NC Medicaid Community Alternatives Program Clinical Coverage Policy - 3K-2 - For Disabled Adults (CAP/DA)

Sep 4, 2026

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NC Medicaid Community Alternatives Program Clinical Coverage Policy 3K-2 outlines clinical coverage rules for Disabled Adults (CAP/DA). It establishes procedure, product, and service coverage determinations by describing definitions, eligibility requirements, special provisions including EPSDT-related exceptions, and criteria for when services are covered or not covered. The policy also specifies requirements and limitations on coverage, including prior approval and the CAP/DA participation framework, including service-specific categories and related conditions.

LanguageEnglish

CategoryForms

FormatPDF

Pages170

Reading Time59 min

AccessFree to download

Description of the Procedure, Product, or Service

Definitions

Eligibility Requirements

Provisions

General

Specific

Special Provisions

EPSDT Special Provision

EPSDT and CAP/DA Participation

Local Education Agency Special Provision

When the Procedure, Product, or Service Is Covered

General Criteria Covered

Specific Criteria Covered

Specific criteria covered by Medicaid

Level of Care Determination Criteria

Priority Consideration for CAP/DA Participation

When the Procedure, Product, or Service Is Not Covered

General Criteria Not Covered

Specific Criteria Not Covered

Requirements for and Limitations on Coverage

Prior Approval

CAP/DA Participation

NC Medicaid Medicaid Community Alternatives Program Clinical Coverage Policy No: 3K-2 For Disabled Adults (CAP/DA) Amended Date: September 1, 2025 To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and services available on or after implementation, please contact your PHP. Table of Contents 1.0 Description of the Procedure, Product, or Service ........................................................................... 1 1.1 Definitions .......................................................................................................................... 3 2.0 Eligibility Requirements .................................................................................................................. 3 2.1 Provisions............................................................................................................................ 3 2.1.1 General ............................................................................................................ 3 2.1.2 Specific............................................................................................................ 3 2.2 Special Provisions ............................................................................................................... 4 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age .................................................................4 2.2.2 EPSDT and CAP/DA Participation ................................................................. 5 2.2.3 Local Education Agency Special Provision for Services at school for Beneficiary age 5 through 21 years of age ...................................................... 5 3.0 When the Procedure, Product, or Service Is Covered...................................................................... 6 3.1 General Criteria Covered .................................................................................................... 6 3.2 Specific Criteria Covered.................................................................................................... 6 3.2.1 Specific criteria covered by Medicaid............................................................. 6 3.2.2 Specific criteria covered by Medicaid............................................................. 7 3.2.3 Level of Care Determination Criteria.............................................................. 7 3.2.4 Priority Consideration for CAP/DA Participation......................................... 10 3.3 Transfers of Eligible Beneficiaries ................................................................................... 11 3.4 Medicaid Additional Criteria ............................................................................................ 12 3.4.1 Adult Day Health Services ............................................................................ 13 3.4.2 Coordinated Caregiving ................................................................................ 13 3.4.3 Meal Preparation and Delivery...................................................................... 13 3.4.4 Community Services ..................................................................................... 13 3.4.5 Equipment, Modification and Technology.................................................... 14 3.4.6 Respite Care .................................................................................................. 14 3.4.7 Goods and Services ....................................................................................... 15 3.4.8 CAP/DA In-Home Aide Service I................................................................. 16 3.4.9 Personal Emergency Response Services (PERS) .......................................... 17 3.4.10 Specialized Medical Supplies........................................................................ 17 3.4.11 Training, Education and Con

FAQs

What is the purpose of NC Medicaid CAP/DA Clinical Coverage Policy 3K-2?

It defines the clinical coverage policy for Disabled Adults (CAP/DA), including eligibility, when services are covered, when they are not covered, and coverage limitations.

What eligibility requirements and special provisions are covered in the policy?

The policy covers eligibility requirements and provisions, including special provisions such as EPSDT-related exceptions and participation rules for CAP/DA.

What are the main coverage decision points in the policy?

The policy details criteria for when procedures, products, or services are covered and lists general and specific criteria for when they are not covered, along with requirements like prior approval.

Sep 4, 2026

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