Adult Medicaid Manual MA-2280 COMMUNITY ALTERNATIVES PROGRAM (CAP)

REVISED 08/01/10-CHANGE NO. 12-10

I. INTRODUCTION

A. General

1. Community Alternatives Programs (CAP)

The CAP programs are Medicaid home and community based services waivers granted by the Centers for Medicare and Medicaid Services (CMS).

2. At Risk of Institutionalization

a. The CAP programs allow North Carolina to use Medicaid funds to provide home and community based services to Medicaid recipients who require institutional care (placement in a nursing facility), but for whom care can be provided cost-effectively and safely in the community with CAP services. CAP participants must meet all Medicaid eligibility requirements.

b. Institutional care for CAP is defined as follows:

(1) CAP for Children (CAP/C): at the Nursing Facility (NF) level, and hospital level.

(2) CAP for Disabled Adults (CAP/DA): at the ICF and SNF level.

(3) CAP for Persons with Mental Retardation/Developmental Disabilities (CAP-MR/DD): Intermediate care for the mentally retarded (ICF-MR) level.

(4) CAP/Choice: at the ICF and SNF level.

3. Services

The CAP programs provide for both medical and non-medical home and community-based services to prevent or delay institutionalization. The programs involve an assessment process, development of a plan of care, and ongoing monitoring of service delivery by a case manager.

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(I.A.)

4. Costs

Each CAP program has a cost limit that is related to the cost of comparable institutional care. The total potential Medicaid cost of home and community services for a CAP participant may not exceed the cost limit. These cost limits are sent out as memoranda from the CAP unit to County Directors.

B. Available CAP Programs

North Carolina has 4 CAP waivers to provide services to a limited number of persons in specific groups within the state:

1. CAP for Children (CAP/C)

a. CAP/C is a statewide program which provides an alternative to nursing facility and hospital care for individuals:

(1) Under age 21,

(2) Who live in a primary private residence, and whose health, safety and wellbeing can be maintained in their primary residence, (I.B.2.a.)

(3) Who are medically high risk children and who would be institutionalized in a nursing facility or hospital without the Medicaid payment for the home care available through CAP/C,

(4) Who can have their needs met through the monthly cost limit,

(5) Who require Medicaid coverage through CAP/C services in addition to CAP/C case management to remain safely in their primary residence,

(6) Who have been ruled disabled by Disability Determination Services (DDS.)

NOTE: Children may also be IAS or HSF to qualify for CAP/C.

b. The CAP Unit of DMA determines whether medical necessity has been established and if an individual may participate.

c. The Division of Medical Assistance is the state lead agency for CAP/C programs.

d. CMS determined the number of individuals the state may serve each year. The program serves individuals statewide.

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(I.B.1.d.)

NOTE: The "waiver year" varies, depending upon the start-up date of the waiver.

2. CAP for Disabled Adults (CAP/DA)

a. CAP/DA provides an alternative to nursing facility care for persons who are:

(1) Age 18 and older, and

(2) Live in a private residence.

b. Number of Participants

(1) CMS determines the number of individuals the state may serve each year.

(2) DMA allots a portion of the state's limit to each CAP/DA county.

c. County Participation

(1) The Board of County Commissioners in each county must decide if the county will participate in the program.

(2) If a CAP/DA recipient moves to another county, it does not affect his eligibility for CAP services. Refer to V.B.8 below for CAP/DA transfer instructions.

d. Lead Agency

(1) The lead agency, selected by the Board of County Commissioners, may be either:

(a) The county department of social services (dss),

(b) The county health department,

(c) The county agency for the aged, or

(d) A hospital within the county.

(2) A list of CAP/DA lead agencies is published annually in the Medicaid Provider Bulletin.

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(I.B.)

3. CAP for Disabled Adults, Consumer Directed Care (CAP/Choice)

a. CAP/Choice is similar to CAP/DA. The eligibility requirements are the same as CAP/DA in I.B.3.a. above.

b. The allotments are part of the CAP/DA allotment for each county.

c. Requirement for county participation is the same as for CAP/DA in I.B.3.c. above.

d. Lead agency selection is the same as CAP/DA in I.B.2.d. above.

e. CAP/Choice uses a non-traditional case management service. CAP/Choice has four (4) additional services to the usual CAP/DA services.

(1) Care Advisor: The care advisor replaces the case manager. This person guides and supports the consumer throughout the planning and delivery process and monitors the provision of care and expenditures.

(2) Financial Management Services: A financial manager bills Medicaid for the consumer-directed services available under CAP/Choice, including the personal assistant and also pays the personal assistant for time spent working with the consumer.

(3) Personal Assistant Services: The personal assistant provides help with personal and home maintenance tasks. This person is hired by the client and may be a family member.

(4) Consumer-Designated Goods & Services: These are services, equipment or supplies not otherwise provided that the client purchases through the Plan of Care to increase independence for daily tasks. For example, the client may purchase a microwave to help the client cook or heat meals, decreasing the time the personal assistant would be needed for such tasks.

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(I.B.)

4. CAP for the Mentally Retarded/Developmentally Disabled (CAP/MR-DD)

a. CAP-MR/DD provides an alternative to care in an ICF-MR facility for individuals of all ages who require ICF-MR care and who reside:

(1) In a private residence, or

(2) In a domiciliary care facility.

b. CAP-MR/DD:

(1) Is tiered waivers utilized statewide with the exception of counties participating in the Piedmont Innovations Waiver. The counties are Cabarrus, Davidson, Rowan, Stanley and Union.

(a) The two waivers are the Supports Waiver (C2) and the Comprehensive Waiver (CM). All CAP recipients in the Piedmont counties have CAP code of CM.

(b) The assigned waiver is based on the cost of care for an individual per year. Services are limited, to a set maximum dollar amount.

(c) The approved waiver, C2 or CM, will be indicated on line 11, Recipient Level of Care, of the MR-2.

(2) Is administered at the local level by area mental health programs.

(3) When a CAP-MR/DD recipient transfers to another county, it does not affect his eligibility for CAP services. This also applies to recipients who are participating in the Piedmont Innovations Waiver and move to a non-Piedmont county. Refer to VII.B.6 below for CAP-MR/DD transfer instructions.

c. CMS determines the specific number of individuals the state may serve each year.

d. The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) is the state lead agency for CAP-MR/DD. The Division of Mental Health (DMH):

(1) Allots a portion of the state's limit to each area program,

(2) Determines which individuals may participate in the program, and

(3) Is responsible for the program's operation, with oversight provided by DMA.

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(I.)

C. Where To Get Assistance With CAP Programs

1. Refer to the CAP program manuals for detailed information and instructions about the various services and requirements of the CAP waiver programs.

2. Use this section of the M-AABD Medicaid Eligibility Manual for information regarding eligibility requirements for the various CAP programs.

3. For assistance in other than eligibility matters with the CAP for Children (CAP/C) program, contact the DMA CAP Unit at 919/855-4380.

4. For assistance in other than eligibility matters with the CAP for Disabled Adults (CAP/DA) program, or the CAP/Choice Program contact the local CAP/DA lead agency.

5. For assistance in other than eligibility matters with the CAP for the Mentally Retarded and Developmentally Disabled (CAP-MR/DD) program, contact the area mental health, developmental disabilities, and substance abuse program.