North Carolina Medicaid Personal Care Services Program: Benefits & Eligibility

Last updated: May 27, 2021

 

Overview of North Carolina’s Personal Care Services Program

North Carolina’s Personal Care Services (PCS) Program provides in-home personal care assistance for state residents who cannot independently complete their activities of daily living (ADLs) due to a chronic illness, a disability, or a cognitive impairment. Via PCS, program participants receive help with taking a bath, combing their hair, getting dressed / undressed, using the toilet, mobility, and eating. While this program is relevant for state residents of all ages, it is particularly relevant for the elderly since with aging often comes chronic conditions or cognitive issues, such as those resulting from Alzheimer’s Disease or a related dementia.

Many long-term care Medicaid programs offer a self-directed option, allowing program beneficiaries to hire their own caregiver. The PCS Program does not allow this option. Instead, personal care assistance is provided by licensed personal care service providers. However, program participants do have some flexibility in choice, as they can select their care provider from a list of qualified providers serving their area.

Personal care assistance can be provided in one’s home, an adult care home (assisted living facility), a family care home (adult foster care home), and some group homes, such as those for persons with mental illness or developmental disabilities.

The Personal Care Services Program is part of North Carolina’s regular state Medicaid program. It is an entitlement program, which means meeting eligibility requirements equates to immediate receipt of program benefits. Stated differently, there is never a waitlist to receive personal care assistance.

 HCBS Medicaid Waivers versus HCBS State Plan Medicaid?
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

 

Benefits of the Personal Care Services Program

Program beneficiaries receive up to 130 hours per month of assistance with the daily living activities listed below. The number of hours one can receive assistance is based on a functional needs assessment.

– Bathing / Showering – includes personal hygiene tasks (i.e., combing hair and brushing teeth)
– Dressing – putting on & taking off clothing
– Mobility – getting in / out of wheelchair, walking from one room to another
– Toileting – using the toilet and cleaning up oneself
– Eating – using a fork and getting food in the mouth, drinking from a glass

Other assistance, when directly related to the above tasks, may be provided. This might include light housecleaning, such as cleaning up the kitchen after meals or washing bath towels after bathing.

 

Eligibility Requirements for Personal Care Services Program

 The American Council on Aging provides a quick and easy Medicaid eligibility test for NC seniors. Start here

The PCS Program is for North Carolina residents who have a medical condition, cognitive impairment, or a physical or developmental disability that results in the need for personal care assistance. Additional eligibility criteria are as follows:

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. However, for NC Medicaid, the income limits increase each April. For aged, blind and disabled Medicaid, the effective income limit from April 2021 – March 2022 is $1,073 / month for a single applicant. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,452.

 While many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, the Personal Care Services Program does not. In contrast, North Carolina’s Community Alternatives Program for Disabled Adults (CAP/DA) does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants. Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, this is not relevant for the Personal Care Services Program. In other words, the look back period is not applicable.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our NC Medicaid spend down calculator

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, North Carolina Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A non-applicant spouse lives in the home.
– The applicant has a dependent relative living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require assistance with their daily living activities as determined by an in-home functional assessment. The five ADLs that are considered are bathing, dressing, toileting, mobility, and eating. As part of the assessment, applicants are asked to imitate how they do specific tasks. This might include pretending to change clothing, preparing a meal, walking from the living room to the toilet, and sitting down / getting up from the toilet. Input from relatives and other persons familiar with the applicant’s situation and capability to complete these activities is included in the assessment process. To meet the functional criteria, one of the following statements must be true:

– The applicant requires limited hands on assistance with 3 of the 5 ADLs
– The applicant requires extensive assistance with 2 of the 5 ADLs
– The applicant is 100% dependent with 2 of the 5 ADLs

Furthermore, a “Request for Independent Assessment for Personal Care Services (PCS) Attestation of Medical Need Instructions” must be completed by a doctor. This form verifies that the applicant requires assistance with their daily living activities.

 For more information about long-term care Medicaid in North Carolina, click here

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

NC Medicaid has a Medically Needy Program for Medicaid applicants who have high medical expenses relative to their income. Sometimes called a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to become income eligible for Medicaid.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on home improvements (i.e., updating plumbing, replacing a water heater), home modifications (i.e., adding a first floor bedroom, addition of grab bars), and replacing an older car with a newer one. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of North Carolina to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month look back rule is not applicable to the Personal Care Services Program, some applicants will require more extensive care, such as nursing home Medicaid or home and community based services via a Medicaid Waiver in the future. For these programs, the look back rule is relevant. Therefore, while there are many planning strategies, they should only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the Personal Care Services Program

Before You Apply

Prior to submitting an application for the Personal Care Services Program, applicants need to ensure they meet the eligibility criteria for NC Medicaid. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, proof of income, copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for the Personal Care Services Program, applicants must be enrolled in North Carolina’s Medicaid program. Persons can apply for Medicaid via North Carolina’s Department of Health and Human Services’ Division of Social Services. Contact information can be found here.

To receive assistance via PCS, an applicant’s doctor must 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. LHC-NC is contracted by NC Medicaid to complete the functional assessments for PCS eligibility. An in-home assessment with a nurse will be scheduled. Questions can be directed to Liberty Healthcare at 919-322-5944 or 855-740-1400. On average, persons should expect the assessment process to take about 3 – 4 weeks.

For additional information about the Personal Care Services Program, click here. The NC Medicaid Division of Health Benefits (NCDHHS) administers the Personal Care Services Program.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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