Typically services within an Integrated System of Care are
paid for through private insurance or by Medicaid. However, coverage
by private insurers varies widely from carrier to carrier, and Medicaid
restricts what it will cover, including types of treatment, equipment
and medications.
These restrictions may leave huge gaps in coverage, particularly as
the individual leaves the inpatient facility or nursing home to live
once again within his or her own home. Coverage of services in the
community is less well developed than coverage of intensive medical
and rehabilitation care.
However, in 1995, in New York State, the Department of Health and
the Department of Social Services obtained federal approval to use
Medicaid funds to help pay for services and supports needed by individuals
with TBI who want to live in the community rather than in a nursing
facility. This special funding resource is called the Home and Community
Based Services (HCBS) Medicaid Waiver.
Historically, the Medicaid system funded only institutional care,
but with the arrival of the HCBS waiver, an individual with TBI is
now able to use Medicaid funding to live in the community of choice,
in a situation of choice -- it waives Medicaid's requirement for funding
only institutional care.
All existing services covered under the regular Medicaid program and
under other publicly funded services are available to the recipient
of a waiver. It is expected that with the waiver services, the participant
will increase his/her level of independence, self-reliance, inclusion
in the community, range of choices and productivity. Waiver services
include:
- Service Coordination
- Structured day programs
- Training in independent living skills
- Substance abuse programs
- Transitional Living*
- Therapeutic foster care*
- Home and community support services
|
- Community integration counseling
- Environmental modifications
- Vehicle modifications
- Intensive behavioral programs
- Respite care
- Medical equipment supplies
- Transporation
|
*As of date of publication, these services were anticipated,
but not yet approved. |
Who is eligible? All of the following criteria must be met:
What is the process for applying for the waiver? In the first step,
the individual with TBI must decide to live in the community, not
in a nursing facility. He or she must then choose a service coordinator
to help in developing the documentation needed as part of the waiver
application. How does one select a service coordinator? The HCBS/TBI
Waiver Management office maintains a list of approved service coordinators.
The individual with TBI, the service coordinator and other individuals,
as needed, then develop the service plan, which is submitted to the
Department of Health's HCBS/TBI Waiver Management staff for review.
Notification of the decision about the application will then be sent
to the applicant and service coordinator.
Regional Resource Development Specialists are available in every region
of New York State to provide a preliminary decision about each waiver
application, before the application is forwarded for formal review
by the DOH.
