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Traumatic Brain Injury Waiver

Traumatic Brain Injury Waiver (TBI)

The Traumatic Brain Injury Waiver provides HCBS to Medicaid eligible people of any age who have experienced an external insult resulting in a traumatic brain injury and who require services ordinarily only available in a nursing facility. This waiver is designed to provide supports, such as personal assistance, limited habilitation services, and respite care, as well as limited environmental modifications.

WHO IS ELIGIBLE?

You must meet HCBS waiver eligibility and Medicaid eligibility guidelines in order to be eligible for a Medicaid HCBS waiver. To be eligible, you must be:

  • Aged or disabled;
  • Meet Nursing Facility Level of Care (if brain injury occurred prior to age 22, an individual may meet the ICF/IID Level of Care)
  • Determined to have a Traumatic Brain Injury;
  • Income must not exceed 300% of maximum Supplemental Security Income (SSI) amount (parental income for children under 18 years of age is disregarded)

For more information on eligibility, see the Eligibility Guide.

What is Nursing Facility Level of Care?

To be eligible for services, an individual must meet the required "nursing facility level of care."  Level of care is the minimum need an individual must have to be considered eligible for HCBS waiver services. Level of care is evaluated both when you apply and then at least once a year after that.  The initial level of care determination is made by the Area Agency on Aging.  For the purposes of nursing facility level of care, a person must have one of the following:

  • an unstable, complex medical condition, which requires direct assistance from others for the following conditions: decubitus ulcers, comatose condition, or management of severe pain
  • direct assistance from others for medical equipment, such as ventilator, suctioning, tube feeding, central intravenous access (I.V.)
  • direct assistance for special routines or prescribed treatments from others, such as tracheotomy, acute rehabilitation conditions, administration of continuous oxygen
  • medical observation and physician assessment due to a changing, unstable physical condition
  • other substantial medical conditions.

Level of Care is required in order for the person to be admitted into a nursing facility or initially start waiver services. The waiver case manager will complete an annual Level of Care evaluation for waiver services.

What is ICF/IID Level of Care?

To be eligible for intellectual disability services, an individual must meet the required "ICF/IID level of care."  Level of care is the minimum need an individual must have to be considered eligible for HCBS waiver services. Level of care is evaluated both when you apply and then at least once a year after that. For the purposes of ICF/IID level of care, a person must have a disability that:

  • Results in impairment of functioning similar to that of a person who is intellectually disabled, including autism spectrum disorder, epilepsy, cerebral palsy, or a similar condition (other than mental illness)
  • Originates before the person is twenty-two (22) years of age
  • Has continued or is expected to continue indefinitely
  • Substantially limits a person's ability to function normally in society in three of the six major life areas: self-care, receptive and expressive language, learning, mobility, self-direction, and capacity for independent living
  • Requires access to 24-hour assistance, as needed

AVAILABLE TBI WAIVER SERVICES

  • Adult Day Service
  • Adult Family Care
  • Assisted Living Service
  • Attendant Care
  • Behavior Management/ Behavior Program & Counseling
  • Case Management
  • Community Transition
  • Environmental Modifications
  • Health Care Coordination
  • Homemaker
  • Home Delivered Meals
  • Nutritional Supplements
  • Personal Emergency Response System
  • Pest Control
  • Residential Based Habilitation
  • Respite
  • Specialized Medical Equipment and Supplies
  • Structured Day Program
  • Supported Employment
  • Transportation
  • Vehicle Modifications

APPLYING FOR the TBI WAIVER

When should I apply?

It is helpful to apply as soon as you identify a need for waiver services.

Where Do I Apply?

First, go to your local Area Agency on Aging (AAA). There are 16 Area Agencies on Aging throughout the State. You can learn more about applying for Medicaid by going to the Apply for Medicaid webpage.

If you have been denied Medicaid eligibility before applying for HCBS services, you can re-apply after visiting a AAA office.

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