CAP/C Case Managers Frequently Asked Questions

This happens in CAP/C usually because a foster child, whose legal guardian is County X DSS, finds a foster care placement in County Y. In these situations

• the Medicaid is based in the county where the legal guardian is, and
• the CAP/C case management is based in the county in which the child resides.

The case management agency will need to coordinate with the other county’s DSS. This means that:

• when calling in the FL-2 to EDS, the county (in Box #5) is county X,
• the stamped FL-2 will go to county X,
• all correspondence regarding approvals and terminations will go to county X,
• if there is an error with the CAP indicator code,  you would contact county X, and
• if you needed to discuss an eligibility issue, such as a prolonged lapse in services, you would contact county X

Billing is NOT an issue in these cases.  You will be able to bill for and receive payment for your case management services even if your agency is not in county X.

The following ‘identifiers’ are included in the HIPAA Privacy Rule and should be protected as confidential information. They apply to the recipient, recipient’s relatives, recipient’s employers, or recipient’s household members.

• full name [You may use initials (JD); first name, last initial (Jane D.); or first initial, last name (J. Doe), but you should not use full name (Jane Doe)]
• social security number
• street address, city, county, zip code (except for first three digits of zip code if combined population is over 20,000)
• medical record number
• date of birth, date of death, date of admission, date of discharge (year may be used but not month or day)
• health plan beneficiary number (example:  Medicaid ID number)
• telephone or fax numbers
• account number
• Email addresses
• Certificate or license numbers
• vehicle identifiers, serial numbers, license plate numbers
• URLs
• device identifiers, serial numbers
• IP address numbers
• biometrics identifiers, including voice or fingerprints
• full face photos
• other unique identifying number (example: claim numbers)

You have three options:

1. Phone – Your consultant’s voice mail is password-protected and secure.  You may leave any type of confidential information on a voice mail.
2. Fax – The fax machine is used only by CAP/C, and is located in a secure environment. You may include any type of confidential information in a fax.

3. E-mail – To communicate confidential information by e-mail, it would need to be sent through an application that will  encrypt sensitive email messages and attachments.  DMA’s application is ZixMail.

When you receive ZixMail from your Consultant–
You will receive an email, in your regular email system, to let you know that you have a Zix message.  There will be a link in the email that you receive that will take you to the message. You will be instructed to set up a user name (your email address) and a password.  Once that has been done you will be able to open, save and reply to the Zix message.

Even with ZixMail, do not put protected health information within the subject of an email; put it only in the body or attachment of the email. Remember that emails are considered public record.

Please do not email initials, revisions, or CNRs. Email should be used only for back-and-forth discussion between you and your consultant, or for questions you have for your consultant.

The client's CAP/C eligibility will end on the day before she turns 21, although her Medicaid eligibility will not end until the last day of the month in which she turns 21.  The last day of CAP/C services is the last day on which the recipient is 20 years old. No CAP/C services are to be provided on the 21st birthday.

The case manager should help the family look at other options for care starting well before the 21st birthday.  Other options may include CAP/DA or regular Medicaid services such as Private Duty Nursing or Personal Care Services. 

Once a date has been chosen for transfer into the new program, the case manager should submit a voluntary termination form signed by the caregiver/legal guardian stating what date the last day of CAP/C services will be and which program will be taking over. It is always advisable to schedule such transfers so that the last day of CAP/C is the last day of the month before the recipient’s birthday, and the first day of the new program is the first day of the next month.  If transferring prior to the 21st birthday, still change at the change of month.

The child’s family. According to federal regulations, a CAP client has the freedom of choice to select among enrolled Medicaid providers. This applies to CAP services as well as other Medicaid services, such as durable medical equipment and home health services. The case manager may assist the client and family in selecting an agency, such as telling the client which agency serves a part of the county, and may answer the client’s questions, but may not attempt to restrict the client's choice.

The agency must have a DMA-approved provider agreement specifying CAP/C PCS and/or Pediatric Nurse Aide services.

No. CAP/C staff may never transport a child to any destination. CAP/C children are medically fragile, and thus for safety reasons, CAP/C staff cannot drive and care for the client simultaneously. CAP/C staff may accompany the child during transport if that child requires care during transport (e.g., the nurse needs to suction the child’s trach).

1. The case manager should submit a revision for the increased hours. The doctor’s order and any supporting documentation such as nurses’ notes or a hospital discharge summary should be attached.  The revision must be signed by the caregiver/legal guardian.
2. The DMA Nurse Consultant will review the revision considering, but not limited to, the following factors:
   • Have the care needs of the child actually increased? Are there new interventions, or are the old interventions occurring more frequently? 
   • What other support is available to the child during the extra hours?
   • Do the extra hours fit within the program limitations for CAP/C?
   • Can the child’s health, safety, and well-being be maintained at home within those hours?
3. If DMA approves the extra hours, the case manager submits a service authorization to the provider agency.  If DMA does not approve the hours, the family will receive notice of their appeal rights.
   
   This procedure is basically the same if the additional hours are requested because of the caregiver’s health issues rather than the child’s. In that case, the revision should include a note from the caregiver’s physician stating the nature and duration of the restriction (e.g., not allowed to lift greater than 25 pounds for next six weeks). In this case, we do not require that the child’s care needs actually increase, but we do expect that there will be care performed during the extra hours approved (e.g., we will not approve 24h/day care because of the mother’s lifting restriction if the child does not normally need to be lifted during the night and the patient’s father is at home at night and can do the lifting if it is needed.)
   
   DMA only approves 24 hour care for a maximum of two consecutive two week periods per incident. If 24 hour care needs extend beyond the four weeks, the case manager will need to assist the family in making other arrangements for that care.

Respite hours are provided to allow leisure time for the child’s caregivers.  Examples of appropriate use of respite time would be: going away for a weekend, going out to dinner and a movie, going to a sibling’s soccer game, taking an exercise class. Respite hours are subject to a limit based on how much formal support the child regularly receives.

Short-term-intensive hours are provided when the cause of the need for extra hours is not leisure activity for the caregivers. Examples of appropriate use of short-term-intensive hours are: the child needs temporary extra hours for increased care needs during an acute illness, family emergency, or family work obligations including those that occur when the child has a school vacation. Short-term-intensive hours have no program limit. They must be approved by DMA per occurrence.

Yes, but care will need to be taken to avoid duplication of nursing and case management services.

1. Case Manager discusses options with recipient/parent. If the recipient is aging out of CAP/C, this is done well before 21st birthday. Remember not all CAPC recipients will qualify for PDN – there must be a substantial, complex and continuous need for nursing care.   Other recipients may be appropriate for CAP/DA or PCS.  From a family’s perspective, the most significant differences between CAP/C and PDN are:
   

   	CAP/C	PDN
   Medicaid Eligibility	only child’s income considered	normal Medicaid eligibility rules apply
   Age Limit	birth through 20 years	none
   Case Management	yes	no
   Respite	yes	no
   Expense Limit	yes; each service has a time and/or dollar annual limit	no; equipment and services are limited only by medical necessity, not cost
   Level of staff	Nurse Aide, LPN, RN	LPN, RN
   Number of Agencies	more than one nurse/ nurse-aide agency may be used to staff the approved hours	only one nurse agency may be used to staff the approved hours

   
   
2. The Case Manager must remind the recipient/parent to contact the local DSS office to ensure the recipient has the proper Medicaid eligibility for PDN.  
3. The Case Manager assists with identifying a local Home Care Agency willing to serve the recipient based on recipient choice.  The Case Manager places a phone call to the Home Care Agency Clinical Nursing Staff to discuss continuous, substantial, and complex nursing needs of the recipient.
4. The CAP/C Case Manager, in collaboration with the home care agency, completes the PDN Prior Approval Referral Form and the Hourly Nursing Review Criteria form, and arranges for the  Primary Care Physician to complete a letter of medical necessity or the Physician Request form for Private Duty Nursing.  (S)he determines if the MD will continue to follow the recipient as a Private Duty Nursing recipient. (S)he faxes the  completed forms/letter to the Private Duty Nursing Consultant at 919-715-9025 for review.
5. The Private Duty Nursing Consultant will contact the Home Care Agency for any additional information and will send a written approval/denial letter.  If approved, the letter will detail the number of approved hours and will provide a copy to the recipient and physician. 
6. If approved, the Case Manager, in collaboration with the family and the provider agency, will establish a Transfer Date The transfer date should be the date on the PDN approval letter or as soon as possible thereafter. Authorization for PDN will start at midnight on that date, and CAP/C authorization will stop.  This Transfer Date MUST be before the recipient’s 21st birthday or services will not be covered!!
7. The Case Manager has the recipient/parent sign a ‘voluntary withdrawal letter’ from CAP/C. The withdrawal letter specifies the last date that CAP/C services will be provided. The Case Manager faxes a copy of that letter to the attention of the CAP/C Consultant and the PDN Consultant.
8. The CAP/C consultant proceeds with a written ‘termination letter’ from the CAP/C program. The Case Manager proceeds with discontinuing the service authorizations and participation notices for that recipient.
9. The Case Manager follows up with DSS to make sure that the CAP indicator code gets removed.

1. The Home Care Agency or parent contacts the county CAP/C Case Manager. The Case Manager discusses options with the parent. From a family’s perspective, the most significant differences between CAP/C and PDN are:
   

   	CAP/C	PDN
   Medicaid Eligibility	only child’s income considered	normal Medicaid eligibility rules apply
   Age Limit	birth through 20 years	none
   Case Management	yes	no
   Respite	yes	no
   Expense Limit	yes; cost of medically necessary equipment and services must be contained within monthly budget	no; equipment and services are limited only by medical necessity, not cost
   Level of staff	Nurse Aide, LPN, RN	LPN, RN
   Number of Agencies	more than one nurse/ nurse-aide agency may be used to staff the approved hours	only one nurse agency may be used to staff the approved hours

   
   
2. Once the parent has made the informed decision to pursue CAP/C, the Case Manager completes the CAP/C Referral Form and submits it to DMA by fax to 919-715-9025 for review.
3. Once the referral is approved:   
• The Case Manager must remind the recipient/parent to contact the local DSS office to report that the recipient is applying for CAP. (A recipient must have MAD, MAB, I-AS, or H-SF in order to receive CAP/C.  If they have a different type of Medicaid, they will need to apply for one of these four types.)
• The Case Manager seeks out approval of the referral, FL-2, initial assessment and initial plan of care as with any other potential recipient. Since the recipient is already receiving services in the home, the nurses notes, CMS-485, and MAR should be included as part of the assessment.
4. Once CAP/C participation is approved:
• The Case Manager, in collaboration with the family and the provider agency, will establish a Transfer Date. The transfer date should be the date on the CAP/C approval letter or as soon as possible thereafter. Authorization for PDN will stop at midnight on that date, and CAP/C authorization will begin. 
• The Case manager sends the provider agencies a service authorization or a participation agreement, as applicable, with the transfer date as the date to begin services.
• The Case Manager faxes a copy of the service authorization to the attention of the CAP/C and PDN Nurse Consultants to 919-715-9025.
• The Case Manager follows-up with DSS to ensure that the CAP indicator code gets entered correctly.

Call the LME.

The CAP/C Case Manager is not prohibited from doing it if (s)he is comfortable doing so, but it is the LME’s responsibility.

The LME knows what number a recipient is, but emergency situations and higher-priority needs may come up, so it is difficult to tell where a child may be placed on the list in terms of priority.

If the client needs aggressive habilitative services (acquiring skills (s)he never had), refer to CAP/MR-DD. Recipients that just need assistance, such as a personal care services and other CAP/DA waiver services should be referred to CAP/DA.

• Please allow a turn-around time of 15 business days on revisions.
• Please submit revisions by fax OR mail; not both.
• Plan ahead, so that you can send in one revision with all the changes you need, rather than submitting a revision one or two weeks after you submitted the last one.
• Revisions should be submitted when any waiver service or supply is added, deleted, or changed in amount or frequency.
  Revisions do not need to be submitted for additions, deletions, or changes to State Plan services.
• Revisions also do not need to be submitted for temporary/one time changes, changes in the cost of waiver items, change in provider agencies, or changes to the 24 hour coverage schedule when the total number of hours remains within the approved weekly limit.
• If we do make corrections to your cost summary, make sure you correct your own copy so that the next time you send in a revision, you don’t send in the same mistakes again.
• Please remember to visit the Fee Schedules page of this site. The date the fee schedule was last updated is written next to the name of the fee schedule. If the fee schedule has been updated, click on it to view or print it.
• Please make every effort to include school holiday hours and summer vacation hours on the plan of care at the time of the CNR.  This will help avoid delays in getting approvals because of the deluge of revisions we receive at those times.
• Few children receive school-based therapies during the summer, and the plan of care should reflect that.
• In the “Reason for Revision” section, please don’t state what was revised – state why it was revised. For example, please don’t simply state “increase in nurse hours”; state “increase in nurse hours because caregiver has new job with longer commute – added 30 minutes at beginning and at end of day M-F”.
• Please indicate the amount or percentage of private insurance limits copays, if applicable.   For example, private insurance pays 4 hours per day of nursing at $35/hr. Remember that Medicaid picks up the copay only up to the amount of the Medicaid maximum allowable for the item.

Please carefully document your attempts to get the FL-2 approved. If, for example, it is late because the doctor did not return it to you in a timely manner, document all of the contacts you made with the doctor's office to try to obtain the FL-2. Please submit a copy of the documentation with the CNR.

You cannot bill for anything prior to the CAP effective date.

You cannot get reimbursed for any case management activities that take place after a patient's discharge, termination or death.

Yes. CSC is not private or for-profit, so even though it’s within your agency there is no problem with conflict of interest.

Yes. Any nurse performing the nursing functions of a case manager must meet all of the case manager qualifications and abide by the same policies.

Have the family sign a statement that they are aware they are free to choose other providers, and have voluntarily chosen to have the same provider for both purposes. Renew the statement annually.

It is no different than normal – six years from the last date of service or from the date of majority (24th birthday), whichever is later.

It can. But it would be simpler for the therapist to bill it directly as an evaluation visit.

Possible, but doubtful.  The school therapist is only going to make recommendations on things that will be used in the school and assist the child with educational goals.

Preferred, but not required by CAP/C policy.

A rehabilitation engineer is a person who evaluates the needs of the person with a disability and designs and/or selects the proper equipment depending on that person’s need.

An adaptive vehicle supplier has a person who performs the same function but specific to vehicles.

Since they are not directly billing, no.  Vehicle modifications will often need to be done out of state.  Home modifications done by an out of state provider would still need to meet the NC county’s building codes, etc.

The individual contractor does not enroll as a Medicaid provider.  That is why they cannot bill for the home modifications and the case manager has to do so. When the case management agency gets paid, the case management agency pays the contractor (or reimburses themselves if they advanced the money).

Licensed, yes.  Bonded, no.

Yes. The family member would have to be a licensed contractor and follow all the normal building codes, permits, inspections, etc.  He could not be reimbursed for the labor, because a family member can’t be the paid provider of a waiver service.

Yes.  If the modifications are approved per the plan of care, then, based on the assessment, the modification can be split within the two homes. The limitations apply and they do not get twice the amount of money.

Free choice takes precedence.  Depending on the modifications needed, $10,000 may still not pay for everything.  Families will need to use their money wisely.  If they are choosing the most expensive vendor, there must be a reason for it – i.e., they didn’t like the quality of work of the other vendors.  If there does not seem to be a good reason for their choice, the case manager should initiate a discussion about it with the family.

The county is not ultimately taking on the liability of the work.  The person performing the work takes on that liability.  The only time a county would have liability is if they did not follow the CAP/C policies and procedures including using a vendor that meets the qualifications. 

Not providing freedom of choice would be a violation of one of our waiver assurances.  That doesn’t mean that you can’t still contract with someone, but the family must be given a list of other providers and informed that they can choose someone other than the contracted provider.

Three is a good guideline; some areas may not have that many contractors available to be listed.

Part of the family’s decision should be the cost, as funds are limited.  So multiple bids should be obtained if the family does not have access to cost information in some other way.

Yes

No. You just need to choose a contractor that meets the qualifications; the contractor would get their own supplies.

The date of service for a home modification is the first day that the modification is complete and available to the recipient.  So, if the work was begun in June, but completed in July, it is counted in the new fiscal year.

To an extent – the adapted vehicle supplier/rehab engineer would determine which modifications are needed – you would just verify that those modifications are for the benefit of the child – in other words, there is no reason to put hand-operated brakes if the child is not driving age.

This is recommended.

You are only liable for the work that you are responsible for doing.  You do not provide or install the modification, so you are not liable if it is done poorly – the contractor is.  You are responsible for following the CAP/C policy and could be held liable if you did not do so – for example, you could be held liable for using a contractor that was not licensed. 

Balance billing occurs when a provider bills a recipient for the difference between what the provider usually and customarily charges and the maximum Medicaid allowable unit rate on the fee schedule.

Balance billing is not allowed.  For home and vehicle modifications, there is no Medicaid rate.  (If you look at the fee schedule, you will see asterisks instead of numbers in the unit rate and maximum allowable cost columns.)  Without a Medicaid rate, there can be no difference between the usual and customary rate and the Medicaid rate.  Therefore, balance billing is not possible.  The family or any other third party can assist with expenses for home and/or vehicle modifications.

Correct.

The agency. They should show you the certificates of completion upon request.

In-home respite services at the nurse aide level are not subdivided into CAP/C PCS and CAP/C Pediatric Nurse Aide.  All in-home nurse aide respite is billed under S5150 at the rate on the current fee schedule.

The department that normally oversees that service.  For example, if it is a pharmacy item, the pharmacy department will make the decision. If the request is denied, they will issue appeal rights to the recipient.

The same services that normally count, such as equipment, supplies, and in-home services. Dental benefits, for example, would not count, as they are not counted now.

All referrals are automatically reviewed under EPSDT. There is no EPSDT “program” or “funds” to be requested.

As a non-covered DME request.

Yes. In CAP/C, this is stated on the Service Authorization. In PDN, the agency must send a patient update every 60 days in order for the recipient to continue receiving PDN services. The update should indicate the need for change, if any. If the provider agency, physician, or recipient/guardian initiates a reduction or termination of service, Medicaid is not required to send a written notice with appeal rights.

Correct. However, you may be able to find other sources of non-Medicaid respite care.