• CAP/C stands for Community Alternatives Program for Children. It's considered an alternative to institutionalization, which may be needed if services aren't in place.
• CAP/C is under the 1915(c) waiver to provide Medicaid Home and Community-Based Services (HCBS). It's authorized by Centers for Medicare & Medicaid Services (CMS) although the state has freedom to request changes.  Our current waiver is approved through Feb 28, 2022 and the state has just started the renewal process.
• Currently 4,000 slots allocated in the state and approximately 3,000 children are in the program.

• Children up through 20 years of age
• Determined to be medically fragile / medically complex (see next question)
• Meets institutional level of care criteria
• Needs at least one CAP/C service
• Qualifies for Medicaid based on child's income only (not parents)
• Deemed disabled by Disability Determination Services (DDS)

Child must meet one in each of the 3 categories:

• Has a primary chronic medical condition or diagnosis that has or will last more than 1 year
• Been inpatient at least 3 times in the last 12 months OR had a hospital stay for more than 10 days in the last 12 months OR had at least 4 exacerbations of the chronic medical condition requiring same day sick, urgent care, or ER visit OR requires ongoing specialized treatment or intervention performed, supervised or delegated by a physician (some examples include IV infusions,rescue meds for seizures or asthma or oxygen titration)
• Use of a life-sustaining device OR requires life-sustaining hands-on care to compensate for the loss of bodily function OR requires non-age appropriate ADL assistance (some examples include feeding assistance, trach, ventilator/CPAP, incontinence care)

• Case Management (at least monthly contact)
• In-home care -- CNA and PNA through agency or Consumer Direction (Private Duty Nursing is covered under straight Medicaid)
• Respite for all levels of care (720 hrs/fiscal yr)
• Home/vehicle modifications and assistive tech ($28,000 combined budget for life of waiver)
• Adaptive trikes ($3,000 budget for life of waiver)
• Adaptive car seats and transport vests
• Goods and services ($800 / fiscal year)
• Training, education and consultative services ($500 / fiscal year)
• Financial management (for CNA/PNA who choose Consumer Direction)
• Community Transition Services ($2500 one time, after 90 day institutionalization/hospital)

• Contact a local case management agency (last update Oct 2020)
• Call DHB CAP/C referral line -- 919-855-4340 Leave a message and have them call back to start the referral - don't call/transfer to the other number as that is Medicaid Customer Service and they aren't able to start a referral

• DHB will mail family a packet with consent, agency selection form and physician paperwork. It's the family's responsibility to get all of these forms back to Division of Health Benefits (DHB) for review.
• If referral is accepted, the case management agency will be sent the assessment from DHB and then will contact the family to schedule.
• Assessment is completed (virtually during COVID) and submitted for DHB for review. During this time, Medicaid application will also need to be submitted through county DSS/Medicaid office and request to Disability Determination Services (DDS) will be sent by Medicaid office, if needed.
• Once all three pieces of approval (CAP/C, Medicaid application, and DDS) are obtained, then Medicaid becomes active and services can start.

Medicaid CAP/C Website

CAP/C Clinical Coverage Policy

PDN (Private Duty Nursing) is a service available under regular Medicaid and not through the CAP/C waiver. Nursing level kids will receive their regular weekly hours through PDN and respite through CAP/C. (Other levels of care kids receive both their regular weekly hours and respite through CAP/C.)

To qualify for PDN, kids must meet criteria of having a life-threatening medical condition with frequent acute illnesses, require medically necessary skilled interventions, and be dependent on a life-sustaining device or require care to compensate for the loss of bodily function. The amount of weekly hours are based on the child’s needs and caregiver availability.

Beneficiary Fact Sheet provided by NC Medicaid

PDN Clinical Coverage Policy