Community Alternatives Program (CAP) FAQs

NC Medicaid’s primary concern is beneficiary health, safety and well-being. Concerns should be emailed to Medicaid.ProviderOmbudsman@dhhs.nc.gov. Critical incidents should be reported by case managers. Families may request a State Fair Hearing.

Yes. CAP/C denial letters include policy citations. NC Medicaid works closely with NCLIFTSS on expectations and training.

Provider-led care has oversight built into that care model through licensure and supervisory requirements. In Consumer Direction (CD) with paid LRIs, monitoring is provided by the CME for health, safety and wellbeing and to ensure services are provided in alignment with the plan of care.

Hours are based on the annual assessment of need. Families have appeal rights for any denial, suspension or reduction.

Yes. Hands-on services remain active during the review. Families do not need to contact NC Medicaid unless there is an issue.

Email Medicaid.ProviderOmbudsman@dhhs.nc.gov. Tickets route directly to the CAP team.

No. There are no plans to end Legally Responsible Individual (LRI) paid caregiving under Consumer Direction. LRIs must meet waiver and policy requirements, including extraordinary circumstances.

LRIs must meet extraordinary circumstances criteria. LRI hours are limited to 40 paid hours per week, regardless of living arrangement.

It is currently under development.

It covers all extraordinary care needed that day due to the live-in nature of the caregiver.

All cases are reviewed individually. Denials often occur because required documentation was not submitted initially. Many denials overturned in appeal are due to additional information provided later. NC Medicaid is developing additional guidance and training.

Each case is reviewed individually. Documented aggression or caregiver resistance is considered. There is no one-size-fits-all approach.

Yes. NC Medicaid is developing additional training and publishing guidance to support consistent messaging and clearer expectations for Extraordinary Circumstances (EC) documentation.

They are experiencing higher-than-usual volume and complex cases. NC Medicaid meets weekly with NCLIFTSS and continues monitoring to reduce the backlog. Previously approved services remain active until decisions are made.

NC Medicaid acknowledges this challenge and is developing additional guidance for documenting Criterion A.

Respite is allowed, but Coordinated Caregiving stipends cannot be paid on the same day as respite. Respite is encouraged but not required.

Yes, but the coordinated caregiving daily stipend and Adult Day Health cannot be billed on the same day.

Yes, Community Alternatives Program for Children (CAP/C) recipients have priority status. Transition planning must occur between age 18 and prior to turning 21. Case Management Entities (CMEs) can start conversations at the beneficiary’s 18 birthday.

Approximately 4,536 individuals (as of April 2026).