Medicaid for nursing home and home care in North Carolina

Who qualifies

North Carolina covers long-term care under Medicaid for the Aged, Blind and Disabled (MAABD). You must be 65 or older, blind or disabled, live in North Carolina, and need the level of care a nursing home gives.

The income test

North Carolina does not use a single income limit for nursing home care. The county compares your income with what the nursing home charges. If your countable income is at or below the facility's private-pay rate, you are financially eligible. If it is higher, the county looks at your expected medical costs to see if you still have an unmet need. So apply even if your income seems high.

For CAP/DA, only your own income counts, starting the month CAP is approved. Your spouse's income is not counted against you.

What counts and what does not

Savings that count include cash, bank accounts, stocks and similar things you could turn into cash.

Things that do not count include:

• Your home, if it is your main residence. But for nursing home or CAP care, your equity in the home must be under a set limit, which changes each January. Ask your DSS for the current amount. The limit does not apply if your spouse, a child under 21, or a blind or disabled child of any age lives there.
• Burial money: up to $1,500 of savings set aside for burial, plus burial spaces.
• Business property used in a trade or business.

Gifts and transfers. The county looks back 60 months (5 years) for money or property you gave away or sold for less than it was worth. A transfer can cause a waiting period for nursing home care and for CAP services.

What Medicaid pays for

Nursing home care

Medicaid pays the nursing home. You keep $70 a month for personal needs. Most of the rest of your income goes to the nursing home. This is called your patient monthly liability. Before that is figured, the county takes off:

• money for a spouse or dependent family member at home (see below), and
• private health insurance premiums you pay, such as a Medicare supplement.

Report changes in income or costs within 10 days.

CAP/DA: care at home

The Community Alternatives Program for Disabled Adults (CAP/DA) is a Medicaid waiver for adults 18 and older with disabilities who need a nursing home level of care, and for people 65 and older at risk of going into a nursing home. It can pay for:

• personal care aides, meal preparation and delivery
• adult day health and respite for family caregivers
• home changes for access, medical equipment and supplies
• an emergency response button
• case management

Under CAP/Choice, you direct your own care, with a personal assistant, a care advisor and help with payroll.

Other options

• PACE covers all care for people 55 and over who need nursing home care and live in a PACE area.
• Special Assistance In-Home is a monthly payment for people who need adult care home care but stay at home. See all benefits in North Carolina.

If your spouse stays at home

North Carolina protects money for the spouse who lives at home (the "community spouse").

If the spouse at home has income below the standard, part of your income can go to them. A dependent family member at home can get up to $902 a month. The income standard changes each July and the maximum each January.

How to apply

1. Gather papers: photo ID or birth certificate, your Social Security card, proof of income such as award letters, proof you live in North Carolina, and papers about your savings and property. Send copies, not originals. Only your name, birth date, address and signature are required to start.
2. Apply in one of these ways:
   • online at epass.nc.gov (you need an NCID);
   • in person at your county DSS (walk-ins are taken at all offices) or by phone with your DSS;
   • by mail, fax or email with form DHB-5200-ia plus DMA-5202D-ia (Appendix D, for income and savings when you need long-term care or in-home services). Find your DSS at ncdhhs.gov/localDSS.
3. For CAP/DA, also contact the CAP/DA case management agency for your county, or NC LIFTSS at 833-522-5429. They arrange the needs assessment.
4. Wait for the letter. Most decisions take up to 45 days; up to 90 days if a disability decision is needed.

A family member can apply for you. Use form DHB-5202C-ia to name an authorized representative.

After you apply

• Renewals: Medicaid must be renewed. Answer any letter from your DSS by the date shown, or your coverage can stop.
• Report changes in income, savings, address or living situation within 10 days.
• Appeals: If you are denied or your benefits are cut, you can ask for a hearing within 60 days of the notice date (90 days with good cause). You can ask in writing, by phone, in person, or through ePASS. A local hearing comes first. If you disagree with it, you have 15 days to ask for a state hearing. If you already get Medicaid and ask before the change takes effect (10 business days after the notice), your benefits can continue during the appeal.

Things people miss

• Estate recovery: After death, North Carolina may seek repayment for long-term care from the estate of people 55 and over. It is not sought if the estate is under $50,000 or Medicaid paid less than $10,000, and it waits while a spouse is alive.
• Do not spend down in a hurry. Giving money to family can delay care. Talk to DSS first.
• CAP/DA is not automatic. You need Medicaid and a CAP referral and assessment.

Free help

• NC Medicaid Contact Center: 888-245-0179 (TTY 711), Monday to Friday, 8 a.m. to 5 p.m.
• NC Navigator (help with the application): 1-855-733-3711.
• SHIIP (free Medicare counseling): 855-408-1212.
• Area Agency on Aging: Eldercare Locator, 1-800-677-1116 or eldercare.acl.gov.

Read more about paying for a nursing home, Medicare and all benefits in North Carolina.

Phone numbers: Free help lines for North Carolina agencies

Check what you may qualify for