CurrentAlliance HealthPolicy 8H-5

Community Living and Supports

Defines Medicaid coverage, eligibility, and requirements for 1915(i) Community Living and Supports (CLS) services for beneficiaries with I/DD or TBI in North Carolina.

Policy Summary

PayerAlliance Health

PolicyCommunity Living and Supports

Policy CodePolicy 8H-5

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior approval and submit required supporting documentation (independent evaluation, assessment, service order, and authorization request) before providing CLS services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3+min age

1915(i)authority

I/DD or TBIdiagnoses

≤15 hrs/wkschool-session limit

≤28 hrs/wknon-school/22+ limit

18+min staff age

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Coverage Criteria for Community Living and Supports (1915(i))

Medicaid Additional Criteria Covered

Medicaid shall cover Community Living and Supports when ALL following criteria are met:

ALL of the following

The beneficiary is ages 3 or above.
One of the following diagnoses
- I/DD as defined currently in section 1.1.
- A DSM-5 (or later) diagnosis of Intellectual Disability (ID), Unspecified ID, or Autism Spectrum Disorder (ASD).
- A genetically diagnosed syndrome that is typically associated with I/DD (e.g., Down Syndrome).
- Traumatic Brain Injury (TBI) as defined in section 1.1: An injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment, involving an open or closed head injury, may include multiple concussions, with or without loss of consciousness, causing impairments in cognition, language, memory, attention, reasoning, judgment, problem-solving, sensory/perceptual/motor abilities, psychosocial behavior, physical functions, information processing, or speech; excludes congenital or degenerative brain injuries.
The beneficiary can benefit from skill acquisition, monitoring and/or supervision (beyond what is expected of natural supports) in one or more areas: interpersonal, independent living, community living, self-care, self-determination; or assistance/monitoring for a health condition, nutrition or physical condition, incidental supervision, daily living skills, community participation, or interpersonal interactions.

Admission Criteria

ALL of the following

A standardized independent evaluation completed by the Division of Health Benefits to determine beneficiary eligibility for the 1915(i) benefit based on needs-based criteria.
An Independent Assessment completed by a tailored care manager or the Cherokee Indian Hospital Authority (CHIA) for Tribal members that indicates the beneficiary would benefit from Community Living and Supports.

Continued Stay Criteria

ALL of the following

The beneficiary continues to meet Admission Criteria for service.
The beneficiary requires assistance with at least one functional deficit and can benefit from either skill acquisition in at least one area (interpersonal, independent living, community living, self-care, self-determination) or assistance in monitoring a health condition, nutrition or physical condition, incidental supervision, daily living skills, community participation, or interpersonal skills.

Transition and Discharge Criteria

The beneficiary meets the criteria for discharge if any ONE of the following applies:

ANY of the following

The beneficiary no longer meets Admission Criteria for service.
The beneficiary no longer requires assistance with at least one functional deficit.
The beneficiary has requested discharge.
The beneficiary is enrolled in an NC Medicaid Home and Community Based Services Waiver.

Coverage conditions

Coverage conditions and provider/staffing requirements for Community Living and Supports (1915(i)):

ALL of the following

Transportation to and from the school setting is not covered and is the responsibility of the school system. Community Living and Supports provide transportation only to and from the beneficiary's primary private residence or any community location where the beneficiary is receiving services.
Incidental housekeeping and meal preparation for other household members is not covered under Community Living and Supports.
A beneficiary who receives 1915(i) Community Living and Supports shall not concurrently receive services through a 1915(c) waiver.
Relatives who live in the same primary private residence as a beneficiary under 18 years old cannot provide Community Living and Supports. Relatives living in the same primary residence as a beneficiary over 18 years old may provide services if they meet required staffing qualifications.

Coding, Units, and Service Limits

Units and billing incrementsmixed

15 minutes

Units are 15-minute increments.

Covered HCPCS CodesHCPCSCovered

T2012	Community Living and Supports only in the community non-EVV
T2013	Community Living and Supports

Modifiers referencedModifier

U4	Modifier referenced for Community Living and Supports (only in the community, non-EVV)
TF	Modifier referenced for Community Living and Supports Group/Individual subject to EVV
HQ	Modifier referenced for Community Living and Supports Group (subject to EVV)
GC	Modifier referenced for Community Living and Supports relative as provider lives in home (non-EVV)

Weekly service hour limits

When school is in sessionUp to 15 hours per week (60 units)

When school is not in sessionUp to 28 hours per week (112 units)

Beneficiaries age 22+ or eligible after graduationMay be authorized up to 28 hours per week (112 units)

Combined CLS + Supported Employment capCLS and 1915(i) Supported Employment together cannot exceed 40 hours per week

Minimum staff age

Minimum staff age18 years

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Required

Prior approval is required before rendering the service. For beneficiaries under age 21 (EPSDT), the requirement for prior approval remains — EPSDT does not waive the prior approval process. Submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor (or Cherokee Indian Hospital Authority where applicable) as described in NCTracks guidance.

Prior approval required for Community Living and Supports
EPSDT (beneficiaries <21) still requires prior approval — EPSDT may allow exceptions to policy limits but not to prior approval
Submit prior approval request and supporting records to the DHHS Utilization Review Contractor or Cherokee Indian Hospital Authority

Billing Rule

Claims and Billing Compliance

Background on Community Living and Supports

Community Living and Supports (CLS) is a 1915(i) habilitative service delivered by paraprofessionals intended to help beneficiaries learn or maintain daily living and community skills, provide supervision and assistance, and monitor health or nutrition. The service supports increased independence, community participation, and the ability to live in a private residence by teaching new skills, reinforcing existing skills, and offering supervision beyond natural supports.

Key Definitions

Community Living and Supports (CLS) definition

Service type1915(i) individualized or group habilitative service to enable living in a primary private residence and community integration

Primary purposeAssist beneficiaries to learn new skills, practice or improve existing skills, and provide supervision/assistance to complete activities to their level of independence

Supported activitiesIndependent living, community living, self-care, self-determination; monitoring health, nutrition, or physical condition; incidental supervision; daily living skills; community participation; interpersonal skills

Traumatic Brain Injury (TBI) definition

Core definitionInjury to the brain from external physical force causing functional disability or psychosocial impairment; includes open or closed head injury and may include multiple concussions

Clinical features

Level of Care and Service Setting Criteria

Treatment Modalities Covered

Service Frequency and Visit Limits

Community Living and Supports; combined with Supported Employment limits

Weekly limits when school is in sessionUp to 15 hours per week (60 units)

Weekly limits when school is not in session or for beneficiaries 22+Up to 28 hours per week (112 units)

Combined CLS + Supported Employment limitCLS and Supported Employment together cannot exceed 40 hours per week

Group size limitCLS Group size cannot exceed 3 beneficiaries per 1 staff (3:1)

Community Living and Supports — follow PIHP billing guidelines

Follow PIHP billing guidelinesProviders must follow PIHP billing guidelines for Community Living and Supports reimbursement and billing units

Policy Summary

PayerAlliance Health

PolicyCommunity Living and Supports

Policy CodePolicy 8H-5

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior approval and submit required supporting documentation (independent evaluation, assessment, service order, and authorization request) before providing CLS services.

SourceLink

On This Page

Services are not covered when the beneficiary does not meet eligibility requirements (Section 2.0) or the criteria in Section 3.0, when the service duplicates another provider's service, or when the procedure/product/service is experimental, investigational, or part of a clinical trial.

Providers: An I/DD or TBI agency contracted with the Tailored Plan and PIHP must be a legally constituted entity capable of meeting all requirements of the Tailored Plan and PIHP and must have the capacity and adequate workforce to offer services at times that meet beneficiary needs (including evenings/weekends as needed).

Staff requirements: Services must be under the supervision of a Qualified Professional (QP) meeting 10A NCAC 27G .0104 (19). Staff must complete special population training as appropriate (I/DD, geriatric, TBI, deaf/hard of hearing, co-occurring conditions). Agency staff must be at least 18 years old; if providing transportation, have a valid driver's license, safe driving record, and automobile liability insurance; have a criminal background check that presents no health and safety risk; not be listed in the North Carolina Health Care Personnel Registry; be trained in CPR and First Aid; be qualified in the beneficiary's customized needs and supervised by a QP with at least 2 years' experience working with the population; have a high school diploma or GED; and paraprofessional supervision must meet 10A NCAC 27G.0204 requirements and applicable licensure/certification.

Driver requirements for staff providing transportationValid NC or other valid driver’s license, safe driving record, and automobile liability insurance

Education requirementHigh school diploma or high school equivalency (GED)

Background checkCriminal background check must present no health and safety risk to beneficiary

Providers must follow NCTracks billing procedures, the NCTracks Provider Claims and Billing Assistance Guide, applicable Medicaid fee schedules, NC Medicaid clinical coverage policies, and any relevant PIHP/tribal billing guidelines. Institutional claims should follow National Uniform Billing Guidelines; professional claims use CMS-1500/837P formats. Federally recognized tribal and IHS providers may have applicable exemptions by law.

Use NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
Follow Medicaid bulletins, fee schedules, and clinical coverage policies
Bill institutional claims per National Uniform Billing Guidelines; professional claims via CMS-1500/837P

Denial Risk

Eligibility and Prior Approval Risks

Verify beneficiary eligibility at each visit. Failure to verify enrollment or rendering services to an ineligible beneficiary may result in claim denial or recoupment. Providers should confirm eligibility and any service restrictions associated with the beneficiary's eligibility category before providing or billing the service.

Verify Medicaid eligibility for each date of service
Services may be restricted by beneficiary's eligibility category — confirm coverage prior to provision

Denial Risk

General Denial Triggers

Claims may be denied for a variety of reasons including non‑eligibility, failure to meet the policy's medical necessity criteria, duplicate services, services that are experimental or part of a clinical trial, or when required prior approval was not obtained.

Non‑eligibility or service restrictions
Service does not meet medical necessity/criteria in Section 3.0
Duplicate billing for the same service by another provider
Service deemed experimental, investigational, or part of a clinical trial
Prior approval not obtained when required

Documentation Required

Service Documentation Requirements

Providers must maintain complete, dated, and signed documentation for each billed service. The individual who provided the service is responsible for documenting and signing the entry; the signature must include credentials or job title. Documentation must support medical necessity and the elements required by this policy.

Staff member who provided the service must sign and date entries and include credentials or job title
Documentation must support medical necessity and connection to the beneficiary's service plan and rehabilitative goals
Maintain records supporting prior approval requests and clinical criteria

Documentation Required

Service Note / Grid Requirements

A full service note or grid is required for each date of service and must be written and signed by the person who provided the service. Each note/grid must include: beneficiary name, Medicaid ID, date of service, name and place of service, purpose of contact tied to the person-centered or individual support plan, detailed description of the intervention (matching the time billed), duration/amount of time, assessment of effectiveness and progress toward goals, and dated signature with credentials/job title.

Beneficiary name and Medicaid identification number
Month/day/year of service provision
Name of service provided and place of service
Purpose of contact as it relates to the person-centered plan or individual support plan goals
Description of the intervention provided reflecting activities and duration
Duration of service (time spent)
Assessment of intervention effectiveness and beneficiary progress toward goals
Dated signature with credentials or job title of the staff member who provided the service

Note

Conservative‑Treatment Consideration

Conservative‑treatment options must be considered. Services are covered only when individualized, medically necessary, consistent with diagnosis and not in excess of needs, and when no equally effective, more conservative or less costly statewide alternative exists.

Service must be individualized and consistent with confirmed diagnosis
No equally effective and more conservative or less costly statewide alternative available

Prior Authorization

Authorization Clinical Requirements

Authorizations are granted based on documented medical necessity and must be directly related to the beneficiary's diagnostic and clinical needs and expected to achieve specific rehabilitative goals in the service plan. Medical necessity is evaluated against North Carolina community practice standards by the DHHS Utilization Management Review Contractor or Cherokee Indian Hospital Authority. Submit required assessment, independent evaluation, service order, and NC Medicaid authorization request form with the authorization request.

Authorizations require documentation of medical necessity and relation to service plan rehabilitative goals
Medical necessity determined by NC community practice standards as reviewed by the UM Review Contractor or Cherokee Indian Hospital Authority
Include individual assessment, independent evaluation, service order, and NC Medicaid authorization request form when requesting authorization

May occur with or without loss of consciousness and results in impairments in cognition, language, memory, attention, reasoning, judgement, problem-solving, sensory/perceptual/motor abilities, psychosocial behavior, physical functions, information processing, or speech

ExclusionsDoes not include brain injuries that are congenital or degenerative

Intellectual or Developmental Disability (I/DD) definition

Age of onsetDiagnosed or becomes obvious before age 22

Nature and durationSevere, chronic disability likely to continue indefinitely

Functional impactSubstantially impacts functioning in three or more areas (self-care, language, learning, mobility, self-direction, independent living, economic self-sufficiency)

Meaningful Day Services definition

MeaningHabilitative or rehabilitative services focused on keeping, learning, or improving skills and functioning for daily living

Relation to CLSMeaningful Day Services are the habilitative/rehabilitative focus that CLS and Supported Employment can provide as day options

Intended outcomeImprove or maintain daily living skills and community participation

Eligible diagnoses/conditions — age and diagnostic criteria

Minimum beneficiary ageAges 3 and above

Eligible diagnostic categoriesIntellectual or Developmental Disability (I/DD) per policy, DSM-5 diagnosis of ID/Unspecified ID/ASD, or a genetically diagnosed syndrome typically associated with I/DD (e.g., Down syndrome)

Traumatic Brain Injury eligibilityTraumatic Brain Injury (TBI) as defined in policy is eligible (external physical force, non-congenital/degenerative)

Functional requirementBeneficiary must be able to benefit from skill acquisition, monitoring and/or supervision beyond natural supports in one or more listed areas

Qualified Professional (QP) — supervision requirements

Supervision requirementCommunity Living and Supports must be under the supervision of a Qualified Professional (QP) meeting 10A NCAC 27G .0104 (19)

QP experienceQP must provide supervision and have at least 2 years' experience working with the population served focused on IDD or TBI services for paraprofessional supervision

Staff supervision standardSupervision of paraprofessionals must follow 10A NCAC 27G.0204 (b)(c)(f) and applicable licensure/certification requirements

T2012 / T2013 — HCPCS code references and distinctions

T2012 descriptionHCPCS T2012 — Community Living and Supports only in the community, non-EVV

T2013 descriptionHCPCS T2013 — Community Living and Supports (used for EVV-subject services and other variants)

Modifier usagePolicy specifies modifiers (e.g., U4, TF, HQ, GC) to denote non-EVV, group, individual, or relative-as-provider scenarios

Billing codes and specificityReport the most specific CPT/HCPCS code that accurately describes the service; T2012 and T2013 are referenced for CLS

Tribal/IHS providersFederally recognized Tribal or IHS providers may be entitled to alternate reimbursement methodologies under federal law