As we move forward under the North Carolina Innovations Waiver, we felt it important to try to explain as clearly as we can the process for Provider Agencies and Employers of Record within the Alliance network to employ relatives/legal guardians as paid caregivers based on the guidelines in NC DMA Clinical Coverage Policy No. 8-P amended November 1, 2016.

Under NC DMA Clinical Coverage Policy 8-P, Relative as Provider policy applies to waiver participants ages 18 and older who live with a relative or legal guardian who is employed by a provider agency contracted with Alliance Health to provide Innovations waiver services. Wavier beneficiaries under the age of 18 may not receive services provided by a relative who is residing in the same home.

Relatives are defined as individuals related by blood or marriage to the waiver participant. The relative must live in the home of the waiver participant.  Biological or adoptive parents of a minor child, stepparents of a minor child or the spouse of a waiver participant are excluded from being employed as a Relative as Provider.

If the prospective employee is the legal guardian of the waiver participant, the guardian must be legally able to provide services as defined in HB543.

After November 1, 2016, Community Living and Support is the only waiver service that may be provided by a relative who resides in the home of the individual (age 18 and older).

It is recommended that a relative residing in the home of the waiver participant provide no more than 40 hours per week of service to the person. This must be reported to Alliance Health, but does not require prior approval.

Provider Agencies and Employers of Record are required to report relatives/legal guardians acting as paid supports to the waiver participant’s Alliance  Health I/DD Care Coordinator. The I/DD Care Coordinator must include this information in the waiver participant’s Innovations ISP. The ISP must contain documentation that the waiver participant is in agreement with the employment of the relative and that he/she has been given the opportunity to fully consider all options for employment of non-related staff for waiver service provision.

If more than 40 hours are requested to be provided by relatives residing in the home of the participant, then PRIOR APPROVAL must be obtained from Alliance. All of the following justification should be provided:

  • Why there is no other qualified staff to provide Community Living and Support
  • Assurances that the waiver participant had choice in staff
  • The waiver participant will not be isolated from his/her community.

In exceptional situations, up to 56 hours per week may be approved.  This is the total number of hours that one relative may provide regardless of the number of waiver participants residing in the home.

Relatives who were providing more than 56 hours per week of service(s) on 12/31/2015 may exceed the 56 hour limit and be approved to provide the amount of services they were approved to provide as of December 31, 2015 as long as:

  • The waiver participant continues to choose the relative as the staff member AND
  • There are no health and safety issues for the waiver participant AND
  • The waiver participant is not isolated from their community.

Alliance Behavioral Healthcare must ensure compliance with the conditions of this policy through a prior approval process. Alliance must provide an increased level of monitoring for services delivered by relatives/legal guardians. Services delivered by relatives/legal guardians are monitored monthly. The Alliance I/DD Care Coordinators monitor through on-site monitoring and documentation review to ensure that payment is made only for services rendered and that the services are furnished in the best interest of the individual. Provider agencies and Employers of Record must comply with all monitoring requests from I/DD Care Coordinators.

The relative or legal guardian will not be reimbursed for any activity that would be provided to a person without a disability of the same age.  It is our hope that relatives are allowed to be just that, relatives, and provide the same natural supports they would any family member. Some of the questions provider agencies and Employers of Record should ask before employing a relative as provider:

  • Is this about the participant’s wishes, desires and needs or about supplementing a family member’s income?
  • As an adult is it appropriate or best for the individual to still have a family member with the participant throughout the day?
  • If a family member supports an individual from birth onwards into adulthood, does the individual learn to adapt to different people and increase his/her flexibility and independence?
  • If a participant with a disability is always supported by a family member, what happens when that caregiver becomes unable, through age, disability or death, to care for the participant? Who else knows how to interact with and care for the participant?
  • Can a family member be a barrier to increased community integration or friendship development?
  • Does having a family member as direct support staff expand the participant’s circle of support or risk shrinking it?

The application process asks about other potential non-relative employees that were interviewed and why they were not appropriate. Alliance may require or offer the use of a neutral advocate (either through Community Guide/Community Navigator or an advocacy organization such as Disability Rights NC) in this process to ensure that the desires and needs of the waiver participant are addressed by the ISP planning team.

When making decisions about whether to seek employment to provide Innovations Waiver services to a ward, in addition to compliance with HB543, legal guardians have a duty to always act in the best interest of their ward and comply with the following legal requirements:

  • Ensure that the guardianship is tailored to meet the actualneeds of each individual ward.
  • Make decisions that ensure the health and well-being of the ward, based on what the ward would decide if capable of making the decision.
  • Involve the ward in all decisions to the extent possible.
  • Allow the ward the opportunity to exercise rights that are within his/her comprehension and judgment, allowing the ward the same possibility for error as a person who is not incompetent.
  • Support the ward in developing the necessary skills to assume responsibility for his/her own decision-making.
  • Ensure the guardianship is periodically reviewed, and consider alternatives to guardianship, including restoration to competency or a limited guardianship.

In order to request approval for a relative/ legal guardian to serve as provider for more than 40 hours/week, the provider agency that currently employs or seeks to employ the relative/legal guardian must fill out the appropriate application and submit to Alliance.

This application must show that the relative/legal guardian meets the qualifications to provide the service and explain the justification for using the relative or legal guardian as the service provider rather than an unrelated provider. The request must be approved prior to service provision by the relative/legal guardian to exceed 40 hours/week. Access the application form used to make this request and note that this is a new application effective November 1, 2016.

Applications must be sent electronically via secure encrypted email to [email protected].

If the application is incomplete, it will be returned to the provider agency and will not be processed. Providers are strongly encouraged to submit complete and timely applications.

Applications are reviewed by a sub-committee of the Alliance Credentialing Committee. This committee meets the fourth Tuesday of every month. Decisions are communicated by e-mail. If the request is approved, services must be provided in accordance with the authorization.

Approvals are provider agency and relative/legal guardian specific. If the relative/legal guardian as provider changes the waiver recipient’s services to a new provider agency, and intends to provide more than 40 hours/week of service, the new provider must submit an application.

If a current relative as a provider is denied to provide more than 40 hours/week of service, there is a 60 day transitional period allowed to find a non-relative to provide those services over 40 per week. If the issue has not been resolved at that point, an additional 45 day extension may be granted. After that process, another 45 day extension may be granted if more time is needed to locate non-relative staff to provide the hours over 40/week. During the extension periods the provider is required to give an update of activities taking place to find a non-relative every 15 days to Alliance. There is no transitional period for denials when it is an initial request to provide over 40 hours/week. Participants or family members/guardians dissatisfied with a denial may file a grievance. If a request is denied, Alliance can help identify other agencies that may have non-relative staff available to serve the individual.

As the provider nears the end of its final extension (at least 15 days before) and has done its due diligence and cannot find a non-relative staff person and can document those efforts on a new application, then they can reapply for approval of the relative as provider to provide more than 40 hours/week.

Family members with questions about this process may contact Doug Wright, Director of the Office of Individual and Family, at (919) 651-8425.

Providers with questions about this process may email [email protected].