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Vocational Rehabilitation (VR)

State Resources for Disability Employment and Workforce Supports

New York Department of Rehabilitation Services
New York State Commission for the Blind
New York Department of Labor
New York Department of Mental Health
New York Division of Developmental Disabilities
New York State Department of Education
New York Department of Public Health
New York State Medicaid Agency
New York Workforce Development Board

Program	Income Eligibility Individual	Income Eligibility Couple	Asset Limit Individual	Asset Limit Couple	Age Limit	Premium Structure	Grace Period / Continuous Coverage
*Medicaid Buy-In program for Working People with Disabilities (MBI-WPD)*	Countable income up to 250% FPL If the only income is earned income, gross income may be as high as $79,384	Countable income up to 250% FPL	$33,038	$44,796	16-64	No premium (Current moratorium on premiums)	Up to 6-month grace period if: For medical reasons, individual is unable to continue working. Medical verification required. Through no fault of individual, job loss occurs (layoff, etc.). Verification required that individual is reasonably expected to return to work if temporary layoff, or that individual is actively seeking new employment.

State-by-State Medicaid-Funded Employment Services Inventory

Learn more about this inventory on our State-by-State Inventory page.

New York Medicaid Redesign Team (formerly called Partnership Plan)1115
Effective: 12/07/2016 – Expires: 03/31/2027

Target Population:Individuals with intellectual or developmental disabilities, physical disabilities, or serious mental illness who meet eligibility criteria

Type of Medicaid Authority:1115

Managed Care:Yes

Overview

(Excerpts from Demonstration Approval)

The state’s goal in implementing the Medicaid Redesign Team Section 1115(a) demonstration is to improve access to health services and outcomes for low-income New Yorkers by:

• Improving access to health care for the Medicaid population;

• Improving the quality of health services delivered;

• Expanding coverage with resources generated through managed care efficiencies to additional low-income New Yorkers;

• Advancing health equity, reducing health disparities, and supporting the delivery of HRSN services.

The demonstration is designed to permit New York to use a managed care delivery system to deliver benefits to Medicaid recipients, create efficiencies in the Medicaid program, and enable the extension of coverage to certain individuals who need long term care and supports. It was originally approved in 1997 to enroll most Medicaid recipients into MCOs (Medicaid managed care program). As part of the demonstration’s renewal in 2006, authority to require some disabled and aged populations to enroll in mandatory managed care was transferred to a new demonstration, the Federal-State Health Reform Partnership (F-SHRP). Effective April 1, 2014, this authority was restored to this demonstration as F-SHRP was phased out.

In 2010, the Home and Community Based Services Expansion program (HCBS Expansion program) was added to the demonstration. It covers cost-effective home and community-based services to certain adults with significant medical needs as an alternative to institutional care in a nursing facility. The benefits and program structure mirrors those of existing section 1915(c) waiver programs and aims to cover quality services for individuals in the community, ensure the well-being and safety of the participants and increase opportunities for self-advocacy and self reliance.

In 2012, New York added to the demonstration an initiative to improve service delivery and coordination of long-term care services and supports for individuals through a managed care model. Under the MLTC program, eligible individuals in need of more than 120 days of community-based long-term care are enrolled with managed care providers to receive long term services and supports as well as other ancillary services. Other covered services are available on a fee-for-service basis to the extent that New York has not exercised its option to include the individual in the MMMC program. Enrollment in MLTC was phased in geographically and by group.

The state’s goals specific to MLTC are listed below:

• Expanding access to managed long-term care for Medicaid enrollees who are in need of long-term services and supports(LTSS)

• Improving patient safety and quality of care for enrollees in MLTC plans

• Reducing preventable inpatient and nursing home admissions

• Improving satisfaction, safety and quality of life

In August 2015, CMS approved New York’s request to implement HARP to integrate physical, behavioral health and BH HCBS for Medicaid enrollees with Serious Mental Illness (SMI) and/or SUD to receive services in their own homes and communities. Under the demonstration, HARPs are a separate coverage product that is targeted to Medicaid enrollees that meet need based criteria for SMI and/or SUD established by the state. HIV SNP under MMMC will also offer BH HCBS services to eligible individuals meeting targeting, risk, and functional needs criteria. All MMMC plans will offer BH benefits in integrated plans including four new demonstration services.

The overarching goal of this amendment (amended 01/09/2024) is to advance health equity, reduce health disparities, and support the delivery of social care through Social Care Networks (SCNs) and improve overall quality and health. Through the combination of a Medicaid Hospital Global Budget Initiative, HRSN activities, workforce initiatives, and HERO, the state is working to improve health equity. As a result, CMS considers this amendment a Health Equity Initiative. Additionally, by the end of the demonstration, the state’s goal is to have made significant movement towards value-based payment (VBP) strategies, multi-payor alignment, and population health accountability. Each program has individual goals that align with the overall goal:

1. Investments in Health Related Social Needs (HRSN) via greater integration between primary care providers (PCPs) and community-based organizations (CBOs) with a goal of improved quality and health outcomes;

2. Goal of improving quality and outcomes of enrollees in geographies that have a longstanding history of health disparities and disengagement from the health system;

3. Focus on integrated primary care, BH, and HRSN with a goal to improve population health and health equity outcomes for high-risk enrollees including kids/youth, pregnant and postpartum individuals, the chronically homeless, and individuals with SMI and SUD;

4. Workforce investments with a goal of equitable and sustainable access to care in Medicaid 5. Developing regionally-focused approaches, including new value-based payment programs, with a goal of statewide accountability for improving health, outcomes, and equity.

HCBS Expansion Program

The individuals eligible for this component of the demonstration will receive the same HCBS as those individuals determined eligible for and enrolled in the state’s Nursing Home Transition and Diversion Program (NHTDP) and Traumatic Brain Injury Program (TBIP) authorized under section 1915(c) of the Act. The specific benefits provided to participants in this program are listed in Attachment A. The state will operate the HCBS Expansion program in a manner consistent with approved NHTDP and TBIP 1915(c) waiver programs and must comply with all administrative, operational, quality improvement and reporting requirements contained therein. [See 1915(c) waivers and service descriptions below]

Health and Recovery Plans (HARPs)

Health and Recovery Plans (HARPs) offer BH HCBS as a covered benefit for enrollees meeting eligibility criteria. A Health and Recovery Plan (HARP) is a Medicaid managed care insurance plan that manages physical health, mental health, and addiction services in an integrated way for adults with significant behavioral health needs (mental health or addiction). Eligible individuals include Medicaid adult beneficiaries age 21 or over eligible for Medicaid furnished in MMMC under the demonstration with a specified SMI and/or serious SUD diagnosis and who meet categorical criteria or risk factors specified by New York’s Office of Mental Health (OMH) or New York’s Office of Addiction Services and Supports (OASAS).

Service Definitions and Limitations (if applicable)	Service Definitions and Limitations (if applicable)
Intensive Supported Employment (ISE)	ISE services that assist recovering individuals with MH/SUDs to obtain and keep competitive employment. These services consist of intensive supports that enable individuals to obtain and keep competitive employment at or above the minimum wage. This service uses evidence-based principles of the Individual Placement and Support (IPS) model. This service is based on Individual Placement Support (IPS) model which is an evidence-based practice of supported employment. It consists of intensive employment supports that enable individuals for whom competitive employment at or above the minimum wage is unlikely, absent the provision of supports, and who, because of their clinical and functional needs, require supports to perform in a regular work setting. Individual Employment Support Services are individualized, person-centered services that provide supports to individuals who need ongoing support to learn a new job and maintain a job in a competitive employment or self-employment arrangement. Individuals in a competitive employment arrangement receiving Individual Employment Support Services are compensated at or above the minimum wage and receive not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this activity is documentation of the individual’s stated career objective and a career plan used to guide individual employment support. Components include: • Assist the individual to locate a job or develop a job on behalf of the individual via the use of Individualized Placement and Support services that include rapid job search including acquisition of hard and soft skills to retain employment, training and systematic instruction, as well as providing support for the job application process such as resume writing, interviewing and application submission. • Support the individual to establish or maintain self-employment, including home-based self employment. • Provide ongoing job-related discovery and assessment. Provide job placement, systematic job development, job coaching, negotiation with prospective employers, job analysis, job carving (creating, modifying, or customizing a community-based job such that it can be successfully performed by an individual on supported employment), customize employment training and systematic instruction, benefits counseling support, training and planning, transportation, asset development and career advancement services, customized employment, and other workforce support services. Workforce support services include benefits counseling support (e.g., personalized benefits counseling that assists individuals in obtaining personalized information about their government entitlements), training and planning, transportation navigation, asset development and career advancement services. Modality: Intensive Supported Employment is a face-to-face intervention and is provided 1:1. Setting: This service is generally, based on individual need, provided at an employment program but can also be provided at a location of the individual’s choosing that may include the workplace. Admissions/Eligibility Criteria: • In order to achieve a successful outcome in ISE, an individual must have made a clear decision to work in competitive employment in the community. • The basic tenet of ISE is that all individuals are capable of working in competitive employment in the community even without prior training and all individuals interested in employment should be given the opportunity. • The ongoing level of care criteria including service duration, intensity and effectiveness should be reviewed by the BH HCBS provider and/or the MCO at least quarterly. Limits on the amount, duration, or frequency of this service: 250 hours per calendar year. For all employment supports services, documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses, such as the following: • incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program, • payments that are passed through to users of supported employment programs, • and payments for training that is not directly related to an individual’s supported employment program. When employment support services are provided at an integrated work site where individuals without disabilities are employed, payment is made only for the adaptations, supervision, and training required by OMH participants who receive services as a result of their disabilities but does not include payment for the supervisory activities rendered in as a normal part of the regular business setting.
Ongoing Supported Employment	This service is provided after an individual successfully obtains and becomes oriented to competitive and integrated employment. Ongoing follow-along support is available for an indefinite period as needed by the individual to maintain their paid competitive employment position. Individual employment support services are individualized, person centered services providing supports to individuals who need ongoing support to learn a new job and maintain a job in a competitive employment or self-employment arrangement. Individuals in a competitive employment arrangement receiving Individual Employment Support Services are compensated at or above the minimum wage and receive not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by other individuals without disabilities. Service components include: • Provide support in a variety of settings, particularly work sites where individuals with and without disabilities are employed: o Assists individuals to determine identify reasonable accommodations necessary to manage MH mental health symptoms or SUD triggers that may emerge at work o Provides activities needed to retain paid work including job coaching and non-work task related training o Ongoing Supported Employment services may include assessment of issues and linkage/referral to other recovery-oriented community resources as appropriate • Provide activities needed to sustain paid work by individuals, including supervision and training: o Provides supports to individuals who are currently employed in settings that are competitive and integrated o Assists individuals to establish positive workplace relationships, including interactions with supervisors, and co-workers o Helps individuals to build and sustain skills in the workplace, including time management, co-worker relationships and/or interactions, understanding supervisory roles and expectations, and accessing workplace supports, including EAP and job training for career advancement • Providing reminders of effective workplace practices and reinforcement of recovery skills gained during the period of intensive supported employment services: o Assist individuals to manage behavioral health issues that may impact their recovery and ability to sustain long term employment. The basic tenet of ISE is that all individuals are capable of working in competitive employment in the community even without prior training and all individuals interested in employment should be given the opportunity to work. Modality: Ongoing Supported Employment is a face-to-face intervention and is provided 1:1. Setting: Ongoing Supported Employment services may be provided in any community location as well as at the workplace. Its primary focus is to support individuals to manage behavioral health disorders in a manner that will not jeopardize their employment. Focus and delivery of Ongoing Supported Employment may not duplicate vocational services for which the person is eligible through Rehabilitation Services Act (RSA/ACCES-VR). Admissions/Eligibility Criteria: Must have made a clear goal to maintain employment in work in a competitive work environment employment located in the community. Limits on the amount, duration, or frequency of this service: 250 hours per calendar year. For all employment supports services, documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses, such as the following: • incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program, • payments that are passed through to users of supported employment programs, and • payments for training that is not directly related to an individual’s supported employment program. When employment support services are provided at a work site where individuals without disabilities are employed, payment is made only for the adaptations, supervision, and training required by participants receiving services as a result of their disabilities but does not include payment for the supervisory activities rendered as a normal part of the business setting.
Transitional Employment	This service is designed to strengthen the individual’s work record and work skills toward the goal of achieving assisted or unassisted competitive employment at or above the minimum wage paid by the competitive sector employer. This service is provided, instead of Intensive Supported Employment, only when the individual specifically chooses this service and may only be provided by clubhouse, psychosocial club program, OASAS recovery center, or agency previously in receipt of a BH HCBS designation for this service. This service specifically provides learning and work experiences where the individual with behavioral health and/or substance use disorders can develop general, non-job-task-specific strengths and soft skills that contribute to employability in the competitive work environment in integrated community settings paying at or above minimum wage. The outcome of this activity is documentation of the individual’s stated career objective and a career plan used to guide individual employment support. Service components include: • Provide time-limited employment and on-the-job training in one or more integrated employment settings as an integral part of the individual’s vocational rehabilitation growth. • Provide support to individuals to gain skills to enable transition to integrated, competitive employment. • Training activities provided in regular business, industry, and community settings • Promote integration and interaction between individuals with and without disabilities in the workplace. • Provide Transitional Employment supports during placement. This support includes initial and ongoing employment planning and advancement, employment assessment not otherwise covered in the annual career planning, job placement, job development, negotiation with prospective employers, job analysis, training and systematic instruction, job coaching, benefits counseling, training, and planning transportation. • Training or referral to a training program. • Plan transportation to and from work. • Encourage and improve motivation and self-confidence to work in competitive employment • Teach Activities of Daily Living (ADL) skills specific to the Transitional Employment placement and may include but is not limited to appropriate dress, hygiene, walk, talk, and eye contact, money management, dealing with address outstanding warrants, and legal and criminal justice history, time management, and the collection of work-related documentation and credentials • Offer services not specifically related to job skill training that enable the waiver participant to be successful in integrating into the job setting • Provide on the job supports, to include: o On-site job training o Assisting the participant to develop natural supports in the workplace that support recovery, without the use of substances. o Adopt an identity as a worker. o Accept responsibility for decisions. o Examine past work experiences for setbacks and successes. o Consider potential for transferability of skills. o Coordinate with the individual to identify employers and subsequently coworkers, as necessary, who may be able to accommodate the individual in meeting employment expectations, to address work related and personal issues as they may arise. Modality: Transitional Employment is a face-to-face intervention that is provided 1:1 Setting: Transitional Employment may only be provided by a clubhouse, psychosocial club program, OASAS recovery center, or agency previously in receipt of a BH HCBS designation for this service. Admissions/Eligibility Criteria: • An individual must have made a clear decision to work in competitive employment in the community regardless of limited or unsuccessful work history, or present status of sobriety and/or abstinence. • The basic tenet of Transitional Employment is that all individuals are capable of working in competitive employment in the community even without prior training and all individuals interested in employment should be given the opportunity. Limits on the amount, duration, or frequency of this service: The total combined hours for pre-vocational and transitional supported employment) are limited to no more than a total of 250 hours and a duration of 9 months of service in a calendar year. Additionally, Transitional Employment placements should be part-time and time-limited, usually 15-20 hrs./week from 6-9 months in duration. For all employment supports services, documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses, such as the following: • incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program, • payments that are passed through to users of the state VR supported employment programs, and • payments for training that is not directly related to an individual’s supported employment program. When employment support services are provided in a competitive and integrated work site where individuals without disabilities are employed, payment is made only for the adaptations, supervision, and training required by individuals who receive services as a result of their disabilities and does not include payment for the supervisory activities rendered as a normal part of the business setting.
Prevocational Services	Pre-vocational services are time-limited services that prepare an individual for paid or unpaid employment. This service specifically provides learning and work experiences where the individual with mental health and/or disabling substance use disorders can develop general, non-job-task-specific strengths and soft skills that that contribute to employability in competitive work environment as well as in the integrated community settings. Pre-vocational services occur over a defined period of time and with specific person centered goals to be developed and achieved, as determined by the individual and his/her employment specialist and support team and ongoing person-centered planning process as identified in the individual’s person-centered Plan of Care, Pre-vocational services provide supports to individuals who need ongoing support to learn a new job and/or maintain a job in a competitive work environment or a self-employment arrangement. The outcome of this pre-vocational activity is documentation of the individual’s stated career objective and a career plan used to guide individual employment support. Service components include: • Teach concepts such as: work compliance, attendance, task completion, problem solving, and safety, and, if applicable, teach individuals how to identify obstacles to employment, obtain paperwork necessary for employment applications, and how to interact without the use of drugs with people who have not used drugs especially in the workplace. • Coordinate scheduled activities outside of an individual’s home that support acquisition, retention, or improvement in job-related skills related to self-care, sensory-motor development, daily living skills, communication community living, improved socialization, and cognitive skills. This could include opening and maintaining a bank account for work-related direct deposit. • Gain work-related experience considered crucial for job placement (e.g., volunteer work, time limited unpaid internship) and career development. Services do not include development of job specific skills. Modality: Pre-vocational services are face-to-face services and are 1:1. Setting: This service is generally provided at the program site, but also includes support at a work location where the individual may acquire work-related experience such as volunteering and internships in the community. Admissions/Eligibility Criteria: Individuals must have a clear desire to work in competitive employment. Limits on the amount, duration, or frequency of this service: The total combined hours (for pre-vocational services and transitional supported employment) are limited to no more than a total of 250 hours and a duration of 9 months of service in a calendar year. For all employment supports services, documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses, such as the following: • Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program. • Payments that are passed through to users of supported employment programs • Payments for training that is not directly related to an individual’s supported employment program. When Pre-vocational services are provided at a work site where individuals are competitively employed, payment is made only for the adaptations, supervision, and training required by individuals receiving services as a result of their disabilities but does not include payment for the supervisory activities rendered as a normal part of the business setting or work environment.
Habilitation Services	Habilitation services are provided on a 1:1 basis and are designed to assist individuals with a behavioral health diagnosis (i.e., SUD or mental health) in acquiring, retaining and improving skills such as communication, self-help, domestic, self-care, socialization, fine and gross motor skills, mobility, personal adjustment, relationship development, use of community resources and adaptive skills necessary to reside successfully in home and community-based settings. These services assist individuals with developing skills necessary for community living and, if applicable, to continue the process of recovery from an SUD disorder. Services include things such as: instruction in accessing transportation, shopping, and performing other necessary activities of community and civic life including self-advocacy, locating housing, working with landlords and Page 7 of 23 Reissued 09/26/2022 roommates and budgeting. Services are designed to enable the participant to integrate full into the community and ensure recovery, health, welfare, safety, and maximum independence of the participant. Habilitation services may help individuals develop skills necessary for community living and recovery with ongoing assessment of individuals’ functional status and development of rehabilitative goals, such as: o Instruction in accessing and using community resources such as transportation, translation, and communication assistance as identified as a need in the plan of care and services to assist the participant in shopping and performing other necessary activities of community and civic life, including self-advocacy; for example, coordinating and helping to secure TTY services, language bank services, or other adaptive equipment needs. o Instruction in developing or sustaining financial stability and security (e.g., understanding budgets, managing money, and the right to manage their own money). Assistance in developing financial skills through instruction of budget development, money management skills, and self-direction with regards to managing own funds and relapse triggers. (Specifically, if a resident has a representative payee, one goal must be to develop skills to manage more independently). o Skill training and hands-on assistance of instrumental activities of daily living, including assistance with shopping, cooking, cleaning, and other necessary activities of community and civic living (voting, civic engagement via community activities, volunteerism). o Habilitation provides onsite modeling, training, and/or supervision to assist the participant in developing maximum independent functioning in community living activities. The on-site modeling, cueing, and /or instruction and support may assist participant in developing maximum independent problem-solving, interpersonal, communication, and coping skills, including relapse prevention planning, integration/adaptation to home/community, on-site symptom monitoring, and self – management of symptoms. o Facilitation of family reunification through coordination of family services as applicable and self-advocacy instruction. The goal would be to facilitate communication with family members/natural supports to encourage the development of recovery support plans, i.e., medication compliance, ADL skills, and functional changes. o Housing preservation and advocacy training, including assistance with developing positive landlord-tenant relationships, and accessing appropriate legal aid services if needed including skills to successfully live with roommates. o Assistance with developing strategies and supportive interventions for avoiding the need for more intensive services such as inpatient detoxification, coordinating crisis services, and consulting with current service providers (including SUD providers, mental health providers, health care providers, family-friends-natural supports, parole probation-drug courts, state vocational rehabilitation services and other stakeholders) to develop a plan for intervention. o Assistance with increasing social opportunities and developing social support skills that ameliorate life stressors resulting from the individual’s disability and promote health, wellness, and recovery. For example, helping an individual to connect to community based organizations based on individuals’ identified interests that are available to the public and promote recovery and social integration. o Instruction in self-advocacy skills including activities designed to facilitate participants’ ability to access social service systems (health care, substance abuse, employment, vocational rehabilitation, entitlements/benefits, self-help groups) and other recovery oriented systems of care are included. o Instruction in developing strategies to manage trauma induced behaviors and/or PTSD as per a Trauma Informed Assessment. o The cost of transportation provided by residential service providers to and from activities is included as a component within the rate of the residential service. Providers of residential services are responsible for the full range of transportation services needed by the individuals they serve to participate in services and activities specified in their recovery-oriented service plan. This includes transportation to and from recovery-oriented services and employment services, as applicable. Modality: Habilitation is a face-to-face service that is delivered 1:1. Setting: Habilitation may be delivered (on-site), or in the community (off-site). This service can be provided by the individual’s provider of housing services. Admissions/Eligibility Criteria: The Individual requires habilitation and onsite services that may include but are not limited to cognition (cognitive skills), functional status (ADLs), and recovery-oriented community support. Limits on the amount, duration, or frequency of this service: The total hours for Habilitation are limited to no more than a total of 500 hours in a calendar year. Time limited exceptions to this limit for individuals transitioning from institutions are permitted if prior authorized and found to be part of the cost-effective package of services provided to the individual compared to institutional care.

Rate Code Description	Unit Measure	4/1/2025 Downstate[1]	4/1/2025 Upstate
HARP HCBS Intensive Supported Employment	Per 15 min	$37.24	$33.21
HARP HCBS On-going Supported Employment	Per 15 min	$37.24	$33.21
HARP HCBS Transitional Employment	Per 15 min	$37.24	$33.21
HARP HCBS Pre-vocational	Per hour	$148.96	$132.82
HARP HCBS Residential Supports (Habilitation)	Per 15 min	$34.35	$30.64

Note [1]: The Downstate region consists of NYC and the counties of Nassau, Suffolk, Westchester, Rockland, Orange, Putnam, and Dutchess.

HARPs Services Utilization Thresholds

The following thresholds will limit coverage of HARPs-specific services for individual HARPs enrollees. These limits will not affect state plan or other demonstration benefits. The state will track and report overall utilization, including any utilization threshold exceeded for clinical reasons, to ensure cost containment as well as compile sufficient fee for service data to submit HARPs capitation rates to CMS for approval.

1. Tier 1 –– Threshold of $8,000 per person, per 12-month period. Up to $10,000 in services are permitted. For ROS, the thresholds will be adjusted to reflect the HCBS rate differentials.

2. Tier 2 –– Threshold of $16,000 per person, per 12-month period. Up to $20,000 in services are permitted. For ROS, the thresholds will be adjusted to reflect the HCBS rate differentials.

New York Medicaid Redesign Team – MBI-WPD and CPT Amendment Request

(Pending as of 08/09/2025)

Target Population: Individuals with disabilities age 16 or older who are working and earning more than the allowable limits for regular Medicaid

New York’s current Medicaid Buy–In program for Working People with Disabilities (MBI-WPD) offers Medicaid coverage to people with disabilities who are working and earning more than the allowable limits for regular Medicaid, the opportunity to retain their health care coverage through Medicaid. This program allows working people with disabilities to earn more income without the risk of losing vital health care coverage.

On May 6, 2025, New York submitted an amendment request to CMS, “Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD) Demonstration Program and Career Pathways Training (CPT) Program Amendment,” to its New York Medicaid Redesign Team section 1115(a) demonstration. The amendment would authorize an 1115 demonstration program that would become the state’s new MBI-WPD program to help more working individuals with disabilities qualify for Medicaid. In addition, the state is requesting a change to the Special Terms and Conditions (STC) language governing the maximum number of allowable days for backfill payments in the CPT Program. The state is requesting an increase from the current limit of two days per week to up to five days per week to accommodate more intensive training programs.

Service Types

Intensive Supported Employment
Ongoing Supported Employment
Transitional Employment
Pre-Vocational Services
Habilitation Services

NYS OPWDD Comprehensive Waiver (0238.R07.00)1915(c)
Effective: 10/01/2024 – Expires: 09/30/2029

Target Population:Individuals with autism, intellectual disabilities, or developmental disabilities ages 0 or older who meet an ICF/IID level of care

Type of Medicaid Authority:1915(c) – This waiver operates with a concurrent 1915(a)(1)(a) and 1915(b)(4) authority.

Managed Care:Yes

Service Types

Supported Employment
Pathway to Employment
Prevocational Services
Community Habilitation

Service Definitions and Limitations

Supported Employment

Supported Employment (SEMP) services are the ongoing supports to participants who, because of their disabilities, need on- going support to obtain and maintain a job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage. The outcome of this service is paid employment at or above minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals; as such, career planning is also an allowable service. Supported employment services can be provided through many different service models. Some of these models can include evidence-based supported employment or customized employment for individuals with significant disabilities.

Supported employment services may be provided individually or in groups of two (2) to eight (8) workers with disabilities. Group employment may include training activities and employment services provided in regular business, industry and community settings. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in employment in the community. Supports provided to a group must be provided in a manner that promotes integration into the workplace and interaction between participants and people without disabilities in those workplaces.

Supported employment services may include any combination of the following services: vocational/job-related discovery or assessment, person-centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job carving, training and systematic instruction, job coaching, benefits support, training and planning, transportation, asset development and career advancement services, and other workplace support services including services not specifically related to job skill training that enable the waiver participant to be successful in integrating into the job setting.

SEMP services may also include services and supports that assist the participant in achieving self-employment through the operation of a business including home-based self-employment. However, Medicaid funds are not used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include: (a) aiding the participant to identify potential business opportunities; (b) assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business; (c) identification of the supports that are necessary in order for the participant to operate the business; and (d) ongoing assistance, counseling and guidance once the business has been launched.

SEMP services consist of two distinct phases: Intensive SEMP and Extended SEMP which can be provided on an individual or group basis. Intensive SEMP services include job development and/or intensive job coaching. If an individual is not employed, the service provider must document, in a format prescribed by OPWDD, the individual’s need for Intensive SEMP services, including information on how the services will assist the individual in obtaining employment. Extended SEMP services include ongoing job coaching and career development services for individuals who are employed. An individual is eligible for Extended SEMP if he or she is employed in an integrated workplace and earning at least minimum wage.

Individuals receiving supported employment services may also receive prevocational, day habilitation and Pathway to Employment.

SEMP is reimbursed at an hourly rate. For individuals who are self-directing their SEMP services using ‘self-hired’ staff, the maximum payment rate allowed is described in Addendum A of this agreement.

Documentation must be maintained indicating that Supported Employment services are not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation cannot be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

1. Incentive payments made to an employer to encourage or subsidize the employer’s participation in supported employment; or

2. Payments that are passed through to users of supported employment services.

The State will allow the remote delivery of Supported Employment services through the telephone or other technology in accordance with State, Federal, and Health Insurance Portability and Accountability Act (HIPAA) requirements where:

• a certified provider agency exercising good clinical judgment determines a telehealth encounter is appropriate for the delivery of services to an individual;

• the delivery of services can be effectuated via verbal prompting only;

• the health and safety of the individual continues to be met via this service modality; and

• the individual agrees to the delivery via telehealth.

Remote delivery includes an electronic method of service delivery. More specifically, “other technology” includes any two-way, real-time communication technology that meets HIPAA requirements.

OPWDD’s guidance establishes that remote supports meet all of the following requirements:

• The remote supports ensure the participant’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

• The remote supports do not isolate the participant from the community or interacting with people without disabilities.

• The participant has other opportunities for integration in the community via the other Waiver program services the participant receives and are provided in community settings; The request to use remote technology must be initiated by the person and his/her representative and not the provider.

• The remote supports must be described in the person’s Life Plan (LP) and Staff Action Plan (SAP).

Remote supports cannot be the only service delivery provision for a participant seeking the use of remote technology to deliver a given service. To be appropriate for the person, the remote delivery of services must be able to be effectuated via verbal prompting only. The health and safety of the individual will continue to be met via telehealth delivery of the service.

The request to use remote technology is confirmed as part of the person-centered planning process. People must have an informed choice between in person and remote supports, that is confirmed using the person-centered planning process. The planning team must determine how the need for hands-on services can be met during time when remote services are provided (e.g. natural support assisting with toileting). If these needs cannot be met and the person’s privacy assured, then the delivery of services using remote technology would not be appropriate. The planning team will establish an agreed upon schedule for in-person and remote technology-delivered services.

Participants must affirmatively choose remote service provision over in-person supports. The individual provides written consent to the delivery via telehealth. The LP documentation will be amended to accommodate consent specific to the use of telehealth. The signed consent will last for a period of up to six (6) months to coincide with the LP Review. Consent may be withdrawn by the individual and/or their representative at any time for any reason by contacting the Care Manager. The Care Manager will then modify the LP and follow-up with the provider to inform them of this change in the LP.

In addition, as part of the person-centered planning process the person and/or his or her representative are made aware that the use of remote technology for service delivery is his/her choice and permission to use remote technology may be withdrawn at any time.

The use of remote technology is subject to ongoing review by OPWDD Division of Quality Improvement as part of its Person-Centered Review (PCR).

Supported employment supports do not include vocational services provided in facility based work settings or other similar types of vocational services furnished in specialized facilities that are not a part of general community workplaces.

Supported employment supports do not include volunteering. Such volunteer learning and un-paid training activities that prepare a person for entry into the paid workforce are addressed through pre-vocational and pre-employment services.

Supported employment supports do not include payment for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business.

Personal care/assistance may be a component part of the supported employment services, but may not comprise the entirety of the service. Individuals receiving supported employment services may also receive prevocational, day habilitation, and Pathway to Employment. A participant’s service plan may include two or more types of non-residential habilitation services. However, different types of non-residential habilitation are not billed during the same period of time, unless the allowable services are provided on behalf of the individual when the individual is not present such as contacting a business about a potential job, while the person participates at another non-residential habilitation service. Individuals who self-direct their Community Habilitation, Respite and Supported Employment services with budget authority, may be eligible for “Special Populations Funding” if they have been discharged from a more restrictive residential setting such as a developmental center as described in Addendum A to this waiver. As described in Appendix E, the eligible individual’s budget may be increased up to the level of the Special Populations Funding and therefore could be used to fund self- directed, “self-hired” staff who deliver Supported Employment). The rate paid for the self-directed services follows the same limitations as are in place for all Individuals who exercise budget authority. The higher PRA funding is designed to provide additional supports required to assist an individual transitioning to a less restrictive setting.

Limits on the amount, duration, or frequency of this service:

OPWDD has established limits in regulation regarding the maximum number of hours of day service that a person can receive based upon where he/she resides. These limits are outlined in 14 NYCRR 635-10.5 and for individuals residing in non- certified settings limit services to no more than 1.5 units of service per day (or its equivalent in hourly unit services) or roughly 8-9 hours of service. Individuals residing in certified settings are limited to the equivalent of six hours of services which can be received only on weekdays beginning prior to 3 pm, except in the instance of non-site-based employment services which can also be received in the evening/weekend within the hourly limit.

Intensive and Extended SEMP services are limited as follows: OPWDD authorizes the number of hours of services across 365 days that can be reimbursed for an individual receiving Intensive SEMP services and must authorize all hours over 200 hours of services across 365 days that can be reimbursed for an individual receiving Extended SEMP services. An individual may receive up to 45 days of Extended SEMP services while unemployed but if not employed within 45 days, an agency must be approved by OPWDD for Intensive SEMP services to continue billing SEMP. If a service provider considers that an individual needs more than 365 days of Intensive or Extended services and/or additional hours, the service provider may submit a written request to OPWDD in accordance with the guidelines established in regulation.

Pathway to Employment

The Pathway to Employment is a person-centered, comprehensive career planning and support service that provides assistance for participants to obtain, maintain or advance in competitive employment or self- employment.

The Pathway to Employment service will be available to individuals expressing an interest in competitive employment or self- employment including (but not limited to) individuals who receive Day Habilitation, Pre- Vocational and Supported Employment services, as well as students leaving high school.

It is a focused, time limited service that engages a participant in identifying a career direction, provides instruction and training in pre-employment skills, and develops a plan for achieving competitive, integrated employment at or above the state minimum wage. Within 12 months, or sooner, the outcome of this service is documentation of the participant’s stated career objective; a detailed career plan used to guide individual employment supports; and preparation for supported employment services that assist a participant in obtaining, maintaining or advancing in competitive employment or self-employment.

Pathway to Employment participants must have competitive employment or self-employment as a stated goal in their service plans. The Pathway to Employment service will combine an individualized career planning process that identifies the person’s support needs with the provision of services that will strengthen the skills needed to obtain, maintain or advance in competitive employment. Services provided under the Pathway to Employment service will be person-centered and may include; but not be limited to: vocational assessment; situational assessment; job readiness training including individualized and appropriate work- related behaviors; community experiences; pre- employment skills including tasks necessary to obtain employment based on the individualized needs of the participant; job related discovery; experiential learning in career exploration and vocational discovery; experiential learning to achieve a specific vocational outcome; assessment for use of assistive technology to increase independence in the workplace; community experiences through paid or unpaid internships, mentorships, apprenticeships, job clubs, work site visits, job placement, and other job exploration modalities; education and counseling around benefits management and employment; person-centered vocational planning; customized job development; individualized, ongoing job coaching; travel training; and behavioral interventions and supports.

The Pathway to Employment service may also provide planning for self-employment. Specific services include: identifying skills that could be used to start a business, and identifying business training and technical assistance that could be utilized in achieving self-employment goals.

Employment Related Goals: All Pathway to Employment participants will develop a specific individualized career plan with the Pathway to Employment provider for services that will focus on the individual’s unique employment needs, talents, employment goals, and natural supports. At the end of Pathway to Employment, the provider in cooperation with the individual will create a formal vocational plan that will allow the individual to have a map of their career path. This Pathway to Employment career plan will outline the responsibilities of the participant and the responsibilities of the provider towards achievement of the employment goals.

It is anticipated that the majority of the Pathway to Employment service will be provided in community settings or at particular work sites. The cost of any reimbursable transportation associated with Pathway to Employment is included in the Pathway to Employment fee.

Services provided under Pathway to Employment are not available if it is funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).

The State will allow the remote delivery of Pathway to Employment services through the telephone or other technology in accordance with State, Federal, and Health Insurance Portability and Accountability Act (HIPAA) requirements where:

• a certified provider agency exercising good clinical judgment determines a telehealth encounter is appropriate for the delivery of services to an individual;

• the delivery of services can be effectuated via verbal prompting only;

• the health and safety of the individual continues to be met via this service modality; and

• the individual agrees to the delivery via telehealth.

Remote delivery includes an electronic method of service delivery. More specifically, “other technology” includes any two-way, real-time communication technology that meets HIPAA requirements.

OPWDD’s guidance establishes that remote supports meet all of the following requirements:

• The remote supports ensure the participant’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

• The remote supports do not isolate the participant from the community or interacting with people without disabilities.

• The remote supports must be described in the person’s Life Plan (LP) and Staff Action Plan (SAP).

The use of remote technology is subject to ongoing review by OPWDD Division of Quality Improvement as part of its Person-Centered Review (PCR).

Limits on the amount, duration, or frequency of this service:

A detailed vocational career plan and preparation for supported employment services that assist an individual in obtaining competitive, integrated employment at or above the state minimum wage is the expected outcome from this service. Pathway to Employment services are limited to 1 year, however, providers may request and be approved for an extension of services.

Prevocational Services

Prevocational Services are those services that provide learning and work experiences, including volunteering, where participants can develop general, non-job-task-specific strengths and skills that contribute to employability in paid employment in integrated community settings and increase levels of independence. Services are expected to occur over a defined period of time which is determined based upon a person-centered planning process, and with specific outcomes to be achieved, as determined by the individual and their service and supports planning team through an ongoing person-centered planning process.

Individuals receiving prevocational services must have employment-related goals in their person-centered services and supports plan; the general habilitation activities must be designed to support such employment goals. Competitive, integrated employment in the community for which an individual is compensated at or above minimum wage is considered to be the optimal outcome of prevocational services.

Prevocational services should enable each individual to attain the highest level of work in the most integrated setting and with the job matched to the individual’s interests, strengths, priorities, abilities and capabilities, while following applicable

federal wage guidelines from the U.S. Department of Labor. Services are intended to develop and teach general skills. Examples include, but are not limited to: ability to communicate effectively with supervisors, co-workers and customers; generally accepted community workplace conduct and dress; ability to follow directions; ability to attend to and complete tasks; punctuality and attendance; appropriate behaviors in and outside the workplace; workplace problem solving skills and strategies; mobility training; career planning; proper use of job-related equipment and general workplace safety.

Services include activities that are not primarily directed at teaching skills to perform a particular job, but at underlying habilitative goals (e.g., attention span, motor skills, interpersonal relations with co-workers and supervisors) that are associated with building skills necessary to perform work and optimally to perform competitive, integrated employment.

Prevocational services do not include vocational services provided in facility based work settings that are not integrated settings in the general community workforce.

There are two separate types of prevocational services: Site Based Prevocational Services and Community Prevocational Services. Site based prevocational services are prevocational services that are delivered in OPWDD certified non-residential facilities. Community prevocational services are provided primarily in community settings, as regulated by OPWDD. All prevocational services are delivered in the most integrated setting appropriate to the needs of the individual, except under limited circumstances specified in the regulations (e.g. when service delivery in the community may jeopardize the health and safety of individuals).

Prevocational services may not be provided if funding is available under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.)

The service may be provided in the community or a worksite (where the person makes less than 50% of the minimum or prevailing wage) to introduce the participant to the world of work, use of transportation options and adult education resources that will contribute to learning about employment. Transportation costs may be part of an agency rate depending upon the needs of the individual(s) and the availability of public transportation. Additional details are available in Addendum A of this Waiver application.

Community Prevocational Services will be reimbursed at an hourly fee and Site Based Prevocational Services will be reimbursed at a daily rate. Effective October 1, 2020, the rate setting regions for Community Prevocational Services will be

realigned with the rate setting regions already in use for Community Habilitation regions.

The State will allow the remote delivery of Prevocational Services through the telephone or other technology in accordance with State, Federal, and Health Insurance Portability and Accountability Act (HIPAA) requirements where:

• a certified provider agency exercising good clinical judgment determines a telehealth encounter is appropriate for the delivery of services to an individual;

• the delivery of services can be effectuated via verbal prompting only;

• the health and safety of the individual continues to be met via this service modality; and

• the individual agrees to the delivery via telehealth.

Remote delivery includes an electronic method of service delivery. More specifically, “other technology” includes any two-way, real-time communication technology that meets HIPAA requirements.

OPWDD’s guidance establishes that remote supports meet all of the following requirements:

• The remote supports ensure the participant’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

• The remote supports do not isolate the participant from the community or interacting with people without disabilities.

• The remote supports must be described in the person’s Life Plan (LP) and Staff Action Plan (SAP).

Participants must affirmatively choose remote service provision over in-person supports. The individual provides written consent to the delivery via telehealth. The LP documentation will be amended to accommodate consent specific to the use of telehealth. The signed consent will coincide with the LP Review. Consent may be withdrawn by the individual and/or their representative at any time for any reason by contacting the Care Manager. The Care Manager will then modify the LP and follow-up with the provider to inform them of this change in the LP.

The use of remote technology is subject to ongoing review by OPWDD Division of Quality Improvement as part of its Person-Centered Review (PCR).

Limits on the amount, duration, or frequency of this service:

OPWDD has established a maximum daily amount of services that are available to individuals based upon their residence. For individuals residing in a non-certified or certified setting site based prevocational services are limited to a maximum of one full unit per day. Community prevocational services are limited to a maximum of 6 hours per day. There are billing limits when combining services in one day and they are outlined in 14 NYCRR 635-10.5. Individuals residing in certified settings are limited to a maximum of six hours of non-residential services (or its equivalent) which must begin no later than 3 pm on weekdays. The exception to this time of day restriction is employment services, as many individuals have jobs where supports are required on weekday evenings and weekends.

Community Habilitation

Community Habilitation is similar in scope to residential habilitation supports and day habilitation supports, however, the focus of this service is directed towards service delivery occurring largely in the community (non- certified) settings to facilitate and promote independence and community integration. Community Habilitation is defined as a face to face service in the waiver and in all guidance issued by OPWDD. Therefore, in order for a service to be billed, the staff must be with the individual. This service provides another option to participants and families who wish to have their habilitation services available in a variety of every-day community settings.

Community Habilitation will offer skill training and supports as follows: adaptive skill development, assistance with activities of daily living, travel, health, adult educational supports, communication, social skills, leisure skills, money management, socially appropriate behaviors, life safety, hands-on-assistance provided by staff as necessary, professional oversight services as necessary (for example QIDP oversight), self-advocacy, informed choice, community inclusion, and relationship building. Community Habilitation may also include personal care, health care, protective oversight and supervision, including in the person’s home, and program-related transportation but these components do not constitute the entirety of the service.

Community Habilitation services are generally not vocational in nature. However, Community Habilitation services do support individuals in their attainment of life goals, including career goals. Therefore, Community Habilitation may include habilitation activities such as volunteering, learning about different types of jobs, visiting job sites and other experiences that are not long-term vocational commitments; yet the person is exposed to the world of work and the experience broadens his or her understanding of the types of employment they may wish to actively pursue in the future.

Once an individual is employed, community habilitation services may be used in a work setting to facilitate and promote independence, community inclusion, relationship building and socially appropriate behaviors. Community habilitation services cannot be used for job coaching or job development related activities and cannot be provided at the same time as supported employment services.

The State will allow the remote delivery of Community Habilitation services through the telephone or other technology in accordance with State, Federal, and Health Insurance Portability and Accountability Act (HIPAA) requirements where:

• a certified provider agency exercising good clinical judgment determines a telehealth encounter is appropriate for the delivery of services to an individual;

• the delivery of services can be effectuated via verbal prompting only;

• the health and safety of the individual continues to be met via this service modality; and

• the individual agrees to the delivery via telehealth.

Remote delivery includes an electronic method of service delivery. More specifically, “other technology” includes any two-way, real-time communication technology that meets HIPAA requirements.

OPWDD’s guidance establishes that remote supports meet all of the following requirements:

• The remote supports ensure the participant’s rights of privacy, dignity and respect, and freedom from coercion and restraint.

• The remote supports do not isolate the participant from the community or interacting with people without disabilities.

• The remote supports must be described in the person’s Life Plan (LP) and Staff Action Plan (SAP).

The use of remote technology is subject to ongoing review by OPWDD Division of Quality Improvement as part of its Person-Centered Review (PCR).

Through its ongoing review of waiver services, OPWDD’s DQI reviews the CH service to ensure that services are provided in accordance with the requirements.

OPWDD HCBS Waiver services including Community Habilitation services are authorized by the OPWDD DDROs. The DDROs will implement clinical review tools to formalize a three-step review process for consistency and efficiency of decision making and fairness and equity of service authorizations for Community Habilitation.

Community Habilitation participants will be offered the opportunity to participant-direct the service as outlined in Appendix E or participants may use a provider managed service delivery model.

Individuals who self-direct their Community Habilitation, Respite and Supported Employment services with budget authority, may be eligible for “Special Populations Funding” if they have been discharged from a more restrictive residential setting such as a developmental center as described in Addendum A to this waiver. As described in Appendix E, the eligible individual’s budget may be increased up to the level of the Special Populations Funding and therefore could be used to fund self- directed, “self-hired” staff who deliver Community Habilitation. The rate paid for the self-directed services follows the same limitations as are in place for all Individuals who exercise budget authority. The higher PRA funding is designed to provide additional supports required to assist an individual transitioning to a less restrictive setting.

The service definition of Community Habilitation will not change with the alignment of the currently approved CFCO State Plan and the fee schedule is realigned with other service systems. Only those services not reimbursable under the currently approved Community First Choice Option (CFCO) State Medicaid Plan will be reimbursable under the HCBS Waiver.

Limits on the amount, duration, or frequency of this service:

Individuals living in their own home/leased residence or family home may receive Community Habilitation services at any time. People living in Family Care homes and IRAs or Community Residences may only receive Community Habilitation Services on week day days (start time prior to 3:00 pm) unless the CH service is delivered at the person’s integrated and competitive job and the CH service allows the person to maintain employment.

The provision of Community Habilitation in the certified residential setting may be authorized when the person is unable to participate in another HCBS habilitation service outside the residence due to his or her health status, the person chooses this mode of service delivery, and the person has regular opportunities for community integration activities and the provision of this service does not tend to isolate the person.

In order to use in-residence services for a person with behavioral health needs, the person must have a Behavioral Support Plan that outlines the clinical and/or behavioral criteria that must be met to justify provision of in-residence services for the person on a given day.

The request to use in-residence services is confirmed as part of the person-centered planning process. People must have an informed choice between in-residence services and services available at another location, that is confirmed using the person-centered planning process. OPWDD’s guidance establishes that when these services are provided in a residence at least 51% of a person’s Community Habilitation services should be provided away from the home. If the actual schedule does not provide that level of outside activity, then the SAP should contain information which explains why any portion of the day services may take place in the home. Plans which justify day services occurring in the home should retain a community focus in accordance with the person’s interests and abilities. For those individuals it would be expected that people from the community or community-oriented activities could be brought into the home or, if the person were unable to interact with anyone, that fact would be so noted.

Additionally, as part of the on-going person-centered planning process the person’s choice to receive Community Habilitation and the choice to receive that service in the residence is confirmed during LP review meetings. The person and/or his or her representative may request a change to the in-residence service delivery by contacting the care manager.

In addition to payment edits barring weekend CH for individuals receiving residential habilitation services, payment combination edits also preclude payment of CH services for residential habilitation recipients who already have a full contingent of day services on a given day.

Unit of Service

Year 1

Waiver Service/ Component	Type	Unit	# Users	Avg. Units Per User	Avg. Cost /Unit	Component Cost	Total Cost
Supported Employment (SEMP)	SEMP – Self-Directed – FFS	Hourly	413	152.00	57.47	3,607,736.72	96,649,912.35
Supported Employment (SEMP)	SEMP – Hourly – MC	Hourly	141	109.00	92.37	1,419,634.53	96,649,912.35
Supported Employment (SEMP)	SEMP – Self-Directed – MC	Hourly	7	152.00	57.47	61,148.08	96,649,912.35
Supported Employment (SEMP)	SEMP – Hourly – FFS	Hourly	9,094	109.00	92.37	91,561,393.02	96,649,912.35
Pathway to Employment	Pathway to Employment – MC	Hourly	5	189.00	51.82	48,969.90	352,583.28
Pathway to Employment	Pathway to Employment – FFS	Hourly	31	189.00	51.82	303,613.38	352,583.28
Prevocational Services	Prevocational Services – Site Based – FFS	Daily	382	93.00	165.83	5,891,276.58	75,676,384.15
Prevocational Services	Prevocational Services – Site Based – MC	Daily	3	93.00	165.83	46,266.57	75,676,384.15
Prevocational Services	Prevocational Services – Community Based – FFS	Hourly	4,129	566.00	29.69	69,385,945.66	75,676,384.15
Prevocational Services	Prevocational Services – Community Based – MC	Hourly	21	566.00	29.69	352,895.34	75,676,384.15
Community Habilitation	Community Hab – Hourly – MC	Hourly	127	411.00	48.17	2,514,329.49	757,525,956.82
Community Habilitation	Community Hab – Self-Direction –	Hourly	21,766	725.00	28.27	446,110,494.50	757,525,956.82
Community Habilitation	Community Hab – Self-Direction – MC	Hourly	163	725.00	28.27	3,340,807.25	757,525,956.82
Community Habilitation	Community Hab – Hourly – FFS	Hourly	15,434	411.00	48.17	305,560,325.58	757,525,956.82

Year 5

Waiver Service/ Component	Type	Unit	# Users	Avg. Units Per User	Avg. Cost /Unit	Component Cost	Total Cost
Supported Employment (SEMP)	SEMP – Self-Directed – FFS	Hourly	341	122.00	63.44	2,639,230.88	89,457,688.80
Supported Employment (SEMP)	SEMP – Hourly – MC	Hourly	168	94.00	101.96	1,610,152.32	89,457,688.80
Supported Employment (SEMP)	SEMP – Self-Directed – MC	Hourly	8	122.00	63.44	61,917.44	89,457,688.80
Supported Employment (SEMP)	SEMP – Hourly – FFS	Hourly	8,884	94.00	101.96	85,146,388.16	89,457,688.80
Pathway to Employment	Pathway to Employment – MC	Hourly	6	200.00	57.20	68,640.00	91,520.00
Pathway to Employment	Pathway to Employment – FFS	Hourly	2	200.00	57.20	22,880.00	91,520.00
Prevocational Services	Prevocational Services – Site Based – FFS	Daily	79	81.00	183.05	1,171,336.95	85,770,774.45
Prevocational Services	Prevocational Services – Site Based – MC	Daily	3	81.00	183.05	44,481.15	85,770,774.45
Prevocational Services	Prevocational Services – Community Based – FFS	Hourly	4,130	621.00	32.77	84,046,202.10	85,770,774.45
Prevocational Services	Prevocational Services – Community Based – MC	Hourly	25	621.00	32.77	508,754.25	85,770,774.45
Community Habilitation	Community Hab – Hourly – MC	Hourly	151	457.00	53.17	3,669,102.19	968,647,965.22
Community Habilitation	Community Hab – Self-Direction –	Hourly	28,513	686.00	31.20	610,269,441.60	968,647,965.22
Community Habilitation	Community Hab – Self-Direction – MC	Hourly	194	686.00	31.20	4,152,220.80	968,647,965.22
Community Habilitation	Community Hab – Hourly – FFS	Hourly	14,427	457.00	53.17	350,557,200.63	968,647,965.22

Rate Determination Methods

The following services within the Waiver Amendment are calculated utilizing methodologies based on provider reported costs and are periodically rebased: Residential Habilitation (Supervised IRA and Supportive IRA), Group Day Habilitation and Site-Based Prevocational.

On an annual basis, OPWDD reviews the certified cost reports submitted by voluntary agencies delivering HCBS Waiver Services. The latest review was conducted in 2023. The primary aim is to ensure provider stability, quality, and continuity of care. In addition, the fiscal effect of reimbursement by waiver program for each provider is reviewed. Reimbursement to OPWDD-licensed and certified non-profit provider agencies has been reviewed and adjusted to recognize inflation and escalation of cost pressures related to delivering OPWDD programs and services. Consistent with New York State legislation directing wage and operational support increases, and pursuant to the approved HCBS Waiver, upward rate adjustments were made to OPWDD reimbursement levels in 2015 (January 1 and April 1), 2016 (April 1), 2018 (January 1 and April 1), 2020 (January 1 and April 1), 2021 (April 1), 2022 (April 1), 2023 (April 1) and 2024 (April 1). These adjustments had the effect of increasing reimbursement levels from the initial dates that rates were established for the following programs: Community Habilitation (November 1, 2010); Intensive Behavioral Services (October 1, 2013); Pathway to Employment (July 1, 2014); Family Care, Supported Employment and Prevocational -Community Based (July 2015); and Respite – Hourly (July 2017). These adjustments were also applied to the rate programs of Supervised IRA, Supportive IRA, Group Day Habilitation and Site-based Prevocational Services. Given the interruption of COVID-19 these services were not rebased during the previous five years. OPWDD is seeking a contractor to complete a comprehensive rate review, and the scheduling of this review is contingent on completing the procurement process. This review may result in OPWDD deciding to rebase one or more rates .

Individuals who reside in a supervised IRA will be eligible to receive Intensive Respite services from a Crisis Services for Individuals with Intellectual and/or Developmental Disabilities (CSIDD) provider at a CSIDD Resource Center. This eligibility is limited to Intensive Respite services provided at a Resource Center to address the crisis needs of the individual. During the person’s stay, the time spent in Respite will be counted towards the available retainer day limit, as those limits are described in Addendum A. No additional payment will be made available to the residential habilitation provider.

Rates for residential services include an acuity factor which is developed utilizing components of DDP-2 scores, average bed size, Willowbrook class indicators and historical utilization data to predict direct care hours need to serve individuals. Additionally, Supervised IRA rates include an Occupancy Factor to account for days when Medicaid billing cannot occur because of the death or relocation of an individual.

The occupancy adjustment for Supervised IRAs is being reduced to 0% effective on or after 10/1/2024 to maximize the use of existing, approved capacity and incentivize the provision of residential supports to people who require such critical services.

Group Day Habilitation and Site-Based Prevocational services include a to/from transportation component which will be rebased on 07/01/2024. After 07/01/2024 to/from transportation will be updated annually. These services also include capital costs that are helpful in developing and maintaining the provision of HCBS waiver services to beneficiaries determined in accordance with the cost principles described in the Medicare Provider Reimbursement Manual (Publication-15), with some exceptions. The “to/from transportation” component of the Group Day Habilitation and Site-based Prevocational Services rates are based on costs for the reporting period of January 1, 2019 – December 31, 2019 or July 1, 2019 – June 30, 2020. The annual update of these rates was paused during the PHE, consistent with Appendix K authority, and extended under the 10/1/2023 Waiver Amendment to resume effective 7/1/2024.

The rates for the identified programs are currently based on cost information from cost reports for the reporting period of January 1, 2017 – December 31, 2017 or July 1, 2017 – June 30, 2018, except that the “to/from transportation” component of the Group Day Habilitation and Site-based Prevocational Services rates are based on costs for the reporting period of January 1, 2019 – December 31, 2019 or July 1, 2019 – June 30, 2020. Consistent with our Waiver agreement, rates are rebased at an interval no longer than every 5 years. As such, the rates for the identified programs will be rebased July 1, 2024 utilizing costs reports for the reporting period of January 1, 2021 – December 31, 2021 or July 1, 2021 – June 30, 2022. The rates were most recently rebased effective July 1, 2019 with the exception of the “to/from transportation component” of the Group Day Habilitation and Site-based Prevocational Services rates which was rebased effective July 1, 2021.

The remaining services are fee-based. The fees are calculated utilizing various factors, including but not limited to, provider costs, historical utilization, DDP-2 scores, regional averages and review of nationally accepted methodologies and fees. Fee schedules are posted on the Department of Health’s webpage at: https://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/index.htm.

All waiver services are available to individuals who are enrolled in the NYS Fully Integrated Duals-Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) managed care demonstration. The FIDA-IDD managed care plan operates under 1915(a) authority. Additionally, there is a contract in place with CMS, NYS DOH and Partners Health Plan (PHP- the managed care organization) that establishes quality, fiscal and programmatic standards. Contract terms and conditions around capitated payments can be found in section 4.1. General Financial Provisions – 4.1.1. Capitation Payments of the FIDA-IDD contract.

There is no difference in rate determination methodology between self-directing and provider managed services. For rate or fee-based services, any adjustments or increase would be consistent between self-directed and provider managed services. Additionally, for individuals who are self-directing their services, the Personal Resource Allocation funding threshold is regularly adjusted for consistency with any rate or fee fiscal actions, such as statutory wage increases or Cost of Living Adjustments (COLA).

The DOH establishes all payment rates for waiver services. These payment rates are subject to the approval of the New York State Division of the Budget (DOB).

The Rate Methodology for payment of HCBS Waiver services are described in Addendum A to this document. The public can access information regarding rates paid for waiver service on the DOH website at: https://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/ and the OPWDD website where the waiver application is published at: https://opwdd.ny.gov/providers/home-and-community-based-services-waiver.

During the public comment period, hard copies of the Waiver language are available at all OPWDD Regional Offices for provider review and a Public Notice is also placed in the State Registry. The Waiver language published for public comment includes the rate determination methods as described further in Main Section 6-I.

In addition, OPWDD meets with the Provider Associations on a monthly basis. During rate updates, OPWDD has additional meetings with small Provider Rate Work Groups to discuss the impact methodology changes and to share rate runs.

Consistent with our Waiver agreement, OPWDD will review all rate setting methodologies at least every five years. However, OPWDD purposely chose not to make any rebasing changes during the COVID period, beginning in 2020. Our focus at that time was the continuity of services to individuals and the stabilization of providers. Methodology enhancements and billing flexibilities were made in accordance with this goal through Appendix K changes.

NY Traumatic Brain Injury (TBI) Waiver (0269.R05.00)1915(c)

Target Population:Individuals with TBI who are eligible for nursing home level of care and are between the ages of 18 and 64

Type of Medicaid Authority:1915(c) – This waiver operates with a concurrent 1115 authority.

Managed Care:Yes

Service Types

Independent Living Skills and Training Services
Non-Medical Transportation

Service Definitions and Limitations

Independent Living Skills and Training Services

Independent Living Skills and Training (ILST) services include assessment, training, and supervision of, or assistance to, an individual with issues related to self-care, medication management, task completion, communication skills, interpersonal skills, socialization, sensory/motor skills, mobility, community transportation skills, reduction/elimination of maladaptive behaviors, problem solving skills, money management, pre-vocational skills and skills to maintain a household.

ILST is provided in the environment and situation that results in the greatest positive outcome for the waiver participant and in an environment where the trained skills are most commonly used. ILST cannot be provided in the Structured Day Program.

The ILST provider utilizes the comprehensive functional assessment of the waiver participant provided through UAS-NY to identify the participant’s strengths and weaknesses in performing Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) related to his/her established goals. The UAS-NY/Community Health Assessment is the basis for developing an ILST plan that describes the milestones and interim steps necessary to attain these goals. The UAS-NY also includes a determination of the participant’s manner of learning new skills and responses to various interventions. This comprehensive and functional assessment is conducted at least annually from the date of the last assessment and approved by the RRDS in conjunction with the service plan. The UAS-NY is used to develop the detailed plan and service goals for ILST services.

Only in extraordinary situations where the participant benefits specifically from a group setting will this service be approved by the RRDS on other than an individual basis. This arrangement requires prior approval from the RRDC. In such situations, the provider may bill for a pro-rated percentage of the time spent with a participant (total hourly unit(s) divided by the total number of participants in the group). Training time provided to informal supports or waiver or non-waiver service providers must be designated in the service plan in order to be reimbursed and the participant must be present at the time of training.

This service is also used to assist a waiver participant in returning to employment, or expanding the waiver participant’s involvement in meaningful activities such as volunteering. The use of this service for these purposes occur only after it is determined that the waiver participant is not eligible for services provided through the New York State Education Adult Career and Continuing Education Services Vocational Rehabilitation (ACCES-VR) or the Commission for the Blind and Visually Handicapped (CBVH); that ACCES-VR and CBVH services have been exhausted; or the activity is not covered by ACCES-VR or CBVH services. ILST is not used as “job coaching”, but to provide training in other skills that support vocational opportunities.

This service may continue only when the waiver participant has reasonable and attainable goals. It is used for training purposes and not ongoing long term supports. Justification to provide or continue this service must be clearly stated in a service plan and approved by the RRDS.

ILST is not intended to be a long-term support. Independent Living Skills Training and Development under this waiver is cost-effective and necessary to avoid institutionalization.

ILST providers must participate in Team Meetings and are reimbursed at the hourly rate for their time at the Team Meeting. Meeting time is included in the service plan. Each service plan contains an approved number of annual service units a provider is authorized to deliver. Regularly scheduled Team Meetings with the participant and service providers are an essential part of assuring the participant’s health and welfare. This meeting is instrumental in the development and implementation of the service plan. Failure to participate in Team Meetings may jeopardize the ability of the waiver provider to continue to provide waiver services. Participation at the team meeting is to garner information from the participant and informal supports about needed services, change in physical or cognitive status, discussion about individual progress and to make recommended service changes. It is a direct service to the participant. Team Meetings may be held virtually, via telephone or in person at the request of the participant.

All agencies that employ two (2) or more ILSTs must provide supervision by an individual who fully meets the qualifications as an ILST provider. The supervisor is expected to meet any waiver participants prior to approving the training plan developed by an ILST under their supervision, have supervisory meetings with staff on at a monthly basis, and review and sign-off on all training plans. A supervisor may maintain an active caseload of waiver participants.

All ILST services must be documented in the service plan and provided by individuals or agencies approved as a provider of waiver services by the DOH. The cost effectiveness of this service is demonstrated in Appendix J.

Limits on the amount, duration, or frequency of this service:

No additional hours are allowed to complete initial and re-assessments. Not to exceed 220 hours annually not to exceed 4 hours per day.

Providers will not be reimbursed for time spent writing ILST plans, reviewing data or writing assessment reports.

The participant must be present at service delivery.

In all cases, service limits are soft limits that may be exceeded due to medical necessity. If the individual’s needs cannot be met within the established limits, a participant may request to exceed the limit by providing sufficient medical justification to the RRDC. The RRDC will approve or deny the request for additional services.

Non-Medical Transportation

Note: Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Unit of Service

Year 1

Waiver Service/ Component	Unit	# Users	Avg. Units Per User	Avg. Cost /Unit	Component Cost
Independent Living Skills and Training Services	hour	1050	140.00	41.42	6,088,740.00

Year 5

Waiver Service/ Component	Unit	# Users	Avg. Units Per User	Avg. Cost /Unit	Component Cost
Independent Living Skills and Training Services	hour	1490	140.00	41.42	8,640,212.00

Rate Determination Methods

The Bureau of Mental Hygiene Rate Setting within the Division of Finance and Rate Setting in NYSDOH OHIP is responsible for rate setting and oversight.

Pursuant to 29 USC Ch 8, the Fair Labor Standards Act (FLSA), the state was required effective October 13, 2015 to compensate for overtime and travel between service recipients. Rate methodology is amended to ensure compliance with FLSA requirements to be effective the date the federal regulation required implementation. A trend will be applied at the discretion of the State and will result in updating the fiscal integrity demonstration and fee tables. The trend factor used will be the applicable year from the Medical Care Services Index for the period April to April of each year from www.bls.gov/cpi; Table 1 Consumer Price Index for All Urban Consumers (CPI-U); U.S. city average, by expenditure category and commodity and service group, or as prescribed in State statute.

Provider Reimbursement of Waiver Services

TBI HCBS services are provided by Non-State Government, Private provider agencies and sole proprietors. Private provider agencies are nonprofit organizations, for-profit organizations or proprietary agencies. The rates for Service Coordination (SC), Community Integration Counseling (CIC), Home and Community Support Services (HCSS), Independent Living Skills and Training Services (ILST), Positive Behavioral Interventions and Support Services (PBIS), Respite, Substance Abuse Program Services and Structured Day Program Services (SDP) were derived from rates in effect during the previous waiver period (2017-2022). Please note that the waiver year 5 rate in the currently approved application has been amended through Appendix K actions pursuant to the COVID-19 public health emergency. The current effective average rate for HCSS has been increased because of New York State minimum wage requirements which impacts only HCSS on the waiver. Future amendments may be required to accommodate future minimum wage requirements and Appendix K unwind activities. The rates for Assistive Technology (AT), Community Transitional Services (CTS), Environmental Modifications Services (E-Mods) are based on actual costs.

Rate information is made available to waiver participants in their Service Plans, which describe the frequency and duration of each service, the annual amount of units, the rate per unit and the total annual cost of each service. All approved TBI service providers receive notice of the rates for their approved services at the time of provider enrollment.

NYSDOH gives public notice required by the State Administrative Procedure Act and other State Laws of any amendment to its regulations regarding the rate-setting methodology. SAPA requires that a Notice of Proposed Rulemaking include a name, public office address and telephone number for an agency representative to whom written views and arguments may be submitted. Public comment information is available in Main 6-I.

NYS will be reviewing the existing provider payment rate structure to address 2022 NYS Budget initiatives targeted to strengthen and expand the healthcare (waiver service) workforce and provider base. These initiatives may warrant a change in rates and require future amendments to the waiver application. NYS will seek to implement wage and rate parity across the NHTD and TBI waiver programs.

Prompted by a decline in Personal Care and HCBS waiver services in rural counties, NYS passed legislation in SFY 18/19 requiring NYSDOH to study to determine if any actions should be taken to address the situation. The study determined that providers are under reimbursed in rural areas due to long driving distances, which increases the transportation component of cost and reduces billable hours. The proposed rural adjustment applied only to HCSS (rate code 9879-9883) and consisted of an $8.00 per hour add-on to the rate which applied only to Allegany, Clinton, Delaware, Essex, Franklin, Hamilton and St. Lawrence counties, which are comprised of zip codes designated as “Frontier and Remote” by the USDA Economic Research Service. The add-on took effect on September 1, 2019.

I. Definitions Applicable to this Section

a. Cost Report: On and after January 1, 2021, the Cost Report is the report and associated instructions utilized by all government and non-government providers to communicate annual costs incurred as a result of operating TBI waiver services, along with related patient utilization and staffing statistics.

b. Rate: A reimbursement amount based on a computation using annual provider reimbursable cost divided by the applicable annual units of service.

c. Units of Service: The unit of measure varies by the type of service, i.e., hourly or one-time occurrence.

NYSDOH has assigned separate rate codes for each of these services to track the amount/cost of each service provided. This allows the waiver provider to bill, through the eMedNY system, the specific number of units which reflects the cost for these services.

Transportation costs reflect non-medical trips captured by the service coordinators and transportation contractors for TBI waiver participants, through NYSDOH’s contracted transportation system.

TBI Regions: Each provider must seek approval to provide services in each statewide region designated by NYSDOH. Services are provided as reported on the cost report. Fee schedules are based on the following geographic indicators:

• Downstate for all waiver services, except HCSS: The Counties of New York, Kings, Queens, Richmond, Bronx, Nassau, Suffolk, Rockland, and Westchester.

• Upstate for all waiver services, except HCSS: All other counties of the state that are not included in the downstate region.

Regional indicators for HCSS service rates, with the consideration of minimum wage requirements, are as follows:

NYC (Bronx, Kings, NY, Queens, Richmond)

Long Island (Nassau, Suffolk, Westchester)

Rockland

Rest of State

Rural (Allegany, Clinton, Delaware, Essex, Franklin, Hamilton, St. Lawrence)

The statewide $15 minimum wage was enacted as part of the 2016-17 State Budget. As of December 31, 2016, the first in a series of wage increases went into effect. Rates differ based on region and industry because the increases are calibrated to provide businesses ample time to adjust .The minimum wage rates are scheduled to increase each year on 12/31 until they reach $15.00 per hour. Future increases will be based on an indexed schedule to be set by the Director of the Division or Budget in consultation with the Department of Labor following an annual review of the impact and until such time that state reaches statewide compliance with the law. Effective January 1, 2017, and thereafter, TBI rates of payment for services have been increased to address the implementation of Chapter 54 of the Laws of 2016 for New York State, amending Section 652 of the Labor Law (minimum wage adjustment – see table below).

To the extent possible, the minimum wage adjustment has been developed and implemented based on provider attested data and will be incorporated into the TBI fees using an add-on inclusive of associated fringe. Because the reimbursement methodology for the TBI waiver is fee based, the adjustment did not vary by provider. After the end of each calendar year, the Department of Health will survey providers to obtain the necessary information to reconcile the annual minimum wage reimbursement to actual provider expenditures and to assure that providers have fully complied with the minimum wage statutory requirements by passing the additional reimbursement along to their hourly employees.

Minimum Wage Table

General Minimum Wage Rate Schedule from NYSDOL website: https://dol.ny.gov/minimum-wage-0

Location 12/31/2016 12/31/2017 12/31/2018 12/31/2019 12/31/2020 12/31/21*

NYC – Large

Employers (of 11 or more) 11.00 13.00 15.00 – – –

NYC – Small

Employers (10 or less) 10.50 12.00 13.50 15.00 – –

Long Island &

Westchester 10.00 11.00 12.00 13.00 14.00 15.00

Remainder of

New York State 9.70 10.40 11.10 11.80 12.50 *13.20

NOTE: The statewide minimum wage prior to 12/31/2016 was $9.00

The unit of measure used for the following waiver services are:

• SC – Initial and Monthly

• AT – Per Occurrence

• CIC – Hourly

• CTS – Per NF Discharge

• Environmental Modification – Per Modification

• HCSS – Hourly

• ILST – Hourly

• PBIS – Hourly

• Respite – Per diem (24 hour block of time)

• Structured Day Programs – Hourly

• Substance Abuse Program – Hourly

• Waiver Transportation – Per Person Per Year

NY Children’s Waiver (4125.R06.00)1915(c)
Effective: 04/01/2022 – Expires: 03/31/2027

Target Population:Individuals with physical or other disabilities ages 0-20, with brain injury ages 0-20, with HIV/AIDS ages 0-20, who are medically fragile ages 0- 20, who are technology dependent ages 0-20, with autism ages 0-20, with developmental disabilities ages 0-20, with intellectual disabilities ages 0-20, with mental illness ages 18-20, and individuals with serious emotional disturbance ages 0-18 years who meet a hospital, nursing facility, or ICF/IID level of care

Type of Medicaid Authority:1915(c) – This waiver operates with a concurrent 1915(b)(4) and 1115 authority.

Managed Care:Yes *

Service Types

Supported Employment
Prevocational Services
Non-Medical Transportation
* Note: a portion of children under the Children’s Waiver (approximately 50% of enrollees) remain in FFS

Service Definitions and Limitations

Supported Employment

Supported Employment services are individually designed to prepare youth with disabilities (age 14 or older) to engage in paid work. Supported Employment services provide assistance to participants with disabilities as they perform in a work setting.

Supported Employment provides ongoing supports to participants who, because of their disabilities, need intensive on-going support to obtain and maintain an individual job in competitive or customized employment, or self- employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals.

Supported employment services are individualized and may include any combination of the following services: vocational/job-related discovery or assessment, person-centered employment planning, job placement, job development, negotiation with prospective employers, job analysis, job carving, training and systematic instruction, job coaching, benefits support, training and planning, transportation, career advancement services, and other workplace support services including services not specifically related to job skill training that enable the participant to be successful in integrating into the job setting.

Supported employment services may also include services and supports that assist the participant in achieving self- employment through the operation of a business including home-based self-employment. However, Medicaid funds are not used to defray the expenses associated with starting up or operating a business. In addition to the need for an appropriate job match that meets the individual’s skills and interests, individuals may also need long term employment support to successfully maintain a job due to the ongoing nature of the HCBS participant’s support needs, changes in life situations, or evolving and changing job responsibilities.

Supported employment services may be provided in a variety of settings, particularly work sites. Supported employment services include the following:

• Supervision and training that are not job-related

• Intensive ongoing support

• Transportation to and from the job site

• Interface with employers regarding the individual’s disability(ies) and needs related to his or her healthcare issue(s)

• Other activities needed to sustain paid work (e.g., employment assessment, job placement, and/or adaptive/assistive technology necessary for employment)

• Job finding and development training in work behaviors

• assessing the interest and fit of an individual for particular job opportunities, staff work with employers and job sites preparing them to be able to make necessary and reasonable accommodations

• On-site support for the individual as they learn specific job tasks

• Monitoring through on-site observation through communication with job supervisors and employers. Supported employment is provided through individual face-to-face intervention.

Limits on the amount, duration, or frequency of this service:

Allowable settings in compliance with Medicaid regulations and the Home and Community Based Settings Final Rule (§441.301(c)(4) and §441.710) (see Appendix F) will exhibit characteristics and qualities most often articulated by the individual child/youth and family/caregiver as key determinants of independence and community integration. Services should be offered in the setting least restrictive for desired outcomes, including the most integrated home or other community-based settings where the beneficiary lives, works, engages in services and/or socializes. While remaining inclusive of those in the family and caregiver network, family is broadly defined, and can include families created through: birth, foster care, adoption, or a self-created unit.

Medicaid funds may not be used to defray the expenses associated with starting up or operating a business.

Supported Employment service will not be provided to an HCBS participant if:

(i) Special education and related services that is otherwise available to the individual through a local educational agency, under the provisions of the Individuals with Disabilities Education Act (IDEA).

(ii) Vocational rehabilitation services that are otherwise available to the individual through a program funded under section 110 of the Rehabilitation Act of 1973.

(iii) Supported employment does not include facility based, or other similar types of vocational services furnished in specialized facilities that are not a part of the general workplace.

(iv) Supported employment does not include payment for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business.

(v) Supported employment does not include volunteer work. Such volunteer learning and un-paid training activities that prepare a person for entry into the paid workforce are addressed through pre-vocational services.

Medicaid funding cannot be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

• Incentive payments made to an employer to encourage or subsidize the employer’s participation in supported employment; or

• Payments that are passed through to users of supported employment services.

Supported employment is limited to 3 hours per day.

Prevocational Services

Prevocational Services are individually designed to prepare a youth (age 14 or older) to engage in paid work, volunteer work or career exploration. Prevocational Services are not job-specific, but rather are geared toward facilitating success in any work environment for youth whose disabilities do not permit them access to other prevocational services. The service will be reflected in youth’s plan of care and must be directed to teaching skills rather than explicit employment objectives. In addition, Prevocational Services assist with facilitating appropriate work habits, acceptable job behaviors, and learning job production requirements.

Prevocational Services may include volunteer work, such as learning and training activities that prepare a person for entry into the paid workforce. Prevocational Services should enable each participant to attain the highest level of work in the most integrated setting and with the job matched to the participant’s interests, strengths, priorities, abilities, and capabilities, while following applicable federal wage guidelines from the U.S. Department of Labor. Services are intended to develop and teach general skills. Examples include, but are not limited to:

• ability to communicate effectively with supervisors, co-workers and customers;

• generally accepted community workplace conduct and dress;

• ability to follow directions;

• ability to attend to and complete tasks;

• punctuality and attendance;

• appropriate behaviors in and outside the workplace;

• workplace problem solving skills and strategies;

• mobility training;

• career planning;

• proper use of job-related equipment and general workplace safety.

Prevocational Services include activities that are not primarily directed at teaching skills to perform a particular job, but at underlying habilitative goals (e.g., attention span, motor skills, interpersonal relations with co-workers and supervisors) that are associated with building skills necessary to perform work and optimally to perform competitive, integrated employment.

• Resume writing, interview techniques, role play and job application completion.

• Exploring career options, facilitating appropriate work habits, acceptable job behaviors, and learning job production requirements

• Assisting in identifying community service opportunities that could lead to paid employment

• Helping the youth to connect their educational plans to future career/vocational goals

• Helping youth to complete college, technical school or other applications to continue formal education/training

• Helping youth to apply for financial aid or scholarship opportunities

Limits on the amount, duration, or frequency of this service:

Documentation is maintained that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.).

This service may be delivered in a one-to-one session or in a group setting of two or three participants. Allowable settings in compliance with Medicaid regulations and the Home and Community Based Settings Final Rule (§441.301(c)(4) and §441.710) (see Appendix F) will exhibit characteristics and qualities most often articulated by the individual child/youth and family/caregiver as key determinants of independence and community integration. Services should be offered in the setting least restrictive for desired outcomes, including the most integrated home or other community-based settings where the beneficiary lives, works, engages in services and/or socializes. While remaining inclusive of those in the family and caregiver network, family is broadly defined, and can include families created through: birth, foster care, adoption, or a self-created unit.

Prevocational services will not be provided to an HCBS participant if:

(i) Special education and related services that are otherwise available to the individual through a local educational agency, under the provisions of the Individuals with Disabilities Education Act (IDEA).

(ii) Vocational rehabilitation services that are otherwise available to the individual through a program funded under section 110 of the Rehabilitation Act of 1973 (Access VR).

(iii) Vocational services that are provided in facility based work settings that are not integrated settings in the general community workforce.

Prevocational services are limited to 2 hours a day.

Non-Medical Transportation

Non-Medical Transportation services are offered, in addition to any medical transportation furnished under the 42 CFR 440.17(a) in the State Plan. Non-medical Transportation services are available for individuals to access authorized HCBS and destinations that are related to a goal included on the child/youth’s Plan of Care.

Limits on the amount, duration, or frequency of this service:

Examples where this service may be requested include transportation to: HCBS that an individual was determined eligible to receive, a job interview, college fair, a wellness seminar, a GED preparatory class, community integration activity, etc. This service will be provided to meet the participant’s needs as determined by an assessment performed in accordance with Department requirements and as outlined in the participant’s plan of care. The care manager must document a need for transportation to support an individual’s identified goals. The Health Home Care Manager will include justification for this service within the Person-Centered Plan of Care. For individuals not enrolled in a Health Home, MCO Care Coordinator, or the Independent Entity will be responsible for completing documentation of which goals in an individual’s Plan of Care to which the trips will be tied.

For each participant utilizing Non-Medical Transportation, the Transportation Manager will provide a monthly report of authorized trips to the State.

Generally, the same rules used to determine reimbursement of trips to medical appointments should be followed when considering reimbursement of non-medical trips for eligible participants. Only those services not reimbursable under the Community First Choice Option (CFCO) State Medicaid Plan will be reimbursable under the HCBS Waiver.

The following guidelines apply to Non-Medical Transportation:

• Transportation must be tied to a goal in the Plan of Care.

• Transportation is available for a specified duration and annual cost.

• Individuals receiving residential services are ineligible for Non-Medical Transportation.

• Use transportation available free of charge.

• Use the medically appropriate mode of transportation.

• Travel within the common marketing area.

• When possible, trips should be combined.

• Justify need for travel outside the common marketing area.

• Vouchers submitted for personal vehicle mileage reimbursement must be submitted within 90 days of the date of service. Only when there are extenuating circumstances, will the Department allow payment for trips that are submitted after the 90 day time period. These requests will be considered on a case-by-case basis provided valid justification is given.

• Reimbursement for travel can be denied when the destination does not support the participant’s integration into the community.

• A participant’s Plan of Care outlines the general parameters of his or her Non-Medical Transportation needs. However, these needs can change or be amended based upon the participant’s stated goals and/or successful ongoing integration into the community. Transportation may be provided for routine trips for an approved limited period of time for the participant to integrate into the community or for employment and schooling opportunities.

Unit of Service

Year 1

Waiver Service	Component/ Type	Unit	# Users	Avg. Units Per User	Avg. Cost /Unit	Component Cost	Total Cost
Supported Employment	Supported Employment	15 min	54	38.59	26.24	54,680.49	54,680.49
Supported Employment	Supported Employment Capitated	15 min	1	0.01	0.01	0.00	54,680.49
Prevocational Services	Prevocational Services Capitated	15 min	1	0.01	0.01	0.00	1,428,092.16
Prevocational Services	Prevocational Services	15 min	620	100.30	22.91	1,424,681.26	1,428,092.16
Prevocational Services	Prevocational Services Group of 2	15 min	4	33.62	13.99	1,881.38	1,428,092.16
Prevocational Services	Prevocational Services Group of 2 Capitated	15 min	1	0.01	0.01	0.00	1,428,092.16
Prevocational Services	Prevocational Services Group of 3	15 min	7	21.01	10.40	1,529.53	1,428,092.16
Prevocational Services	Prevocational Services Group of 3 Capitated	15 min	1	0.01	0.01	0.00	1,428,092.16
Non -Medical Transportation	Non -Medical Transportation	Trip	20	54.15	22.40	24,259.20	24,259.20

Year 5

Waiver Service	Component/ Type	Unit	# Users	Avg. Units Per User	Avg. Cost /Unit	Component Cost	Total Cost
Supported Employment	Supported Employment	15 min	34	40.45	34.58	47,557.87	87,730.29
Supported Employment	Supported Employment Capitated	15 min	30	39.35	34.03	40,172.42	87,730.29
Prevocational Services	Prevocational Services Capitated	15 min	467	129.20	29.98	1,808,885.27	2,275,539.42
Prevocational Services	Prevocational Services	15 min	239	64.59	29.89	461,412.23	2,275,539.42
Prevocational Services	Prevocational Services Group of 2	15 min	2	27.83	18.30	1,018.58	2,275,539.42
Prevocational Services	Prevocational Services Group of 2 Capitated	15 min	2	46.39	18.30	1,697.87	2,275,539.42
Prevocational Services	Prevocational Services Group of 3	15 min	4	18.56	13.61	1,010.41	2,275,539.42
Prevocational Services	Prevocational Services Group of 3 Capitated	15 min	4	27.83	13.61	1,515.07	2,275,539.42
Non -Medical Transportation	Non -Medical Transportation	Trip	22	59.78	29.30	38,534.19	38,534.19

Rate Determination Methods

The waiver will operate concurrently with the 1115 beginning October 1, 2019. This fee schedule expense reimbursement covers claims effective for dates of service beginning with the approval of the waiver. Provider Reimbursement of Waiver Services:

Children’s HCBS are provided by Non-State Govt and Private provider agencies. Private provider agencies are non- profit organizations or proprietary agencies. Non-profit organizations include not-for profit corporations formed under the NYS Law or authorized to do business in NY. The New York State (NYS) Children’s waiver transitioned into managed care concurrent with the 1115 authority on October 1, 2019. The HCBS services will be capitated no earlier than the second year of the waiver beginning 4/1/2023. As of 11/1/23, due to the PHE and subsequent labor shortage, the DOH and its actuaries have determined that NY’s recent utilization experience does not provide sufficient data necessary to make credible actuarial adjustments carving Children’s HCBS into the MCO monthly capitated rates. Effective with the 3/1/2024 amendment, HCBS will tentatively be included in capitation under the Managed Care capitation on 7/1/24. The fiscal report will be submitted to CMS within 16 months after the close of the reporting period.

The State’s HCBS provider fee schedule is found at: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/2021-04-01_bh_kids_hcbs_rate_summary.pdf

Waiver rates are posted on the DOH website at: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/manuals.htm

I. Definitions Applicable to this Section

a. Consolidated Fiscal Report: The Fiscal Report is the report and associated instructions utilized by all government and non-government providers to communicate annual costs incurred as a result of operating the Children’s waiver programs and services, along with related patient utilization and staffing statistics.

b. Rate: a fee established for reimbursement of each unit of service provided.

c. The waiver services and units of Service: The unit of measure varies by the type of service, i.e., 15 min., per episode, per project.

The waiver service unit of measure are:

Community Habilitation per 15m

Day Habilitation per 15m

Caregiver/Family Advocacy and Support Service (individual, group of 2, group of 3) per 15m

Pre-Vocational Services (individual, group of 2, group of 3) per 15m

Supported Employment per 15m Palliative Care Pain and Symptom Management per hour

Palliative Care Counseling and Support Service per hour, per episode (2 per episode units) (Counseling and End of Life Duties are separate per episode fees)

Palliative Care Massage Therapy per hour

Palliative Care Expressive Therapy per hour

Respite Planned (individual, group of 2 and group of 3 – up to 6 hours per 15m)

Respite Planned (individual – 6-12 hours, 12-24 hours) per diem

Respite Crisis (up to 6 hours) per 15m

Respite Crisis (6-12 hours and 12-24 hours) per diem

Habilitation (individual, group of 2 or group of 3) per 15m

Non-Medical Transportation-per trip

FMS-Per project II.

Reporting Requirements

a. The State Government Providers, Non-State Government Providers and Private Providers shall identify provider costs in accordance with Generally Accepted Accounting Principles (GAAP.)

b. The State’s required Consolidated Fiscal Reporting forms are completed annually

Consolidated Fiscal Reporting for non-profit waiver services will be subject to review. The Consolidated Fiscal Report will be submitted to CMS within 16 months after the close of the reporting period. The Children’s waiver does not include state providers.

III. Services Paid via Fee Schedule: Statewide Rates for All providers includes:

Caregiver/Family Advocacy and Support Service

Pre-Vocational Services

Supported Employment

Palliative Care Pain and Symptom Management

Palliative Care Counseling and Support Service

Palliative Care Massage Therapy

Palliative Care Expressive Therapy

Respite Planned

Respite Crisis

Community Habilitation

Day habilitation

FMS

For the 4/1/22 renewal: Fees are based on historical provider costs adjusted for trend. Additionally, fees established for the first 6 months of waiver year 1 have been set at an increase of 25% over historical reimbursements to assist providers to build capacity to meet the increasing need as per New York’s CMS Approved 9817 spending plan. For Waiver Year 1, New York uses an increase on price of 20% which is a blend of 25% for half the year (ARPA 9817 rate update, since those rate updates weren’t in the system when the base data was pulled) and a PROJECTED 15% for Rate Rebasing to remain in effect after October in the first year. The second year the price trend is reduced by 5%, to bring the price down from a 20% increase to 15% PROJECTED as the rebased rates continue. In Subsequent years, NY projected services with the 6.8% Price trend from CPI as the waiver included trend language.

Effective 11/1/23, rates are permanently amended to continue the 25% rate increase awarded under New York’s Spending Plan under Section 9817 of the American Rescue Plan Act and the 5.4% cost of living adjustment, both of which were authorized under Appendix K during the COVID-19 Public Health Emergency. In Subsequent years, NY projected services with the 6.8% Price trend from CPI as the waiver included trend language. New York allows for annual COLA increases to rates, subject to state budget requirements and legislative approval.

All fees are for an individual setting and a 15-minute unit of service unless otherwise indicated. Group rates are individual rates adjusted for expected group size. Per diems for extended periods of time were developed separately from associated individual rates and may vary for different lengths of time.

Geographical rate variations for all of the above services are included to reflect wage and resource cost differences between upstate, downstate and rural regions. Effective 11/1/23 a new regional geographic rate variation is being added for designated rural regions. NY developed upstate, downstate and rural rates for all rates because of specific variations in wages and resource costs affecting the service delivery. For Adaptive and Assistive Technology, Vehicle Modifications, Environmental Modifications the vendor will bill the actual amount of the technology or modification.

Non-Medical Transportation-per trip rate: fees will be established by the local social services districts and subsequently approved by the Office of Health Insurance Programs. Fees will be reviewed to ensure they do not exceed the current usual and customary amount charged to the general public. A fee will be negotiated under extenuating and unique circumstances where a higher fee is necessary to assure safe and appropriate transportation to necessary medical services.

IV. Services paid using a Contract Amount

a. Environmental Modifications, Vehicle Modifications or Adaptive and Assistive Technology.

i. Prior to 3/1/2024, the governmental entity/Health Home/MCO is the provider of record for Environmental Modifications, Vehicle Modifications, or Adaptive and Assistive Technology for billing purposes. The work is done by a contractor who is selected by the governmental entity using a standard bidding process, following the state rules or Health Home (for FFS) or the MCO process (for managed care). Environmental Modifications or Vehicle Modifications are only billed to Medicaid or the MCO once the contract work is verified as complete and the amount billed is equal to the contract value. Environmental modifications are limited to individual or family owned or controlled homes.

After 3/1/2024, the FMS will be the provider of record for new Environmental Modifications, Vehicle Modifications, and Adaptive and Assisted Technology. Projects are only billed to Medicaid once the contract work is verified as complete and the amount billed is equal to contract value. Environmental Modifications are limited to individual or family owned or controlled homes.

ii. The maximum expenditure for Environmental Modifications or Vehicle Modifications for the benefit of the individual Medicaid beneficiary may not exceed $25,000 per year for environmental modifications, $35,000 per year for safe passenger, and $65,000 per five years for driver vehicle modifications. If the person requires an expenditure which exceeds the maximum expenditure amount the Medicaid agency may grant exceptions with medical necessity documentation as outlined in the E-Mod or Safe passenger V-Mod service definition, if applicable.

After 3/1/2024, the FMS in conjunction with DOH may grant these exceptions.

V. Trend Factors

The trend factor applied will be the applicable years from the Medical Care Services Index for the period April to April of each year from www.bls.gov/cpi; Table 1 Consumer Price Index for All Urban Consumers (CPI-U); U.S. city average, by expenditure category and commodity and service group. The consolidated children’s waiver rates may be trended from time to time, at the discretion of DOH and only with the approval of CMS. When trended, the trend used will be based on the CPI-U Medical Services for all Urban Consumers, as published by the BLS, over the period of the trend and extrapolated as needed. If parents/guardians of participants have any questions about the payment rates made to the Children’s waiver providers, they may contact their care manager or the DOH Public Affairs Office to obtain this information.

NYSDOH is responsible for HCBS rate determination in all years of the waiver. NYSDOH is responsible for capitation rate determination for MCO rates that include HCBS no earlier than year two of the waiver.

Public Input Process and Rate Sufficiency

New York utilized the public input process in Main section 6-I to solicit public comments on reimbursement methodologies. New York will ensure rate sufficiency consistent with the November 2016 and January 2019 technical guide to ensure access to services including:

1. Date the rates were initially set and last reviewed: Children’s Waiver – Because this is a major program change, New York reviewed and set the rates for the Children’s waiver effective April 1, 2019 and revised the rates with the renewal effective April 1, 2022.

2. NY measures rate sufficiency and compliance with §1902(a)(30)(A) of the Act: DOH will utilize techniques outlined in the CMS training Ensuring Rate Sufficiency: Rate Review and Revision Approaches – November 2016 to ensure access

3. The rate review method(s) used: DOH will utilize the following three methods.

-Analyze and incorporate feedback from stakeholders specifically

o Collect data on Fair Hearings, grievances or complaints related to lack of providers

o Complement Fair Hearing and grievance/complaint information with data from individual and provider surveys

-Collect evidence from QIS D, Sub-assurance whether services are delivered in accordance with the service plan, including the type, scope, amount, duration, and frequency specified in the service plan. If individuals are not receiving services in accordance with the service plan, it could indicate that there are insufficient providers to meet individuals’ needs.

-Measure changes in provider capacity. Measure the change in the number of new providers and those providers’ capacity following a change in waiver service rates. Request provider capacity information approximately a year after the rate change. Compare provider capacity information to the percentage change in enrollment for the previous two years or more.

4. The frequency of rate review activities: DOH will review the feedback from stakeholders, evidence from QIS D, and changes in provider capacity at least annually.