North Dakota Medicaid Home and Community-Based Waivers for Long-Term Care (2026)

Group One: Households the Medicaid Waiver Actually Reaches

The Medicaid waiver reaches a household where the applicant clears two gates. Financially, countable assets at or under North Dakota’s limit, which has been $3,000 for an individual and $6,000 for a couple, above the $2,000 baseline that most states use. Confirm the current figure with your Human Service Zone. Functionally, a determination that the person needs the level of care a nursing facility provides.

Concretely, that describes a widow living on Social Security in a paid-off house with a few thousand dollars in the bank who can no longer bathe or dress without help. Her house is excluded while she lives there or intends to return, subject to the lower federal home equity limit. Her car is excluded. Her furniture is excluded. Her checking account is the only thing being measured, and it is under the limit.

North Dakota also operates a medically needy pathway with a recipient liability, so income above the standard does not automatically end the case; incurred medical expenses are applied against excess income. Ask the Human Service Zone to show you the liability calculation in writing.

What the waiver buys for this household: personal care, homemaker services, adult day care, respite so a family caregiver can rest, home-delivered meals, chore services, environmental modifications such as ramps and grab bars, an emergency response system, transportation, and case management. Ask for the plan of care and the authorized hours in writing, and if the hours do not match the documented need, ask for reassessment rather than accepting the plan.

Group Two: Households the Waiver Misses and SPED Catches

This is the North Dakota group most other states do not have a good answer for, and it is the reason this page exists in this shape.

North Dakota funds Service Payments for Elderly and Disabled, and an expanded version of it, with state dollars rather than Medicaid dollars. These programs serve people who need help with daily activities but who do not qualify for Medicaid, generally with a cost share based on income and assets. They are administered through North Dakota Health and Human Services and coordinated through the aging services network and the Human Service Zones.

Who this catches: the retired couple with a modest certificate of deposit and a farm rental income who are several thousand dollars over the Medicaid asset limit and cannot afford $30 an hour privately, five days a week. In most states that household is simply on its own. In North Dakota there is a program to ask about, and a great many families never hear about it because they called asking about Medicaid and were told no.

The exact eligibility rules, cost-share formulas, and service packages for these programs are set by the state and change. Confirm the current criteria and the current cost share with North Dakota Health and Human Services and your Human Service Zone before you conclude a household does not qualify for anything.

The instruction, then, is a specific sentence to say on the phone: if we do not qualify for Medicaid home and community based services, what state-funded home care programs should we be screened for? That question routes you to a different desk than a Medicaid application does.

Group Three: Households Neither Program Reaches

Honesty is more useful here than encouragement. A household with substantial liquid assets, a second property, or income well above the thresholds is not going to be served by either program, and pretending otherwise wastes time a family does not have.

What that household should do instead. First, price the actual care. North Dakota home health aide rates in recent cost-of-care surveys have generally run in the range of roughly $32 to $40 an hour, and semi-private nursing facility costs have generally been in the range of roughly $9,000 to $13,000 a month, with wide variation between Fargo, Bismarck and the rural western counties. Confirm current figures against a published cost-of-care survey; these are ranges, not quotes. Twenty-five hours a week of private aide time is on the order of $3,500 to $4,300 a month.

Second, check for benefits that are not means-tested. Older Americans Act services through the aging services network, including home-delivered meals, transportation and caregiver support, have their own eligibility. Veterans and surviving spouses should ask a county veterans service officer about VA Aid and Attendance, which is not Medicaid and has separate rules.

Third, understand that a household with assets today may be a Group One household in eighteen months of private-pay spending, and that the way it spends matters. Spending down on things you need is permitted; giving assets to children is not, and that is a 60-month look-back problem that a family creates for itself. Read how the look-back period works before anyone signs a deed.

Household	Likely route	Who to call
Under $3,000 in countable assets, needs facility level of care	Medicaid HCBS waiver	Human Service Zone
Over the Medicaid limit, cannot afford private care	State-funded SPED or Expanded SPED	North Dakota Health and Human Services
Substantial assets or high income	Private pay, plus non-means-tested benefits	Aging services network; county veterans service officer
Needs a relative paid	Qualified Service Provider enrollment	Case manager and the department
Living in a frontier county	Authorized hours may go unfilled	Case manager, in writing each time
Heirs after death	Estate recovery, broader than the federal minimum	A North Dakota attorney

Who Delivers the Care: The Qualified Service Provider Model

North Dakota’s answer to the workforce problem is structurally different from most states and it directly affects who can be paid to care for you.

Rather than routing all services through licensed agencies, North Dakota enrolls individuals as Qualified Service Providers. An individual who meets the state’s standards can enroll, be listed, and be paid directly for approved services under a client’s plan. That is a real and distinctive North Dakota mechanism, and it is why in a county with no home care agency there may still be someone who can be paid to help.

It is also the route by which many North Dakota families get a relative paid. Confirm with North Dakota Health and Human Services and your case manager which relatives may enroll, which services a relative may provide, whether a spouse is excluded, and what training or background requirements apply. Get that answer in writing before anyone leaves a job.

The sequence is the same as everywhere and it is where families lose money: approval, then provider enrollment, then payable hours. Nobody is paid retroactively for care already given while an application was pending.

Practical caution about rural delivery. An authorization is a funding decision, not a staffing guarantee. In frontier counties, an approved plan may go partly unfilled simply because nobody is available at that address. Report unfilled hours to your case manager in writing every time; that record supports a reassessment, supports a request for a different provider, and becomes the evidence base for an appeal.

Who Is Affected After Death: North Dakota’s Estate Recovery

This section reaches a group most families never anticipate: the heirs, and in North Dakota potentially the surviving spouse’s heirs.

Federal law requires every state to seek recovery from the estates of people who received long-term care services at age 55 or older, and recovery is deferred while a surviving spouse is living or while there is a surviving child who is under 21, blind or disabled. That much is national. Read what Medicaid estate recovery is for the framework.

North Dakota is among the states that have taken a broader approach than the federal minimum, including pursuing recovery in connection with the estate of a surviving spouse in some circumstances. That is a genuine departure and it matters enormously to a family that assumed the deferral was permanent. Do not treat this description as legal advice or as a statement of your case. Confirm the current North Dakota rules with North Dakota Health and Human Services and take the specifics to a North Dakota attorney before any estate is distributed.

Two other groups sit outside the ordinary rules. Federal protections shield certain American Indian and Alaska Native trust property and related income from Medicaid estate recovery, which is a live question in a state with five tribal nations. And hardship waivers exist and must be applied for; they are not granted automatically.

The instruction for a personal representative is the same in North Dakota as anywhere: do not distribute assets before you know whether the state has a claim and whether a deferral or a hardship waiver applies. Distributing first and asking afterward is how heirs end up personally exposed.

Who Is Affected by the Life Insurance Rule, and Who Is Not

Not everyone reading this has a policy problem, and the fastest way to tell is to check two facts.

You are not affected if the policy is term insurance with no cash value, or if the total face value of all permanent policies on the insured is at or under the exclusion threshold, historically $1,500 under the federal baseline. In those cases the policy is not a countable resource and the right action is to leave it alone.

You are affected if there is permanent insurance with cash value above that threshold, because waiver eligibility applies the same countable-asset test as institutional Medicaid. A $40,000 whole life policy with $13,000 of cash value is $13,000 against North Dakota’s $3,000 limit, and it blocks home care exactly as it blocks a nursing facility admission. Confirm current treatment with your Human Service Zone.

If you are affected, work the options in order. An irrevocable funeral arrangement absorbs value as a permitted spend rather than a gift and is usually the simplest route. A reduced paid-up election ends premiums and shrinks the death benefit while typically leaving cash value on the books, which solves affordability more reliably than eligibility. Surrender is third. A life settlement is fourth: it may exceed surrender value but produces countable cash needing its own spend-down plan and sits inside the 60-month look-back as a documented transaction.

Keeping the policy is often the right answer, and for a Group Three household it usually is, because nothing needs to be spent down at all. It is also right where a surviving spouse will need the death benefit, where the face amount is small, or where the insured is in good health for their age. Where North Dakota departs from the national baseline: the $3,000 asset limit, the 19 Human Service Zones replacing county social service offices in 2020, the Qualified Service Provider model, the state-funded programs for people above Medicaid limits, and a broader estate recovery approach. Where it follows the baseline: the 60-month look-back, the nursing facility level of care standard, spousal impoverishment protections, and the lower federal home equity limit. For a read on what a policy is worth before you surrender it, a free policy review is available at (732) 978-9575; Pine Lake Legacy does not purchase policies. Legal, tax and eligibility questions belong with your own attorney, your CPA, your Human Service Zone, or North Dakota’s State Health Insurance Assistance Program.

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Frequently Asked Questions

What is a Human Service Zone in North Dakota?

In 2020 North Dakota consolidated county-run social services into 19 multi-county Human Service Zones, which now handle local eligibility work including Medicaid applications. If you were told to call the county social services office, the Human Service Zone covering your county is the office that actually decides financial eligibility. North Dakota Health and Human Services, formed by a 2022 merger, administers the programs statewide.

Is North Dakota’s Medicaid asset limit $2,000 or $3,000?

North Dakota has used a $3,000 countable asset limit for an individual and $6,000 for a couple, above the $2,000 baseline most states apply. Treat that as the 2026 working figure and confirm it with your Human Service Zone before spending down, since a stale published number can cost a family money it did not need to spend. Exempt assets never enter the calculation at all.

What if we make too much for Medicaid but cannot afford home care?

Ask specifically about North Dakota’s state-funded Service Payments for Elderly and Disabled program and its expanded version, which serve people who need help with daily activities but do not qualify for Medicaid, generally with an income-based cost share. Many families never hear about these because they called asking about Medicaid and were told no. Confirm current criteria with North Dakota Health and Human Services.

Can a family member be paid to care for me in North Dakota?

North Dakota enrolls individuals as Qualified Service Providers rather than routing everything through agencies, and that is often how a relative gets paid. Confirm with your case manager and the department which relatives may enroll, which services they may provide, whether a spouse is excluded, and what training applies. Nobody is paid retroactively, so enrollment must happen before the hours are worked.

Does North Dakota recover from a surviving spouse’s estate?

North Dakota is among the states that have taken a broader approach to estate recovery than the federal minimum, including pursuing recovery connected to a surviving spouse’s estate in some circumstances. That is a significant departure from what families expect. Confirm the current rules with North Dakota Health and Human Services and take the specifics to a North Dakota attorney before distributing any estate.

Related Reading

• North Dakota Medicaid Asset Income Limits
• Medicaid Estate Recovery North Dakota
• What Is Medicaid Estate Recovery
• What Is The Medicaid Look Back Period
• North Dakota Insurance Department Consumer Help
• Home Care Hourly Cost Funding
• Nursing Home Medicaid Spend Down
• Life Insurance Counts Medicaid Asset

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Pine Lake Legacy does not purchase life insurance policies and does not provide legal, tax, or investment advice. Information provided is for educational purposes only. Eligibility for any option, including life settlements, is not guaranteed and depends on individual circumstances, policy terms, underwriting, and market conditions. Consult independent legal, tax, or financial professionals before making decisions regarding a life insurance policy.