TBI Medicaid Waiver Program
The TBI Medicaid Waiver Program is designed to provide community-based rehabilitative services and support to help with your rehabilitation after traumatic brain injury (TBI). This is a pilot program managed by Alliance Health in four North Carolina counties (Durham, Wake, Cumberland and Johnston).
What is a TBI Medicaid Waiver?
- Medicaid is a federal and state program that provides health coverage to some individuals who have limited income and resources.
- There are several different types of Medicaid waivers, but all allow individual states to accomplish certain goals, such as reducing costs, expanding coverage, or improving care for certain target groups.
- Home and Community-Based Services (HCBS) waivers are designed to provide home and community-based services to people in need of long-term care. This means they can stay in their own home or a community setting (such as a relative’s home or a supported living community) instead of going into a nursing facility.
Who might be eligible for the TBI Waiver?
Individuals that have sustained an injury to the brain caused by an external force (car/pedestrian accident, fall, abuse, blast, gunshot wound/assault, etc.). This injury can result in long-term changes to one’s thinking, feeling, sensations, and actions.
- Individuals with a non-traumatic brain injury (such as an overdose, lack of oxygen to the brain, tumor, stroke, etc.) are not eligible for this waiver due to their injury being sustained because of internal causes.
Since this an Adult waiver, if your TBI occurred on or after your 22nd birthday, you may be eligible for this waiver.
- For individuals that sustained their TBI on or before their 21st birthday, there are other waivers available (such as the Medicaid Innovations Waiver or the Community Alternative Programs for Children also called CAP-C).
Some individuals after brain injury need specialty hospital care or skilled nursing care due to medical or cognitive (thinking/processing/memory) needs.
- Common needs might be physical movement, thinking/memory, assistance with daily activities (dressing, bathing, eating, etc.), or life skills (budgeting, cooking, cleaning, etc.).
- Documentation for this might include a neuropsychological evaluation or hospitalization/doctor's discharge notes. The more information you have to give to Alliance, the quicker the determination process.
As this is a Medicaid Waiver, individuals need to be eligible for Medicaid to participate in the program. Your first step should be contacting Alliance Health and starting the Medicaid application process online or through your local Social Services office.
- For individuals that do not initially meet Medicaid eligibility, you may be able to pay a “spend down” or an amount you pay to reach eligibility. Other options for securing eligibility may be setting up a Special Needs Trust, accessing an ABLE Account, or seeking out benefits counseling for individuals with disabilities.
What type of services would be available?
Services provided may vary on a case by case basis and will be affected by the county in which the beneficiary (Medicaid recipient) resides.
- Personal care services and supervision, at home or in an assisted living facility
- In-home intensive supports
- Residential supports
- Assistive Technology, Medical supplies and medical equipment
- Chore and homemaking services, such as shopping, laundry, and cleaning
- Respite care to relieve a primary caregiver and natural supports education
- Allied health therapeutic services (physical therapy, speech therapy, occupational therapy) and specialized consultation services
- Cognitive rehabilitation & Life skills training
- Home and/or vehicle modifications, such as ramps and safety rails, to increase independence
- Resource facilitation & community networking
- Assistance transitioning from a rehabilitation/ specialty hospital, psychiatric hospital, skilled nursing facility, licensed living arrangement or family home/one-person AFL (one-time service)
- Access to day supports, services, and activity
- Non-medical transportation services
- Personal emergency response systems or crisis services
What does the pilot program look like & how do I apply?
- The TBI Waiver Pilot Project was approved by Center for Medicare & Medicaid Services (CMS) on May 1, 2018, and is now operational in Alliance Health’s four-county service area (Durham, Wake, Cumberland, and Johnston).
- The services are provided in your own home and community, or in a group living setting – giving you choices and promoting your independence. Under this three-year pilot, 49 individuals will have the opportunity to participate in the TBI waiver the first year, 99 in the second and 107 in the third year.
- The more documentation (diagnosis history, neuropsychological assessment, etc.) you have when you start the process, the quicker eligibility determination for the Waiver may be. If you do not have this information, contact Alliance Health as soon as possible to be connected to a Community Guide. They may help to determine the information needed, eligibility criteria, and next steps.
- If you have questions about eligibility, call Alliance Health’s 24-hour Access and Information line at (800) 510-9132 and request information about the TBI Waiver. Callers should expect to experience a brief crisis screening initially, but continually request to speak to someone about the TBI Waiver.