Traumatic Brain Injury Waiver
Traumatic Brain Injury Waiver
The Traumatic Brain Injury (TBI) waiver provides home- and community-based services (HCBS) to individuals who would require institutional care without such services. Through the use of the TBI waiver, the Indiana Office of Medicaid Policy and Planning (OMPP) and the Indiana Division of Aging (DA) seek to increase availability and access to cost-effective TBI services to people who have suffered a traumatic brain injury. Indiana defines a traumatic brain injury as a trauma that has occurred as a closed or open head injury by an external event that results in damage to brain tissue, with or without injury to other body organs. Examples of external events are: mechanical; or events that interfere with vital functions. Traumatic brain injury means a sudden insult or damage to brain function, not of a degenerative or congenital nature. The insult of damage may produce an altered state of consciousness and may result in a decrease in cognitive, behavioral, emotional or physical functioning. This could cause partial or total disability not including a birth trauma-related injury.
Individuals must meet both HCBS waiver eligibility and Medicaid eligibility guidelines to be eligible for a Medicaid HCBS waiver. To be eligible, individuals must:
- Be aged or disabled
- Be determined to have a traumatic brain injury
- Have income no greater than 300% of the maximum Supplemental Security Income amount (parental income for children under 18 years-of-age is disregarded)
- Meet nursing facility level of care if brain injury occurred at 22 years of age or older or meet Intermediate Care Facility for Individuals with Intellectual Disabilities/Development Disabilities (ICF/IID) level of care if brain injury occurred before 22 years of age.
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
- 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 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 22 years of age
- Has continued or is expected to continue indefinitely
- Substantially limits the 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 Waiver Services
Eligible individuals may receive authorized waiver services in conjunction with Traditional Medicaid. Authorized waiver services may include:
- 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
- Home Delivered Meals
- Nutritional Supplements
- Personal Emergency Response System
- Pest Control
- Residential Based Habilitation
- Specialized Medical Equipment and Supplies
- Structured Day Program
- Supported Employment
- Vehicle Modifications
The specific services that meet the needs of the individual member are identified by the member’s case manager. These services are submitted to the state agency for approval and are listed on the member’s Plan of Care (POC)/Notice of Action (NOA).
To apply, go to your local Area Agency on Aging (AAA). There are 16 Area Agencies on Aging throughout the State. It is helpful to apply as soon as you identify a need for waiver services.
You must also apply for Medicaid. You can learn more about applying for Medicaid by going to the Apply for Coverage webpage.
If you have been denied Medicaid eligibility before applying for HCBS services, you can re-apply after visiting an AAA office.
To become a Medicaid provider under the TBI waiver, a provider must first be certified by the Indiana Family and Social Services Administration, Division of Aging (FSSA, DA). Waiver providers can be certified to provide multiple waiver services. To find out more about the certification process, visit the DA’s Indiana Home and Community Based Services Waiver webpage.
After certification, the provider must then enroll as an Indiana Health Coverage Programs provider. Visit the IHCP Become a Provider webpage for more information about that process. Note that some providers also offer nonwaiver services within the IHCP. These providers are issued two unique provider identification numbers for billing purposes - one for waiver billing and one for nonwaiver billing. Providers must submit claims using the provider ID number that corresponds to the services entered on the claim. The waiver services that can be provided to a TBI Waiver member are limited to those listed on the member’s individualized POC/NOA.
For more information about providing TBI waiver services, see the Division of Aging Home and Community-Based Services Waivers and the Home and Community-Based Services Billing Guidelines provider reference modules.