Overview and Assessments

​​Overview

Individuals receiving services under the NC Innovations 1915(c) Waiver must be diagnosed with an intellectual disability (formerly classified as mental retardation) or a closely related condition that results in substantial functional limitations in three or more major life activity areas.  They also must meet criteria for Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) level of care. Individuals accessing (b)(3) services must be diagnosed with an intellectual disability or a closely related condition that results in substantial functional limitations in three or more major life activity areas. For services under the 1915(b) waiver or the 1915(c) waiver, an individual must meet all criteria identified in the service definitions found in the North Carolina DMA Clinical Coverage Policies.

Waiver services offer support to facilitate opportunities for each participant to explore and enhance their quality of life by maximizing self-determination, self-advocacy, and self-sufficiency. Services are intended to support participants in living in homes of their choice, having employment or engaging in purposeful daytime activities of their choice, achieving their life goals and providing an opportunity to direct their services to the extent they choose. Waiver services are designed to provide the necessary support to keep participants in the home setting with their families.

Assessments

Psychological evaluations establish diagnoses and may assist with identifying goals and intervention strategies. Psychological evaluations often include IQ testing and adaptive skills testing. When clinically appropriate, evaluations conducted by the appropriate professional may need to be explored in areas such as assistive technology, communication, feeding, and mobility. The Supports Intensity Scale (SIS®) assesses the level of support needed by an individual with intellectual disabilities or developmental disabilities to successfully accomplish life activities.

The Functional Behavior Assessment is used when an individual is experiencing challenging behaviors that interfere with the ability to function or the ability to access integrated community settings. The Functional Behavior Assessment helps the team identify the function of the behavior, positive support strategies, replacement behaviors, and reinforcement strategies. Most often the function of challenging behavior is related to trauma responses, communication difficulties, skill deficits, medical conditions, access to something desirable, attention, escape, sensory input, or pain relief. Challenging behaviors are subject to improvement when interventions reflect best practices. In addition, intervention must correspond with the function of the behavior in order for the individual to achieve optimal outcomes. It is considered best practice for assessments to include an accurate presentation of functioning levels across developmental domains and indicate preferences of the individual. 

NC Innovations – 1915(c) Waiver

Individuals who seek services funded through the NC Innovations Waiver are served on a first-come, first-served basis.  Individuals apply for the NC Innovations Waiver by contacting Cardinal Innovations. If the individual is determined potentially eligible for waiver , but funding is not available at the time of the referral, the individual will be placed on the Registry of Unmet Needs when all necessary documentation has been received. Individuals on the Registry of Unmet Needs are also referred to other resources while they are waiting for waiver funding.

The NC Innovations Waiver is designed to provide an array of community-based services and supports that promote choice, control, independence and community membership.  These services provide a community-based alternative to institutional care for persons who require an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) level of care.

Services

Waiver services are designed to support opportunities for participants to enhance their quality of life by assisting to maximize self-determination, self-advocacy, and self-sufficiency.  Services are designed to teach and maintain skills, provide support/supervision from either paid staff or through the use of technology or modifications when appropriate, and foster community integration. Services that focus on teaching skills include In-Home Skill Building, Community Networking, Day Supports, and Supported Employment. If the individual lives in a residential setting, Residential Supports includes the skills teaching component. The service that is intended to help an individual maintain learned skills and provide supervision from a paid staff is Personal Care. If the individual lives in a residential setting, Residential Supports includes the support, supervision and skill maintenance components. Services such as Assistive Technology, Home Modification, and Vehicle Modifications provide funding for unique opportunities for support or supervision. Community Networking, Community Guide, Supported Employment, and Day Supports are designed to assist with community integration.

For planning and budgeting purposes, services fall under two categories: Base Budget Services and Non-Base Budget Services. Base Budget Services are the services that are included in the cost limit or individual budget for Cardinal Innovations participants.  Non-Base Budget Services are services that do not count in the cost limit or individual budget for Cardinal Innovations participants. Non-Base Budget Services are sometimes referred to as Add-On Services.  Base Budget services are the core habilitation and support services in the Innovations Waiver. Non-Base Budget services are preventative services and equipment.  The total cost of Base Budget Services and Non-Base Budget Services combined cannot exceed the cost limit of $135,000 annually.

Base Budget Services include the following services:

  1. Community Networking Services
  2. Day Supports
  3. In-Home Skill Building
  4. Intensive In-Home Supports
  5. Personal Care
  6. Residential Supports
  7. Respite
  8. ​Supported Employment

 

Non-Base Budget Services include the following services:

  1. Assistive Technology Equipment and Supplies
  2. Community Guide Services
  3. Community Transition Services
  4. Crisis Services
  5. Financial Support Services
  6. Individual Goods and Services
  7. Home Modifications
  8. Natural Supports Education
  9. Specialized Consultation Services
  10. Vehicle Modifications

 

*For all services described below, please see North Carolina DMA Clinical Coverage Policies, Behavioral Health section (http://www.ncdhhs.gov/dma/mp/) for complete service requirements.

Agency with Choice/Employer of Record
The NC Innovations Waiver gives people with disabilities clear choice about how they receive services. The NC Innovations Waiver refers to self-directed services as Individual and Family Directed Supports.  Individuals can direct some or all of the services that are paid through the Waiver. Cardinal Innovations offers two models of Individual and Family Directed Supports.

  • The Employer of Record Model allows the individual or the legally responsible person for the individual to be the person who legally can exercise authority over support workers and assume the other responsibilities associated with individual direction of services, just as any other agency or employer of support workers would do. The individual or the legally responsible person in this model is known as the Employer of Record.
  • The Agency with Choice Model allows the individual or legally responsible person for the individual to work with an agency that agrees to hire employees referred by them.  The agency approves/disapproves the hiring of the referred individuals and ultimately retains the responsibility of being the employer, while allowing the individual or legally responsible person to partner in managing the employee's training and supervision.  In this model, the individual or the legally responsible is known as the Managing Employer.

Cardinal Innovations has developed a Self Direction Booklet (http://www.cardinalinnovations.org/nc-innovations-waiver/individual-family) to assist members and their families choosing how they wish to direct their services.

 

Base-Budget Services

  1. Community Networking services are intended to provide support for activities that increase a participant's opportunity to develop meaningful community relationships in integrated community settings. Services are designed to promote the maximum participation in community life while developing natural supports within integrated settings.
  2. Day Supports is primarily a group service that provides assistance to the participant with acquisition; retention; or improvement in self-help, socialization, and adaptive skills. Day Supports focus on enabling the participant to attain or maintain his or her maximum functional level. Day Supports can be provided in individual or group settings.
  3. In-Home Skill Building is a habilitative service, which means it provides training to enable the participant to acquire and build skills that support independent functioning. This service must be provided in a way that meets evidence-based habilitative guidelines, which are outlined in Cardinal Innovations' Clinical Guidelines.
  4. In-Home Intensive Support is available to support participants in their private home, when the participant needs extensive support and supervision. Habilitation, support, or supervision is provided to assist with positioning and intensive medical needs, as well as preventing/addressing elopement or other behaviors that would result in injury to self or other people.
  5. Personal Care services include support, supervision and engaging participation with eating, bathing, dressing, personal hygiene and other activities of daily living.  The concepts of supporting the individual and engaging the individual describes the flexibility of activities that may encourage the member to maintain skills gained during habilitation, while also providing supervision for independent activities. This service also provides support for maintaining skills taught during habilitative services.
  6. Residential Supports consists of an integrated array of individually designed training, assistance, and supervision that includes community integration activities, skill building and/or physical assistance across adaptive areas such as communication, mobility, self-help, mobility, independent living, and self-determination.  Residential Supports provide the array of base budget services outlined here for those living in paid residential settings. Thus Personal Care, In-Home Skill Building and other basic services cannot be billed at the same time as Residential Supports, as this service encompasses all those services together.
  7. Respite services provide periodic support and relief to the primary caregiver(s) for the responsibility of caring for the participant. The primary caregiver is the individual(s) with the responsibility of care for the member who has the same primary residence as the member. This service enables the primary caregiver to meet or participate in planned or emergency events.
  8. Supported Employment services provide assistance with choosing, acquiring, and maintaining a job. Employment options reflect options available to individuals without disabilities such as traditional employment or operating a microenterprise. Supported Employment allows for a continuum of activities necessary for employment from initial support, intermediate support, and long term follow up support.

Special Initiative:

Beginning in 2013, Cardinal Innovations partnered with Elsevier to offer the College of Direct Support online education and training, included in the DirectCourse curricula portfolio, to Cardinal Innovation's network of Intellectual/Developmental Disability (IDD) providers across North Carolina at no cost to providers.  The curriculum provides the knowledge, skills and attitudes that are nationally validated to be important for providing effective direct support.  In 2015, Cardinal Innovations will be focused on expanding this program further for Mecklenburg County providers.

Non-Base Budget Services

  1. Assistive Technology Equipment and Supplies are necessary for the proper functioning of items and systems, whether acquired commercially, modified, or customized, that are used to increase, maintain, or improve functional capabilities of members. This service covers purchases, leasing, shipping costs, and (as necessary) repair of equipment required to enable participants to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise.
  2. Community Transition offers one-time financial assistance for adult participants who transition from a Developmental Center, Community ICF/IID Group, nursing facility, or another licensed living arrangement to a non-provider owned, private living arrangement where the individual is directly responsible for his or her own living expenses. The service is provided when the individual is unable to pay for non-routine expenses such as a security deposit; essential furnishings; and deposits for utility or service access such as telephone, heating, electricity, and water.
  3. Community Guide provides support to participants and planning teams that assist in developing social networks and connections within the community. The purpose of the service is to promote self-determination, increase independence, and enhance the individual's ability to interact and contribute in the local community. Some activities of the Community Guide include advocacy, assistance in accessing non-Medicaid services, and informal counseling to help guide the individual in problem solving and decision-making. This service also supports individuals, representatives, and managing employers who direct their own waiver services. Activities may include training for the Individual and Family Directed Supports Agency with Choice option, assisting with development of staff schedules for Agency with Choice, and guidance with managing the participant-directed budget.
  4. Crisis Services is a tiered approach to support waiver participants when crisis situations occur that present a threat to their health/safety or the health/safety of others. These behaviors may result in the participant losing his or her home, job, or access to activities and community involvement. Crisis Services is an immediate intervention to support the person who is primarily responsible for the care of the participant. Crisis Services is provided as an alternative to institutional placement or psychiatric hospitalization.
  5. Financial Support Services is the umbrella service for the continuum of supports offered to NC Innovations participants who choose to participate in the Individual and Family Directed Services option with the Employer of Record model. Financial Support Services are provided to assure that funds for self-directed services are managed and distributed as intended. The service also facilitates employment of support staff by the employer.
  6. Home Modifications are physical modifications to a private residence that are necessary to ensure the health, welfare, and safety of the participant or to enhance his/ her level of independence. This service includes an exhaustive list of purchases, installation, maintenance, and (as necessary) the repair of home modifications required to enable participants to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise.
  7. Individual Goods and Services are services, equipment or supplies not otherwise provided through the NC Innovations Waiver or through the NC Medicaid State Plan that address an identified need in the Individual Support Plan that aims to improve and maintain the participant's opportunities for full membership in the community.
  8. Natural Supports Education provides training to families and the participant's natural support network in order to enhance the decision-making capacity of the natural support network, provide orientation regarding the nature and impact of the intellectual and other developmental disabilities upon the participant, provide education and training on interventions/strategies, and provide education and training in the use of specialized equipment and supplies. The requested education and training must have outcomes directly related to the needs of the participant or the natural support network's ability to provide care and support to the participant.
  9. Specialized Consultation Services (SCS) provide expertise, training, and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy or nutrition). The team must have  exhausted their expertise to address the identified need of the individual before requesting SCS.  Under this model, a participant's need is assessed and then therapeutic interventions are developed by the SCS professional in collaboration with the team. Family members and paid/unpaid caregivers are trained by the SCS professional to carry out therapeutic interventions.

Adjustments for Individual Circumstances

There are a number of ways to access additional funding for individuals receiving services under the NC Innovations Wavier. However, it is important to note that the waiver cost limit of $135,000 per year may not be exceeded when pursing additional funding. There are generally two different reasons to access additional funding. The first reason is for unexpected situations. An example is the need to access additional funding for respite because the caregiver is experiencing health problems and requires more relief than initially planned.  The second reason is the need to access additional funding because there has been a significant change in support needs. An example is the need for additional Personal Care to provide supervision and support because the individual has recently been diagnosed with dementia and is experiencing a regression of skills. ​

ID/DD (b)(3) Services

Section 1915(b)(3) of the Social Security Act allows states to use savings generated from a managed care delivery system to provide additional services to eligible Medicaid recipients.  These services are optional, and the services are only offered up to the amount of available funding.  Cardinal Innovations Healthcare Solutions offers (b)(3) services to support individuals with intellectual disability/developmental disability, mental health, and substance abuse disorders who have Medicaid. Providers must provide all comparable services regardless of the funding source.

**For all services described below, please see North Carolina DMA Clinical Coverage Policies (http://www.ncdhhs.gov/dma/mp/) for complete service requirements.

The following services are included in the Cardinal Innovations Healthcare Solutions (b)(3) service array for individuals who have Medicaid, are diagnosed with an intellectual or developmental disability, and meet any additional entrance criteria for the specific to the service.

  1. Community Guide: (b)(3) Community Guide provides support to members and planning teams that assist members in developing social networks and connections within the community. The purpose of the service is to promote self-determination, increase independence, and enhance the individual's ability to interact and contribute in the local community.
  2. Community Transition: (b)(3) Community Transition offers one-time financial assistance for adult members that transition from a Developmental Center, Community ICF/IID Group Home, nursing facility, or another licensed living arrangement to a non-provider owned, private living arrangement where the individual is directly responsible for his or her own living expenses. The service is provided when the individual is unable to pay for non-routine expenses such as a security deposit; essential furnishings; and deposits for utility or service access such as telephone, heating, electricity, and water. The service does not provide financial assistance for on-going, routine expenses such as rent, phone bill, and electric bill.
  3. Deinstitutionalization (b)(3) Service Array: The Deinstitutionalization (b) (3) Service Array Service Definition allows individuals who are moving from an ICF/IDD facility to a residential setting within the community to receive needed NC Innovations Waiver services without occupying a NC Innovations Waiver slot, because the service array is funded by 1915(b)(3) dollars.
  4. Psychiatric Consultation: See MH/SA Continuum of Care.
  5. Respite (Individual and Group): Respite provides periodic support and relief to the primary caregiver(s) for the responsibility and stress of caring for the member. The primary caregiver is the individual(s) with the responsibility of care for the member who has the same primary residence as the member. This service enables the primary caregiver to meet or participate in planned or emergency events. Respite may include in-home or out-of-home services, including overnight and weekend care. Emergency care (family emergency based, not to include out of home crisis) or continuous care up to 10 consecutive days is also available.
  6. Supported Employment: Supported Employment services provide assistance with choosing, acquiring, and maintaining a job for individuals 16 years and older who have not been able to achieve competitive employment, or if competitive employment has been interrupted. Employment options reflect options available to individuals without disabilities, such as traditional employment or operating a microenterprise. Supported Employment allows for a continuum of activities necessary for employment from initial support, intermediate support, and long term follow up support. ​

Special Initiative:

In 2013, a new (b)(3) In-Home Skill Building service was approved for Medicaid members who have a documented intellectual or developmental disability, but who are not on the Innovations Waiver. The intent of the service is for the participant to acquire skills that will increase opportunities to maximize independent functioning and community integration to enhance quality of life. The service also includes a caregiver training component to help the caregiver learn how to effectively teach the participant. The service will be implemented following evidence-based practices for caregiver/parent training and teaching the skill to individuals with intellectual or developmental disabilities. Cardinal Innovations began implementing this service in 2014 and will continue implementation and monitoring in 2015.