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.
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.
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
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.
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.
4. Community First Choice Option (CFCO)
NYS DOH Website https://www.health.ny.gov/health_care/medicaid/redesign/community_first_choice_option.htm
NYS DOH Directive 19 ADM-01 - Community First Choice Option (Feb. 2019) (Attachments to ADM available here)
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:
6. Long Term Home Health Care Program (Lombardi/ LTHHCP, includes AIDS LTHHCP) --CLOSED