NC DMA: 3K-1, Community Alternatives ... - North Carolina

NC Division of Medical Assistance Community Alternatives Program for Children (CAP/C)

Medicaid and Health Choice Clinical Coverage Policy No: 3K-1

Amended Date: March 1, 2018

Table of Contents

1.0 Description of the Procedure, Product, or Service...........................................................................1 2.0 Eligibility Requirements .................................................................................................................. 3

2.1 Provisions............................................................................................................................ 3 2.1.1 General...................................................................................................................3

2.1.2 Specific .................................................................................................................. 3

2.2 Special Provisions...............................................................................................................5 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age ....................................................................... 5

2.2.2 EPSDT does not apply to NCHC beneficiaries ..................................................... 6

2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through 18 years of age ....................................................................................................... 6

3.0 When the Procedure, Product, or Service Is Covered......................................................................6 3.1 General Criteria Covered .................................................................................................... 6 3.2 Specific Criteria Covered....................................................................................................6 3.2.1 Specific criteria covered by both Medicaid and NCHC ........................................ 6

3.2.2 Medicaid Criteria Covered.....................................................................................6

3.2.3 Level of Care Determination Criteria .................................................................... 8

3.2.4 Expedited Criteria (Prioritization) for CAP/C Consideration..............................11

3.2.5 Transfers of Eligible Beneficiaries ...................................................................... 12

3.2.6 NCHC Additional Criteria Covered .................................................................... 12

4.0 When the Procedure, Product, or Service Is Not Covered ............................................................. 12 4.1 General Criteria Not Covered ........................................................................................... 12 4.2 Specific Criteria Not Covered...........................................................................................13 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC..............................13

4.2.2 Medicaid Criteria Not Covered............................................................................13

4.2.3 NCHC Additional Criteria Not Covered.............................................................. 14

5.0 Requirements for and Limitations on Coverage ............................................................................ 15 5.1 Prior Approval .................................................................................................................. 15 5.2 Prior Approval Requirements ........................................................................................... 15 5.2.1 General.................................................................................................................15

5.2.2 Specific ................................................................................................................ 15

5.3 CAP/C Participation ......................................................................................................... 16 5.3.1 Approval Process ................................................................................................. 16

Inquiries and Referrals:.....................................................................................................16

Assessment Approval: ...................................................................................................... 16

Coordinate with Medicaid Eligibility Staff:...................................................................... 16

Coordinate with Community Care of North Carolina (CCNC) ........................................ 16

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NC Division of Medical Assistance Community Alternatives Program for Children (CAP/C)

Medicaid and Health Choice Clinical Coverage Policy No: 3K-1

Amended Date: March 1, 2018

5.3.2 Minimum required documents for CAP/C participation approval: ..................... 17

5.4 CAP/C Comprehensive Interdisciplinary Needs Assessment Requirements....................17 5.5 CAP/C Person-Centered Service Plan Requirements ....................................................... 18

5.5.1 Changes and Revision to the Service Plan...........................................................19

5.5.2 Person-Centered Service Plan Denial .................................................................. 19

5.6 Continued Need Review (CNR) Assessment Requirements ............................................ 20 5.6.1 Continued Need Review Person-Centered Service Plan Requirements .............. 20

5.6.2 CAP/C Effective Date..........................................................................................21

5.6.3 Authorization of Services .................................................................................... 21

5.7 Waiver Service Requests and Required Documentation .................................................. 21 5.7.1 Assistive Technology, Equipment, Supplies, Home Accessibility and Adaption, and Vehicle Modifications...................................................................................21

5.7.2 Supportive Services ............................................................................................. 23

5.7.3 CAP/C Budget Limits .......................................................................................... 24

6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service ............................................... 24 6.1 Provider Qualifications and Occupational Licensing Entity Regulations.........................24 6.2 Case Management Entity Qualifications .......................................................................... 25 6.2.1 CAP/C Mandated Requirements to be An Appointed Case Management Entity 25

6.2.2 Coordination of Care ........................................................................................... 27

6.2.3 Appointed Case Management Entities are Required to Provide Case Management as follows: ............................................................................................................ 28

6.3 General Case Management Responsibilities.....................................................................31 6.4 Specific Case Management Entity Responsibilities.......................................................... 31 6.5 Medicaid Provider Requirement to Provide CAP Waiver Services.................................. 31

6.5.1 Providers for Community Transition Funding.....................................................32

6.5.2 Providers for Home Accessibility and Adaptation Modifications ....................... 32

6.5.3 Providers for Institutional Respite Services.........................................................32

6.5.4 Providers for Non-Institutional Respite Services ................................................ 32

6.5.5 Providers for Specialized Medical Equipment and Supplies ............................... 32

6.5.6 Providers for In-Home Care Aide........................................................................32

6.5.7 Provider for Financial Management .................................................................... 33

6.6 Licensure and Certification...............................................................................................33 7.0 Additional Requirements ............................................................................................................... 33

7.1 Compliance ....................................................................................................................... 33 7.2 Service Record .................................................................................................................. 34 7.3 General Documentation Requirements for Reimbursement of CAP/C Service ............... 34 7.4 Service Note......................................................................................................................35 7.5 Signatures.......................................................................................................................... 35 7.6 Frequency of Monitoring of beneficiary and services ...................................................... 35

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NC Division of Medical Assistance Community Alternatives Program for Children (CAP/C)

Medicaid and Health Choice Clinical Coverage Policy No: 3K-1

Amended Date: March 1, 2018

7.7 Corrections in the service record ...................................................................................... 36 7.8 Waiver Service Specific Documentation .......................................................................... 36 7.9 General Records Administration and Availability of Records ......................................... 37 7.10 Health, Safety and Well-being .......................................................................................... 38 7.11 Individual Risk Agreement ............................................................................................... 40 7.12 Absence from CAP/C Participation .................................................................................. 40

Hospital Stays of 30 Calendar-days or Less ..................................................................... 40

7.13 Voluntary Withdrawals.....................................................................................................41 7.14 Disenrollment....................................................................................................................41 7.15 Quality Assurance.............................................................................................................42 7.16 Program Integrity (PI).......................................................................................................46 7.17 Use of Telephony and Other Automated Systems ............................................................ 46 7.18 Beneficiaries with Deductibles ......................................................................................... 46 7.19 Marketing Prohibition.......................................................................................................46 8.0 Policy Implementation/Revision Update Information ................................................................... 47 Attachment A: Claims-Related Information ............................................................................................... 53 A. Claim Type ....................................................................................................................... 53 B. International Classification of Diseases, Tenth Revisions, Clinical Modification (ICD-10-

CM) and Procedural Coding System (PCS)......................................................................53 C. Code(s)..............................................................................................................................53 D. Modifiers...........................................................................................................................54 E. Billing Units......................................................................................................................54 F. Place of Service ................................................................................................................ 54 G. Co-payments ..................................................................................................................... 54 H. Reimbursement ................................................................................................................. 54 CAP/C Claim Reimbursement ....................................................................................................... 54 Appendix A: CAP/C Service Request Form..............................................................................................57 Appendix B: Service Definitions and Requirements .................................................................................. 62 CASE MANAGEMENT ............................................................................................................... 62 RESPITE........................................................................................................................................ 64 PEDIATRIC NURSE AIDE .......................................................................................................... 66 CAP IN-HOME AIDE SERVICE ................................................................................................. 69 FINANCIAL MANAGEMENT SERVICES ................................................................................ 72 ASSISTIVE TECHNOLOGY ....................................................................................................... 74 COMMUNITY TRANSITION SERVICES..................................................................................75 HOME ACCESSIBILITY AND ADAPTATION ......................................................................... 76 PARTICIPANTS GOODS AND SERVICES ............................................................................... 79 SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES ...................................................... 81 TRAINING, EDUCATION AND CONSULTATIVE SERVICES .............................................. 82 VEHICLE MODIFICATION ........................................................................................................ 82 Appendix C: Determination Nurse Aide Hours of Support ........................................................................ 86 BASIC FORMULA ....................................................................................................................... 86 WORKING AT HOME ................................................................................................................. 86 ATTENDING SCHOOL ............................................................................................................... 86 CAREGIVER'S OVERTIME AND ON-CALL ........................................................................... 87 WORK AND SCHOOL OR MULTIPLE JOBS ........................................................................... 87 MULTIPLE SIBLINGS.................................................................................................................87

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NC Division of Medical Assistance Community Alternatives Program for Children (CAP/C)

Medicaid and Health Choice Clinical Coverage Policy No: 3K-1

Amended Date: March 1, 2018

Appendix D: Beneficiary Rights and Responsibilities................................................................................ 88 Appendix E: Individual Risk Agreement....................................................................................................92 Appendix F: Glossary of CAP Terms ......................................................................................................... 93 Appendix G: Consumer-directed Self-Assessment Questionnaire ........................................................... 103 Appendix H: Emergency Back-Up plan ................................................................................................... 133 Appendix I: Decision Tree for Determining Medical-Fragility ................................................................ 136

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NC Division of Medical Assistance Community Alternatives Program For Children(CAP/C) Waiver

Medicaid and Health Choice Clinical Coverage Policy No: 3K-1

Amended Date: March 1, 2018

Related Clinical Coverage Policies

Refer to for the related coverage policies listed below:

2A-3, Out-of-State Service 2B-1, Nursing Facilities 3A, Home Health Services 3D, Hospice Services 3G-2, Private Duty Nursing for Beneficiaries Under 21 Years of Age 3H-1, Home Infusion Therapy 5A-1, Physical Rehabilitation Equipment and Supplies 5A-2, Respiratory Equipment and Supplies 5A-3, Nursing Equipment and Supplies 5B, Orthotics and Prosthetics 8A, Enhanced Mental Health and Substance Abuse Services 8A-1, Assertive Community Treatment (ACT) Program 8C, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers 8J, Children's Developmental Service Agencies (CDSAs) 8L, Mental Health/Substance Abuse Targeted Case Management 8-O, Services for Individuals with Intellectual and Developmental Disabilities and Mental Health or Substance Abuse Co-Occurring Disorders

1.0 Description of the Procedure, Product, or Service

The Community Alternatives Program for Children (CAP/C) is a Medicaid Home and Community-Based Services (HCBS) Waiver authorized under section1915(c) of the Social Security Act and complies with 42 CFR ? 440.180, Home and Community-Based Waiver Services. This waiver program provides a cost-effective alternative to institutionalization for beneficiaries, in a specified target population, who are at risk for institutionalization if specialized waiver services were not available. These services allow these targeted beneficiaries to remain in or return to a home and community-based setting.

HCBS waivers are approved by Centers of Medicare and Medicaid Services (CMS) for a specified time. The waiver establishes the requirements for program administration and funding. Federal regulations for HCBS waivers are found in 42 CFR Part 441 Subpart G, Home and CommunityBased Services: Waiver Requirements. The NC Division of Medical Assistance (DMA) can renew or amend the waiver with the approval of CMS. CMS may exercise its authority to terminate the waiver when it believes the waiver is not operated properly.

This waiver serves a limited number of medically fragile and medically complex children. To enroll and participate in this waiver, the individual shall meet the Medicaid eligibility requirements for long-term care.

CPT codes, descriptors, and other data only are copyright 2017 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

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