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Disability-Based NC Medicaid

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    Disability-Based NC Medicaid

    What You Pay

    Most people who get NC Medicaid don’t have to pay a monthly premium, which means that you only have to make payments when you need medical care.

    Generally, if you are 21 years old or older, you may have to pay small copayments ($4 or less) when you use certain medical services that NC Medicaid covers.

    You do not need to make copayments if you are:

    • Under 21 years old
    • Pregnant
    • In hospice care
    • An American Indian in a federally recognized tribe
    • In foster care
    • Living in a nursing home or medical facility, or
    • Enrolled in Breast and Cervical Cancer Medicaid through the North Carolina Breast and Cervical Cancer Control Program (NC BCCCP).
    Example

    Dahlia is on NC Medicaid and never has to pay a monthly premium. One hot day in early July, she feels sick and goes to the doctor. When she gets there, the doctor tells Dahlia that she has allergies and prescribes her a medication that will help her feel better.

    NC Medicaid has a $4 copayment when you are sick and go to the doctor, so Dahlia pays $4 for her doctor's visit and another $4 copayment for her medication.

    Compared to Private Insurance

    NC Medicaid’s copayments are much lower than the copayments required by private insurance plans. Also, many private insurance plans have annual deductibles, which means you may have to pay thousands of dollars before the plan will cover most services, and even after the deductible is paid, many private insurance plans require $50 or more copayments for services.

    NC Medicaid with a spend down

    If you meet the other program requirements for disability-based NC Medicaid, but your countable income is higher than 100% of the Federal Poverty Guidelines (FPG), you can still get NC Medicaid services through an NC Medicaid category called NC Medicaid with a spend down.

    Your Countable Income:

    NC Medicaid with a spend down is like having a six-month deductible: after you pay for a certain amount of medical costs over a six-month period, NC Medicaid covers your medical expenses for the rest of the six months. If your medical bills don't reach the spend down amount in a six-month period, you don't have to pay the whole spend down that period.

    The amount you have to pay, or "spend down," is the difference between your countable monthly income and the Medically Needy Income Limit ($242 for an individual; $317 for couples), over six months.

    For example, Raheem's monthly countable income is $1,505, which is $1,263 more than the Medically Needy Income Limit. That number is multiplied by six to see Raheem's entire spend down amount for a six-month period, which is $7,578. Once Raheem spends $7,578 on medical bills in a six-month period, NC Medicaid will start paying for the rest of his covered medical expenses.

    Note: NC Medicaid with a spend down is very expensive. It's usually a lot better to pay a monthly premium and get Health Coverage for Workers with Disabilities (HCWD) or to get a private insurance plan through HealthCare.gov or through work. Look into those other options in DB101’s Health Programs section.

    Learn more

    Health Coverage for Workers with Disabilities (HCWD)

    HCWD is NC Medicaid for people with disabilities who work.

    Buying Health Coverage on HealthCare.gov

    You can get private health coverage on HealthCare.gov. The government may help you pay for it.