Summary
Medicaid’s rules, benefits and name can all vary by state. In North Carolina, Medicaid is run by the Division of Medical Assistance (DMA). This article focuses on North Carolina Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers and ABD Medicaid. This is different than regular Medicaid, which is for financially limited people of all ages.
North Carolina Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited North Carolina seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:
Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.
North Carolina Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are allowed to keep a “personal needs allowance” (PNA) of $30/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid recipients.
North Carolina Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.
A Nursing Home Alternative – North Carolina Nursing Home Medicaid beneficiaries who want to leave their nursing home and return to living “in the community” can receive financial and functional help with that transition through the Money Follows the Person program (MFP). This help can include paying for moving expenses, as well as long-term care services and supports in the new residence. MFP beneficiaries must be moving from a Medicaid-approved facility and into their own home, the home of a relative or a small group home with a maximum of four unrelated residents.
North Carolina’s Home and Community Based Services (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. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for North Carolina residents who live in their home or the home of a loved one. While North Carolina’s HCBS Waivers will cover some long-term care services in those settings, it will not cover room and board costs, such as mortgage payments, rent, utilities or food expenses.
The HCBS Waiver relevant to North Carolina seniors is the Community Alternatives Program for Disabled Adults Waiver.
Community Alternatives Program for Disabled Adults Waiver (CAP/DA)
The name for this HCBS Waiver can be misleading because it can be used by seniors (65 and over) who have a functional need for care assistance as well as for disabled adults age 21-64. The CAP/DA Waiver is for North Carolina residents who require a Nursing Facility Level of Care but live in their own home or the home of a loved one instead. CAP/DA benefits are not available for people who live in assisted living residences or adult foster care homes.
CAP/DA Waiver benefits 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). Program participants receive these benefits depending on their needs and circumstances.
CAP/DA Waiver benefits can be provided by licensed care workers, or program participants have the ability to self-direct their care through the CAP/Consumer-Directed option. This allows CAP/DA Waiver beneficiaries to choose their own caregivers for certain services, including friends, family members and even spouses.
Unlike Nursing Home Medicaid, the CAP/DA Waiver is not an entitlement. Instead, there are a limited number of enrollment spots (approximately 13,500 per year), and once those spots are full additional applicants will be placed on a waitlist.
North Carolina’s Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to financially limited North Carolina residents who are aged (65 and older), blind or disabled. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via ABD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.
1. ABD Long Term Care Benefits
Eligible North Carolina seniors who show a medical need for long-term care goods and services can receive those goods and services through ABD Medicaid. These benefits can include case management, adult day care, meal delivery, home modifications and Personal Emergency Response Systems (PERS). ABD Medicaid recipients qualify for these benefits one at a time. This is different from Nursing Home Medicaid, which makes all of its benefits immediately available for anyone who qualifies. Instead, North Carolina seniors will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.
2. Personal Care Services (PCS) Program
North Carolina’s Personal Care Services (PCS) Program provides an in-home personal caregiver for ABD Medicaid recipients 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. While the PCS Program will pay for a caregiver in those settings, it will not cover room and board costs.
The PCS Program will provide up to 130 hours per month of personal caregiver services. While these services are focused on the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), the caregiver 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.
3. Program of All-Inclusive Care for the Elderly (PACE)
North Carolina residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. North Carolina’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. North Carolina’s PACE programs are located Asheboro (Randolph Health StayWell Senior Care), Asheville (CarePartners PACE), Chapel Hill (Piedmont Health SeniorCare), Charlotte (PACE of the Southern Piedmont), Durham (Senior CommUnity Care of North Carolina), Fayetteville (LIFE St. Joseph of the PINES), Gastonia (Senior TLC), Greensboro (PACE of the Triad), Lexington (Carolina SeniorCare), Newton (PACE@Home) and Wilmington (Elderhaus PACE). To learn more about PACE, click here.
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 Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid. In North Carolina, some of the financial requirements also vary depending on the cost of nursing home care in the applicant’s area.
Just For You: The easiest way to find the most current North Carolina Medicaid eligibility criteria for your specific situation is to use our Medicaid Eligibility Requirements Finder tool.
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. The asset limit for a single applicant from April 2024 to March 2025 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 How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant 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. This amount will vary depending on where you are in the state, but it can run as much as $9,000/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. However, North Carolina Nursing Home Medicaid recipients are required to give most of their income to the state to help cover the cost of care. They are only allowed to keep $30/month of their income as a “personal needs allowance,” plus enough to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy spouses who are not covered by Medicaid.
For married applicants with both spouses applying, the asset limit for North Carolina Nursing Home Medicaid from April 2024 to March 2025 is a combined $3,000, and the income limit is the amount North Carolina Medicaid pays for nursing home care in their area of residence. For a married applicant with just one spouse applying, the asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit for the applicant is the amount North Carolina Medicaid pays for nursing home care in their area of residence, which, again, can run as much as $9,000/month. The income of the non-applicant spouse is not counted.
Plan Ahead: There are alternative pathways to eligibility for North Carolina Nursing Home Medicaid applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, North Carolina has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid 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 is normally associated with nursing homes. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals. The assessment will evaluate the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as cognitive and behavioral issues.
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 Services (HCBS) Waivers. The asset limit for a single applicant from April 2024 to March 2025 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 How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The income limit for HCBS Waivers in North Carolina for a single applicant from April 2024 to March 2025 is $1,255/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 asset limit for HCBS Waivers in North Carolina from April 2024 to March 2025 is a combined $3,000, and the income limit is a combined $1,704/month. For a married applicant with just one spouse applying, the asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit for the applicant is $1,255/month and the income of the non-applicant spouse is not counted.
Plan Ahead: There are alternative pathways to eligibility for North Carolina HCBS Waiver applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, North Carolina 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 Services (HCBS) Waivers in North Carolina is needing a Nursing Facility Level of Care, which means the applicant requires the kind of full-time care that is usually associated with a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals. The assessment will evaluate the applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as any cognitive or behavioral issues.
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. The asset limit for a single applicant from April 2024 to March 2025 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 How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The income limit for North Carolina ABD Medicaid for a single applicant from April 2024 to March 2025 is $1,255/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 asset limit for North Carolina ABD Medicaid from April 2024 to March 2025 is a combined $3,000, and the income limit is a combined $1,704/month. These limits are used for both married couples with both spouses applying for ABD Medicaid and married couples with only one spouse applying.
Plan Ahead: There are alternative pathways to eligibility for North Carolina ABD Medicaid applicants who are over the asset limit and/or the income limit, such as Medicaid Planning. While North Carolina has a Look-Back Period of five years for Nursing Home Medicaid and Home and Community Based Services Waivers applicants to make sure they don’t give away their assets to get under the limit, there is no Look-Back Period for ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid, or an HCBS Waiver, and those programs will deny or penalize the applicant for giving away assets.
Functional Requirements
The only functional requirement to receive basic healthcare coverage through North Carolina ABD Medicaid is being aged (65 and over), blind or disabled. For ABD Medicaid applicants and beneficiaries who require long-term care services and supports, the state will administer an assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and Instrumental Activities of Daily Living (which include shopping, cooking, housekeeping and medication management) to determine the kind of long-term care benefits the state will cover.
One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:
These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.
North Carolina Medicaid Long Term Care applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in North Carolina and how you can protect your home from it, click here.
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 Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) 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 may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.
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.
For a comprehensive guide that will take you through the application process for all three types of Medicaid Long Term Care, click on the program you want: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.
Professional Help: Many seniors need support when it comes to Medicaid Long Term Care’s rules, benefits and application process. These are all complicated, constantly changing and vary by state. The best place to get help with Medicaid Long Term Care is through a professional like a Certified Medicaid Planner or an Elder Law Attorney.
After being approved for Nursing Home Medicaid through North Carolina Medicaid, you or your loved one needs to choose which Medicaid-accepting nursing home you will live in. Even though Nursing Home Medicaid is an entitlement, not all nursing homes take Medicaid, and those that do may not have any available beds. Finding a nursing home that meets all your needs can be a chore, especially if you’re looking in a specific part of the state.
North Carolina has roughly 425 nursing homes that are spread throughout the state with clusters around the larger cities. There are about 50 nursing homes within 25 miles of Charlotte that accept Medicaid. The Raleigh/Durham area, including Cary, has around 30 facilities take Medicaid. There are about a dozen facilities in both the Greensboro and Winston-Salem areas, and there are roughly 15 nursing homes around Fayetteville that accept Medicaid. Moving to the coast, there are another 15 or so nursing homes in the Wilmington area that take Medicaid, four in Morehead City and four in Elizabeth City. In the western part of the state, there are about 30 nursing homes that accept Medicaid around Asheville.
TOOLS: To find and compare nursing homes, North Carolina residents can use Nursing Home Compare, which is a search tool administered by the Centers for Medicare & Medicaid Services (CMS) that has information on more than 15,000 nursing homes across the country. They can also use this interactive map from the North Carolina Health Care Facilities Association to find facilities in their area.
When you’ve found nursing homes in your area that accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. And you can contact your local Area Agency on Aging to find out more information about nursing homes in North Carolina.
After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: Does the residence offer social activities? How does it handle dental and vision care? Who are the staff doctors? What is the food like? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.
CMS data collected from 2019-2022 shows that just 3.6% of residents in North Carolina nursing homes had depressive symptoms, which is less than half of the national average of 8.1%. North Carolina nursing homes also fared well when it came to fire inspections. They averaged just 8.8 fire safety deficiencies that led to citations during that three-year period from 2019-2022, while the national average was 13.5.
If you need Medicaid long term care but do not meet the financial eligibility criteria, consider working with a Medicaid Planning professional. These fee-based experts help families structure their finances to become eligible, while streamlining the application process and preserving assets for spouses and family members.
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