SPECIAL BULLETIN COVID-19 #22: CAP/C and CAP/DA Home and Community-Based Services (HCBS) Flexibilities for Waiver Beneficiaries Enrolled in 1915(c) HCBS Waivers

NOTE: SPECIAL BULLETIN COVID-19 #22 has been replaced in its entirety by SPECIAL BULLETIN COVID-19 #143: CAP/C and CAP/DA Home- and Community-Based Services Flexibilities Update for Beneficiaries Enrolled in 1915(c) Waivers

The Centers for Medicare & Medicaid Services (CMS) have approved Appendix K flexibilities mentioned below. - April 9, 2020

NC Medicaid has implemented flexibilities on how Medicaid providers and beneficiaries may access and receive Medicaid services in the wake of COVID-19. Prior approval and service utilization limits for specific State Plan Medicaid services will be relaxed for all Medicaid beneficiaries impacted by COVID-19, including individuals participating in the Community Alternatives Program (CAP) waivers.

 NC Medicaid has created an emergency planning document called Appendix K to modify the scope, frequency, amount and setting of how waiver services are used and approved.

An Appendix K was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 13, 2020. This emergency planning document will be effective from March 13, 2020, to March 12, 2021, or until the COVID -19 pandemic is no longer a public health emergency, whichever is sooner. An Appendix K waives specific requirements and limitations under the authority of the 1915(c) HCBS waiver during an emergency by allowing flexibilities in the areas of access and eligibility, services, settings (in and out of the state), payments and retainer payments to the caregivers, the required due date to complete annual reviews of need, and monthly and quarterly monitoring tasks.

The flexibilities extended through Appendix K are intended only for Community Alternatives Program  for Children (CAP/C) and Community Alternatives Program for Disabled Adults (CAP/DA) beneficiaries impacted by COVID-19 either directly or due to their staff being impacted and unable to provide services. The CAP case management entities (CME) should assess the need for flexibilities of all Medicaid services, including Appendix K services, for each CAP beneficiary using the CAP COVID-19 Care Management Plan. The CME should then assist the CAP beneficiary to assess flexibilities for which he or she is qualified. The CAP unit at NC Medicaid will provide specific standard operating procedures on how to use and access flexibilities through the 1915(c) HCBS waivers in a separate communication.

The Appendix K for the CAP/C and CAP/DA HCBS waivers excludes the coverage of State Plan Medicaid services and  includes the following modifications in scope and coverage to mitigate risk factors directly related to COVID-19:

1. Case management – Covers monthly telephonic contact with waiver participant and quarterly telephonic contact with service providers to monitor COVID-19 service plan, other essential case management needs, and initial and annual telephonic assessments of level of care and reasonable indication of need.
2. Participant goods and services – Covers disinfectant wipes, hand sanitizer and disinfectant spray for certified nursing assistants (CNA) or personal assistants who can continue to render in-home, pediatric  and nurse care to waiver participant. Covers facial tissue, thermometer and specific colored trash liners to distinguish dirty linen of infected household member to prevent spread. Includes coverage of over-the-counter prescription medication and supplements for the management or prevention of COVID-19.
3. Training/Education/Consultative Services – Covers training to the paid worker on personal protective equipment (PPE) and other identified training needs specific to the care needs of waiver participant to prevent the spread of COVID-19.
4. In-home care, pediatric nurse aide, personal care assistance and congregate – Services are not required to be used on a monthly basis. Services approved in the service plan may be  rendered in various amounts, frequencies  durations and settings, but no less than what has been approved in the service plan. Covers payment to in-home care, pediatric nurse aide, personal care assistance and congregate to a non-live-in close relative or legally responsible person for waiver participant whose hired worker is not able to render the service because of impact from COVID-19. 
5. Community transition – Covers a less than 90-day institutionalized Medicaid beneficiary experiencing COVID-19 symptoms who can safely transition to a home and community-based placement using HCBS services.
6. Meals - Covers one lunch meal per day for aged and disabled adults participating in CAP/DA who are approved to receive meal preparation and delivery and their meal delivery services are suspended due to COVID-19. This service may cover one food delivery meal (e.g., Uber Eats, DoorDash, Grub Hub) or a similar service. 
7. Home accessibility and adaptation – Covers germicidal air filters.
8. Retroactive approval dates - Allows retroactive approval dates to the effective date of the Appendix K when services are needed and the waiver beneficiary, caregiver or provider is impacted by COVID-19 and cannot complete the service plan.
9. Telephonic contact - Allows changing required quarterly face-to-face visits to a quarterly telephonic contact when waiver beneficiary, caregiver or the provider is directly impacted by COVID-19.
10. Reassessment of need – Allows extended date for annual reassessment of need (level of care-LOC) when the assessment cannot be conducted due to the waiver beneficiary, caregiver or provider being directly impacted by COVID-19.
11. Retainer payments – Allows the authorization of retainer payments to a direct worker in the amount, frequency and duration as listed on the currently approved service plan when a waiver participant or hired worked is directly impacted by COVID-19.   Look for future guidance about the retainer payments in a separate communication document.  

These flexibilities extended through the Appendix K are assessed using the CAP COVID-19 Care Management Plan. The CME will assist the CAP beneficiary to assess flexibilities for which he or she is qualified in the scope, type, amount, frequency and duration as identified by assessed needs when directly related to COVID-19, including the following expanded waiver service limitations:

1. Home accessibility and adaptation – May exceed the waiver limit of $28,000
2. Equipment, modification and technology – May exceed the waiver limit of $13,000
3. Case management units – Allows additional monthly reimbursement of case management time when determined necessary as evidence in case notes to manage needs of the waiver participant experiencing COVID-19 symptoms and ensure linkage to resources needed. 
4. Participant goods and services – May exceed the $800 fiscal year limit
5. Assistive technology -  May exceed the CAP/C waiver limit of $28,000
6. Training/Education/Consultative Services – May exceed $500 fiscal year limit
7. Respite – May exceed the 720 in-home respite hours per fiscal year for in-home and coverage of 30 or more days in an institution.
8. Cost Limits – Allows the established cost threshold for waiver enrollment to be exceeded, based on averages, if the individual care needs are more than the waiver year cost neutrality projections.