As we age or encounter health issues, long-term care questions arise—especially about Medicaid covering assisted living in North Carolina. Medicaid’s coverage for assisted living is very limited and depends on specific programs and individual circumstances.

While Medicaid does help with some care, coverage depends on individual needs and specific programs. Understanding the nuances of Medicaid coverage for long-term care is important for seniors and their families planning for future care needs.

What Does Medicaid Cover for Assisted Living?

In North Carolina, Medicaid is primarily designed to help with medical needs, not long-term room and board costs. Medicaid, however, does offer programs that can ease some financial burdens associated with assisted living.

Personal Care Services (PCS)

North Carolina Medicaid’s Personal Care Services program helps with daily activities. This might include help with bathing, dressing, eating, and mobility. However, these services are intended for individuals who can live in a private residence or assisted living community but still need support. PCS can be a huge relief for families who want to keep a loved one in assisted living without shouldering the full cost of care.

Special Assistance (SA)

For those who qualify, North Carolina’s Special Assistance program may provide help with room and board in certain assisted living communities. While Medicaid itself doesn’t pay the full cost of staying in an assisted living facility, Special Assistance can cover some of these living expenses, making assisted living more affordable. The SA program is available to individuals who meet both financial and health requirements, as determined by the Department of Social Services (DSS).

The Medicaid Waiver Program

North Carolina also has a Community Alternatives Program for Disabled Adults (CAP/DA), often called a Medicaid waiver. This waiver allows individuals to receive care in a community setting, which can sometimes include assisted living. CAP/DA is specifically for people who would otherwise need nursing home care but could still manage with extra support in a less intensive setting.

While CAP/DA doesn’t pay for room and board, it can cover in-home care services, equipment, and other support costs. This option is ideal for those who can remain in assisted living with additional medical support.

How to Qualify for Medicaid Assistance in North Carolina

Meeting Medicaid’s eligibility requirements is essential to accessing these benefits. Here are the general qualifications:

Financial Need

North Carolina’s Medicaid program considers both income and assets. The income limit changes annually and varies depending on the applicant’s marital status and health needs. As a general rule, applicants must have limited resources, including checking and savings accounts, investments, and property (excluding a primary residence).

Medical Necessity

For programs like PCS and CAP/DA, Medicaid will assess if the applicant needs assistance with daily activities. Those who qualify must demonstrate a level of need that would otherwise require a higher level of care, such as nursing home placement.

Age Requirement

Medicaid’s Special Assistance program is primarily for individuals over the age of 65 or those with disabilities. However, North Carolina expanded Medicaid eligibility in December 2023, making it available to younger adults with qualifying medical conditions.

Applying for Medicaid Assistance in Assisted Living

Applying for Medicaid can be a long process, but many resources in North Carolina can help guide families. Applications generally go through the local Department of Social Services. A Medicaid caseworker will review the applicant’s financial situation, health needs, and other eligibility factors to determine if they qualify.

To get started, here are a few steps to follow:

  • Gather Financial Documents: Proof of income, assets, and insurance information is required. It’s also helpful to collect information about any healthcare expenses.
  • Complete the Application Process: Applications can be submitted online, by mail, or in person through the local DSS office.
  • Schedule a Health Assessment: Medicaid programs often require a healthcare provider to assess the applicant’s needs and provide a statement of medical necessity.

While the paperwork may seem overwhelming, some resources and agencies offer free assistance with Medicaid applications. Some families also choose to consult with elder care planning professionals who can help organize finances to maximize Medicaid eligibility.

Limitations and Important Considerations

Medicaid in North Carolina offers some support for assisted living, but it doesn’t cover everything. Here are some key points to keep in mind:

  • Room and Board Costs: Medicaid generally does not pay for room and board in assisted living, except under the Special Assistance program. Even then, the SA program only offers room and board expenses to eligible individuals.
  • Income Limits and Spend-Down Requirements: Families might need to consider a “spend-down” strategy, which means reducing assets to meet Medicaid’s eligibility criteria. This can involve careful planning and, in some cases, assistance from a professional.
  • Waiting Lists for Waivers: Programs like CAP/DA are popular, which can lead to wait times. Planning ahead and understanding eligibility can help families prepare because there are long waitlists for this program. Also, it may not cover significant care needs in assisted living settings.

Medicaid and Long-Term Care: What Are Your Options?

If you’re considering assisted living for yourself or a loved one in North Carolina, exploring all available options is a good idea. While Medicaid may not cover all costs, various programs can ease the financial impact. Remember, each program has its requirements, so exploring which best matches the needs of the individual seeking care is essential.

Planning for long-term care often involves questions about eligibility, coverage, and the application process. For families feeling uncertain, taking that first step toward understanding Medicaid options can be empowering. Even if it means diving into some paperwork and financial preparation, the potential benefits—like peace of mind and financial support—can be well worth the effort.

We’re Here to Help

If you’re considering long-term care options in North Carolina and need guidance on Medicaid or other elder care planning services, contact Salines-Mondello Law Firm, PC. Our mission is to help families make informed decisions with compassion and clarity.

Whether you’re planning ahead or facing an immediate need, our team is committed to helping you find the right path forward for your family. Call us at 910-541-8134 to discuss your options and learn how we can help support your loved ones’ future with confidence and care.