Potential Watershed Moment For Brain Injury Advocates: Traumatic Brain Injury Recognized as a Chronic Health Condition
On July 31, 2024, the Brain Injury Association of America (BIAA) released a statement celebrating the Centers for Medicare and Medicaid Services (CMS) recognition of traumatic brain injury (TBI) as a chronic health condition. This recognition is the culmination of strong and persistent education and advocacy by the BIAA and its network of advocates. There is a real possibility that one day, the brain injury community – survivors, family members, supporters, providers, and advocates – will view this decision as a watershed moment in the struggle for access to rehabilitation and long-term care for people living with a brain injury.
Shortly after the BIAA announcement, MBIPC posted our reaction and released a statement applauding the decision. MBIPC’s purpose is to enhance the ability of its members to provide high-quality, ethical rehabilitation, health care, and related services to people with a brain injury. This is accomplished through, among other things, promotions of beneficial legislation and advocacy for brain injury services. Key components to our ability to achieve our purpose are an informed public and educated policymakers. The recognition by CMS of brain injury as a chronic health disease – like heart disease, cancer, diabetes, and autoimmune disorders – will help in these efforts.
As a 2022 report by Public Sector Consultants demonstrates, coverage in Michigan “for post-acute rehabilitation brain injury treatment is severely limited.” This report identifies specific gaps that exist in Michigan that make it extremely difficult to impossible for post-acute providers to serve people who sustain a brain injury in an equitable way, and it documents examples from other states that demonstrate strategies to overcome these barriers.
This edition of Diving Deeper with MBIPC provides an overview of models from other states that Michigan policymakers can learn from and adapt to meet the needs of their constituents living with a brain injury.
State Trust Fund Programs
According to a 2020 report from the National Association of State Head Injury Administrators (NASHIA), twenty-five states have enacted legislation that creates a public-funded trust fund specifically designated for brain injury services. The funds are typically gathered from assessments tacked on to traffic fines or surcharges on license plate renewals, for example.
Oversight of the funds is typically performed by a state agency, and county clerks usually collect the funds. According to the NASHIA report, the use of the funds is targeted and designed by the state and may include:
The creation and maintenance of a registry
Research
Public education and awareness
Prevention
Rehabilitation
Case management or service coordination
Family education
Durable medical equipment or other goods requested by the consumer
An array of rehabilitation and community services and supports
States also design their funds to be paid out through grants, provider agreements, contracts, or direct applications to the state. States can limit access to the funds based on such things as an annual or lifetime limit to the recipient and/or financial requirements.
Medicaid Home and Community-Based Waiver Program
The 2020 NASHIA report provides a concise overview of the Medicaid program and provides context for when and how a state may develop a 1915(c) Home and Community-Based Services (HCBS) Waiver specific to the brain injury population. However, before providing an overview of this type of program, a distinction needs to be made between what we currently have in Michigan and where an HCBS waiver may fit.
Michigan’s state Medicaid program does have a specific Brain Injury Services Program (BISP). Yet, this is not a 1915(c) HCBS program (nor is it a Memorandum of Understanding Program). It is part of the state plan and has a limited scope. For example, there are certain restrictions and requirements in the BISP:
To be eligible for BISP, an individual must meet the following criteria:
Be Medicaid-eligible and at least 21 years old.
Have a qualifying brain injury that occurred within 15 months of application to the BISP.
Be medically stable.
Be able to participate in appropriate therapies as indicated:
For beneficiaries using Transitional Residential services, at least 15 hours per week upon approval for BISP.
For beneficiaries receiving outpatient services, at least nine (9) hours per week.
Be determined appropriate for 60 to 90 days of BIS as supported by a Physical Medicine and Rehabilitation (PMR) physician's order:
For beneficiaries using Transitional Residential services, the order must specify that the physician expects significant progress within the next 90 days to allow for community-based discharge.
These requirements and restrictions significantly limit who can participate in this program. The BISP is a solid program that leads to positive outcomes for those who can access the services through it, and MBIPC appreciates the collaboration we have with the Michigan Department of Health and Human Services with this program; however, limitations such as a 90-day limit in the residential program, age minimum, medical stability requirement, and the length of time since the injury, leave people without access.
One way to overcome this barrier could be to develop a brain injury specific HCBS Waiver Program. According to the NASHIA report, this type of program serves to “offer a broad range of home- and community-based services to people who may otherwise be institutionalized. This option allows states to waive certain Medicaid program requirements, including:
Statewideness: Allows states to target waivers to areas of the state where the need is greatest or where certain types of providers are available.
Comparability of services: Allows states to offer waiver services to only certain groups of people who are at risk of institutionalization, such as brain injury.
Income and resource rules applicable in the community: Allows states to provide Medicaid to people who would otherwise be eligible only in an institutional setting, often due to the income and resources of a spouse or parent. States can also use spousal impoverishment rules to determine financial eligibility for waiver services.”
Nearly half of the states have some version of a TBI/ABI HCBS Waiver Program (a couple of states actually have more than one). These programs are typically not limited to transitional rehabilitation and care but can offer long-term support for someone living with chronic disease while cost-effectively keeping them out of an institution (i.e., nursing home).
Services covered under a HCBS Waiver Program are defined by the state and may include:
Adult daycare
Personal assistant
Case management
Cognitive rehabilitation
Homemaker
Home and vehicle modifications
Durable medical equipment
Therapies
Behavioral programming
Family counseling
Respite
Prevocational services
Supported employment
Personal emergency response systems.
The state’s Medicaid Brain Injury Services Program fills a need for those who fit into the scope of the program and who require short-term intensive rehabilitation; but, to ensure appropriate long-term support exists, an HCBS Waiver Program—specifically designed for the unique needs of people living with the chronic disease of brain injury—has worked for several years in several states.
Commercial Health Insurance Coverage
“The mandate has changed face of brain injury in Texas…The law has enabled providers to provide between three and six months of intensive post-acute treatment. The treatment prepares people for going home and ensures the success of a home plan instead of being doomed to failure because of inadequate resources,”
– Drew Nagele, board-certified neuropsychologist
The 2022 Public Sectors report discusses legislation in Texas and efforts in other states that mandate private commercial health insurance plans to provide coverage for cognitive rehabilitation and post-acute services. The report chronicles the development of the public policy over several years in Texas as their legislature learned of loopholes that were taken advantage of by health insurers and other areas to expand coverage. As Texas paved the way, advocates in other states are advancing similar legislation.
Legislative champions in Massachusetts have advanced legislation intended for commercial health benefit to include the following elements:
Health benefit plans cannot include any lifetime limitation or unreasonable annual limitation on the number of days for acute and post-acute care.
The health benefit plan must also include coverage for reasonable expenses for periodic reevaluation.
The health benefit plan must provide adequate training to personnel responsible for preauthorization of coverage or utilization review in order to prevent denial of coverage.
Expansion of coverage for treatment facilities to include individual practitioners and treatment facilities qualified to provide acute and post-acute care.
A Multi-Dimensional Approach
“This comprehensive approach, with a focus on mandating health plan coverage for brain injury care, is likely to produce substantial health benefits and long-term savings that would likely to outweigh the costs and provide better quality of life for TBI survivors.”
– Concluding statement in 2022 Public Sector report
Each year, 58,000 Michiganders sustain a brain injury. A brain injury can happen to anyone on any given day, without regard to race, ethnicity, gender, age, available support systems, and certainly without regard to health insurance coverage or resources available to access the necessary services that will lead to a healthy recovery and long-term health. Unfortunately, current public policy in Michigan creates extensive barriers to access to care, leaving thousands of citizens each year – and for the rest of their lives - in turmoil.
Michiganders deserve better. They deserve robust public policy designed to minimize the risk of citizens falling through the cracks. They deserve a strategic approach to ensure early and equitable access to post-acute brain injury services and, if needed, long-term support.
This requires a multidimensional approach designed with purpose and clarity. Thankfully for policy makers and elected leaders – trusted by the citizens to act with their welfare in mind – there are roadmaps out there. There are examples from around the country that Michigan can learn from and adapt to meet the needs of our state and our citizens.
Commercial health coverage, a long-term brain injury home and community-based waiver program, and a public trust fund would significantly minimize the chances of someone losing out on positive rehabilitation outcomes and specialized long-term care. In the long run, these public policy initiatives save money. Early intervention significantly reduces the likelihood of health problems down the road, re-hospitalization, re-occurrence, permanent unemployment, involvement in the justice system, and homelessness. But most importantly, early and equitable access to care increases the chances of a productive life full of dignity and worth – things every Michigander deserves.
The MBIPC network is proud to be the leader in providing quality, ethical, evidence-based, expert services to people living with a brain injury. And we are committed to advancing public policy that eliminates barriers to access to care for all Michiganders. We are optimistic about the potential for serious solutions and look forward to working with legislative champions who share the goal of ensuring every Michigander has early and equitable access to the rehabilitation and care they need and deserve.
Sincerely,
Tom Judd
Executive Director
