Home and Community Based Services Manual


4.35.4 Brain Injury Waiver Service Coordination

Introduction

The Brain Injury Waiver (BIW) is a Home and Community Based Services (HCBS) waiver offered through the Division of Senior and Disability Services (DSDS). BIW aims to promote and support an individual to reach their highest degree of independence after a traumatic brain injury (TBI).

Purpose

The service is designed to be person centered, outcome oriented and relies on community inclusion. It provides a variety of services which includes home modifications, assistive technology, and therapy services.

Eligibility

All BIW participants must meet the following eligibility criteria:

  • Be between the ages of 21 to 65
    • Once a participant reaches the age of 65, the participant shall be disenrolled from the BIW. The participant shall be offered eligible services provided through the Division of Senior and Disability Services.
  • Be in active Medicaid status
    • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive the BIW during periods when they meet their spenddown liability.
    • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
    • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may not be authorized for the BIW.
    • Authorization of the BIW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
  • Have an appropriate Medicaid Eligibility (ME) code
  • Meet Nursing Facility Level of Care (LOC)
  • Have medical documentation of a Traumatic Brain Injury

Restrictions and Limitations 

Initial and continued enrollment in BIW is subject to the following:

  • BIW services may not exceed $32,000 a year per participant.
  • May not be enrolled in any other waiver programs (ILW, SFCW, ADW).
  • The BIW year runs from October 1st of each year through September 30th of the following year.

Note: If a participant leaves the BIW during a waiver year for any reason, the slot is still considered occupied for the period of the waiver authorization.

Process

An initial assessment is completed within 15 business days of receipt of referral. An individual is required to meet nursing home level of care to qualify for the BIW. Once nursing home level of care is met, the appropriate services and needs of the participant are determined through the Service Coordination Assessment (SCA). A reassessment is then conducted at least twice a year to determine if the participant’s needs have changed.

Brain Injury Waiver Services

Physical Therapy

Physical Therapy (PT) treats physical motor dysfunction through various routes. The service includes evaluation, plan development, direct therapy, and consultation/training of caretakers and others who work with the individual. Therapies available to adults under the state plan are for rehabilitation needs only.

Occupational Therapy

Occupational therapy (OT) assists individuals to learn or regain skills of daily living. OT requires a prescription by a physician and evaluation by a certified Occupational Therapist or Certified Occupational Therapy Assistant under the supervision of an Occupational Therapist. The service includes:

  • Evaluation
  • Plan development
  • Direct therapy
  • Consultation
  • Training of caretakers and others who work with the participant.

Speech Therapy

Speech Therapy is for individuals who have speech, language, or hearing impairments. The need for services must be identified in the care plan and prescribed by a physician. Services must be provided by a licensed speech language therapist. Speech Therapy provides treatment for:

  • Delayed speech
  • Stuttering
  • Spastic speech
  • Aphasic disorders
  • Hearing disabilities that require specialized auditory training, lip reading, signing, or use of a hearing aid.

Note: The services may also include consultation provided to families, other caretakers, and habilitation service providers.

Home Modifications

These are modifications to the home required by the participant’s plan of care, which are necessary to ensure the health, welfare, and safety of the individual; or which enable the individual to function with greater independence in the community; and without which, the recipient would require institutionalization. Such adaptations may include the installation of ramps, widening of doorways, modifications of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate a medical need.

Note: There is a $5,000 annual cost limit per participant. This is part of the $32,000 annual cost maximum for the participant.

Personal Care

Personal care (PC) services are intended to meet personal requirements that enable the participant to remain in his/her home and maintain a functional capacity by fulfilling needs that cannot be met by other resources. PC services are authorized when the participant requires hands on assistance in one or more of the following categories that exceeds typical level of care for an individual of that age: dressing, grooming, bed mobility, toileting, bathing, eating, ambulating, transferring, and/or housekeeping. PC services only occur in the home of the participant.

Note: Consumer Directed Services (CDS) is not an option under BIW and state plan services must be utilized first.

Applied Behavioral Analysis

Applied Behavioral Analysis may be provided to assist a person in learning new behaviors directly related to existing challenges. Services may also be provided to increase/reduce existing behaviors or to omit behaviors under environmental conditions. The service shall include monitoring of data from continuous assessments of the individual’s skills in the following areas:

  • Learning
  • Communication
  • Social competence
  • Self-care

Assistive Technology

Assistive Technology (AT) is assistive, adaptive, and rehabilitative devices for people with disabilities and the elderly. They can be used by individuals with disabilities to perform functions that might otherwise be difficult or impossible and protect the health and welfare of the participant.

Note: There is a $5,000 annual cost limit per participant. This is part of the $32,000 annual cost maximum for the participant.

Cognitive Rehabilitation Therapy

Cognitive Rehabilitation Therapy (CRT) therapy includes goal-oriented counseling to maximize strengths and reduce behavior problems and/or functional deficits which interfere with a participant’s personal, familial, vocational, or community adjustment. CRT can be provided to the participant and families when the participant is present. This service is not available to adults when State Plan psychology services are appropriate to meet the individual’s needs.

Neuropsychological Evaluation

Neuropsychological Evaluation and Consultation consists of the administration and interpretation of a standardized battery of neuropsychological tests to provide information about a participant’s cognitive strengths and weaknesses following a TBI. It includes consultation with the participant, guardian, family, or other significant key persons designated by the participant and BIW staff for information gathering and/or interpretation of results.

Coordination Process

Referrers Responsibility

  • Confirm all eligibility requirements are met
  • Submit referral to the following:

When submitting a referral, the following information is required:

  • Name of participant (full, legal name)
  • DOB (must be between the ages of 21-64)
  • Responsible Party:
    • Is the referral their own responsible party?
    • Do they have a legal guardian?
    • Do they have a DPOA-HC? If so, who is that person and what is their contact information?
  • Contact information to include current home/mailing address, phone number, email contact, etc.
  • What services does the referral source believe would benefit the referred?

BIW Support Coordinators (SC) responsibility

  • Process the referral to determine eligibility.
  • Ensure there is a slot available for the participant, as there are a limited number available.
    • If slot is not available, participant will be added to wait list.
  • Complete the assessment and discuss service options with the participant.
  • Authorize appropriate services with approval of state waiver manager.
  • Conduct monthly phone calls and bi-annual home visits to ensure services are still active and appropriate for participants.
  • Participate in care planning/treatment team meetings with participants and stakeholders. May include treatment planning, waiver updates, concerns.

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