BASIC MEDICAID ELIGIBILITY

BASIC REQUIREMENTS **
MONTHLY RESOURCE SPECIAL PROVISIONS
GROUP BENEFITS BASIC ELIGIBILITY WHOSE INCOME and INCOME LIMIT LIMIT DEDUCTIBLE/SPEND DOWN Updated 07/18
REQUIREMENT RESOURCES COUNT Updated 04/19Updated
04/19
• Beneficiaries receiving Supplemental Security Income (SSI) -Federal cash assistance program for the aged, blind, and
disabled, are automatically entitled to Medicaid. No separate application or Medicaid determination is required.
Full Medicaid coverage
S-ABD, • Beneficiaries receiving State/County Special Assistance (SA) - program for aged and disabled individuals who are
only if a Medicaid
SSI cases application is submitted primarily in adult care facilities- includes Medicaid eligibility.
• Beneficiaries receiving Special Assistance In-Home- the individual must be determined Medicaid categorically needy
eligible.
Age 65 or older Spouse’s income and 100% of Poverty Level SSI Limits If income exceeds Protection of income for spouse
Aged Full Medicaid at home: When an individual is in
resources if live together 1 – $1,041 1 - $2,000 YES income limit and the
MAA Coverage indicator is “yes,” the a nursing facility and has a spouse
2 – $1,410 2 - $3,000
individual or family may living at home, a portion of the
Blind by Social Spouse’s income and
100% of Poverty Level SSI Limits be able to be eligible for income of the spouse in the facility
Security Standards resources if live together.
Blind Full Medicaid may be protected to bring the
Parents’ income and 1 – $1,041 1 - $2,000 YES Medicaid if they can
MAB Coverage meet a deductible. See income of the spouse at home up
resources if under age 18 2 – $1,410 2 - $3,000
discussion of Medical to a level specified by federal law.
and live with parents.
Deductible on page 2 of Currently, that amount is
Disabled by Social Spouse’s income and $2,057.50/mo and can be as much
this same column.
Security Standards resources if live together. 100% of Poverty Level SSI Limits
Disabled Full Medicaid as $3,160.50 depending upon at-
Parents’ income and 1 – $1,041 1 - $2,000 YES home spouse’s cost for housing.
MAD Coverage
resources if under age 18 2 – $1,410 2 - $3,000 The amount protected for the at-
and live with parents. Individuals in nursing
facilities generally do home spouse is not counted in
Health Care Spouse’s income and not have to meet a determining the eligibility of the
150% of Poverty Level
for Working resources if live together. Min. CSRP deductible to be eligible spouse in the nursing facility.
Full Medicaid Parents’ income and 1- $1,562
Disabled * See Footnote limit NO for Medicaid. However,
Coverage resources if under age 18 2- $2,114
(HCWD) $25,284 they must pay all of their Protection of resources for
MAD and live with parents. monthly income, less a spouse at home: Additionally, the
Payment of Medicare Entitled to Medicare Spouse’s income and $30 personal needs countable resources of the couple
Qualified premiums and Parts resources if live together. allowance and the cost are combined and a portion is
100% of Poverty Level protected for the spouse at home.
Medicare deductibles and co- A&B Parents’ income and 1 - $7,730 of medical expenses not
1 – $1,041 NO covered by Medicaid or That portion is ½ the total value of
Beneficiaries insurance charges for resources if under age 18 2 - $11,600
Medicare covered and live with parents. 2 – $1,410 other insurance to the the countable resources, but
MQB-Q
services nursing facility. currently not less than $25,284 or
Medicaid pays the more than $126,420. The amount
Specified Entitled to free Spouse’s income and 120% of Poverty Level remainder of their cost protected for the at-home spouse
Low Income Medicare Part A resources if live together.
Payment of Medicare 1 - $1,249 1 - $7,730 of care. is not countable in determining the
Medicare Parents’ income and NO
Part B premium 2 - $1,691 2 - $11,600 eligibility of the spouse in the
Beneficiaries resources if under age 18
facility.
MQB-B and live with parents.
Entitled to free Spouse’s income and Transfer of resources: When a
Medicare Part A resources if live together. person gives away resources and
Qualifying Payment of Medicare 135% of Poverty Level
Parents’ income and 1 - $7,730 does not receive compensation
Individual Part B Premiums 1 - $1,406 NO
resources if under age 18 2 - $11,600 with a value at least equal to that
MQB-E and live with parents. 2 - $1,903
of the resources given away, he
NOTE: Total number of eligible individuals is limited to available funds. may be penalized. Medicaid will
Lost entitlement to Spouse’s income and not pay for care in a nursing facility
free Medicare A due resources if live together. or care provided under the
Payment of Medicare 200% of Poverty Level Community Alternative Program
Working to earnings but still Parents’ income and 2X SSI Limits
Part A premiums 1 - $2,082 (CAP) or other in-home health
Disabled has disabling resources if under age 18 1 - $4,000 NO
2 - $2,819 services & supplies for a period of
MWD impairment. and live with parents. 2 - $6,000
time that depends on the value of
the transferred resource.
* For Basic Coverage, the beneficiary does not have to meet the Social Security SGA requirement to be disabled. For Medically Improved coverage, the beneficiary does not have to meet the Social Security medical requirements for disability.
 BASIC REQUIREMENTS **
MONTHLY RESOURCE
GROUP BENEFITS BASIC ELIGIBILITY WHOSE INCOME and LIMIT
INCOME LIMIT DEDUCTIBLE/SPEND DOWN
REQUIREMENT RESOURCES COUNT Updated
Updated 04/19 04/19
Parents/Caretaker 1 - $434 If income exceeds income
Relatives, and the 2 - $569 limit and the indicator is
spouse must be living “yes” the individual or
Families & 3 - $667
with and caring for a family may be able to be
Children Full Medicaid 4 - $744
child to whom they are MAGI Methodology. $3,000 YES eligible for Medicaid if they
MAF Coverage related who is under age 5 - $824 he can meet a deductible
18. Medicaid Deductible:
Children must be under When an individual/family is
age 21. ineligible for Medicaid due to
A self-attestation of 196% of Poverty Level income over the income
pregnancy and due limit, they may become When determining the family
Pregnant Coverage is limited to date can be accepted 1 - $2,041 eligible by meeting a size for the pregnant woman the
Women treatment for conditions as proof of pregnancy 2 - $2,762 Medicaid deductible. The unborn child is included. For
MAGI Methodology NO NO example, the family size for a
MPW that affect the unless the county has 3 - $3,484 deductible is determined by
pregnancy information that subtracting the Medically single pregnant woman would
4 - $4,206
contradicts the Needy Income Limit (MNIL) be 2.
attestation. 5 - $4,928 (see limits below) from the
210% of Poverty Level countable monthly income to
Children determine the monthly
1- $2,186
under excess income. Medicaid
Full Medicaid 2 - $2,960 deductibles are generally
age 6 Must be under age 6. MAGI Methodology NO NO
Coverage 3 - $3,733 determined for 6 months, so
MIC the monthly excess income
4 - $4,507
is multiplied by 6 to
5 - $5,280 determine the 6-mo.
deductible. Once medical
133% of Poverty Level bills for which they are
Children responsible totaling the
1 - $1,385
age amount of the deductible are
Full Medicaid Must be age 6 thru age 2 - $1,875
6 thru 18 MAGI Methodology NO NO incurred, they are authorized
Coverage 18. 3 - $2,365
MIC for the rest of the 6-mo.
4 - $2,854 period. Medicaid cannot pay
5 - $3,344 for any of the bills applied to
the deductible.
IV-E Adoption Subsidy Resource
and Foster Care for a limit:
Title IV-E child residing in NC All deductible
Children Full Medicaid cases have a
and receiving IV-E There is no income. NO NO
Coverage resource
IAS Foster Care regardless
of the state providing MNIL: limit: $3000
assistance. for families
1 - $242 and children
A child under 21 and 2 - $317 and $2,000
currently in the legal 1. MAGI
State 3 - $367 (1) and
Full Medicaid custody of the state
Foster Care MAGI Methodology 2. MAF-M $3000 (MAF) YES $3000 (2) for
Coverage sponsored foster care 4 - $400
Children 3. NCHC aged, blind
and ineligible for Title 5 - $433
and disabled.
IV-E.
Be 18-20 and had been 5. MAGI
Full Medicaid in Foster Care at age
Expanded MAGI Methodology (excluding NCHC) $3000 (MAF) YES
Coverage 18 and enrolled in
Foster Care Medicaid program. 2. MAF-M
 BASIC REQUIREMENTS **
MONTHLY RESOURCE
GROUP BENEFITS BASIC ELIGIBILITY WHOSE INCOME and LIMIT DEDUCTIBLE/SPEND DOWN
INCOME LIMIT
REQUIREMENT RESOURCES COUNT Updated
Updated 04/18 04/19
Children with medical
or rehabilitative needs,
which are barriers to 1. MAGI
adoption are 2. MAF-M
considered special
Non-IV-E/ 3. Authorize ongoing
needs adoption
Special Full Medicaid Medicaid (**See
children. These MAGI Methodology $3000 (MAF) YES
Needs Coverage Footnote)
children are ineligible
Adoption 4. Evaluate NCHC if
through Title IV-E
because at the time of not eligible for any
placement in foster categories above.
care they did not meet
IV-E requirements.
MFC-
Medicaid Be age 18-26 and have
for Former Full Medicaid been in foster care at
Foster Care There is no income. NO NO
Coverage age 18 and enrolled in
NC Medicaid.

Be under the age 65

and not enrolled in any
creditable medical
Breast & insurance. Breast and
Cervical Cervical Cancer
Cancer Full Medicaid There is no income
Control Program NO NO
Medicaid Coverage (BCCM).
(BCCCP) provider
MAF-W determines eligibility for
Breast and Cervical
Cancer Medicaid
(BCCM).
195% of Poverty Level
Family 1 - $2,030 If a beneficiary’s income
Planning Family Planning 2 - $2,748 increases to more than 195%,
NO AGE LIMIT MAGI Methodology NO NO he/she will be ineligible for
MAF-D Program 3 - $3,467
family planning coverage.
4 - $4,185
5 - $4,903
Beneficiaries with household
Medicaid-equivalent Must be age 6 through income over 159% of poverty
211% of Poverty Level
coverage with four 18, ineligible for level must pay enrollment fee.
NC Health exceptions: Medicaid, Medicare, or 1 - $2,197
Choice 2 - $2,974 1- $1,655.01
no long-term care, no other federal
(NCHC) MAGI Methodology NO NO 2- $2,241.01
EPSDT, no non- government-sponsored 3 - $3,751
emergency medical health insurance, be 4 - $4,528 3- $2,827.01
transportation, and uninsured, a NC 4- $3,412.01
resident. 5 - $5,305
restricted dental. 5- $3,998.01
** If ineligible under MAGI, the child must have been enrolled in or eligible for Medicaid immediately before the adoption agreement, is under a Non-IV-E state adoption agreement or determined to be special needs
by the State adoption assistance agreement.
***This chart addresses benefits and basic eligibility requirements. Other requirements (such as citizenship/alien status, incarceration, & state residence) which can also affect eligibility, or the level of benefits are
not reflected on this chart. Revised 4/1/2019