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.
The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a North Carolina 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.
|2020 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||**Must be less than the amount Medicaid pays for nursing home care (est. $5K – $7K / mo.)||$2,000||Nursing Home||**Must be less than the amount Medicaid pays for nursing home care (est. $5K – $7K / mo. per spouse)||$3,000||Nursing Home||**Must be less than the amount Medicaid pays for nursing home care (est. $5K – $7K / mo.)||$2,000 for applicant & $128,640 for non-applicant||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$1,064 / month||$2,000||Help w/ 2 Activities of Daily Living||$1,437 / month||$3,000||Help w/ 2 Activities of Daily Living||$1,064 / month for applicant||$2,000 for applicant & $128,640 for non-applicant||Help w/ 2 Activities of Daily Living|
|Regular Medicaid / Aged Blind and Disabled||$1,064 / month||$2,000||None||$1,437 / month||$3,000||None||$1,437 / month||$3,000||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.
When only one spouse of a married couple is applying for nursing home Medicaid or a Medicaid waiver, only the income of the applicant is counted. Said another way, the income of the non-applicant spouse is disregarded. However, for a married couple with just one spouse applying for Regular Medicaid, the income of both spouses is counted towards the income limit. For additional information on how Medicaid counts income, click here.
There is a Minimum Monthly Maintenance Needs Allowance (MMMNA), which is the minimum amount of monthly income to which the non-applicant spouse of a spouse applying for nursing home Medicaid or a Medicaid waiver is entitled. As of July 2019, this figure is $2,113.75 / month, and will increase again in July 2020. Simply put, if the non-applicant spouse has monthly income under $2,113.75, the applicant spouse can transfer a portion of his/her income to bring the non-applicant spouse’s income up to this level. Based on the non-applicant’s shelter costs (mortgage, rent, utility bills), he/she may be entitled to an even greater spousal allowance. The maximum monthly maintenance needs allowance, as of January 2020 (it will increase again in January 2021), is $3,216. This spousal impoverishment rule is intended to prevent the non-applicant spouse from having too little income from which to live. To be very clear, when one spouse of a married couple applies for Regular Medicaid, the non-applicant spouse is not entitled to an income allowance from his/her applicant spouse.
*Unlike many states that change their income limits the beginning of each year, the income limits in North Carolina are updated annually in April.
** While the Medicaid-funded rate for nursing homes varies based on geographic location, the approximate rate ranges from $4,966 per month to $7,191 per month.
What Defines “Assets”
Countable assets include cash, stocks, bonds, investments, credit union, savings, 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/her spouse lives in the home and the home is valued under $595,000 (in 2020).
For married couples with one spouse as a Medicaid nursing home or Medicaid waiver applicant, the non-applicant spouse is entitled to an asset allowance. This, in Medicaid speak, is referred to as the Community Spouse Resource Allowance (CSRA). As of 2020, the community spouse (the non-applicant spouse) can retain half of the couple’s joint assets, up to a maximum of $128,640, as the chart indicates above. There is also a minimum CSRA, which is set at $25,728, and enables the community spouse to keep 100% of the couple’s joint assets up to this amount.
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.
Also important is the U.S. federal gift tax rule, which allows individuals to give away a certain amount of their money without incurring taxes ($15,000 / recipient in 2020). 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. Please note that the medically needy income limits are lower than the income limits listed in the chart above. As of April 2020, the medically needy income limits are $242 for a single individual and $317 for a married couple.
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.
How to Apply for North Carolina Medicaid
To apply for Medicaid in North Carolina, seniors can apply online at ePASS, go to their local Division of Social Services (DSS) office and apply in person, or print and submit a completed Medicaid application to their local DSS office. Persons can also contact their local DSS office for more information or for application assistance. Find the location and contact information of your local DSS office here.
It is imperative that North Carolina Medicaid applicants be certain that they meet all eligibility requirements, which are covered in detail above, prior to applying for Medicaid benefits. Seniors who are uncertain as to whether they meet the criteria, or who have excess income and / or assets, should make preparations to ensure all eligibility requirements will be met. This is where Medicaid planning comes in. Applying for Medicaid can be a difficult and drawn out process, and if not done correctly, it can cause a delay or denial of benefits. To learn more about the application process for long-term care Medicaid, click here.