North Carolina Medicaid Nursing Home Eligibility: A Complete Guide

North Carolina nursing home costs average approximately $75,000–$90,000 annually for a semi-private room. NC Medicaid, administered by NCDHHS, covers nursing home care for eligible residents. North Carolina expanded Medicaid in December 2023, significantly broadening access — though nursing home eligibility rules remain governed by the long-term care standards below.

Who Qualifies

1. Medical necessity — Physician certifies need for nursing facility level of care. NC uses a Health Assessment and nursing facility pre-admission screening (PASARR).
2. Financial eligibility — Income and asset limits.
3. North Carolina residency — U.S. citizenship or qualifying immigration status.

Income Requirements

• Monthly income limit: $2,829/month (300% of SSI, 2025)

A Qualified Income Trust (Miller Trust) is typically required if income exceeds the cap. Community spouse: Monthly Maintenance Needs Allowance up to approximately $3,715/month.

Asset Requirements

• Individual applicant: $2,000 in countable assets
• Community spouse: Up to $148,620 (2025 CSRA)

Exempt assets: Primary home (if intent to return or spouse/dependent lives there), one vehicle, personal property and household goods, irrevocable prepaid burial arrangements.

Look-back period: North Carolina enforces a 60-month (5-year) look-back period.

Application Process

Apply through your county Department of Social Services (DSS):

1. Find your county DSS at ncdhhs.gov/divisions/social-services or call 1-888-245-0179.
2. The NC Medicaid application process includes a PASARR pre-admission screening.
3. Submit: income records, 60 months of bank statements, asset documentation, physician certification.

What North Carolina Medicaid Covers

Covered: Semi-private room and board, skilled and custodial nursing care, physical/occupational/speech therapy, physician and specialist visits, prescriptions, medical equipment, mental health services.

Not covered: Private rooms (unless medically required), personal convenience items, cable TV and telephone.

Home- and Community-Based Programs

• Community Alternatives Program for Disabled Adults (CAP/DA): NC's primary HCBS waiver for adults 18+ who qualify for nursing home level of care but prefer the community. Services include personal care, home health, respite, home modifications, and assistive technology.
• NC Medicaid Managed Care (Tailored Plans): NC is transitioning to a managed care model that includes long-term services and supports.
• PACE North Carolina: Available in certain regions.

Frequently Asked Questions

Did NC Medicaid expansion affect nursing home eligibility?

Medicaid expansion (December 2023) broadened coverage for adults 19–64 with income up to 138% of the Federal Poverty Level. It does not directly change nursing home long-term care eligibility rules.

My mother lives in Raleigh — where does she apply?

Wake County DSS. Visit wakegov.com/departments/human-services or call 919-212-7000.

How long is the CAP/DA wait?

Wait times vary by county. Contact NCDHHS or your local DSS for current estimates. Getting on the list early is the most important step.