North Carolina Medicaid Eligibility



 

North Carolina Medicaid Income Guidelines

Typically, those who have less access and means to pay for health care need it most. Enter Medicaid. Medicaid, or Medical Assistance, is a state-funded insurance program for certain low-income residents of North Carolina whose income does not allow them to receive the medical services they may require. All eligible residents must meet an income guideline based on the group they fall under, including children and parents, and elderly, blind, or disabled individuals. Once enrolled, you will have access to a comprehensive set of benefits, available for free in most cases.

Covered services offered through Medicaid range from the necessary preventative tools to keep you are your family well, to emergency coverage for unexpected health crises, to coverage for conditions that some would not otherwise be able to treat. Though limited, the program has its hopes of expanding coverage in the next few years to add more low-income residents, not exclusive to very impoverished. North Carolina’s Medical Assistance program is like other states’, in that the major groups are covered, and eligibility depends on income, health, and age.

The following list includes the current income guidelines for North Carolina Medicaid, according to the groups they accept for coverage and their income in relation to Federal Poverty Level (FPL). All who qualify must be residents of the state, U.S. citizens or legal residents/qualified immigrants, and have a Social Security Number or have applied for one. A physical or other medical exam is not required for the application, unless you are applying due to a disability. Proof of pregnancy is also required for pregnant women applicants in North Carolina. Those who have Supplemental Security Income do not need to apply for Medicaid, as they are automatically enrolled.

 

Group                                       Income (percent of FPL)

Infant                                                    185%

Child age 1-5                                        133%

Child age 6-19                                      100%

Parent (unemployed)                            35%

Parent (employed)                                49%

Pregnant Women                                  185%

Single Aged/Blind/Disabled                   100%

Aged/Blind/Disabled Couple                  100%

 

 

Other Eligible Groups

  • Families with income from Temporary Assistance for Needy Families (TANF)
  • Supplemental Security Income (SSI) recipients
  • Disabled individuals who no longer qualify for SSI benefits
  • Qualified Medicare Beneficiaries (QMB): Medicare members with income below the FPL. Medicaid covers your Medicare monthly premium, deductibles, and coinsurance if you meet the income guidelines.
  • Specified Low-Income Medicare Beneficiaries (SLMB): Medicare members whose income is under 120 percent of FPL can get their monthly premiums paid by Medicaid.
  • Medically Needy: Coverage for adults and children whose health care bills are so high that they qualify for Medicaid when medical costs are deducted from their total income.

 

Medicaid Eligibility Guidelines Chart

Medicaid Deductible

North Carolina Medicaid members whose income is over a certain amount for their family size will have a deductible. Eligibility for Medicaid is determined for six months at a time, which is known as the certification period.  The deductible amount will be calculated by subtracting the maximum monthly income from a household’s countable monthly income. Dividing that resulting amount by six, for each month of the period, the deductible is decided upon.

The certification period typically starts with the month that you apply for Medical Assistance. Members who are given a deductible requirement are not eligible for Medicaid coverage for health care costs until the deductible has been met. As health care costs add up quickly in most cases, paying out-of-pocket for prescriptions, medical care, and supplies will result in your deductible being met, as a private health plan would.

Because the state decides your family can afford to pay these expenses, you must do so prior to receiving your free Medicaid. Unlike private coverage, you will not have any monthly payments to meet. However, depending on how much you use the health care system, it could take some longer than others to reach the deductible. North Carolina also allows residents to meet their deductible with unpaid medical bills that are less than 2 years old. They must fall under the qualified medical expenses that Medicaid has set in place.

Medicaid Deductible-Qualified Health Care Costs

  • Hospital expenses
  • Laboratory and clinic costs
  • Office visits with a physician, dentist, or therapist
  • Transportation to the doctor or hospital
  • Prescription medications
  • Over-the-counter medicines (e.g. Tylenol, Benadryl, Pepto-Bismol, and cold medicines)
  • Medical supplies (e.g. gauze, bandages, sterile alcohol, needles for medical injections)
  • Equipment (e.g. crutches, wheelchairs, braces, dentures, eyeglasses, hearing aids, walkers)
  • Vitamins or supplements prescribed by your doctor

 

Resources

NC DHHS: Medicaid

Apply for North Carolina Medicaid

DHHS Customer Service: 800-662-7030