TBI Waiver Initiative

NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF LONG TERM CARE
Traumatic Brain Injury Initiatives
Home and Community-Based Services
Medicaid Waiver for Individuals with
Traumatic Brain Injury

The Home and Community-Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury (HCBS/TBI) is one component of a comprehensive strategy developed by the New York State Department of Health to assure that New Yorkers with a traumatic brain injury could receive services within New York in the least restrictive setting.

Philosophy

The HCBS/TBI waiver was developed based on the philosophy that:

  • An individual with a TBI has the same right to be in control of his or her life as anyone else in our society.
  • An individual with a TBI must be able to choose where he or she wants to live, with whom he or she will live and who will provide any needed services.
  • An individual with a TBI has the right to learn as a member of society, by encountering and managing risks and, through experience, learn from related failures.

What is a HCBS Medicaid Waiver?

  • Medicaid has an institutional bias providing comprehensive services only on an inpatient basis; a waiver is an opportunity for comprehensive services to be available in the community.
  • A HCBS waiver allows states to assemble a package of carefully tailored services to comprehensively meet the needs of a targeted group in a community-based setting.
  • A state must assure, through an individualized service plan, the waiver participant’s health and welfare.
  • A state must assure that the overall cost of serving the waiver participants in the community is less than the cost of serving this same group in an institution.

Why did New York State Develop the HCBS/TBI Medicaid Waiver?

  • In the 1970′s and 80′s New York was sending individuals with TBI to out-of-state nursing homes. By the late 1980′s, 500 people were in those facilities at a cost to Medicaid of $56 million.
  • The HCBS/TBI waiver provides a cost-effective community- based alternative to nursing facility care.
  • Individuals with TBI and their families advocated for community-based services and supports.
  • Institutional care prevents an individual with a TBI from becoming reintegrated into his/her home community.

Expected Outcomes from the HCBS/TBI Waiver

  • Individuals with TBI will be able to choose where and with whom they live.
  • Individuals with TBI will be able to live self-satisfying lives.
  • With a decrease in reliance on expensive nursing facility care, the State Medicaid program will realize significant savings.

To be Eligible for the HCBS/TBI Waiver an Individual

Must:

  • Have a diagnosis of TBI or a related diagnosis
  • Be eligible for nursing facility level of care as determined bya Patient Review Instrument (PRI) and SCREEN
  • Be a Medicaid recipient
  • Be 18-64 years old
  • Choose to live in the community rather than a nursing facility
  • Have or find a living arrangement which meets the individual’s needs
  • Be able to be served with the funds and services available under the HCBS/TBI waiver and New York State Medicaid State Plan Regional Resource Development Centers (RRDC)

The HCBS/TBI waiver is administered through a network of RRDCs, each covering specific counties throughout the State. The contact person at the RRDC is the Regional Resource Development Specialist (RRDS).

The RRDS is responsible for:

  • Interviewing potential waiver participants
  • Assisting participants to access approved providers
  • Approving Service Plans
  • Reviewing Incident Reports
  • Maintaining regional budgets for waiver services

Source of Supports and Services for Waiver Participants

Informal Supports

  • Family
  • Friends
  • Community

Other State and Federally Funded Services

  • VESID
  • HEAP
  • Housing subsidies/subsidized housing
  • Education benefits
  • Mental health
  • Substance abuse services
  • Other

Medicaid State Plan Services and Supports

  • Clinic
  • Physician/dentist
  • Hospital
  • Therapies
  • Home health – including personal care
  • Pharmaceuticals
  • Medical transportation
  • Medical supplies and equipment
  • Eyeglasses
  • Hearing aids
  • Consumer Directed Personal Assistance Program
  • Other

HCBS/TBI Waiver Services

  • Service coordination
  • Independent living skills training and development
  • Structured day program
  • Substance abuse programs
  • Intensive behavioral programs
  • Community integration counseling
  • Home and community support services
  • Environmental modifications
  • Respite care
  • Assistive Technology
  • Transportation
  • Community Transition Services

HCBS/TBI Waiver Services

  1. Service CoordinationThe key to individual choice and satisfaction is person- centered service coordination. The Service Coordinator:
    • Is responsive to the individual and helps the waiver participant identify his or her unique needs;
    • Promotes activities which will increase the individual’s independence and life satisfaction;
    • Assists in the integration of the individual in the community of his/her choice;
    • Helps in increasing the individual’s productivity and participation in meaningful activities; and
    • Assists in arranging for daily living supports and services to meet the individual’s needs.
  2. Independent Living Skills Training and Development
    Improves and maintains the individual’s community living skills so that the individual can live as independently as possible. This will be done primarily in one-on-one training, and focuses on practical needs such as shopping, cooking, money management, use of public transportation, etc. This service is provided in the individual’s residence and in the community.
  3. Structured Day Programs
    Improves and maintains the individual’s community living skills in a congregate non-residential, non-medical setting. The focus will be on the development of social, problem-solving and task-oriented skills.
  4. Substance Abuse Programs
    Reduces and/or eliminates substance abuse which may interfere with the individual’s ability to be maintained in the community. This service will be specifically designed to meet the needs of individuals with cognitive deficits, and will work with existing community support systems, such as AA or Al- Anon, to assist them in becoming more responsive to people with traumatic brain injuries.
  5. Intensive Behavioral Programs
    Eliminates and/or reduces an individual’s severe maladaptive behavior(s) which, if not modified, will interfere with the individual’s ability to remain in the community. These services are provided in the individual’s residence and in the community and are provided by a highly trained team to an individual, his/her family, or anyone else having significant contact with the individual.
  6. Community Integration Counseling
    Assists the waiver to adjust to the participant and family members to more effectively manage the stresses and difficulties associated with the waiver participant living in the community.
  7. Home and Community Support Services
    Assists the individual’s with the support of non-medical assistance, and includes safety monitoring assistance with activities of daily living and integration into the community.These services can be provided in the individual’s residence or in the community. These non-medical services are a compliment to personal care services provided under Medicaid.
  8. Environmental Modifications
    Provide for physical adaptations to the individual’s residence and primary vehicle which ensure the individual’s health, safety and welfare and which increase the individual’s independence and integration in the community.
  9. Respite Care
    Provides short-term relief for informal caregivers of individuals who are unable to care for themselves. This service will be provided primarily in the individual’s residence.
  10. Assistive Technology
    Provides durable and non-durable medical equipment not usually funded under the Medicaid State Plan. An example of the equipment available through this service is a three wheel cart for mobility purposes.
  11. Social Transportation
    Provides the means to access non-medical services in the community in order to improve the individual’s ability to make use of needed services, and to improve the individual’s integration in the community.
  12. Community Transition Services
    Assists individuals leaving nursing homes by providing assistance with payment of a Security deposit, utility set up fees, moving expenses, purchase of essential furniture, and initial cleaning service. This service has a budget cap.

Room and Board

The federal government does not allow funds provided under any Medicaid waiver to be used for housing or food. These necessities must be paid for through other funds including:

  • Family or personal funds
  • SSI/SSDI
  • Subsidized housing
  • HCBS/TBI waiver housing funds
  • Food Stamps

The Use of a Regional Aggregate Budgeting System

The HCBS/TBI waiver will use a regional aggregate cap in determining the amount of funds available for waiver services. This will:

  • Provide the opportunity to serve individuals with greater needs
  • Assure that the maximum benefits possible under the waiver will be realized
  • Allow for maximum creativity and innovation
  • Increase flexibility to accommodate an individual’s short term needs

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