Traumatic Brain Injury Medicaid Waiver Program
What is the Traumatic Brain Injury Medicaid Waiver?
The New York State Department of Health (DOH) Traumatic Brain Injury (TBI) waiver program provides services to persons with a TBI. The purpose of the program is to help persons with a TBI live in the community setting of their choice. Medicaid funds the program.
To enroll in the TBI waiver, you must:
- Be a Medicaid recipient;
- Choose to live in the community rather than in a nursing facility;
- Be between 18 and 64 years old at the time you apply for waiver services;
- Have a primary diagnosis of TBI or similar non-degenerative condition that results in deficits similar to a TBI such as stroke, or anoxia (oxygen supply loss);
- Be assessed to need nursing home level of care; and
- Have an approved plan of available services that reflects the services you need in order for you to live safely in the community.
In the TBI Medicaid waiver, a Service Coordinator assists you with developing a service plan designed to help you reach your personal goals for living and receiving care, and for achieving maximum independence in your home community. The waiver services in your plan are determined by your strengths, needs, and choice for care.
The New York State Department of Health oversees the TBI waiver program. DOH contracts with “Regional Resource Development Centers” (RRDC) to manage the waiver throughout the State. Each RRDC has a contact person, the “Regional Resource Development Specialist” (RRDS), who oversees enrollment in the waiver and assists in developing needed services.
Services included in the TBI Waiver are:
- Service Coordination;
- Independent Living Skills Training;
- Structured Day Programs;
- Substance Abuse Programs;
- Positive Behavioral Interventions and Supports;
- Community Integration Counseling;
- Home and Community Support Services;
- Environmental Modifications;
- Respite Care;
- Assistive Technology (special medical equipment and supplies);
- Waiver Transportation; and
- Community Transitional Services.
Services not included in the TBI Medicaid Waiver
The TBI Medicaid waiver does not pay for services unless they are identified in your approved service plan. The TBI Medicaid waiver does not include payment for housing, food, or other personal expenses.
Other resources to help with expenses may include:
- Family funds, personal funds, Special Needs Trusts;
- Social Security Insurance (SSI)/Social Security Disability Insurance (SSDI);
- Subsidized housing such as Federal Section 8;
- New York State TBI Housing Program (rental subsidy and housing supports for eligible persons who participate in the TBI Medicaid waiver program); and
- Food stamps.
If you need help to apply for housing or food assistance programs, your TBI Medicaid waiver Service Coordinator will help you.
Important things to remember
- You are responsible for the success of your services.
- You must participate in the development of your service plan.
- You should ask for help if you need it.
- You can express concerns without jeopardizing your waiver participation.
The waiver is a program of choice!
- You choose where to live.
- You choose which services to receive.
- You choose who is on your service plan team: family, friends, and doctors.
- You choose your service providers.
If you are enrolled in the TBI Medicaid waiver, your job is to:
- Follow your service plan;
- Tell staff about your strengths, goals, and areas in which you need help;
- Participate in your team meeting to talk about your services;
- Ask for help when you need it; and
- Read and sign the Waiver Participant Rights and Responsibilities once a year.
The Service Coordinator helps eligible persons to become waiver participants and coordinates their waiver services. When you become a waiver participant, you should remember that you are the primary decision maker in the development of your goals. Together with your Service Coordinator and other individuals that you choose, you select your service providers and other supports. It is your Service Coordinator’s responsibility to learn about you, your situation, and your goals.
- You and your Service Coordinator will meet in person at least once a month to go over your plan. A meeting will be held in your home at least every three months.
- Your Service Coordinator is responsible for making sure that your service providers provide what you need.
- Your Service Coordinator must give you a copy of your service plan, service reports and contact information for all of your providers.
Independent Living Skills Training and Development Services
The purpose of Independent Living Skills Training and Development Services (ILST) is to help you live as independently as possible. These services may include help with self-care, task completion, medication management, problem solving, running your household and money management. ILST services are used to help you become as independent as possible but are not long term.
Structured Day Program Services
Structured Day Program Services are provided in the community and are focused on improving or maintaining your skills and your ability to live as independently as possible. These services may include activities that improve socialization; problem solving skills; supervision of, or assistance with, self-care; medication management; task completion; communication skills; mobility; transportation skills; money management skills; and the skills needed to maintain a household.
Substance Abuse Program Services
Substance Abuse Program Services provide individually designed interventions to reduce or eliminate the use of alcohol and/or other substances that, if not effectively dealt with, will interfere with an individual’s ability to remain in the community.
Positive Behavioral Interventions and Support Services
Positive Behavioral Interventions and Support Services (PBIS) are designed to help you if you have behavioral difficulties that put you at risk for not being able to remain in the community. If you have difficulty responding appropriately to events in your environment, PBIS services will help you to decrease the intensity or frequency of inappropriate behaviors and learn ways to replace them with behaviors that are more socially appropriate.
Community Integration Counseling Services
Community Integration Counseling Services (CIC) are designed to help you manage emotional difficulties that can arise from living in the community. Counseling services may help you in relation to your other family members and friends.
Home and Community Support Services
Home and Community Support Services (HCSS) are provided when you need oversight and supervision to help maintain your health and welfare to live in a community setting. These services may include personal care assistance with Activities of Daily Living (dressing, bathing, hygiene, grooming, toileting, and eating). They may also include Instrumental Activities of Daily Living (housekeeping, shopping, meal preparation, and laundry). These services are supervised by a Registered Nurse and may only be provided if ordered by your physician.
Respite Services provide relief to informal, non-paid supports, such as family and friends, who help you with primary care and support. These services may be provided in your home or another home in the community.
Environmental Modifications Service
Environmental Modifications (E-mods) are physical adaptations to your home or vehicle, which are necessary to ensure your health, welfare, and safety. They are designed to give you greater independence and to help you to remain in the community. Examples of E-mods in your home are ramps, lifts, widened doorways, handrails, and water faucet controls. Examples of E-mods in your vehicle are hand controls, spinner knobs, wheelchair lock downs, and wheelchair lifts.
Assistive Technology Services
Assistive Technology Services are provided to help you with your independence, your ability to access needed supports and services in the community, to maintain or improve your health and safety and which are medically necessary. Examples are devices that help with memory or speech. All other resources must be utilized before considering this service.
TBI waiver services include transportation for non-medical activities that support your living in the community. You must explore and use all other options for transportation (such as informal supports, public transportation, community services) before you request waiver transportation. The need for this service must be included in your Service Plan.
Community Transitional Services
Community Transitional Services (CTS) provide funding for the reasonable costs of one-time expenses for you to transition from a nursing home to your own home or apartment in the community.
Nursing Home Transition Diversion Medicaid Waiver Program
Nursing Home Transition and Diversion (NHTD) Medicaid Waiver Program
The Nursing Home Transition and Diversion (NHTD) Medicaid Waiver Program is a Home and Community Based Services (HCBS) program, administered by the New York State Department of Health (DOH) through contractual agreements with Regional Resource Development Centers (RRDC) and Quality Management Specialists (QMS). The RRDC employs the Regional Resource Development Specialist (RRDS) and Nurse Evaluator (NE), who serve specific counties throughout the State.
The Nursing Home Transition Diversion Medicaid Waiver Program uses Medicaid funding to provide supports and services to assist individuals with disabilities and seniors toward successful inclusion in the community. Waiver participants may come from a nursing facility or other institution (transition), or choose to participate in the waiver to prevent institutionalization (diversion).
Waiver services may be considered when informal supports, local, State and federally funded services and Medicaid State Plan services are not sufficient to assure the health and welfare of the individual in the community, or when waiver services are a more efficient use of Medicaid funds.
Philosophy of the Nursing Home Transition Diversion Medicaid Waiver Program
The Nursing Home Transition Diversion Medicaid Waiver Program was developed based on the philosophy that individuals with disabilities and/or seniors have the same rights as others. This includes the right to be in control of their lives, encounter and manage risks and learn from their experiences. This is balanced with the waiver program’s responsibility to assure the waiver participants’ health and welfare.
Waiver services are provided based on the participant’s unique strengths, needs, choices and goals. The individual is the primary decision-maker and works in cooperation with providers to develop a Service Plan. This process leads to personal empowerment, increased independence, greater community inclusion, self-reliance and meaningful productive activities. Waiver participant satisfaction is a significant measure of success of the Nursing Home Transition Diversion Medicaid Waiver Program.