North Carolina Assisted Living and In Home Care Medicaid Waiver Information and Rules for 2017

Introduction

North Carolina provides long-term care resources to seniors through the Department of Health and Human Services, Division of Medical Assistance (DMA). There are many programs that assist persons who would otherwise require a nursing home level of care to stay in their own home or a community-based setting while receiving services they need. In addition to Nursing Home Facilities and Medicaid waivers for seniors on Medicaid for long-term care, North Carolina also provides the following programs: 1) the Program for All-Inclusive Care for the Elderly (PACE); 2) Money Follows the Person Program; and 3) Adult Day Services.

  • The PACE program provides care to the individual in the home, such as in-home personal care services and home health care. PACE provides a PACE Center that includes a primary care clinic, therapy, personal care and dining. To beeligible to participate in PACE, you must: 1) Be 55 years of age or older; 2) Need the same level of care for Medicaid nursing facility services; 3) Live in a PACE organization’s service area; 4) Be able to live in a community setting without jeopardizing your health or safety; 5) Meet other conditions listed in the PACE organization’s agreement.
  • Money Follows the Person (MFP) is a state project that assists Medicaid-eligible North Carolinians who live in inpatient facilities to move into their own homes and communities with supports. To qualify for the MFP program, the applicant must: 1) currently reside in a hospital, skilled nursing home facility or intermediate care facility for at least 90 days; 2) meet the eligibility requirements for the CAP/DA waiver program; 3) be receiving Medicaid services before the transition; and 4) choose to move to a “qualified residence,” either: the person’s own home or apartment, a family member’s home, or a group home with four or fewer people.
  • Adult Day Services provides an organized program in a community group setting to promote social, physical and emotional well being. These programs offer a variety of activities designed to meet the needs and interests of each older adult who receives care. Costs to consumers vary as there is limited funding for adult day care from state and federal sources. is provided by the Division of Aging and Adult Services and more information can be found through the local Area Agencies on Aging (see below)

In addition to these statewide programs, the regional Area Agencies on Aging (AAAs) are offices established through the Older Americans Act that facilitate and support programs addressing the needs of older adults in a defined geographic region and support investment in their talents and interests. In North Carolina AAAs are located within regional Councils of Government. These AAAs function in five basic areas: advocacy; planning; program and resource development; information brokerage; funds administration quality assurance.

Medicaid Waiver Programs for Assisted Living and In Home Care

North Carolina Community Alternatives Program for Disabled Adults (CAP/DA) Medicaid Waiver (HCBS CAP/DA (CAP/Choice) Waiver)

Community Alternatives Program (CAP) offers home- and community-based services to seniors (aged 65+) and adults with disabilities who are at risk for institutionalization in a nursing home. In addition, the CAP/Choice program is a subsidiary of the CAP/DA waiver and provides adults with more control over the types of services received, when and where they are provided and who delivers the services.

Services

Services include: adult day health, personal care services, specialized medical equipment and supplies, home accessibility and adaptation, meal preparation and delivery, personal emergency response system, non-institutional respite, institutional respite, case management, participants goods and services, community transition services, training, education and consultative services and assistive technology.

Individuals choosing the consumer-direction option are eligible for the above listed services as well as care advice, financial management, and personal assistant services. In addition, approved beneficiaries are eligible for State Plan services when medical necessity is determined.

Eligibility

  1. Health: An applicant must require a Nursing Home Level of Care.
  2. Financial: An applicant must meet the waiver’s requirements for Medicaid for the Elderly, Blind and Disabled to receive benefits under the CAP/DA program.Medicaid financial eligibility has certain income and asset limits for purposes of determining eligibility. For 2017, an individual can make up to $1,005 per month in income (or $1,354 for a couple) and retain assets up to $2,000 (or $3,000 for a couple). However, if your income is too high to qualify under the standard, the state allows a “deductible” for medical expenses, also known as a “medically-needy” spend down provision.

Practical Considerations

The CAP/DA (CAP/Choice) waiver is unique in that it offers the ability for consumers, once eligible, to determine whether they want be have more self-directed care (CAP/Choice) or receive traditional services under the CAP/DA program. The CAP/DA (CAP/Choice) waiver program does not have a special income limit, and theMedicaid long-term care eligibility category is equal to 100% of the Federal Poverty Level (FPL), or $1,005 in 2017. This means the income requirements are stricter than some other states. However, the deductible or medically-needy spend down provision allows for persons with too much income but high medical costs to qualify for the benefit.

Additionally, through the Money Follows the Person program, individuals who wish to leave nursing home facilities to return to a community-based setting or their own home can qualify under the same Medicaid eligibility rules, and, in fact, receive priority in determining the wait list for entering the CAP/DA waiver program. Further, the process for leaving a nursing home under the Money Follows the Person Program is transparent and accessible.

Conclusion

North Carolina has a strong state support network for seniors looking to receive long-term care services outside the nursing home setting. Although the financial eligibility criteria are more stringent than most states, a Medicaid Planning specialist can help with the deductible, or spend down, provision for “medically-needy” category applicants. By doing this, planning ahead may help you receive the benefit sooner and save money in the process.