Medicaid
Medicaid is a joint federal and state program that pays for medically necessary nursing home care for patients in skilled or intermediate care nursing homes or in intermediate care facilities for the mentally retarded. If your income and resources are limited, you may qualify for Medicaid.Eligibility
Most often, eligibility for Medicaid is based on your income and personal resources. Your income must be less than the cost of care in the facility at the Medicaid rate.
Be sure to ask whether NC law or nursing home policy will guarantee that you will be able to stay at that nursing home if your care is covered by Medicaid later.
Automatic Eligibility for Medicaid
If you qualify for certain cash assistance programs, you automatically qualify for Medicaid without a separate application. If cash assistance ends, the Medicaid may be continued if you are eligible for another type of Medicaid. The programs that include automatic Medicaid are:
- Work First Family Assistance for families with children
- Supplemental Security Income (SSI) for elderly, blind and disabled individuals
- State/County Special Assistance (SA) assistance for payment of rest home expenses for elderly, blind and disabled individuals
How to Apply
You may apply for North Carolina Medicaid at the county Department of Social Services (DSS) in the county where you live. Staff in some health centers and hospitals may also be able to assist you in completing a North Carolina Medicaid application.
If you are unable to go to a DSS office, you may call and ask that an application be mailed to you or arrange for someone to come to your home to take the application. Once you have completed and returned the application, the county DSS may need to contact you for further information.
If you receive Supplemental Security Income (SSI), you are automatically covered for Medicaid. You may apply for SSI at the nearest local Social Security Office. You can call the SSI Office at 1-800-772-1213 or 1-800-325-0778 (TTY) between 7 a.m. and 7 p.m. for more information. Most applications can be completed over the telephone.
Financial Protection for a Spouse
Federal law protects spouses of nursing home residents from losing all of their income and assets to pay for nursing home care for their spouse. Medicaid policy specifies that when a legally married individual needs Medicaid to help pay for nursing facility services, a portion of the couple's income and assets may be protected for the spouse at home (also called "the community spouse").
The Spousal Impoverishment Law allows for the following:
- Medical services provided to the non-community spouse: nursing home care, hospital care that exceeds 30 days, or services provided by the Community Alternatives Program (services that enable an individual to remain at home who would otherwise be institutionalized).
- The community spouse is allowed to keep one-half of the couple's assets, with a minimum of $20,328 and a maximum of $101,640 (current as of 1/1/2007).
- The protected share is calculated by assessing the value of all assets owned separately or jointly by either spouse at the point the individual becomes institutionalized. The home is generally not counted in determining the value of assets since the home is protected for the spouse.
- The nursing facility spouse must spend his half of the assets on his care prior to becoming Medicaid eligible. A nursing home patient is allowed a maximum of $2,000 in assets. The protected assets, including the home, must be transferred to the name of the community spouse.
- Once assets have been allocated following spousal impoverishment rules, and the spouse in the nursing facility is found eligible for Medicaid, spousal financial responsibility ends and each spouse will be treated separately for Medicaid purposes.
- A portion of a married institutionalized Medicaid recipient's income may also be allocated to the community spouse.
- Income is allocated for the needs of the community spouse if the community spouse's income is less than 150% of the poverty level (currently $1,712). It is also possible to allocate additional income to the community spouse for excessive shelter costs.
- Income may also be allocated for the needs of other dependents.
Transfer of Assets
Medicaid law prohibits the transfer of assets for less than market value by an institutionalized Medicaid applicant/recipient or anyone acting on their behalf. Certain transfers are allowable, such as the transfer of a home to a spouse or disabled child.
For 5 years from the date of application or institutionalization (whichever occurs later), if you do transfer assets, a sanction, or penalty, is applied. During the sanction period, Medicaid will not pay for your SNF care. The sanction begins the month that you would have been eligible for Medicaid. The length of the sanction is determined by dividing the value of the transferred assets by the average monthly private cost for nursing home care.
To avoid a penalty, talk with your state Medicaid office or an attorney about what you can and can't do with your assets.
Estate Recovery
When a Medicaid recipient in a nursing home or receiving Community Alternatives Program (CAP) services dies, Medicaid files a claim against the estate to recover expenses paid by Medicaid.
Estate recovery is waived if there is a spouse or dependents who continue to live on the property, the total estate assets are less than $5,000, Medicaid charges are less than $3,000, or in cases of hardship.
Note: This information is effective as of 07/01/2007. Eligibility rules and income/asset amounts are subject to change.
For further information regarding Medicaid, please contact your local county Department of Social Services, or call the Medicaid Eligibility Unit through the toll-free CARE-LINE at 1-800-662-7030.
Other resources on Medicaid:
North Carolina financial rules for Medicaid long term care
Long-term care frequently asked questions
Medicaid general information