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. WARNING: This manual has not been updated. Older cites may be correct, but more updated cites in this article.
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.
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.
DOH Fact Sheet on TBI waiver - not updated with new contact info for NYC - see below
DOH webpage on TBI Waiver includes links to:
WHERE TO APPLY -- TBI and NHTDW waivers are administered by RRDCs or Regional Resource Development Centers. However both the fact sheet and RRDC list on DOH website HAVE NOT BEEN UPDATED with new RRDC for New York CIty.
From Nov 1st, 2019 Westchester Independent Living Center (WILC) is the RRDC for NYC and will administer new NHTD/TBI applications filed after that date.
Changes with application process for NYC:
WILC/RRDC will not be accepting NHTD/TBI Waiver referral/application through fax or email. Make all referrals by phone to Daniel Montgomery, WILC at 914-682-3926 extension 2122. (provide Medicaid number, address, contact info, services sought, primary diagnosis/disability). Case will be assigned to staff for the borough.
Contacts related to NHTD (not for new application - see above contact for application):
Contacts related to TBI ((not for new application - see above contact for application):
Description of services available under TBI waiver - in F.R.E.E. Family Residences & Essential Enterprises, Inc. website (one of many providers of TBI waiver services in NYS)
Home and Community Support Services (HCSS) Letter (Apr. 29, 2009, requiring providers of Home and
Community Support Services (HCSS) in the waiver to be licensed home care services agency (LHCSA)
GIS 07 MA/018 (elimination of transfer penalty in all waiver programs)
GIS 12 MA/013 - reinstates spousal impoverishment protections in the Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) waiver programs, in addition to Lombardi (thus repealing NYS DOH GIS 08-MA-024, Aug. 26,2008 which eliminated spousal protections in TBI and NHTDW waivers). See more at Spousal Impoverishment Protections Available in All 1915 Waiver Programs
See NEW RRDC info for New York City above - for applications filed after Nov. 1, 2019
NHTDW/TBI Housing Subsidy -Traumatic Brain Injury Program and Nursing Home Transition and Diversion Program Housing Program Guidelines, October 2019 (PDF) - click on main NHTDW page for all of the attachments
NOTE: The mandatory transition of this waiver to Managed Long Term Care and managed care has been postponed to Jan. 1, 2022 (announced per NYS budget 4/2018). Participants who do not have Medicare will then be required to join Medicaid managed care plans and receive TBI waiver services through the plans. Those with Medicare will be transitioned to MLTC. Assembly bill A07598/ S.5535 - proposes delaying the transition of TBI and NHTD waiver populations to managed care plans. For info contact Traci Allen. See more here.
GIS 07 MA/018 (elimination of transfer penalty in all waiver programs)
GIS 12 MA/013 - establishes spousal impoverishment protections in the Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) waiver programs, in addition to Lombardi. See more at Spousal Impoverishment Protections Available in All 1915 Waiver Programs
3. Home and Community-Based Services Waiver- administered by OPWDD- Office for People with Developmental Disabilities (formerly OMRDD)
***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.
Gene Coffey, The-Medicaid-Long-Term-Services-And-Supports-Provisions-In-The-Senate’s-Patient-Protection-And-Affordable-Care-Act, National Senior Citizens Law Center, January 2010
NSCLC, Advocates Guide to Medicaid Long Term Services and Supports, Sept. 2012
Community First Choices Option in NYS (Leah Farrell, CDRNYS)
Leading Age info on Community First Choice
5. New Children’s Home and Community Based Services began on April 1, 2019 through the consolidated 1915(c) Children’s Waiver. Waiver consolidates various 1916(c) individual waivers listed below and others listed on this DOH webpage about the children's transition.
This brochure is available online. Translated versions in Arabic, Chinese, French, Haitian-Creole, Italian, Korean, Russian, Spanish, and Urdu will be available in the coming weeks (per DOH release 4/18/19).
See DOH webpage about the children's transition.with many resources. Also see 19ADM-02 - Consolidated Children’s Waiver and Medicaid Case Processing Requirements (PDF)
These are some of the children's waivers being consolidated:
Care at Home Case Management Waiver Program for Children - state directives in http://www.health.state.ny.us/health_care/medicaid/publications/index.htm
GIS 09 OLTC/004 (April 2009);
GIS 10 OLTC/002 (palliative care now available),
90-ADM-20 (May 30, 1990); 92 LCM 170 --
DOH - Care At Home: A Manual for Parents (Currently under revision)
6. Long Term Home Health Care Program (Lombardi/ LTHHCP, includes AIDS LTHHCP) --CLOSED
GIS 16 MA/011 - Closing the Long Term Home Health Care Program (LTHHCP) PDF CLOSED!!!
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