In order to be considered for the NHTD program, an individual must meet the following eligibility criteria:

• Eligible for community-based Medicaid,
• Assessed as needing nursing home level of care, and
• Either between the ages of 18-64 and have a verified physical disability or are age 65 or older when applying to the program.

The individual must also be able to live safely in the community with the services and supports offered through Medicaid, the waiver program and other community resources.

An individual currently residing in or planning to reside in a facility 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 (MLTC) Program, 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 request to be disenrolled from the applicable program.

The Open Doors program, Discharge Planners and the Regional Resource Development Centers (RRDCs) can assist with this. The Open Doors program provides information on transition from nursing facilities, hospitals or health care facilities to the community and provides support to residents of nursing homes, hospitals or health care facilities; their families or representatives; nursing home staff, community service providers, managed care plans and Discharge Planners. Open Doors serves as a bridge between the pre-discharge planning that takes place in the facility and the delivery of medical and supportive services in the community.

The Discharge Planner is a person in the facility responsible for transition of care needs, and for developing a discharge plan that promotes effective continuation of care to support long-term health. The Discharge Planner assists with transition from nursing facilities, hospitals or health care facilities to the community. Also, the RRDCs have an extensive knowledge of community-based long term care services and can be contacted directly to initiate a referral to the NHTD program.

Open Doors also has peer support. Peers are people who live independent lives in the community. By sharing their life experiences in transitioning from facilities to the community, peers provide support during the transition process and can assist with community integration. Family members of individuals who have previously transitioned are also available to meet with the families of transitioning individuals. Veteran peers are available as well.

If a resident of a nursing home or health care facility is interested in living in the community, the Discharge Planner or staff of the nursing home or facility work with the Open Doors Transition Specialist to explore housing options, services, supports, and/or home modifications for the resident. The resident and their family, legal guardian, or other representative will then decide whether to initiate a referral to the NHTD program. Also, the resident and their family, legal guardian, or other representative can contact the RRDC directly to inquire or initiate a referral to the NHTD program.

The Open Doors Program is a free source of information and helps referrals to many programs, including the NHTD program. It is funded by the NYS Department of Health through the Money Follows the Person Program.

More information about the Open Doors Program is available through these resources:

• Open Doors Program website
• Find a local office
• Open Doors 30 second video
• 2017 webcast: "The Money Follows the Person Program - Facilitating Return to Community-Based Settings"

Most NHTD applicants reside in their own home. The individual or their representative must be able to identify an appropriate residence where waiver services will be provided. Open Doors Transition Specialists, Service Coordinators, discharge planners will help individuals in need of housing identify and locate a residence. Individuals living in residential settings of 4 or more unrelated individuals are excluded from receiving waiver services. The setting must be Home and Community-Based Setting (HCBS) compliant and cannot be a congregate care setting. Community Transitional Services may be used for applicants transitioning out of a nursing facility who need help paying for certain aspects of securing a home.

• Programs are available to provide rental subsidies and housing services. Information on these programs is included on the Resources & Community Outreach page of this site.
• The NYS Office for the Aging website includes tools to search for housing throughout New York State.
• The Service Coordinator who will help the applicant with the program application can also help the individual identify a residence.

There are many services and supports available in the NHTD waiver program. Below is a list of all available waiver services in the NHTD waiver program:

• Assistive Technology (AT)
• Community Integration Counseling (CIC)
• Community Transitional Services (CTS)
• Congregate and Home Delivered Meals
• Environmental Modifications (E-Mods)
• Home and Community Support Services (HCSS)
• Home Visits by Medical Personnel
• Independent Living Skills and Training Services (ILST)
• Moving Assistance
• Nutritional Counseling/Educational Services
• Peer Mentoring
• Positive Behavioral Interventions and Supports (PBIS)
• Respiratory Therapy
• Respite Services
• Service Coordination (SC)
• Social Transportation
• Structured Day Program Services (SDP)
• Wellness Counseling

A description of all the NHTD waiver services can be found on the NHTD Medicaid Waiver Initiative document.

Yes, with the approval of the person, a representative can assist the individual with the application process. A representative can be anyone the individual wishes, and can include a family member, legal guardian, nursing home discharge planner, social worker, or an Open Doors Transition Specialist who is supporting the individual.

The following steps outline the current application process.

Prior to Applying: Enrollment in Medicaid

The NHTD program is available to New Yorkers who are enrolled in Medicaid and are eligible for coverage supporting community-based long term care. Individuals with New York State Medicaid who are living in out-of-state facilities and are seeking to return to New York State may also be eligible. If an applicant is already enrolled in the Medicaid program and has appropriate coverage, the referral can proceed. If an applicant is not already enrolled in the Medicaid program, they will need to apply and have their Medicaid eligibility determined by the Local Department of Social Services (LDSS) prior to seeking waiver services.

Step 1: Referral to Regional Resource Development Center (RRDC)

All referrals must begin with the RRDC. The RRDCs manage and approve applications for participation in the NHTD program. (NHTD program services cannot start until the application is approved by the RRDC.)

The application process begins with a phone call, written referral or request from the nursing home discharge planner to the RRDC in the area where the applicant wants to live. The list of RRDCs and their contact information is available here.

• If the applicant is not a nursing home or health care facility resident, the applicant (or a person acting on their behalf, such as a guardian or family member) will submit a referral form, call or write to the RRDC.
• If the applicant is in a nursing home or health care facility resident, the discharge planner at the nursing home or facility, social worker, or Open Doors Transition Specialist supporting the individual may call or write the RRDC. The applicant may also submit a referral form, call or write to the RRDC directly.

During this referral phone call, RRDC staff will confirm the applicant meets the basic eligibility criteria and collect information needed to complete a referral form. On this call, the applicant will also provide consent for the referral.

The RRDC will follow up by contacting the applicant to arrange a meeting and the referral moves to intake or the appointment can be arranged during the call.

Step 2: Intake Meeting with Applicant and RRDC

The following actions will be completed at the intake meeting:*

• The RRDC will provide detailed information regarding the following:
  • NHTD program philosophy
  • Available services
  • Service Plan development
  • Role of the Service Coordinator
  • Selection of a Service Coordinator
  • Fair Hearing and complaint processes.
• The required forms will be completed:
  • The forms will be provided by the RRDC. (The forms are available on the Resources & Community Outreach page of this website.)
  • The RRDC will complete the intake form and review it with the applicant.
  • Family members or representatives are encouraged to provide input into the applicant´s service goals.
  • The applicant or legal guardian must choose to participate in the program by indicating consent on the Freedom of Choice form.
• The following required documentation will be reviewed by the RRDC:
  • Verification of Medicaid coverage
  • Verification of age
  • Verification of physical disability for any applicant younger than 65 years of age

By the end of the intake, the RRDC will determine if the applicant appears to be eligible for the program.

• If the RRDC determines that the applicant does not meet basic eligibility criteria or if the applicant chooses not to continue applying to the NHTD program, the RRDC will discuss available options or referrals to other programs and services. The RRDC will also issue a Notice of Decision to document this action advising of the applicant´s due process rights.
• If the RRDC determines the applicant appears eligible and the applicant indicates their continued interest in the waiver program, the RRDC will provide the applicant a current list of available Service Coordination providers along with a Service Coordination Agency Selection form. This form is used to inform the RRDC of their selected Service Coordination provider.

* At the discretion of the NYS Department of Health, such as in times of a public health emergency, the in-person requirements for the intake meeting may be waived and this meeting may be conducted by such other means as the Department determines appropriate.

Step 3: Selection of Service Coordination Provider and
              Assignment of Service Coordinator

Service Coordination providers employ Service Coordinators. The Service Coordinator is a vital resource for the applicant. The Service Coordinator helps the applicant complete the application process while providing unbiased and comprehensive information about available services and providers. The Service Coordinator also works with the applicant to obtain all necessary referrals, assessments, approvals, and authorizations.

From the date of the intake meeting with the RRDC, the applicant has 30 calendar days to choose a Service Coordination provider.

• An individual applying to the NHTD program is encouraged to interview potential Service Coordination providers with the help of a family member, legal guardian, or other representative. If the individual is a nursing home or health care facility resident, an Open Doors Transition Specialist or discharge planner of the nursing home or facility could help the individual with choosing their Service Coordination provider
• Within 14 days after the intake meeting, the applicant will contact, interview, and select a Service Coordination provider. The Service Coordination provider must agree to accept the applicant as a client.
• After the applicant has been accepted as the Service Coordination provider´s client, the applicant will complete the Service Coordination Agency Selection form and return it to the RRDC.
• If the RRDC does not receive the completed Service Coordination Agency Selection form within 30 days after the intake meeting, the RRDC will contact the applicant to assist with the selection of a Service Coordination provider.

The RRDC will then send the applicant written confirmation of the Service Coordination provider selection.

Upon selection, the assigned Service Coordinator will contact the applicant to complete the application process.

Step 4: Completion and Submission of Application

Upon selection, the Service Coordinator will:

• Work with the applicant to develop an Initial Service Plan (ISP),
• Work with the applicant to develop a Plan of Protective Oversight (PPO),
• Secure a community health assessment (UAS-NY-CHA) to determine the Level of Care (LOC), and
• Complete the application packet on behalf of the applicant.

If the applicant is transitioning out of a nursing facility or hospital, an alternate assessment called the HC-PRI and SCREEN may be used instead of the UAS-NY-CHA. The UAS-NY-CHA must then be conducted within 90 days of enrollment to the program.

The Service Coordinator must review all pertinent forms and plans with the applicant. After reviewing and confirming the information provided, the applicant will sign the application and their Initial Service Plan.

The Service Coordinator will then submit the Initial Service Plan, Plan of Protective Oversight, Level of Care findings (UAS-NY-CHA, or HC-PRI and SCREEN, as applicable), and completed application packet to the RRDC. All of these documents must be submitted by the Service Coordinator to the RRDC within 60 days of the RRDC approval date on the Service Coordination Agency Selection form.

Descriptions of the ISP, PPO, UAS-NY-CHA, and the HC-PRI are provided below.

Initial Service Plan

The Initial Service Plan (ISP) contains demographic information of the applicant and an assessment of their strengths, needs/challenges and goals. (For an applicant residing in a nursing/rehabilitation facility or hospital, the ISP will include a summary of all services provided and a discharge summary from the facility.)

The ISP also identifies which services are necessary to support the applicant in the community and which agency (or agencies) has agreed to provide those services. The applicant is the primary decision maker regarding the services included in the ISP. This maximizes their independence and self-direction. The ISP is specific to each applicant, and therefore varies from application to application.

Additionally, the ISP includes strategies to minimize isolation and lower the chance of preventable risks. These strategies should include interventions, assistive technology devices, and/or environmental modifications and other resources necessary to secure the health and safety of the individual in the community.

During the development of the ISP, the applicant must identify a residence where the services are to be provided. The Service Coordinator may assist the applicant in identifying a residence. Community Transitional Services may be utilized for applicants transitioning out of a nursing facility.

Plan of Protective Oversight

The Plan of Protective Oversight (PPO) assesses safety risks, develops strategies to reduce risk, and addresses safety issues. The PPO also identifies fire or safety issues; back up plans; supports in case of an emergency; and the people who are responsible for assisting the applicant with daily activities, medication management, and financial transactions.

Uniform Assessment System New York (UAS-NY)

The community health assessment (UAS-NY-CHA) establishes the applicant´s nursing home Level of Care (LOC), which is required for waiver eligibility. It also offers a summary of their strengths, challenges/needs and level of functioning used to develop the service plan.

The LOC must be finalized and signed by a NYS Registered Professional Nurse who is certified to complete the UAS-NY. A Nursing Facility Level of Care (NFLOC) score of 5 is required for waiver eligibility.

If the applicant does not achieve the required score during the first assessment, a second assessment may be completed by the RRDC Nurse Evaluator.

Hospital and Community Patient Review Instrument (HC-PRI) for Nursing Home or Hospital Transitions

If the applicant is transitioning out of a nursing home or hospital, the HC-PRI may be utilized for establishing initial eligibility instead of the UAS-NY. The HC-PRI instrument is used to identify medical events. Medical events include current medical diagnosis, abilities to perform activities of daily living, and behavioral difficulties. The UAS-NY will be conducted for such participants within 90 days of waiver eligibility.

Step 5: Application Review and RRDC Decision

The RRDC will review the applicant´s Initial Service Plan, Plan of Protective Oversight, UAS-NY documentation, and completed application packet. The RRDC has 14 days after receiving the complete application package to make an eligibility determination. The applicant will be determined eligible or provided a reason why they are not eligible.

Step 6: Notice of Decision

A Notice of Decision (NOD) is a written document that notifies an applicant/participant of an action being taken by the NHTD Waiver Program and includes an explanation of the reasons for the action.

If the applicant is determined eligible, the RRDC will issue a Notice of Decision of Authorization. (If the applicant is in a nursing home or health care facility resident, the notice will include the date of discharge from the nursing home or facility.)

If the applicant is denied, the RRDC will issue a Notice of Decision - Denial. The notice will identify the reason for the denial and inform the applicant of their due process. Some reasons for the denial of an application include, but are not limited to, the following:

• The RRDC determines (at any point during the process) that the applicant cannot be safely served in the community with the available waiver services and supports.
• The RRDC establishes the applicant/participant is not able to identify an HCBS compliant community residence where waiver services will be provided.
• The RRDC establishes that the applicant/participant does not require nursing home level of care (NFLOC) and has not received a NFLOC score of 5.

Any time a Medicaid service is denied, the individual may request a case conference and/or Fair Hearing to appeal the decision. Applicants/participants have sixty (60) days from the date of the NOD to request a Fair Hearing. The Office of Temporary and Disability Assistance (OTDA) notifies the appellant of the time, date and place of the hearing at least ten (10) calendar days prior to the hearing date.

Step 7: Participation and Service Renewal

Services may begin on the date that the Notice of Decision authorizes eligibility.

In order to maintain waiver eligibility, the participant must remain Medicaid eligible, continue to require nursing facility level of care, participate in Service Coordination services monthly, remain living in the community and have an approved Service Plan. This criteria is reviewed at least annually.

The Service Coordinator will assess the participant´s needs and arrange the services identified in the participant´s service plan. They will meet with the participant to discuss their on-going goals, progress and plans. On an annual basis, the Service Coordinator and participant will review the outcome of their services and develop a Revised Service Plan (RSP) for the upcoming year. The plan will be submitted to the RRDC for service authorization. If a change in service(s) is needed before the yearly review, the Service Coordinator will submit a Service Plan Addendum. The RRDC will review the plan and authorize, increase or decrease services and issue the related Notice of Decision.If at any time the participant no longer meets eligibility criteria, the RRDC will issue a Notice of Decision of Discontinuation. Any time the RRDC initiates an adverse action (Notice of Decision-Denial/Discontinuation), the participant is afforded a case conference and/or Fair Hearing to appeal the decision.

The time frame for becoming a waiver participant will vary. If the applicant has a residence, sufficient informal supports, and a Service Coordinator, ideally the process will take approximately 2-4 months.

If an applicant is a resident of a nursing home or health care facility, the time between choosing the Service Coordination provider and leaving the nursing home or facility may take longer.

During the initial intake process, the RRDC provides information regarding the Notice of Decision, Case Conference, and Fair Hearing processes. The Service Coordinator ensures that the applicant/participant understands their rights regarding Case Conferences and Fair Hearings throughout the application process. The RRDC and Service Coordinator will review the Participant´s Rights and Responsibilities with the applicant/participant. On an on-going basis, the Service Coordinator will provide information to participants to ensure they are aware of and understand the Fair Hearing process.

The complaint protocols are posted on the New York State Department of Health´s Long-Term Care website, under the tab titled "Complaint Process for Medicaid Long Term Care Waivers".