A. Brain injury case management services are intended for Medicaid and Family Access to Medical Insurance Security (FAMIS) eligible individuals 18 years of age and older who have a physician or primary care physician documented diagnosis of a severe traumatic brain injury (TBI). Individuals younger than 21 years of age may receive case management services through other state plan options, including developmental disability case management (12VAC30-50-490), mental health and addictions treatment case management (12VAC30-50-430 and 12VAC30-50-491), treatment foster care case management (12VAC30-50-480), or early intervention case management for individuals younger than three years of age (12VAC30-50-415) who meet the criteria to receive case management services. Medicaid and FAMIS eligible individuals who qualify for other state plan targeted case management options may only receive one targeted case management service at a time. The individual will need to choose the targeted case management service option that meets individualized service and support needs. Brain damage secondary to other neurological insults (e.g., infection of the brain, stroke, brain tumor, Alzheimer's disease, and similar neuro-degenerative diseases) shall not be covered. The TBI shall be severe as indicated by a T-score of 50 or above on the Mayo-Portland Adaptability Inventory (MPAI-4).

B. Case management services will be made available for up to 180 days consecutive days of a covered stay in a medical institution. This does not apply to individuals between 22 and 64 years of age who are served in institutions for mental disease or individuals who are inmates of public institutions.

C. Services will be provided to the entire state.

D. Services are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Social Security Act (the Act) is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act.

E. Brain injury services case management services are services furnished to assist individuals eligible under the State Plan in gaining access to needed medical, social, educational, and other services. An individual receiving brain injury services case management services shall have an individual service plan that requires a minimum of one brain injury services case management service activity each month and at least one face-to-face contact with the individual at least every 90 calendar days.

Brain injury case management service activities to be provided shall include:

1. Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social, or other services, including services provided as an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service if applicable. These assessment activities include:

a. Taking client history;

b. Identifying the individual's needs and completing related documentation;

c. Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary) to form a complete assessment of the eligible individual; and

d. Periodic reassessments, including evaluating and updating the individual's progress toward meeting the individual service plan objectives and shall occur as needed and at a minimum every 90 calendar days during a review of the individual service plan with the individual.

2. Development (and periodic revision) of a specific individual service plan that is based on the information collected through the assessment that:

a. Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

b. Includes activities, such as ensuring the active participation of the eligible individual and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and

c. Identifies a course of action to respond to the assessed needs of the eligible individual.

3. Referral and related activities, such as scheduling appointments for the individual, to help the eligible individual obtain needed services, including activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the individual service plan, and

a. Enhancing and linking to community integration through increased opportunities for community access and involvement, such as opportunities to learn living skills to promote community adjustment to the maximum extent possible, vocational, civic, recreational services, and the use of other local community resources available to the general public;

b. Making collateral contacts for the direct benefit of the individual with the individual's significant others (i.e., legally responsible individuals, legal guardians, service providers, anyone with a role in the individual's recovery) with properly authorized releases to promote implementation of the individual's individual service plan and community adjustment;

c. Assisting the individual directly to locate, develop, or obtain needed services, resources, and appropriate public benefits to promote implementation of the individual's individual service plan and community adjustment; and

d. Ensuring the coordination of services and service planning within a provider agency, with other providers, and with other human service agencies and systems, such as local health and social services departments.

4. Monitoring and follow-up activities:

a. Activities and contacts necessary to ensure the individual service plan is implemented and adequately addresses the eligible individual's needs that may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary and including at least one annual monitoring to determine whether the following conditions are met:

(1) Services are being furnished in accordance with the individual's individual service plan;

(2) Services in the individual service plan are adequate; and

(3) Changes in the needs or status of the individual are reflected in the individual service plan. Monitoring and follow-up activities include making necessary adjustments in the individual service plan and service arrangements with providers.

b. On an annual basis, the person-centered individual service plan is conducted to review current status and changes from previous years. It also includes a review of provider plans. As needed outside the annual review, the case manager may convene a meeting to re-evaluate the appropriateness of the plan if the individual's needs have changed. Case managers conduct reviews every 90 calendar days of a services plan and effectiveness of that plan to determine if it remains appropriate and whether modifications are needed.

F. Brain injury services case management includes contacts with noneligible individuals who are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs.

G. Qualifications of providers:

1. The provider of brain injury case management services must meet the following criteria:

a. The enrolled provider must be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) or be licensed by the Department of Behavioral Health and Developmental Services (DBHDS) as a provider of case management services;

b. The enrolled provider shall guarantee that individuals have access to emergency services on a 24-hour basis;

c. The enrolled provider shall demonstrate the ability to serve individuals in need of comprehensive services regardless of the individual's ability to pay or eligibility for Medicaid or Children's Health Insurance Program (CHIP) reimbursement;

d. The enrolled provider must have the administrative and financial management capacity to meet state and federal requirements; and

e. The enrolled provider must have the ability to document and maintain individual case records in accordance with state and federal requirements.

2. Providers may bill Medicaid or CHIP for brain injury case management only when the services are provided by a professional or professionals who meet the following criteria:

a. At least a bachelor's degree from an accredited college or university and a Qualified Brain Injury Support Provider (QBISP) or Certified Brain Injury Specialist (CBIS) or

b. Licensure by the Commonwealth as a registered nurse and a QBISP or CBIS.

H. The state ensures that the provision of brain injury case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act.

1. Eligible recipients will have free choice of the providers of brain injury services case management services.

2. Eligible recipients will have free choice of the providers of other services under the plan.

I. The Commonwealth ensures the following regarding access to services:

1. Case management services will not be used to restrict an individual's access to other Medicaid or CHIP services.

2. Individuals will not be compelled to receive case management services, condition receipt of case management services on receipt of other Medicaid or CHIP services, or condition receipt of other Medicaid or CHIP services on receipt of case management services, and the receipt of case management services shall not be a condition for receipt of other Medicaid or CHIP services.

3. Providers of case management services do not exercise Department of Medical Assistance (DMAS) authority to authorize or deny the provision of other Medicaid or CHIP services.

J. Payment for brain injury case management services under the State Plan does not duplicate payments for other case management made to public agencies or private entities under other program authorities for this same purpose.

K. Brain injury case management shall not include the following:

1. Activities not consistent with the definition of case management services in 42 CFR 440.169.

2. The direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred.

3. Activities integral to the administration of foster care programs.

4. Activities for which third parties are liable to pay, except for case management that is included in an individualized education program or individualized family service plan consistent with § 1903(c) of the Act.