Most US long-term care is paid for by Medicaid — not Medicare. Medicare covers short rehab stays after a hospital admission, then stops. The bill for ongoing skilled nursing, Basic Care Facility residence, or significant in-home care has to be paid by someone, and for the majority of ND seniors that someone is ND Medicaid.1

North Dakota runs its Medicaid program through the Medical Services Division of the ND Department of Health and Human Services. Long-term-care benefits are accessed through several programs: nursing-facility Medicaid (the “institutional” track), the HCBS Waiver for in-home services, and the Service Payments for Elderly and Disabled (SPED) and Ex-SPED programs which operate outside the waiver structure for limited home-care services.

Three eligibility tests, in order

1. Medical eligibility

Before the financial math starts, your parent has to be medically eligible — meeting nursing-facility level of care through ND’s Long-Term Care Functional Screen. The screen evaluates ability to perform activities of daily living (bathing, dressing, toileting, transferring, eating) and instrumental activities of daily living (medication management, meal preparation).2

Schedule the screen through your county Human Service Zone or through ADRL. Waits in ND are typically shorter than in larger states because the application volumes are lower — this is one of the small-state advantages of ND Medicaid.

2. Income

For nursing-facility Medicaid, the gross income cap is approximately $2,901/monthin 2026 — 300% of the federal SSI benefit rate, changes annually. If your parent’s gross income exceeds the cap, they are not automatically disqualified; they’ll need a Qualified Income Trust (Miller Trust) to divert above-cap income.

3. Assets

The applicant’s countable assets must be at or below approximately $3,000 on the date of application .

Not counted (in most cases):

Counted:

ND has a distinctive consideration for many families: farmland and agricultural assets. Working farms that produce income for the applicant or community spouse have different treatment than passive land holdings — this is a planning area where ND attorneys with agricultural-law experience add real value.3

The 60-month look-back, in plain English

ND (like every state) reviews any transfer of assets for less than fair market value made in the 60 months before the Medicaid application. If a transfer is found, Medicaid assesses a penalty period— a window during which the applicant is otherwise eligible but Medicaid won’t pay.

The penalty math is straightforward: the value of the transfer divided by ND’s penalty divisor. The divisor approximates the statewide average monthly cost of nursing-facility care (recent figures around $8,000-$9,500). A $50,000 gift becomes roughly a 5-6 month penalty. The clock does not start until your parent is otherwise eligible — spent down and in care — so the penalty hits at exactly the moment families need Medicaid most.

The community-spouse situation (one spouse in care, one not)

If one spouse needs care and the other doesn’t, ND follows the federal spousal-impoverishment rules. The well spouse (the community spouse) keeps:

Most one-spouse-needs-care situations can be planned to a non-catastrophic outcome with 12-24 months of lead time. Talk to an ND elder-law attorney before doing anything — the spousal rules involve a snapshot-date determination that DIY planners frequently get wrong.

HCBS waiver and SPED: in-home services

ND’s HCBS Waiver for the Aged and Disabled is the primary Medicaid avenue for in-home long-term care for adults. Eligible participants receive personal care, adult day services, respite, and (importantly) consumer-directed care — the option to hire and pay a caregiver of their choice, including an adult child.4

ND also operates the Service Payments for Elderly and Disabled (SPED) program and the Expanded SPED (Ex-SPED) program. These provide more limited in-home services for ND residents who may not qualify for full Medicaid but meet functional and income thresholds. SPED is state-funded and operates as a sliding-scale program; details and current eligibility levels are available through ADRL.

Tribal long-term care: a distinctive ND context

ND has five federally recognized tribes — Standing Rock Sioux, Spirit Lake, Turtle Mountain Band of Chippewa, MHA Nation (Mandan, Hidatsa, and Arikara), and the Sisseton-Wahpeton portion of Lake Traverse — covering a significant share of ND geography and a meaningful tribal-member population. Long-term-care planning for tribal members has additional considerations:

ND Medicaid estate recovery

ND, like every state, has a Medicaid Estate Recovery Program (MERP). After the death of a Medicaid recipient who received LTC benefits at age 55 or older, ND files a claim against the probate estate for the value of LTC services paid. Estate recovery is pursued through probate; non-probate transfers (joint tenancy, beneficiary designations, properly funded revocable trusts) are generally outside the reach of recovery.

What to do this month

For the broader picture on Medicaid eligibility nationally see our Medicaid pillar overview. For ND-specific legal and estate-planning content see Legal & Financial in ND.