Adult Care Home Medicaid Personal Care Services Coverage.

2025-2026 Session Introduced by Mary Belk and 30 co-sponsors

The bill would seek CMS approval to extend Medicaid personal care services to certain adult care home residents with income above SA limits but within 180–200% FPL, cost-neutral.

Withdrawn From Com

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Summary — HB 485: Adult Care Home Medicaid Personal Care Services Coverage

Status (from provided record)
- Introduced: November 12, 2024.
- Procedural note: Considered in public hearing (May 5, 2025); listed as “Withdrawn From Com” on May 27, 2025 in the provided actions. (If reenacted, the bill requires further committee/senate action.)

Purpose and intent
- Require the North Carolina Department of Health and Human Services, Division of Health Benefits (DHB), to seek federal (CMS) approval to extend Medicaid coverage of personal care services (PCS) to certain residents of licensed adult care homes and special care units who currently exceed State‑County Special Assistance (SA) income limits but fall below expanded poverty thresholds. The broader aim is to expand community‑based long‑term services as alternatives to nursing home placement for dual eligibles.

Key provisions
- DHB must consult stakeholders and submit a federal request (e.g., waiver or state plan amendment) that:
1. Extends Medicaid PCS to adult care home / special care unit residents whose income exceeds the State‑County SA eligibility limit but does not exceed:
- 180% of the Federal Poverty Level (FPL) for individuals who would otherwise qualify at the SA basic rate, or
- 200% of FPL for individuals who would otherwise qualify at the SA enhanced rate.
2. Ensures any new Medicaid coverage is budget‑neutral or offset by savings/cost avoidance (i.e., the request must demonstrate fiscal offset).
3. Complies with applicable federal legal requirements.
- Timeline: DHB must submit the CMS request within 90 days after the act becomes law.
- Implementation is conditional: DHB may implement the requested Medicaid coverage only if CMS approves the request and the request meets the goals in Section 1.
- Effective date: the act is effective when it becomes law.

Who would be affected
- Primary beneficiaries: residents of licensed adult care homes / special care units who currently earn too much to qualify for State‑County Special Assistance but whose incomes fall at or below the specified FPL thresholds — potentially enabling access to Medicaid PCS while remaining in adult care homes.
- Secondary impacts: DHB (administration and federal negotiation), adult care home operators, Medicaid program budget and oversight, county social services administering SA, and federal CMS (approval authority).

Potential policy and fiscal impacts
- Programmatic: Could expand home‑ and community‑based PCS access within adult care homes, potentially reducing transitions to nursing homes for some dual eligibles.
- Fiscal: The bill requires any new coverage to be cost‑neutral (offset by savings or cost avoidance). Actual state‑level fiscal impact would depend on CMS approval, the number of eligible individuals, service utilization, and the offset measures identified.
- Administrative: DHB must undertake stakeholder consultation and prepare a federal submission within a short statutory window (90 days).

Limitations and procedural caveats
- Action requires federal approval from CMS; absent that approval, coverage cannot be implemented.
- As recorded, the bill was withdrawn from committee (May 27, 2025) — it is not currently in force and would need reintroduction or further legislative action to proceed.