Upcoming changes for CAP MR/DD Waiver recipients

Changes are coming to North Carolina’s  Medicaid Waiver program, commonly referred to as the Community Alternatives Program for Persons with Mental Retardation/Developmental Disabilities or CAP MR/DD.

In July, the NC Division of Medical Assistance (DMA- which oversees Medicaid in NC) and the Division of Mental Health/Developmental Disabilities/Substance Abuse (MH/DD/SAS) announced new policies for CAP MR/DD waiver services that will limit recipients to 129 habilitative service hours per month. There are other changes in the policies as well.

When the new policies were announced, the Autism Society of North Carolina, Inc., The Arc of NC, and other advocacy and provider groups, voiced strong concerns about many of the changes during and after the public comment period. Despite our opposition, these utilization limits and policy changes are moving forward with slight changes from the original policy.

The following is a short overview of some of the upcoming changes. To view complete information about the changes and related documents click here to go the Division of MH/DD/SAS CAP Waiver website.

Changes:

People using CAP DD Waiver services will be limited to a total of 129 hours of month of habilitative service hours. At this time the 129 hour limit does not include the Residential Support or Home Support hours.  There are also new requirements for direct contact hours for Residential and Home Supports, but these do not go into effect until October 31, 2011.

The habilitative services that are counted toward the monthly 129 hour limit are:

  • Supported Employment
  • Day Supports
  • Long-Term Vocational Supports and/or
  • Home and Community Supports.

This means that you will add up the monthly hours of the 4 services listed above and the total cannot be more than 129 hours in any given month. These limits will go into effect on May 30, 2011 UNLESS your Case Manager fills and submits out an Extension/Exception Request Form on time (and it is approved).

If you/your family member currently receive more than 129 hours of habilitative supports, your Case Manager will need to do a plan revision to change the habilitative hours to meet the 129 hour monthly limit.

If you and your Case Manager believe that you cannot cut your habilitative services to meet the May 30th deadline and/or the health and safety of the waiver recipient is in danger, then an Extension/Exception Request must be filled out and submitted by your Case Manager to your LME no later than December 1.  The exception request will be reviewed by the LME and then sent to the Division of MH/DD/SAS to be reviewed.

If your Extension/Exception is denied, you WILL have the right to appeal.

If you do not have your Case Manager fill out and submit the Extension/Exception Request Form to your LME on time, you do NOT have the right to appeal because these limits are based on a change in state policy.

For questions, and if you need an Exception/Extension filed contact your Case Manager. If you are having difficulty contacting your Case Manager, please contact their supervisor.  If you are still having problems and are concerned the Extension/Exception form will not go in on time, contact your LME.

Again, the policy changes limiting habilitative hours go into effect on May 30, 2011 unless your Case Manager has submitted the “Exception/Extension Form” on time (by December 1, 2010). Then you need to wait to find out the outcome of your Extension/Exception request.

You should talk to your Case Manager about these changes. If you have additional questions you may contact an Autism Society of North Carolina parent advocate line at 919-865-5093 or 1-800-442-2762, ext 1138 or The Arc of NC at 1-800-662-8706.

If you need legal assistance with your appeal you can contact:

There are also other changes coming to CAP DD waiver services:

Parents/legal guardians and any other person living in the home cannot provide any CAP services to their minor (under 18) children in all settings, effective Feb 1, 2011 unless an Extension/Exception is filed. Also adult participants (18 and older) residing with their natural, adoptive and/or step parents may receive Home Supports provided by parents, family and/or guardians residing with them. Home Supports is the only service that can be provided by a parent of an adult participant. All of the changes can be found on the Division of MH/DD/SAS website.

Information from The Division of MHDDSAS on CAP MR/DD changes can be viewed by clicking here. The “Talking Points” document is an overview of the new policies and the “CAP Utilization Review Guidelines” is a Power Point presentation which reviews the technical amendments in the new clinical policy manual and new policies (Before printing, please note that the presentation is 99 slides). You will find other information and links as well.

If you want to voice your dissatisfaction with these changes you can write to:

Craigan Gray, Director                                                                       Steve Jordan, Director
NC Div. of Medial Assistance                                                           NC Div of MH/DD/SAS
2501 Mail Service Center                                                                  3001 Mail Service Center
Raleigh, NC 27699-2501                                                                   Raleigh, NC 27699-3001

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