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Departments » Social Services » Medicaid


  

Medicaid   

  • Adult Medicaid
  • Family and Children

Adult Medicaid

  • Medicaid for the aged, blind or disabled: This program is for individuals 65 years of age or older or, if under 65, be disabled based on the Social Security Administration’s definition of disability. Blind persons of any age who meet the required definition of blindness may also receive Medicaid. For further information on this program, click here
     
  • Medicare qualified beneficiaries (MQB): MQB provides payment of the Medicare premium for those beneficiaries who have Medicare B and who meet program income and reserve guidelines. Under this program, Medicare recipients who meet the income limit for Medicaid, but are over reserve, can receive a MQB cared which will pay the deductibles and co-payment for Medicare covered services. For further information on this program, click here
     
  • Community Alternatives Program (CAP): CAP provides an alternative to nursing home placement by allowing individuals to remain in their home with support services. The program does not provide 24-hour support, but works in conjunction with existing caretaker support. Unlike other Medicaid programs, CAP considers the income of only the person who is receiving services. For further information on this program, click here
     
  • Special Assistance (SA): The Special Assistance Program provides a cash supplement and medical assistance to low-income, aged, blind or disabled persons who reside in a rest home or family care home. For further information on this program click here

Family and Children’s Medicaid

  • Medicaid for Pregnant Women (MPW): The MPW program provides Medicaid to help with prenatal care, delivery and postpartum care for women with income at or below 185% of the poverty level. For further information on this program, click here
     
  • Medicaid for Infants and Children (MIC): Medicaid for infants and children is a program for infants and children to age 19 who meet income and eligibility criteria. There is no reserve limit and no deductible for children who qualify for assistance under MIC. For further information on this program, click here

     
  • Medicaid for Families with Dependent Children (MAF): MAF provides medical assistance to low income families with children under 21 who meet the eligibility requirements. There is a reserve limit of $3000.00 and families with income exceeding the required limit must meet a deductible before Medicaid will pay. For further information on this program, click here
     
  • NC Health Choice: NC Health Choice is an insurance program to provide medical coverage for children up to age 19 who are not eligible for Medicaid, but whose families can not afford private health insurance. Eligibility is based on an income of up to 200% of poverty income level. For further information on this program, or an application, click here

NC Health Choice Applications:
   English (PDF Format)
   Spanish (PDF Format)

What is Children’s and Caretaker Relative Medicaid and NC Health Choice?

Medicaid is a program that pays medical bills and prescriptions for eligible families who cannot afford the cost of health care. Federal, state and county taxes pay the program costs.

Who is eligible?

In the Family Medicaid program, it may be a child/children and may or may not include the adult caretaker.

In short some of the basic guidelines:

    • Be under 19 (income eligible)
    • Be under 21 and not living with a parent or considered emancipated (income & reserve eligible)
    • Be pregnant (income eligible)
    • Have minor children in the home for caretaker relative to receive. (income & reserve eligible).

What are the basic eligibility criteria for children?
For a child 18 and younger, eligibility is based solely on the income of the financially responsible adult the child lives with. There are different income levels based on the age of the child as shown below in the income limit chart. There is no resource evaluation in this program. (Resources include money in the bank, vehicles, cash on hand, etc.) If the child does not meet the income guidelines in this program, then an evaluation can be made in another program with lower income limits, resource limits, and a deductible.

Can an adult be covered in this program?
In order for the adult caretaker to receive in the Family Medicaid program, first of all, their child must be Medicaid eligible. Eligibility for the adult is based on the child. If there is an eligible child, then the adult can possibly receive. But, the income guidelines for an adult to receive are much lower than for the child. Also, there is a resource evaluation that must be met for the adult to receive. 

Can a pregnant woman receive Medicaid who has no other children in the home?
Yes. There is a Medicaid program titles Medicaid for Pregnant Women (MPW). This program is based solely on the income of the pregnant woman and the father of the unborn if in the home. There are no resource limits in this program and the income limit is shown below. These income limits, referred to as poverty level, are established by Congress each fiscal year. This coverage begins with approval of an application and continues for two months after the birth of the baby. When the baby is born and birth reported the baby gets Medicaid automatically for one year.

Can someone receive Medicaid if he/she is not a U.S. Citizen?
There are many factors to this question.

If he/she is an Illegal Alien, the person can not receive full Medicaid. They may be eligible for Emergency Medicaid Services. Emergency Medicaid is determined by DMA (Division of Medical Assistance).

If she is illegal and pregnant, she may be eligible for Presumptive Medicaid for the later part of the pregnancy. When an Illegal Alien delivers her child, she can then apply for Emergency Labor and Delivery Services. The baby would then be eligible for Automatic Newborn coverage for 1 year, since the child is a U.S. Citizen.

If they are Lawful Permanent Residents (LPR) admitted to the U.S. on or after August 1, 1996 they are not eligible for full Medicaid for 5 years from the date they are admitted to the U.S. as an LPR. Residency status is determined Immigration and Naturalization Services. This is a mandatory 5-year disqualification period. After the 5-year disqualification period has expired, LPR's are potentially eligible for full Medicaid just like U.S. citizens.

If they are LPR under a political designation (ex. Refugee) admitted on or after August 1, 1996, they can only receive full Medicaid for the first 60 months they have entered this country. Refugees admitted before August 1, 1996 have been exempted from this.

What is Retroactive Medicaid?

Someone who has medical bills in one or all 3 months prior to application date may apply for these bills, if all other eligibility factors are met

What is Carolina Access?

Linking Medicaid recipients to a Primary Care Doctor for their health needs in their community. Dental or Eye doctors are excluded.

What is NC Health Choice?

Low-income families are able to get health insurance for their children. North Carolina's children's health insurance plan " NC Health Choice" will cover children from low-income families that make too much to qualify for Medicaid.

Why health insurance is important:
When working families cannot afford health care for their children, the consequences can be dire. Babies may not get the checkups that make sure they are growing healthy and strong. Families may wait until a child is very sick before seeking medical help, sometimes getting help only in an emergency. Untreated illnesses can have long-lasting consequences, such as hearing loss caused by ear infections.

Who is eligible for NC Health Choice:
For the first six months of the program's existence, a child must have been uninsured for six months to be eligible. After the program has been in place for six months, children must have been uninsured for two months before they can be eligible. The purpose of the first six-month period is to make sure that the 71,000 (statewide) children with no health insurance get the first chance to get into the program. If the family income falls below the following, the family may be eligible for NC Health Choice or Medicaid. 

Some allowances are made for child care costs and other work related expenses so those individuals who make slightly more than the limit should still consider coming to Social Services and discussing Medicaid and NC Health Choice.

What it costs:
For families who make less than 150% of the federal poverty level, there will be no additional cost. For those families with an income greater than the levels listed below, there will be an annual cost of $50 for one child and $100 for two or more children. There will also be a copayment levied of $5 per visit to physician, dentist, optometrist, clinic, outpatient hospital visit, etc.; $6 per prescription for drugs; and $20 for nonemergency emergency room visits. There will be no charge for anyone for well child and other preventive health visits. 

What is covered?
This is a comprehensive health insurance plan which covers not only hospitalization but also outpatient care. Preventive dental, vision and hearing benefits are available. The following is a summary of benefits:

Hospital Care - Semiprivate room, medications, laboratory texts, x-rays, surgeries, and professional care.

Outpatient care - includes diagnostic services, therapies, laboratory services, X-rays, and outpatient services.

Physician and clinic services - office visits; preventive services such as four well-baby visits up to one year of age, three visits per year between one and two years of age and one visit per year between 2 and 7, and once every three years between 7 and 19. Immunizations are covered.

Surgical services - includes standard surgical procedures, related services, surgeon's fees, and anesthesia.

Prescription drugs

Laboratory and radiology services

Inpatient mental health services - requires precertification

Outpatient mental health services - requires precertification after 26 outpatient visits per year.

Durable medical equipment and supplies such as wheelchairs

Vision

Hearing

Home health care - limited to patients who are homebound and need care that can only be provided by licensed health care professionals or in the case that a physician certifies that the patient would other wise be confined to a hospital or skilled nursing facility. Professional health care is covered; care provided by an unlicensed caregiver is not.

Nursing care

Dental care includes oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X-rays once every 60 months, bitewing X-rays of the back teeth once during a 12 month period and routine fillings.

Inpatient substance abuse treatment and outpatient substance abuse treatment -is covered. See the mental health inpatient and outpatient notes above.

Physical therapy, occupational therapy and therapy for individuals with speech, hearing and language disorders

Hospice care

Special needs children with chronic mental or physical conditions or illness may receive services beyond those listed above if services are medically necessary and receive precertification.

Once a child has been covered under this plan, should family economic conditions change so that the child is no longer eligible, but the family wants the child to continue in the program, the family will be allowed to purchase the plan at full premium for one year.

Applying for Health Choice insurance for your children:

A two page application form, income verification and enrollment fee (if required) are needed to approve the application. This application form will be made available at the Social Services and the Health Department. The application can be mailed in or taken to your county social services department. To expedite the process, come to Department of Social Services for a face to face interview. Each application will first be looked at to see if the child is eligible for Medicaid and, if not, then looked at to see if the child is eligible for the new program. If the child is found to be eligible, the application will be processed and the parents will receive a health card, a benefits booklet and instructions in the mail. Once parents are notified, the child is eligible to receive care.

Note: Unlike Medicaid, this program is limited by the amount of funds which are available. Therefore, it is open only to children on a first come, first served basis. Once the program is full, a waiting list will be taken, so it is in the best interest of the child to enroll as soon as it is possible. The state does feel that there are enough funds to cover all available children, however, there is no exact count of the numbers of uninsured children in the state. Every effort will be made to notify families through various media that this program exists and who is eligible.

The state discourages families from dropping current health coverage in order to enroll in the new child health insurance plan. Therefore, during the first six months of the program (through April 1999), children can be enrolled who have not had health insurance for six months. After April 1999, children can be enrolled who have not had health insurance for two months.

Social Services Main Page




Lee County Social Services
 

 

 

For Left Side

530 Carthage Street
P.O. Box 1066
Sanford, NC 27330

Phone 919-718-4690
Fax 919-718-4634

Hours of Operation
Monday - Friday
8 am - 5 pm

Board Members:

Ophelia Livingston, Chairman
Gail Dickens, Vice Chairman
David Riddle
Paul Utley
Charlie Parks