North Carolina Medicaid Long Term Care Programs, Benefits & Eligibility Requirements
Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on North Carolina Medicaid Long Term Care, which is different from regular Medicaid. Medicaid will help pay for long-term care for North Carolina residents in a nursing home, in their home and in other residential settings through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid.
North Carolina Medicaid Long Term Care Programs
Nursing Home / Institutional Medicaid
North Carolina Medicaid will cover the cost of long term care in a nursing home for eligible North Carolina residents through its Nursing Home / Institutional Medicaid. This includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with Activities of Daily Living (eating, bathing, moving, dressing, toileting).
Some of the things that North Carolina Medicaid won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.
Any North Carolina Medicaid beneficiary who receives Nursing Home Medicaid coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $30 / month. This can be spent on personal items such as clothes, snacks, books, haircuts, cell phones, etc. It cannot be spent on any item that Medicaid covers, including hygiene basics like a toothbrush, soap, deodorant, razors and incontinence supplies, unless the Medicaid beneficiary wants a specific brand that is not covered by North Carolina Medicaid. In this case, they could spend their personal needs allowance on the item.
Home and Community Based Service (HCBS) Waivers
Home and Community Based Service (HCBS) Waivers will pay for long-term care goods and services that help North Carolina Medicaid recipients who require a Nursing Facility Level of Care remain living “in the community” instead of moving to a nursing home. Living “in the community” can mean living in their home or the home of a loved one. Unlike Nursing Home Medicaid, HCBS Waivers are not an entitlement. This means that even if an applicant is eligible for an HCBS Waiver, they are not guaranteed by law to receive the benefits.
Community Alternatives Program for Disabled Adults Waiver (CAP/DA)
The name for this North Carolina Home and Community Based Service Waiver can be misleading, because the Community Alternatives Program for Disabled Adults Waiver (CAP/DA) is for seniors (age 65+) who have a functional need for care assistance as well as for disabled adults age 21-64. The CAP/DA Waiver provides long-term care supports and services for North Carolina residents who require a Nursing Facility Level of Care (NFLOC), but instead live in their home or the home of a loved one. CAP/DA benefits are not available for people who live in assisted living residences or adult foster care homes.
CAP/DA Waiver beneficiaries receive program benefits depending on their needs and circumstances. These benefits can include adult day care, home modifications, medical supplies, meal delivery, personal emergency response services and personal assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). These services can be provided by licensed care workers, or program participants have the ability to self-direct their care services through the CAP/Consumer-Directed option. This allows CAP/DA Waiver beneficiaries to choose their own caregivers (like friends and family members, including spouses and adult children) for certain services.
Like all HCBS Waivers, the CAP/DA Waiver is not an entitlement. This means that even if an applicant is eligible, they are not guaranteed to receive the benefits. Instead, there are a limited number of enrollment spots and once those spots are full any additional eligible applicants will be placed on a waiting list. Currently, the CAP/DA Waiver is approved for a maximum of 13,588 program participants per year.
Aged Blind and Disabled / Regular Medicaid
North Carolina’s Aged Blind and Disabled (ABD) Medicaid, also known as Regular Medicaid for seniors, provides healthcare and personal service benefits to low-income North Carolina residents who are aged (65 and older) or disabled and live “in the community.” Living “in the community” can mean living in their home, the home of a loved one, an assisted living facility, an adult foster care home or some group homes, such as those for people with mental illness or developmental disabilities. While ABD Medicaid will cover services in all of those settings, it will not cover room and board costs.
ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait. This includes a variety of long-term care benefits such as adult day care, doctor’s visits, skilled nursing care, in-home personal care, prescription assistance and transportation. ABD Medicaid beneficiaries qualify for these benefits and services one at a time, which is different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. Instead, ABD Medicaid recipients will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.
There are two programs available through ABD Medicaid relevant to persons requiring long term care.
Personal Care Services (PCS) Program
North Carolina Aged Blind and Disabled (ABD) Medicaid recipients can also enroll in the Personal Care Services (PCS) Program for long-term care support. This program provides an in-home personal care attendant for people who need help with their Activities of Daily Living (mobility, bathing, dressing, eating, toileting) due to chronic illness, disability or cognitive impairment. The personal care attendant can provide services in the beneficiary’s home, the home of a loved one, an assisted living facility, an adult foster care home and some group homes, like those for people with mental illness or developmental disabilities.
The PCS Program will provide up to 130 hours per month of personal care attendant services. While these services are focused on the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), the care attendant may also provide some housekeeping help.
In order to be eligible for this program, applicants must need limited hands-on assistance with three of the five Activities of Daily Living (mobility, bathing, dressing, eating, toileting), or need extensive help with two of the five Activities of Daily Living.
Program of All-Inclusive Care for the Elderly (PACE)
Elderly (age 65 and up) North Carolina residents who have Aged Blind and Disabled (ABD) Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE is intended to help North Carolina residents who need a Nursing Facility Level of Care but want to keep residing and receiving care in their home or somewhere else in the community. This program can be used by people who are “dual eligible” for Medicaid and Medicare and will help them coordinate the care from those two programs. The National PACE Association can help locate a PACE program near you.
Eligibility Criteria For North Carolina Medicaid’s Long Term Care Programs
To be eligible for North Carolina Medicaid, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid. In North Carolina, some of the financial requirements also vary depending on the cost of nursing home care in the applicant’s area.
North Carolina Medicaid Nursing Home Medicaid Eligibility Criteria
Financial Requirements
North Carolina residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid. For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The income limit for a single applicant is the amount North Carolina Medicaid pays for nursing home care in the applicant’s area of residence, which is estimated to be between $5,942 – $7,955 / month in 2022. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Nursing Home Medicaid recipients are only allowed to keep $30 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.
For married applicants with both spouses applying, the 2022 asset limit for Nursing Home Medicaid through North Carolina Medicaid is $3,000 combined, and the income limit is the amount North Carolina Medicaid pays for nursing home care in their area of residence, which is estimated to be between $5,942 – $7,955 / month in 2022. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse. The income limit for the applicant is the amount North Carolina Medicaid pays for nursing home care in their area of residence, which is estimated to be between $5,942 – $7,955 / month in 2022. The income of the non-applicant spouse is not counted.
North Carolina Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, North Carolina Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Nursing Home Medicaid in North Carolina is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.
North Carolina Home and Community Based Service (HCBS) Waivers Eligibility Criteria
Financial Requirements
North Carolina residents have to meet an asset limit and an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2022, the asset limit for HCBS Waivers in North Carolina is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $1,133 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants with both spouses applying, the 2022 asset limit for HCBS Waivers in North Carolina is $3,000 combined, and the income limit is $1,526 / month combined. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse, and the income limit is $1,133 / month for the applicant. The income of the non-applicant spouse is not counted.
North Carolina Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, North Carolina Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers in North Carolina is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.
North Carolina Aged Blind and Disabled Medicaid Eligibility Criteria
Financial Requirements
North Carolina residents have to meet an asset limit and an income limit in order to be financially eligible for Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid. For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $1,133 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants, the 2022 asset limit for North Carolina ABD Medicaid is $3,000 combined between the two applicants/spouses, and the income limit is a combined $1,526 / month. These limits are used for both married couples with both spouses applying for ABD Medicaid and married couples with only one spouse applying.
North Carolina Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, North Carolina Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional requirements for North Carolina Aged Blind and Disabled (ABD) Medicaid are being disabled, blind or aged (65 or over), and needing help with Activities of Daily Living (mobility, bathing, dressing, eating, toileting). North Carolina Medicaid will conduct an assessment of ABD Medicaid applicants and their ability to perform Activities of Daily Living to determine the kind of services the beneficiary needs and the state will cover.
One’s home is often their most valuable asset, and if counted toward North Carolina’s Medicaid asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest is less than $636,000 (as of 2022), then the home is exempt from the asset limit. Home equity interest is portion of the home’s equity value that the applicant owns, and the home’s equity value is the current value of the home minus any outstanding mortgage / debt against the home. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $636,000. These rules apply to all three types of Medicaid.
Applying For North Carolina Medicaid Long Term Care Programs
The first step in applying for a North Carolina Medicaid Long Term Care program is deciding which of the three programs discussed above you or your loved one wants to apply for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled (ABD) Medicaid / Regular Medicaid.
The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for North Carolina Medicaid when not financially eligible will result in the application, and benefits, being denied.
During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the North Carolina Medicaid applicant. These documents will be needed for the official North Carolina Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.
After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, North Carolina residents can apply for Medicaid online at ePASS. They can also apply in person at their local Division of Social Services (DSS) office. Or they can print out an application here and return it to their local DSS office.
To apply for the Community Alternatives Program for Disabled Adults (CAP/DA) Waiver, applicants must complete a referral request form and fax it to North Carolina Medicaid at 919-715-0052. Individuals can also contact a local CAP/DA case manager for help.
To apply for the Personal Care Services (PCS) Program, North Carolina residents must have their doctor fill out Form DMA-3051 (Request for Independent Assessment for Personal Care Services Attestation of Medical Need) and fax it to Liberty Healthcare of North Carolina (LHC-NC) at 919-307-8307. After this is done, an in-home assessment with a nurse will be scheduled. Questions on this process can be directed to LHC-NC at 919-322-5944.
Choosing a North Carolina Medicaid Nursing Home
After an applicant has been approved for Nursing Home Medicaid through North Carolina Medicaid, they need to choose which Medicaid-approved nursing home they will live in. Even though Nursing Home Medicaid is an entitlement, North Carolina Medicaid will only cover stays and care in approved nursing homes. North Carolina residents can find and compare nursing homes using this North Carolina Healthcare Facilities Association searchable directory. They can also use Nursing Home Compare, which is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.