What is a Medicaid Waiver?
For persons with limited financial resources, Medicaid pays for nursing home care. For those who wish to live at home or in assisted living, sometimes Medicaid will pay for care in those locations if it can be obtained at a lower cost than in a nursing home. It does this through "Medicaid Waivers," which are also called Home and Community Based Services (HCBS) Waivers or Waiver Funded Services.
The Community Alternative Program for Disabled Adults (CAP/DA) is North Carolina Medicaid's home and community based services waiver program. In this program, low-income, disabled state residents have an alternative to nursing home placement. Program participants remain in their private residences or receive care in the home of a friend or family. By offering medical and personal care services, North Carolina aims to increase the disabled and seniors' autonomy. The program also covers the cost of minor home adaptations that increase the independence or safety of the program participant.
Under CAP/Choice, certain family members can be hired as personal caregivers.
Associated with this program is the Community Alternatives Program for Choice (CAP/Choice). This option offers participants consumer direction of some of their care services as well as expands some of the services covered by this waiver. This model of program is based on the Medicaid concept of Cash and Counseling and is sometimes called self-directed care or participant direction. Under CAP/Choice, participants can hire family members (or whomever they choose) to provide personal assistance services. Phrased another way, the adult children of aging parents can be paid to be their caregivers.
Paying family members (or whoever the program participant chooses) works as follows. The participant / care recipient is the “employer”, but a third-party agency sits between NC Medicaid and the care provider. The care provider submits timesheets for the hours of care they provide. The 3rd party bills Medicaid, receives payment from Medicaid, withholds taxes, unemployment insurance and administrative fees, and pays the care provider. In 2019, it is estimated that care providers receive between $9.25 and $11.25 per hour for their caregiving efforts.
Did You Know? NC seniors are eligible to receive free quotes for bath safety modifications, such as the replacement of a shower with a walk-in bathtub. Learn more.
CAP/DA and CAP/Choice are both available to North Carolina residents who are at least 18 years of age and have a physical or mental disability that results in a need for the level of care typically found in nursing homes.
These waivers are intended for low-income families, and as such, persons must meet the eligibility requirements for North Carolina Medicaid. NC considers both the applicant's income and assets.
NC 2019 Medicaid Income Guidelines
Individual applicants will qualify automatically if their monthly income is no greater than $1,041. For married applicants with both spouses applying, that limit is $1,409 per month. These figures are 100% of the Federal Poverty Level (FPL), which changes every year.
Applicants with higher incomes may also qualify if their cost of care (using Medicaid's rates) significantly reduces their disposable income. For example, in 2019, an individual’s monthly income after subtracting medical and care costs should not exceed $242, and married applicants with both spouses applying should not have more than $317. These individuals are referred to as being Medically Needy, whereas the other pathway to Medicaid is called Categorically Needy.
Another option if the applicant is married, is to transfer some of the applicant’s income to the non-applicant spouse. This is called the Monthly Maintenance Needs Allowance and is intended to prevent spousal impoverishment. Persons interested in this option should speak with a professional knowledgeable in NC Medicaid eligibility.
NC 2019 Medicaid Asset Guidelines
Individual applicants are allowed up to $2,000 in countable resources, while married couples with both spouses as applicants can keep up to $3,000. Married couples with only one spouse applying have different rules regarding assets. In order to prevent the non-applicant spouse from becoming impoverished, that spouse may have up to $126,420 in assets. This is referred to as a Community Spouse Resource Allowance. In addition, the applicant spouse is still able to retain $2,000 in assets.
When determining "countable resources," there are several considerations. One's home is not a countable resource provided the applicant, or his or her spouse lives there, or intends on returning to live there. The value of their home and real estate must be less than $585,000. There are other resources that are not counted, including a vehicle, burial plot, and final expense insurance policies.
Families considering having their loved one give away his or her money to meet the asset limit should be aware. Significant financial gifts, or asset transfers, as far back as 60 months, may be audited and potentially subject to penalties that would delay valuable benefits. This is referred to as the Medicaid Look-Back Period.
As with income, potential Medicaid applicants that are concerned about their assets being over the limit should contact a Medicaid planner to ensure they qualify. Read more.
Benefits and Services
Services available to CAP/DA and CAP/Choice beneficiaries are selected individually with the objective of enabling them to live or return to living outside of a nursing home environment. These can include any of the following.
Respite Care (both in-home and out-of-home to relieve the primary caregiver)
Transition Services (to assist one in moving from a nursing home back into the community)
In February 2017, North Carolina expanded the number of spaces in this program for persons suffering from Alzheimer’s Disease. This enabled 320 new dementia participants to enroll simultaneously in the Community Alternatives Program.
How to Apply / Learn More
Both the CAP/DA program and the CAP/Choice participant directed option are now available statewide, and are administered by North Carolina’s Division of Medical Assistance. This waiver program limits the number of participants and waiting lists to receive services are the norm. At the time of this writing, statewide demand for these positions exceeded the existing capacity for services. A waiting list is used to keep track of those needing services.
To apply for these programs or have one's name added to a wait list, one should contact the lead agency in his or her county. A list with contact information is available for download here. More information about CAP/DA and CAP/Choice is available on the NC Health and Human Services website.
NC Medicaid also offers personal care under its State Plan. Learn more.