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Home  •  Waiver & Medicaid Services  •  CAP/C  •  Consumer Direction

Cap/C Waiver


Consumer Direction

What is Consumer Direction?

Consumer direction is an alternative care option offered under the CAP/C waiver. It is a self-directed care model for a CAP/C beneficiary and his or her caregivers who wish to remain at their primary private residence and have increased control over their own services and supports. It offers a CAP/C beneficiary the choice, flexibility, and control over the types of services they receive, when and where the services are provided, and by whom the services are delivered.

When electing to direct care (through consumer direction in the CAP/C waiver), all of the following criteria must be met by the beneficiary or their parent/guardian:

1. Understand the rights and responsibilities of directing his or her own care as evidenced by a completion of a mandatory self-assessment questionnaire and successful completion of an introduction to consumer-direction training and orientation;

2. Be willing and emotionally capable to assume the responsibilities of employer of record (EOR) under consumer direction by ensuring health and safety and identifying training opportunities to build competencies for him or herself and hired personal assistants as evidenced by a mandatory self-assessment questionnaire,
Selects a representative who is willing and capable to assume the responsibilities to direct the beneficiary’s care.

See 4.1 and 4.2 in Clinical Coverage Policy 3K-1 for the full list of specific disqualifying criteria.

Consumer direction providers shall:

a. Undergo a criminal background and registry check prior to hire; and

b. Demonstrate competencies and skill sets to care for the CAP/C beneficiary as documented by the consumer-directed beneficiary or responsible party through the self-assessment questionnaire and uploaded to the case file by the case manager.

Yes, if eligible. See the Parents as Paid Caregivers Section on this website.

Financial Management services are provided for a CAP/C beneficiary who is directing his or her own care, to ensure that consumer direction funds outlined in the service plan are managed and distributed as intended. An approved financial manager shall perform financial management services to reimburse the designated providers. Financial managers shall provide education and training to orient the CAP/C beneficiary to the roles and requirements of the consumer direction.

Financial managers facilitate the employment of the employees and the requirements of the consumer direction by completing the following tasks: 


  1. Serving as the beneficiary’s Power of Attorney for Internal Revenue Service’s processes; 
  2. Submitting payment of payroll to employees hired to provide services and supports;
  3. Ordering employment-related supplies and paying invoices for approved waiver-related expenses; 
  4. Deducting all required federal, state taxes, including insurance and unemployment fees, prior to issuing payment; 
  5. Maintaining separate accounts on each beneficiary’s services and producing expenditure reports, as required by the state Medicaid agency; 
  6. Providing payroll statements on at least a monthly basis to the employees;
  7. Completing necessary background checks (criminal and health care registry) and age verification on employees; 
  8. Administering benefits to the employees as directed by the CAP/C beneficiary; and 
  9. Filing claims for self-directed services and supports

There are three companies providing financial management services to CAP/C beneficiaries in consumer direction. CAP/C beneficiaries (or their parent/legal guardian on their behalf) are able to select their preferred agency or change agencies at their discretion. (In order to change to a new FM agency, a beneficiary or their EOR must contact the beneficiary’s case manager to request a plan of care revision to change providers.) 

  1. Acumen Financial Management *all of their paperwork is on their website
  2. GT Independence Financial Management *click here for their paperwork
  3. Secure Direction Financial Management *all of their paperwork is on their website

*See definition for difficulty of care here

Federal Taxes (NC follows federal guidelines)

Certain Medicaid Waiver Payments May Be Excludable From Income | Internal Revenue Service FAQs (

IRS Notice 2014-7 (Difficulty of Care Payments Excludable Under § 131 of the Internal Revenue Code)

NC Medicaid Status

Basic Medicaid Eligibility 

Food Stamps Eligibility

FNS 300 Sources of Income

Housing Status

SSI/SSDI Income 

SSA – POMS: SI 01320.175 – Deeming – In-Home Supportive Services Payments – 05/18/2009 

(read the gray box at the bottom of the page)

The CAP/C beneficiary (if over 18 and their own guardian) or someone designated by the CAP/C beneficiary or their parent/legally responsible individual (but NOT the paid parent/legally responsible individual) must act as the Employer of Record (EOR) to participate in the following required tasks:

  • Financial management (FM) agency communication; 
  • CAP/C case management (CM) contacts; 
  • CAP/C Program Consumer Direction training webinars (at service initiation and annually); 
  • FM agency online training session(s), as determined by each FM agency; 
  • Caregiver staff training;
  • Caregiver CPR certification maintenance/renewal; 
  • Timesheet approvals and troubleshooting any issues with biweekly payroll; and 
  • Completion of CAP/C CM and FM agency paperwork (at service initiation, as needed, and annually) to add/remove staff, adjust wages, or renew authorizations.

Beneficiaries and their parent(s)/guardian(s) who are interested in pursuing consumer-directed care should initiate the process by contacting their CAP/C case manager to request a plan of care revision called a change of status to consumer direction. The CAP/C case manager will then complete the following steps in order to submit a change of status (COS) assessment to NCLIFTSS for review. 

  1. The CAP/C case manager will provide information about the consumer direction waiver service, determine the beneficiary’s eligibility for consumer direction (refer to the Who is Eligible for Consumer Direction? Section above), and, if eligible, open a change of status (COS) assessment in eCAP (the online CAP/C database used for capturing beneficiary plan updates, completing assessments, and submitting any revision requests to the plan). A delay may occur, at this stage, if there is an open plan of care revision for the beneficiary. A COS assessment cannot be completed until the most recent revision has been submitted and reviewed and a determination has been made and acknowledged by the case manager.   
  2. The CAP/C case manager will provide the beneficiary and/or the parent/guardian with the Self-Assessment Questionnaire. Once the beneficiary and/or the parent/guardian has completed the Self-Assessment Questionnaire, the CAP/C case manager will review it to determine if additional education and training need to be provided. The completed self-assessment questionnaire must explicitly detail the care needs of the beneficiary and how the care interventions specifically meet the needs of the beneficiary. The Self-Assessment Questionnaire also identifies training needs or opportunities for the employer and employees (if applicable), as well as how assurances of health, safety, and well-being will be managed in the areas of abuse, neglect, and exploitation; fraud, waste and abuse; and emergency and disaster planning.
  3. The CAP/C case manager will work with the beneficiary and parent(s)/guardian(s) to determine who will serve as the employer of record (EOR)  and to help identify who will provide paid caregiving services to the beneficiary through the waiver (Keep in mind that the EOR cannot provide any paid caregiving services to the beneficiary for whom they are providing EOR services.) The CAP/C case manager will then provide a link to register for the CAP/C New Start Consumer-Direction Training Webinar and confirm the plan for the proposed EOR AND primary caregiver to complete the training.
    1. When determining who should complete the New Start CD Training webinar, consider the following: 
      1. In the traditional consumer direction waiver service, in which an employee is hired from outside the primary residence and is not a parent or legal guardian, the EOR and the primary caregiver may be the same person, so only one training webinar would need to be completed prior to the start of consumer direction. If the EOR is separate from the primary caregiver, then both individuals must complete the training.  
      2. When a parent or legal guardian residing in the primary residence is requesting to be the paid caregiver, the EOR and the primary caregiver are separate, and both individuals must complete the training.    
  4. Following completion of the training, proof of attendance must be provided to the CAP/C case manager. The New Start webinars are offered monthly by the CAP/C unit in the Division of Health Benefits, and proof of attendance is required before consumer-directed care may begin. 
  5. The CAP/C case manager will provide a list of financial management agencies (see below) to the beneficiary or parent/guardian and send a referral to the selected agency to initiate the onboarding process that is completed in parallel to the COS assessment. With assistance from the case manager, the EOR is the primary point person for the onboarding process and all communication moving forward with the financial management agency. EORs may also initiate the referral to the chosen FM agency, but the CM is required to complete paperwork in the onboarding process. The FM agencies currently providing services to beneficiaries in NC are as follows: 
    1. Acumen Financial Management *all of their paperwork is on their website
    2. GT Independence Financial Management *click here for their paperwork
    3. Secure Direction Financial Management *all of their paperwork is on their website
  6. The CM will submit the COS application with the following documentation: 
    1. Completed and approved self-assessment questionnaire (completed by EOR)
    2. Competency validations for each potential employee (completed by EOR), 
    3. CPR certifications for each potential employee (can be completed online),
    4. Confirmation from financial manager of employability of selected employee(s) via completed background checks via phone or email to EOR and CM,
    5. Referral to financial management (official document completed by CM agency), 
    6. Financial management budget (completed and provided by FM agency to CM), 
    7. Signed provider Freedom of Choice form (sent by CM agency), 
    8. Verification of completed required training (email sent by NC Medicaid with attached certificate following training), and 
    9. Signed plan of care summary (sent by CM to parent/legal guardian).  

Once the COS assessment has been approved by NCLIFTSS, the authorizations for weekly waiver services (the beneficiary’s approved weekly hours), respite services, and financial management are sent to the financial management agency designated by the beneficiary or parent/guardian. The designated employees can begin billing on the approved start date agreed upon by NC Medicaid, case management, and the FM agency. Consumer direction authorizations begin on the first day of the month, but an individual employee cannot bill unless the CM and FM agency have authorized them to start. This individual authorization is based on completion of their CPR certification, completion of their competency validation by the EOR, and completion of their background check by the FM agency. An individual employee can begin on the date that all of these items have been completed, but not before the NC Medicaid approved start date. (For example, if a proposed CD employee has completed a background check, received their CPR certification, and completed a competency validation in February, and NC Medicaid has approved CD to start March 1, then the proposed CD employee can begin to bill on March 1. If any of the items have not been completed, billing for the individual employee will be delayed until the last item has been received.) As stated in 3K-1, a prospective employee submitting an application for hire under the consumer direction program shall not perform services until competencies and trainings are verified or completed.

Beneficiaries enrolled in consumer direction must complete an annual refresher training (separate from the New Start Training described above). This training is for those who have already been participating in consumer direction for one year. This required annual training must be completed by the waiver participant (or parent/legal guardian) and the designated employer of record. Trainings will be held quarterly, and only one is required annually. Registration, and preferably training completion, must be done in order for the case manager to submit your child’s annual review. Register at the link below (make sure to choose the date you’re requesting from the drop down):

Attendant Nurse Care (ANC) is the nursing level of care version of consumer direction. The employee hired for this service must be a nurse–RN or LPN. If hiring an LPN, an RN must also be employed to provide oversight. The employer of record (EOR) must coordinate hours between ANC and the PDN agency, if the family desires to split the hours.

In addition to the regular consumer direction paperwork, further documentation is required for Attendant Nurse Care. First, The POC will need a statement that includes the following:

  1. Employer of record’s name
  2. Names of any employees (RN/LPNs) along with their nurse license numbers
  3. Name of the supporting/PDN agency
  4. Statement of the agreement of the PDN agency to transition over to consumer direction and hours being coordinated by the EOR (form in process by DHB)
  5. The hours of both the Attendant Care nurse and PDN (hours of both must be in POC)


Then, the family will need to complete (or, in some cases, have their physician complete), the following documents attached here:

The employer of record will also need a statement of agreement from their PDN agency/agencies acknowledging both the CAP/C beneficiary’s transition to consumer direction and their willingness for the EOR to oversee the management of hours. The financial management agency will be responsible for completing the nursing license verification and a copy must be scanned into eCAP. The budget obtained includes ANC hours plus EOR hours. Hours are determined by family for EOR or RN oversight (usually 5-10 per month).

Must meet one of the following nursing experience requirements:

  • A minimum of 1000 hours of experience in the previous two years in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
  • A minimum of 2000 hours of experience in the previous three years in an acute care hospital caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
  • A minimum of 2000 hours of experience in the previous five years, working for a licensed and certified home health agency caring for individuals with the care need(s) of individuals at the levels of care specified in this waiver.
  • A minimum of 2000 hours of experience in the previous five years in an area not listed above that, in the opinion of DHHS, would demonstrate appropriate knowledge, skill, and ability in caring for individuals at one or more of the levels of care specified in this waiver.

Extraordinary Circumstances:

  1. There are not sufficient nurse aides in the waiver participant’s county or adjunct counties through a Home Health Agency/In-home aide agency due to a lack of qualified providers, and the waiver participant needs extensive to maximal assistance with bathing, dressing, toileting, and eating daily to avoid an out-of-home placement.

  2. The waiver participant requires short-term isolation, 90 days or less, due to experiencing an acute medical condition/healthcare issue requiring extensive to maximal assistance with bathing, dressing, toileting, and eating, and the waiver participant chooses to receive care in their home instead of an institution.

  3. The waiver participant requires physician-ordered 24-hour direct observation and/or supervision specifically related to the primary medical condition(s) to assure the health and welfare of the participant and avoid institutionalization, and the legal guardian is not able to maintain full or part-time employment due to multiple absences from work to monitor and/or supervise the waiver participant; regular interruption at work to assist with the management of the waiver participant’s monitoring/supervision needs; or employment termination.

  4. The waiver participant has specialized health care needs that can be only provided by the legal guardian, as indicated by medical documentation, and these health care needs require extensive to maximal assistance with bathing, dressing, toileting, and eating to assure the health and welfare of the participant and avoid institutionalization.

  5. Other documented extraordinary circumstances not previously mentioned places the waiver participant’s health, safety, and well-being in jeopardy resulting in an institutional placement.