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Effective: July 1, 2008 |
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03.40.20ar2 - Traumatic Brain Injury (TBI) (Archive) |
Archived: May 1, 2010 |
Traumatic Brain Injury (TBI) Waiver is a federally approved home and community-based services program for people who have an acquired or traumatic brain injury requiring a level of care provided in a specialized nursing facility or neurobehavioral hospital. These individuals may be eligible to receive services in community settings rather than in a nursing facility or neurobehavioral hospital.
The individual must be:
l Eligible for Medical Assistance (MA) payment of long-term care (LTC) services;
l Certified disabled by the Social Security Administration (SSA) or State Medical Review Team (SMRT) process.
l Under age 65 at the time of acceptance to the waiver.
Note: A person who receives TBI waiver services may choose to stay on the waiver when they turn age 65 years or go onto the Elderly Waiver (EW).
l Assessed through a screening process (LTCC) and determined to need the level of care provided in a nursing facility or neurobehavioral hospital.
l In need of supports and services beyond those available through the standard MA benefit set according to the LTCC screening.
More information about the disability waivers can be found in the Disability Services Program Manual.
Eligibility factors and links to standard program guidelines are provided below.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Application Process (standard guidelines)
Follow standard MA guidelines.
Refer all applicants or their authorized representatives to the appropriate area of the county to obtain a LTCC screening if they have not already done so at the time they apply for MA.
Eligibility for waiver services cannot begin before an LTCC is completed, a care plan is developed, and eligibility for MA payment of LTC services has been determined.
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.
The lead agency case manager will verify the following information on the Lead Agency Case Manager/Worker Communication Form (DHS-5181):
l Waiver program conversion or diversion status.
l LTCC date.
l Anticipated start date of waiver services.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Residency (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
TBI enrollees who are not eligible for the Medicare Savings Programs may be eligible for payment of Medicare premiums as cost effective insurance.
Exception: TBI enrollees who are also enrolled in MA-EPD must have income at or below 200% FPG to qualify for reimbursement of Medicare Part B premiums. Part B premiums must be reimbursed for any month(s) the enrollee’s income was at or below 200% FPG back to the date of MA-EPD eligibility, regardless of the amount of the premium. No cost effective determination is needed.
Household Composition (standard guidelines)
Use a household size of one for all months in which the person receives TBI services.
l If the person is requesting retroactive MA for months before TBI services will 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.
l For MA-EPD eligibility, follow the household size and deeming guidelines of the MA-EPD program.
Use Method B for assets and income.
Asset Guidelines (standard guidelines)
l Asset limit:
Only count the assets of the applicant or enrollee toward the asset limit in any month he or she receives TBI services. Do not deem the assets of a spouse in any month the applicant or enrollee receives TBI services.
The asset limit is $3,000 (household size of one) except:
n There is no asset limit for children under 21.
n Follow the MA-EPD asset guidelines for adults who are concurrently eligible for MA-EPD.
l Transfers:
TBI applicants and enrollees may transfer assets to their spouses without penalty. Asset transfers to others may be uncompensated and result in a transfer penalty period during which the client is ineligible for MA payment of LTC services, including LTC services received through the TBI waiver. See Transfers for more information on transfers.
l Home Equity Limit:
TBI applicants and enrollees are subject to a Home Equity Limit.
l Annuities:
TBI applicants and enrollees are subject to certain rules regarding annuity interests. See Bulletin 08-21-04 for more information.
Income standard is 100% FPG.
Only count the income of the applicant or enrollee in any month he or she receives TBI services.
l Do not deem the income of a parent or spouse in any month the applicant/enrollee receives TBI services.
l Exclude child support and RSDI payments received by or on behalf of children under age 18.
Example:
Simon is a disabled adult who is applying for MA under the TBI waiver. He is also eligible for Medicare. His income meets the income standard for TBI and QMB. However, when his wife’s income is deemed to him, their combined income is over the standard.
Action:
Because his wife’s income must be deemed to him under QMB program guidelines, deny QMB for Simon. However, because only his income is used to determine his MA eligibility under the TBI waiver, he is under the income standard for that program. Approve TBI for Simon.
Parents of children who are eligible for TBI may have to pay a parental fee. See Parental Fees for information about when to refer the case to DHS for a parental fee determination.
Exception: Follow MA-EPD income guidelines for adults who are concurrently eligible for MA-EPD.
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 day 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 (Prepaid MHCP Manual)
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 (Prepaid MHCP Manual)
People who are not enrolled in a managed care plan receive services through fee-for-service (FFS).
People under age 65 who are eligible for MA due to blindness as determined by the Social Security Administration (SSA) or the State Medical Review Team (SMRT) are excluded from mandatory managed care enrollment. However, people may voluntarily enroll in one of the following managed care programs:
1. Minnesota Disability Health Options for People with Physical Disabilities (MnDHO-PD) if they are:
n Ages 18-64 and are eligible for MA with or without Medicare Parts A and B.
n Certified disabled by SSA or SMRT and have a chronic physical disability that needs ongoing treatment.
n Reside in Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, or Washington counties.
2. Special Needs BasicCare (SNBC) if they are:
n Ages 18-64 and are eligible for MA with or without Medicare Parts A and B.
n Certified disabled by SSA or SMRT.
n Reside in any Minnesota county except Clearwater, Beltrami, Hubbard, or Lake of the Woods.
Note: Long-term care services, such as personal care attendant (PCA), private duty nursing (PDN), ICF-MR, county case management, and home and community-based waiver services provided under TBI continue to be paid through fee-for-service (FFS).
Not applicable.
Follow standard MA guidelines.
TBI enrollees who apply for Medicare Savings Programs must meet all requirements for those programs. Refer to the guidelines noted earlier in this section.
Children who do not require the additional services provided by the TBI waiver may be eligible under TEFRA.