Different Types of Adult Medicaid and Long Term Care Medicaid

Private Living Arrangement Medicaid (PLA):  PLA Medicaid is health insurance for individuals and couples aged 65 and older, and individuals blind or disabled according to the Social Security definition of disability, who live in their own homes, or the homes of relatives or friends.  Applicants must also meet income and resource eligibility requirements.  There are co-payments for some services.  Individuals and couples with income greater than the federal poverty levels may have to meet a deductible before Medicaid can be authorized.  

Medicare Savings Programs (MQB):  The Medicare Savings Programs are limited assistance Medicaid programs that can help individuals and couples enrolled in Medicare Part A and/or Part B. The programs pay for Medicare premiums, coinsurance, and Medicare deductibles.  The process where Medicaid pays the Medicare premiums is called Buy-In.  Buy-In can take 3 to 4 months from the date approval of the application.  If Medicaid terminates for any reason, the Medicare premiums will no longer be paid.  Individuals and couples whose income falls within federal poverty level guidelines may be dually eligible for a Medicaid Card and the MQB programs.  

Long Term Care Medicaid:  Medicaid recipients residing in nursing facilities must use their income to pay for nursing home care.  Medicaid pays the difference between the recipient’s income and the nursing home rate.  The recipient keeps $30 per month for personal needs that are not provided by the nursing facility. Additional amounts may be set aside (protected) for a spouse living at home, for health insurance premiums, or for eligible medical costs not covered by Medicaid.  

Community Alternative Programs (CAP) & Alliance Programs:  CAP and Alliance programs waivers allow North Carolina Medicaid funds to be used to provide home and community based services to Medicaid recipients  (adults and children)who require institutional care, but wish to remain at home when care can be provided safely and cost-effectively in the community.  CAP recipients must meet all Medicaid eligibility requirements.  

Program for All-Inclusive Care for the Elderly (PACE):  PACE is a managed care program that enables elderly individuals who are certified to need nursing facility care to live as independently as possible at home while receiving services. This prevents institutionalization. The PACE organization provides all Medicaid covered services, in addition to other services determined necessary by PACE for the individual beneficiary. The PACE program becomes the sole source of services for Medicaid enrollees.  PACE recipients must meet all Medicaid eligibility requirements.  PACE participants may have a monthly liability (monthly cost), depending on the customer’s income.  

Special Assistance (SA): The Special Assistance program provides assistance for individuals or couples residing in state licensed adult care homes, rest homes, and other domiciliary facilities.   SA helps pay the cost of living in licensed adult care facilities.  The SA recipient’s income is used to pay the cost of care in the facility.  The individual may keep $66 per month of their income for personal needs.  The individual must apply for SSI and meet NC residency requirements for the SA program.  Eligibility is limited to individuals 18 and older and individuals under age 65 must be determined disabled based on Social Security’s definition of disability.  

Special Assistance In-Home (SA-IH): The Special Assistance In-Home program provides assistance to individuals who require care in a licensed adult care facility, but who desire to reside at home, or in a private living setting.  The SA-In Home program provides cash payments to help eligible individuals continue to live at home. The individual must apply for SSI and meet NC residency requirements for the SA program. Income must be below the federal poverty level. Eligibility is limited to individuals 18 and older and individuals under age 65 must be determined disabled based on Social Security’s definition of disability.  The SA-IH program requires an assessment by a social worker and eligibility is determined on a case by case basis.

 

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(910) 677-2433 / 2019

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