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NC Medicaid: Waiver v. Non -Waiver Services – What’s the Difference?
There is a 4.9 year waiting list to receive a spot on the Innovations Waiver. The waiting list is unhelpful when you have a child or adult with severe developmental disabilities who needs Waiver services NOW. What services are available for the disabled who qualify for Waiver services, but have not received a spot on the Innovations Waiver yet?
For children (up to age 20), the alternative to the Innovations Waivers is the Community Alternatives Program for Children (CAP/C) 1915(c) Home and Community-Based Services (HCBS) waiver was approved by the Centers for Medicare & Medicaid Services (CMS). The waiver took effect March 1, 2017.
Here is a breakdown of services offered for the Innovations Waiver versus CAP/C:
| Category | CAP/C Waiver [1] | NC Innovations Waiver [2] |
| Cost limit under waiver | $129,000
(Section 5.7.3) |
$135,000
(Attachment F) |
| Case Management | 80 hours (320 units) per calendar year
(Appendix B) |
|
| Respite | 720 hours/fiscal year
Each day of institutional respite counts as 24 hours towards the annual limit. (Appendix B) |
The cost of respite care for 24 hours cannot exceed the per diem rate for the average community ICF-IID Facility |
| Pediatric Nurse Aide | Type, frequency, tasks and number of hours per day are authorized by the case management entity based on medical necessity.
(Appendix B) |
|
| In-Home Aide | Type, frequency, tasks and number of hours per day are authorized by the case management entity based on medical necessity.
(Appendix B) |
|
| Financial Management Service | Consumer-directed initiation fee must be assessed the first month of enrollment and shall not exceed 4 units (1 hour). Monthly management fees shall be assessed each month and shall not exceed 4 units (1 hour) per month.
(Appendix B) |
Financial Support Services are available and provider directed. |
| Assistive Technology | Included in a combined home and vehicle modification budget of $28,000 per beneficiary per the cycle of the CAP, which is renewed every 5 years.
(Appendix B) |
Limited to $50,000 (ATES and Home Modifications) over the life of the waiver period, 5 years
(Attachment C) |
| Community Transition Services | To transition CAP beneficiaries from 90-day or more institutional setting;
One-time expenses, not to exceed $2,500 over the cycle of the CAP, 5 years. (Appendix B) |
To provide initial set-up expense for adults to facilitate transition from community living;
Life of the waiver limit of $5,000 per beneficiary. (Attachment C) |
| Home Accessibility and Adaptation/Home Modifications | Included in a combined home and vehicle modification budget of $28,000 per beneficiary per the cycle of the CAP, which is renewed every 5 years.
(Appendix B) |
Home modifications are limited to expenditures of $50,000 of supports (ATES, Home Modifications) over the duration of the waiver, 5 years. |
| Goods and Services | Not to exceed $800 annually (July-June)
(Appendix B) |
Not to exceed $2,000 annually
(Attachment C) |
| Training, Education, and Consultative Services/Natural Supports Education | Limited to $500 per fiscal year (July 1-June30)
(Appendix B) |
Reimbursement for class and conferences limited to $1,000 per year
(Attachment C) |
| Vehicle Modification | Included in a combined home and vehicle modification budget of $28,000 per beneficiary per the cycle of the CAP, which is renewed every 5 years.
(Appendix B) |
Limited to $20,000 over the life of the waiver
(Attachment C) |
| Community Living and Support (allowing for a paraprofessional) | Subject to limits on sets of services
(Attachment C)
For adult beneficiaries who live in a private home[3], no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports (Attachment D) |
|
| Community Navigator | Provider directed service | |
| Community Networking | Payment for attendance at classes and conferences cannot exceed $1,000 per beneficiary per plan year.
(Attachment C) |
|
| Crisis Services | Crisis Intervention and stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.
Out-of-home Crisis services may be authorized in increments of up to 30 calendar days. (Attachment C)
|
|
| Day Supports (A group, facility-based service that provides assistance to the individual with acquisition, retention or improvement in socialization and daily living skills.)
|
Subject to limits on sets of services
(Attachment C)
For adult beneficiaries who live in a private home, no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports (Attachment D) |
|
| Residential Supports (for Group Home or Alternative Family Living) | Subject to limits on sets of services
(Attachment C)
For adult beneficiaries who receive residential supports, no more than 40 hours per week for any combination of community networking, day supports and supported employment services. For child beneficiaries who receive residential supports, during the school year, no more than 20 hours per week for any combination of community networking, day supports and supported employment services. (Attachment D) |
|
| Supported Employment Services (provide assistance with choosing, acquiring, and maintaining a job for beneficiaries 16 and older) | Subject to limits on sets of services
(Attachment C)
For adult beneficiaries who live in a private home, no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports (Attachment D) |
|
| Supported Living (flexible partnership that enables a person to live in his own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the person | Subject to limits on sets of services
For adult beneficiaries who live in a private home, no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports (Attachment D)
Person receiving Supported Living may not also receive Community Living and Supports, Respite Services or Personal Care Services |
[1] See NC Division of Medical Assistance, Clinical Coverage Policy No: 3K-1, Amended Date: March 1, 2018. The CAP/C waiver was renewed by CMS effective March 1, 2017-February 28, 2022.
[2] See NC Division of Medical Assistance, Clinical Coverage Policy No: 8-P, Amended Date: November 1, 2016.
