Adult Medicaid

Adult Medicaid

Adult Medicaid has two specialized sections - Long Term Care (nursing home, rest home, group home and CAP) and Private Living Arrangements (PLA). A lead worker oversees each section.

In North Carolina, the Department of Health and Human Services administers the Medicaid program through the Division of Medical Assistance (DMA). The county departments of social services (DSS) and the Social Security Administration (SSA) for Supplemental Security Income (SSI) recipients determine eligibility for Medicaid. It is jointly financed with federal, state and county funds.

The Social Security Act mandates certain groups of individuals who must be covered by Medicaid. The state is also mandated to cover certain Medicare beneficiaries.

In order to receive Medicaid, individuals must meet the requirements under a specific categorical group covered by North Carolina. In addition, financial and non-financial criteria for each group must be met.

Long Term Care (LTC) (Nursing home, group home and CAP)

Medicaid will also help to pay cost of care in a nursing home if all eligibility requirements are met.

The applicant/recipient must have begun a continuous period of institutionalization which begins when: 1) he/she is admitted to a LTC facility or 2) he/she is admitted to a general hospital and his/her stay exceeds 30 days of continuous care. Financial need must also exist.

State/County Special Assistance (SA) (Rest Home)

This SA program provides financial assistance to a person 18 years or older who is in a home for the aged, disabled, family care home, group home for developmentally disabled adults or an area operated mental health home. These facilities must be licensed and comply with civil rights regulations. SA-In Home program provides financial assistance for eligible recipients so they may remain in their own home instead of placement in a facility.

Individuals may apply at the local county Department of Social Services in the county where they live or where they lived prior to entering a facility. A representative may apply for the applicant on their behalf.

Community Alternatives Program (CAP)

The CAP program allows North Carolina to use Medicaid funds to provide home and community based services to Medicaid recipients who require institutional care (placement in a nursing facility), but for whom care can be provided safely in the community with CAP services. CAP participants must meet all Medicaid eligibility requirements.

Private Living Arrangements (PLA)

This program allows recipients to live in their home and receive Medicaid benefits. If the recipient is eligible for full Medicaid benefits. This program will pay for a limited number of prescriptions per month, a limited number of doctor visits per year, hospital visits, routine eye exam, eyeglasses once every two years, routine dental care, and dentures once every ten years. Medicaid covered services change periodically. A complete list of covered and non-covered services can be accessed at the link below for the NC Division of Medical Assistance. If the individual is not eligible for this program, they may be eligible to have their Medicare premiums paid if they have Medicare Part A or B.

Medicaid Income/Reserve Limits

This program is based on income and reserves. The income limits range from $908 to $1655 depending on the program of eligibility. The reserve limits range from $2000 to $10,020 depending on the program of eligibility.