Covered Services

Covered Services A. The Division of Medicaid covers the following through the Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver services: 1. Case Management services are defined as services assisting beneficiaries in accessing needed waiver services, as well as needed medical, social, educational, and educational services, regardless of the funding source for the services. a) Case Management services, as an administrative activity, must be provided by Mississippi Department of Rehabilitation Services (MDRS) case managers/registered nurses who meet minimum qualifications listed in the waiver and Miss. Admin. Code Part 208, Rule 4.3. b) Responsibilities include, but are not limited to, the following: 1) Initiate and oversee the process of assessment and reassessment of the beneficiary’s level of care. Initial and readmission assessments must be conducted in person in conjunction with a registered nurse. Annual recertification assessments must be conducted in person by the case manager, and a registered nurse must be available for consultation if necessary. 2) Provide ongoing monitoring of the services included in the beneficiary’s Plan of Services and Supports (PSS). 3) Develop, review, and revise the PSS at intervals specified in the waiver. 4) Conduct quarterly in person visits with the person. 5) Complete monthly contacts with the beneficiary. Monthly contacts may be completed telephonically or virtually; however, in person visits for monthly contacts must be completed with beneficiaries if any of the following concerns are identified: (a) Beneficiary/representative is unable to communicate by phone or virtual electronic device due to an auditory, speech or cognitive impairment (b) Beneficiary has unmet needs that cannot be resolved by phone or virtual electronic device. (c) Beneficiary has identified risks for Abuse, Neglect, or Exploitation including the use of restraints or seclusion that require in person monitoring. (d) Beneficiary/representative is unable to be reached by phone or virtual electronic device. 6) Document all contacts, progress, needs, and activities carried out on behalf of the beneficiary. 7) Ensure that all personal care attendants for the waiver meet basic competencies that include both academic requirements (i.e., infection control, principles of safety, disability awareness, etc.) and functional requirements (i.e. bathing, transferring, skin care, dressing, bowel and bladder programs). 2. Personal Care Services (PCS) are non-medical, hands-on care of both a supportive and health-related nature. PCS services are provided to meet daily living needs to ensure adequate support for optimal functioning at home or in the community, but only in non- institutional settings. a) PCS services must be provided in accordance with the approved PSS, cannot be purely diversional in nature, and may include: 1) Support for activities of daily living such as, but not limited to, bathing (sponge/ tub), personal grooming and dressing, personal hygiene, toileting, transferring, and assisting with ambulation. 2) Assistance with housekeeping that is directly related to the beneficiary's disability, and which is necessary for the health and well-being of the beneficiary such as, but not limited to, changing bed linens, straightening area used by the beneficiary, doing the personal laundry of the beneficiary, preparation of meals for the beneficiary, cleaning the beneficiary's equipment such as wheelchairs or walkers. 3) Food shopping, meal preparation and assistance with eating; however, the cost of food, groceries, and meals is not reimbursed by the Division. 4) Support for community participation by accompanying and assisting the beneficiary as necessary to access community resources; participate in community activities; including appointments, shopping, and community recreation/leisure resources, and socialization opportunities; however, the cost of any such activity is not reimbursed by the Division. b) If the beneficiary/representative has not located or chosen a DCW within six (6) months after admission to the waiver, or after being without a DCW for six (6) consecutive months, the beneficiary is reevaluated to determine if the waiver can meet the needs of the beneficiary. 3. Respite services are defined as services to assist beneficiaries unable to care for themselves and are necessary because of the absence of, or the need to provide relief to the primary caregiver. Institutional Respite is limited to thirty (30) days or less annually. In-home Companion and Nursing respite is limited to sixty (60) hours per month. a) Services must be provided in the beneficiary’s home, foster home, group home, or in a Medicaid certified hospital, nursing facility, or licensed respite care facility. b) All respite providers must be certified by the Mississippi Department of Rehabilitation Services (MDRS). 4. Specialized Medical Equipment and Supplies include devices, controls, or appliances specified in the PSS, enable beneficiaries to increase their abilities to perform activities of daily living or to perceive, control, or communicate with the environment in which they live. a) The need for/use of such items must be documented in the assessment/case file, ordered by a physician and approved on the PSS. b) Items reimbursed with waiver funds are in addition to specialized medical equipment and supplies furnished under the Medicaid State Plan. Items not of direct medical or remedial benefit to the person are not covered under the waiver and cannot be reimbursed by the Division. c) Specialized medical equipment and supplies must meet the applicable standards of manufacture, design, and installation. d) Requests for specialized medical equipment and supplies must be evaluated by the Mississippi Department of Rehabilitation Services (MDRS) case manager or the Division of Medicaid to determine if an Assistive Technology (AT) evaluation and recommendation is needed. If an AT evaluation is performed, it must be submitted to the Division of Medicaid along with the PSS and the request for specialized medical equipment and/or supplies for approval. e) Medicaid waiver funds are utilized as the payor of last resort. 5. Transition Assistance services are provided to a Mississippi Medicaid eligible nursing facility (NF) resident to assist in transitioning from the nursing facility into the TBI/SCI Waiver program. a) Transition Assistance services include the following: 1) Security deposits required to obtain a lease on an apartment or home. 2) Essential furnishings required to occupy and use a community domicile. Televisions or cable TV access are not essential furnishings. 3) Moving expenses. 4) Fees/deposits for utilities and service access for a telephone. 5) Health and safety assurances including, but not limited to, pest eradication, allergen control, or one-time cleaning prior to occupancy. b) Transition Assistance is a one (1) time initial expense required for setting up a household and is capped at eight hundred dollars ($800.00) per lifetime. These expenses must be included in the approved PSS. c) To be eligible for Transition Assistance, the beneficiary must meet all of the following criteria: 1) Be currently residing in a nursing facility whose services are paid for by the Division of Medicaid. 2) Have no other source to fund or attain the necessary items/supports. 3) Be moving from a nursing facility where these items/services were provided, and 4) Be moving to a residence where these items/services are not normally furnished. d) Transition Assistance must be completed by the day the beneficiary relocates from the institution. e) Beneficiaries whose NF stay is temporary or rehabilitative, or whose services are covered by Medicare or other insurance, wholly or partially, are not eligible for this service. 6. Environmental Accessibility Adaptation are physical adaptations to the home, required by the individual’s PSS, necessary to ensure the health, welfare, and safety of the individual, or enables the individual to function with greater independence in the home. a) Environmental accessibility adaptations must be included in the approved PSS. b) Environmental accessibility adaptations include the following: 1) Installation of ramps and grab bars. 2) Widening of doorways. 3) Modification of bathroom facilities. 4) Installation of specialized electric and plumbing systems necessary to accommodate medical equipment and supplies. c) Environmental accessibility adaptations exclude the following: 1) Adaptations or improvements to the home which are not of direct medical or remedial benefit to the beneficiary. 2) Adaptations which add to the square footage of the home. d) Requests for environmental accessibility adaptations must be evaluated by the MDRS Rehabilitation Counselor to determine if an Assistive Technology (AT) evaluation is indicated. If an AT evaluation is performed, it must be submitted to the Division of Medicaid along with the PSS and the request for environmental accessibility adaptation. e) MDRS must certify and document that providers meet the criteria/standards in the waiver.