What Medicare does and doesn't pay
Medicare.gov says Medicare doesn't pay for long-term custodial care, such as help with dressing, bathing and using the bathroom, in assisted living or anywhere else, and it doesn't pay rent or meals. While you live in assisted living, Medicare still covers doctor visits, hospital stays, hospice, home health care if you meet its rules, and Part D drugs.
How North Carolina defines assisted living
Under G.S. 131D-2.1, an assisted living residence is group housing for two or more unrelated adults with at least one meal a day, housekeeping and personal care. Most are adult care homes, which provide 24-hour personal care. The Division of Health Service Regulation (DHSR) licenses them, and Adult Home Specialists in county DSS offices monitor them. NCDHHS counts more than 1,200 adult care homes in the state.
State-County Special Assistance
| Question | Answer |
|---|---|
| What it is | A cash supplement that helps people with low incomes pay for room and board in adult care homes, family care homes and group homes |
| Who can get it | People 65 or older, or disabled, who live in a facility approved for Special Assistance that accepts the state rate |
| Medicaid link | People who get Special Assistance are automatically eligible for NC Medicaid |
| Dementia care | A different rate applies in a licensed special care unit for Alzheimer's or related disorders |
| How to apply | Your county Department of Social Services |
The Special Assistance In-Home program gives a similar cash supplement to people at risk of moving into a facility, so they can stay home with a care plan from a county DSS case manager. More in what is Special Assistance.
NC Medicaid personal care in adult care homes
NC Medicaid's Clinical Coverage Policy 3L-1 pays for personal care services in licensed adult care homes for residents with NC Medicaid who need hands-on help with at least three of five daily activities (bathing, dressing, mobility, toileting and eating), or extensive help with two. Room and board are paid by Special Assistance or your own income.
Choosing a residence
- Check the license. Ask whether the home is a licensed adult care home or family care home and whether it accepts Special Assistance.
- Know who to call. Regional long-term care ombudsmen at the area agencies on aging help adult care home residents with rights and complaints. Care complaints go to DHSR at 1-800-624-3004.
A licensed insurance agent who works with Benefits Life can explain how Medicare and Medicare Advantage work when you move to assisted living, at no cost to you. You can request a call from a licensed insurance agent.
Related questions
Does Medicare cover nursing home care?
The 100-day skilled care rule.
Does Medicare cover home health care?
Skilled care at home, plus CAP/DA.
How do I get rides to the doctor?
County DSS rides and more.
Sources
- Medicare.gov — Long-term care
- North Carolina General Statutes — G.S. 131D-2.1, Definitions (assisted living residences)
- NCDHHS Division of Aging — Adult Care Homes
- NCDHHS — State and County Special Assistance for Adult Care Home Residents
- NCDHHS — State and County Special Assistance for In Home Residents
- NC Medicaid — Clinical Coverage Policy 3L-1, Personal Care Services Provided in Congregate Settings (amended Jan. 1, 2026)
- NCDHHS Division of Aging — Long-Term Care Ombudsman
More questions in this guide
- Can I keep my doctor when I go on Medicare in North Carolina?
- Does Medicare cover dental in North Carolina?
- Does Medicare cover eye exams and glasses in North Carolina?
- Does Medicare cover hearing aids in North Carolina?
- Does Medicare cover home health care in North Carolina?
- Does Medicare cover mental health care in North Carolina?
- Does Medicare cover nursing home care in North Carolina?
- How do I get rides to the doctor with Medicare in North Carolina?
Part of the guide: Medicare basics for North Carolinians · All questions
Frequently asked questions
Who qualifies for State-County Special Assistance?
NCDHHS says you must be 65 or older, or disabled, have a low income, and live in a residential facility approved for Special Assistance that accepts the state rate. People who get Special Assistance are automatically eligible for NC Medicaid. Apply at your county Department of Social Services.
Is an adult care home the same as assisted living in North Carolina?
Mostly. North Carolina law (G.S. 131D-2.1) uses assisted living residence as the umbrella term and names three types: adult care homes, adult care homes that serve only elderly people, and multiunit assisted housing with services. Adult care homes with two to six residents are called family care homes.
Does Medicare Advantage pay for assisted living?
Assisted living rent and custodial care aren't Medicare benefits. Medicare Advantage plans cover what Original Medicare covers while you live in assisted living, such as doctor visits and hospital care. Check a plan's Evidence of Coverage for anything else.
Medicare in your North Carolina county
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