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Medicaid Home-and-Community-Based Waiver Programs in New York State

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Posted: 02 Sep, 2010
by Valerie Bogart (New York Legal Assistance Group)
Updated: 16 Aug, 2018
by Valerie Bogart (New York Legal Assistance Group)

Medicaid home and community-based services [HCBS] are available through waiver programs to groups of individuals who would be eligible for Medicaid if institutionalized and, but for the services, would be institutionalized in a hospital or nursing facility. Under section 1915(c) of the Social Security Act, the federal government grants waivers of requirements that are otherwise applicable to Medicaid “state plan” services.

Congress enacted section 1915(c) of the Social Security Act in the Omnibus Reconciliation Act (OBRA) of 1981. Until then, comprehensive long-term care services through Medicaid were available only in institutional settings. Although mandatory home health services and optional personal care services were available as Medicaid benefits before OBRA 1981, states had largely restricted their use and limited the amount of services - New York being an exception with its personal care program and the Lombardi or Long Term Home Health Care Program (LTHHCP), which was established by Chapter 895 of the New York Laws of 1977. In fact, Congress reportedly modeled 1915(c) waivers in part on New York’s experience with the Lombardi program.

In waiver programs, CMS waives key requirements that apply to Medicaid “state plan” services – those provided to all Medicaid recipients in the state. State plan services are either “mandatory” or “optional,” meaning that a State may elect to include them in the state plan. Once elected by a state, an optional service must still comply with all of the federal requirements. For a waiver, however, waivers of the “statewideness” or “comparability” requirements of federal Medicaid law allow states to create waiver programs that target only a particular population -- limited by age, diagnosis, or geographic area of the state, or that limit the number of waiver slots available. Waiver of the financial eligibility requirements allow states to include individuals who would normally not meet Medicaid’s income/resource guidelines.

Waivers have grown nationally with the momentum to “rebalance” long term care services from institutional care to care in the communities. However, they are not the only Medicaid home care services -- Medicaid programs offer “state plan” services which are part of the state’s statewide Medicaid plan, offered to all people of all ages and diagnoses in the state, if eligible. Unlike waiver services, state plan services may not have a waiting list. New York State has long led the nation in these two state plan services:  personal care (also known as home attendant services in NYC) and certified home health care program (CHHA) services. 

This training outline by Selfhelp Community Services provides background, with statutory and regulatory references, about the various Home and Community Based Waiver Programs in New York State.  A Table of Contents is set forth below.  

Related Links and Documents on Waivers in New York

Note that many of these waivers have been or will be in 2015 or later "carved into" Medicaid managed care, so that managed care plans will be required to provide the waiver services to members who qualify.  Advocates are raising concerns that plans lack the expertise and resources to provide these niche services to vulnerable members.

  1. Traumatic Brain Injury (TBI) waiver
  2. Nursing Home Transition & Diversion waiver
  3. OPWDD waivers
  4. Care at Home waivers for children with physical disabilities
  5. OMH Waiver for Children and Adolescents with Serious Emotional Disturbance
  6. Bridges 2 Health (behavioral health
  7. Community First Choice and other New Federal Options for Waivers
  8. Long Term Home Health Care Program (Lombardi/ LTHHCP, includes AIDS LTHHCP) (NOW CLOSED)

Background on Waivers - Federal Law Requirements and Trends - See Cynthia Shirk, Rebalancing Long Term Care: The Role of the Medicaid HCBS Waiver Program, Georgetown University National Health Policy Forum, 2006

GIS 07 MA/018   (elimination of transfer penalty in all waiver programs)1. 

1.   Traumatic Brain Injury (TBI) Waiver

3.    Home and Community-Based Services Waiver- administered by OPWDD- Office for People with Developmental Disabilities (formerly OMRDD)

  • THE HCBS WAIVER IS BEING OVERHAULED INTO THE "People First Waiver" - See this webpage for developments, including videos, message boards, sign up for e-mail information, monthly updates, etc. 
  • The NYS DOH webpage provides a brief description of the HCBS Waiver and which individuals can apply to enroll. 
  • To enroll in the HCBS Waiver, contact the Eligibility Coordinator at the Developmental Disabilities Regional Office that covers the county where the individual lives or search for a provider agency that provides “service coordination” in the county where the individual lives by using the OPWDD Provider Directory.  
  • GIS 07 MA/018 explains that there is no transfer penalty, or “look-back” period, for HCBS Waiver applicants. 

***NOTE: Individuals who have Medicaid do not need to be enrolled in the HCBS Waiver in order to receive OPWDD services, however OPWDD does need to determine them “eligible” for OPWDD services.  The eligibility review process starts at one of OPWDD’s five Developmental Disability Regional Offices (DDROs).  Each DDRO provides services to a specific county or group of counties.   Certain documents, including reports from assessments conducted by qualified practitioners to support a qualifying diagnosis of “developmental disability,” must be submitted to the DDRO to receive an eligibility determination, and an individual must be given notice and appeal rights.

4.   Care at Home for Children with Physical Disabilities - Levels I & II

5.  OMH Waiver for Children and Adolescents with Serious Emotional Disturbance

6.   Bridges to Health (B2H) Waiver

7.  Community First Choice and other New Federal Options for Waivers

8.    Long Term Home Health Care Program (Lombardi/ LTHHCP, includes AIDS LTHHCP)

  • GIS 16 MA/011 - Closing the Long Term Home Health Care Program (LTHHCP)   PDF   CLOSED!!!

  • As of April 1, 2013, this program is no longer an alternative to Managed Long Term Care for "dual eligibles" (have Medicare and Medicaid) adults age 21+ who need Medicaid home care services in New York City and other counties in which enrollment in MLTC is otherwise mandatory for this population.  The State has received  approval from CMS to require all LTHHCP/Lombardi recipients in mandatory counties to enroll in MLTC plans.  Additionally, those who are not dual eligibles and who are subject to mandatory enrollment in mainstream Medicaid managed care must enroll in those plans to receive home care services, and leave the Lombardi program.  See MICSA Alert from NYC HRA regarding this mandatory transition.
  • 02 OMM/ADM-4 (May 28, 2002)(Notice and Fair Hearing Procedures for the LTHHCP);

  • 11-LTC-ADM-01 - Long Term Home Health Care Program Waiver Renewal (continuation of spousal protections, some new services within waiver)(April 26, 2011)

    Long Term Home Health (Lombardi) Program Complaint Process

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Training Outline on Waivers in New York State by Selfhelp Community Services

Provides background, with statutory and regulatory references, about the various Home and Community Based Waiver Programs in New York State. 

1.   HCBS Waivers:  Federal Landscape.............................................................................................................4
2.   Introduction – 1915(c) Waivers.......................................................................... .......................................... 4
  • Waivers vs. State Plan Services..........................................................................                                    5
  • Table 1 -- Comparison of  National and NYS Medicaid Spending on Community-Based vs. Institutional 
    Long-Term Care.......... ................................ ..............................................................................           6
  • Two Main Waiver Requirements – Avoid Institutionalization and Cost Neutrality  ..................................       7
3.    Medicaid HCBS Waiver Programs in NYS (adults) ...................................... .............................................   7
  1. TABLE 2:  COMPARISON OF NYS AND NATIONAL ENROLLMENT, EXPENDITURES, AND WAITING LISTS FOR HCBS WAIVERS............................................................................................................................................8

  2. FINANCIAL ELIGIBILITY ISSUES FOR WAIVERS...................................................................................9

  3. Long Term Home Health Care PROGRAM (LTHHCP) Lombardi     ...............................................   11                         

  4. Traumatic Brain Injury (TBI) Waiver Program........................................................................................   14

  5. Nursing Home Transition and Diversion Waiver (NHTD).................................. .......................................  20

  6. NYS Office of PEOPLE WITH DEVELOPMENTAL Disabilities Waivers (formerly called OMRDD)..   24

4.   CHILDREN’s WAIVERS:................................................................................... .......................................28

  • Care at Home for Children with Physical Disabilities - Levels I & II...............  ..........................................28
  • OMH Waiver for Children  with Serious Emotional Disturbance..............................................................  30
  • Bridges to Health (B2H) Waiver....................................................................... ....................................33
5.  New Options under Federal Law – PPACA................................................................................................. 35
  • Community First Choice Option, PPACA § 2401, Recon. Act § 1205.
  • Removal of Barriers to Providing HCBS  services, PPACA § 2402.
  • Expansion of State Plan 1915-i Option to Provide HCBS Services..
  • Money Follows the Person Rebalancing Demonstration, PPACA § 2403.
  • State Balancing Incentive Program (Sec 10202 PPACA).

This article was authored by the Evelyn Frank Legal Resources Program of Selfhelp Community Services, Inc.

Selfhelp


Attached files
item Lombardi Program List Statewide with County.pdf (126 kb) Download
item Medicaid Waivers Outline.pdf (221 kb) Download
item 2013-04-18 lombardi mltc.pdf (102 kb) Download

Also read
item Medicaid Personal Care or Home Attendant Services
item The Various Types of Medicaid Home Care in New York State
item New "HARP" Plans Roll out for Managed Care Members who need Behavioral Health Services - Services Start January 2016 in NYC
item Medicaid Certified Home Health Agency (CHHA) Services
item Nursing Home Medicaid Coverage - Basic Financial Eligibility Rules about Income, Resources, and Spousal Protections
item Managed Long Term Care
item Medicaid Managed Care
item Spousal Impoverishment Protections for Married Couples where One Spouse is in a Managed Long Term Care Plan - Pooled Trusts Allowed as an Option

Also listed in
folder Medicaid -> Other Services

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