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					                                        NC DMA - Community Alternatives Program for Children (CAP/C)
                                                  Plan of Care Part B, Services and Supplies

Recipient Name:                           Recipient MID:                       POC Effective From                     Through
Year Recipient Entered Current Waiver:           1 (7/10-6/11)    2 (7/11-6/12)    3 (7/12-6/13)                4 (7/13-6/14)       5 (7/14-6/15)
pg    HCPCS Code         Waiver Service or Supply           Planned Waiver      Revised Planned                 Revised Planned          Revised Planned
#                                                           Costs               Waiver Costs                    Waiver Costs             Waiver Costs
3     T1016              Case Management                    $                   $                               $                        $
3     T1016 SC           Case Management SC                 $                   $                               $                        $
4     T1000              Nurse                              $                   $      *                        $      *                 $      *
5     T1000, T1019,      Short-Term-Intensive               $                   $                               $                        $
      or S5125                                                         $                    $                              $                       $
4     T1019, S5125       Pediatric Nurse Aide, Personal     $                   $      *                        $      *                 $      *
                         Care Nurse Aide
6     T1005, S5150,      Respite                            $                   $                               $                        $
      H0045
7     T2027              Attendant Care                         $                       $                       $                        $
8     T4539              Waiver Supplies: Incontinence          $                       $                       $                        $
                         Undergarments
8     T4535              Waiver Supplies: Disposable            $                       $                       $                        $
                         Liners
9     T2029              Waiver Supplies: Adaptive              $                       $                       $                        $
                         Tricycle
9     S5110              Caregiver Training and                 $                       $                       $                        $
                         Education
10    S5165              Home Modifications                     $                       $                       $                        $
10    T2039              Vehicle Modifications                  $                       $                       $                        $
11    T2038              Community Transition Funding           $                       $                       $                        $
12    99510              Palliative Care: Counseling            $                       $                       $                        $
12    S5108              Palliative Care: Expressive            $                       $                       $                        $
                         Therapies
12    S5111              Palliative Care: Bereavement           $                       $                       $                        $
                         Counseling
                         Total                                  $                       $                       $                        $
* Remember not to over-count services. For example, if your planned cost of nurse services was based on 76 hours per week, and then after six months you
revise the plan to 126 hours per week, your revised planned waiver costs should be for 26 weeks of 76 hours and 26 weeks of 126 hours.

You may submit only pages 1-3 and 13-15 and any other pages corresponding to the services in the recipient’s individualized Plan of Care. You can do this by
selecting ‘print current page’ or ‘print pages ____’ on the print page range section of the print menu.


    DMA-3161       CAP/C Plan of Care Part B            01/2011           Cover Sheet                                                        1
                                    NC DMA - Community Alternatives Program for Children (CAP/C)
                                              Plan of Care Part B, Services and Supplies


Recipient Name:                         Recipient MID:                              POC Effective From          Through

                                                           RECIPIENT SUMMARY

Case Management                                hours per month, routine ongoing activities         hours per year, assessment and crisis
Regularly Scheduled Care -SELECT-              hours per week        Monday                  Wednesday                   Friday
                                         Sunday                      Tuesday                 Thursday                    Saturday
Short-Term-Intensive Care                      additional hours per day on/for
Respite Care -SELECT-                          hours available for use before July 1               hours available for use beginning July 1 and
                                                                                             ending June 30
Incontinence Undergarments                      per
Disposable Liners                               per
Adaptive tricycle                               per
Counseling                                      per
Expressive Therapy                              per
Bereavement
Home Modifications                       amount available at entrance into        amount spent              amount left that can be used by June
                                         waiver                                                             30, 2015
Vehicle Modifications                    amount available at entrance into        amount spent              amount left that can be used by June
                                         waiver                                                             30, 2015
Community Transition Funding             amount available at entrance into        amount spent              amount left that can be used by June
                                         waiver                                                             30, 2015
Caregiver Training and Education
                                                      Total Waiver Costs Per Year

Type of Service or Supply                      Provider                 Type of Service or Supply                     Provider




_____________________________________________________                    _____________________________________________________
Parent/Legal Guardian                           Date                     Case Manager                               Date

Parents/Caregivers: Your signature above indicates that you have participated in developing this Plan of Care, are in agreement with it, and are
aware of any request that exceeds policy limitations. Please also review and sign the Caregiver Letter of Understanding and Freedom of Choice.

 DMA-3161         CAP/C Plan of Care Part B        01/2011          Cover Sheet                                                  2
                                NC DMA - Community Alternatives Program for Children (CAP/C)
                                          Plan of Care Part B, Services and Supplies

Recipient Name                      Recipient MID                                       POC Effective From         Through

T1016 CASE MANAGEMENT
Maximum allowed three hours (12 units) per month.
Provider    Hours                                 Hours                Total Units             Unit Rate   Total Annual Cost
Agency      Per Month                             Per Year             (15 minutes = 1 unit)
                  hours x         months per      =        hours       x4=         units       x$          =$
                         year
REVISION EFFECTIVE           /      /         REASON:
Provider    Hours                                 Hours                Total Units             Unit Rate   Total Annual Cost
Agency      Per Month                             Per Year             (15 minutes = 1 unit)
                  hours x         months per      =        hours       x4=         units       x$          =$
                         year


T1016SC CASE MANAGEMENT
Maximum allowed six hours (24 units) per year.
Provider Agency       Hours                    Total Units                Unit Rate                        Total Annual Cost
                      Per Year                 (15 minutes = 1 unit)
                                hours           x4=        units          x$                               =$

REVISION EFFECTIVE      /               /     REASON:
Provider Agency   Hours                        Total Units                Unit Rate                        Total Annual Cost
                  Per Year                     (15 minutes = 1 unit)
                                hours           x4=        units          x$                               =$




 DMA-3161        CAP/C Plan of Care Part B   01/2011        CAP/C Nursing, CAP/C PNA, CAP/C PCS                              3
                                   NC DMA - Community Alternatives Program for Children (CAP/C)
                                             Plan of Care Part B, Services and Supplies

Recipient Name                        Recipient MID                                        POC Effective From           Through

 REGULARLY SCHEDULED CAP/C NURSING, CAP/C PEDIATRIC NURSE AIDE, OR CAP/C PERSONAL CARE
1. Personal Time determined according to need and does not exceed 20 hours per week
2. Work Time calculated as (time worked per day              ) + (1/2 to 1 hour lunch per day        ) + (1/2 to 2 hour commute per day
      ) x (number of days           ) = total work time per week, not to exceed 50 hours
3. Sleep Time determined as 8 hours per day, not to exceed 56 hours per week              , generally for nurse level only
Personal Time           + Work Time            + Sleep Time         = Hours Per Week
Maximum formal support per week may not exceed 126 hours. Medicaid cost may not exceed $265,000 per year for nursing, $60,000
per year for nurse aide. For nurse aide level, only 70 of the 126 hours may be CAP/C.
For the first request for nurse level care, attach the Physician’s Request form. If a mid-year or annual review, attach 3-5 days of
nurses’ notes or 3-5 nurse aide task sheets plus the other documentation listed in Chapter 46 of the CAP/C Manual (for mid-year
review) or Chapter 47 of the CAP/C Manual (for CNR).
   Payer          Code       Provider Hrs Per                   Hours Per year            Units Per Year $ Per Unit        Annual Cost
                                         Week                                                                              waiver other
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
REVISION EFFECTIVE                 /      /        REASON:
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
REVISION EFFECTIVE                 /      /        REASON:
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
REVISION EFFECTIVE                 /      /        REASON:
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =
-SELECT- -SELECT-                                hours x       weeks =         hours x 4 =            units x $         =




  DMA-3161       CAP/C Plan of Care Part B      01/2011         CAP/C Nursing, CAP/C PNA, CAP/C PCS                               4
                                  NC DMA - Community Alternatives Program for Children (CAP/C)
                                            Plan of Care Part B, Services and Supplies

Recipient Name                       Recipient MID                                       POC Effective From            Through

SHORT-TERM-INTENSIVE IN-HOME CARE (STI)
No more than two weeks of 24 hour care may be requested at one time. If not indicated or if changed from assessment, indicate back-
up care plan. Cost is included in limit for nurse or nurse aide care. Submit any supporting documentation such as a physician’s letter
of medical necessity.
Date of Request         /     /           Date(s) of STI           Reason for STI
Code         Provider Amount/Frequency             Duration            = Total Hours Total Units         $ Per Unit Total Cost
                                                                                                                       waiver other
-SELECT-                   hours per          X                    =        hours X 4 =      units        x$
Date of Request      /   /           Date(s) of STI             Reason for STI
Code        Provider Amount/Frequency         Duration             = Total Hours Total Units              $ Per Unit   Total Cost
                                                                                                                       waiver other
-SELECT-                   hours per          X                    =        hours X 4 =      units        x$
Date of Request      /   /           Date(s) of STI             Reason for STI
Code        Provider Amount/Frequency         Duration             = Total Hours Total Units              $ Per Unit   Total Cost
                                                                                                                       waiver other
-SELECT-                   hours per          X                    =        hours X 4 =      units        x$
Date of Request      /   /           Date(s) of STI             Reason for STI
Code        Provider Amount/Frequency         Duration             = Total Hours Total Units              $ Per Unit   Total Cost
                                                                                                                       waiver other
-SELECT-                   hours per          X                    =        hours X 4 =      units        x$
Date of Request      /   /           Date(s) of STI             Reason for STI
Code        Provider Amount/Frequency         Duration             = Total Hours Total Units              $ Per Unit   Total Cost
                                                                                                                       waiver other
-SELECT-                   hours per          X                    =        hours X 4 =      units        x$
Date of Request      /   /           Date(s) of STI             Reason for STI
Code        Provider Amount/Frequency         Duration             = Total Hours Total Units              $ Per Unit   Total Cost
                                                                                                                       waiver other
-SELECT-                      hours per          X                  =        hours X 4 =          units   x$


DMA-3161           CAP/C Plan of Care Part B       01/2011    Short-Term-Intensive Services                                      5
                                  NC DMA - Community Alternatives Program for Children (CAP/C)
                                            Plan of Care Part B, Services and Supplies

Recipient Name                        Recipient MID                                        POC Effective From           Through

RESPITE
recipient receives this much is allowed this maximum which is this many                or this many units of
formal support per week        number of respite hours      units of in-home care      institutional care
0-30 hours per week            720 hours per year           2880 units                 30 units (days)
31-60 hours per week           540 hours per year           2160 units                 22.5 units (days)
61-90 hours per week           360 hours per year           1440 units                 15 units (days)
91 or more hours per week 180 hours per year                 720 units                 7.5 units (days)
If there is more than one recipient in the home receiving respite, hours are determined for both children based on the child with the
most respite hours available. Services will be provided simultaneously.
Respite may not be the only waiver service besides case management.
No more than two weeks of 24 hour care may be given. If not indicated or if changed from assessment, indicate back-up care plan.
Payer         Provider           Respite Type       Billing Unit Units Per Year            Cost Per Unit        Total Annual Cost
                                                                                                                waiver       other
-SELECT-                         -SELECT-           -SELECT-                               X$                   =$           =$
-SELECT-                        -SELECT-           -SELECT-                               X$                    =$          =$
REVISION EFFECTIVE               /   /          REASON:
-SELECT-                        -SELECT-          -SELECT-                                X$                    =$          =$
-SELECT-                        -SELECT-           -SELECT-                               X$                    =$          =$
REVISION EFFECTIVE               /   /          REASON:
-SELECT-                        -SELECT-          -SELECT-                                X$                    =$          =$
-SELECT-                        -SELECT-           -SELECT-                               X$                    =$          =$
REVISION EFFECTIVE               /   /          REASON:
-SELECT-                        -SELECT-          -SELECT-                                X$                    =$          =$
-SELECT-                        -SELECT-           -SELECT-                               X$                    =$          =$


DMA-3161       CAP/C Plan of Care Part B       01/2011        Respite Services                                                    6
                                  NC DMA - Community Alternatives Program for Children (CAP/C)
                                            Plan of Care Part B, Services and Supplies

Recipient Name                       Recipient MID                                        POC Effective From           Through

T2027 Attendant Care
Medicaid maximum allowed 10 hours per day (40 units per day); 50 hours per week (200 units per week); 2600 hours per year (10,400
units per year). If attendant care is used as a substitute for daycare or school, submit letter of medical necessity from physician, or
documentation from two daycares stating they cannot accept the child because of the child’s medical condition, or a copy of the IEP.
  Payer      Provider Staff Level Hrs Per Week                   Hours Per Year            Units Per Year     $ Per Unit     Annual Cost
                                                                                                                             waiver other
-SELECT-                  -SELECT-              hours      x    weeks =         hours x 4 =           units x $          =
-SELECT-                  -SELECT-              hours      x    weeks =         hours x 4 =           units x $          =
REVISION EFFECTIVE                /      /        REASON:
  Payer      Provider Staff Level Hrs Per Week                   Hours Per Year             Units Per Year    $ Per Unit     Annual Cost
                                                                                                                             waiver other
-SELECT-                  -SELECT-              hours      x    weeks =         hours     x4=          units x $         =
-SELECT-                  -SELECT-              hours      x    weeks =         hours     x4=          units x $         =
REVISION EFFECTIVE                /      /        REASON:
  Payer      Provider Staff Level Hrs Per Week                   Hours Per Year             Units Per Year    $ Per Unit     Annual Cost
                                                                                                                             waiver other
-SELECT-                  -SELECT-              hours      x    weeks =         hours     x4=          units x $         =
-SELECT-                  -SELECT-              hours      x    weeks =         hours     x4=          units x $         =
REVISION EFFECTIVE                /      /        REASON:
  Payer      Provider Staff Level Hrs Per Week                   Hours Per Year             Units Per Year    $ Per Unit     Annual Cost
                                                                                                                             waiver other
-SELECT-                  -SELECT-              hours      x    weeks =         hours     x4=          units x $         =
-SELECT-                  -SELECT-              hours      x    weeks =         hours     x4=          units x $         =




DMA-3161       CAP/C Plan of Care Part B      01/2011     Attendant Care Services                                                7
                                NC DMA - Community Alternatives Program for Children (CAP/C)
                                          Plan of Care Part B, Services and Supplies

Recipient Name                     Recipient MID                              POC Effective From         Through

T4539 WAIVER SUPPLY: REUSABLE INCONTINENCE UNDERGARMENTS
Maximum Medicaid allowed $500 per year. Must have a physician’s order, renewed annually, on file. The order
must include the type and amount. If provided by a DME company, must have copies of monthly invoices on file.
Payer           Provider     Number         Frequency       Total Number     Unit Rate       Annual Cost
                Agency                                      Per Year         (each)          waiver other
-SELECT-                                    x               =                x$        = $              $
-SELECT-                                    x               =                x$        = $              $
REVISION EFFECTIVE            /       /       REASON:
Payer           Provider     Number         Frequency       Total Number     Unit Rate       Annual Cost
                Agency                                      Per Year         (each)          waiver other
-SELECT-                                    x               =                x$        = $              $
-SELECT-                                    x               =                x$        = $              $


T4535 WAIVER SUPPLY: DISPOSABLE LINERS
Maximum Medicaid allowed $1000 per year. Must have a physician’s order, renewed annually, on file. The order
must include the type and amount. If provided by a DME company, must have copies of monthly invoices on file.
Payer           Provider     Number         Frequency       Total Number      Unit Rate      Annual Cost
                Agency                                      Per Year          (each)         waiver other
-SELECT-                                    x               =                 x$        = $            $
-SELECT-                                    x               =                 x$        = $            $
REVISION EFFECTIVE            /       /       REASON:
Payer           Provider     Number         Frequency       Total Number      Unit Rate      Annual Cost
                Agency                                      Per Year          (each)         waiver other
-SELECT-                                    x               =                 x$        = $            $
-SELECT-                                    x               =                 x$        = $            $




DMA-3161         CAP/C Plan of Care Part B     01/2011     Waiver Supplies: Incontinence                           8
                                NC DMA - Community Alternatives Program for Children (CAP/C)
                                          Plan of Care Part B, Services and Supplies

Recipient Name                      Recipient MID                                    POC Effective From        Through

 T2029 WAIVER SUPPLY: ADAPTIVE TRICYCLE
Maximum Medicaid allowed $600 per year. The quote, physician’s certification of medical necessity, the PT/OT
assessment justifying the need for the equipment, and the invoice must be on file.
Payer                                    Provider Agency                        Total Annual Cost
                                                                                waiver            other
-SELECT-                                                                        $                 $
Payer                                    Provider Agency                        Total Annual Cost
                                                                                waiver            other
-SELECT-                                                                        $                 $



S5110 CAREGIVER TRAINING AND EDUCATION
Maximum allowed Medicaid cost $500 per year. Description of training and cost of enrollment must be submitted. Documentation of
paid registration or invoice and certificate of attendance must be on file.
Payer                  Date(s) of Training Name/Type/                       Registration/   ÷ Unit Rate        = Units Billed
                                               Purpose of Training          Enrollment Cost
                                                                            waiver other
-SELECT-                                                                    $         $     ÷$                 =
-SELECT-                                                                    $         $     ÷$                 =
REVISION EFFECTIVE               /       /         REASON:
Payer                  Date(s) of Training Name/Type/                       Registration/   ÷ Unit Rate        = Units Billed
                                               Purpose of Training          Enrollment Cost
                                                                            waiver other
-SELECT-                                                                    $         $     ÷$                 =
-SELECT-                                                                    $         $     ÷$                 =




 DMA-3161        CAP/C Plan of Care Part B   01/2011    Waiver Supplies: Adaptive Tricycle                                9
                                                        Caregiver Training and Education
                                         NC DMA - Community Alternatives Program for Children (CAP/C)
                                                   Plan of Care Part B, Services and Supplies

Recipient Name                                 Recipient MID                                POC Effective From           Through

S5165 HOME MODIFICATIONS
A recipient who enters the waiver during 7/10-6/11 has a CAP/C Home Modification allowance of       $10,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/11-6/12 has a CAP/C Home Modification allowance of       $8,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/12-6/13 has a CAP/C Home Modification allowance of       $6,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/13-6/14 has a CAP/C Home Modification allowance of       $4,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/14-6/15 has a CAP/C Home Modification allowance of       $2,000 to use by June 30, 2015.
$     allowance – [ amount spent 7/10-6/11 $      + 7/11-6/12 $   + 7/12-6/13 $   + 7/13-6/14 $   +7/14-6/15 $   ]= $     amount remaining
The physician’s order and the invoice must be on file. Please submit the home modification assessment and the itemized quote and
maintain a copy on file.
Modification                       Payer                               Provider Agency                  Total Annual Cost
                                                                                                        waiver           other
                                   -SELECT-                                                             $                $
REVISION EFFECTIVE               /     /       REASON:
Modification                       Payer                               Provider Agency                  Total Annual Cost
                                                                                                        waiver           other
                                   -SELECT-                                                             $                $

T2039 VEHICLE MODIFICATIONS
A recipient who enters the waiver during 7/10-6/11 has a CAP/C Home Modification allowance of       $15,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/11-6/12 has a CAP/C Home Modification allowance of       $12,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/12-6/13 has a CAP/C Home Modification allowance of       $9,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/13-6/14 has a CAP/C Home Modification allowance of       $6,000 to use by June 30, 2015.
A recipient who enters the waiver during 7/14-6/15 has a CAP/C Home Modification allowance of       $3,000 to use by June 30, 2015.
$     allowance – [ amount spent 7/10-6/11 $      + 7/11-6/12 $   + 7/12-6/13 $   + 7/13-6/14 $   +7/14-6/15 $    ]= $     amount remaining
The physician order and the invoice must be kept on file. The quote and assessment by the vehicle modification assessment must be
submitted and on file.
Modification                       Payer                              Provider Agency                    Total Annual Cost
                                                                                                         waiver          other
                                   -SELECT-                                                              $               $
REVISION EFFECTIVE              /     /       REASON:
Modification                       Payer                              Provider Agency                    Total Annual Cost
                                                                                                         waiver          other
                                   -SELECT-                                                              $               $

DMA-3161          CAP/C Plan of Care Part B             01/2011   Home and Vehicle Modifications/Community Transition Funding
                                                                                            10
                                 NC DMA - Community Alternatives Program for Children (CAP/C)
                                           Plan of Care Part B, Services and Supplies

Recipient Name                       Recipient MID                                       POC Effective From           Through

T2038 COMMUNITY TRANSITION FUNDING (CTF)
Recipient who      has Medicaid max allowed          has Medicaid max allowed                            amount spent
entered waiver     CTF home modifications            CTF vehicle modifications            year         CTF home       CTF vehicle
7/10-6/11          $0                                $0                                   7/10-6/11    $              $
7/11-6/12          $2,000                            $3000                                7/11-6/12    $              $
7/12-6/13          $4,000                            $6,000                               7/12-6/13    $              $
7/13-6/14          $6,000                            $9,000                               7/13-6/14    $              $
7/14-6/15          $8,000                            $12,000                              7/14-6/15    $              $
The quote, physician’s certification of medical necessity, and assessment by the vehicle supplier must be submitted and on file. The
invoice must be kept on file.
Type                 Modification                       Payer                 Provider Agency            Total Annual Cost
                                                                                                         waiver         other
-SELECT-                                                -SELECT-                                         $              $
Type                 Modification                       Payer                 Provider Agency            Total Annual Cost
                                                                                                         waiver         other
-SELECT-                                                -SELECT-                                         $              $
Type                 Modification                       Payer                 Provider Agency            Total Annual Cost
                                                                                                         waiver         other
-SELECT-                                                -SELECT-                                         $              $
Type                 Modification                       Payer                 Provider Agency            Total Annual Cost
                                                                                                         waiver         other
-SELECT-                                                -SELECT-                                         $              $




DMA-3161       CAP/C Plan of Care Part B      01/2011     Home and Vehicle Modifications/Community Transition Funding
                                                                                    11
                                 NC DMA - Community Alternatives Program for Children (CAP/C)
                                           Plan of Care Part B, Services and Supplies

Recipient Name                       Recipient MID                                      POC Effective From             Through

99510 PALLIATIVE CARE: COUNSELING
Maximum allowed Medicaid cost 98 visits per year. Physician’s order, renewed annually, must be on file.
Payer        Provider       Frequency                  X Duration         = Number of Visits      X Unit Rate         = Total Cost
                                                                                                                      waiver other
-SELECT-                              visit per       X                      =                       X$          =    $        $
REVISION EFFECTIVE             /     /        REASON:
Payer       Provider            Frequency             X Duration             = Number of Visits      X Unit Rate      = Total Cost
                                                                                                                      waiver other
-SELECT-                               visit per          X                  =                       X$          =    $        $

S5108 PALLIATIVE CARE: EXPRESSIVE THERAPIES
Maximum allowed Medicaid cost 39 hours per year. Physician’s order, renewed annually, must be on file.
Payer        Provider   Amount, Frequency         Duration              = Number of Units      X Unit Rate           Total Cost
                                                                                                                     waiver other
-SELECT-                         hours per week  X        weeks             X4=         units      X$        =       $        $
REVISION EFFECTIVE            /     /       REASON:
Payer       Provider        Amount, Frequency    Duration                   = Number of Units      X Unit Rate       Total Cost
                                                                                                                     waiver other
-SELECT-                           hours per week     X        weeks        X4=         units      X$        =       $        $

S5111 PALLIATIVE CARE: BEREAV EMENT COUNSELING
Maximum allowed Medicaid cost 1visit per year. Must be billed prior to recipient’s death. Physician’s order must be on file.
Provider Agency         Total Annual Cost
                        waiver                                                 other
                        $                                                      $




 DMA-3161        CAP/C Plan of Care Part B     01/2011    Palliative Care                                                        12
                                NC DMA - Community Alternatives Program for Children (CAP/C)
                                          Plan of Care Part B, Services and Supplies
Recipient Name                      Recipient MID                                     POC Effective From   Through
(Attach to recipient Summary)
NON-WAIVER SERVICES
Service                                  Provider          Frequency             Duration
Physical Therapy
Physical Therapy
Occupational Therapy
Occupational Therapy
Speech Therapy
Speech Therapy
Visual Instruction
Home Health Nurse Visit
Hospice
Home Infusion Therapy
PCS, PCS +
PDN




Service                         New Provider         New Amount/ Frequency        New Duration
-SELECT- of
-SELECT- of
-SELECT- of
-SELECT- of
-SELECT- of
-SELECT- of
-SELECT- of

The following services listed above have been approved for exceptions to policy under EPSDT:     .



 DMA-3161       CAP/C Plan of Care Part B      01/2011   Non-Waiver Services and Supplies                            13
                              NC DMA - Community Alternatives Program for Children (CAP/C)
                                        Plan of Care Part B, Services and Supplies
Recipient Name                       Recipient MID                              POC Effective From     Through
(Attach to Recipient Summary)
NON-WAIVER EQUIPMENT AND SUPPLIES (Attach to Recipient Summary)
         Supply             Provider         Quantity               Supply                  Provider     Quantity
                        MOBILITY                                              PERSONAL CARE
walker                                                bath/shower chair
stander                                               hand-held shower
manual wheelchair
power wheelchair
hospital bed
transfer bench                                                                     FEEDING
Hoyer lift                                            formula
                                                      NG tube
                                                      G/J tube, standard
                                                      G/J tube, low profile
                       ELIMINATION                    G/J tube low profile extension set
diapers/pull-ups                                      feeding kit
chux                                                  enteral pump
indwelling catheters                                  syringes
intermittent catheters                                TPN
ostomy bag
skin barrier

                                                                                     DRESSINGS
                                                        sterile saline
            ORTHOTICS AND PROSTHETICS                   hydrogen peroxide
arms/hands                                              sterile cotton-tip applicators
legs/feet/hips                                          gauze
spine                                                   tape
                                                        transparent dressing
                                                        sterile gloves




 DMA-3161     CAP/C Plan of Care Part B   01/2011    Non-Waiver Services and Supplies                            14
                                 NC DMA - Community Alternatives Program for Children (CAP/C)
                                           Plan of Care Part B, Services and Supplies
Recipient Name                     Recipient MID                                         POC Effective From          Through
(Attach to Recipient Summary)
           Supply            Provider        Quantity                          Supply        Provider                Quantity
                       RESPIRATORY                                                 MISCELLANEOUS/OTHER
pulse oximeter
apnea monitor
BiPAP
CPAP
ventilator
oxygen concentrator
portable oxygen tank
trach
Passey-muir valve
trach mask
humidifier
suction machine
suction canisters
suction tubing
suction catheters
yankauer suction
saline bullets
nebulizer
cough assist device
chest PT vest


Date        Reason                         Action               Supply or Equipment       New Provider       New Quantity
                                           -SELECT-
                                           -SELECT-
                                           -SELECT-

The following supplies or equipment listed above have been approved for exceptions to quantity limitations, lifetime expectancies, or
coverage criteria under EPSDT:       .

 DMA-3161       CAP/C Plan of Care Part B      01/2011     Non-Waiver Services and Supplies                                     15

				
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