NC Medicaid Guidance on Sunsetting of Traumatic Brain Injury Appendix K Flexibilities

Permanent flexibilities approved in the TBI Waiver amendment effective March 1, 2024.

In response to the COVID-19 public health emergency (PHE) in March 2020, the Centers for Medicare & Medicaid (CMS) approved several flexibilities to the Innovations Waiver to support waiver members to ensure they remain safe in their communities during the PHE. While some of the flexibilities have been added as a permanent part of the Waiver, other flexibilities will end effective Feb. 29, 2024.  

To support Traumatic Brain Injury (TBI) Waiver members, families, and LME/MCO’s in sunsetting flexibilities, this document is provided as a guide to outline the permanent flexibilities approved in the TBI Waiver amendment effective March 1, 2024.

Appendix K Flexibilities

Will this flexibility change?

March 1, 2024 Implementation Guidance

Plan of Care

Allow  extension of development of

person-centered plan.


Effective March 1, 2024, there will be no extensions of the person-centered planning process.


Allow extension up to 90 days for Level of Care (LOC) redetermination.


Effective March 1, 2024, no LOC redetermination extensions will be allowed. If this flexibility was utilized and the waiver member is outside of the 90-day time frame, a redetermination must be completed.


Allow an increase in service hours from what is in the person-centered plan without prior authorization.



Effective March 1, 2024, service hours must be completed according to the person-centered plan and must be within the $135,000 waiver cap. (Please note NC Medicaid is engaging our fiscal partners to review an increase to the TBI waiver limits).


Provide retainer payments for direct care workers to address emergency related issues.



Effective March 1, 2024, retainer payments will no longer be available for direct care workers.

Waive $135,000 waiver limit.


Effective March 1, 2024, waiver members must remain within the $135,000 waiver cap. Member’s budget above the waiver limit must align with the Waiver cap.


Services/Service Providers

Allow home delivered meals (up to seven meals per week/one per day).


Home delivered meals is now a waiver service available to individuals not receiving a per diem residential service.


Waive requirement for the Letter of Medical Necessity or Prescription from the Physician, Nurse Practitioner or Physician’s Assistant for ongoing supplies or replacement equipment for which member has an already established authorization for Assistive Technology, Equipment, and Supplies services.



Effective March 1, 2024, documentation of medical necessity by a physician, physician assistant, or nurse practitioner is required to request assistive technology, equipment, and supplies services.

Allow access to real time two-way interactive audio and video telehealth for the following services: Life Skills Training, Cognitive Rehabilitation, Day Supports, Supported Employment, Supported Living, Community Networking.



Waiver members may access Life Skills Training, Cognitive Rehabilitation, Day Supports, Supported Employment, Supported Living, Community Networking via telehealth.


  • Telehealth is not intended to supplant a full meaningful day, but rather to complement it. Services that support community integration are not eligible for 100% telehealth delivery.


  • The provider shall document that any platforms used to conduct telehealth activities are in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).


  • The use of telehealth shall not exceed 25% of the authorized service hours per week (i.e. if an individual is authorized 40 hours a week, the individual may use the real time two-way interactive audio and video telehealth 10 hours week).


Waive requirement for waiver member to attend Day Supports provider once per week.


Waiver members will not be required to attend Day Supports provider once per week. Individuals may maximize their time in the community.


Allow direct care services to be rendered in a hotel, shelter, church, or alternative facility-based settings or the home of direct care worker under specific circumstances.



Waiver members may receive services in alternative locations under specific circumstances.

  • If a member has been displaced from their home due to public health emergency or state of emergency
  • If the caretaker of the member becomes ill and is not able to care for the individual.
  • If the member’s health and safety is at risk due to family health concerns.

Allow respite to be provided when family is out of state due to evacuation/displacement until they return home. Out of home respite may be provided more than 30 days on a case-by-case basis.


Waiver services may be covered out of state only to members living in counties bordering another state; the agency providing services must be an enrolled NC provider agency located within 40 miles of the border of the county.

Allow Life Skills Training (for behavioral intervention) and Personal Care to be provided in an acute care hospital or short-term institutional stay, when the waiver member is displaced from home due to COVID-19 and the waiver member needs direct assistance with ADL’s behavioral supports, or communication supports on a continuous and ongoing basis and such supports are otherwise not available in these settings.



Effective March 1, 2024, payment may not be allowed for Life Skills Training and Personal Care for a member currently in an acute care hospital or short-term institutional stay.


Allow waiver members to receive fewer than one service per month for 90 days without being subject to discharge from the waiver.



Effective March 1, 2024, all waiver members must receive at least one waiver service per month to remain on the waiver.

Allow existing staff to continue to provide service, for 90 days, when CPR and NCI recertification has lapsed.



Effective March 1, 2024, all staff must be up to date on CPR and NCI certification.

Allow Day Supports, Life Skills Training, Personal Care, Supported Employment and Community Networking to be provided in the home of the participant, the home of the direct care worker, or the residential setting.



Effective March 1, 2024, Waiver members may receive services in locations identified in the specified Clinical Coverage Policy.

Allow relatives of TBI waiver individuals to provide Personal Care and/or Life Skills training (or a combination of those two services) up to 40 hours a week.


Family members living under the same roof as the waiver individual may provide services. Objective written documentation is required as to why there are no other providers available to provide the services.


Note: Written objective documentation may be provided in ISP or separate document.


Family members who provide these services must meet the same standards as providers who are unrelated to the individual.


Examples of situations meeting the criteria of no other providers available might include:

  • Individuals living in a remote area unserved or underserved by other providers.
  • Individuals with documented complex medical or behavioral needs, which do not require skilled nursing services and are best met by the family member(s).
  • Individuals who require services at hard-to-staff hours.
  • Numerous providers have been unsuccessful at appropriately supporting the individual.
  • Numerous providers have assessed the situation and responded in writing that they cannot provide services.


Waive the face-to-face requirements for monthly and quarterly care coordination/waiver member meetings for individuals receiving residential supports or new to waiver. Individuals who do not receive at least one service per month will receive monthly monitoring (which can be telephonic) as quarterly meetings are not sufficient for such individuals. Monthly and quarterly monitoring will occur telephonically. This telephonic assessment / monitoring will be conducted in accordance with HIPAA requirements.



Effective March 1, 2024, monthly and quarterly care coordination meetings shall occur face-to-face.

Internet/Connectivity Services

This change was not a part of Appendix K flexibilities. CMS requested the State update the amendment to remove access to internet services from the waiver based on affordable connectivity (internet) options available for internet services.


Assistance with internet services was provided to waiver members during the PHE however, it was not implemented as a waiver flexibility.


The Affordable Connectivity Program is a benefit program that aids with internet services. Waiver members may access the program to determine eligibility at


Resource Facilitation Services

This change was not a part of Appendix K flexibilities. CMS requested the State update the amendment to remove Resource Facilitation from the Waiver due to member access to Tailored Care Management, which duplicates Resource Facilitation.



NC Medicaid Contact Center. 888-245-0179

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