The NC Innovations Waiver leverages existing natural and community supports while fostering the development of stronger natural support networks. This helps participants be less reliant on formal support systems.
However, at times it is necessary for relatives (or legally responsible persons) who live with the participant to provide paid supports to enable the member to stay in the home. NC Medicaid Clinical Coverage Policy (CCP) 8P – NC Innovations allows providers or Employers of Record (EORs) to employ relatives to provide Community Living and Supports (CLS) within specific parameters. This policy is known as Relative as Direct Support Employee, or RADSE.
However, having relatives provide paid supports is not the preferred option for Innovations Waiver participants. It is Vaya Health’s hope that relatives are allowed to be just that—relatives—and provide the same natural supports as they would for any family member. In general, a relative should provide paid supports under only two circumstances:
- No other staff is reasonably available to provide the service; or
- A qualified staff is only willing to provide the service at an extraordinarily higher cost than the fee or charge negotiated with the qualified family member or legal guardian.
It is important to remember RADSEs are employees of the provider/EOR and must comply with all requirements applicable to provider staff, including supervision as outlined in CCP 8P.
Vaya reviews RADSE data to inform network development decisions. We are invested in ensuring a quality network of Innovations Waiver service providers that work toward increasing natural home and community connections for people with I/DD.
For more information, email RADSE@vayahealth.com.
RADSE Q&A
Some questions family members and providers/EORs should ask are:
- Is this about the participant’s wishes, desires, and needs, or is it about supplementing a family member’s income?
- As an adult, is it appropriate or best for the participant to be with their guardian or family member throughout the day?
- If a family member supports a person from birth into adulthood, does the person learn to adapt to different people and increase their flexibility and independence?
- If a participant 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 family as direct support staff expand the participant’s circle of support or risk shrinking it?
Providers and EORs must receive written approval from Vaya before employing a relative to provide services under the following circumstances:
- For a new or continuing RADSE to provide more than 40 total hours per week of CLS to a participant residing in the same home (e.g., RADSE provides 45 hours of CLS/week to the participant)
- For multiple RADSEs (whether new or continuing) to provide a combined total of more than 40 hours per week of CLS to a participant residing in the same home as the RADSEs (e.g., RADSE A provides 25 hours of CLS/week to the participant and RADSE B provides 20 hours of CLS/week to the same participant, for a combined total of 45 hours of CLS/week)
- For a new or continuing RADSE to provide more than 40 total hours per week of CLS to multiple participants residing in the same home (e.g., RADSE provides 25 hours of CLS/week to Participant A and 20 hours of CLS/week to Participant B, for a combined total of 45 hours of CLS/week)
Prior approval is also required if a participant who is supported by an approved relative in excess of 40 hours per week of CLS changes providers or moves to/from the EOR model. The new provider or EOR must request approval.
Requests for relatives to provide paid supports require documented efforts of attempts to find Direct Support Professionals through multiple providers. Relatives or legal guardians may not be reimbursed for any activity they would provide to a person of the same age who does not have a disability.
Employing a RADSE to provide 40 or fewer hours per week of CLS does not require prior approval. However, the provider or EOR must report the RADSE to the member’s Care Manager and ensure the member’s care plan includes the following information:
- The RADSE’s name
- The relationship of the RADSE to the participant
- The number of hours per week the RADSE provides CLS
The Innovations Waiver service provider or EOR must initiate the prior approval process through DocuSign: (1) at least five business days prior to a new RADSE requesting to provide services and (2) on an annual basis on or before the first day of the member’s birth month for a continuing RADSE.
Vaya reviews RADSE applications within 14 calendar days. We may pend our review for an additional 14 calendar days if additional information is needed. To check on the status of your request, email RADSE@vayahealth.com.
Vaya may require additional justification or documentation of efforts to locate non-relatives to deliver services. We will notify the provider/EOR of our decision in writing.
Please note the approval process for RADSE applications is separate from the service authorization process—service authorization does not mean a RADSE is approved, and approval of a RADSE does not mean the service is authorized. RADSE approval in one year does not guarantee approval in later years.
The North Carolina Office of Administrative Hearings has determined RADSE decisions are not appealable, but the provider/EOR or member may file a grievance by calling Vaya’s Member and Recipient Service Line at 1-800-962-9003, 7 a.m. to 6 p.m., Monday-Saturday.