General

General A. The Division of Medicaid covers certain Home and Community-Based Services (HCBS) as an alternative to institutionalization in a nursing facility through the Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver. B. Beneficiaries enrolled in the TBI/SCI Waiver must reside in a private residence which is fully integrated with opportunities for full access to the greater community and meets the requirements of a Home and Community-Based (HCB) setting in 42 C.F.R. § 441.301(c)(4) and (5). C. The Division of Medicaid does not cover TBI/SCI waiver services to persons in congregate living facilities, institutional settings, on the grounds of or adjacent to institutions, or any other setting that has the effect of isolating persons receiving Medicaid Home and Community-Based Services (HCBS). D. Beneficiaries enrolled in the TBI/SCI Waiver are prohibited from receiving additional Medicaid services through another waiver program. E. Beneficiaries enrolled in the TBI/SCI Waiver who elect to receive hospice care may not receive waiver services which are duplicative of any services rendered through hospice. Beneficiaries may receive non-duplicative waiver services in coordination with hospice services. F. The TBI/SCI Waiver is administered by the Division of Medicaid and jointly operated by the Division of Medicaid and Mississippi Department of Rehabilitative Services (MDRS). G. The Division of Medicaid maintains responsibility for the administration of the waiver and formulates policies, rules, and regulations. Under the direction of the Division of Medicaid, the fiscal agent is responsible for processing claims, issuing payments to providers, and notifications regarding billing. MDRS is responsible for operational functions and maintaining a current Medicaid provider number as outlined in an interagency agreement. H. The average cost for a waiver applicant/beneficiary must not be above the average estimated cost for nursing facility level of care approved by the Centers for Medicare and Medicaid Services (CMS) for the current waiver year. The Division of Medicaid may refuse entrance to the waiver to any otherwise eligible individual when the Division of Medicaid reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State.