The N.C. Innovations Waiver is designed to leverage existing natural and community supports while fostering the development of stronger natural support networks. This helps participants to 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 participant to stay in the home. NC Medicaid Clinical Coverage Policy No. 8P – NC Innovations allows providers or Employers of Record (EORs) to employ relatives to provide Community Living and Support (CLS) services 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 adults on the Innovations Waiver. It is our 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.
Vaya will review RaDSE data to inform network development decisions. Vaya is invested in ensuring a quality network of Innovations providers that, to the fullest extent possible, work toward increasing natural home and community connections for individuals with an IDD.
Some of the questions family members and you/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(s) or family members throughout the day?
- If a family member supports an individual from birth onward 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?
Please email questions about RaDSE requirements to RaDSE@vayahealth.com.
Innovations providers and EORs must acquire prior written approval from Vaya Health before employing a relative to provide services to a participant 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)
Requests for relatives to provide paid supports will require documented efforts of attempts to find direct support professionals through multiple Innovations providers. Ordinarily, a relative will not be approved to provide more than 40 hours of paid supports per week. The relative or legal guardian is not to be reimbursed for any activity that would be provided to a person without a disability of the same age. Additional paid supports by a relative may be authorized to the extent that another provider is not available or is necessary to assure the participant’s health and welfare.
Except in those circumstances described above, a provider employing a RaDSE to provide 40 or fewer hours per week of CLS to a waiver participant is not required to obtain prior approval. However, you must report the RaDSE to the Vaya-assigned care coordinator for the member and must ensure that the care plan includes the following information:
- The name of the RaDSE
- The relationship of the RaDSE to the waiver participant
- The number of hours per week of CLS waiver service being provided by the RaDSE
The procedure for prior approval must be initiated by the Innovations provider through DocuSign®: (1) at least five business days prior to a new RaDSE requesting to provide services and (2) on an annual basis, at least four calendar weeks prior to the start of the participant’s plan year for a continuing RaDSE. The form requires the Innovations provider to enter detailed information that will provide Vaya with all information necessary to approve or deny the request. Completion of the form will generate a prior approval request.
Prior approval is also required if a member who is supported by an approved relative in excess of 40 hours per week of CLS changes provider agencies or to or from the self-directed EOR model. The new provider agency/EOR must request the approval.
We will issue a decision within 14 days. If you do not receive a timely response to the request, please contact Vaya’s Provider Network Operations Department at email@example.com to determine the status of the request.
This form is required to be submitted annually and should be submitted simultaneously with the annual care plan. The approval process for RaDSE applications is separate and apart from the service authorization process, i.e., approval of service authorizations does not mean that RaDSE application is approved and vice versa, approval of the RaDSE application does not mean approval of service authorizations. Further, RaDSE approval in one year does not guarantee approval in subsequent years.
We will review location information and attestations indicated on the request form. Additional justification or documentation of efforts to locate non-relatives to deliver services may be required. Decisions will be based on this information. For approvals, the Innovations provider/EOR will receive the approved DocuSign® form. For denials, you/the EOR will receive the denied DocuSign® form and a formal letter that explains the decision. Rejections due to improper or incomplete requests will not be followed by a formal letter.
If the request is rejected because of improper or incomplete information, it may be resubmitted. Please note that the N.C. Office of Administrative Hearings has determined that RaDSE decisions are not appealable, but you or the participant may file a grievance by calling Vaya Customer Services at 1-800-849-6127.
You/the EOR is responsible for communicating Vaya’s RaDSE decision to the affected participant and relative. It is important to remember that relatives who are direct support professionals are employees of you/the EOR and must comply with all requirements applicable to provider staff. The Innovations-qualified professional is required to provide supervision as outlined in NC Medicaid Clinical Coverage Policy No. 8P – NC Innovations. Supervision includes clear communication regarding authorization for the relative to provide services.