Frequently Asked Questions for CAP/C Case Managers

The following includes some of the common questions about CAP/C and the answers to those questions. If your question is not answered here, you may submit your question to dma.capcquestions@ncmail.net.

• What do I do when a child’s Medicaid is in a different county than the child’s residence and CAP/C services? (New 9/28/07)
• Communicating Confidential Information (New 9/12/07)
  • What type of information is considered confidential?
  • How do I communicate confidential information to my CAP/C Consultant?
• When and how do CAP/C services end for a recipient that is about to turn 19? 
• Who selects which agency provides nursing or nurse-aide services to a CAP/C client?
• Can an agency which provides Medicaid PCS also provide CAP/C nurse aide services?
• Can a CAP/C Nurse or Nurse Aide transport a child to a doctor’s appointment?
• Does CAP/C pay for van modifications?
• What is the procedure when a physician has recommended an increase in the number of hours of nursing care for a CAP/C recipient?
• What is the difference between respite and short-term-intensive hours?
• Can a CAP/C recipient also receive Medicaid Hospice Services?
• How do I transfer a recipient form CAP/C to PDN?
• How do I transfer a recipient from PDN to CAP/C?
• What are the steps for completing a Revision Review?

What do I do when a child’s Medicaid is in a different county than the child’s residence and CAP/C services? 

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.

Communicating Confidential Information

What type of information is considered confidential?

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)

How do I communicate confidential information to my CAP/C Consultant?

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 – There are two methods for sending confidential e-mail:  ZixMail and password-protected documents sent through NC Mail.
   
   

ZixMail is an application that will automatically encrypt sensitive email messages and attachments.  

Sending Zix Mail –

If you have ZixMail installed on your system, you may compose and send your message within the ZixMail.  Please do not send messages by ZixMail if they do not contain protected health information.
If you do not have ZixMail on your system, you will be able to reply to Zix mail messages sent to you, but you will not be able to compose an original message.

Receiving ZixMail –

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.  

Sending a Password-Protected Attachment through NC Mail -

1. Arrange with your Consultant (via telephone) a password for you to use.
2. Type and save your question/information as a Word document.
3. Go to Tools, click on the down arrow, and click on Options, then Security.
4. In the ‘Password to open’ box, enter the password, click OK, re-enter the password, click OK.
5. Click on File, Send To, Mail recipient (as attachment).
6. Open the email message and type the subject and body of your message.

Receiving a Password-Protected Attachment through NC Mail -
Open your email as you would any other.  When prompted, type in the password that you and your consultant arranged.

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.

When and how do CAP/C services end for a recipient that is about to turn 19? 

The client's CAP/C eligibility will end on the day before she turns 19, although her Medicaid eligibility may not end until the last day of the month in which she turns 19.  The last day of CAP/C services is the last day on which the recipient is 18 years old. No CAP/C services are to be provided on the 19th birthday.

The case manager should help the family look at other options for care starting well before the 19th 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 a month, and the first day of the new program is the first day of the next month.

Who selects which agency provides nursing or nurse-aide services to a CAP/C client?

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.

Can an agency which provides Medicaid PCS also provide CAP/C nurse aide services?

The agency must have a DMA-approved provider agreement specifying CAP/C PCS  services.

Can a CAP/C Nurse or Nurse Aide transport a child to a doctor’s appointment?

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).

Does CAP/C pay for van modifications?

No. CAP covers only home modifications, and then only stationary wheelchair ramps, safety rails, grab bars, non-skid surfaces, handheld showers, and widening of doorways for wheelchair access.  The case manager should assist the family in locating help to pay for the van modification.

What is the procedure when a physician has recommended an increase in the number of hours of nursing care for a CAP/C recipient?

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 additional actual hands-on interventions which need to be performed during the extra hours? Hours will not be approved for monitoring, or just in case something happens.
     
     
   • 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.

What is the difference between respite and short-term-intensive hours?

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 of 720 hours per fiscal year or whatever lesser amount fits in the budget. Respite hours can be built into the budget on a monthly basis so that approval from DMA is not required for each occurrence.

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 and fit within the monthly budget limit.

Can a CAP/C recipient also receive Medicaid Hospice Services? 

It depends on whether the client is at IC, SC, or HC level of care. A client at IC or SC level usually may not receive Medicaid Hospice services because the cost of Hospice causes the client's home care costs to exceed the CAP/C limit. A CAP/C client at hospital level of care may be able to participate concurrently in Medicaid Hospice and CAP/C; however, the CAP/C case manager and the hospice will have to plan and coordinate services carefully to avoid duplication.

REMEMBER: CAP/C cannot provide services that duplicate or replace the care that is the responsibility of the hospice agency.

How do I transfer a recipient form CAP/C to PDN?

1. Case Manager discusses options with recipient/parent. If the recipient is aging out of CAP/C, this is done well before 19th 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 18 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. 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 19th 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.

How do I transfer a recipient from PDN to CAP/C?

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 18 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

   
   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.
   Once the referral is approved:
2. 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.)
3. 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. 
5. 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.
6. 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.
7. The Case Manager follows-up with DSS to ensure that the CAP indicator code gets entered correctly.

What are the steps for completing a Revision Review?

• 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 service or supply is added or deleted, or when the frequency of a CAP/C service (nurse, nurse aide, respite, waiver supplies) changes.
  
  NOTE CHANGE: Revisions do not need to be submitted when the frequency of a regular Medicaid supply or service (DME, medical supplies, therapy) changes, as long as the budget remains within the limit. The change should, however, be reflected on the next plan of care that is submitted.
  
  
• Revisions also do not need to be submitted for temporary/one time changes, changes in the cost of items when the total budget remains within the limit, change in provider agencies, or changes to the 24 hour coverage schedule when the total number of hours remains within the approved limit. Please review chapter 12 of the CAP/C Manual.
  
  
• Don’t put two items on one line of the cost summary.  This makes it difficult to read, especially when faxed.  It also leaves us no room to make corrections, which makes the final copy even more difficult to read. Please use a separate line for each item.
  
  
• 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 one has been updated, click on it to view or print it. Expect many fee schedules to be updated effective July 1 (the start of the new fiscal year).
  
  If you use the IPP fee schedules, you would use the Non-Facility Fee. Facility rates are valid for locations such as nursing homes, long-term-care facilities, etc. Non-Facility rates are valid for locations such as office, home, school, etc.
  
  
• 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. Example 1
  
  
• Remember that the codes 420, 430, and 440, are used only for therapies provided by a home health agency.  Therapies provided in the home by a therapy agency, in a school, or outpatient, all are considered IPP.  Check the IPP fee schedule for codes and prices, or write ‘IPP’ as the code, and use an estimated price of $53.81 per visit. Example 2
  
  
• Few children receive school-based therapies during the summer, and the budget should reflect that. Example 3
  
  
• Under informal support, please be very specific about the availability of the caregivers.  “Before and after work, and on weekends” is not sufficient.  We need to see that the parent works from 8:00 to 5:00 Monday through Friday.  The availability should correlate with the 24 hour coverage schedule and with the care needs described in section 5K of the assessment.
  
  
• 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 of private insurance deductible as a line item on your budget, prorated over the year. Example 4
  
  
• Please indicate the amount or percentage of private insurance copays.   For example; 80% of DME, or 30 therapy visits per year. Remember that Medicaid picks up the copay only up to the amount of the Medicaid maximum allowable for the item. Example 5
  
  
• The Client Statement of Understanding needs to be signed by the caregiver/legally responsible party and the case manager at the initial assessment and with each CNR. The Agreements needs to be signed by the Case Manager with each Plan of Care submitted, and by the caregivers/guardians according to the rules in sections 10 and 12 of the CAP/C Manual (generally, they need to sign when the change involves a waivered service or supply:  CAP/C Nursing, CAP/C In-Home-Aide, CAP/C respite, home modifications, and waiver supplies).

Updated January 15, 2008