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Effective: December 1, 2006 |
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03.40.20ar1 - Traumatic Brain Injury (TBI) (Archive) |
Archived: July 1, 2008 |
People who suffer traumatic brain injuries (TBI) may be eligible for additional covered services beyond what Medical Assistance (MA) normally provides if they are MA-eligible and:
l Have a disabled basis of eligibility.
l Are under age 65 at the time of opening to the waiver.
l Diagnosed with one of the following documented primary or secondary diagnoses of brain injury or related neurological condition that resulted in significant cognitive and significant behavioral impairment.
n Acquired brain injury, including traumatic brain injury that is not congenital.
n Degenerative disease where cognitive impairment is present and diagnosis is not congenital.
n Documented brain impairment from an event, disease or condition that is not congenital.
l Able to function at a level that allows participation in rehabilitation.
l In need of a service that is only available through the TBI Waiver or requires a higher level of service than is available through other waivers due to cognitive and behavior impairments.
l If not for the provision of waiver services, the person would reside in or require the level of care of one of the following:
n A specialized nursing facility, such as a unit designed to work with brain injury and/or behavioral management. Individuals in this category are known as TBI-NF (Traumatic Brain Injury-Nursing Facility Level of Care). TBI-NF clients must have a Long-Term Care Consultation (LTCC).
n A long-term neurobehavioral hospital. Individuals in this category are known as TBI-NB (Traumatic Brain Injury - Neurobehavioral Hospital Level of Care). TBI-NB clients must have an interdisciplinary team assessment which recommends waiver services. The county case manager is responsible for obtaining the assessment.
l Have a cost to MA for community-based services that does not exceed the cost of services provided in a health care facility.
l Choose community-based services.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
Application Process (standard guidelines)
Follow standard MA guidelines.
The date of the LTCC or interdisciplinary team assessment and approval is the earliest possible date of TBI eligibility. Coordinate the MA/TBI determination with the case manager.
Renewals (standard guidelines)
Follow standard MA guidelines.
Disability must be certified by the State Medical Review Team (SMRT) or the Social Security Administration (SSA). Do not refer TBI applicants/enrollees who are certified disabled by SSA to SMRT.
Verify that the county case manager has determined the person to be TBI-eligible through developing a county service plan that ensures the person's health and safety, and completed a cost determination. The recommendation and plan must be approved by DHS.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Residency (standard guidelines)
Follow standard MA guidelines.
TBI enrollees who are not eligible for the Medicare Savings Programs are not eligible for payment or reimbursement of Medicare premiums unless they also receive MA for Employed Persons with Disabilities (MA-EPD).
Note: MA-EPD enrollees must have income under 200% FPG to qualify for payment or reimbursement of Medicare premiums.
Household Composition (standard guidelines)
MA eligibility is determined using only the person's own income and assets (household size of one) for all months in which the applicant/enrollee receives TBI services.
l If the person is requesting retroactive MA for months before TBI services begin, follow standard MA household size and deeming guidelines.
l For Medicare Savings Program eligibility, follow the household size and deeming guidelines of the Medicare Savings Program.
Use Method B for assets and income.
Asset Guidelines (standard guidelines)
Asset limit is $3000 (household size of one), except for:
l Children under 21, who have no asset limit.
l Adults who are concurrently eligible for MA-EPD; then follow the MA-EPD asset guidelines.
Note: When eligibility for a Medicare Savings Programs is also being determined, follow that program’s asset guidelines for the Medicare Savings Program eligibility.
TBI applicants and enrollees may transfer assets to their spouses without penalty. Asset transfers to others may be improper, and result in a period during which the client is still eligible for MA, but ineligible for TBI waiver services.
Income standard is 100% FPG.
Exception: If concurrently eligible for MA-EPD, there is no separate income limit. Follow MA-EPD income guidelines.
Exclude child support and RSDI payments received by or on behalf of children under age 18.
Deductions/Disregards (standard guidelines)
Follow standard MA guidelines.
If income is greater than 100% FPG, the person must spend down to 75% FPG. Use a monthly spenddown. Treat the projected amount of TBI services for the month as a medical bill incurred on the first of the month. The TBI enrollee is responsible for payment of the spenddown amount.
Exception: If the person is concurrently eligible for MA-EPD, follow MA-EPD rules to determine the premium amount.
Covered Services (standard guidelines)
TBI funds the following services in addition to the standard MA services:
l Case management/Case management aide.
l Adult day care/Adult Day Care Bath.
l Assisted living/Assisted living plus.
l Behavior programming.
l Chore services.
l Cognitive rehabilitation therapy.
l Companion services.
l Consumer Directed Community Supports.
l Family counseling and training.
l Foster care.
n Extended home health care services, including home health aide, LPN, RN, respiratory therapy, speech therapy, physical therapy and occupational therapy. These services are available through TBI only after regular MA coverage is exhausted.
n Home delivered meals.
l Homemaker services.
l Independent living skills counseling, maintenance, and therapies.
n Mental health and mental health psychological testing and explanation of findings.
n Modifications and adaptations.
n Night supervision.
n Prevocational services.
l Residential care.
n Respite care.
n Specialized equipment and supplies
n Structured day program
n Supported employment.
l Transportation services.
TBI services are not available during periods of hospitalization or nursing facility care.
Service Delivery (standard guidelines)
TBI enrollees age 65 or older are not exempt from managed care enrollment if they live in managed care counties.
Refer TBI enrollees under age 18 to DHS to determine and collect parental fees.
Note: If the child receives adoption assistance, either note that on the referral form or notify the DHS Parental Fee unit by other means. Parents of children who receive adoption assistance are not liable for parental fees.
A person is eligible for the TBI waiver through the month of the person's 65th birthday. If the person’s needs cannot be met by other programs, the person may continue on TBI after age 65, as long as the cost of services in the community does not exceed the cost of LTC care to MA.
TBI enrollees who apply for Medicare Savings Programs must meet all requirements for those programs. Refer to the guidelines noted earlier in this section.
Not applicable.