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CAP/C Beneficiary FAQs

Frequently Asked Questions

What is CAP/C?

CAP/C is the Community Alternatives Program for Children. It is a waiver program authorized under the Waiver, and must comply with 42 CFR 441 Subpart G, 42 CFR 440.180, HCBS. CAP/C provides a cost-neutral alternative to institutionalization for Beneficiaries in a specified target population, who would be at risk for institutionalization if specialized Waiver services were not available. These services allow the targeted Beneficiaries to remain in or return to a home and or community-based setting.

What services are provided under the CAP/C program?

The Waiver supplements, rather than replaces, the formal and informal services and supports already available to an approved Beneficiary. Services are intended for situations where no household member, relative, caregiver, landlord, community agency, volunteer agency, or third-party payer is able or willing to meet the assessed and required medical, psychosocial, and functional needs of the approved CAP Beneficiary. The following services are available under the Waiver: (a) Assistive Technology; (b) CAP/C In-home aide; (c) Care Advisor; (d) Case management; (e) Community transition service; (f) Financial management services; (g) Home accessibility and adaptation; (h) Vehicle modifications and adaptation; (i) Goods and services – Participant, Individual-directed, Pest eradication, Nutritional services and Non-medical transportation; (j) Pediatric nurse aide services; (k) Respite care (institutional and non-institutional); (l) Specialized medical equipment and supplies; and (m) Training, education and consultative services.

Who is eligible for the CAP/C program?

For Waiver participation under CAP/C, eligible Beneficiaries must: (1) Be less than twenty-one (21) years of age; (2) Meet the clinical definition of medical fragility as defined in Clinical Coverage Policy 3K-1 policy: (a) A medically fragile child has a primary chronic medical condition or diagnosis (physical rather than psychological, behavioral, cognitive or developmental) that has lasted, or is anticipated to last, more than twelve (12) calendar months; (b) The child’s chronic medical condition: i. Requires medically necessary, ongoing, specialized treatment or interventions (treatments or interventions that are supervised or delegated by a physician or registered nurse) without which hospitalization may be needed; or ii. Resulted in at least four (4) exacerbation of the chronic medical condition requiring urgent or emergent physician-provided care within the previous twelve (12) calendar months; or iii. Required at least one (1) inpatient hospitalization of more than ten (10) calendar-days within the previous twelve (12) calendar months; or iv. Required at least three (3) inpatient hospitalizations within the previous twelve (12) calendar months; and (c) The child’s chronic medical condition requires one of the following: i. the use of life-sustaining device(s); or Page 12 of 201 ii. life-sustaining hands-on assistance to compensate for the loss of bodily function; or iii. non-age-appropriate hands-on assistance to prevent deterioration of the chronic medical condition that may result in the likelihood of an inpatient hospitalization. (3) Require an institutional Level of Care by the approval of a SRF and a completed and approved comprehensive assessment that identifies reasonable indication of need for one or more Waiver services to avoid institutionalization and meet the following requirements: (a) Be assigned a Waiver slot; (b) Require CAP/C Waiver service(s) that mitigates institutionalization or maintains community placement; and (c) Agree to participate in the CAP/C Waiver by signing a waiver participation agreement which selects home based care versus institutional care.

What defines a child as requiring an ‘institutional level of care’?

A full list of conditions that are considered when assessing a beneficiary for nursing facility level of care can be found in Clinical Coverage Policy 3K-1 here:

https://files.nc.gov/ncdma/documents/files/3K-1_4.pdf

How do I apply for the CAP/C program?

  • Contact a local CAP/C case management entity in the county of residence to request a CAP/C referral.
  • If you are a CAP/C case management entity or a qualified home and community-based provider, a referral can be completed in the e-CAP system.
  • A referral may also be made by calling Acentra at 919-568-1717 or 833-522-5429 (toll free).

What can I expect after I apply for the program?

You can expect to receive a service request packet in the mail within 2 business days from the date of referral, from Acentra. They are the independent assessing contractor for Medicaid. Three forms are included with the service request packet that must be returned to Acentra for review of eligibility for CAP services. These three forms are:      

  • Service Request Consent form 
  • Selection of Case Management form
  • Physician’s Worksheet

Instructions are included in the packet on how to return the three required forms.

IMPORTANT: These forms are required to be returned within 7 days from date of receipt for the applicant to be considered for the program. 

How long does it take to get an approval determination once I apply for the program?

When the signed and dated consent form is received, the review of your medical condition begins in order to access medical fragility. If medical fragility or a defined level of care is determined, an Acentra Nurse Assessor will conduct a face-to-face, comprehensive assessment. The timeline to receive CAP services, if all requirements are met, can be up to 45 days.

Is there a current waitlist for the program?

Waitlist vary from county to county. You can call Acentra at 919-568-1717 or 833-522-5429 (toll free) to get an update of the waitlist status in your county.