NC Medicaid’s CAP/DA (Community Alternatives Program for Disabled Adults)

Last updated: May 27, 2021

 

Overview of North Carolina’s CAP/DA Program

North Carolina’s Community Alternatives Program for Disabled Adults (CAP/DA) is a bit misleading in name. In addition to serving disabled adults, it also serves seniors with a functional need for care assistance. Through CAP/DA, a variety of home and community based services (HCBS) are provided to prevent and delay the need for nursing home placement. The benefits available to program participants vary based on one’s needs and current supports. For instance, adult day care, in-home respite care, and personal emergency response services might be appropriate to supplement care already being provided by a friend or relative. For persons who live more independently, in-home assistance with everyday activities (i.e., bathing, dressing, eating, mobility), homemaker services (i.e., light housecleaning, laundry, shopping for essentials), and home delivered meals might be more appropriate.

The services offered under this statewide program may be provided by licensed care workers or program participants have the option to self-direct their personal care services via a participant directed option called CAP/Consumer-Directed. This was previously called CAP/Choice. CAP/Consumer-Directed allows the hiring of a friend or a relative, including one’s spouse or adult child, to provide care. A financial management services agency handles the financial aspects of employment responsibilities, such as tax withholding and caregiver payments.

Program beneficiaries can live in their private home or the home of a friend or family member. Persons cannot reside in an adult care home (assisted living residence) or family care home (adult foster care home) and receive assistance via this program.

CAP/DA is not an entitlement program, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the program limits the number of participant slots, and once the slots have been filled, a waitlist forms.

The Community Alternatives Program for Disabled Adults is a Home and Community Based Services (HCBS) 1915(c) Medicaid Waiver. In addition to being abbreviated as CAP/DA, one might see it as CAP/DA HCBS.

 What are 1915(c) HCBS Medicaid Waivers?
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for “Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a nursing home level of care and are at risk of institutionalization such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.

 

Benefits of CAP/DA

In addition to case management, follows is a list of the benefits available via the CAP/DA Medicaid Waiver. However, an individual care plan will determine which services and supports a program participant will receive.

– Adult Day Health Care – daytime supervision and assistance in a community group environment
– Chore Services – removal of garbage / clutter from one’s home for health / safety puposes
– Community Integration – intended to assist a program beneficiary in maintaining housing
– Community Transition – assistance with security deposit and utility set-up fees for persons transitioning to a private home from a nursing home
– Coordinated Caregiving – coordination of community supports, skill development / improvement, and in-home services (i.e., personal care assistance / housekeeping services) to promote independent living
– Delivery of Prepared Meals (i.e., Meals on Wheels)
– Equipment, Modification and Technology – includes minor home modifications for safety and accessibility
– Financial Management Services – for persons self-directing their care
– Individual Directed Goods and Services – supportive devices not otherwise covered by this program (i.e., sock aids, bed raisers, orthopedic pillows, no spill cups, magnifying glass, etc.)
– In-Home Aides – personal care assistance is provided
– Non-Medical Transportation – includes public transit and private transportation (i.e., cabs)
– Nutritional Services – vitamins / health supplements ordered by one’s doctor
– Personal Emergency Response Services (PERS) – includes service fees each month
– Pest Eradication
– Respite Care – in-home and out-of-home care to relieve a primary caregiver
– Specialized Medical Supplies – i.e., adult diapers, pill dispensers
– Training, Education and Consultative Services – for program participants / caregivers and is related to a program beneficiary’s illness / disability

 

Eligibility Requirements for CAP/DA

The CAP/DA Medicaid Waiver Program is for disabled NC adults (18-64 years old) and seniors (65 years old+) at risk of nursing home placement. Disabled program beneficiaries who are enrolled in the program prior to the age of 65 can continue in the program when turning 65. Additional eligibility criteria can be found below. Alternatively take a NC Medicaid eligibility test here.

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. However, for NC Medicaid, the income limits increase each April. To be income eligible for CAP/DA, a single applicant is limited to a monthly income of $1,073 (effective April 2021 – March 2022). Married couples, with both spouses as applicants, are limited to $1,452 / month in income. When only one spouse is an applicant, the applicant spouse can have income up to $1,073 / month. The income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred is $3,259.50 / month (effective January 2021 – December 2021) and is intended to ensure the non-applicant spouse does not become impoverished. The exact amount that can be transferred is based on the non-applicant spouse’s income and shelter costs.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is slightly higher at $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, North Carolina Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A non-applicant spouse lives in the home.
– The applicant has a dependent relative living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the CAP/DA Waiver, this level of care need must result from a physical disability or a chronic medical condition. The inability to independently complete one’s activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) is a strong consideration when making this determination. Relevant to some persons with Alzheimer’s disease or a related dementia, behavioral issues, such as regular wandering from one’s home or removal of one’s clothes at inappropriate times, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 North Carolina also has a Personal Care Services (PCS) Program. In-home personal care assistance is provided, but an applicant does not have to require a nursing home level of care as with the CAP/DA Program.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

North Carolina Medicaid has a Medically Needy Program for Medicaid applicants who have high medical expenses relative to their income. Sometimes called a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to become income eligible for Medicaid. Please note that the income limits for the medically needy program are lower than the income limits listed above.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option, but for married couples who have a significant amount of assets over Medicaid’s limit, is a Medicaid Divorce. This strategy protects assets for the non-applicant spouse. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of North Carolina to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but also protect assets from Medicaid’s estate recovery program. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for CAP/DA

Before You Apply

Prior to submitting an application for the CAP/DA Waiver, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

Since the CAP/DA Waiver is not an entitlement program, there may be a waitlist for program participation. The CAP/DA Waiver is approved for a maximum of 13,588 program participants per year. In the case of a waitlist, an applicant’s access to a participant slot is based on the date of Medicaid application with a few exceptions. For instance, priority is given to persons who are transitioning from a nursing home back into the community. Furthermore, 320 participant slots are reserved for persons with Alzheimer’s Disease or a related dementia. Please note that waitlists are county specific, which means a waitlist may exist in some counties of the state, while no waitlist exists in other counties.

 

Application Process

To begin the application process for the Community Alternatives Program for Disabled Adults, a Referral Request form must be completed and faxed to North Carolina Medicaid at 919-715-0052. Persons can also contact a CAP/DA case management provider in their county for assistance. Contact information by county can be found here. Applicants must be eligible for NC Medicaid, and if not currently enrolled in Medicaid, must apply. Persons can apply via North Carolina’s Department of Health and Human Services’ Division of Social Services. Contact information can be found here.

For additional information about the Community Alternatives Program for Disabled Adults (CAP/DA), click here.

The NC Medicaid Division of Health Benefits’ (NCDHHS) Unit of Long-Term Care administers the CAP/DA Waiver Program.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.

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