This bulletin provides updated guidance on the Legally Responsible Individual (LRI) as the Paid Caregiver in the CAP/C HCBS waiver Consumer Directed model. NC Medicaid has updated and published a revised version of the LRI Toolkit effective Sept. 22, 2026.
This revision supersedes any previous guidance and is intended to provide clarity and consistency to all parties, stakeholders and beneficiaries. No changes have been made to the CAP/C waiver approved 2023-2028, CAP/C clinical coverage policy 3K-1, extraordinary circumstances, or monitoring requirements.
The Case Management Entity (CME) should leverage the revised LRP Paid Caregiver Review Tool v.3 – September 2026 document as a guide during the initial assessment and the annual Continued Needs Review (CNR) for considering extraordinary circumstances (EC) when a LRI or Legal Guardian (LG) serves as the Paid Caregiver.
The LRI Toolkit describes the written documentation that must accompany the request for the LRI to act as paid caregiver. The documentation required has been amended.
Key revisions include:
- Guidance on supporting documentation options has been updated.
- The supporting documentation has been amended to include a letter from the beneficiary’s treating practitioner as an option to support the request.
- EC Criteria Checklist has been summarized and reformatted but remains aligned with the waiver.
Beneficiaries or LRI’s who have been previously denied as the paid LRI who wish to be reconsidered under the new guidance may work with their case manager to update their plan of care for review. New requests to be a paid caregiver under the new guidance will be effective upon the POC approval date. Requests for retroactive dates will not be considered.
Beneficiaries with a CNR currently under review can ask their case managers to upload the letter from the beneficiary’s treating practitioner to e-CAP if they want it to be considered during their review.
NC Medicaid will accept the optional treating practitioner or physician letter as an interim measure to help address the current CNR backlog. When the letter addresses the applicable EC and meets the requirements outlined in the revised toolkit, it will be accepted as sufficient supporting documentation. This interim approach may be reconsidered when the CAP/C waiver is resubmitted to the Centers for Medicare & Medicaid Services.
Additional Information
Link to the Requirements for Legally Responsible Individuals as Paid Caregivers
- Webpage Requirements for Legally Responsible Individuals as Paid Caregivers | NC Medicaid and
- Updated LRP Paid Caregiver Review Tool v.3 – Sept 2026 LRP Paid Caregiver Review Tool