays under the indexed rules.3

Applications are processed through the county Human Service Zone office, not a central state agency. North Dakota has county-level caseworkers who handle both financial and procedural questions.

For full income and asset rules, see North Dakota Medicaid Eligibility & Income Limits.

North Dakota Medicaid Long-Term Care

Nursing Facility Coverage

North Dakota Medicaid covers nursing facility care for eligible older adults who meet the state's clinical level-of-care standard. Once financially and clinically eligible, Medicaid pays the cost of care and the resident contributes most of their monthly income toward it. North Dakota works out that contribution by taking deductions in a set order: first the nursing care income level, then amounts allowed to a spouse or family member for maintenance needs (N.D.A.C. 75-02-02.1-38.1). Whatever net income is left after all deductions, disregards, and income levels, the resident's "recipient liability," must go toward the medical services provided to them (N.D.A.C. 75-02-02.1-41.1).

North Dakota's nursing care income level is $118 per month effective July 1, 2026, and the level for a resident of an intermediate care facility for the intellectually disabled is $153. That is well above the federal personal needs allowance floor of $30/month. The related personal needs allowance is reviewed and adjusted annually for inflation under HB 1485, which raised it by $15.00 per month beginning July 1, 2025, so expect these figures to move again each July 1.1,4

HCBS Waivers

ND HHS administers home and community-based services (HCBS) waivers that fund personal care, respite, adult day services, and other supports for people who would otherwise need nursing facility care. Waiver eligibility uses the same asset standard and spend-down approach as nursing facility Medicaid.

The 5-Year Lookback

North Dakota counts back 60 months from the first date on which a person is both receiving skilled nursing care, swing-bed, or home and community-based services and has applied for benefits (N.D.A.C. 75-02-02.1-33.2), following the federal rule under 42 U.S.C. 1396p(c). Transfers for less than fair market value inside that window create a penalty period of ineligibility for long-term care services, calculated by dividing the transferred value by the state's average monthly private-pay nursing-facility cost. Federal law allows an undue-hardship waiver where the penalty would deprive the applicant of medical care or the necessities of life. Advance planning well before any application is important.1,3

Estate Recovery

After a recipient's death, North Dakota files a preferred claim against the estate under N.D. Cent. Code 50-24.1-07. Note the scope: the claim is for the total medical assistance paid, not only the long-term care portion, and it is triggered when the recipient was 55 or older when they received the assistance, or was a resident of a nursing facility, intermediate care facility, or other medical institution the department determined could not reasonably be expected to return home. The claim is paid after recipient liability for the month of death, funeral expenses up to $3,500, last-illness expenses, and estate-administration costs including court-approved attorney fees.3

North Dakota is an expanded-estate recovery state, not a probate-only state: its statute reaches joint-tenancy property (personal representatives must report surviving joint tenants and joint-tenancy tax clearance proceedings), and it recovers on the death of the recipient's spouse as well, presuming all assets in the deceased spouse's estate were assets the recipient had an interest in. Recovery is deferred, not waived, while a surviving spouse is living or while a surviving child is under 21, blind, or permanently and totally disabled: the claim may not be required to be paid and interest may not accrue during that time, but a timely-filed claim is not disallowed. An undue-hardship waiver process is required by federal law and administered by ND HHS. North Dakota imposes no statute of limitations on its recovery claim (N.D. Cent. Code 50-24.1-08).3

See North Dakota Medicaid Estate Recovery for the full rules and hardship process, and North Dakota Medicaid Appeals and Fair Hearings to challenge a determination.

North Dakota Medicare Savings Programs

North Dakota Medicaid administers Medicare Savings Programs (MSPs) for low-income Medicare beneficiaries who need help with premiums and cost-sharing. North Dakota uses the standard federal income tiers and resource limits:5

These are the federal standards, not absolute cutoffs: states can effectively raise both the income and the resource limits by disregarding certain income and resources, so someone somewhat over should apply rather than rule themselves out. Enrollment in any of the three automatically qualifies you for Extra Help, the Part D low-income subsidy, and federal law bars providers from billing a QMB enrollee for Medicare cost-sharing. Three limits are worth knowing on QI specifically: it is granted first-come, first-served out of limited annual funding, you cannot hold QI and full Medicaid at the same time, and you have to apply again every year, since being selected one year does not entitle you to help the next. Applications go through a county Human Service Zone, and North Dakota's SHIP counselors will help you file at no charge.5,6

See North Dakota Medicare Savings Programs for full details.

Spousal Impoverishment Protections

When one spouse needs long-term care and the other stays home, North Dakota applies federal spousal impoverishment protections to prevent the community spouse from being left with too little.7

Key 2026 figures:

• Community Spouse Resource Allowance (CSRA): North Dakota allows the community spouse a spousal share equal to one-half of the couple's countable assets, but never less than $32,532 and never more than $162,660 (N.D.A.C. 75-02-02.1-24, with the 2026 federal standards effective January 1, 2026).7
• Monthly Maintenance Needs Allowance: This is where North Dakota is less generous than national guides suggest. Federal law lets a state set the community spouse's allowance anywhere from the minimum up to a maximum of $4,066.50/month, and North Dakota elects the minimum. N.D.A.C. 75-02-02.1-24(1)(e) defines the allowance as "the minimum amount permitted under section 1924(d)(3)" of the Social Security Act, and the ND Medicaid Policy Manual sets the income level for an ineligible community spouse at $2,705/month effective July 1, 2026. A higher amount applies only if a court or a hearing officer orders one. Do not plan on the $4,066.50 figure.7
• Home: Exempt from the eligibility calculation while the community spouse lives there.

ND HHS also requires that the institutionalized spouse be screened as needing long-term care, that the care be expected to last at least 30 days in a row, and that the community spouse not be enrolled in Medicaid themselves.1

These protections are applied through a financial snapshot taken at the time of application. See North Dakota Spousal Impoverishment Protections for how the snapshot process works and how income is allocated between spouses.

How to Apply for North Dakota Medicaid

North Dakota Medicaid applications for long-term care are processed at the county level. Gather your paperwork first, then submit through one of the agency pathways.

See How to Apply for North Dakota Medicaid for the full step-by-step process and required documents.

Keeping North Dakota Medicaid Once You Have It

Missing a renewal is one of the most common ways people lose coverage they still qualify for, and federal rules put most of the work on the agency rather than on you. Before it asks you for anything, North Dakota Medicaid must first try to renew your coverage automatically from information it already holds, and may only request documents if it cannot.8 If it does need paperwork, it must send a renewal form and give you at least 30 days from the date on that form to return it.8 That duty, and the 90-day reconsideration window below, cover eligibility based on modified adjusted gross income (MAGI). If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, North Dakota may offer the same windows but is not required to, so ask ND HHS what applies to you.8

If coverage does close because a form went unreturned, that is not the end of it. Federal rules require the agency to reconsider your eligibility without a new application if you return the renewal form within 90 days of the termination (required for MAGI-based coverage; a state option otherwise).8 So a MAGI-based renewal missed by a few weeks is usually recoverable, provided you act.

Return a renewal form the week it arrives. See North Dakota Medicaid Recertification and Renewal for the full cycle and how to recover coverage that has already closed.

Where to Get Help

North Dakota Medicaid FAQ

Learn More

Find personalized help with North Dakota Medicaid programs at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.