CAP/C is a Medicaid home and community-based waiver program for medically fragile children from birth through age 20. This waiver allows medically fragile children to be cared for and remain in (or return to) their homes and community, instead of living in skilled nursing facilities or hospitals. As an alternative to institutionalization, this Medicaid waiver is available to children who might not otherwise qualify for Medicaid because their family income is too high (the family’s income is “waived”; only the income of the child is considered for Medicaid eligibility purposes.
The CAP/C Waiver provides services for your child that may not be available under the regular state Medicaid plan. Some examples of additional services that can be provided are: assistive technology, in-home aide, care advisor, case management, community transition service, home accessibility and adaptation, specialized medical equipment and supplies, respite care, pediatric nurse aide, goods and services such as vehicle modification, nutritional services, and non-medical transportation.
How to Apply
This Waiver program serves a limited number of children so there may be a wait list for services. Therefore, you should apply as soon as possible. To apply please speak with the CAP/C case management entity in your county (see attached list) or call the NC Medicaid Clinical Section at 919-855-4340 to make a referral. County case managers can be found here: http://files.nc.gov/ncdma/documents/Providers/Programs_Services/CAPC/CAPC-Case-Management-Providers–Master-List-.pdf
You can find more information on the NC DHHS Division of Health Benefits website: https://medicaid.ncdhhs.gov/providers/programs-services/long-term-care/community-alternatives-program-for-children
More detailed information about CAP/C is also available in Clinical Coverage Policy 3K-1. Clinical Coverage Policy 3K-1 explains how DHHS implements the CAP/C waiver, including eligibility criteria and types of services authorized: https://medicaid.ncdhhs.gov/media/12375/download?attachment (Amended Date: July 1, 2021).
What if my child is denied CAP/C?
It is important to note that if your child is found not to be eligible for CAP/C, you have the right to appeal that decision. The information on how to appeal must be provided in the decision letter. If you believe you have been unfairly denied CAP/C services, please contact us.
There is another program available for children and adults diagnosed with Intellectual and/or Developmental Disabilities. This is called the Innovations Waiver. There is a long wait list for this service and some families have waited 10 years or more. If you think that your child may be eligible for the Innovations Waiver, the sooner you put your child on that wait list (called the Registry of Unmet Needs or ‘RUN’), the better. You can apply for the Innovations Waiver and have the child added to the wait list at the same time that the child is receiving CAP/C services.
If your medically fragile child on CAP/C also has an intellectual or developmental disability, they should automatically be provided with the Innovations Waiver once they turn 21. Your child’s case manager should discuss this with you and begin the process of switching from CAP/C to Innovations long before your child reaches 21.
http://files.nc.gov/ncdma/documents/Providers/Programs_Services/CAPC/CAPC-Case-Management-Providers–Master-List-.pdf (to print and merge with fact sheet)