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TBI WAIVER

TBI WAIVER. MEDICAID BUREAU OF BENEFITS AND REIMBURSEMENT POLICY LLOYD FORBES, STATE PLAN AND WAIVER SERVICES MANAGER ARLA FARMER, R.N., ALTERNATIVE CARE COORDINATOR. WHAT ARE WAIVERS?.

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TBI WAIVER

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  1. TBI WAIVER MEDICAID BUREAU OF BENEFITS AND REIMBURSEMENT POLICY • LLOYD FORBES, STATE PLAN AND WAIVER SERVICES MANAGER • ARLA FARMER, R.N., ALTERNATIVE CARE COORDINATOR

  2. WHAT ARE WAIVERS? • State Medicaid programs which use federal funding matches to provide services in a consumer’s home as an alternative to institutional care. • In general, services must be cost-effective and consumer must meet an institutional level of care criteria.

  3. TBI WAIVER HISTORY FY 96 Idaho’s Legislature designated funds for 20 persons with TBI in a specialized treatment facility FY 97 Department of Health and Welfare released a Request for Proposal to the public - no proposals came back Oct. 97 Department decided to write a Home and Community Based Services (HCBS) Waiver for adults with TBI

  4. Dec. 97 Waiver submitted to Health Care Financing Administration (HCFA) Apr. 98 Implementation Team developed to outline steps for implementation May 98 Division of Medicaid mailed statewide survey to determine number of persons eligible for TBI Waiver: TBI WAIVER HISTORY(continued)

  5. 250 SURVEYS MAILED STATEWIDE; 77 RESPONSES (30.8%) - 59 MALES, 18 FEMALES Average age of injury was 35.2 years Cause of Injury - 44 vehicular accidents Current living situations - 28 living in family home, 28 in nursing facility, 13 in “other” settings, 7 receiving services in their home WHAT WERE THE SURVEY RESULTS?

  6. Services received on DAILY basis: 49 received meal prep 48 received personal care 46 received medication assistance Lowest responses: Respite care (7), therapies (11). No responses to supported employment OTHER SURVEY FINDINGS:

  7. MORE SURVEY FINDINGS: Services received on a REGULAR basis: • Behavior Consult/crisis management (29) • Supervised care (27) • Transportation (26) • Emergency response assistance (24) • Least Frequent: chore services(5)

  8. TBI WAIVER APPROVED 10/98

  9. WHAT CRITERIA IS REQUIRED FOR TBI WAIVER? • PLAN MUST BE COST EFFECTIVE • CONSUMER MUST MEET NURSING HOME LEVEL OF CARE • DIAGNOSTIC CRITERIA MUST BE MET • BRAIN INJURY MUST HAVE OCCURRED ON OR AFTER AGE 22

  10. 1. WHAT IS “COST EFFECTIVE”? • CONSUMER’S COMMUNITY-BASED WAIVER COSTS MUST BE LESS THAN INSTITUTIONAL CARE. • COST EFFECTIVENESS LOOKS AT COSTS SUCH AS: Home Health/Hospice, Supplies, Equipment, Therapies, Case Management, Transportation, Attendant Care, etc.

  11. 2. WHAT IS NURSING HOME LEVEL OF CARE? • UNIFORM ASSESSMENT INSTRUMENT (UAI) IS DONE BY DEPARTMENT. Other assessment instruments may also be considered. • UAI DETERMINES THE FUNCTIONAL ABILITIES AND ASSISTANCE NEEDED FOR CONSUMERS IN AREAS SUCH AS: DRESSING, BATHING, WALKING, EATING, TOILETING, ETC.

  12. CONSUMER MUST HAVE TOTAL OF 12 OR MORE POINTS FROM THE UAI: NEEDS EXTENSIVE BATHING ASSIST = 6 points NEEDS TOTAL MOBILITY ASSIST = 6 points TOTAL = 12 points

  13. 3. WHAT IS THE DIAGNOSTIC CRITERIA? • Client must have a traumatically acquired, non-degenerative structural brain injury which was sustained after the age of 22, and • Residual deficits and disability which require level of care provided in a nursing facility in the absence of waivered services.

  14. WHAT IS THE RANGE OF TBI WAIVER SERVICES? • RESIDENTIAL HABILITATION • CHORE SERVICES • RESPITE CARE • SUPPORTED EMPLOYMENT • TRANSPORTATION - NON MEDICAL • HOME MODIFICATIONS • SPECIALIZED MEDICAL EQUIPMENT/SUPPLIES

  15. WHAT IS THE RANGE OF TBI WAIVER SERVICES? (cont.) • PERSONAL EMERGENCY RESPONSE • HOME DELIVERED MEALS • EXTENDED STATE PLAN SERVIC ES (THERAPIES) • SKILLED NURSING SERVICES • PERSONAL CARE SERVICES • BEHAVIORAL CONSULTATION/CRISIS MGMT. • DAY REHABILITATION SERVICES

  16. HOW MANY CAN BE ON THE TBI WAIVER? • 1ST YEAR (1999) - 25 • 2ND YEAR (2000) - 50 TOTAL • 3rd YEAR (2001) - 100 TOTAL • 4th YEAR (2002) - 30 TOTAL • 5th YEAR (2003) - 50 TOTAL • 6th through 7th YEAR - 70 TOTAL

  17. WHO IS ON THE TBI WAIVER? • REGIONS 3 & 4 – Caldwell & BoiseCLIENTS IN “BUNDLED” TBI WAIVER PROGRAMS – clients live in their own apartments with 24 hour services • REGION 7 - Idaho Falls area CLIENTS LIVING IN HOMES WITH FAMILY MEMBERS (“UNBUNDLED” SERVICES MODEL).

  18. WHY AREN’T MORE CLIENTS ON THE TBI WAIVER? • Lack of qualified and interested providers • TBI Waiver is relatively new and “unadvertised” • Clients may have their needs already being met under the Aged and Disabled (A&D) or Developmental Disability (DD) Waivers.

  19. WHAT ARE THE ADVANTAGES OF THE TBI WAIVER? • Supported employment not offered on the A&D Waiver • Residential Habilitation (in home services) • Day Rehabilitation (outside of home) • “REHAB” model of services • Array of TBI services may meet client needs better than the A&D or DD Waivers

  20. WHO DO WE GET MORE INFORMATION? • REGIONAL MEDICAID SERVICES: • Region I - Coeur d’Alene 769-1567 • Region 2 - Lewiston 799-4430 • Region 3 - Caldwell 455-7150 • Region 4 - Boise 334-6700 • Region 5 - Twin Falls 736-3020 • Region 6 - Pocatello 235-2875 • Region 7 - Idaho Falls 528-5790 • Medicaid Policy - Arla Farmer - 364-1958

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