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Home  •  Waiver & Medicaid Services  •  CAP/C  •  What is CAP/C?

Cap/C Waiver

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What is CAP/C?

CAP/C stands for Community Alternatives Program for Children. It’s considered an alternative to institutionalization, which may be needed if services aren’t in place. CAP/C is under the 1915(c) waiver to provide Medicaid Home and Community-Based Services (HCBS). It’s authorized by Centers for Medicare & Medicaid Services (CMS) although the state has freedom to request changes.  The current waiver was approved starting March 1, 2023 through Feb 29, 2028. CMS approved the NC Medicaid’s request to increase the number of CAP/C waiver individuals by 500 each year of the waiver renewal period (i.e., year 1 – 4000; year 2 – 4500; year 3 – 5000; year 4 – 5500; and year 5 – 6000).

The CAP/C waiver serves children through age 20 who are determined to be medically fragile, meet institutional level of care criteria, and have a reasonable indication of need for at least one CAP/C waiver service. They must also qualify for Medicaid based on child’s income only (not parent’s) and be deemed disabled by Disability Determination Services (DDS).

In order to meet the medically fragile definition, they must meet one in each of the 3 categories:

  • 1. Has a primary chronic medical condition or diagnosis that has or will last more than 1 year
  • 2A. Been inpatient at least 3 times in the last 12 months
    – OR –
    2B. Had a hospital stay for more than 10 days in the last 12 months
    – OR –
    2C. Had at least 4 exacerbations of the chronic medical condition requiring same day sick, urgent care, or ER visit
    – OR –
    2D. Requires ongoing specialized treatment or intervention performed, supervised or delegated by a physician (some examples include IV infusions,rescue meds for seizures or asthma or oxygen titration)
  • 3A. Use of a life-sustaining device
    – OR –
    3B. Requires life-sustaining hands-on care to compensate for the loss of bodily function (some examples of this include turning to prevent bed sores or incontinence care to prevent skin breakdown)
    – OR –
    3C. Requires non-age-appropriate ADL assistance (some examples of this include a 2 year old unable to sit up in the bathtub or a 1 year old still requiring head support when taking a bottle)


NC Medicaid Community Alternatives Program Clinical Coverage Policy No: 3K-1 for Children (CAP/C)

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.