Fillable ME MORANDUM of CAP WAIVER ENROLLMENT STATUS (Case (North Carolina)

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ME MORANDUM of CAP WAIVER ENROLLMENT STATUS (Case (North Carolina)

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ME
MORANDUM of CAP WAIVER ENROLLMENT STATUS
DATE: ______________________
FROM: ______________________________
______________________________
______________________________
(Case Manager Contact Information)
TO: _______________________________
_______________________________
_______________________________
(County Department of Social Services)
RE: ______________________________________ ___________________
(CAP Beneficiary’s Name/MID) (Date of Birth)
Not
ification Type (please note additional document(s) to be submitted with each notification type):
Referral to apply for Medicaid (Potential CAP Beneficiary):
Date CAP Services Requested*: ________________________________________.
Beneficiary assigned for assessment. Beneficiary Denied for Waiver Enrollment
Beneficiary approved for CAP participation:
CAP Effective Date*: ____________________ Service Plan/Plan of Care Effective Date*: ________________
The approval for CAP in the following waiver type:
CAP/C- Community Alternatives Program for Children
CAP/DA-
Community Alternatives Program of Adults
CAP/CD-Community Alternatives Program for Consumer Direction (Adults)
Level of Care Effective Date*: ____________
CI SC
ID SD
HC CS
Reassessment of Active CAP Beneficiary
CNR
Change in Status:
Assessment Effective Date: _____________________
SC
CI HC
ID
No Change
Hospitalized Date of Hospitalization: ___________________ Discharge Date:____________________
Returned to CAP after hospital stay 30 days or less.
Returned to CAP after hospital stay greater than 30 days.
Nursing Facility Placement Date of Nursing Facility Placement: ____________________
Nursing Facility Discharge Date: ____________________
Returned to CAP after nursing facility stay 30 days or less
Returned to CAP after Nursing facility stay 31-90 days
Disenrollment from the Waiver Waiver Enrollment Termination Date: _________________
Transfer Between Counties: Name of County transferring to: ___________________ Date of Transfer: __________________
Address of new residence: _____________________________________________________________________________________
(Section below to be completed by County DSS Staff & returned to CAP Case manager via fax or encrypted email)
Eligible: Medicaid Number: _________________________________
Medicaid Eligibility Category:
Date approved: _____________
Certification period:
___________
Level of Care Code:
______________
Assessed to have a monthly deductible in the
amount of: ________________________
Ineligible:
Application withdrawn by applicant
Chooses Special Assistance In-Home instead of CAP.
Ineligible due to Sanction. Length of Sanction period: ____________.
Ineligible due to Resources.
Other: ________________________________________________________________________________________
Date IMC returned to CAP Case Manager:
__________________________
IMC Contact Information (include phone#, email & fax)
__________________________________________
__________________________________________
__________________________________________
*See next page
DHB-2193 09/2020
DEF
INTION OF TERMS
Da
te CAP Services Requested: The date applicant/beneficiary requests CAP services.
CAP Effective Date: The date all eligibility requirements are met, and the beneficiary was assigned a slot for CAP
participation.
This is used for the CAP Effective Date for Medical Institution Evidence.
Serv
ice Plan/Plan of Care Date: The date the Service Plan/Plan of Care is approved to start.
Lev
el of Care Effective Date:
For CAP deductible beneficiaries, apply medical expenses toward the monthly deductible.
Cost of Care cannot be applied prior to the effective date of the Service Plan/Plan of Care Date.
The date Level of Care is approved.
This is used as the Entered Date for Medical Institution Evidence and the FL-2/MR
-2
Approved Date for Level of Care Evidence.
CAP CODES
CI: CAP/DA INTERMEDIATE CARE FACILITY
CS: CAP/DA SKILLED NURSING CARE
ID: CAP CONSUMER-DIRECTION INTERMEDIATE CARE FACILITY (ADULTS)
SD: CAP CONSUMER-DIRECTION SKILLED NURSING CARE (ADULTS)
SC: CAP/C SKILLED NURSING CARE
HC: CAP/C HOSPITAL LEVEL OF CARE
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ME MORANDUM of CAP WAIVER ENROLLMENT STATUS (Case (North Carolina)

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Completed 1 February 2022

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