The Traumatic Brain Injury Waiver is a Medicaid program that provides home and community-based services to eligible individuals with TBI who are at risk of institutionalization or currently living in an institution and want to transition to the community.
Traumatic brain injury (TBI) is a severe condition affecting millions of Americans yearly. It can cause physical, cognitive, and behavioral impairments that require long-term care and support. According to the Centers for Disease Control and Prevention, TBI contributes to about 30% of all injury deaths in the United States.
For many people with TBI, living in an institution such as a nursing home or a hospital is not the best option. They may prefer to stay in their homes or community settings where they can receive personalized care and maintain their independence. However, the cost of home and community-based services (HCBS) can be prohibitive for many families.
That's why the North Carolina Department of Health and Human Services (NCDHHS) offers a Medicaid program called the Traumatic Brain Injury Waiver. This program provides HCBS to eligible individuals with TBI who are at risk of institutionalization or currently living in an institution and want to transition to the community.
Overview of the Traumatic Brain Injury Waiver in North Carolina
The Traumatic Brain Injury Waiver in North Carolina is authorized under Section 1915c of the Social Security Act. It was approved by the Centers for Medicare and Medicaid Services (CMS) in 2018 and renewed in 2023. It operates in six counties: Cumberland, Durham, Johnston, Mecklenburg, Orange, and Wake.
The waiver aims to provide HCBS to Medicaid beneficiaries who have suffered a traumatic brain injury and have significant cognitive, behavioral, and rehabilitative needs. These services allow beneficiaries, through person-centered planning, to receive the HCBS necessary to enable them to live in the community and avoid institutionalization.
The waiver has two categories: TBI Hospital (BH) and TBI Nursing Facility (BN). The BH category serves individuals who need a specialty hospital rehabilitative level of care, while the BN category serves individuals who need a specialized nursing facility level of care. Both categories have the same eligibility requirements, services, and supports.
The waiver has a limited number of slots available for each category. As of June 2023, there were 100 slots for BH and 150 spaces for BN. The waiver is administered by Alliance Health, a local management entity/managed care organization (LME/MCO) that contracts with NCDHHS to provide behavioral health services in the six counties.
Eligibility Requirements
To be eligible for the Traumatic Brain Injury Waiver in North Carolina, an individual must meet the following criteria:
- Be age 18 or older.
- Be aged, blind, disabled, or both (MAABD or SAABD)
- Have a diagnosis of traumatic brain injury that occurred after age 22
- Have significant cognitive, behavioral, and rehabilitative needs as determined by a comprehensive clinical assessment
- Meet the BH or BN level of care as determined by an independent assessment entity.
- Live in either a private living arrangement or in a living arrangement of six beds or less.
- Reside in one of the six counties where the waiver operates.
- Meet all financial and non-financial eligibility requirements for Medicaid.
- When under age 65, have been determined to be disabled by Disability Determination Services (DDS) or the Social Security Administration (SSA)
Services and Supports
The Traumatic Brain Injury Waiver in North Carolina offers a range of services and supports designed to meet each beneficiary's individual needs and preferences. These include:
- Day supports: Activities that provide opportunities for socialization, education, skill development, recreation, and community integration.
- Personal care: Assistance with activities of daily living such as bathing, dressing, eating, toileting, etc.
- Residential supports: Services that provide supervision, training, assistance, and/or therapeutic interventions in a residential setting
- Resource facilitation: Services that assist beneficiaries with accessing resources such as medical care, transportation, housing, education, employment, etc.
- Respite: Services that provide temporary relief for primary caregivers
- Supported employment: Services that help beneficiaries find and maintain competitive employment in integrated settings
- Occupational therapy: Services that help beneficiaries improve their ability to perform daily activities and participate in meaningful occupations
- Physical therapy: Services that help beneficiaries improve their mobility, strength, balance, and coordination
- Speech and language therapy: Services that help beneficiaries improve their communication, swallowing, and cognitive skills
- Assistive technology: Devices, equipment, or software that help beneficiaries perform tasks that they would otherwise be unable to do or have difficulty doing
- Cognitive rehabilitation: Services that help beneficiaries improve their cognitive functions such as memory, attention, reasoning, problem-solving, etc.
- Community networking: Services that provide opportunities for beneficiaries to develop relationships and participate in community activities
- Community transition: Services that help beneficiaries move from an institutional setting to a community setting
- Crisis supports: Services that provide immediate intervention and stabilization for beneficiaries who experience a behavioral or psychiatric crisis.
- Home modifications: Changes or adaptations to the home environment that increase the safety, accessibility, and independence of beneficiaries
- In-home intensive support: Services that provide intensive behavioral and/or medical help for beneficiaries who have complex needs and require frequent interventions
- Life skills training: Services that teach beneficiaries money management, household management, self-care, etc.
- Natural supports education: Services that provide information and training to family members and other natural supports of beneficiaries
- Remote supports: Services that use technology to monitor and respond to the needs of beneficiaries who live independently or semi-independently
- Specialized consultation: Services that provide expert advice and guidance on specific issues or topics related to TBI
- Supported living: Services that provide ongoing support for beneficiaries who live independently or semi-independently
- Vehicle modification: Changes or adaptations to a vehicle that increase the safety, accessibility, and independence of beneficiaries
Compensation for Caregivers
One of the benefits of the Traumatic Brain Injury Waiver in North Carolina is that it allows beneficiaries to choose who provides their services. This means they can hire family members, friends, or other people they trust as caregivers. This option is called self-direction.
Self-direction gives beneficiaries more control and flexibility over their care. It also allows caregivers to get paid for the work they do. Caregivers can receive compensation for providing personal care, respite, day supports, supported employment, and other services under the waiver.
To become a paid caregiver under the waiver, a person must meet specific requirements such as:
- Be at least 18 years old.
- Have a valid driver's license and reliable transportation.
- Pass a criminal background check and a drug test.
- Complete an orientation and training program.
- Agree to follow the individual support plan (ISP) of the beneficiary.
Caregivers are paid by a financial management service (FMS) agency that handles the payroll, taxes, insurance, and other administrative tasks. The FMS agency also helps beneficiaries budget, hire, manage, and fire their caregivers.
The amount of compensation that caregivers receive depends on several factors, such as:
- The type and amount of services they provide
- The rate of pay set by the LME/MCO
- The budget allocated to the beneficiary by the LME/MCO
The average hourly rate for caregivers under the waiver is $11.50. However, this rate may vary depending on the county, the service category, and the level of experience of the caregiver.
A Note from Givers
If you or someone you love has a TBI and needs home and community-based services, you may be eligible for this program. To find out if you qualify for the waiver and how much you might get paid as a caregiver, please fill out this form. We will contact you shortly with more information.
