Medicaid for North Carolina Residents Needing Assisted Living or Home Health Care

North Carolina's main Medicaid program does not pay for assisted living facilities or home health care as it does for nursing home care, but it offers a few waiver programs and special assistance programs that may help pay the costs. (For more on nursing home coverage, see Nolo's article on when Medicaid pays for nursing homes in North Carolina.)

Medicaid Coverage of Assisted Living Services in North Carolina

Assisted living facilities are generally less expensive and less medically intensive than nursing homes, but are not cheap by any means. Most North Carolina residents living in assisted living facilities pay their own costs. Generally speaking, Medicaid does not cover room and board fees in assisted living facilities. However, if you have little income and few assets, you may qualify for a program that helps pay for assisted living facilities.

If you receive SSI and live in an assisted living facility, you may qualify for a benefit called Special Assistance (SA) that will pay for room and board expenses, up to $1,182/month, at adult care homes (also known as assisted living facilities). People with dementia who live in specialized care units can receive more money each month ($1,515). You will also recive a $46 per month personal needs allowance.

If you don't receive SSI, your income must be lower than $1,229 per month (in 2018) and you must have less than $2,000 in countable assets (excluding your car, home, and personal effects). Those seeking to live in special care units must have income less than $1,561 per month.

A separate program, called Special Assistance In-Home (SA/IH), provides a similar benefit for low-income people who could reside in an assisted living home but want to stay in their own homes. To apply for SA or SA/IH, contact your local county Department of Social Services office.

Medicaid Coverage of Home Health Services in North Carolina

Home health care can include skilled nursing or therapy services, home health aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning. If you already receive Medicaid in North Carolina for doctor's and hospital visits, the program will pay for some home health services like nursing, therapy, medical supplies, and equipment. Your doctor must prescribe home health services for you as part of a plan of care for a particular condition.

Medicaid may also pay for personal care services, but only as prescribed by your doctor according to a plan of care, and only up to 80 hours/month. To qualify for personal care services, you must show that you need assistance with your activities of daily living.

Waiver programs. If you have an ongoing need for personal care services, you should apply for assistance from one of North Carolina's Medicaid waiver programs or its PACE Program (see below). North Carolina's two waiver programs are Community Alternatives Program for Disabled Adults (CAP/DA) and Community Alternatives Program/Choice (CAP/Choice).

To qualify for either waiver, you must be 65 or older, blind, or disabled. In addition, you must show that you meet the nursing facility level of care and that you are at risk of institutionalization within 30 days.

CAP/DA. If you qualify for CAP/DA, you can receive a wide range of services like adult day health, personal care aide, home modification and mobility aids, meal preparation and delivery, respite services, personal emergency response services, transition services, assistive technology, and case management. In CAP/DA, an agency arranges your services and oversees your plan of care for you.

CAP/Choice. If you prefer to select and train your own service providers, you can participate in CAP/Choice. CAP/Choice offers all of the services that CAP/DA offers, but you have a larger role in directing your own care. To help you, CAP/Choice also pays for people to advise you, like a personal assistant, a care advisor, and a financial manager. To find out more about the CAP/DA and CAP/Choice programs, contact the Lead Agency for CAP in your area. (You can download a list of of agencies here.)

Developmental disabilities. North Carolina has other waiver programs for individuals with developmental disabilities and for children with fragile medical conditions. For more information about these waivers, contact the Department of Health and Human Services Customer Service Center at 800-662-7030.

North Carolina's PACE Programs

Programs of All-Inclusive Care for the Elderly (PACE) currently operate in several communities in North Carolina. To qualify for PACE, you must be 55 or older, live in an area served by a PACE agency, and meet North Carolina's nursing home level of care standard, and you must be able to live safely in the community with PACE services. If you do not receive Medicaid, you can use Medicare to pay for PACE, or you can pay for the program yourself.

PACE participants receive their services from an interdisciplinary team of professionals like physicians, nurses, and social workers, whose role is to coordinate individualized care and services to keep seniors in their own homes and communities. If you receive Medicaid and participate in a PACE, Medicaid pays for all of the services recommended by your care team. If you are interested in a PACE program, contact it directly to apply. You can find a PACE program in your community here.

Wanting to Move Out of a Nursing Home?

North Carolina operates a program called the Money Follows the Person (MFP) that helps people move out of institutions and into less restrictive settings. If you are elderly or disabled, have lived in an institution for at least 90 days, and meet the nursing facility level of care, but want to live in your home or in a community-based setting, then you might qualify for assistance from the MFP program.

MFP provides a variety of services designed to help a recipient live independently in his or her home, including homemaker and chore help, day services, home accessibility adaptations, and home health aide services. To apply, call the North Carolina Money Follows the Person Project at 855-761-9030.

Supportive Services for North Carolinians Who Do Not Qualify For Medicaid

If you do not qualify for Medicaid and do not meet the nursing home level of care, you may still qualify for some services like transportation, meals, and in-home help. North Carolina's Area Agencies on Aging administer various programs that offer support to seniors.

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