1915i Medicaid State Plan Amendment

Updated: October 2026

Purpose

The 1915(i) program allows Medicaid to pay for home and community-based services to support members with behavioral health conditions including mental illness, substance use disorders, and/or brain injury, to live in the community rather than an institution.

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

Interested 1915(i) providers must:

Enroll with ND Medicaid as a 1915(i) group and individual provider. This includes providers already enrolled with ND Medicaid. Most providers, including providers such as Federally Qualified Health Centers (FQHCs) that are generally reimbursed on an encounter basis, can provide 1915(i) services, if they enroll as 1915(i) providers and follow 1915(i) requirements.
Sign a provider agreement indicating they will serve 1915(i) members.
Meet required qualifications specific to each service. Individual providers must affiliate with an enrolled 1915(i) group provider.
Group providers are responsible for maintaining qualifications required for their group enrollment and overseeing qualifications for individuals affiliated with their group.

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.

To receive 1915(i) services, members must:

Be currently enrolled with ND Medicaid or Medicaid Expansion;
Have a household income of 150% or below the federal poverty level;
Have a qualifying behavioral health diagnosis (a list of qualifying diagnoses can be found attached to the 1915(i) Eligibility Form – SFN 741);
Have a qualifying World Health Organization Disability Assessment Schedule (WHODAS 2.0) score of 25 or higher or a Daily Living Activities (DLA-20) score of 5 or lower; and
Reside in a HCBS compliant setting. See the HCBS Settings rule for more information.

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories.

Covered Services and Limits

General provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

The provider must be enrolled in ND Medicaid;
Services must be medically necessary;
The member must be eligible on the date of service; and
If applicable, the service has an approved service authorization.

The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid along with code specific details such as Ordering Referring Provider (ORP) requirements, Service Authorization requirements, and current rates.

1915(i) providers assisting members in applying for 1915(i) services must inform the members of other available 1915(i) providers that are available to them in their area.

The care coordinator is a professional who is responsible for plan of care development and coordinating access to needed services. This is not the same person who will be delivering the services. The care coordinator will assist eligible members with developing their 1915(i) plan of care and submit referrals to additional service providers as needed. Conflict of interest standards apply. See the 1915(i) Conflict of Interest policy for more details.

Covered Services

Service Type	Description	Age
H2015 - Care Coordination	Assessing the member’s need for services, connecting a member with needed services, and ensuring that services are delivered appropriately. Care coordinators help the member create a person-centered process to create a member’s plan of care.	0+
H2023 – Prevocational Training	Time-limited, community-based services to prepare a member for employment or volunteer work. H2023 can be billed for an individual or group setting. If a group setting is provided, modifier UA must be appended to the link, and reimbursement will be 25% of the allowed amount. H2023 may be delivered via telehealth.	Available to members starting at 6 months before their 18th birthday or receipt of a high school diploma or GED, whichever comes first and all members over age 18.
H2025 – Supported Education	Individualized services to restore a member’s ability to function in, engage with, and sustain participation in their learning environment. Modifier U3 must be reported on all claim lines for this service. H2025 may be delivered via telehealth.	5+


H2025 – Supported Employment	Individualized, person-centered services providing supports to 1915(i) eligible individuals who need ongoing support to learn a new job and maintain a job in a competitive employment or self-employment arrangement. Modifier U4 must be reported on all claim lines for this service. H2025 may be delivered via telehealth.	14+

H2021 – Housing Support Services	Assists members with accessing and maintaining stable housing in the community. Modifier UK must be reported on all claim lines for this service. H2021 may be delivered via telehealth	17.5+
H0038 – Family Peer Support	Provides guidance and support to the caregivers of children under age 18 and who are enrolled in 1915(i). Modifier UK should be used as applicable. H0038 may be delivered via telehealth.	0 to 17
H0038 – Peer Support	Peer support assists members in beginning recovery, maintaining recovery, and enhancing the quality of personal and family life in long-term recovery. H0038 may be delivered via telehealth.	18+
T5999 – Community Transition Services	Consists of funding for time-limited, non-recurring set-up expenses to help an individual transition from an institutional setting to a community-based living arrangement.	0+
H0039 (per 15 minutes) and T2025 (per service) – Training and Supports for Unpaid Caregivers	For preserving, educating, and support the member’s family and support systems.	0+
Supports for Unpaid Caregivers	Modifier UK must be reported on all claim lines for this service. H0039 can be billed for an individual or group setting. If a group setting is provided, modifier UA must be appended to the line and reimbursement will be 25% of the allowed amount. H0039 may be delivered via telehealth.
H2021 – Benefits Planning	Help members make informed choices regarding public benefits and available work incentives. Modifier U3 must be reported on all claim lines for this service. H2021 may be delivered via telehealth.	0+
T2027 – Respite	A short-term service to provide needed relief to a caregiver or in the absence of a caregiver.	0-20
T2001 – Non-Medical Transportation	Assists members with gaining access to 1915(i) and other community services, activities, and resources as specified in the member’s person-centered plan of care when no other sources of transportation are available to the member at no cost.	0+

Service Authorization Requirements

Effective November 1, 2024, service authorizations are only required for Community Transitions Services and Training and Supports for Unpaid Caregivers (T5999). The 1915(i) Service Authorizations policy covers the service authorization requirements.

Noncovered Services

General Noncovered Services

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.

1915(i) supports and services are HCBS and must be delivered in HCBS-compliant settings. The 1915(i) program may not serve members residing in institutions such as nursing facilities, institutions for mental disease (IMD), intermediate care facilities for individuals with intellectual disabilities (ICF/IID), psychiatric residential treatment facilities (PRTF), qualified residential treatment programs (QRTP), jails/prisons, or hospitals (including the State Hospital). The member’s 1915(i) care coordinator will verify that the setting(s) where the member receives services is a compliant HCBS setting. See the 1915(i) Home and Community-Based Settings policy for more information.

Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information.

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement.

Click on each service below to review each service’s policy.
Care Coordination
Benefits Planning
Community Transition Service
Family Peer Support
Housing Support
Non-Medical Transportation
Peer Support
Prevocational Training
Respite
Supported Education
Supported Employment
Training and Supports for Unpaid Caregivers

Claim Submission

Detailed claim instructions are available on the ND Medicaid 1915(i) Provider Guidance and Policies webpage.

Claim Requirements

See the 1915(i) Claims policy for claim requirement details.

Definitions

Care coordinator – the professional responsible for plan of care development and coordinating access to needed services.

Home and Community Based Setting (HCBS) – a member’s private residence or community location rather than an institution or other isolated setting.

Institutional setting – settings include nursing facilities (NF), intermediate care facilities for individuals with intellectual disabilities (ICF/IID), Qualified Residential Treatment Programs (QRTPs), Psychiatric Residential Treatment Facilities (PRTF), hospitals, and jails/prisons.

Person-centered planning – a planning technique emphasizing member preferences, strengths and choices and providing an opportunity to fully participate in the process. Further definitions are found in each 1915(i)’s service policy.

References

Related Policies

Contact

Medical Services
600 East Boulevard Ave
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov