NC Medicaid - North Carolina

NC Medicaid is a government health insurance program that helps people with low income get health care services at a lower cost. There are several different Medicaid programs in North Carolina, each serving a different group of people.

What does NC Medicaid cover?

North Carolina Medicaid pays for routine and acute health care services. This includes:

• Visits to health care providers (including physicians and nurse practitioners)
• Inpatient and outpatient hospital services
• Early and periodic screening, diagnostic, and treatment services
• Preventive care (e.g., vaccinations)
• Lab tests and X-rays
• Dialysis services
• Mental health services
• Substance use treatment
• Rural health clinic services
• Medical transportation
• Long-term care (e.g., nursing facility care, home health services)

Most states also cover optional services such as:

• Physical, respiratory, and occupational therapy
• Home- and community-based care
• Case management
• Prescription drugs
• Dental and vision care

Since the program serves those with limited income and resources, people with North Carolina Medicaid pay few to no out-of-pocket costs. To get coverage once you are enrolled, you must go to health care providers that take part in the Medicaid program.

In North Carolina, Medicaid is administered by the NC Medicaid Division of Health Benefits.

How do I know if I qualify for NC Medicaid?

In general, to be eligible, you must:

• Be a North Carolina resident
• Be a U.S. citizen or qualified non-citizen
• Have a Social Security number (or proof you applied for one)
• Meet the income and (if applicable) resource limits for your coverage group

Also, if you receive or qualify for Supplemental Security Income (SSI) in North Carolina, you are automatically enrolled in Medicaid.

If you need help with your health care coverage and costs, you should apply for Medicaid even if you think you are over the income limit. This is because:

• Not all types of income are counted toward the income limit.
• You may qualify for a different form of health care assistance.
• If you are over the income limit, but you have very high medical costs, you may be able to qualify for Medicaid through the Spend-Down Program.

What are the different Medicaid programs in North Carolina?

You may be able to get health coverage if you fall into one of the following categories.

Aged, Blind, and Disabled (ABD) Medicaid

ABD Medicaid in North Carolina covers people who are age 65+, blind, or living with a disability who also have limited income and resources.

Community Alternatives Program for Disabled Adults (CAP/DA)

The CAP/DA program provides health care and support services so you can stay in your own home and avoid having to move into a nursing home. These services may include meal preparation and delivery, adult day health services, in-home care, and case management. You may take part in this program if you meet the disability requirements. You must also have limited income and resources.

Medicaid for Workers with Disabilities

If you are a worker in North Carolina who has a disability and limited income and resources, the Medicaid for Workers with Disabilities program can provide you with access to health care benefits. In some situations, working and earning money could prevent you from getting public benefit programs such as Medicaid. This program lets you work, keep money in savings, and still get health care coverage. You may have to pay a monthly premium.

Nursing Home Medicaid

Nursing Home Medicaid covers health care and support services in a nursing home or other medical facility. If you qualify, NC Medicaid may cover room and board, nursing care, rehabilitation services, and other services. You can get this coverage if you have limited income and resources. You must also have a medical condition that requires the skills of a licensed nurse on a regular basis.

Medicaid Spend-Down Program (Medically Needy Medicaid)

The Spend-Down Program, also called the Medically Needy Program, lets you get NC Medicaid benefits even if your income is higher than program guidelines. It works by letting you spend down your income so that you meet Medicaid’s income limits. The spend-down amount is the amount of income that is over the Medicaid limit. This amount is different for each person.

To get NC Medicaid benefits, you must submit current paid or unpaid medical bills equal to or greater than your monthly spend-down amount. Once your medical bills reach this amount, you will get Medicaid coverage for the rest of the calendar month. While using Medicaid to pay for your medical expenses, you should use a health care provider who takes part in Medicaid.

Some examples of medical expenses you can use to spend down your income include:

• Unpaid medical bills (that have not been used to spend down your income before)
• Health insurance premiums
• Medical bills you paid within the last three months
• Medical bills that will not be paid by health insurance (or any other source)
• Co-pays for medical bills
• Medical services prescribed by your doctor
• Transportation by ambulance, bus, or taxi to get health care services

How do Medicare and Medicaid work together?

NC Medicaid pays for some services not covered by Medicare. If you get Medicare, you may also be able to get help from North Carolina Medicaid. Millions of Americans have both Medicare and Medicaid coverage. This is called being "dual eligible."

If you have Medicare and qualify for full Medicaid coverage, the state will pay your Medicare Part B (Medical Insurance) monthly premiums. Depending on the level of Medicaid you qualify for, the state might also pay for:

• Your share of Medicare costs, like deductibles, coinsurance, and copayments
• Part A (Hospital Insurance) premiums, if you have to pay a premium for that coverage

If you have both Medicare and Medicaid in North Carolina, you should show both cards to your health care provider each time you receive services.

In addition, if you are dual-eligible for Medicare and Medicaid:

• You will automatically be signed up for the Low-Income Subsidy (LIS)/Extra Help program through Medicare Part D (prescription drug coverage). This program helps people with low income pay for their medicines.
• You can get your coverage through a Medicare Advantage Special Needs Plan (SNP) instead of having original Medicare with separate Medicaid coverage. This plan can help you manage the health care services you need. SNPs may also offer more benefits than what you already get from original Medicare. In some cases, you may have no monthly premiums and/or you may pay lower co-payments. All SNP plans are different, so check with the plans to see what they cover and if you can enroll.

Note: SNPs are not available in every community. To find out if there is an SNP in your area, visit the Medicare website or call 1-800-633-4227 or 1-877-486-2048 (TTY).

How do I prepare to apply for NC Medicaid?

When you apply for NC Medicaid, you’ll be asked for important information to help determine if you qualify for benefits.

Before you start, gather some basic details to make your application process easier: 

• A document that shows your age, such as your birth certificate or driver’s license
• Your Social Security card (or proof you have applied for a Social Security number)
• Pay stubs for anyone in your household who has earned income
• Documentation that shows any other form of income, such as letters from Veterans Affairs (VA) or the Social Security Administration (SSA)
• Information about your financial assets, such as bank account or investment account statements

How do I apply for Medicaid in North Carolina?

There are a few different ways you can apply for NC Medicaid. Read below to learn more about which option might be right for you.

The quickest and easiest way to apply for NC Medicaid and other public assistance benefits is online through the ePASS portal. All your personal information is kept 100% confidential and protected by special security technology.

Apply on ePASS Portal

To apply in person or by mail, you will need a paper application. Click below to download and print the North Carolina application:

• Application for Health Coverage & Help Paying Costs (English)

Once you fill out the application, you can drop off, mail, fax, or email it to your local Department of Social Services (DSS) office.

To apply for NC Medicaid by phone, find and contact your local DSS office or call the NC Medicaid Contact Center at 1-888-245-0179.

How can I get help with my application?

• Call your local DSS office directly.
• Visit a Benefits Enrollment Center (BEC), if there’s one near you. See if there’s one in your area.
• NCOA also has a HelpLine you can call to get free support. To get started today, call 1-800-794-6559.