North Carolina Medicaid Definition
Medicaid is a wide-ranging, jointly funded state and federal health care program for low-income people of all ages, including pregnant women, children, families, disabled, and the elderly. However, this page is focused on Medicaid eligibility for North Carolina senior residents (65 and over), and specifically for long-term care Medicaid, whether that is in one’s home, a nursing home facility or in assisted living. The North Carolina Department of Health and Human Services’ Division of Medical Assistance (DMA) administers North Carolina’s Medicaid Programs.
Income & Asset Limits for Eligibility
There are several different Medicaid long-term care programs for which North Carolina seniors may be eligible, and the eligibility requirements and benefits vary based on the program. Further complicating eligibility is the fact that not only does the state of North Carolina offer multiple pathways towards eligibility, but the criteria also varies based on if one is single or married.
1) Institutional / Nursing Home Medicaid – is an entitlement (anyone who is eligible will receive assistance) & is provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – Limited number of participants, and waiting lists may exist. Provided at home, adult day care, or in assisted living.
3) Regular Medicaid / Aged Blind and Disabled – is an entitlement (meeting the eligibility requirements guarantees assistance) and is provided at home or adult day care.
As mentioned above, eligibility for these programs is complicated by the facts that the criteria vary with marital status and that North Carolina offers multiple pathways towards eligibility. The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a Medicaid program. Alternatively, one can take the Medicaid Eligibility Test. IMPORTANT: Not meeting all of the criteria below does not mean one is not eligible or cannot become eligible for Medicaid in North Carolina. More.
|2019 North Carolina Medicaid Long Term Care Eligibility for Seniors|
|Type of Medicaid||Single||Married (both spouses applying)||Married (one spouse applying)|
|Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required|
|Institutional / Nursing Home Medicaid||$1,041 / month||$2,000||Nursing Home||$1,409 / month||$3,000||Nursing Home||$1,041 / month for applicant||$2,000 for applicant & $126,420 for non-applicant||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$1,041 / month||$2,000||Help w/ 2 Activities of Daily Living||$1,409 / month||$3,000||Help w/ 2 Activities of Daily Living||$1,041 / month for applicant||$2,000 for applicant & $126,420 for non-applicant||Help w/ 2 Activities of Daily Living|
|Regular Medicaid / Aged Blind and Disabled||$1,041 / month||$2,000||None||$1,409 / month||$3,000||None||$1,041 / month||$2,000 for applicant & $126,420 for non-applicant||None|
What Defines “Income”
For Medicaid eligibility purposes, any income that a Medicaid applicant receives is counted. To clarify, this income can come from any source. Examples include employment wages, alimony payments, pension payments, Social Security Disability Income, Social Security Income, IRA withdrawals, and stock dividends. However, when only one spouse of a married couple is applying for Medicaid, only the income of the applicant is counted. Said another way, the income of the non-applicant spouse is disregarded. There is also a Minimum Monthly Maintenance Needs Allowance (MMMNA), which is the minimum amount of monthly income to which the non-applicant spouse is entitled. As of July 2018, this figure is $2,057.50 / month, and will increase again in July 2019. Based on one’s shelter costs (mortgage, rent, utility bills), one may be entitled to an even greater spousal allowance. The maximum monthly maintenance needs allowance, as of January 2019 (it will increase again in January 2020), is $3,160.50 / month. This spousal impoverishment rule allows the Medicaid applicant to transfer income to the non-applicant spouse to ensure he or she has sufficient funds with which to live. (For additional information on how Medicaid counts income, click here).
What Defines “Assets”
Countable assets include cash, stocks, bonds, investments, credit union, savings, and checking accounts, and real estate in which one does not reside. However, for Medicaid eligibility, there are many assets that are considered exempt (non-countable). Exemptions include personal belongings, household furnishings, an automobile, irrevocable burial trusts, and one’s primary home, given the Medicaid applicant or his or her spouse lives in the home and the home is valued under $585,000 (in 2019). For married couples, as of 2019, the community spouse (the non-applicant spouse) can retain up to a maximum of $126,420 of the couple’s joint assets, as the chart indicates above. This, in Medicaid speak, is referred to as the Community Spouse Resource Allowance (CSRA).
It’s important to be aware that North Carolina has a 5-year Medicaid Look-Back Period. This is a period of 5 years in which Medicaid checks to ensure no assets were sold or given away under fair market value in order to meet Medicaid’s asset limit. If one is found to be in violation of the look-back period, a period of Medicaid ineligibility will ensue.
It’s also important to mention the U.S. federal gift tax rule, which allows individuals to give away a certain amount of their money without incurring taxes ($15,000 in 2019). Unfortunately, this gift tax rule sometimes causes confusion in regards to Medicaid’s look-back period. However, to be clear, if one does “gift” money during the 5-year look-back period, this is a violation of the look-back period. Said another way, the federal gift tax rule is not exempt from Medicaid’s 5-year look-back period.
Qualifying When Over the Limits
For North Carolina residents, 65 and over who do not meet the eligibility requirements in the table above, there are other ways to qualify for Medicaid.
1) Medically Needy Pathway –via the Medically Needy Pathway, Medicaid applicants who have income over the eligibility limit may still be eligible for Medicaid services, given they have high medical expenses in comparison to their income. In North Carolina, this program is called the Medically Needy program. Sometimes referred to as a “Spend-down” program, or a “Medicaid Deductible”, the way this program works is one’s “excess income,” (income over the Medicaid eligibility limit), is used to cover medical bills, which may include insurance premiums, prescription drugs, doctor visits, hospitalizations, and medical supplies.
North Carolina has a six-month period for one to meet their “Medicaid deductible”, or said another way, to “spend-down” their excess income to the Medicaid eligibility limit. Once the deductible has been met, one will qualify for Medicaid for the remainder of the six-month period.
Unfortunately, the Medically Needy Pathway does not assist one in spending down extra assets in order to meet Medicaid qualification. Therefore, if one meets the income requirement for Medicaid eligibility, but not the asset requirement, the above program cannot assist one in “spending down” extra assets. However, one can “spend down” assets by spending excess assets on ones that are non-countable, such as home improvements (installing new air conditioning, purchasing new furniture), home modifications (wheelchair ramps, grab bars, stair lifts), prepaying funeral and burial expenses, and paying off debt.
2) Medicaid Planning – the majority of persons considering Medicaid are “over-income” or “over-asset” or both, but still cannot afford their cost of care. For persons in this situation, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible. Read more or connect with a Medicaid planner.
Specific North Carolina Medicaid Programs
Like all states, North Carolina pays for nursing home care for those persons who medically require a nursing home level of care and who are financially eligible. NC also has several programs for seniors who require nursing home level care or have slightly lesser care requirements and do not wish to reside in a nursing home. These programs provides care at home or “in the community”.
1) Community Alternatives Program for Disabled Adults Waiver – commonly referred to as the CAP/DA Waiver, this program will pay for adult day care, home care, home modifications and other services that help disabled or elderly persons live at home.
2) Community Alternatives Program / Choice – called CAP/Choice for short, this is less a distinct program and more an alternative way for persons to receive services under CAP/DA. CAP/Choice allows beneficiaries to choose their care providers. Under CAP/Choice, family members can be hired as personal caregivers and paid by the Medicaid program.
3) Personal Care Services (PCS) – this Medicaid service provides for a personal care attendant in the home for an approved number of hours. It is a regular Medicaid program, which means it is an entitlement as opposed to CAP/DA and CAP/Choice, which are approved only for a specific number of beneficiaries and may have waiting lists.