New Beginnings - TBI Waiver Information
The Home and Community Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury (HCBS/TBI) began providing services in April 1995. The original Program Manual was created to provide guidelines about the processes and services associated with this innovative program.
Since its inception, the waiver has remained flexible and responsive to the needs of participants and providers. This revised Program Manual reflects these changes and provides further clarification of definitions and scope of the HCBS/TBI waiver services.
The revised Program Manual is dedicated to all participants of the past, present and future, and to those individuals who have assisted people with brain injuries to be in control of their lives and to live as independently as possible in the community.
Introduction to the HCBS/TBI Waiver
The HCBS/TBI waiver is administered centrally by the New York State Department of Health (DOH) and implemented through Regional Resource Development Centers (RRDC) and Specialists (RRDS) who serve to assure access to services in communities throughout the State.
The waiver uses Medicaid funding to provide supports and services to assist individuals with a traumatic brain injury (TBI) toward successful inclusion in the community. Waiver participants may choose to move into the community from a nursing facility. Others may choose to participate in the waiver to prevent unnecessary institutionalization.
HCBS/TBI waiver services are available to supplement informal supports; the broad array of local, State and federally funded services, as well as Medicaid State Plan services to assure the health and welfare of the individual in the community.
Philosophy of the HCBS/TBI Waiver
The dignity of risk and right to fail are integral parts of the waiver’s philosophy. The philosophy of the waiver supports the participant’s right to choose where to live, who to live and socialize with, and what goals and activities to pursue.
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 plan for services. This process leads to personal empowerment, increased independence, greater community inclusion, self-reliance and meaningful and productive activities.
An individual applying to participate in the waiver must meet all of the following criteria:
1. Be a recipient of Medicaid coverage that supports community based long term care services.
2. Have a diagnosisof traumatic brain injury (TBI). NOTE: Individuals who experience deficits similar to a traumatic brain injury as a result of anoxia, toxic poisoning, stroke or other neurological conditions may also be eligible. Individuals with gestational or birth related difficulties such as cerebral palsy or autism or who have a progressive degenerative disease, are not eligible for the waiver.
3. Be between the ages of 18 and 64 upon application to the waiver.
4. Be assessed to need a nursing home level of care as a direct result of the traumatic brain injury. Nursing home eligibility is determined by the Hospital and Community Patient Review Instrument and SCREEN (PRI/SCREEN). The form must be dated within 90 calendar days of the individual’s application packet to the waiver and be completed by an individual certified to use the tool.
5. Choose to participate in the waiver rather than reside in a nursing facility by signing the Freedom of Choice form, Application for Participation form and Service Coordination Selection form.
6. Identify the residence in which the waiver participant will be living when receiving waiver services.
7. Complete an Initial Service Plan and Application Packet in cooperation with a Service Coordinator and be approved by the RRDS. This Plan must describe why the individual is at risk for nursing home placement without the services of the waiver and indicate how the available supports and requested waiver services identified in the Plan will support the health and welfare of the potential participant.
8. Have a completed Plan for Protective Oversight (PPO).
Steps to Becoming a Waiver Participant
The following steps describe the application process for becoming a waiver participant:
STEP 1 Potential participant contacts the RRDS in the region where he/she chooses to reside.
STEP 2 The RRDS describes the waiver philosophy and available services to the potential participant and makes a preliminary determination of probable eligibility for the waiver.
The RRDS provides the potential participant with a list of approved Service Coordination providers and encourages him/her to interview potential Service Coordinators.
The potential participant selects a Service Coordination Agency from the list of approved providers, completes the Service Coordinator Selection Form and returns it to the RRDS.
The RRDS forwards the Service Coordinator Selection form to the selected provider for their signature, indicating that they are willing and able to accept the applicant.
The applicant, and anyone he/she may choose, work with the Service Coordinator to develop an Initial Service Plan and complete the Application Packet.
The Service Coordinator sends the completed Application Packet to the RRDS.
The RRDS reviews the Application Packet and either approves the Packet or requests, in writing, revisions and /or additional information needed for approval.
A Notice of Decision (NOD) is issued by the RRDS for an approved Application Packet. The Notice of Decision indicates the start date for the initial six months of waiver participation. Ongoing program participation is based on the participant’s choice to remain in the waiver, continued Medicaid and level of care eligibility, and the completion of periodic Revised Service Plan updates and approval by the RRDS.
Every NOD must include information regarding an individual’s fair hearing rights.
NOTE: On occasion, a participant may choose to relocate. If the participant relocates to a region covered by another RRDS, the current RRDS is responsible for making the initial contact with the RRDS in the relocation region. The RRDS from the new region must then contact the individual to provide the list of approved Service Coordination providers in that region.
Notice of Decision for Denial or Discontinuation of Waiver Services
A Notice of Denial is sent when an individual is not eligible to receive waiver services for the following reasons:
(1) The participant chooses not to receive waiver services.
(2) The participant is: • Not Medicaid eligible;
• Not assessed to a nursing home level of care based on the PRI/SCREEN; or • Not capable of living in the community with a combination of informal supports,
non-Medicaid public and/or private supports, State Plan Medicaid services, and/or supports available through the waiver program.
(3) The services and supports available through the waiver and all other sources are not sufficient to maintain the individual’s health and welfare in the community.
(4) The participant chooses to receive services from another Home and Community Based Services Medicaid Waiver.
(5) The cost of the Service Plan is above the level necessary to meet the federally mandated requirement that waiver services must be cost neutral in the aggregate when compared to statewide nursing home costs.
A Notice of Discontinuation will be sent to the participant when any of the following occur:
(1) The participant is hospitalized for more than 30 days and there is no scheduled discharge date;
(2) The participant is admitted to a nursing home, psychiatric facility or other institution for other than a short term; or
(3) The participant is incarcerated for more than 30 days.
Fair Hearings/Administrative Meeting
Individuals receiving a Notice of Decision (NOD) for issues related to the waiver are eligible for a fair hearing and, in some instances, may request aid to continue. All NODs must include information regarding an individual’s fair hearing rights.
An individual has the right to seek a Medicaid Fair Hearing for many reasons including issues related to the HCBS/TBI waiver. Decisions regarding Medicaid eligibility are addressed through the fair hearing process with the local Department of Social Services.
If a participant receives any Notice of Decision from the RRDS, an Administrative Meeting may be conducted prior to pursuing a formal Medicaid Fair Hearing. A review by the RRDS may be requested by the participant, an advocate, Service Coordinator or anyone involved in the development of the Service Plan.
This review is an opportunity for the participant and advocates to review with the RRDS the reasons for the NOD and address information they feel is not properly represented. Through discussion and negotiation, it may be possible to resolve issues without a Medicaid Fair Hearing.
Issues about the waiver that are addressed through the Medicaid Fair Hearing process include:
(1) Was the applicant offered the choice of waiver service(s) as an alternative to a nursing home;
(2) Was the applicant or participant denied the service(s) of his or her choice;
(3) Was the applicant or participant denied the services of a qualified provider that was willing to serve the applicant or participant;
(4) Was the decision of denial or discontinuance of waiver services correct; and (5) Was the decision to reduce or eliminate waiver services correct.
Issues about the waiver that are NOT addressed through the Medicaid Fair Hearing process include:
(1) Was the applicant or participant in need of a nursing home level of care (as determined by the PRI/SCREEN);
(2) Does the waiver have any openings based on the number of participants approved for the waiver as specified by the federal government; and
(3) Does the applicant have a traumatic brain injury (TBI) as defined by the waiver.
Waiver Participant’s Rights and Responsibilities
A waiver participant is assured certain rights, and must agree to certain responsibilities related to participation in the waiver program.
The Service Coordinator is responsible for explaining to the waiver applicant/participant, the rights and responsibilities of being a waiver participant. These rights and responsibilities should be reviewed with the participant at least annually, and any time the Service Coordinator is aware that the participant does not understand his/her rights or responsibilities.
The Waiver Participant’s Rights and Responsibilities must be signed and dated by the applicant. The original document is included in the Application Packet. A copy is given to the participant to be maintained in an accessible location in the participant’s home.
As a Waiver Participant, You Have The Right To:
Be informed of your rights prior to receiving waiver services;
Receive services without regard to race, color, creed, gender, national origin, sexual orientation or disability;
Be treated as an individual with consideration and respect;
Have access to services that support your health and welfare;
Assume reasonable risks and have the opportunity to learn from these experiences;
Be provided with an explanation of services available through the HCBS waiver and other health and community resources that may benefit you;
Have the opportunity develop, review and approve all Service Plans, including changes to the Service Plan;
Select individual service providers and choose to receive additional waiver services from different agencies or different providers within the same agency without jeopardizing participation in the waiver;
Request a change in services (increase, decrease or discontinuation) at any time;
Be informed of the name and duties of any person providing services to you under your Service Plan;
Have input into when and how waiver services will be provided; Receive services from approved, qualified individuals;
Receive from the Service Coordinator a list of telephone numbers and supervisors for all your service providers, the RRDS and DOH;
Refuse care, treatment and services after being fully informed of and understanding the consequences of such actions;
Have your privacy respected, including the confidentiality of your personal records, and have the right to refuse the release of the information to anyone not authorized to have such records, except in the case of your transfer to a health care facility or as required by law or Medicaid requirements;
Submit complaints about any violation of rights or and any concerns regarding your services provided without jeopardizing your participation in the waiver;
Receive support and direction from the Service Coordinator to resolve your
concerns and complaints about services and service providers;
Receive additional support and direction from the RRDS and/or DOH in the event that if your Service Coordinator is not successful in resolving your concerns and complaints about services and service providers;
Have your complaints responded to and be informed of the resolution;
Have your service providers help protect and promote your ability to exercise all your rights; identified in this document; and
Have all rights and responsibilities outlined in this document forwarded to the committee or legal guardian authorized to act on your behalf.
Waiver Participant’s Responsibilities
As a participant, you are responsible for:
Working with your Service Coordinator to develop/revise your Service Plan to assure timely reauthorization of the Service Plan;
Working with waiver providers as described in your Service Plan;
Talking to your Service Coordinator and your other waiver service providers if you want help to change your goals or services;
Not participating in any criminal behavior. You understand that, if you do, your service provider(s) may leave, the police may be called and your continuation in the waiver program may be jeopardized.
Maintaining your home in a manner which enables you to live in the community.
Complying with the rules of the waiver program, and the terms and conditions of any contract you sign regarding the provision of waiver services.