NC Medicaid Managed Care Behavioral Health &
Intellectual/Developmental Disabilities Tailored Plan
Innovations Waiver Member Handbook
Introduction to the NC Innovations Waiver
As an NC Innovations waiver participant, certain community-based services and supports are available to help you live and take part in the many activities in your community. These services help you create and maintain relationships with family and friends. North Carolina supports serving individuals with disabilities in the least restrictive and most inclusive settings possible. We use a person-centered planning process to figure out the best way to do this. These settings may be different for NC Innovations waiver participants because of their choices and the supports they need to live in the community.
This handbook helps you understand the services and supports available through the NC Innovations waiver and your rights as a participant in this program. It is important that you know and understand your rights so you can make sure they are followed and enforced. Along with your rights come certain responsibilities. This handbook discusses:
- The purposes and goals of the NC Innovations waiver;
- The processes in place to support and serve you; and
- How to address potential problems you may face.
We recommend that you read this as a guide to the NC Innovations waiver alongside any other materials about the Innovations waiver program.
This section of the handbook gives you:
- Purpose and goals of the NC Innovations waiver.
- Basic services provided by the NC Innovations waiver.
If there is a conflict between what is included in this handbook and the NC Innovations waiver, the NC Innovations waiver will apply.
Purposes and Goals of the NC Innovations Waiver
The NC Innovations waiver provides home and community-based services and supports to allow participants to make their own choices and participate in their communities. The goals of the NC Innovations waiver are to:
- Promote dignity and treat with you with respect
- Allow you to choose your services and say no
- Support you to live and work within your community.
- Support where you choose to live.
- Support your right to take part in community activities.
- Provide you opportunities to find employment and work side by side with everyone else
- Give you the opportunity to make meaningful life choices and decisions.
- Support you to choose and direct your services and to support you in developing an Individual Support Plan (ISP).
- Support your right to privacy, which includes:
- The chance to have private living and sleeping spaces
- Having privacy when visiting with family and friends
- Being able to be alone
- Protect you from neglect, harm, other people taking advantage of you and any abuse or actions that make you feel unsafe.
Freedom of Choice
If you choose to get NC Innovations Waiver services, this means you are choosing to receive services in the community rather than placement in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) institutional facility. As part of the initial and annual Individual Support Plan (ISP) process, you will sign a “Freedom of Choice Statement” to receive or continue receiving NC Innovation Waiver services. You are free to choose between ICF-IID institutional services and NC Innovations Waiver services. Individuals receiving NC Innovation Waiver services may choose providers within the Trillium network and may change providers at any time.
NC Innovations Participant Responsibilities
As an NC Innovations waiver participant, you also have some responsibilities. Your care manager will help you review and sign the Participant Responsibilities form. This form lists the responsibilities of each person participating in the NC Innovations waiver, and important policies each person needs to be aware of before they agree to participate. Your care manager will discuss your responsibilities with you when you enter the NC Innovations waiver and each year you continue to receive services.
- If you do not follow NC Innovations waiver requirements, you may lose NC Innovations waiver funding and services. The form is signed each year you participate.
Basic Features of the NC Innovations Waiver
Tailored Care Management
Each individual getting NC Innovations waiver services will receive either tailored care management or care coordinator services. A care manager is a trained health professional who works with you, your doctors and other waiver service providers to make sure you get the right care when and where you need it and are based in Trillium or in a provider agency. Trillium will give you a single care manager who is trained to manage your care and address all your needs, including physical health, behavioral health, traumatic brain injury (TBI), intellectual/developmental disabilities (I/DD), NC Innovations waiver services, pharmacy, long-term services and supports, and other health-related needs. NC Innovations waiver participants have the choice to keep their current care coordinator if the care coordinator meets Trillium care manager requirements. For more information on tailored care management, see the Trillium Tailored Plan Member Handbook section “Services Covered by Trillium’s Network” or call Member and Recipient Services with questions at 1-877-685-2415.
If you decide to leave Trillium tailored care management, you can continue to get NC Innovations waiver services and Trillium will provide a care coordinator to help you access NC Innovation Waiver services. While a care manager can help you with all of your health needs, a care coordinator works specifically on getting you NC Innovations waiver services. You may have only a care coordinator or a care manager, but not both.
It is important you stay in contact with your care manager about changes in your needs and notify them immediately of emergency happenings that may affect your life and could require a change in your Individual Support Plan (ISP). Emergencies may include serious changes in your health or the health of your primary caregiver, the need for assistance following your own hospital stay or the death of your primary caregiver. Emergency situations can also include natural disasters such as hurricanes, tornados, floods and fires.
Your care manager can help you:
- Identify your needs to get services and create an ISP that lists your goals and ways to reach those goals;
- Find information about services available in the community;
- Monitor your services to make sure they meet your needs and you are happy with them;
- Stay safe and healthy;
- Get information on how to direct your services; and
- Work through problems or complaints about services or crisis situations, if needed.
Individual Support Plan (ISP)
As an NC Innovations waiver participant, you will have an ISP that includes important information about you, your life goals, and the services and supports needed to help you reach your goals. The planning process identifies your strengths, abilities, wishes and support needs, and helps you develop a health plan for your life.
Trillium includes information on how you can reach your goals through the combined support of NC Innovations waiver services, family and friends, and the use of community supports. You, along with your planning team, will create your ISP and revise it as you progress or your needs change. More information on the ISP section.
Quality Monitoring and Improvement
We want to make sure you are happy with the services and care that you are getting, and that they are helping you meet your Individual Support Plan (ISP) goals. Trillium, along with state and federal government departments, monitor the use of waiver funding to make sure it helps meet your goals and that you are safe and healthy.
As you participate in the NC Innovations waiver, you and your family or guardian will be asked to participate in in some or all of the following quality processes:
- Tailored care management monitoring visits to your home and other places you receive services;
- Individual satisfaction surveys; and
- Reviews of the services you receive from Trillium.
Re-Enrollment in NC Innovations Waiver
NC Innovations waiver operates on a “waiver year,” which runs from July 1 through June 30. If you leave the NC Innovations waiver during the waiver year, you may re-enter the NC Innovations waiver if you re-enter before the current waiver year ends, provided that you continue to meet NC Innovations waiver requirements. Your care manager can help you with this process if needed.
If you leave the NC Innovations waiver and return after the current waiver year has ended, you may be unable to enter the NC Innovations waiver right away. If funding is not available, you will be placed on the Registry of Unmet Needs, also known as the “Innovations waitlist.”
Individuals who want to leave the Trillium and move to another Medicaid health care option outside of the Tailored Plan must leave the NC Innovations waiver first, unless you are a Tribal member and move to NC Medica. More information on how to change your health plan can be found in the Trillium Tailored Plan Member Handbook on section “Changes to Your Health Care Option (Disenrollment)” or on our webpage NC Innovations Waiver. Your care manager can also answer any questions you may have.
Services and Supports From The Community And The Individual Support Plan
You will be involved in a person-centered planning process to help determine what services and supports you will receive in the community. Person-centered planning puts you at the center of the process and focuses on your strengths, interests and needs. The planning process allows you to make your own choices about your care and the services you receive in the community. You will have many chances to share what you think and how you feel.
Supports Intensity Scale™ (SIS)
As the first step in the person-centered planning process, the Trillium will arrange for your services and support needs to be identified using the Supports Intensity Scale™ (SIS). The SIS is an interview that focuses on the support needs of a person with an intellectual disability. You assist in this assessment by determining the people, referred to as respondents, who, along with yourself, will be interviewed during the SIS. The SIS is done at least every 3 years for adults and every 2 years for children (age 16 and younger) who participate in the NC Innovations waiver.
The SIS is only one way to think about your support needs. The results from the SIS may be used to determine the amount of services you receive, but the results are not binding. Trillium must also look at and consider all evidence of your other needs.
After a new SIS is completed, Trillium will send you a mailing that includes:
- Results of your SIS
- How to raise concerns with Trillium on the process and findings. NC Innovations waiver participants are able to talk about the results of the SIS with Trillium. If Trillium decides that the SIS results do not completely capture the participant’s supports needs, Trillium can correct the error. Waiver participants can also file an appeal about the SIS findings. Additional information on the appeal process can be found in the Trillium Member Handbook in section “Medicaid Service Appeals.”
If something is not correct in the findings from you SIS, you can discuss your concerns with your care manager and guardian, if applicable. If you believe your support needs have changed, you should also talk with your care manager.
Risk/Support Needs Assessment
A Risk/Support Needs Assessment is completed by your care manager with input from you, your family, and other team members. Your care manager makes sure these risks/needs are addressed in your ISP and as needed, in a crisis plan. Potential risks and safety considerations can include health, medical, and behavioral areas of concern.
Individual Support Plan
The sections below have information on how to develop, approve, appeal and change your individual support plan (ISP).
Individual Support Plan Development
Your care manager works with you to develop an ISP. In your ISP, you set goals for living in the community and determine what supports you need to meet your goals. Your ISP lists NC Innovations waiver program services, and other NC Medicaid services and informal supports. If there is more than 1 provider who can provide a service, you are involved in choosing the provider you want from available NC Innovations waiver providers and determining the schedule for the services you choose.
To create your ISP, you care manager will:
- Ask you, your family and your guardian, if applicable, who you want included in your planning team and what part you want to take in leading the planning meeting, and
- Document the results of your planning meeting after the team develops the ISP.
Your ISP should:
- Be clear to you and the important individuals supporting you.
- Identify the services and supports (paid and unpaid) that will help you achieve the goals you identified, and the providers of those services and supports, including family and friends.
- Include a schedule of when you need support and the kinds of support you need at different times of day.
- Clearly demonstrate medical necessity for services you need.
- Be shared with you and other people involved in the plan.
- Help identify risks that are present and ways to address them.
- Reflect the decisions you make.
- Be respectful of you and those who support you.
- Assist you and the people who support you to find information easily.
- Identify how required emergency back-up services will be furnished for direct support provider providing your services.
- Not allow for services that are not needed or inappropriate to be provided.
Individual Support Plan Approval
When your ISP is completed, you (or your guardian, if applicable) will be asked to sign it. If the ISP is missing information, or you or your guardian have any concerns, talk with your care manager. You cannot receive NC Innovations waiver services if you do not have an approved ISP. Your care manager submits the ISP to Trillium Utilization Management and requests approval of the services in the ISP. The ISP approval process is separate from the service approval. Not all services are approved on an annual basis.
The Trillium’s Utilization Management Department has 14 days to review the ISP and approve it, deny it or request additional information. If additional information is requested, then up to an additional 14 days may be needed to complete the review. You will receive a letter notifying you if additional information has been requested. You will receive a copy of your ISP.
Appealing Individual Support Plan Decisions
You have the right to appeal a decision, action, or inaction about your ISP. For example, you can appeal if Trillium Utilization Management:
- Denies your service request.
- Does not act on your service request within 14 days of receiving it if no additional information was requested.
- Denies your choice of an available provider to provide services.
- Reduces the services that are within your ISP.
- Changes the services that are within your ISP.
- Stops the services that are within your ISP.
Your care manager and Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY can tell you more about the appeal process. See the Trillium Tailored Plan Member Handbook for more information on the appeal process.
Changing the Individual Support Plan
You will review your ISP with your care manager to make sure that the ISP still reflects your goals, needs and supports to attain your goals. This review will occur once every year and when there is a need to make a change. A change in services may happen if there is a change to your goals or support needs, or may be due to your experiences.
You or your legal representative review and sign the document when the ISP is developed and when a change to the ISP is made.
You can request to make updates to your ISP with the care manager at any time.
Starting Your Individual Support Plan Services
Implementation of the ISP is a shared responsibility of you, your family members and the members of your planning team. Services must start within 45 calendar days of initial ISP approval.
After Your Individual Support Plan is Approved
- The provider agency of your choice develops short-term goals and ways to help the agency staff support you to consistently meet longer-term goals.
- Back-up staffing will be identified in the event that your direct support provider is unavailable.
Choosing NC Innovations Waiver Services
Each NC Innovations waiver participant can choose the services and supports they want to receive, the provider they want to receive the services from and, for certain services, how they want to manage their services. Work with your care manager to choose the NC Innovations waiver services that will best meet your needs.
When developing your ISP, remember that NC Innovations waiver services are not supposed to replace or double services and resources that are already available to you. Non-paid supports are an important part of everyday life and Medicaid services are not supposed to replace supports that are currently working for you. Non-paid supports are people who provide support, care and help without payment for that support, and can include parents, spouses, siblings, children, extended family members, neighbors, church members and coworkers.
Limitations on Services
NC Innovations waiver services help you continue living in and participating as an active member of your home community. It is important to understand there are special limitations on services. You cannot go above the limit in any category of service or the limits described in the Limits on Sets of Services listed in Appendix B. The total of your base and “add-on” services cannot exceed the NC Innovations waiver cost limit of $135,000 per year, with the following exceptions:
- NC Innovations beneficiaries may exceed $135,000 NC Innovations waiver cost limit to ensure health, safety and wellbeing, if the following criteria is met:
- Individual lives independently without their family in a home that they own, rent or lease; and
- Individual receives Supported Living Level III, and
- ndividual requires 24-hour support. Individuals requesting services and supports in excess of the $135,000 cost limit must make this request through the ISP or follow the ISP update process (reference section Changing the Individual Support Plan.
- Services and supports that exceed $135,000 must be first approved by Trillium and must be related to the participant’s needs and not for the convenience of the provider agency or caregiver.
- If another Medicaid or other available service will meet your needs instead of an NC Innovations waiver service, the other service must be used.
- Your care manager will help you understand the limits on your services. These limits also include services that:
- Cannot be provided at the same time of day as other services
- Cannot be provided on the same day as other services
- Cannot be provided if you receive other services
- Can only be provided if you self-direct services, refer to the section Choosing How to Receive Your Services
- Have spending limits per year or over the duration of the NC Innovations waiver (5 years)
- Cannot be provided in certain locations
Services for School-Aged Individuals
School-aged individuals ages 3 through 21 can get NC Innovations waiver services outside of school hours or during school hours if the student attends a private school. Your care manager can share additional information on when and where NC Innovations waiver services can be provided to individuals ages 3 through 21.
Your care manager will help you understand the limits of your services, depending on the individual’s age and if school is in session, which include no more than a set number of hours of the combination of the following:
- Community networking
- Day supports
- Supported employment services
- Community living and supports
It is important to understand there are special limitations on services. You cannot go above limits in any category of service or the limits described in the Limits on Sets of Services listed in Appendix B.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s Comprehensive Child Health Program for individuals under age 21. EPSDT is authorized under the Medicaid Act and includes periodic screening of children, including vision, dental and hearing services. The Act requires any medically necessary health care service that is listed in the Act be provided to an EPSDT beneficiary even if the state Medicaid plan does not cover those services. Your care manager can provide you with additional information about EPSDT.
Equipment and Supplies
If you need equipment or supplies, discuss your needs with your care manager. Your care manager can help you get the equipment and supplies you need. NC Innovations waiver funds cannot pay for equipment or supplies covered by your private health insurance, Medicare, TRICARE or NC Medicaid. For more information on durable medical equipment available under Medicaid, visit the webpage Durable Medical Equipment.
Some equipment and supplies are covered under specific NC Innovations waiver services. Each service has categories of coverable items and how they are approved. Because gathering the information needed for approval takes time, you should let your care manager know your needs as soon as possible so the needed items can be added to your ISP and the supporting documentation obtained.
Your care manager can help you try to locate another way to pay for an item or supply that is not otherwise covered through NC Medicaid, the NC Innovations waiver, your private health insurance or Medicare.
Location of Services
You can get services at locations that best meet your needs. Some services must be provided at a specific location. See the Service Definitions section for specific information about any limitation where a service can be provided.
In very special cases, you, your planning team or both may decide that you should receive periodic services in the home of a direct support provider.
There is a special process that the network provider agency must complete with your approval before you can receive services in the direct care worker’s home. Your care manager can answer any questions you may have on the process.
Services in Residential Settings
If you are new to the NC Innovations waiver or are an existing participant, you may live in a private home or residential setting that meets the NC Innovations waiver criteria.
Choosing How You Receive Your Services
You can choose how to receive services when you choose them as part of the ISP process. You can choose to receive your services in one of two ways:
- Provider-directed Services. Choosing a network provider agency to deliver your services.
- Individual and Family-directed Services. You can choose one of two options for these services.
- Employer of Record Option: You can hire and manage workers who help you and you can get help from a financial support services agency offered to NC Innovation Waiver participants who choose this option. Employer of record supports are provided to ensure funds for self-directed services are managed and distributed correctly.
- Agency with Choice Option: You can self-direct your services by training and supervising workers with the help of a network provider agency.
Please note that not all services are available to be self-directed.
It is also important to know you may also self-direct some services and get other services through a provider agency.
Individual and Family-Directed Services
“Self-direction” is when you choose who provides your services, set your provider’s schedule, and decide what tasks your provider performs. The Service Definition section indicates which services may be self-directed.
Trillium understands that individuals and their families may need help deciding whether to self-direct services and how to choose who provides services. Your care manager and Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY can tell you more about the individual and family-directed services option, and help you develop the skills needed to direct services.
If you feel that you could benefit from additional services/supports, you should ask your Care Manager (who can be reached by calling Member and Recipient Services Line at 1-877-685-2415 or for TTY dial 711 about the other services you may be eligible for that could meet your needs. The available services will vary from person to person.
Choosing Who Provides Your Services
Trillium maintains and monitors a network of qualified provider agencies for NC Innovations Waiver services. You choose the provider agency in the network to deliver your services. Trillium monitors the provider agency to make sure it protects your health and safety, and that you are happy with the care you receive.
Trillium’s NC Innovations waiver provider network agency you choose has responsibilities, including:
- Working with you, your family and your care manager to develop your ISP
- Hiring, training and supervising staff who provide direct waiver services
- Developing short-term goals, and ways to achieve your goals
- Monitoring services to ensure they are consistent with your ISP
- Notifying the care manager of significant changes in your situation, needs and service delivery
During the development of your ISP, you decide which service provider best meets your needs. Your care manager provides you with a list of approved providers in your area who offer the services you need. You decide which ones will be the best for you.
You may choose your provider agency from Trillium’s network providers. If your needs cannot be met by 1 of these providers, Trillium may contract with an out-of-network provider.
Service definitions are included in the handbook. Your care manager can also provide additional information about any service. Your care manager can provide a copy of definitions for the services you are receiving, including if you are self-directing
Assistive Technology Equipment and Supplies
The assistive technology equipment and supplies service covers purchases, rentals, shipping costs and, as needed, fixes to equipment required to increase, maintain or improve your ability to do daily life tasks.
You can spend up to $50,000 over the duration of the NC Innovations waiver for this service and home modifications (combined over 5 years). The limit does not include nutritional supplements and monthly alert monitoring system charges. The list of items covered includes certain daily living aids, items to help you control your environment, some types of positioning systems and some types of alert systems. If you need equipment or supplies, let your care manager know and they can help you determine if it can be covered by NC Innovations waiver, Medicaid or other resources.
Community Living and Supports
Community living and supports (CLS) is an individual or group service that helps you live successfully in your own home, the home of your family or natural supports, and be an active member of your community. CLS can help you to learn new skills, practice and improve skills you have already learned and support you in living as independently as possible. CLS does not take the place of natural supports but can provide assistance and training to natural supports who live with you in helping you practice and maintain skills you learn with CLS.
Natural supports are relationships with people that include coworkers, classmates, neighbors, family and others. These relationships are typically developed in the community through associations in schools, the workplace and participation in clubs, organizations and community activities.
Community Networking Services
Community networking may be self-directed.
Community networking services include activities that support you in creating a day that is personally meaningful to you, and with people who are not disabled. Community networking services are not provided in your home, anyone else’s home, residential programs or day programs. Some of the things community networking services can help you do:
- Participate in classes at the community college; for example, take a class in photography.
- Participate in community classes to develop hobbies, leisure or cultural interests; for example, take a class to learn to knit. Other people in the class may later decide to meet weekly at a community center where everyone could work on their own knitting project together.
- Perform volunteer work such as stocking food at a food pantry.
- Join a group that meets regularly in the community; for example, a group that meets at a coffee shop every morning to discuss community events.
- Learn to use public transportation.
- Take classes on self-determination and participate in a self-advocacy group.
- For children, provide support to go to an after-school program designed for children who do not have disabilities.
- Pay for you to attend a class or conference (but not hotel, meals, transportation to the conference or day care fees) up to $1,000 per year. This does not include child care fees, overnight camps, fees for summer programs whose primary purpose is child care or memberships.
Community transition funds are one-time, set-up expenses for adults to live in homes of their own. It can help if you are moving from a state developmental center, ICF-IID group home, nursing facility or other licensed living arrangement (such as a group home, foster home or alternative family living home) to a living arrangement where you are directly responsible for your own living expenses. The lease must be in your name or that of your legal guardian or representative, or you must own the home. Community transition services can pay for security deposits, essential furnishings, window coverings, food preparation items, sheets, towels and deposits for utilities, including telephone, electricity, heating and water. Community transition can only be used once. The limit of the NC Innovations waiver for this service is $5,000 over 5 years
Crisis services help you if a situation is a threat to your health and safety or the health and safety of others. This service could help you if you are at risk for losing your job, your home or other important activity in your life, and help prevent you from needing institutional placement or hospitalization. Crisis services are available to help you 24 hours per day, 7 days per week. There are 3 types of crisis services that can help you:
- Crisis Intervention and Stabilization: Trained staff are available to provide first response crisis services to you. They can help identify the type of help you need, contact other agencies to help you, and help staff or caregivers work with you during the crisis.
- Crisis Consultation: Psychologists or psychological associates are available to you if you have challenging behaviors that have resulted in a crisis situation requiring the development of a comprehensive crisis plan.
- Out-of-Home Crisis: A short-term service that can help you if you experience a crisis and require a period of regular support. The service takes place in a licensed facility or licensed private home respite setting, separate from your living arrangement.
Day supports help you get, keep or improve socialization and daily living skills and is 1 option for a meaningful day. Day supports are provided by licensed day programs and licensed childcare facilities. If you receive day supports, your day supports provider is responsible for transporting you from your home to and from the day supports facility. Usually, you receive day support services in a group. One-on-one day support services are available only if you have special needs that require individual support.
Home modifications are physical changes to the private home where you live or will be living, and owned by you or your family (including your foster family, if applicable) that are needed to protect your health, welfare and safety or to help you be more independent. The adaptations cannot add total square footage to your home and are limited to $50,000 over the duration of the NC Innovations waiver (limit includes assistive technology equipment and supplies).
Individual Goods and Services
Individual goods and services are available to you if you self-direct 1 or more services through the individual and family-directed services option. The cost is limited to $2,000 each year. They include services, equipment or supplies that address an identified need in your ISP and meet the following requirements:
- Item or service would decrease your need for other Medicaid services; AND/OR
- Promote inclusion in your community; AND/OR
- Increase your safety in your home environment; AND
- You do not have the funds to purchase the item or service.
Natural Supports Education
Natural supports education may be self-directed.
Natural supports education provides training to your family and your natural supports network to educate and train them about the nature and impact of your disability, on strategies for helping you, and specialized equipment and supplies you use.
This service will also pay for up to $1,000 for enrollment fees and materials related to attendance at conferences and classes by your primary caregiver that help your caregiver develop skills to support you in having greater access to the community.
Relative/Legal Guardian as Direct Support Provider
Relatives or legal guardian who live with you may provide paid supports to help you stay in home. They must be 18 years old or older. Your relative or legal guardian may provide you with community living and support services as part of the NC Innovation Waiver. Your care coordinator will work with your relative or legal guardian and monitor your care to ensure that you are receiving the services that your need.
There are limitations to your relative or legal guardian as your direct support provider, which include but are not limited to:
- Your relative must be related you by blood or marriage.
- Your relative must live in the same home as you.
- Your relative or legal guardian may not provide more than 40 hours of service per week unless you can prove that the services you require are not available by any other provider.
Residential supports are individually designed training activities, assistance and supervision. Residential supports are provided in licensed/unlicensed community residential settings that include group homes and alternative family living homes. Residential supports include:
- Habilitation services that help you develop, improve and maintain self-help skills, general household management, meal preparation skills, personal financial management skills and socialization skills.
- Assistance and support in activities of daily living to ensure your health and safety.
- Transportation to/from your residence and community activities/licensed day programs
Respite (Individual, Group, Nursing, Facility)
Respite services may be self-directed.
Respite services are provided on a short-term basis and provide you support when your natural support is unavailable. They provide a break for your primary caregiver, and they can be scheduled or provide support when an emergency occurs. Respite may include in and out-of-home services, and can include overnight, weekend care, or emergency care (if a family emergency occurs).
Specialized Consultation Services
Specialized consultation services provide training and help in a specialty area. The specialty areas are psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy and nutrition. Family members and other paid/unpaid caregivers are trained by a certified, licensed and/or registered professional or qualified assistive technology professional to carry out therapeutic interventions, increase the effectiveness of the specialized therapy and participate in your team meetings. This service is very important as it can help your family, caregivers and paid service providers learn how to provide the right supports for you.
Supported Employment Services (Initial and Long-term Follow-up)
Supported employment may be self-directed.
Supported employment services help you choose, get and maintain a job in settings with people who do not have disabilities. Before you can get supported employment services funded by the NC Innovations waiver, you must first use any services vocational rehabilitation offers you.
Supported employment services include:
- Pre-job training to prepare you to start work and may include career counseling, job shadowing, help using educational resources, training in resume preparation, job interview skills and help learning skills necessary for keeping the job.
- Training and support to get employment in a group such as an enclave or mobile crew (groups of workers with disabilities who work in a business in the community).
- Assisting you in starting and running a small business you own.
- Training and support to complete job training or maintaining employment.
- Transportation between work/home or between activities related to employment.
- Consultation with your employer to address any problems or needs you may have.
Supported living services allow you to live in your own home with support that is suited to your individual needs. You can choose who lives with you (up to 2 other people) and how you want help. The purpose of this service is for you to live independently, so you cannot live with family members, with certain exceptions. This service also cannot pay for your rent or room and board unless to pay for a live-in caregiver.
Supported living services include:
- Direct assistance with daily activities, household chores, budget management, attending appointments and building social skills.
- Training activities, supervision and assistance to help you participate in home or community life.
- Help with keeping track of your health and physical condition.
- Help with transportation, emergencies that require ambulances, and using devices that help you move around.
Vehicle modifications are devices, services or controls that can help you increase your independence or physical safety by enabling your safe transport in and around the community. The installation, repair, maintenance and training in the care and use of vehicle modifications are included. You or your family must own or lease the vehicle being modified. Modifications do not include the cost of the vehicle or lease. Modifications include door handle replacements; door modifications; installing a raised roof; lifting devices; devices for securing wheelchairs or scooters; adapted steering, acceleration, signaling and braking devices; handrail and grab bars; seating modifications; lowering of the floor of the vehicle; and safety/security modifications. Vehicle modifications are limited to $20,000 over the duration of the NC Innovations waiver (5 years).
Monitoring Your Services
Your care manager is responsible for monitoring your person-centered Individual Support Plan (ISP), including all of your waiver services and all other Medicaid services provided to you, and your overall health and safety. Monitoring will take place in all service settings and on a schedule outlined in your ISP.
What Does Your Care Manager Monitor?
Your care manager monitors that:
- Services are provided as written in your ISP.
- You can access services.
- Problems that happen are identified and addressed.
- Services meet your needs.
- Back-up staffing plans are implemented.
- You are healthy and safe.
- You are offered a free choice of network providers.
- Your non-waiver service needs have been addressed.
- Face-to-face contact with you and your care team.
- Telephone contact with you and your care team.
- Observation of services.
- Review of documentation and billing
Care Manager Individual Monitoring Schedule
- If you are new to the NC Innovations waiver, you receive at least monthly in-person visits for the first 6 months and then on the schedule in your ISP, no less than quarterly.
- If your services are provided by guardians and relatives living in your home, you receive at least monthly in-person visits.
- If you live in a residential program, you receive at least monthly in-person visits.
- If you choose to self-direct (individual and family-directed services option) your services, you receive at least monthly in-person visits.
- If you are not listed in 1 of the above categories, you will receive in-person visits on the schedule in your ISP, no less than quarterly.
- If you do not receive an in-person visit during the month, your care manager will contact you by telephone
Concerns about Abuse, Neglect and Exploitation
Your health and safety are very important. You should be able to lead your life without fear of abuse or neglect by others or someone taking advantage of you (exploitation). Anyone who suspects any allegations of abuse, neglect or exploitation of a child (age 17 or under) or disabled adult must report these concerns to the local Department of Social Services (DSS). Visit your Local Department of Social Services website. There are also rules that no one will be punished for making a report when the reporter is concerned about the health and safety of an individual.
Providers are required to report any concerns of abuse, neglect or exploitation of a child or disabled adult from an unlicensed staff for a potential investigation to the local DSS and the Health Care Personnel Registry Section of the North Carolina Division of Health Service Regulation. The provider will also take steps to ensure the health and safety of individuals receiving services.
For additional information on how to report concerns, contact your care manager or Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY.
Continuing Eligibility for NC Innovations Waiver Participants
As an NC Innovations waiver participant, you have already gone through an initial eligibility process. To remain in the program, you must continue to meet certain clinical and financial criteria. This section provides information about ongoing clinical and Medicaid eligibility.
- You must not live in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) but continue to require ICF-IID-level of care.
- You must continue to need and use 1 or more of the services or supports offered under the NC Innovations waiver monthly.
- You must be able to maintain your health, safety and well-being in the community with NC Innovations waiver services.
- You must reside in a qualified setting in which NC Innovations waiver services can be delivered.
Continuing clinical eligibility assessments take place annually and as needed due to changes in your circumstances. It is important for you to provide information about changes in your circumstances. Changes that affect 1 or more of the clinical eligibility criteria may also affect your eligibility for the NC Innovations waiver program. If you do lose eligibility for the NC Innovations waiver, your eligibility will end on the last day of the month that your clinical eligibility changed.
For additional information on clinical eligibility, contact your care manager or Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY.
In addition to continuing to meet clinical eligibility, you must continue to meet Medicaid eligibility to remain in the waiver.
It is important that you provide your local Department of Social Services (DSS) with all of the information they need to update your Medicaid eligibility, and that you read and respond to all letters they send you. It also important to let your care manager know of any address change, as this change can affect Medicaid eligibility and your NC Innovations waiver services. Your care manager and your local DSS will let you know if a move will affect your Medicaid eligibility and Trillium enrollment. Your NC Innovations waiver services will move with you across North Carolina.
For additional information and questions you have on Medicaid eligibility, contact your care manager or Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY.
Residential Settings Where Nc Innovations Waiver Services Can Be Delivered
You must continue to live in private homes or residential settings that meet NC Innovations waiver criteria.
Leaving The Nc Innovations Waiver (Disenrollment)
NC Innovations waiver participants can choose to leave the NC Innovations waiver at any time. If you want to leave Trillium and move to another Medicaid health care option, you must leave the NC Innovations waiver first. For more information contact your care manager or Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY.
There are reasons why you must leave the NC Innovations waiver even when you do not ask to leave, including:
- You are no longer eligible for Medicaid.
- Your Individual Support Plan (ISP) is not approved. (This can be appealed.)
- You choose to live in a facility or setting that is not a qualified setting for NC Innovations waiver services.
- You are hospitalized for longer than 30 days.
- You move out of state.
- You do not use at least 1 NC Innovations waiver service (other than assistive technology, community transition, home modifications, vehicle modifications or respite) each month.
- You no longer meet intermediate care facilities for individuals with ICF-IID eligibility. (This can be appealed.)
When you must leave the NC Innovations waiver when you did not ask to leave, appeal rights are provided to you or your legal guardian in writing by the agency disenrolling them from the NC Innovations waiver, Medicaid or both. For most disenrollments, the effective date is the last day of the month.
Other State Waivers That May Meet Your Needs
Your care manager can help you if you have questions about any of the other North Carolina waivers. You may receive funding from only 1 waiver at a time. Other waivers are:
- CAP/C: Community Alternatives Program for Children provides an alternative to nursing facility and hospital care for individuals up to age 21 who live in a private residence, who have complex medical needs (medically fragile) and who have been ruled disabled by Disability Determination Services.
- CAP/DA: Community Alternatives Program for Disabled Adults provides an alternative to nursing facility care for persons with disabilities who are age 18 and older and who live in a private residence
Other Services That Might Meet Your Needs
If you are disenrolled from the NC Innovations waiver, you should ask your care manager about other services that you may be eligible for that could meet your needs. Available services will vary from person to person since some individuals will no longer have Medicaid coverage when they are disenrolled from the NC Innovations waiver. Your local DSS) will let you know if you will continue to have Medicaid coverage.
Ways To Share Experiences With Nc Innovations Waiver
The Trillium wants to hear about your experiences getting NC Innovations waiver services and about ways Trillium can make sure you are happy with the services you are receiving. You can contact your care manager or Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY to share your experiences.
You can also participate in the Trillium’s NC Innovations waiver Stakeholder Group that meets every 3 months and share your ideas for improving the delivery of NC Innovations waiver services. You will have the opportunity to meet with NC Innovations waiver participants, families, providers and other individuals during these meetings. Contact your care manager or Member and Recipient Services at 1-877-685-2415 or dial 711 for TTY to learn more about how you can participate.
Abbreviations and Acronyms
|CAP||Community Alternative Program|
|CAP/C||Community Alternatives Program for Children|
|CAP/DA||Community Alternatives Program for Disabled Adults|
|CMS||Centers for Medicare and Medicaid Services|
|DHB||Division of Health Benefits|
|DHHS||Department of Health and Human Services|
|DSS||Department of Social Services|
|EPSDT||Early and Periodic Screening, Diagnosis and Treatment (under age 21)|
|HCBS||Home and Community Based Services|
|ICF-IID||Intermediate Care Facility for Individuals with Intellectual Disabilities|
|IDEA||Individuals with Disabilities Education Act|
|IEP||Public School’s Individual Education Plan|
|ISP||Individual Support Plan|
|LME||Local Management Entity|
|MCO||Managed Care Organization|
|MD||Medical Doctor or Physician|
|MH/DD/SA||Mental Health, Developmental Disability, Substance Abuse|
|NCDHHS||North Carolina Department of Health and Human Services|
|PIHP||Prepaid Inpatient Health Plan|
|PRTF||Psychiatric Residential Treatment Facility|
|SIS™||Supports Intensity Scale™|
|SNF||Skilled Nursing Facility|
|SSA||Social Security Administration|
Key Words Used in this Handbook
As you read this handbook, you may see some new words. Here is what we mean when we use them.
Appeal: If the health plan makes a decision you do not agree with, you can ask them to review it. This is called an "appeal." Ask for an appeal when you do not agree with your health care service being denied, reduced, stopped or limited. When you ask your plan for an appeal, you will get a new decision within 30 days. This decision is called a “resolution.” Appeals and grievances are different.
Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plan: A North Carolina managed care health plan that provides Medicaid members with services to meet their health care needs, and additional care for behavioral health, intellectual/developmental disabilities (I/DD) and traumatic brain injuries (TBI). Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plan covers additional services not available in standard plans.
Beneficiary: A person who is receiving Medicaid.
Care Coordination: A service where a care coordinator or care manager helps organize your health goals and information to help you achieve safer and more effective care. These services may include, but are not limited to, identification of health service needs, determination of level of care, addressing additional support services and resources or monitoring treatment attendance.
Care Management: A service where a care manager can help you meet your health goals by coordinating your medical, social and behavioral health services and helping you find access to resources like transportation, healthy food and safe housing.
Care Manager: A health professional who can help you meet your health goals by coordinating your medical, social and behavioral health services and helping you find access to resources like transportation, healthy food and safe housing.
For NC Innovation Waiver participants, they also have special training to support waiver services such as tracking progress on goals in the Individual Support Plan (ISP), making recommendations, and referring for additional or different services and amounts of services and supports based on their findings. Care managers also monitor waiver compliance.
Complaint: Dissatisfaction about your health plan, provider, care, or services. Contact you plan and tell them you have a "complaint" about your services. Complaints and appeals are different.
Community Supports: Organizations that provide support to a person. Community supports may include advocacy organizations, community service organizations, faith-based organizations, civic organizations and/or educational organizations.
Complaint: Dissatisfaction about your health plan, provider, care, or services. Contact your health plan and tell them you have a "complaint" about your services. Complaints and appeals are different.
Department of Health and Human Services (NCDHHS): The state agency that includes NC Medicaid (Division of Health Benefits), Division of Mental Health, Developmental Disabilities and Substance Abuse Services, the State Division of Social Services, the Division of Aging and Adult Services and other health and human services agencies. Visit the NCDHHS website.
Durable Medical Equipment: Certain items (like a walker or a wheelchair) your doctor can order for you to use at home if you have an illness or an injury.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT): A Medicaid benefit that provides comprehensive and preventive health care services for children under 21 who are enrolled in Medicaid. When children need medical care, services are not limited by Trillium’s coverage policies. Medicaid makes sure that members under 21 years old can get the medical care they need, when they need it, including health care services to prevent future illnesses and medical conditions. The EPSDT benefit does not apply to services received through the NC Innovations waiver.
Excluded Services: Services covered by the NC Medicaid Direct program, but not by your health plan. You can get these services from any provider who takes Medicaid.
Habilitation Services and Devices: Health care services that help you keep, learn or improve skills and functioning for daily living.
Health Care Option: Health care options include Standard Plans, Tailored Plans, ECBI Tribal Option and NC Medicaid Direct These options are based on the individual beneficiary.
Health Insurance: A type of insurance coverage that helps pay for your health and medical costs. Your Medicaid coverage is a type of insurance.
Health Plan (or Plan): The organization providing you with health care services.
Hospitalization: Admission to a hospital for treatment that lasts more than 24 hours.
Innovations Waiver: Special federal program designed to meet the needs of people with intellectual/developmental disabilities (I/DD) who prefer to get long-term services and supports in their home or community rather than in an institutional setting.
Institution: For purposes of the NC Innovations waiver, an “institution” is a residential facility that is licensed and funded as an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID). NC Innovations waiver funding cannot be used in an institution, including Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (ICF-IID), hospitals, skilled nursing facilities and state developmental centers.
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID): Facility that provides residential, medical and other supports to people with intellectual and developmental disabilities who have behavioral and/or medical conditions.
Local Department of Social Services (DSS): The local (county) public agency that is responsible for determining eligibility for Medicaid and other assistance programs.
Managed Care: A health care program where North Carolina contracts with health plans, called managed care organizations (MCOs), to arrange for integrated and coordinated physical, behavioral health and other health services for Medicaid beneficiaries. In North Carolina, there are 3 types of managed care plans.
Medicaid: Medicaid is a health coverage program that helps families or individuals who have low income or serious medical problems. It is paid with federal, state and county dollars and covers many physical health, behavioral health and I/DD services you might need. You must apply through your local Department of Social Services. When you qualify for Medicaid, you are entitled to certain rights and protections.
Medically Necessary: Medical services, treatments or supplies that are needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Member and Recipient Services: A phone number you can call to speak with someone and get help when you have a question. The number for Trillium is 1-877-685-2415.
NC Innovations Waiver Level of Care: The tool used to determine the minimum amount of help a person may require to receive services in an institutional setting under the state Medicaid plan. Individuals must meet Intermediate Care Facility for Individuals with Intellectual Disabilities level of care to meet the NC Innovations waiver level of care.
NC Medicaid (State Medicaid Agency): The agency that manages the state’s Medicaid health care programs, pharmacy benefits and behavioral health services.
Network (or Provider Network): A group of doctors, hospitals, pharmacies and other health professionals who have a contract with your health plan to provide health care services for members.
Network Provider: A provider that is in your health plan’s provider network.
Non-paid Supports: People who provide support, care and assistance to a person with a disability without payment for that support. Non-paid supports may include parents, spouses, siblings, children, extended family members, neighbors, church members or coworkers.
Participant/Individual/Member: The person who is approved to receive services under the NC Innovations waiver.
Physician: A person who is qualified to practice medicine.
Plan (or Trillium): The company providing you with health care services.
Primary Care Provider or Primary Care Physician (PCP): Your primary care provider (PCP) is the doctor or clinic where you get your primary care (immunizations, well-visits, sick visits, visits to help you manage an illness like diabetes.) Your PCP should also be available after hours and on weekends to give you medical advice. They also refer you to specialists (cardiologists, behavioral health providers) if you need it. Your PCP should be your first call for care before going to the emergency department.
Private Living Arrangement: The home that an individual owns or rents in their name or the home where an NC Innovations waiver participant resides with spouse, other family members or friends. A living arrangement (house or apartment) that is owned or rented by a service provider is not a private residence.
Provider Network: Agencies or professionals under contract with [Trillium] to provide authorized services to eligible individuals.
Registry of Unmet Needs: A list of individuals who are waiting for NC Innovations waiver funding for identified needs.
Rehabilitation and Therapy Services and Devices: Health care services and equipment that help you recover from an illness, accident, injury or surgery. These services can include physical or speech therapy.
Skilled Nursing Facility (SNF): A facility that provides skilled nursing care and related services for residents who require medical or nursing care; or rehabilitation services for injured, disabled or sick people.
Standard Plan: A Standard Plan is a NC Medicaid health plan that offers physical health, pharmacy, care management and basic mental health and substance use services for members. Standard Plans offer added services for members who qualify. Some added services may be different for each Standard Plan.
State Developmental Center: A state-operated Intermediate Care Facility (institution) that provides health and habilitation services to individuals with intellectual and/or other developmental disabilities.
Tailored Care Management Care: Care management for members enrolled in Behavioral Health I/DD Tailored Plans that is coordinated by a care manager who can help people with behavioral health, intellectual and developmental disability and/or traumatic brain injury needs. The care manager works with you and a team of medical professionals and approved family members or other caregivers to consider your unique health-related needs and find the services you need in your community.
Traumatic Brain Injury Waiver (TBI Waiver): Special federal program that provides long-term services and supports to allow people who experienced a traumatic brain injury (TBI) on or after their 18th birthday to remain in their homes and communities. The Tailored Plan providing services in Cumberland, Durham, Johnston, and Wake counties manages this special program. The NC TBI Waiver does not operate in all geographic areas of the state.
Participant Responsibilities of NC Innovations Waiver
Beneficiary Responsibilities North Carolina Innovations Waiver
I understand that enrollment in the North Carolina (NC) Innovations waiver is voluntary. I also understand that if enrolled I will be receiving Waiver services instead of services in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID). My Medicaid eligibility must continue in North Carolina for me to continue to be eligible for the NC Innovations waiver and I must continue to meet all other waiver eligibility criteria.
- I understand that by accepting NC Innovations waiver funding that I am in need of waiver services to prevent an immediate need for ICF-IID facility services.
- I understand that to maintain my eligibility for this waiver I require the provision of at least 1 waiver service monthly and that failure to use a waiver service monthly will jeopardize my continued eligibility for the NC Innovations waiver. The services approved in my Individual Support Plan have been determined necessary to improve/support my disability.
- I understand that beneficiaries in the NC Innovations waiver live in private homes or in residential facilities which meet waiver requirements and services must also meet the home and community characteristics defined in the waiver
- I understand if I choose to move to a facility during my participation in the waiver that is larger than 6 beds or does not meet the home and community characteristics defined in the waiver, I will no longer be eligible for the waiver.
- I understand that the total of my waiver services cannot exceed $135,000 when I enter the waiver (unless I am utilizing Supported Living Level 3).
- I understand that at any time during my plan year, the total of my waiver services cannot exceed $135,000 or I will no longer be eligible for the waiver. The only exception is that individuals utilizing Supported Living Level 3 may request medically necessary services that exceed the typical $135,000 Waiver limit.
- I understand if I select the NC Innovations waiver, I will have an Individual Support Plan (ISP) developed that reflects services to meet my needs. My Care Coordinator will explain the planning process and the establishment of my Individual Budget Guideline to me. My ISP will be re-developed annually prior to my birth month. I understand the NC Innovations waiver will deliver services according to my ISP.
- I understand that I may be required to pay a monthly Medicaid deductible if that is part of my financial eligibility for waiver services. My Care Coordinator can assist me in obtaining information on Medicaid deductibles from my local Department of Social Services.
- I understand that I will cooperate in the assessment process to include but not be limited to Supports Intensity Scale (SIS®) no less frequently than every 2 years; NC Innovations Risk/Support Needs Assessment; and Level of Care. I understand that the SIS assessment is a requirement and failure to comply may result in termination of Innovations Waiver services.
- I understand that my ISP will be monitored and reviewed by my Care Coordinator, and that I can contact my Care Coordinator at any time if I have questions about my ISP, Individual Budget or the services that I receive.
- I understand that I have the right to choose a provider within Trillium Provider Network.
- I understand that I am required to meet with my Care Coordinator for care coordination activities in the home and/or all settings where services are provided. The Care Coordinator will schedule meetings as often as needed in order to ensure appropriate service implementation and beneficiary’s needs are met. I may also request meetings.
- I understand that I am required to notify the Care Coordinator of any concerns regarding services provided.
- I understand that I am required to give adequate notice to the Care Coordinator of any change in address, phone number, insurance status, and/or financial situation prior to or immediately following the change.
- I understand that I am required to give adequate notice to the Care Coordinator of any behavior or medication changes as well as any change in health condition.
- I understand that I am required to attend appointments set by the Department of Social Services (DSS) to determine Medicaid renewals to ensure my continued Medicaid eligibility.
- I understand that I will be provided a copy of educational information about the NC Innovations waiver to assist with my understanding the services available through the NC Innovations waiver and guidelines that needs to be followed to ensure continued eligibility.
- I understand that Trillium is responsible for ensuring an adequate network of provider agencies is available to promote choice for the beneficiary.
- I understand that Trillium will make a Care Coordinator available to provide care coordination supports which include:
- Assessment to determine service needs to include but not be limited to the, NC Innovations Risk/Support Needs Assessment.
- Working with the Individual Support Planning Team to coordinate and document the Individual Support Plan (ISP).
- Requesting services that are requested by the beneficiary.
- Making the beneficiaries aware of the amount of their Individual Budget and the process used to establish this budget and make any needed changes as well as the right to request services in excess of his/her budget.
- Monitoring all authorized services to ensure that they are provided as described in the ISP and that meet the beneficiary’s needs.
- Assisting the beneficiary with the coordination of benefits through Medicaid and other sources to include, if needed, linkage with the local Department of Social Services regarding the coordination of Medicaid deductibles.
- Responding to any complaints or concerns and reach resolution within 30 days of the complaint regarding NC Innovations services.
- Promoting the empowerment of the beneficiary to lead as much of his/ her Individual Support Planning, decision making regarding the use of waiver dollars and oversight of waiver services as they choose.
- Obtaining an order from the beneficiary’s physician for all needed medical supplies and specialized equipment.
- Supporting the beneficiary in obtaining all needed information to make an informed choice of provider within the Trillium network, inclusive of notifying the Trillium Network Management Department if providers are needed outside of the current Trillium Network.
|NC Innovations Waiver Service Limitation|
|Living in Residential Setting, Including AFL||Living in Private Home|
No more than 40 hours per week any combination:
May receive up to 1 daily unit of Residential Supports
No more than 84 hours/week any combination:
Child during school year
(Ages 0 to 17 unless 18 and older and enrolled in school)
|Living in Residential Setting, Including AFL||Living in Private Home|
No more than 20 hours per week any combination:
May receive up to 1 daily unit of Residential Supports
|No more than 54 hours/week any combination:
Child when school is not in session
(Ages 0 to 17 unless 18 and older and enrolled in school)
|Living in Residential Setting, Including AFL||Living in Private Home|
No more than 40 hours per week of any combination:
May receive up to 1 daily unit of Residential Supports
No more than 84 hours/week of any combination:
|Services Not Subject to Limits on Sets of Services|
Additional Services: Contained in the Individual Budget
|Living in Residential Setting, Including AFL||Living in Private Home|
Additional Services: Add on to Individual Budget
|Living in Residential Setting, Including AFL||Living in Private Home|
Available to Participants Who Self-Direct Service(s)
|Living in Residential Setting, Including AFL||Living in Private Home|
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