North Dakota - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In North Dakota, congregate residential care combining housing, personal care, and supervision is delivered through two primary models under the Medicaid Home and Community-Based Services (HCBS) Waiver: Assisted Living Facilities and Adult Residential Care (which requires licensure as a Basic Care Facility). Both models provide essential daily living assistance to aged and disabled North Dakotans, though Medicaid strictly covers the care services and excludes room and board costs.

The single biggest structural barrier to entry is obtaining the prerequisite facility license from the North Dakota Department of Health and Human Services (ND HHS) Health Facilities Unit prior to Medicaid enrollment. While North Dakota does not require a Certificate of Need (CON) or competitive RFP procurement for Assisted Living Facilities, providers seeking to offer Adult Residential Care in a Basic Care Facility must navigate strict statewide bed capacity controls and moratoriums, requiring them to acquire existing bed rights before a new license application is even accepted.

1. Service Definition and Scope

North Dakota Medicaid covers congregate residential care under its HCBS Waiver (0273.R06.00) through two distinct service definitions: Assisted Living and Adult Residential Care. Assisted Living provides personal care, supervision, and therapeutic social activities in a licensed Assisted Living Facility. Adult Residential Care is provided in licensed Basic Care Facilities for individuals needing a higher, more structured level of 24-hour support.

Under both service models, Medicaid funds are strictly prohibited from paying for room and board. Participants must pay for their housing and food using private funds, Social Security, or other non-Medicaid assistance programs, while the HCBS Waiver covers the direct care, cueing, and medication administration.

• Service Names: Assisted Living and Adult Residential Care.
• Waiver Authority: ND Medicaid Waiver for Home and Community Based Services (0273.R06.00).
• Covered Services: Hands-on assistance with Activities of Daily Living (ADLs), cueing, medication administration, and non-medical transportation.
• Excluded Costs: Room and board costs are strictly excluded from Medicaid reimbursement.
• Target Population: North Dakota residents who are seniors (aged 65+) or physically disabled (aged 18+) meeting Nursing Facility Level of Care (NFLOC).
• Setting Requirement: Services must be delivered in a facility that complies with the federal HCBS Settings Final Rule, ensuring community integration.

2. Regulatory and Oversight Agencies

Oversight of residential care in North Dakota is consolidated under the North Dakota Department of Health and Human Services (ND HHS). The department divides responsibilities between physical plant safety and Medicaid financial administration.

The ND HHS Health Facilities Unit is responsible for inspecting and licensing both Assisted Living Facilities and Basic Care Facilities. Meanwhile, the ND HHS Medical Services Division manages the Medicaid HCBS Waiver, oversees the MMIS Web Portal, and handles provider enrollment and claims processing.

• Licensing Authority: ND HHS Health Facilities Unit issues facility licenses and conducts physical plant inspections.
• Medicaid Authority: ND HHS Medical Services Division administers the HCBS Waiver and manages provider enrollment.
• Local Administration: Human Service Zones (formerly County Social Services) handle participant eligibility, level of care assessments, and case management.
• Life Safety Oversight: The North Dakota State Fire Marshal or designated local authorities conduct fire and life safety code inspections.
• Federal Oversight: The Centers for Medicare and Medicaid Services (CMS) approves the 1915(c) waiver and enforces the HCBS Settings Rule.

3. Gatekeeping Prerequisites: Who Can Even Apply

North Dakota does not utilize a Certificate of Need (CON) program, competitive RFP procurement, or closed-network managed care contracting for Assisted Living Facilities. Any entity that can secure a physical location and meet the ND HHS architectural and operational standards may apply for an Assisted Living Facility license and subsequent Medicaid enrollment.

However, a major structural barrier exists for providers intending to offer Adult Residential Care. This service requires licensure as a Basic Care Facility, which is subject to a strict statewide bed moratorium. ND HHS will not accept a new Basic Care Facility application unless the provider has successfully purchased or transferred existing basic care bed capacity rights from another licensed facility in the state.

• Certificate of Need (CON): Not required for Assisted Living Facilities in North Dakota.
• Bed Moratorium: Strictly applies to Basic Care Facilities; new beds cannot be created, requiring applicants to acquire existing bed rights before applying.
• RFP/Procurement: None; North Dakota operates an open enrollment fee-for-service network for providers who meet licensure requirements.
• Prerequisite Licensure: Applicants must obtain the ND HHS facility license (Assisted Living or Basic Care) before submitting a Medicaid enrollment application.
• Managed Care Contracting: Not applicable; HCBS waiver services are billed directly to ND Medicaid on a fee-for-service basis.
• HCBS Settings Validation: Facilities must pass a state assessment confirming they are community-integrated and not institutional in nature before Medicaid approval.

4. Licensure and Certification Requirements

Facilities must apply for licensure through the ND HHS Health Facilities Unit. Assisted Living Facilities must comply with North Dakota Century Code requirements regarding tenant rights, lease agreements, and medication administration. Basic Care Facilities are subject to more stringent clinical and environmental regulations outlined in Chapter 33-03-24.1 of the North Dakota Administrative Code.

Before a license is issued, the facility must pass comprehensive architectural plan reviews and on-site inspections. This includes rigorous life safety code evaluations to ensure the physical plant can safely house vulnerable adults.

• Application Form: Submit the formal facility licensure application and architectural plans to the ND HHS Health Facilities Unit.
• Basic Care Regulations: Must strictly comply with North Dakota Administrative Code Chapter 33-03-24.1.
• Life Safety Code: Facilities must pass fire and life safety inspections conducted by the State Fire Marshal.
• Medication Administration: Must meet North Dakota Board of Nursing standards for medication administration and nursing delegation.
• Tenant Agreements: Assisted Living Facilities must utilize state-compliant lease agreements detailing services and eviction protections.
• License Renewal: Facility licensure is mandatory and must be renewed annually with ND HHS.

5. Medicaid Provider Enrollment

Once the facility license is secured, providers must enroll in North Dakota Medicaid via the North Dakota MMIS Web Portal. Because North Dakota delivers HCBS primarily through a fee-for-service model, this state-level enrollment is the central step to begin billing.

The enrollment process requires the submission of the facility's license, ownership disclosures, and a Trading Partner Agreement for electronic billing. The Medical Services Division reviews these applications to ensure all federal and state screening requirements are met.

• Enrollment Portal: Applications must be submitted online through the North Dakota MMIS Web Portal.
• NPI Requirement: Providers must obtain and register a Type 2 (Organizational) National Provider Identifier (NPI).
• Trading Partner Agreement: Required for all billing providers or clearinghouses to exchange electronic data (EDI) with ND Medicaid.
• Application Fee: Subject to the CMS-mandated institutional provider application fee (approximately $731) unless waived by prior Medicare enrollment.
• Ownership Disclosure: Must provide detailed disclosures of all individuals or entities with a 5% or greater ownership interest.
• Processing Time: Credentialing and enrollment typically take 30 to 90 days from the date of a complete submission.

6. Staffing, Training and Background Checks

ND HHS requires strict background screening and training for all facility staff to ensure the safety of waiver participants. Administrators must meet specific educational and experience benchmarks to manage a licensed facility.

Direct care workers must complete state-approved training, particularly regarding medication administration, dementia care, and emergency response. Facilities must maintain sufficient staffing ratios at all times to meet the documented needs of every resident.

• Background Checks: Owners, administrators, and all employees must undergo fingerprint-based criminal background checks.
• Administrator Qualifications: Must meet state-defined educational and experience requirements to operate an Assisted Living or Basic Care Facility.
• Direct Care Training: Staff must complete training on ADL assistance, participant rights, and emergency preparedness before providing independent care.
• Medication Aides: Unlicensed assistive personnel must complete a North Dakota Board of Nursing-approved medication assistant program.
• Staffing Ratios: Must maintain sufficient awake staff 24/7 to meet the care plans of all residents and ensure safe emergency evacuation.
• First Aid/CPR: A designated number of on-shift staff must hold current First Aid and CPR certifications.

7. Documentation, Policies and Records

Providers must maintain comprehensive operational and clinical records subject to audit by the ND HHS Medical Services Division and Health Facilities Unit. Policies must strictly align with the federal HCBS Final Rule, ensuring participant autonomy, privacy, and freedom from coercion.

Clinical documentation must clearly link the services provided to the participant's authorized care plan. Facilities must also maintain clear financial records separating Medicaid-billed services from private room and board charges.

• Service Plans: Must maintain individualized, person-centered care plans updated at least annually or upon a significant change in condition.
• Financial Agreements: Written residency agreements must detail room and board costs entirely separate from Medicaid-covered care services.
• Incident Reporting: Mandatory written policies for documenting and reporting critical incidents, abuse, or neglect to ND HHS within specified timeframes.
• HCBS Compliance: Policies must guarantee residents' rights to lockable doors, choice of roommates, and access to food at any time.
• Medication Records: Must maintain accurate Medication Administration Records (MAR) detailing every dose administered or refused.
• Record Retention: Clinical and billing records must be retained for a minimum of five years per ND Medicaid provider agreements.

8. Billing, Rates and Claims

Billing is conducted through the North Dakota MMIS Web Portal using standard electronic formats (837I or 837P). Providers are reimbursed on a fee-for-service basis according to the ND Medicaid HCBS fee schedule, which establishes specific daily or monthly rates for Assisted Living and Adult Residential Care.

Before any claim can be paid, the services must be prior-authorized in the participant's care plan by their local Human Service Zone case manager. Providers must collect room and board payments directly from the resident.

• Billing System: Claims are submitted electronically via the North Dakota MMIS Web Portal or an approved EDI clearinghouse.
• Reimbursement Model: Fee-for-service based on the published ND Medicaid rate schedule for HCBS waiver services.
• Room and Board: Cannot be billed to Medicaid; must be collected directly from the resident's private income (e.g., SSI or pensions).
• Prior Authorization: Services must be authorized by the Human Service Zone case manager and entered into the MMIS before billing.
• Electronic Remittance: Providers access Electronic Remittance Advice (ERA) through the MMIS portal for payment reconciliation.
• Timely Filing: Claims must generally be submitted within 12 months of the date of service to avoid denial.

9. Approval Sequence and Timeline

The end-to-end process requires sequential approvals, starting with physical plant readiness and ending with MMIS enrollment. Providers should anticipate a 6 to 12-month timeline from initial facility planning to active Medicaid billing status.

Because Medicaid enrollment cannot begin until the facility is fully licensed, any delays in construction, architectural review, or life safety inspections will directly delay the ability to accept waiver participants.

• Step 1: Secure facility location and (if applying for Basic Care) acquire necessary bed capacity rights (1-3 months).
• Step 2: Submit facility licensure application and architectural plans to the ND HHS Health Facilities Unit (2-4 months).
• Step 3: Pass Life Safety and initial health inspections to receive the state facility license (1-2 months).
• Step 4: Submit the Medicaid provider enrollment application via the North Dakota MMIS Web Portal (30-90 days).
• Step 5: Complete HCBS Settings Rule validation with the state.
• Step 6: Receive authorized care plans from Human Service Zones and begin billing for services.

10. Common Denials and Survey Findings

Applications and annual surveys are frequently delayed or cited due to incomplete documentation or failure to meet physical plant standards. ND HHS inspectors rigorously enforce medication management and life safety codes during their unannounced annual surveys.

For Medicaid enrollment, the most common cause of delay is missing ownership disclosures or failure to properly execute the Trading Partner Agreement in the MMIS portal.

• Incomplete Applications: Medicaid enrollment delays due to missing ownership disclosures or incomplete NPI data.
• Life Safety Violations: Citations for failure to maintain fire alarm systems, sprinkler clearances, or unobstructed emergency egress routes.
• Medication Errors: Survey citations for improper storage, expired medications, or lack of nursing delegation documentation.
• HCBS Rule Non-Compliance: Denials or corrective actions for institutional characteristics, such as restrictive visiting hours or lack of privacy.
• Care Plan Deficiencies: Failure to update person-centered service plans to reflect a resident's declining functional status.
• Background Check Gaps: Citations for allowing staff to provide direct care before fingerprint background checks are fully cleared.

11. Key Contacts and Resources

Providers should utilize official ND HHS resources and portals for the most current regulations, fee schedules, and manual updates. The state's MMIS portal is the central hub for all enrollment and billing activities.

Additionally, industry associations like the North Dakota Long Term Care Association (NDLTCA) provide valuable advocacy, training manuals, and support for both Assisted Living and Basic Care providers navigating state rules.

• ND HHS Health Facilities Unit: Primary contact for facility licensure, architectural reviews, and physical plant regulations.
• ND HHS Medical Services Division: Oversees Medicaid policy, waiver administration, and provider enrollment (dhsmed@nd.gov).
• North Dakota MMIS Web Portal: The official system for provider enrollment, Trading Partner Agreements, and claims submission.
• Human Service Zones: Local county offices responsible for participant eligibility, level of care assessments, and case management.
• North Dakota Long Term Care Association (NDLTCA): Industry group offering manuals, training, and support for Assisted Living and Basic Care facilities.
• ND Medicaid Call Center: Available for questions about member eligibility, payments, and general claims (701-328-7098).

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