CAP/DA Services

Medicaid shall cover a service for a CAP/DA beneficiary to attend a certified Adult Day Health Care facility. The service cares for a beneficiary who does not have other appropriate day supports and who needs a structured day program of activities and services with nursing supervision. It is an organized program of services during the day in a community group setting. The program supports the CAP/DA beneficiary’s independence and promotes social, physical, nutritional needs and emotional well-being. Services are health services and consist of a variety of program activities designed to meet the CAP/DA beneficiary’s needs and interests. Nutritional needs are met through personally prepared meals and snacks consistent with medical needs and dietary restrictions. The meals received as a part of adult day health services do not constitute a full nutritional regimen (three meals per day).

Waiver case management services are defined as services furnished to assist a beneficiary in gaining access to needed medical, social, educational and other services

Case Management: Medicaid shall cover case management which consists of assessing, care planning, referral or linkage and monitoring and follow-up. Case management services are necessary to identify needed medical, social, environmental, financial, and emotional interventions. These services are provided to maintain community integration while safeguarding the beneficiary’s health, safety, and well-being. A case management activity must be performed at least monthly with the beneficiary.

Care Advisor: Medicaid shall cover a service that provides advisement to the employer of record in gaining access to needed medical, social, educational and other services. The care advisor focuses on empowering a CAP/DA beneficiary to define and direct his or her own personal assistance needs and services. The care advisor guides and supports the beneficiary, rather than directs and manages the beneficiary, throughout the service planning and delivery process. These functions are done under the guidance and direction of the beneficiary or responsible party.

Institutional Respite Services: Medicaid shall cover a service that provides temporary relief to a caregiver in an institutional setting. This service may be used to meet a wide range of needs, such as family emergencies; planned special circumstances (vacations, hospitalizations, or business trips); relief from the daily responsibility and stress of caring for a beneficiary with a disability; or the provision of time for the caregiver(s) to complete essential personal tasks. Institutional respite is computed on a daily rate.

In-Home Respite Services: Medicaid shall cover a service that provides temporary relief to a caregiver in an in- home setting. These services are provided through direct-led, consumer-led or coordinated caregiving providers and authorized by the case manager to provide the temporary care. This service may be used to meet a wide range of needs, such as family emergencies; planned special circumstances (vacations, hospitalizations, or business trips); relief from the daily responsibility and stress of caring for a beneficiary with a disability; or the provision of time for the caregiver(s) to complete essential personal tasks.

Medicaid shall cover a service for a beneficiary that, during the hours of serviceprovision, provides hands-on (not merely set-up or cuing) assistance with a minimum of two limited to extensive Activities of Daily Living (ADLs) who are unable to perform these tasks independently due to a medical condition identified and documented on a validated assessment. The need for assistance with ADLs relates directly to the beneficiary’s physical, social environmental and functional condition. In-Home Aide Services, when listed in the service plan, are provided in the community, home, workplace, or educational settings. The provider(s) subject to the EVV requirements that provide In-Home respite shall comply with Section 12006 1903(l) of the 21st Century Cures Act and any subsequent amendments, when applicable.

Medicaid shall cover a service that provides hands-on assistance with personal care and basic home management tasks to the CAP/DA beneficiary who is unable to perform these tasks independently due to a medical condition identified and documented on a comprehensive need-based assessment. The need for assistance must be related directly to the CAP/DA beneficiary’s physical, social, environmental, and functional condition as indicated in the comprehensive needbased assessment. Personal assistant services may be provided in the community, home, workplace, or educational settings at the discretion of the CAP/DA beneficiary or designated representative.

Medicaid shall cover supportive services that assist with the acquisition, retention, or improvement of skills related to living in the community. This includes such supports as adaptive skill development, assistance with activities of daily living (ADL’s) and instrumental activities of daily living (IADL’s), linkage to local resources such as adult educational opportunities, social and leisure skill development and protective oversight and supervision. This service is intended to promote the participants independence and provides in-home supportive services for personal care and basic home management tasks due to the participant’s inability to perform these tasks independently as result of a disabling condition. Coordinated caregiving integrates the CAP/DA participant into the usual activities of family and community life.

Medicaid shall cover a service that provides financial assistance and advice to a beneficiary who is directing his or her care to ensure that consumer-directed funds outlined in the service plan are managed and distributed as intended. Financial managers provide education and training to orient the beneficiary to the roles and requirements of the consumer-directed model of care. Financial managers facilitate the employment of the personal assistance and pay the personal assistance.

Medicaid shall cover Community Transition, a service for a prospective CAP/DA beneficiary transitioning from an institutional setting to a community setting. This service may be used for a duration of one yearof the transition to the community to pay for necessary and documented expenses for a CAP/DA beneficiary who make the transition from an institution. These expenditures are for initial set-up expenses to establish a basic living arrangement.

Medicaid shall cover community integration service for an active CAP/DA participant who is in jeopardy of losing his or her community placement due to tenancy related issues.

Medicaid shall cover a service that provides equipment, physical adaptations, minor modifications, devices, supplies, monitoring systems, specialized accessibility, as identified during the comprehensive assessment. These services are intended to: a.improve, maximize or enhance the CAP/DA beneficiary’s mobility, safety, independence; b.improve integration into the community; c.improve the CAP/DA beneficiary ’s environmental andcommunityaccessibility; or d.address 24-hours a day,7 days a week CAP/DA beneficiary’s coverage concerns.

Medicaid shall cover meal preparation and delivery, a service for a CAP/DA beneficiary who requires special assistance with nutritional planning per an assessment of needs. This service is often referred to as “Meals on Wheels” and provides for the preparation and delivery to the CAP/DA beneficiary’s primary residence of one nutritious meal per day. A special diet for a CAP/DA beneficiary is available using this service.

Medicaid shall cover a service for a CAP/DA beneficiary that provides services, equipment, or supplies not otherwise provided through CAP/DA or through the Medicaid State Plan. This service helps assure health, safety and well-being when the beneficiary or responsible party does not have resources to obtain necessary item or service that will aid in the prevention or diversion of institutional placement. Participant goods and services are items that are intended to: increase the beneficiary’s ability to perform ADL’s or IADL’s and decrease dependence on personal assistant services or other Medicaid-funded services.

Medicaid shall cover a service for a CAP/DA beneficiary to assist the CAP/DA beneficiary with transportation to complete activities that promote community inclusion; physical and emotional health; and access to social and community services. Transportation providers are public transit (bus, train, rail system) or private carriers (taxicab services). Waiver funds for transportation consist of the purchase or pre-purchase of items such as: tickets, passes, vouchers, or direct payment to transportation providers as listed above.

Medicaid shall cover a service for a CAP/DA beneficiary to assist the waiver beneficiary with:

One-time garbage disposal when there is a health hazard that exacerbates health care condition; One-time decluttering of the home when there is a health hazard that exacerbates health care condition;

Medicaid shall cover services, equipment, or supplies not otherwise provided through this waiver or through the Medicaid State Plan for a CAP/DA participant directing care, and the CAP/DA participant does not have the funds to purchase the item or service or the item or service is not available through another source. This service helps assure health, safety, and wellbeing when the CAP/DA participant or responsible party does not have resources to obtain the necessary item or service that will aid in the prevention or diversion of institutional placement. Individual directed goods and services are items that are intended to: increase the CAP/DA participant’s ability to perform ADL/s or IADLS’s and decrease dependence on personal assistant services or other Medicaid-funded services.

A service for a CAP/DA beneficiary that provides coverage for physician ordered health supplements, vitamins or mineral supplements, herbal preparations and over-the-counter medications (OTC) that are directly related to the primary physical medical condition and are determined medically necessary but are not available under the State Plan. These nutritional services are necessary to assist the CAP/DA beneficiary to maintain community placement and for the management of health and safety as identified in the person-centered service plan.

A service for CAP/DA beneficiary that provides a one-time pest eradication treatment. This service is coverable when the CAP/DA beneficiary is living in his or her own home, when not already included in a lease, and when the eradication is for the management of health and safety as identified in the person-centered service plan. The eradication procedure is limited to one time per year.

Medicaid shall cover a service for a CAP/DA beneficiary that pays the monthly service charges for electronic device that enables CAP/DA beneficiary to secure help in an emergency. The beneficiary may also wear a portable "help" button to allow for mobility. The system is connected to the beneficiary’s phone and programmed to signal a response center once a "help" button is activated.

Medicaid shall cover specialized medical supplies for a CAP/DA participant, as follows:

-Oral Nutritional Supplement: Provided to promote the health and wellbeing by increasing the ability to perform Activities of Daily Living (ADL’s) and Instrumental Activities of Daily Living (IADL’s). These supplements are necessary to avoid institutionalization and promote continuous community integration.

A signed physician’s order certifying medical necessity for the supply is required.

-Incontinence Supplies: These supplies assist with bowel and bladder management and skin integrity which are necessary to avoid institutionalization.

-Medication Dispensing Box: Assists the CAP/DA participant in knowing when to take their medications. A physician’s order is not required for a medication dispensing box.