TBI Waiver New York: Home and Community Care for Rochester-Area Survivors

# TBI Waiver New York: Home and Community Care for Rochester-Area Survivors

A traumatic brain injury changes everything — the way a person thinks, communicates, moves through the world, and manages daily life. For many TBI survivors in Rochester and Monroe County, returning home after injury or discharge from a rehab facility can feel impossible without the right support.

The TBI Waiver is New York State’s answer. It is a Medicaid-funded program specifically designed to give TBI survivors the structured, ongoing support they need to live at home and in the community rather than in a nursing or long-term care facility.

This guide covers what the TBI Waiver is, who qualifies in the Rochester area, what it pays for, and how families can start the enrollment process.

What Is the TBI Waiver?

The TBI Waiver is a New York State Medicaid Home and Community-Based Services (HCBS) waiver program. “Waiver” refers to the fact that New York has received federal permission to waive standard Medicaid rules and use Medicaid funding for community-based services — rather than only covering nursing home or institutional care.

The TBI Waiver is administered by the New York State Department of Health and is specifically for adults who have sustained a traumatic brain injury. It provides a structured set of services through an Individualized Service Plan (ISP) designed to:

• Support daily functioning and personal care
• Rebuild independent living skills
• Facilitate community integration and social connection
• Provide structured daily programming when needed

All TBI Waiver services are funded by Medicaid for eligible individuals at no out-of-pocket cost.

Who Qualifies for the TBI Waiver in Monroe County?

To be eligible for the TBI Waiver, a Monroe County resident must meet all of the following criteria:

1. Traumatic Brain Injury Diagnosis
The primary qualifying diagnosis must be a traumatic brain injury (TBI). This includes acquired brain injuries caused by external forces — falls, vehicle accidents, assaults, sports injuries, and similar events.
Note: The TBI Waiver does not cover brain injuries from strokes, aneurysms, tumors, or other non-traumatic causes. Individuals with those diagnoses may be eligible for the NHTD Waiver instead.
2. Age
Applicants must be between 18 and 64 years old at the time of application. (Individuals 65 and older with TBI-related needs may qualify for the NHTD Waiver.)
3. Active New York State Medicaid
Standard Medicaid eligibility is required. Most Medicaid managed care plans are accepted.
4. Nursing-Facility Level of Care
A qualified health professional must determine that the individual’s care needs are at the level that would qualify them for nursing home placement.
5. Safe Community Living
The individual must be able to live safely in the community with the support the waiver provides. A service coordinator works with the individual and family to assess what is needed to make community living feasible.
6. Voluntary Participation
The individual must choose to participate. The TBI Waiver cannot be applied without the individual’s consent.

What Does the TBI Waiver Cover?

The TBI Waiver covers a broad range of services tailored to the specific challenges TBI survivors face. For Monroe County participants, covered services include:

Personal Care and Daily Support

• Assistance with bathing, dressing, grooming, meal preparation, and mobility
• Hands-on help with activities of daily living from trained caregivers

Community Integration Counseling
Support for individuals working to rebuild social connections, community participation, and activities outside the home
Residential Habilitation
Skills training in the home focused on maintaining independence — cooking, cleaning, managing schedules, financial literacy, and more
Day Habilitation
Structured daytime programming in a community setting that supports cognitive rehabilitation, social skills, and daily living skills
Service Coordination
A dedicated coordinator who manages the individual’s care plan, connects to community resources, monitors progress, and coordinates with healthcare providers
Behavioral Supports
Assessment and intervention for behavioral challenges that are common consequences of TBI
Positive Behavioral Supports
Environmental and programmatic strategies that reduce challenging behaviors and support community participation
Respite Care
Temporary relief for family caregivers — planned or emergency — so primary caregivers do not burn out
Assistive Technology and Environmental Modifications
Devices, tools, and home modifications that help TBI survivors function more safely and independently at home

TBI Waiver vs. NHTD Waiver: What’s the Difference?

Both programs are NY Medicaid HCBS waivers, but they serve different populations:

| | TBI Waiver | NHTD Waiver |
|—|—|—|
| Primary diagnosis | Traumatic brain injury | Physical disability or senior care needs |
| Age range | 18–64 | 18+ |
| Brain injury from stroke/tumor? | Not covered | May qualify |
| Focus | Cognitive rehab, community integration | Personal care, physical function |

In some cases, an individual may be better suited to one program over the other based on their specific needs and age. A Priority Cares coordinator can help Monroe County families determine which program is appropriate.

How to Enroll in the TBI Waiver in Rochester/Monroe County

Step 1: Contact a TBI Waiver Provider
Reach out to Priority Cares at (585) 201-7179. Our care coordinators handle TBI Waiver enrollment for Monroe County residents including Greece, Irondequoit, Webster, Brighton, Henrietta, Penfield, Pittsford, and Chili.
Step 2: Eligibility Review
We conduct a free initial review to confirm TBI diagnosis documentation, Medicaid status, and basic eligibility requirements.
Step 3: Medical Documentation
Physician documentation confirming the TBI diagnosis and nursing-facility level of care is required. We assist families in obtaining and organizing the necessary paperwork.
Step 4: UAS-NY Assessment
A licensed professional conducts a standardized care needs assessment using New York’s Uniform Assessment System (UAS-NY).
Step 5: Individualized Service Plan Development
A service coordinator develops a detailed ISP specifying which TBI Waiver services will be provided, at what frequency, and by which providers.
Step 6: DOH Approval and Services Begin
Once the ISP is approved by the New York State Department of Health TBI Program, services begin according to the plan.

The process typically takes 60–90 days from initial contact to services starting, depending on documentation availability and assessment scheduling.

Rochester TBI Waiver: Priority Cares Is Here

Priority Cares is a licensed TBI Waiver provider serving all Monroe County communities from our Rochester base. We provide:

• Free eligibility reviews at no cost or obligation
• Full enrollment support — documentation, assessment coordination, ISP development
• Home and community support services (HCSS) as a direct care provider
• Ongoing service coordination for enrolled participants

If you are a TBI survivor in Monroe County looking for home-based support, or a family member trying to help a loved one stay in the community, call us at (585) 201-7179 to start the conversation.