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The Home and Community-Based Services (HCBS) Medicaid Waiver for Nursing Home Transition and Diversion (NHTD) is one of the options available to New Yorkers with disabilities, and seniors, so they may receive services in the most appropriate, least restrictive setting.

What is a Home and Community Based Services (HCBS) 1915(c) Medicaid Waiver?

In 1981, Congress authorized the waiver of certain federal requirements to enable a state to provide home and community services (other than room and board) to individuals who would otherwise require institutional/nursing facility services reimbursed by Medicaid. The waiver programs are called 1915(c) waivers, named after the section of the Social Security Act that authorized them. Under 1915(c) waiver authority, states can provide services not usually covered by the Medicaid program, as long as these services are required to keep the person from being institutionalized.

The Nursing Home Transition and Diversion (NHTD) 1915(c) Medicaid waiver is a Home and Community-Based Services (HCBS) program, administered by the New York State Department of Health (NYSDOH) through contractual agreements with Regional Resource Development Centers (RRDC). The RRDC employs a Regional Resource Development Specialist (RRDS) and a Nurse Evaluator (NE) and other qualified staff and serves designated counties in the state (refer to Section XIII).

The NHTD waiver provides services to assist individuals with disabilities, and seniors, toward successful inclusion in the community. Waiver participants may come from a nursing facility or other institution (transition) or choose to participate in the waiver to prevent institutionalization (diversion).

The development of the NHTD Medicaid waiver was based on the philosophy that individuals with disabilities and/or seniors have the same rights as others. This includes the right to be in control of their lives, encounter and manage risks, and learn from their experiences. This is balanced with the waiver program's responsibility to assure the waiver participants' health and welfare.

The provision of the waiver services is 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 service plan. This process leads to personal empowerment, increased independence, greater community inclusion, self-reliance, and meaningful productive activities. Waiver participant satisfaction is a significant measure of success of the NHTD waiver.

This Program Manual was created to provide policies, procedures, and information about the Nursing Home Transition and Diversion (NHTD) Medicaid waiver program for waiver applicants/participants, stakeholders, Service Coordinators (SC) and other waiver service providers, Regional Resource Development Centers (RRDC), Regional Resource Development Specialists (RRDS), and Nurse Evaluators (NE). Upon request, it can also be shared with applicants and waiver participants.

Sections one (I) through eleven (XI) of this Program Manual outline the policies and procedures of the NHTD waiver. Section fourteen (XIV) contains the forms used in the various areas/components of the waiver program. Section twelve (XII) is the Glossary of Terms relevant to the waiver program. Section thirteen (XIII) contains the map outlining the regions served by the Regional Resource Development Centers (RRDC).

This manual reflects the major changes in 1915(c) Medicaid waiver application approved by the Centers for Medicare and Medicaid Services (CMS) effective July 1, 2018; all subsequent amendments as well are new compliance requirements set forth by CMS.

Special Note: Whenever the term 'applicant' or 'participant' is used in this Program Manual, it also includes reference, if applicable, to a duly authorized representative designated to act on behalf of the applicant/participant, unless specifically stated otherwise.

This manual reflects the major changes in the 1915(c) Medicaid waiver application approved by the Centers for Medicare and Medicaid Services (CMS) effective July 1, 2018, as well as new compliance requirements set forth by CMS. These changes include but are not limited to:

Under the authority provided by Section 1915(c) of the Social Security Act and as approved by the Centers for Medicare and Medicaid Services (CMS), New York State has elected to provide home and community-based services (HCBS) under this Nursing Home Transition and Diversion (NHTD) waiver program.

The approved waiver application specifies the scope and features of the NHTD waiver program, including eligibility criteria and services offered through the program. This manual is intended for Regional Resource Development Centers (RRDCs), NHTD Providers, and stakeholders to assist with the implementation and operationalization of the processes, procedures, and other features of the NHTD waiver program, as approved in the waiver application.

A state must implement the waiver as specified in the approved application. If the state wants to change the waiver while it is in effect, it must submit an amendment to CMS for its review and approval. All requests for new waivers, waiver renewals and amendments must be submitted by the state Medicaid agency. There is no limit on the number of HCBS waivers that a state may operate.

In its application, a state must specify the unduplicated number of individuals that the state intends to serve each year the waiver is in effect. It is up to the state to determine this number, based on the resources that the state has available to underwrite the costs of waiver services. As state resources permit, this number may be modified by amendment while the waiver is in effect. The state may not exceed its approved enrollment without seeking an amendment to the application.

In its application and each year during the period that the waiver is in operation, the state must demonstrate that the waiver is cost neutral. In particular, the average per participant expenditures for the waiver and non-waiver Medicaid services must be no more costly than the average per person costs of furnishing institutional (and other Medicaid state plan) services to individuals requiring the same level of care.

In addition to the web-based application for 1915(c) waivers located here, CMS makes available assorted information and resources via its website (medicaid.gov) regarding the HCBS waiver program. The CMS web pages that are especially pertinent include:

The NHTD waiver makes every effort to promote the right of waiver applicants and participants to choose participation in the NHTD waiver, identify needed services, and select their service providers. Agencies that provide Service Coordination must adhere to conflict-of-interest (COI) requirements established by the Department. Compliance with these practices promotes the independence of the Service Coordinator (SC) and ensures participant choice. The Service Coordinator is responsible for providing unbiased and comprehensive information to the participant about available services and service providers. A Service Coordinator may not "steer" business and may not recommend or indicate a preference for a service provider. A waiver participant cannot get Service Coordination and another direct waiver service from the same provider.

An individual currently residing in or planning to reside in a facility certified under the Assisted Living Program (ALP) or other licensed or certified congregate care setting is not eligible for the NHTD waiver.

In addition, Medicaid regulations will not allow for duplication of services. Therefore, an individual enrolled in a Health and Recovery Plan (HARP), Health Homes, Managed Long Term Care Program (MLTC), a Program of all Inclusive Care for the Elderly (PACE) or receiving Comprehensive Medicaid Case Management (CMCM) through a targeted case management program is not eligible for the NHTD waiver unless they are disenrolled from the applicable programs. These managed care members must seek voluntary disenrollment from the plan and the managed care plan codes must be removed from the applicant's eMedNY profile before the effective date for waiver eligibility. Waiver services may not be billed while an applicant/participant is enrolled in one of these managed care products. The provision of care management/case management/service coordination cannot be duplicated.

A potential participant (applicant) or someone acting on their behalf, contacts the Regional Resource Development Center (RRDC) serving the region in which the individual resides or is seeking to reside. This communication may be completed via phone, email, or other correspondence. The date of first contact made to the RRDC from a potential participant, or someone acting on their behalf, is referred to as the referral date. The RRDC staff completes and signs the Referral form (DOH-5747).

There is an individual in the RRDC to accept and monitor referrals in the office. All calls/communication initiating referrals must be returned and documented within five (5) business days of the referral date and the RRDC continues to complete the Referral form with any additional information obtained. The call will confirm basic referral information such as phone number, address, CIN, etc.

It must first be confirmed that the individual is seeking waiver services and/or consents to the referral. Based on the response, the RRDC then determines whether to proceed to the intake process. For example, if the individual responds they are not interested in receiving services or they did not agree with the referral, the process terminates. During the call the RRDC will confirm that the individual meets the basic eligibility criteria to continue the intake process. If the individual does not meet the basic criteria for the waiver (e.g., the individual does not have the appropriate Medicaid for home and community-based services (HCBS), is under the age of 18 or indicates their preference not to pursue admission into the NHTD waiver program), the RRDC staff will confirm the referral will not move forward to intake and a letter will be provided to the individual within five (5) business days of the date of last contact (referral close-out date). This notification is a letter confirming the conversation and advises the individual of the opportunity to seek waiver services at a later date when basic eligibility criteria changes or individual's choices change. Included in this communication will be information about other programs/services, if appropriate. The RRDC must offer the potential applicant an Intake appointment within ten (10) business days of contact (date of referral contact).

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