Traumatic Brain Injury (TBI) Waiver
State of New Jersey
Department of Human Services
Division of Disability Services
Home and Community-Based Services Waiver
For Persons with Acquired Traumatic Brain Injuries (TBI)
BackgroundThe TBI Waiver was prepared by the Division of Medical Assistance & Health Services (DMAHS) in response to the Omnibus Budget Reconciliation Act of 1981, Section 2176, Public Law 97-35, and to amendments under Public Law 99-509. This law encouraged the development of community-based services as an alternative for individuals who are in need of long term institutional care.
The waiver application was approved by the Centers for Medicare and Medicaid Services (CMS), effective July 1, 1993, for three years. The waiver is then renewable for five-year periods, as long as it meets federal requirements. The TBI waiver was renewed for a third five-year period, commencing July 1, 2006. Administration of this waiver was transferred to the Division of Disability Services (DDS) in July 2001.
PurposeThis program is designed to provide community alternatives for brain-injured individuals who are currently in nursing facilities or who are in the community and at risk for placement in nursing facilities and who meet the established criteria stated below. The population served is primarily ambulatory young adults with cognitive, behavioral and physical deficits which require supervised and supportive care. Most individuals involved have either completed, or would no longer benefit from, a course of intensive rehabilitation.
The objective of the program is to reintegrate and maintain the brain-injured individual in the community so that supervision is no longer needed or minimized.
SlotsThere are 350 funded slots for this waiver. Slots are assigned/reserved by DDS Central Office staff.
Beneficiaries / Population ServedIndividuals must be financially eligible under the New Jersey Medicaid institutional eligibility standards for both income and resources and have been declared permanently disabled by the Social Security Administration or by the DMAHS Disability Review Section.
Individuals must meet nursing facility level of care standards established by the State’s preadmission screening process and also meet the following criteria:
(1) diagnosis of acquired brain injury after their 21st birthday but prior to turning 65 years of age;
(2) exhibit medical, emotional, behavioral and cognitive deficits;
(3) have a rating of at least 4 on the Rancho Los Amigos Level of Cognitive Functioning Scale.
ServicesAll State Plan services are offered under the waiver, with the exception of Nursing Facility placement, plus the following special waiver services: Case Management, Counseling (behavioral, individual/family and drug/alcohol), Community Residential Services (CRS), Therapies (speech, physical, occupational or cognitive provided by CRS providers), Behavioral Program, Environmental/Vehicular Modifications, Structured Day Program, Supported Day Program, Respite Care (in-home or at a CRS) and Adult Companion.
For participants residing in a CRS, certain services (personal care, night supervision, chore services, transportation and therapeutic recreation) are packaged as part of the CRS daily supervision rate.
For individuals living alone or with families, services are unbundled and offered according to a plan determined by the case manager, the participant and/or their designated representative(s).
Case Management services are provided by certified home health agencies, non-profit homemaker agencies or private, incorporated case management consulting firms.
Structured day programs, offered in full- and half-day segments, consist of paid, continuous, onsite-supervised, community activity.
Supported day programs consist of activity development, initial and periodic support from a professional, (but not ongoing) and continuous paid supervision of the beneficiary.
ProvidersAll service providers must be licensed, certified, or accredited as appropriate. Seven regional case management agencies have been selected to serve the waiver beneficiaries. Other non-traditional waiver services such as Structured Day Program, Supported Day, and Behavioral Programs are provided by agencies accredited by the Commission for Accreditation of Rehabilitation Facilities (CARF).
Eligibility Process And Continued StayAfter financial eligibility has been confirmed by the DDS or the County Board of Social Services, DDS staff will request the preadmission screening for nursing facility (NF) level of care be performed by staff from the Department of Health and Senior Services (DHSS), Long Term Care Field Office. As part of that assessment process, DHSS staff prepares a Health Service Delivery Plan (HSDP). Participants enrolled in the TBI Waiver prior to their 65th birthday may remain on the waiver after reaching that milestone.
An annual review of the participant’s need for nursing facility level care and the continued need for waiver services will be conducted by the participant’s assigned case manager.
Regional Representatives from the DDS review and approve plans of care initially and annually thereafter. Program oversight is provided by the DDS and through the DMAHS Surveillance Utilization Review Subsystem (SURS).
Eligibility Process And Continued Stay
Cost Limitations / RequirementsTotal program costs are limited by the number of community care slots used each year and by costs per participant. Each individual’s service package must be no more than the cost of institutional care, determined at a projected weighted cost of institutional care. There is no retroactive reimbursement of waiver services provided prior to program enrollment.
Further InformationInquiries should be directed to the Division of Disability Services located in Trenton, telephone number (609) 292-4800 or (toll free) at (888) 285-3036. Staff is available to provide technical assistance in the application process and additional information on the program.