Case Management Entity Requirements for Legally Responsible Individuals and Persons as Paid Caregivers
Introduction and Purpose
This webpage provides guidance related to the Community Alternatives Program for Children (CAP/C). This guidance is to help Case Management Entities (CMEs) who support CAP/C beneficiaries and provide guidance to CMEs related to requirements when a legally responsible person (LRP) or legally responsible individual (LRI) is a paid caregiver for a CAP/C beneficiary.
An LRP/LRI is defined in the CAP/C waiver on page 150 as any person who has a duty under state law to care for another person and typically includes:
- The parent (biological or adoptive) of a minor child or;
- The guardian of a minor child who must provide care to the child or;
- A spouse of a waiver participant.
Note: A parent is a legal guardian of a minor child unless the parent’s guardianship has been terminated by a court order or another legal document.
When an LRP/LRI is a paid caregiver, they can only be paid to perform tasks for 40 or less hours per week. Additionally, LRPs/LRIs of participants who are under 3 years old may not be a paid caregiver when care needs are within the developmental range.
The 40 hours per week maximum requirement for LRPs/LRIs is documented in the CAP/C waiver on page 153:
A legally responsible individual can only perform personal care tasks for 40 or less hours per week to ensure compliance with Department of Labor requirements. The approved hours are based primarily on the assessed needs identified in the assessment.
The restriction for LRPs/LRIs with children under 3 is documented in the CAP/C waiver on page 153:
A legally responsible individuals of waiver participant under the age of three may not be authorized as the paid caregiver when care needs are within the developmental range.
Monitoring Guidance
CME Monitoring of LRP/LRI as a Paid Caregiver includes weekly telephone contact, monthly in-person visits and quarterly reviews
The CAP/C waiver language states where a guardian is authorized to receive payment, the Case Management Entity (CME) must perform weekly contacts, which can be telephonic, and monthly in-person monitoring visits. Weekly contacts may be conducted by telephone or virtual meeting, and are expected to consist of a real‑time conversation between the CME and the LRP/LRI. Weekly contacts must be documented in case notes in eCAP. Text messaging may be used for coordinating schedules or exchanging basic logistical information. Weekly contacts conducted exclusively by text message do not meet monitoring expectations.
In addition to the weekly and monthly monitoring, quarterly, (i.e., every 3 months), the CME conducts a home visit to observe hands-on assistance to ensure services approved are sufficient for current needs, to adjust upon discovery, and to obtain information which supports hosting a quarterly multidisciplinary monitoring team meeting with all service providers. The intent of observing hands-on assistance is to ensure health, safety and well-being of the beneficiary. Transfers to the tub and other potentially sensitive assistance should be completed in a way that establishes the caregiver’s ability to complete the task, while preserving the beneficiary’s dignity during the in-home visit, such as demonstrating the task fully clothed.
LRPs/LRIs are re-evaluated for meeting extraordinary circumstances (ECs) annually, or at the end of the period approved as a paid caregiver, whichever is less, unless during the quarterly in-home visit the CME identifies a significant change in circumstances or needs affecting the qualifying EC that impact the health, safety or well-being of the beneficiary. If this is identified during the quarterly in-home visit, the plan of care must be updated upon discovery to change paid caregiver status.
All monitoring visits must be documented in eCAP to include the method of contact and all relevant case management notes. In addition to case notes, CMEs are required to document monitoring contacts in the Monthly Contact record template in eCAP. Additionally, CMEs must document quarterly in-home visit findings in the Quarterly In-Home Visit template in eCAP.
For reference, this requirement is documented in the CAP/C waiver on page 153:
When the legal guardian is authorized to receive payment for providing in-home aide or pediatric nurse aide services, and skilled care the waiver participant will be enrolled in the coordinated caregiving or self-directed care. The enrollment in these service options will provide quality assurance of the health, safety and well-being of the waiver participant and provides the controls to ensure that payments are made only for the services authorized. The assigned case management entity will perform weekly contacts to include monthly in-person monitoring visits to ensure the services are provided in accordance with the service plan and the waiver participation business requirements, when the waiver participant elects to enroll in self-directed care.... Every three months, the CME is required to conduct a home visit to observe hands-on assistance to assure services approved for the amount, frequency and duration are sufficient for current needs. Adjustments are made upon discovery. Also, the CME is required to review supporting documentations to determine the need for a reassessment when the participant is hospitalized or endures a significant change in status. Another monitoring task the CME performs to assure services are in the best interest of the individual is a quarterly multidisciplinary monitoring team meeting with all services providers.
Extraordinary Circumstances Guidance
Extraordinary Circumstances Clarification
All CAP/C beneficiaries must meet level of care and medical fragility to qualify for the CAP/C waiver program. To be paid for providing hands-on services to a legal dependent, medical fragility is not enough to qualify LRPs/LRIs to be a paid caregiver. The CAP/C waiver requires extraordinary circumstances over and above medical fragility for payment to an LRP/LRI.
CMS provided guidance to NC Medicaid that LRPs/LRIs should not be paid for care that is the responsibility of the parents/LRPs/LRIs.
For reference, this information is documented in the CAP/C waiver on page 150:
A legally responsible individual is any person who has a duty under state law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the state, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant.
Meeting Extraordinary Circumstances
To be paid as an LRP/LRI, providing in-home care to a CAP/C beneficiary, at least one of the extraordinary circumstances listed on page 151 (for beneficiaries age 17 and under) or page 153 (for beneficiaries age 18 and older) of the CAP/C waiver must be met.
For reference, this information for beneficiaries age 17 and under is documented in the CAP/C waiver on page 151:
A legal guardian, Power of Attorney, Health Power of Attorney of a 17-year-old or younger waiver participant cannot be hired to provide In-home Aide, Respite In-home, Pediatric Nurse aide services, or skilled care to a waiver participant unless extraordinary conditions are met.
For reference, this information for beneficiaries aged 18 and older is documented on the CAP/C waiver on page 153:
This waiver allows a spouse or legally responsible individual of a waiver participant who is 18 years old and older to perform personal care services and receive payment when any one of the following extraordinary circumstances occur…
Annual Evaluation
An evaluation of extraordinary circumstances with supporting documentation will continue to occur annually as part of the Continuing Needs Review by the CME.
For reference, the extraordinary circumstances for beneficiaries under age 18 are documented in the CAP/C waiver on page 151:
Paid care by a legally responsible person may be authorized when extraordinary conditions apply which include the following circumstances:
- There are no available CNAs in the waiver participant's county or adjunct counties through a Home Health Agency/In-Home Aide Agency due to a lack of qualified providers, and the waiver participant needs extensive to maximal assistance with bathing, dressing, toileting and eating daily to prevent an out-of-home placement.
- The waiver participant requires short-term isolation, 90-days or less, due to experiencing an acute medical condition/health care issue requiring extensive to maximal assistance with bathing, dressing, toileting and eating, and the waiver participant chooses to receive care in their home instead of an institution.
- The waiver participant requires physician-ordered 24-hour direct observation and/or supervision specifically related to the primary medical condition(s) to assure the health and welfare of the participant and avoid institutionalization, and the legal guardian is not able to maintain full or part-time employment due to multiple absences from work to monitor and/or supervise the waiver participant; regular interruption at work to assist with the management of the waiver participant's monitoring/supervision needs; or an employment termination.
- The waiver participant has specialized health care needs that can be only provided by the legal guardian, as indicated by medical documentation, and these health care needs require extensive to maximal assistance with bathing, dressing, toileting and eating to assure the health and welfare of the participant and avoid institutionalization.
- Other documented extraordinary circumstances not previously mentioned that places the waiver participant's health, safety and well-being in jeopardy resulting in an institutional placement.
For reference, the extraordinary circumstances for beneficiaries age 18 and older are documented in the CAP/C waiver on page 153:
This waiver allows a spouse or legally responsible individual of a waiver participant who is 18 years old and older to perform personal care services and receive payment when any one of the following extraordinary circumstances occur:
- The waiver participant is experiencing a cognitive or intellectual limitation and the presence of an unfamiliar individual is more disruptive than productive and the waiver participant requires additional assistance with ADLs than ordinary as identified in a service plan.
- The waiver participant is in an area with limited access to service providers and the assessment of needs identifies that the waiver participant requires five or more hours per day of uninterrupted personal care.
- The waiver participant has a secondary diagnosis of mental illness or an intellectual disability and the behavior, because of this illness, poses harm to an unfamiliar person or past behaviors have alienated service providers.
LRP Paid Caregiver Review Tool
The Case Management Entity (CME) should leverage the LRP Paid Caregiver Review Tool document as a guide during the initial assessment and the annual Continued Needs Review (CNR) for considering
extraordinary circumstances (EC) when a Legally Responsible Person (LRP)/Legally Responsible Individual (LRI)/Legal Guardian (LG) serves as the Paid Caregiver.
This page was last modified on 05/12/2026