NC Medicaid for Long-Term Care: What Buncombe County Families Need to Know

NC Medicaid can cover the full cost of a nursing facility for people who qualify financially and medically. For families whose savings are limited or have been depleted by years of care costs, it is often the most important benefit available. It is also one of the most misunderstood.

This guide explains how NC Medicaid works for long-term care, who qualifies, what it covers, how the spend-down process actually works, and where to get help in Buncombe County without paying for information you can get free.

NC Medicaid is a joint federal-state program that pays for medical care and long-term services for people with low income and limited assets. For purposes of this article, we are focused specifically on Medicaid coverage for nursing facility care, which is the only long-term residential care setting that Medicaid covers in North Carolina as a matter of entitlement.

This is different from NC Special Assistance, which is a state-funded benefit that helps pay for assisted living. Medicaid and Special Assistance are separate programs with separate eligibility rules. A person can potentially receive both, but they serve different levels of care. If you are trying to pay for assisted living specifically, the Special Assistance article on this site covers that program in detail.

Medicaid for long-term nursing care pays for:

• Room and board in a Medicaid-certified skilled nursing facility
• Nursing and personal care services provided at the facility
• Most medications and medical supplies
• Physical, occupational, and speech therapy when clinically indicated

The resident retains a small personal needs allowance (currently $46 per month in NC) and is responsible for applying essentially all of their income toward the cost of care. Medicaid covers the rest.

To qualify for Medicaid long-term care coverage, a person must require nursing facility level of care. North Carolina uses an assessment tool to evaluate functional need, looking at whether the person needs assistance with activities of daily living, has significant cognitive impairment, or requires skilled nursing or medical monitoring that cannot be safely provided in a less intensive setting.

People with advanced dementia, significant physical frailty, complex medication regimens, or major mobility impairment commonly meet this standard. The assessment is conducted by the county Department of Social Services or a Medicaid-approved assessor and is a formal step in the application process.

This is the piece that causes the most confusion, and where most families’ assumptions about Medicaid turn out to be wrong. The financial eligibility rules for long-term Medicaid in NC involve both income and assets.

Income: There is no strict income cap for nursing home Medicaid in NC. Instead, nearly all of the applicant’s income is applied toward the cost of care each month. If the facility charges $8,000 per month and the resident receives $2,400 in Social Security and pension income, they contribute $2,354 to the facility (after the $46 personal needs allowance) and Medicaid pays the remainder. High income does not disqualify someone — it reduces the amount Medicaid pays.

Assets: The applicant’s countable assets must be at or below $2,000. Certain assets are excluded from this calculation:

• The primary residence (with conditions — see below)
• One vehicle of any value used by the applicant or a community spouse
• Personal belongings and household furnishings
• A prepaid funeral and burial arrangement up to certain limits
• Term life insurance and some whole life policies below a cash value threshold

Most families who eventually qualify for Medicaid do not start out at the $2,000 asset threshold. They arrive there over time as nursing facility costs deplete savings. This process is called spend-down, and understanding it changes the way families think about the path to Medicaid eligibility.

Here is a simplified example: A widow enters a nursing facility with $120,000 in savings. The facility costs $8,500 per month. Her Social Security income is $1,800 per month, meaning her savings are covering approximately $6,700 each month. At that rate, she reaches the $2,000 asset limit in roughly 17 months and becomes eligible for Medicaid to cover the remaining cost.

Spend-down is not a loophole or a planning strategy — it is simply how the program is designed. Medicaid for long-term care was never intended to pay for care before private resources are used. Families who understand this can plan for it rather than being surprised by it.

Spending down means using countable assets on legitimate expenses. Allowable spend-down uses include:

• Nursing facility care costs
• Medical equipment, prescriptions, and health-related expenses
• Home modifications that were needed before placement
• Prepaid funeral and burial arrangements (within NC limits)
• Paying off debts: mortgage balance, car loan, credit cards
• Purchasing an exempt asset (a reliable vehicle, household items)

What is not allowed is simply giving money away to family members to reduce the asset count. Medicaid applies a five-year lookback period: any asset transfers made below fair market value within five years of the application date can be counted as if the assets were still there, creating a penalty period during which Medicaid will not pay.

When one spouse enters a nursing facility and the other remains at home (the “community spouse”), NC Medicaid has specific protections designed to prevent the at-home spouse from being impoverished.

The Community Spouse Resource Allowance (CSRA) lets the at-home spouse keep up to half of the couple’s combined countable assets, up to a federally set maximum (approximately $154,140 in 2025). The nursing home spouse retains only $2,000. Assets above the CSRA must be spent down before Medicaid eligibility begins.

The at-home spouse also retains a Minimum Monthly Maintenance Needs Allowance (MMMNA), which protects a portion of the nursing home spouse’s income for the community spouse’s living expenses. In some cases, if the community spouse’s income falls short of the MMMNA floor, the community spouse may receive a portion of the nursing home spouse’s Social Security or pension to make up the difference.

These rules are technical and interact with each other in ways that vary significantly by family situation. A Medicaid planning attorney or the Buncombe County DSS can walk through the specific calculations.

Medicaid applications for long-term care are processed by the Buncombe County Department of Social Services. The application requires extensive documentation and the process can take 45 to 90 days. Getting the paperwork organized before submitting significantly reduces processing time.

Key documents typically required:

• Proof of identity and citizenship (birth certificate, passport, or naturalization certificate)
• Social Security card
• Proof of income: Social Security award letter, pension statements, any other income sources
• Bank statements for all accounts, typically 60 months (five years) to document the lookback period
• Insurance policies (life insurance, long-term care insurance)
• Deed or mortgage statements if real property is owned
• Vehicle title
• Documentation of any asset transfers made in the past five years

Buncombe County Department of Social Services

40 Coxe Avenue, Asheville, NC 28801
(828) 250-8750

Pisgah Legal Services provides free civil legal assistance to income-eligible seniors in Western NC, including help with Medicaid applications, appeals, and advance planning documents. Their staff know the NC Medicaid rules in detail and can review your situation before you file. This is among the most valuable free services available to Buncombe County families navigating this process.

(828) 253-0406

Council on Aging of Buncombe County can help families understand whether Medicaid is likely to apply to their situation, explain how it interacts with Social Security and other income, and provide referrals to both Pisgah Legal Services and private elder law attorneys when the situation is complex.

(828) 277-8288

NC Medicaid for nursing facility care does not disqualify a person from other benefits, and several combinations are worth knowing:

Medicare and Medicaid (dual eligibility). Many nursing facility residents are eligible for both Medicare and Medicaid, often called “dual eligible.” Medicare covers skilled nursing facility care following a qualifying hospitalization for up to 100 days (with copays after day 20). After Medicare exhausts, Medicaid can cover ongoing custodial care if the person meets Medicaid eligibility. The transition from Medicare to Medicaid is one of the most important financial moments in long-term care, and it is worth understanding before it happens.

VA benefits and Medicaid. Veterans receiving Aid and Attendance cannot simultaneously receive full Medicaid nursing facility coverage for the same period — the VA benefit is counted as income and applied toward the cost of care under Medicaid. However, VA and Medicaid can work in sequence. A veteran who uses Aid and Attendance in assisted living before eventually needing nursing-level care may transition to Medicaid at that later point. The interaction is worth discussing with both the VA and DSS.

NC Special Assistance and Medicaid. Special Assistance covers assisted living; Medicaid covers skilled nursing. A person may receive Special Assistance in an assisted living setting for years and then transition to Medicaid coverage when they move to a nursing facility. These are sequential rather than simultaneous programs.