Long-Term Community Supports (LTCS)
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Defines coverage, eligibility, service components, and utilization management for Long-Term Community Supports for adults with intellectual and/or developmental disabilities (I/DD) as an in-lieu-of Medicaid service under the Tailored Plan.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
inv-01: Initial Admission Criteria
Covered when ALL of the following are met
Evaluations within 5 years preferred; licensed psychologist/physician may supplement older evaluations
inv-02: Continued Stay Criteria
Continued authorization is indicated by ALL of the following OR any one of the alternatives
Active treatment required; not long‑term maintenance
inv-03: Discharge Criteria
Authorization termination indicated by one or more of the following
inv-04: Exclusions / Not Concurrently Authorized
inv-05: Covered with Criteria
Covered when services are person-centered, based on an evaluation and person-centered plan and meet one of the LTCS levels' requirements
See LTCS Level descriptions for specific staffing/setting details
inv-06: Termination of Continued Authorization
Continue authorization until one or more of the following discharge criteria are met:
LTCS members may not be concurrently authorized for specified services. Prohibited concurrent authorizations include any non‑Medicaid funded residential services, 1915(i) Community Living and Supports (for LTCS Levels 2–5), non‑Medicaid periodic I/DD services, ICF, CAP‑C or CAP‑DA, TBI Waiver services, and 1915(c) Innovations Waiver services. Respite may be used only to provide temporary relief for LTCS Level 1 and Level 3 members. Additionally, LTCS cannot be provided by a relative who resides in the member’s home or by the member’s legal guardian.
Concurrent authorization restrictions explicitly include 1915(i) Community Living and Supports for members at LTCS Levels 2–5. Providers and care teams must verify that members are not authorized for these listed waiver or non‑Medicaid residential services at the same time LTCS authorization is in place, as concurrent funding is not permitted.
Certain outpatient services are not considered part of a coverable LTCS meaningful day. Specifically, Outpatient services, Psychosocial Rehabilitation, and Supported Employment are excluded from being billed as LTCS meaningful Day Activities and must be billed separately from LTCS.
Requests for LTCS that are not individualized or that exceed the member’s needs are not appropriate. The requested service must be individualized, specific, and consistent with the member’s symptoms or confirmed diagnosis, must not exceed the member’s needs, and must be able to be safely furnished. The service must not be primarily for the convenience of the member, caregiver, or provider, and no equally effective, more conservative, or less costly statewide treatment should be available.
Billing, Codes, and Units
Provider Requirements and Operational Rules
Prior authorization required; unit limits apply
LTCS is an in‑lieu‑of Medicaid Tailored Plan service that requires prior authorization and is limited to one unit per day for Levels 2–5 and up to 5 units per week for Level 1. Continued authorization is contingent on meeting the continued stay criteria.
- One unit per day for LTCS Levels 2–5.
- Up to 5 units per week for LTCS Level 1.
- Continued authorization requires meeting continued stay criteria.
NCTracks enrollment required
Providers must be enrolled in NCTracks as a Medicaid‑eligible provider and maintain that enrollment to provide LTCS services.
Active treatment required
LTCS is available only for individuals who are eligible for Tailored Plan Medicaid and who are in need of and receiving active treatment — an aggressive, consistent program of specialized and generic training, treatment, and integrated health services.
- Member must be eligible for Tailored Plan Medicaid Managed Care.
- Service is limited to individuals receiving active treatment (specialized/generic training, treatment, integrated health services).
Discharge/termination must follow specified criteria
Termination of continued authorization must be based on the program's discharge criteria such as improved level of functioning/achievement of service plan goals, lack of benefit or exhaustion of realistic treatment options, regression, or the individual's choice to discontinue the service.
- A. Improved functioning or no longer benefits from the service (goals met).
- B. Achieved goals and discharge to a lower level indicated or member elects to stay as a boarder paying rent/room and board.
- C. Not making progress or regressing with all realistic treatment options exhausted or member retires from active treatment.
- D. Individual no longer desires the service.
Complete unified PCP/ISP and include psychological evaluation
A unified Person‑Centered Plan (PCP/ISP) must be completed for each member and must include the amount, duration, and frequency of LTCS; if the member has multiple services, all providers must be reflected on one unified plan. A current psychological evaluation (within 5 years) documenting functional eligibility for ICF‑IID must be submitted when the member has an intellectual disability.
- PCP/ISP must state amount, duration, and frequency of LTCS.
- All providers for a member must be included on one unified plan when multiple services are provided.
- If diagnosed with intellectual disability, submit a current psychological evaluation (within 5 years) documenting ICF‑IID functional eligibility; licensed psychologist/physician may supplement older evaluations.
Document LTCS per DMH/DD/SAS RMDM (daily note required)
LTCS services must be properly and contemporaneously documented in accordance with the DMH/DD/SAS Records Management and Documentation Manual (RMDM) 45‑2; a daily service note is required and must include the items listed in Chapter 7 of the RMDM. Significant events requiring additional activities or interventions must be documented beyond minimum note contents. Yearly re‑evaluation of level of care is required.
- Document per RMDM 45‑2 prior to seeking reimbursement.
- Daily service note must include items 1–12 under Contents of a Service Note, Chapter 7 of the RMDM.
- Document significant events and additional interventions beyond minimum frequency when they occur.
- Conduct yearly re‑evaluation of level of care.
Obtain valid service order before first billable day
A valid service order must be in place prior to or on the day the service is first provided; without a valid service order the provider cannot bill Medicaid for the service, even if the individual is retroactively eligible.
- Initial service orders may be written by MD, DO, licensed psychologist, NP, or PA.
- Service orders are valid for one year from the date of last required signature on the PCP/ISP; annual/continued orders may be signed by a QP.
- Follow DMHDDSAS guidance on signatures and dates of plan.
Concurrent authorization restrictions — certain residential and waiver services excluded
LTCS may not be concurrently authorized with certain non‑Medicaid residential services, 1915(i) Community Living and Supports for Levels 2–5, non‑Medicaid periodic I/DD services, ICF, CAP‑C/CAP‑DA, TBI Waiver services, or 1915(c) Innovations Waiver services; authorization may be denied if concurrently authorized with these excluded services. Respite may be used temporarily for LTCS Level 1 and 3 members.
- Prohibited concurrent authorizations include non‑Medicaid funded residential services, 1915(i) CLS (for Levels 2–5), non‑Medicaid periodic I/DD services, ICF, CAP‑C/CAP‑DA, TBI Waiver, and 1915(c) Innovations Waiver.
- LTCS cannot be provided by a relative residing in the member's home or by the member's legal guardian.
- Respite may be used temporarily for LTCS Level 1 and Level 3 members.
Definitions and Service Concepts
Background and Scope
Long‑Term Community Supports (LTCS) provides active treatment and skills training for adults with intellectual and/or developmental disabilities (I/DD) to support living in the community. LTCS is intended as an alternative to institutional care (ICF‑IID) or as an option when Innovations waiver slots are unavailable. Services focus on acquisition, retention, and improvement of daily living and socialization skills, and must be delivered as part of a person‑centered plan that documents active treatment goals and measurable progress.
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