Is It Right for You?

Everyone should be able to get health coverage. The question is, which plan is right for you and your family?

This page looks at whether you might qualify for disability-based NC Medicaid.

Just because you have a disability does not mean that you qualify for disability-based NC Medicaid. You may qualify for income-based NC Medicaid or Health Coverage for Workers with Disabilities (HCWD), or you may not qualify for NC Medicaid at all, depending on your situation.

Try out the estimator below. If your income is at or below the limit for income-based NC Medicaid (138% of the Federal Poverty Guidelines (FPG) or less), read our income-based NC Medicaid article.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$15,650
	$5,500
	$15,060
	$5,380
	216
Income-based NC Medicaid, adults (138% FPG)
NC Medicaid for children (216% FPG)
Subsidized private plans, reduced fees (250% FPG)
Subsidized private plans (no income limit)	--
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules. Notes: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). Disability-based NC Medicaid eligibility is not included here. For private plans with subsidies, your monthly premium amount depends on your income.

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Disability-Based NC Medicaid Basic Eligibility Requirements

To qualify for disability-based NC Medicaid, you must:

• Have been determined blind or disabled according to Social Security Administration rules
• Be a U.S. citizen or have an immigration status that is eligible for NC Medicaid
• Meet certain resource requirements, and
• Meet certain income requirements.

Note: If you’re on Supplemental Security Income (SSI) or SSI’s 1619(b) provision, you automatically get NC Medicaid coverage, do not need to apply for NC Medicaid, and do not need to worry about the rules discussed on this page. Learn more about getting NC Medicaid through SSI.

Disability Determination

To get disability-based NC Medicaid, you must have a disability that meets Social Security’s definition of disability. If you currently get disability benefits, like Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards. If not, the state will check to see if your disability qualifies for NC Medicaid.

Under these rules, you have a disability if:

• You have a physical or mental impairment or combination of impairments
• Your impairments limit your ability to work, preventing you from earning Substantial Gainful Activity ($1,620 per month or $2,700 per month if you’re blind), and
• Your condition has lasted or is expected to last for at least 12 months.

To get a disability determination, you will have to provide medical documentation specified by the Social Security Administration (SSA) or North Carolina's Disability Determination Services (DDS).

If your disability does not meet Social Security’s definition of disability, you may still qualify for NC Medicaid through the rules for income-based NC Medicaid, which does not require a disability determination.

Citizenship or Residency

You must be a U.S. citizen or meet specific noncitizen requirements to be eligible for NC Medicaid:

• Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get, including NC Medicaid.
• Most immigrants who have been lawfully present for less than five years do not qualify for NC Medicaid. However, they may qualify to get private coverage subsidized by the government through HealthCare.gov.
• Undocumented immigrants do not qualify for NC Medicaid, but they may qualify for Emergency NC Medicaid. To learn more about this, contact your local Department of Social Services (DSS) office.

Resources

To qualify for disability-based NC Medicaid, your resources must be at or below disability-based NC Medicaid's resource limit ($2,000 for one person; $3,000 for a couple). Some resources don't count towards these limits, like the home you live in and one car.

Also, if your disability began before you turned 26, you can open an ABLE account where you can save up to $19,000 each year and not have it counted by NC Medicaid. Learn more about ABLE accounts.

If you have too much in resources to qualify for disability-based NC Medicaid, you may be able to qualify for NC Medicaid in other ways:

• Income-based NC Medicaid has no resource limit. Learn more in DB101’s income-based NC Medicaid article.
• Health Coverage for Workers with Disabilities (HCWD), an NC Medicaid program for people with disabilities who work, has a resource limit of $30,828. Learn more in DB101's HCWD article.

Income

For disability-based NC Medicaid, you may qualify if your countable monthly income is at or below an income limit:

• To qualify, your countable monthly income must be at or below 100% of the Federal Poverty Guidelines (FPG) ($1,305 per month for an individual, $1,763 for a family of two).
• If your income is higher than 100% of FPG, you may still be eligible for NC Medicaid, but you will have to spend some of your own money on your medical bills before NC Medicaid will start paying. This is called NC Medicaid with a spend down. Note: NC Medicaid with a spend down is usually a lot more expensive than Health Coverage for Workers with Disabilities (HCWD). If you make money through work, you save a lot of money with HCWD!

Figuring Out Your Countable Income

Your countable income is not the same as your real, full income. For disability-based NC Medicaid, your income is counted the same way as it is counted for Supplemental Security Income (SSI): almost all of your unearned income is counted, but less than half of your earned income is counted. For example, if you make $4,000 per month at a job and have no other income, that’s only $1,957.50 in countable monthly income.

Note: This is different than with income-based NC Medicaid, where almost all of your income gets counted. That means that even you make too much money to qualify for income-based NC Medicaid, you may still qualify for disability-based NC Medicaid if you meet the other requirements.

Use this tool to see your countable income:

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
Your Monthly Countable Income
Your Annual Countable Income
	$15,650
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

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If your countable monthly income is less than 100% of FPG, you may qualify for disability-based NC Medicaid.

If your countable monthly income is more than 100% of FPG, you may qualify for NC Medicaid with a spend down. We explain how NC Medicaid with a spend down works later in this article.

NC Medicaid, Private Coverage, and Medicare

If you qualify for NC Medicaid, you should sign up for it. Here we will look at what signing up for NC Medicaid might mean if you also have, or want, private coverage or Medicare.

NC Medicaid and Employer-Sponsored Health Coverage

If you qualify for NC Medicaid, it will always be your best choice, even if your employer offers health insurance. That’s because NC Medicaid has no monthly premium and the copayments for services are usually much lower than copayments required by employer-sponsored plans. Also, NC Medicaid may cover some services that your employer-sponsored coverage does not pay for.

However, there are a couple of advantages to having both NC Medicaid and employer-sponsored coverage at the same time:

• Private insurance may cover some benefits that NC Medicaid doesn’t or vice versa.
• Private coverage may let you choose from more doctors.

If you are eligible for NC Medicaid and have private insurance through your employer or your spouse's or parent's employer, NC Medicaid may help pay your employer-sponsored coverage premiums, if NC Medicaid would save money by doing so. In order to qualify for help paying your employer-sponsored coverage premiums, you must have a high-risk illness, not be able to afford your premiums, and not have Medicare coverage.

NC Medicaid and Individual Plans

If you are eligible for NC Medicaid, then you will not be eligible to get government help to pay for a private insurance plan. That means the private insurance plan may be expensive for you. If you qualify for NC Medicaid, it will always be a better option for you than paying for an individual plan.

NC Medicaid and Medicare

If you qualify for disability-based NC Medicaid, you may be able to get NC Medicaid and Medicare at the same time. Note: You usually cannot get income-based NC Medicaid if you get Medicare.

There are significant advantages to this. Most importantly, if you have both:

• NC Medicaid will usually pay your Part B premium (and your Part A premium, if you have one). It may also pay your Medicare deductibles, co-insurance, and copayments.
• You will automatically be enrolled in a Part D benchmark plan and automatically qualify for the Part D Low Income Subsidy. The Low Income Subsidy means you may not have to pay a premium for your Part D or any deductibles. All you would pay for prescription drugs are Part D’s copayments, which range from $1.60 to $12.15.
• NC Medicaid covers many more services than Medicare, so by having both you’ll have better health care coverage than you would by enrolling in just one or the other.

Contact the Seniors' Health Insurance Information Program (SHIIP) if you have questions about how your NC Medicaid and Medicare benefits work together. To learn more, read DB101’s Medicare article, which has detailed information on Medicare Savings Programs and the Part D Low Income Subsidy.