North Carolina Medicaid Definition
Medicaid is a wide-ranging jointly funded state and federal health care program for low-income people of all ages. While there are several different Medicaid eligibility groups, including pregnant women, children, families, and the disabled, this page is focused on eligibility for North Carolina senior residents (65 and over). Specifically, long-term care Medicaid is covered. In addition to care services in nursing homes and assisted living facilities, NC Medicaid pays for non-medical services and supports to help frail seniors remain living in their homes.
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. These programs have varying eligibility requirements and benefits. Further complicating eligibility are the facts that North Carolina offers multiple pathways towards eligibility and the criteria varies based on marital status.
1) Institutional / Nursing Home Medicaid – This is an entitlement program; Anyone who is eligible will receive assistance. Benefits are provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – This is not an entitlement program; The number of participants is limited and wait lists may exist. Benefits are intended to delay nursing home admissions and may be provided at home, adult day care, or in assisted living. More on Waivers.
3) Regular Medicaid / Aged Blind and Disabled – This is an entitlement program; Anyone who meets the eligibility requirements receives assistance. Limited long-term care services, such as personal care assistance or adult day care, may be available.
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 does not mean one is ineligible or cannot become eligible for Medicaid in North Carolina. More.
|April 2022 – March 2023 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. $5,942 – $7,955 / mo.)*||$2,000||Nursing Home||Must be less than the amount Medicaid pays for nursing home care (est. $5,942 – $7,955 / mo.)*||$3,000||Nursing Home||Must be less than the amount Medicaid pays for nursing home care (est. $5,942 – $7,955 / mo.)*||$2,000 for applicant & $137,400 for non-applicant||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$1,133 / month†||$2,000||Nursing Home||$1,526 / month†||$3,000||Nursing Home||$1,133 / month for the applicant†||$2,000 for applicant & $137,400 for non-applicant||Nursing Home|
|Regular Medicaid / Aged Blind and Disabled||$1,133 / month||$2,000||Help with ADLs||$1,526 / month||$3,000||Help with ADLs||$1,526 / month||$3,000||Help with ADLs|
†Based on one’s living setting, a program beneficiary may not be able to keep monthly income up to this level.
What Defines “Income”
For Medicaid eligibility purposes, any income that a Medicaid applicant receives is counted. 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. Holocaust restitution payments and Covid-19 stimulus checks are not counted as income by Medicaid, and therefore, have no impact on Medicaid eligibility.
When only one spouse of a married couple applies for nursing home Medicaid or a Medicaid Waiver, only the income of the applicant is counted. This means the income of the non-applicant spouse does not impact the income eligibility of their spouse. However, the non-applicant spouse may be entitled to a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their applicant spouse. The MMMNA is a spousal impoverishment rule and is the minimum amount of monthly income a non-applicant spouse is said to require to avoid spousal impoverishment. The MMMNA is $2,288.75 (effective 7/1/22 – 6/30/23). If a non-applicant’s monthly income is under $2,288.75, income can be transferred from their applicant spouse, bringing their income up to this level.
In North Carolina, a non-applicant spouse can further increase their spousal income allowance if their housing and utility costs exceed a “shelter standard” of $686.63 / month (effective 7/1/22 – 6/30/23). However, in 2022, in no case can a spousal income allowance put a non-applicant’s monthly income over $3,435. This is the Maximum Monthly Maintenance Needs Allowance. Learn more about how the spousal allowance is calculated.
Income is counted differently when only one spouse applies for Regular Medicaid; The income of both the applicant spouse and non-applicant spouse is calculated towards the applicant’s income eligibility. For additional information on how Medicaid counts income, click here.
What Defines “Assets”
Countable assets include cash, stocks, bonds, investments, IRAs, 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 generally one’s primary home. For home exemption, the Medicaid applicant must live in it or have intent to return, and in 2022, their home equity interest must be no more than $636,000. The amount of the home’s value owned by the applicant is one’s equity interest. The home is also exempt, regardless of where the applicant lives and their equity interest, if a non-applicant spouse lives in it.
All assets of a married couple are considered jointly owned regardless of the long-term care Medicaid program for which one is applying. However, the non-applicant spouse of a Medicaid nursing home or Waiver applicant is permitted a Community Spouse Resource Allowance (CSRA). In 2022, the community spouse (the non-applicant spouse) can retain 50% of the couples’ joint assets, up to a maximum of $137,400, as the chart indicates above. If the non-applicant’s half of the assets is under $27,480, 100% of the assets, up to $27,480 can be retained by the non-applicant.
North Carolina has a 60-month Medicaid Look-Back Period that immediately precedes one’s Medicaid application date. During this time frame, Medicaid checks all past asset transfers to ensure no assets were sold or given away under fair market value. This includes asset transfers made by one’s spouse. If one has violated the look back rule, it is assumed it was done to meet Medicaid’s asset limit, and a penalty period of Medicaid ineligibility will be calculated.
The U.S. federal gift tax rule, which in 2022, allows individuals to gift up to $16,000 per recipient without incurring taxes, sometimes causes confusion when it comes to Medicaid eligibility. This gift tax rule does not extend to Medicaid, which means it 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 – North Carolina has a Medically Needy program that allows Medicaid applicants who have income over the eligibility limit to still become eligible for Medicaid if they have high medical bills. Also called a “Spend-down” program or a “Medicaid Deductible,” one’s “excess income” is used to cover medical bills, such as insurance premiums, prescription drugs, doctor visits, hospitalizations, and medical supplies. The medically needy income limit has remained the same for many years, and in 2022, continues to be $242 / month for a single individual and $317 / month for a married couple. The “spend down” amount, which can be thought of as a deductible, is the difference between one’s monthly income and the medically needy income limit. In NC, it is calculated for a 6-month period. Once the “spend down” is met, one will be Medicaid eligible for the remainder of the period. The medically needy asset limit is $2,000 for an individual and $3,000 for a couple.
2) Asset Spend Down – Persons who have assets over Medicaid’s asset limit can still qualify for Medicaid by reducing countable assets. 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. Remember, assets cannot be gifted or sold under fair market value. Doing so violates the look back rule and can result in a penalty period of Medicaid ineligibility. It is recommended one keep documentation of how assets were spent as proof the look back rule was not violated.
3) 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 these persons, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible, as well as protect their home from Medicaid estate recovery. 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 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 provide 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, in-home personal care assistance, home modifications, and other services that help disabled or elderly persons live at home. Program participants have the option to self-direct their own care through an option called CAP/Consumer-Directed. This allows beneficiaries to choose their own care providers and allows family members, including adult children and spouses, to be hired as personal caregivers and be paid by the Medicaid program. CAP/Consumer-Directed was previously called Community Alternatives Program for Choice and abbreviated as CAP/Choice.
2) 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. This means it is an entitlement as opposed to CAP/DA, which is approved only for a specific number of beneficiaries and may have waiting lists.
3) Program of All-Inclusive Care for the Elderly (PACE) – The benefits of Medicaid, including long-term care services, and Medicare are combined into one program. Additional benefits, such as dental care and eye care, may be available.
How to Apply for North Carolina Medicaid
Seniors can apply for Medicaid in North Carolina online at ePASS, in person at their local Division of Social Services (DSS) office, or print and submit a completed Medicaid application to their local DSS office. Locations and contact information for local DSS offices can be found here. One’s local DSS office should also be able to provide additional information and application assistance.
It is imperative that North Carolina Medicaid applicants be certain that they meet all eligibility requirements prior to applying for Medicaid benefits. Seniors who are uncertain, 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.