NCI
NC Innovations
For more info, see: NC Medicaid and Health Choice North Carolina Innovations Clinical Coverage Policy No: 8-P
The North Carolina Innovations Waiver Services (NC Innovations) is a resource for funding services and supports for a Medicaid beneficiary with intellectual and other related developmental disabilities who are at risk for institutional care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID)
NC Innovations is authorized by a Medicaid Home and Community-Based Services (HCBS) Waiver granted by the Centers for Medicare and Medicaid Services (CMS) under Section 1915 (c) of the Social Security Act.
​​
It operates concurrently with a 1915 (b) Waiver, the North Carolina Mental Health/Developmental Disabilities/Substance Abuse Services Health Plan (NC MH/DD/SAS Health Plan). The NC MH/DD/SAS Health Plan functions as a Prepaid Inpatient Health Plan (PIHP) through which all mental health, substance abuse and intellectual/developmental disabilities services are authorized for Medicaid enrollees. Local Management Entities-Managed Care Organizations (LME/MCOs) are area authorities in the State of NC which are responsible for certain management and oversight activities with respect to publicly funded Division of Mental Health/Developmental Disabilities /Substance Abuse Services (DMH/DD/SAS) and are PIHPs for the waiver.
Waiver Services Offered:
​
Community Living and Support
​
Community Living and Support is an individualized or group service that enables the waiver beneficiary to live successfully in their own home, the home of their family or natural supports and be an active member of their community. A paraprofessional assists the beneficiary to learn new skills and/or supports the beneficiary in activities that are individualized and aligned with the beneficiary’s preferences. The intended outcome of the service is to increase or maintain the beneficiary’s life skills or provide the supervision needed to empower the beneficiary to live in the home of their family or natural supports or in their private primary residency, maximize his or her self-sufficiency, increase self- determination and enhance the beneficiary’s opportunity to have full membership in his/her community.
Community Living and Support enables the beneficiary to learn new skills, practice and/or improve existing skills. Areas of skill acquisition are:
a. interpersonal, independent living, b. community living,
c. self-care,
d. and self-determination.
​
Community Living and Support provides supervision and assistance for the person to complete an activity to his/her level of independence. Areas of support consist of assistance in monitoring a health condition, nutrition or physical condition, incidental supervision, daily living skills, community participation, and interpersonal skills.
​
Community Living and Support provides technical assistance to unpaid supports who live in the home of the beneficiary to assist the beneficiary to with maintaining skills learned. This assistance can be requested by the unpaid support or suggested by the Individual Support Planning team and must be a collaborative decision. The technical assistance is incidental to the provision of Community Living and Supports.
Residential Supports
​
Residential Supports provides individualized services and supports to enable a beneficiary to live successfully in a Group Home or Alternative Family Living (AFL) setting of their choice and be an active participant in his/her community. The intended outcome of the service is to increase or maintain the beneficiary’s life skills, provide the supervision needed, maximize his/her self-sufficiency, increase self- determination and ensure the person’s opportunity to have full membership in his/her community.
Residential Supports includes learning new skills, practice and improvement of existing skills, and retaining skills to assist the person to complete an activity to his/her level of independence. Residential Supports includes supervision and assistance in activities of daily living when the beneficiary
is dependent on others to ensure health and safety.
​
Transportation to and from the residence and points of travel in the community is included to the degree that they are not reimbursed by another funding source.
Residential Support is provided to a beneficiary who lives in a community residential setting that meets the home and community-based characteristics as outlined in the Waiver in Appendix C.
​
Residential Supports may additionally be provided in an AFL situation. The site must be the primary residence of the AFL provider (includes couples and single persons) who receive reimbursement for the cost of care. These sites are licensed or unlicensed in accordance with state rule. All unlicensed AFL sites will be reviewed using the PIHP AFL checklist for health and safety related issues. NC Innovations respite may also be used to provide temporary relief to individuals who reside in Licensed and Unlicensed AFLs, but it may not be billed on the same day as Residential Supports. Respite may also be provided for participation in non-integrated camps or for participation in non-integrated Support Groups.
LEVELS
Residential Supports levels are determined by the Individual Budget Tool and
other evidence of support need. The SIS Level is only one piece of evidence that may be considered.
Level 1: SIS Level A
Level 2: SIS Level B
Level 3: SIS Level C and D
Level 4: SIS Level E, F, and G
​
The results of a SIS and the Base Budget are guidelines that do not constitute a binding limit that may not be exceeded on the amount of services that may be requested or authorized in a Plan of Care.
Vehicle Modifications may be accessed when the vehicle belongs to the individual and can transition to other settings with the individual.
​
Respite Services
​
Respite services provide periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for the beneficiary. NC Innovations respite may also be used to provide temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL, but it may not be billed on the same day as Residential Supports unless it is for a beneficiary to access a summer camp or support group. This service enables the primary caregiver to meet or participate in planned or emergency events, and to have planned time for him/her and/or family members. This service also enables the individual to receive periodic support and relief from the primary caregiver(s) at his/her choice. Respite may be utilized during school hours for sickness, injury, or when a student is suspended or expelled. Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (family emergency based, not to include out of home crisis). The primary caregiver(s) is the person principally responsible for the care and supervision of the beneficiary and must maintain his/her primary residence at the same address as the beneficiary
Crisis Supports
Crisis Supports provide intervention and stabilization for a beneficiary experiencing a crisis. Crisis Supports are for a beneficiary who experiences acute crises and who presents a threat to the beneficiary’s health and safety or the health and safety of others. These behaviors may result in the beneficiary losing his or her home, job, or access to activities and community involvement. Crisis Supports promote prevention of crises as well as assistance in stabilizing the beneficiary when a behavioral crisis occurs. Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual. Service authorization can be granted verbally or planned through the ISP to meet the needs of the individual. Following service authorization, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.