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Case Management Services Through Better Healthcare Quality!!

What are the CAP/C Waiver Services?

What does CAP/C do?

Who is eligible for CAP/C Case Management Services?

CAP/C is available to any child from birth through 20 years of age who meets both the Medicaid eligibility criteria and the CAP/C criteria. The Medicaid criteria for CAP programs are not the same as the regular Medicaid criteria. Additionally, the child must live in a private residence, must be able to be cared for safely at home, and meet minimum nursing facility level of care. The child’s needs must be able to be met within the average cost limitations of the CAP/C Waiver. The family must be willing to participate in the care and in the care planning for their child.

According to the CAP/C Clinical Coverage Policy: 3K-1, your child could qualify for CAP/C if he or she is under the age of 21 and meets all of the following medically complex conditions:

  1. Has a primary medical (physical rather than psychological, behavioral, cognitive, or developmental) diagnosis(es) to include chronic diseases or conditions such as chronic cardiovascular disease, chronic pulmonary disease, congenital anomalies, chronic disease of the alimentary system, chronic endocrine and metabolic disorders, chronic infectious disease, chronic musculoskeletal conditions, chronic neurological disorders, chronic integumentary disease, chronic renal disease, genetic disorders, oncologic and hematologic disorders; and
  2. Has a serious, ongoing illness or chronic condition requiring prolonged hospitalization (more than 10 calendar-days, or three (3) hospital admissions) with in 12 months, ongoing medical treatments, nursing interventions, or any combination of these that must be provided by a registered nurse or medical doctor; and
  3. Has a need for life-sustaining devices such as endotracheal tube, ventilator, suction machines, dialysis machine, jejunotomy tube and gastrostomy tube, oxygen therapy, cough assist device, and chest PT vest; or care to compensate for the loss of bodily function.