North Carolina Medicaid does cover intermediate care nursing, but only in specific settings and under certain conditions

North Carolina Medicaid pays for intermediate care nursing — skilled nursing care that is less intensive than hospital care but more than basic personal assistance — through two main routes: nursing facilities (also called skilled nursing facilities) and home and community-based services waivers. Which one covers you depends on where you receive care, your income and assets, and whether you meet medical necessity requirements. The state does not cover intermediate care nursing in all settings, and coverage rules differ significantly depending on your age and disability status.

Medicaid in North Carolina is administered by the Department of Health and Human Services, Division of Health Benefits. The actual coverage decisions are made by the state's managed care organizations (MCOs) if you are enrolled in one, or by the state directly if you are on fee-for-service Medicaid. Either way, your doctor must document that you need intermediate care nursing — not just that it would be helpful — before any coverage begins.

Key Takeaways

  • North Carolina Medicaid covers intermediate care nursing in licensed nursing facilities and through home and community-based services waivers, but not in all other settings.
  • Your doctor must order intermediate care nursing and document medical necessity; Medicaid will not pay for custodial care or assistance with activities of daily living alone.
  • Nursing facility coverage requires you to spend down assets to $2,000 (or $3,000 for a married couple with one spouse in care) before Medicaid begins paying.
  • Home and community-based services waivers have waiting lists in North Carolina, and the length of the wait depends on which waiver program you need and your county.
  • If you are under 21 or have a serious mental illness, different Medicaid programs may cover intermediate care nursing with different rules.

Intermediate care nursing in North Carolina nursing facilities

North Carolina Medicaid covers intermediate care nursing in licensed nursing facilities (skilled nursing facilities) under the state's regular Medicaid program. The facility must be certified by the state and must meet federal Medicaid standards. Your doctor must order the care and document that you need skilled nursing — meaning a licensed nurse must provide it because of the medical complexity, not because you need help with bathing or dressing.

Before Medicaid pays, you must meet the asset limit. As of 2024, you can have no more than $2,000 in countable assets if you are single, or $3,000 if you are married and your spouse is not in a facility. Countable assets include bank accounts, stocks, and some other liquid resources, but not your home (if you live there), one vehicle, or certain personal items. You will need to provide bank statements and proof of asset value to the nursing facility's Medicaid coordinator.

Your income does not have to be low to receive Medicaid coverage in a nursing facility — you can have substantial income — but Medicaid will require you to pay a portion of your income toward your care. The amount you pay is called your patient responsibility or patient pay, and it is calculated by the nursing facility based on your income minus certain deductions. Medicaid pays the rest of the facility's bill.

Intermediate care nursing through home and community-based services waivers

North Carolina Medicaid also covers intermediate care nursing delivered in your home or community through home and community-based services (HCBS) waivers. These waivers allow Medicaid to pay for services outside a facility setting. The state operates several different waivers, each designed for a different population: the Innovations waiver (for adults with intellectual or developmental disabilities), the Tailored Care Management waiver (for elderly and disabled adults), the Behavioral Health waiver (for adults with serious mental illness), and others.

HCBS waivers have waiting lists in North Carolina. The wait time varies by waiver program and by county. Some waivers have short waits; others have waits of several years. You can contact your local Department of Social Services office or the Division of Health Benefits to find out the current wait time for the waiver that matches your needs. Being on a waiting list does not may provide you will eventually receive services — you must continue to meet medical necessity and other requirements when a slot opens.

Asset and income limits for HCBS waivers are different from nursing facility limits. Generally, you can have more assets and income while still receiving waiver services, but the exact limits depend on which waiver you are on. Your local DSS office can tell you the specific limits for your situation.

What counts as intermediate care nursing versus custodial care

North Carolina Medicaid distinguishes between skilled nursing care (which it covers) and custodial care (which it does not). Intermediate care nursing falls in the skilled category. Skilled nursing includes wound care, medication management by a nurse, catheter care, tube feeding, physical therapy ordered by a doctor, and other services that require a licensed nurse's judgment and training.

Custodial care — help with bathing, dressing, toileting, eating, and transferring — is not covered by Medicaid as a standalone service, even if a nurse provides it. However, if you are in a nursing facility, the facility provides custodial care as part of its daily operations, and Medicaid's payment to the facility covers it. If you are receiving HCBS waiver services, you may be able to receive personal care assistance (a form of custodial care) as part of your waiver services, depending on which waiver you are on.

Your doctor's order and clinical documentation are critical. If the documentation says you need help with activities of daily living but does not describe a skilled nursing need, Medicaid may deny coverage. Make sure your doctor is clear about why a nurse specifically must provide the care.

Coverage for people under 21 and those with serious mental illness

North Carolina Medicaid covers intermediate care nursing for people under 21 through the regular Medicaid program and through the Katie Beckett option (a federal rule that allows children with disabilities to receive Medicaid even if their parents' income is above the limit). The rules are similar to those for adults, but the asset and income limits are calculated differently, and your child's doctor must document medical necessity.

Adults with serious mental illness may be covered through the Behavioral Health waiver or through regular Medicaid, depending on your situation. The Behavioral Health waiver includes intermediate care nursing as part of its services. If you have serious mental illness and are not on a waiver, regular Medicaid nursing facility coverage still applies, but you should ask your doctor and your Medicaid managed care organization (if you have one) whether the Behavioral Health waiver might be a better fit for your needs.

How to request coverage and what to expect

To request intermediate care nursing coverage, start by having your doctor order the service and document medical necessity. If you are entering a nursing facility, the facility's Medicaid coordinator will help you apply for Medicaid or will verify your existing coverage. If you are seeking HCBS waiver services, contact your local Department of Social Services office to ask about the waiver that fits your needs and to get on the waiting list.

You will need to provide proof of income, assets, citizenship, and residency. The nursing facility or DSS office will give you a list of documents they need. Processing times vary: nursing facility Medicaid applications can take several weeks, and HCBS waiver applications can take longer if you are on a waiting list.

If Medicaid denies your request for coverage, you have the right to request a fair hearing. You can ask for a hearing within 30 days of the denial notice. Contact the Division of Health Benefits or your local DSS office for instructions on how to request a hearing.

Frequently Asked Questions

Does North Carolina Medicaid cover intermediate care nursing at home if I am not on a waiver?

No, not through regular Medicaid. Home-based intermediate care nursing is covered only through HCBS waivers. If you need skilled nursing at home and are not on a waiver, you may be able to receive services through Medicare (if you are may be able to access) or through private insurance, but North Carolina Medicaid will not pay for it outside a waiver program.

What if I have too many assets for Medicaid but need intermediate care nursing?

You can spend down your assets by paying for care, medical expenses, or other allowed costs, and then apply for Medicaid once you are below the asset limit. Some people also use trusts or other legal strategies to protect assets while becoming Medicaid-may be able to access; you should speak with an elder law attorney about your specific situation. In the meantime, you may be able to pay privately or use Medicare if you are 65 or older.

How long does it take to get approved for intermediate care nursing through a nursing facility?

Medicaid approval for nursing facility care typically takes two to four weeks after you submit all required documents, though it can be faster if the facility helps you gather paperwork quickly. The facility can admit you before Medicaid approval is complete, but you will be responsible for paying the daily rate until Medicaid begins paying. Ask the facility about their policy on this.

Can I choose which nursing facility Medicaid pays for?

Yes. You can choose any licensed nursing facility in North Carolina that accepts Medicaid. Not all facilities accept Medicaid, so you should ask before you decide. If you are in a Medicaid managed care organization, your MCO may have a preferred provider list, but you still have the right to choose a different facility; your MCO may just pay a different rate.

What happens if I am on a waiting list for an HCBS waiver and need care now?

You can pursue other options while you wait: nursing facility care (if you meet asset limits), private pay home care, Medicare-covered skilled nursing (if you are 65 or older or meet other Medicare criteria), or services through your local Area Agency on Aging. Some people combine waiting list status with private pay services until a waiver slot opens. Contact your local DSS office to discuss your options.