Transcript TBI WAIVER - Idaho TBI

TBI WAIVER
MEDICAID BUREAU OF
BENEFITS AND
REIMBURSEMENT POLICY
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LLOYD FORBES, STATE PLAN AND
WAIVER SERVICES MANAGER
ARLA FARMER, R.N., ALTERNATIVE
CARE COORDINATOR
7/20/2015
WHAT ARE WAIVERS?
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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 costeffective and consumer must meet an
institutional level of care criteria.
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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
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TBI WAIVER HISTORY
(continued)
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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:
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WHAT WERE THE
SURVEY RESULTS?
250 SURVEYS MAILED STATEWIDE;
77 RESPONSES (30.8%) - 59 MALES, 18
FEMALES
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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
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OTHER SURVEY FINDINGS:
Services received on DAILY basis:
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49 received meal prep
48 received personal care
46 received medication assistance
Lowest responses: Respite care (7), therapies
(11).
No responses to supported employment
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MORE SURVEY FINDINGS:
Services received on a REGULAR basis:
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Behavior Consult/crisis management (29)
Supervised care (27)
Transportation (26)
Emergency response assistance (24)
Least Frequent: chore services(5)
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TBI WAIVER
APPROVED
10/98
WHAT CRITERIA IS
REQUIRED FOR TBI WAIVER?
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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
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1. WHAT IS “COST
EFFECTIVE”?
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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.
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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.
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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
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3. WHAT IS THE
DIAGNOSTIC CRITERIA?
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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.
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WHAT IS THE RANGE OF
TBI WAIVER SERVICES?
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RESIDENTIAL HABILITATION
CHORE SERVICES
RESPITE CARE
SUPPORTED EMPLOYMENT
TRANSPORTATION - NON MEDICAL
HOME MODIFICATIONS
SPECIALIZED MEDICAL
EQUIPMENT/SUPPLIES
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WHAT IS THE RANGE OF
TBI WAIVER SERVICES? (cont.)
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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
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HOW MANY CAN BE ON
THE TBI WAIVER?
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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
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WHO IS ON THE TBI
WAIVER?
REGIONS 3 & 4 – Caldwell & Boise
CLIENTS 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).
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WHY AREN’T MORE CLIENTS
ON THE TBI WAIVER?
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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.
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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
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WHO DO WE GET MORE
INFORMATION?
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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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