Traumatic Brain Injury (TBI) Medicaid Waiver Services


The Home and Community Based Services Medicaid Waiver for individuals with Traumatic Brain Injury (HCBS/TBI) is a community-based program, specifically designed to assist adults who have sustained a brain injury. The intent of this Waiver is to provide specialized services to the individual, in their own home, in order to terminate and/or circumvent a skilled nursing home or rehabilitation center admission. All services through this Waiver are provided under the individual's NYS Medicaid.

The Department of Health TBI Waiver program is driven by participant choice. The participant is considered an intricate part of all aspects of service plan development. The participant has the choice, throughout the enrollment process and beyond, to express personal goals and to interview / choose their approved TBI Waiver service providers. The Regional Resource Development Center (RRDC) provides quality assurance/ improvement and oversight on a program-wide basis, as well as advocates for the program participants in navigating the Waiver system.

Each program participant is viewed as an individual with unique strengths as life experiences. By participating in the TBI Waiver, it is anticipated that the individual will increase his/her independence and self-reliance. The waiver participant is considered the center of all waiver services, with success measured by the individual's satisfaction. The Waiver participant's dignity, right to risk and right to fail must be respected throughout his/her involvement with the waiver.

Eligibility:

To be eligible for the TBI Waiver program, a participant must:

  • Be enrolled in NYS Medicaid.
  • Be between the ages of 18 and 64 at the time of application.
  • Have a diagnosis of traumatic brain injury or related diagnosis (excluding genetic and/or degenerative diseases) with an onset between the ages of birth and 64.
  • Be assessed to be in need of a nursing facility level of care, as determined by using the Patient Review Instrument/Screen (PRI/Screen) tool.
  • Choose to participate in services through the TBI Waiver rather than be a resident of a nursing home.
  • Have an identified residence in the community which meets the individual's needs for a safe and secure environment.
  • Be able to be safely served with funds and services available under the TBI Waiver and Medicaid State Plan.

Service Philosophy:

  • A program participant may have a menu of services that best meets their individual needs and desires. These service can be a combination of TBI Waiver, state plan Medicaid (ie. Home Health Aides, Substance Abuse Counseling, Consumer Directed Personal Care, etc..), natural supports and other community-based agencies. TBI Waiver services should be considered “last resort” on the available spectrum of community services.
  • Services are provided on an individual basis. A program participant may have one or all the outlined TBI Waiver services, dependent on need and necessity at the time.
  • Services are meant to be "fluid" and to flow with the program participant’s life needs.
  • TBI Waiver services are encouraged to be provided in an “unbundled” model. A program participant may chose to have a service from one agency and a different service from another agency. This is the choice of the waiver participant. The Service Coordinator will assist, as necessary, the participant to coordinate, manage and solidify their chosen team.

Access to Independence Services:

  • Service Coordination: The Service Coordinator supports and encourages the individual to increase his/her ability to problem solve, be in control of life situations, and be as independent as possible. This is balanced by the need to assure the Waiver participant’s health, safety, well being, and inclusion in the community. The Service Coordinator develops, with the individual, the Initial Service Plan, outlining all needed services, as well as required six month reviews and addendums. Independent Living Skills Training and Development Independent Living Skills Training and Development are services individually designed to improve the ability of the individual to live as independently as possible in the community. These services are specifically designed to instruct and re-train the participant in life-skills that may have been lost or diminished due to their injury. Services may be provided in the individual’s residence and/or in the community, but are always be provided in the environmental context of the goal, to encourage learning and continuity.
  • Environmental Modifications and Special Medical Equipment: State Plan Medicaid supports and all other funding sources need to be researched and exhausted prior to these services being requested. A budgetary cap is in place, per program participant per year, for all Environmental Modification requests.
  • Independent Living Skills Training and Development: Independent Living Skills Training and Development are services individually designed to improve the ability of the individual to live as independently as possible in the community. These services are specifically designed to instruct and re-train the participant in life-skills that may have been lost or diminished due to their injury. Services may be provided in the individual’s residence and/or in the community, but are always be provided in the environmental context of the goal, to encourage learning and continuity.