What Happens If You’re Denied for the NHTD Waiver in New York — And What to Do Next

# What Happens If You’re Denied for the NHTD Waiver in New York — And What to Do Next

A denial for the NHTD Waiver feels like a dead end. It isn’t.

New York State gives every denied applicant concrete options — including the legal right to challenge the denial at a Fair Hearing. And for many families, the right alternative program exists and can be accessed faster than reapplying for the waiver.

This guide explains what causes NHTD Waiver denials, what your options are, and how to respond strategically.

Common Reasons for NHTD Waiver Denial

Understanding the denial reason is the first step. Common grounds for denial include:

Medicaid eligibility issue: If your Medicaid coverage lapsed, was terminated, or was never active, the NHTD application cannot proceed. This is fixable — restore Medicaid first, then reapply.
Did not meet nursing-facility level of care: The UAS-NY assessment concluded that your care needs, as documented, did not meet the threshold for nursing-facility level of care. This is the most common substantive denial.
Physician documentation was insufficient: The physician documentation did not adequately describe the nature, frequency, and severity of care needs. The assessment process heavily depends on what is in the medical record.
Safe community living could not be established: The assessment team concluded that the individual could not safely live in the community even with the services the waiver provides — for example, due to behavioral issues, housing instability, or inadequate caregiver support.
Program capacity: In some cases, NHTD Waiver enrollment may be paused due to funding or capacity constraints. This is relatively rare but does occur.

Option 1: Request a Fair Hearing

Every person who is denied a Medicaid-funded benefit in New York has the right to a Fair Hearing — a formal administrative review before a neutral hearing officer.

If you believe the denial was incorrect — for example, if the UAS-NY assessment did not fully capture your care needs, or if the physician documentation was misinterpreted — a Fair Hearing gives you the opportunity to present additional evidence.

How to request:

• Call the NY State Fair Hearing Line: 1-800-342-3334
• Or write to: NYS Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, NY 12201-1930
• Deadline: You must request a Fair Hearing within 60 days of receiving your denial notice

What to bring:

• The denial letter with the stated reason
• Updated physician documentation — specifically addressing the reason for denial
• A written summary of the individual’s daily care needs (be specific: how long each task takes, what happens if assistance is not provided)
• Support from your NHTD Waiver provider (Priority Cares can assist with documentation)

Aid-Continuing: If you were already enrolled and received a notice of reduction or termination of services, you can request Aid-Continuing — meaning your services continue at the current level while the hearing is pending. Do this immediately.

Option 2: Reapply With Stronger Documentation

If the denial was based on insufficient documentation of care needs, the solution is often to reapply with better medical records and a more detailed UAS-NY assessment.

Before reapplying:

• Have a direct conversation with your physician about what happened. Share the denial letter. Ask the physician to amend the medical record or write an updated letter that addresses nursing-facility level of care criteria explicitly.
• Work with a care coordinator (Priority Cares can assist) to prepare a detailed written account of daily care needs before the reassessment — assessors can only score what they are told.
• Ensure all medical conditions, behavioral symptoms, fall history, medication complexity, and cognitive issues are documented.

A more thorough submission often produces a different outcome.

Option 3: Managed Long-Term Care (MLTC)

For Monroe County and NYC-area seniors whose NHTD application was denied but who still need significant ongoing home care, Managed Long-Term Care (MLTC) is often the appropriate alternative.

MLTC serves Medicaid-eligible seniors and adults who need more than 120 days of ongoing community-based care. While the level of care criteria for MLTC is related to NHTD, it is assessed and authorized differently — through the MLTC plan rather than through the waiver program.

Some individuals who do not meet NHTD level of care criteria still qualify for substantial MLTC home care hours based on their functional limitations.

Option 4: Standard Medicaid Personal Care Services

If the NHTD denial was because the individual’s care needs do not reach nursing-facility level, Medicaid Personal Care Services (PCS) or Home Health Aide (HHA) services may still be available through the standard Medicaid managed care plan.

PCS and HHA services do not require nursing-facility level of care — they require documented functional limitations (difficulty with bathing, dressing, meals, mobility, etc.) and a physician order.

For many individuals who are borderline on NHTD eligibility, standard PCS or HHA services through their Medicaid plan provide meaningful support even without waiver enrollment.

Option 5: TBI Waiver (If Applicable)

If the individual has a traumatic brain injury and was denied for NHTD, confirm whether the TBI Waiver was also considered. The TBI Waiver is a separate program with some different criteria — particularly focused on adults ages 18–64 with TBI — and may be appropriate even when NHTD is denied.

What Priority Cares Does After a Denial

A denial is not the end of the relationship. Priority Cares works with Monroe County families through the post-denial process:

• Reviewing the denial letter with you to understand the specific grounds
• Connecting you with legal aid or advocacy organizations for Fair Hearing preparation
• Assisting with updated physician documentation
• Evaluating eligibility for MLTC, PCS, or TBI Waiver as alternatives
• Supporting reapplication

Call (585) 201-7179 to talk through your situation. A denial notice does not mean no care — it means the right pathway has not been found yet.