NC Innovations Waiver

The Medicaid 1915(c) Waiver, most commonly referred to as “NC Innovations,” is a Medicaid Waiver program for individuals with intellectual disabilities and other developmental disabilities. It is designed to give individuals and families an alternative to placement in an intermediate care facility (ICF).

NC Innovations offers services and support options designed to help individuals of all ages remain in their community and to live as independently as possible. The NC Innovations Waiver helps individuals have a role in planning and selecting how to receive and maintain community-based services for his/her self. It empowers them to live a more independent life.

The number of individuals who can participate in the NC Innovations Waiver is limited by the State of North Carolina, the Centers for Medicaid and Medicare Services, and available funding.

The NC Innovations Waiver is not an entitlement or right. It is a set of Medicaid services that a person may receive if they meet specific criteria, and there is availability.

Eligibility

To be part of North Carolina’s Innovations Waiver, you must:

  • Meet the requirements for Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) level of care
  • Live in an ICF-IID or be at risk of being placed in an ICF-IID
  • Be able to stay safe, healthy and well in the community while using NC Innovations Waiver services
  • Need and use NC Innovations Waiver services listed in your person-centered plan at least once a month
  • Want to use Home and Community Based services instead of living in an ICF-IID

NC Innovations Waiver Appendix K Unwinding Updates

To avoid a disruption in care and support individuals and their families, NC Medicaid is extending Appendix K temporary flexibilities until Feb. 29, 2024, while the Centers for Medicare & Medicaid Services (CMS) reviews the Innovations and Traumatic Brain Injury (TBI) Waiver amendments.

The Federal Public Health Emergency (PHE) Declaration ended on May 11, 2023. NC Medicaid’s Appendix K flexibilities were approved for six months after the federal PHE expiration.

What is Appendix K?

  • During disasters, where state and/or national states of emergency are declared, NC Medicaid can request short-term flexibilities to be approved related to the 1915(c) waivers.
  • The flexibilities are called Appendix K and require approval from NC Medicaid’s federal partner the Centers for Medicare and Medicaid Services (CMS).
  • The COVID-19 Appendix K flexibilities have been in place for over three years.

The flexibilities that are currently allowed under Appendix K will revert to the original authority/approved limits in the Innovations Waiver, Clinical Coverage Policy 8P unless included in the amended 1915(c) Innovations Waiver.

The following temporary Appendix K flexibilities will end on Feb. 29, 2024, unless it is indicated in the third column of the table below that CMS has approved the continuation of the flexibilities via the Innovations Waiver Technical Amendment effective March 1, 2024.

Tailored Care Manager (TCM), member/Legally Responsible Person (LRP) and treatment team should consult to ensure that the member’s plan reflects all current needs.

 

Flexibilities under Appendix K Innovations Waiver Requirement Flexibilities Status:

Either approved by CMS in the 1915(c) Amended Waiver effective March 1, 2024, OR

Ends Feb. 29, 2024

Increase in service hours without prior authorization All services must be prior approved

CCP 8P Page 11 – “Medicaid shall require prior approval for NC Innovations services. Provider(s) shall obtain prior approval before rendering NC Innovations services for a Medicaid beneficiary.”

Ends Feb. 29, 2024
Respite provided out-of-state if the member is displaced

 

 

No respite during out-of-state travel

CCP 8P Page 41

“Respite services are not provided during out-of-state travel since the caregiver is present during the trip.”

Ends Feb. 29, 2024
Services in alternate settings

Day Supports, Community Living and Supports, Supported Employment and Community Networking provided in the home of the member, the home of the direct care worker, or the residential setting.

·        Services in hotel, shelter, church, alternative facility or home of direct care worker due to COVID-19

·        Community Living and Supports in acute care hospital or short-term institutional stay, when the waiver participant is displaced from home because of COVID-19 and the waiver participant needs direct assistance with Activities of Daily Living (ADLs), behavioral supports or communication supports on a continuous and ongoing basis and such supports are otherwise not available in these settings.

 

Each service definition specifies the settings in which the service can be provided. See service definitions in CCP 8P (Attachment C). Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Direct care services may be provided in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker because of COVID-19-related issues.
  • Real-time, two-way interactive audio and video telehealth for the following services:
    • Community Living Supports
    • Day Supports
    • Supported Employment
    • Supported Living
    • Community Networking

*It has been noted that the use of real-time, two-way interactive audio and video telehealth must be of benefit to the member, meaning the member’s skill level must be in line with the use of this method. For example, if the member relies on physical assistance to complete tasks virtual services would not be appropriate.

Waive requirement for beneficiary to attend the Day Supports provider (facility) once per week. Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Remove the requirement for the beneficiary to attend the Day Supports provider once per week
Delays in Annual Individualized Support Plan (ISP) Annual Plans must be submitted and approved by no later than first day of the month following the member’s birth month.

CCP 8P Page 2 – “Annual plan is defined as a 12-month period for the Annual Plan/Individual Support Plan year that runs from the first day of the month following the birth month to the last day of the month of the birth month.”

CCP 8P Page 14

“The Care Coordinator reassesses each beneficiary’s needs at least annually and develops an updated ISP based on that reassessment”

CCP 8P Page 16

“Annual updates are due during the birth date month of the beneficiary. For example, the annual update for a beneficiary with a birth date of May 5th is due during the month of May. The effective date of the annual update is always the first of the month following the birth month.”

Ends Feb. 29, 2024
 

Waiver of one service per month requirements if due to COVID-19

 

The member must require at least one waiver service monthly as an eligibility requirement for continued waiver participation

CCP 8P Page 10 – “The beneficiary shall require at least one waiver service provided monthly as identified in the person-centered planning process and indicated in the Individualized Support Plan (ISP) and Individualized Budget”

CCP 8P Page 45 – “The following services are excluded from being considered a service to be used monthly: Assistive Technology, Vehicle Modification, Home Modifications, Community Transition, and Respite. If a beneficiary does not use an Innovations waiver service for a period of 30 calendar days, the PIHP shall send a written notice to the beneficiary that failure to use services for a period of 30 calendar days may result in a termination from the waiver. The PIHP shall attempt to engage the beneficiary in services. After a second 30-day period, the PIHP shall contact NC Medicaid to discuss termination of the beneficiary from the waiver. The beneficiary shall be notified of termination in writing and due process is followed.”

Ends Feb. 29, 2024
Waiver of in-person care management In-person care management is required a minimum of quarterly for all waiver participants, monthly for some

CCP 8P Pages 18-19

“The Care Coordinator:

a.      Monitors the provision of services through observation of service provision, review of documentation and verbal reports; and

b.      Maintains close contact with members of the person-centered planning team to ensure that the ISP is implemented as intended; and

c.      Following the PIHP policy, assists the beneficiary and legally responsible person in choosing a qualified provider to implement each service in the ISP.

d.      Meets with the beneficiary and legally responsible person;”

“Care Coordinator monitoring occurs monthly and consists of the following:

a.      A beneficiary that is new to the waiver receives face-to-face visits for the first six months and then on a schedule agreed to by the ISP team thereafter, no less than quarterly, to meet their health and safety needs;

b.      A beneficiary whose services are provided by guardians and relatives living in the home of the beneficiary receives monthly face-to-face monitoring visits;

c.      A beneficiary who lives in residential programs receives face-to-face monitoring visits monthly;

d.      A beneficiary who chooses the individual family-directed service option receives face-to-face monitoring visits monthly;

e.      For the months that the beneficiary does not receive face-to-face monitoring, the Care Coordinator has telephone contact with the beneficiary to ensure that there are no issues that need to be addressed; …”

Ends Feb. 29, 2024
Retainer Payments to address issues related to the COVID-19 emergency

 

Not Applicable – retainer payments are not included within waiver Ends Feb. 29, 2024
Lapses in CPR and NCI re-certification for direct care workers

 

 

 

All agency staff working with member must obtain and maintain certifications in Cardiopulmonary Resuscitation (CPR), First Aid and Alternative to Restrictive Interventions

Service definitions in CCP 8P include:

“Agency staff that work with beneficiaries must be…

e.      Qualified in Cardiopulmonary Resuscitation (CPR) and First Aid

f.       Qualified in alternatives to restrictive interventions”

 

Ends Feb. 29, 2024
Allow relatives of adult and minor waiver beneficiaries to provide services to beneficiaries in Supported Living arrangements prior to background checks and training for 90 days. Supported Living cannot be provided by immediate family members

Criminal Background checks are required before direct support workers provide care to member.

Page 3 – “…a human services agency or health care provider must conduct an investigation prior to hiring a person or permitting an employee to furnish services directly to a beneficiary.”

Supported Living service definition – “The Supported Living provider and provider staff shall not be a member of the beneficiary’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.”

Ends Feb. 29, 2024

  • Allow relatives of adult and minor waiver beneficiaries to provide services to beneficiaries prior to background checks and training for 90 days

Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Relatives of adult waiver beneficiaries can provide Supported Living to waiver beneficiaries
Waive Supports Intensity Scale (SIS) assessment A SIS assessment is required every two years for members ages 5-15 and every three years for members age 16 and older

CCP 8P Attachment E: The Supports Intensity Scale

“An NC Innovations Wavier beneficiary is required to have a SIS assessment. Failure to comply with this requirement may result in the beneficiary’s termination from the waiver. “

“A routine assessment occurs every two years for beneficiaries aged 5-15 years of age and every three years for beneficiaries 16 years of age and older.”

 

Ends Feb. 29, 2024
Waive $135,000 individual limit on a case-by-case basis for individuals who are currently receiving waiver services. The cost of all waiver services cannot exceed $135,000 per year unless the member is receiving Supported Living Level 3 and requires 24-hour support.

CCP 8P Attachment F: Individual Budgets

“…services may not total more than the $135,000 cost limit within the waiver unless the follow criteria is met:

An individual may exceed the $135,000 waiver limit, to ensure health, safety and wellbeing, if the following criteria is met: a. Beneficiaries utilizing Supported Living Level III: 1. lives independently without his or her family in a home that s/he owns, rents or leases, and 2. receives Supported Living Level III, and 3. requires 24-hour support.

 

Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Increase the annual waiver cost limit to $184,000. An individual may exceed the waiver limit, to ensure health, safety and wellbeing, if the following criteria is met:
  1. Beneficiaries utilizing Supported Living Level III:
    1. Lives independently without his or her family in a home that s/he owns, rents or leases, and
    2. Receives Supported Living Level III, and requires 24-hour support.

 

Alternative Family Living (AFL) flexibility

·        Allow primary Alternative Family Living (AFL) Providers to provide Supported Employment, Day Supports or Community Networking to the participant living in the AFL

 

Primary AFL staff cannot deliver other services to the member (unless back-up exception met)

CCP 8P Residential Supports definition

“Primary AFL Staff who provide Residential Supports should not provide other waiver services to the beneficiary. In specific situations, to ensure beneficiary health and safety the LME/MCO may approve the AFL to serve as short term back up staff for day services (Day Supports, Community Networking or Supported Employment). This approval must be documented in the Individuals record at both the LME/MCO and the provider agency.”

 

Ends Feb. 29, 2024
Home Delivered Meals as additional service Not applicable – this is not a service in the waiver at this time Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Home-Delivered Meals (one meal per day and up to seven meals per week)
Increased flexibilities related to Relatives as Direct Support Employees

·        Additional services to be provided by relatives who live in the home of the adult waiver beneficiary (current waiver only allows for Community Living and Supports) to include Community Networking, Day Supports and Supported Employment

·        Allow legally responsible persons of minor waiver beneficiaries who reside in the home and out of the home to provide, Day Supports, Supported Employment, Community Living and Supports, and Community Networking

 

 

Parents/legal guardian in minor children cannot provide paid services.

Relatives who live in the home of adult members can deliver only Community Living and Supports and ordinarily no more than 40 hours per week. In exceptional circumstances, up to 56 hours can be approved by Partners.

Only relatives who were already providing more than 56 hours of services on Dec. 31, 2015 may exceed the 56-hour limit.

CCP 8P Attachment G: Relative a Provider

“A waiver beneficiary under the age of 18 may not receive services provided by a relative who resides in their home.”

“Community living and Support is the only waiver service that may be provided by a relative who resides in the home of the beneficiary (age 18 and older). It is recommended that a relative residing in the home of the beneficiary provide no more than 40 hours per week of service to the person. This must be reported to the PIHP but does not require approval by the PIHP.”

“If more than 40 hours are requested to be provided by relatives residing in the home of the beneficiary, then approval must be obtained by the PIHP. Justification needs to be provided as to why there is no other qualified provider to provide Community living and Support and assurances of provider choice and that the beneficiary shall not be isolated from their community. In exceptional situations, up to 56 hours per week may be approved. This is the total number of hours that one relative may provide regardless of the number of beneficiaries residing in the home. “

“**Relatives who were providing more than 56 hours of services on Dec. 31, 2015, may exceed the 56-hour limit and be approved to provide the amount of services that they were authorized to provide as of Dec. 31, 2015 as long as the beneficiary continues to choose the relative as the staff member, there are no health and safety issues, and the beneficiary is not isolated from their community.”

 

Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Parents of minor beneficiaries can provide Community Living and Supports (CLS), if the beneficiary meets criteria as having extraordinary needs up to 40 hours per week. Definition of Extraordinary Needs: Extraordinary care means exceeding the range of activities that a legally responsible individual would ordinarily perform in the household on behalf of a person without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the participant and avoid institutionalization.” 

Approved by CMS in the 1915(c) Amended Innovations Waiver effective March 1, 2024:

  • Relatives residing in the home with adult beneficiaries may provide up to 84 hours per week of CLS.

 

Ends Feb. 29, 2024

  • Relatives of adult or minor beneficiaries being allowed to provide Community Networking, Supported Employment, Day Supports

Ends Feb. 29, 2024:

  • Employers of Record and/or Managing Employers of members self-directing their services through the Individual and Family Directed Models allowed to provide paid support services.
Individual and Family Directed Services (IFDS) flexibilities

·        Services provide by Employer of Record, Managing Employer or Representative

Services cannot be provided by Employers of Record, Managing Employers or Representatives

CCP 8P Attachment G Relative as Provider and Attachment H: Individual and Family Directed Services

“Employers of Record and Managing Employers participating in the Individual Family Directed option may not be employed to provide waiver services.”

“The representative shall not:

a.      Be paid for being the representative or provide paid supports to the beneficiary; Provide paid trainings to their beneficiary or their staff

b.      Provide paid services to the beneficiary, including employees of agencies providing services, except for guardianship services.”

Ends Feb. 29, 2024:

Employers of Record and/or Managing Employers of members self-directing their services through the Individual and Family Directed Models allowed to provide paid support services. This ends on Feb. 29, 2024.

Updated: December 21, 2023