NC Division of Medical Assistance Medicaid and Health Choice Community Alternatives Program Clinical Coverage Policy No: 3K-2 For Disabled Adults and Choice Amended Date: October 1, 2015 Option (CAP/DA-Choice) End Date: DRAFT Table of Contents 1.0 Description of the Procedure, Product, or Service ........................................................................... 1 1.1 Definitions .......................................................................................................................... 1 1.1.1 Activities of Daily Living (ADLs) .................................................................. 1 1.1.2 AQUIP Data Set .............................................................................................. 2 1.1.3 Community Alternatives Program for Disabled Adults (CAP/DA) ................ 2 1.1.4 CAP/DA lead agencies .................................................................................... 2 1.1.5 Choice Option ................................................................................................. 2 1.1.6 Division of Medical Assistance (DMA) .......................................................... 2 1.1.7 Instrumental Activities of Daily Living (IADL’s) .......................................... 2 1.1.8 Nursing Services ............................................................................................. 2 1.1.9 Participant........................................................................................................ 3 1.1.10 Permanent Private Place of Residence (Home) ............................................... 3 1.1.11 Personal Care Aide or In-Home Aide ............................................................. 3 1.1.12 Beneficiary ...................................................................................................... 3 1.1.13 Risk of Institutionalization .............................................................................. 3 1.1.14 Self-Directed Care ........................................................................................... 3 2.0 Eligibility Requirements .................................................................................................................. 3 2.1 Provisions............................................................................................................................ 3 2.1.1 General ............................................................................................................ 3 2.1.2 Specific ............................................................................................................ 4 2.2 Special Provisions ............................................................................................................... 4 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age ................................................................. 4 2.2.2 EPSDT does not apply to NCHC beneficiaries ............................................... 5 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through 18 years of age ................................................................................... 5 2.3 Benefit Category ................................................................................................................. 5 3.0 When the Procedure, Product, or Service Is Covered ...................................................................... 5 3.1 General Criteria Covered .................................................................................................... 5 3.2 Specific Criteria Covered .................................................................................................... 6 3.2.1 Specific criteria covered by both Medicaid and NCHC .................................. 6 3.2.2 Medicaid Additional Criteria Covered ............................................................ 6 3.2.3 NCHC Additional Criteria Covered ................................................................ 7 4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 7 4.1 General Criteria Not Covered ............................................................................................. 7 4.2 Specific Criteria Not Covered ............................................................................................. 7 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC ......................... 7 4.2.2 Medicaid Additional Criteria Not Covered ..................................................... 7 4.2.3 NCHC Additional Criteria Not Covered ......................................................... 8 5.0 Requirements for and Limitations on Coverage .............................................................................. 9 5.1 Prior Approval .................................................................................................................... 9 16C11 Public Comment i NC Division of Medical Assistance Medicaid and Health Choice Community Alternatives Program Clinical Coverage Policy No: 3K-2 For Disabled Adults and Choice Amended Date: October 1, 2015 Option (CAP/DA-Choice) End Date: DRAFT 5.2 Prior Approval Requirements ............................................................................................. 9 5.2.1 General ............................................................................................................ 9 5.3 Lead Agency Responsibility ............................................................................................... 9 5.4 Level of Care to Qualify for CAP/DA ................................................................................ 9 5.4.1 Intermediate Level of Care ............................................................................ 10 5.4.1.1 Requirements for Intermediate Level of Care include the following: ........... 10 5.4.1.2 Other Factors that alone may not justify Intermediate Level of Care ........... 11 5.4.2 Skilled Level of Care ..................................................................................... 12 5.4.2.1 Requirements for Skilled Level of Care include the need for any of the following: ...................................................................................................... 12 5.4.2.2 Factors that alone may not justify skilled level of care ................................. 14 5.5 CAP/DA Needs Assessment ............................................................................................. 14 5.6 CAP/DA Plan of Care ....................................................................................................... 15 5.7 Adult Day Health Services................................................................................................ 15 5.8 Personal Care Aide ........................................................................................................... 15 5.9 Home Modification and Mobility Aids ............................................................................. 15 5.10 Meal Preparation and Delivery ......................................................................................... 15 5.11 Institutional Respite Care .................................................................................................. 15 5.12 Non-Institutional Respite Services ................................................................................... 16 5.13 Personal Emergency Response Services (PERS).............................................................. 16 5.14 Waiver Supplies ................................................................................................................ 16 5.15 Participant Goods and Services ........................................................................................ 16 5.16 Transition Services ........................................................................................................... 17 5.17 Training and Education Services ...................................................................................... 17 5.18 Assistive Technology ........................................................................................................ 18 5.19 Case Management ............................................................................................................. 19 5.19.1 Assessing ....................................................................................................... 19 5.19.2 Care Planning ................................................................................................ 19 5.19.3 Referral/Linkage ............................................................................................ 19 5.19.4 Monitoring/Follow-up ................................................................................... 19 5.20 Care Advisor (Choice Option only) .................................................................................. 20 5.21 Personal Assistant Services (Choice Option only) ........................................................... 20 5.22 Financial Management Services (Choice Option only) .................................................... 21 5.23 Other Medicaid Services (State Plan Covered)................................................................. 21 5.23.1 Durable Medical Equipment (DME) ............................................................. 21 5.23.2 Home Health ................................................................................................. 22 5.23.3 Hospice .........................................................................................................