N.J. Admin. Code § 10:141-1.11

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:141-1.11 - Eligible supports and services

(a) The following is a list of eligible supports and services that will be considered for sponsorship under the Fund:

1. Service coordination, defined as intensive assistance with resource coordination and advocacy. Only a credentialed care manager with experience in brain injury, who is employed by an agency, shall provide services;

2. Nursing services, defined as assessment and intervention related to professional nursing practice. A registered nurse or licensed practical nurse shall provide nursing services;

3. Neuropsychiatric/neuropsychological evaluation, defined as assessment of the beneficiary's deficits and strengths with recommendations for a treatment plan if necessary. A licensed psychiatrist or psychologist with knowledge of and experience with brain injury shall provide services;

4. Medication management, defined as monitoring of prescription medication, drug interactions, and modifications related to the brain injury. A licensed physician, nurse practitioner or clinic with experience in treating brain injury shall provide services;

5. Prescription medication, defined as the provision of medications to treat/manage the traumatic brain injury, as prescribed by a physician. A licensed pharmacist/pharmacy shall provide service;

6. Behavior management, defined as a time-limited program designed to assess and treat maladaptive or aggressive behavior, which is potentially destructive to the beneficiary or others. A licensed psychologist or psychiatrist, with experience in brain injury, shall provide service;

7. Substance abuse evaluation/treatment, defined as clinical intervention to resolve alcohol and/or drug problems experienced by the person with a traumatic brain injury. A certified alcohol and drug counselor with experience treating brain injury or a licensed alcohol/drug program shall provide services;

8. Counseling services, defined as individual or group intervention to resolve adjustment problems resulting from the brain injury. A licensed psychiatrist, psychologist, social worker or counselor shall provide services;

9. Cognitive rehabilitation therapy, defined as a time-limited intervention to improve memory, orientation, reasoning, appropriate verbal and behavioral responses. A professional who meets the certification standards for cognitive rehabilitation therapy as established by the Society for Cognitive Rehabilitation shall provide services;

10. Physical therapy, defined as a time-limited intervention to improve or maintain physical function, including muscle tone, gait and mobility. A licensed physical therapist or physical therapy assistant under supervision of a physical therapist shall provide services;

11. Occupational therapy, defined as a time-limited intervention to improve or maintain fine motor coordination and dexterity related upper body functions. Services shall be provided by a registered occupational therapist or a certified occupational therapy assistant;

12. Speech-language therapy, defined as a time-limited intervention to improve vocal and verbal skills, comprehension and expression, compensatory strategies or other treatments related to swallowing. A licensed speech-language pathologist or licensed speech therapist shall provide services;

13. Alternative therapy is defined as a heterogeneous set of practices or treatment modalities that are offered as an alternative or complementary adjunct to conventional medicine for the treatment of brain injury. Treatment modalities are time limited and must be approved by a national regulatory authority specifically for the treatment of brain injury. Evidence must be produced by the applicant/beneficiary of the efficacy and cost benefit of the particular therapy in treating brain injury. Providers of alternative therapy must be credentialed and recognized by an appropriate governing/regulatory body. Alternative therapy under the Fund shall be limited to:

i. Aqua therapy, which is a treatment where the patient is submersed in water to strengthen and to stretch muscles, ligaments and tendons and to build physical endurance;

ii. Biofeedback/neurofeedback, which is a non-invasive procedure that involves attaching sensors to the body. The sensors measure physical and cerebral response to internal and external stimuli. The patient can be trained to detect the subtleties of the body signals and learn new physiological responses;

iii. Chiropractic therapy, which is a therapy that emphasizes treatment of mechanical disorders of the musculoskeletal system, focusing on manual manipulation of joints, spine, and soft tissue;

iv. Hippotherapy, which is a physical, occupational and speech therapy treatment strategy that utilizes equine movement; and

v. Acupuncture/accupressure, which are Eastern holistic techniques that utilize needle sticks or pressure to manipulate body energy to relieve pain;

14. Structured day program, defined as a professionally managed program of meaningful group or individual activities provided during the day, in or out of home, with the purpose of developing or maintaining function and independence. A licensed community residential service provider agency, Commission for the Accreditation of Rehabilitation Facilities (CARF) accredited brain injury day program, or licensed medical day care center may provide services;

15. Life skills training, defined as teaching specific instrumental activities of daily living to increase independence and function. A professional with expertise in treating brain injury shall provide services;

16. Vocational services, defined as prevocational and extended vocational support to assist the beneficiary in obtaining and maintaining employment. A vocational professional with experience working with brain injury shall provide services;

17. Educational service, defined as assistance to the beneficiary obtaining educational services, including support while attending school or college and other activities related to education. A beneficiary shall provide the Fund with documents verifying eligibility for the educational program and shall demonstrate appropriate progress to be eligible for consideration of ongoing support. A credentialed professional shall provide services. Services are the provision of tutorial support designed to compensate for cognitive deficits associated with traumatic brain injury;

18. Respite care, defined as intermittent, temporary or short-term care to provide relief to or replace an absent or incapacitated unpaid caregiver. Services shall be provided in-home by a licensed or accredited home care agency or out-of-home by a licensed nursing facility, assisted living facility or community residential services program;

19. Medical care, defined as sub-acute treatment directly related to the traumatic brain injury. A licensed practitioner shall provide services;

20. Vision care, defined as eye care directly related to the traumatic brain injury. A licensed ophthalmologist or optometrist with experience in treating individuals with traumatic brain injury shall provide services. Payment for glasses or contact lenses will be limited to once every 12 months;

21. Dental care, defined as rehabilitative or restorative dentistry directly related to the treatment of dental injury related to the onset of, or care related to the traumatic brain injury. A licensed dentist shall provide services;

22. Protective legal services, defined as provision of guardianship services, preparation of a special needs trust and similar services related to the traumatic brain injury where these services are determined essential to the beneficiary's well being. Only attorneys who are members admitted to a state bar shall provide services;

23. Personal care, defined as assistance with eating, bathing, dressing, personal hygiene, activities of daily living, meal preparation and light housekeeping. A certified personal care assistant or home health aide shall provide services. Payments will be made only to licensed or accredited home care agencies, not individual contractors;

24. Companion care, defined as non-medical care, supervision, and socialization provided to the beneficiary to ensure safety and enhance quality of life. An individual experienced in working with brain injury may provide services, or a relative who is not a regular caregiver and does not reside in the residence of the applicant/beneficiary may provide services;

25. Parental support, defined as time-limited support required by a parent with a brain injury, when the parent is unable to perform with normal child rearing activities or defined as support for the parent when a child with a brain injury has behavioral and management problems. Only an adult with experience and training in brain injury and childcare shall provide this service. Support shall be centered on coaching and training the parent to perform parental care responsibilities independently. The parent must be present and involved in care when the service is rendered;

26. Household management, defined as support and assistance for a brain injured person in organizing the daily activities of managing a household, including shopping, meal preparation, housekeeping, bill paying and assistance with mail. This service may also include non-routine housekeeping required by the beneficiary to maintain a safe sanitary environment. An adult or provider agency with an understanding of brain injury shall provide services;

27. Financial management, defined as assistance with bill paying, banking and long-term financial planning when a knowledgeable family member or friend is not available. A financial professional or unrelated adult with experience and knowledge in financial management, depending on the complexity of the activity, shall provide services;

28. Transportation/vehicle modification, defined as payment for transportation services to provide access for the beneficiary to medical appointments, treatment facilities, or vocational programs. Activities under this service may include:

i. The modification of a vehicle specifically for the use/transport of the beneficiary if it is justified under the service plan as appropriate and cost effective. Certified licensed vendors must provide modifications to vehicles. If the vehicle is to be operated by the beneficiary, the beneficiary must have a valid driver's license, and demonstrate capacity to maintain insurance coverage. This benefit is limited to one vehicle per 12-month period;

ii. The purchase of services from a commercial transportation vendor including certified transportation services, such as ambulances, mobility assistance vehicles, or taxis. Payments may be made to the provider of the service or to the beneficiary/family upon presentation of the proof of purchase or service; and/or

iii. Reimbursement of the cost of travel for a beneficiary. The reimbursement shall not exceed the State's mileage rate as defined by the State Treasurer, the cost of any road tolls, and parking charges with valid receipts. This provision may be invoked by the Fund where beneficiaries demonstrate clear hardship in obtaining commercial transportation, or where individual travel reimbursement is in the best interest of the Fund;

29. Environmental modifications, defined as physical adaptation to the beneficiary's primary home necessary to ensure the health, welfare and safety of the beneficiary and/or to enable the beneficiary to function with greater independence. Modifications may include ramps and devices to assist with activities of daily living, room alterations or electrical and plumbing alterations to accommodate special equipment. This definition excludes adaptations or improvements to the home not directly related to the care of the beneficiary and excludes payment of expenses related to returning the environment to its original condition in accordance with Federal and State law. Services shall be provided by companies/businesses licensed to provide the intended modification. Three price quotations shall be required for any project with a cost over $ 1,500; and

30. Durable medical equipment and assistive technology. Durable medical equipment includes any equipment necessary to the beneficiary's health, safety, and function. Assistive technology is defined as any technological device that improves the functional independence of the beneficiary. Equipment and technology must be justified under the service plan as necessary, cost effective, and directly related to clinical rehabilitation. Social interaction and normal usage activities cannot be considered to justify a purchase of equipment or technology. The Fund shall, with clinical documentation of need, consider replacement of equipment after a period of 36 months after the original purchase date. Age and functionality are insufficient reasons to request replacement of equipment. The Fund shall limit purchases to essential computer periphery. This benefit is limited to one hard drive per applicant. This definition excludes payment for routine repairs, upgrades, or service contracts. Such expenses shall remain the responsibility of the beneficiary. Suppliers must be certified equipment providers. Payments may be made to the provider of service or to the beneficiary/family upon presentation of proof of purchase. A certified durable medical equipment provider or technology provider shall provide this service. Replacement or repair of lost or damaged equipment by the Fund is not guaranteed and shall be evaluated on a case-by-case basis.

N.J. Admin. Code § 10:141-1.11

Amended by 49 N.J.R. 1683(a), effective 6/19/2017