Medicaid General Information

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

Nursing Facility

Covers room and board, nursing care, therapies, general medical supplies, wheelchairs, and durable medical equipment.

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 diagnoses.

Health Tracks

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 medically necessary orthodontia and vaccinations. Learn more about Health Tracks.

Home Health

Covers nursing care, therapy and medical supplies when provided in a member's home. Care must be ordered by a physician.

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 childbearing 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, 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 needs. House Bill 1282 permits ambulance personnel to refuse transport to an individual where medical necessity cannot be demonstrated and recommend an alternative course of action for the individual. If the ambulance was not medically necessary, Medicaid will not pay for the service.

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 24 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 two years.

Therapies

Covers physical and occupational therapy and speech and language pathology.

Waivered Services - Home and Community-Based Services, Traumatic Brain Injury

Provides personal care and other services not otherwise covered under the Medicaid program to individuals who are at risk of institutionalization in a nursing facility.

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.

The items or services listed below are generally not covered by the Medicaid program. Some exceptions do apply; however, the item or service must be medically necessary and ordered by a physician before the exception can be applied.

• Items or services which have been determined by the DHS Medical, Optometric or Dental consultant or the peer review organization to not be medically necessary.
• Items or services provided by immediate relatives or members of the recipient's household.
• Over-the-counter drugs, home remedies, food supplements, nutritional items, vitamins, or alcoholic beverages except for certain items which are prescribed by a doctor.
• Broken or missed appointments.
• Medical equipment and supplies for an individual in a nursing facility, swing bed or ICF/MR.
• Custodial care.
• Services for individuals over 21 and under 65 in the state hospital, a public institution or an institution for mental disease.
• Health services that are not documented in the recipient's medical record.
• Services, procedures, or drugs which are considered experimental by the US Department of Health and Human Services or another federal agency.
• Drugs and biologicals which the federal government has determined to be less than effective (Desi drugs).
• Cosmetic surgery to improve the appearance of an individual when not incidental to repairs following an accidental injury or any cosmetic surgery which goes beyond what is necessary for the improvement of the functioning of malformed body members.
• Acupuncture.
• Organ transplants that are not prior approved.
• Procedures for implanting an embryo.
• Procedures and services to reverse sterilization.
• Autopsies.
• Reports required solely for insurance or legal purposes.
• Record keeping, charting or documentation related to providing a covered service.
• Vocational training, educational activities, teaching, or counseling.
• Self-help devices, exercise equipment, protective outerwear, personal comfort items or services, and environmental control equipment.
• Computers, computer hookups, or printers except for assistive communication devices.
• Payment to hold a bed in a nursing facility, swing bed or ICF/MR unless specifically provided for by the department.
• Payment for a private room in a nursing facility or basic care facility.