What Happens When a TBI Waiver Participant Turns 65 in New York?

# What Happens When a TBI Waiver Participant Turns 65 in New York?

If you or a family member is enrolled in New York’s TBI Waiver and approaching age 65, there is an important program transition ahead — one that many participants discover at the last minute.

The TBI Waiver has an age cap: it serves adults between ages 18 and 64. When a participant turns 65, they are no longer eligible to remain enrolled in the TBI Waiver. But services do not simply end — there is a transition pathway.

This guide explains what happens, what the transition involves, and how to ensure care continuity for Monroe County families.

The TBI Waiver Age Limit

New York’s TBI Waiver is designed for adults ages 18–64 who have an acquired traumatic brain injury and need a nursing-facility level of care. The upper age limit of 64 is a programmatic constraint — it is not negotiable.

When a TBI Waiver participant turns 65, they must transition out of the TBI Waiver. If they continue to have an ongoing care need, they must be evaluated for an alternative program.

The key transition pathway: the NHTD Waiver.

The NHTD Waiver as the Successor Program

The Nursing Home Transition and Diversion (NHTD) Waiver is the natural successor program for most TBI Waiver participants who turn 65. The NHTD Waiver:

• Has no upper age limit — it serves adults 18 and older
• Covers individuals with physical disabilities AND seniors
• Covers acquired brain injuries (including TBI and stroke)
• Provides the same core services as the TBI Waiver: Home and Community Support Services (HCSS), service coordination, community integration counseling, residential habilitation, environmental modifications, assistive technology

For most TBI Waiver participants turning 65, transitioning to NHTD Waiver is essentially a continuation of the same support structure under a different program name.

What Changes and What Stays the Same

What stays the same:

• Your service coordinator (if they are an NHTD Waiver provider — Priority Cares is)
• Your core direct care services (HCSS, personal care, residential habilitation)
• Medicaid coverage with no out-of-pocket cost
• The overall goal: community living with individualized support

What changes:

• The program name and administering structure (NHTD vs. TBI Waiver)
• A new level of care assessment using the UAS-NY tool (required for NHTD enrollment)
• A new Individualized Service Plan (ISP) is developed for NHTD
• Some TBI-specific services (certain cognitive rehabilitation components) may differ in how they are funded under NHTD

When Should You Start the Transition?

At least 90 days before your 65th birthday.

NHTD Waiver enrollment involves a physician documentation step, a UAS-NY assessment, and ISP development and approval. This process typically takes 60–90 days. If you wait until after your 65th birthday to begin, you risk a gap in services.

Priority Cares begins the NHTD enrollment process for aging-out TBI Waiver participants well in advance of the 65th birthday milestone.

The Transition Process: Step by Step

Step 1: Notification
Your TBI Waiver service coordinator should notify you of the upcoming age-out at least 90–120 days before your 65th birthday. If you are approaching 65 and have not been notified, contact your coordinator immediately.
Step 2: NHTD eligibility determination
A care coordinator initiates the NHTD Waiver enrollment process. Because you are already in the TBI Waiver and have an established care need, eligibility documentation is often already in place.
Step 3: Physician documentation
Updated physician documentation confirming nursing-facility level of care for NHTD purposes. In most cases, this is an update to existing documentation rather than a full new evaluation.
Step 4: UAS-NY assessment
A new UAS-NY assessment is conducted. If your care needs have been stable, this typically produces a similar result to your existing TBI Waiver level-of-care determination.
Step 5: NHTD ISP development and approval
A new ISP is developed and submitted to NYSDOH for NHTD program approval.
Step 6: Transition of services
TBI Waiver services conclude and NHTD Waiver services begin on a coordinated schedule — ideally on the same day, with no interruption in care.

What If NHTD Eligibility Is Denied?

If the NHTD assessment produces an unexpected denial — for example, because the individual’s condition has changed and they no longer meet nursing-facility level of care — the pathway includes:

• Fair Hearing rights: Same as for any NHTD denial
• Managed Long-Term Care (MLTC): If the individual is 65+ with ongoing home care needs, MLTC provides an alternative coordination structure
• Standard Medicaid HHA/PCS: Home health aide or personal care services through the Medicaid managed care plan

A denial at age-out is uncommon for participants who have been continuously enrolled in TBI Waiver services. But having a contingency plan is prudent.

For Monroe County Families: Talk to Priority Cares Early

Priority Cares provides both TBI Waiver and NHTD Waiver services in Monroe County. We manage the age-out transition process for our TBI Waiver participants as a standard part of service coordination — identifying the 65th birthday milestone in advance and initiating NHTD enrollment with enough lead time to ensure continuous care.

If you or a family member is enrolled in the TBI Waiver and approaching 65, call (585) 201-7179 as soon as possible. Do not wait for your coordinator to raise the issue — confirm the transition timeline is being managed now.