BIANYS Applauds Delay of Medicaid Waiver Transition to Managed Care


The Brain Injury Association of New York State (BIANYS) today applauded a decision by the State Department of Health (DOH) to delay for one year a plan to move New Yorkers with traumatic brain injury (TBI) into Medicaid managed care programs.

BIANYS and other advocates for New Yorkers with brain injury had worked to derail implementation of the plan because of concerns that, in its current form, it would have led to significantly reduced levels and quality of care.

A determination regarding the DOH managed care plan was anticipated in the 2016-17 state budget, and guidelines for the transition were due to be issued on April 1, 2016. Under the revised plan, transition guidelines are to be disseminated by April 1, 2017.

“New Yorkers with brain injury, caregivers, family members, advocates, concerned state legislators and others worked together successfully to maintain current levels of care and coordinated services,” said BIANYS Executive Director Eileen Reardon. “Now, we intend to work throughout the coming year to ensure that any managed care plan provides individuals with brain injury with the services and support they need to help them live as independently as possible.”

“We will also be advocating for changes in a new assessment tool being used by DOH, which is unsuitable for individuals with brain injury and could end up denying services to many,” added Reardon.

Advocates have advised DOH that a new assessment tool, the Uniform Assessment System for New York (UAS-NY), is not suitable for individuals with TBI. The UAS-NY underestimates cognitive disabilities that may often result from TBI. Individuals with brain injury may have few physical disabilities, yet their cognitive issues mean they need assistance to remain safe and healthy in the community. DOH did add a training component on cognitive issues for nurse evaluators performing assessments. However, the UAS-NY itself has not been adjusted, and according to numbers reported by DOH, this problem could result in a loss of vital services for some 1,000 New Yorkers with TBI.

Brain injury profoundly effects individuals’ physical and cognitive abilities and makes it extremely difficult or impossible to live their lives the way they did before the injury. Brain injury impacts family dynamics, community activities, employment and social life. Behavioral changes that may occur as a result of brain injury can have a significant impact on the ability to interact with others and conform to the rules and structure of society.

Service coordinators, independent living skills trainers, positive behavioral intervention supports and other services address the complex needs and challenges of New Yorkers with brain injury by offering individualized structure, support and assistance to help them live as independently as possible in their home communities.

Without these coordinated services, many with brain injury could end up far from their families and support networks in nursing homes or other institutions – at much greater expense than community-based services.

BIANYS organized the first-ever Brain Injury Advocacy Day at the State Capitol in Albany on March 23. The event included nearly 200 New Yorkers with brain injury and their loved ones and caregivers from around the state. Participants met with dozens of legislators and attended a program that included remarks by New Yorkers with brain injury as well Senate Health Committee Chair Kemp Hannon, Assembly Health Committee Richard Gottfried, Assembly Mental Health Committee Chair Aileen Gunther and Assemblyman John McDonald III.

New Yorkers with TBI currently receive individualized and coordinated community-based services under two Medicaid waiver programs. As part of ongoing efforts to institute managed care for all Medicaid recipients in New York, DOH plans to discontinue the two waiver programs – Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) – and individuals served under those programs will move into managed care.

While not all New Yorkers with brain injury receive services funded by Medicaid, the TBI waiver program has fostered the creation of services focused specifically on the complex needs of individuals with brain injury, making these services available for Medicaid recipients as well as others with brain injury.

Without the clients funded by Medicaid at current levels, some of these programs would no longer have adequate resources to continue to operate, or would not be able to maintain their focus on the unique needs of individuals with brain injuries. Loss of these programs would result in more gaps in services for all New Yorkers with brain injury, whether or not they are served under Medicaid.

The State Senate and Assembly and Senate advanced matching legislation earlier this year to protect New Yorkers with brain injury and ensure continuity of care, service quality, and protections – either by creating a “carve out” to maintain existing waiver programs that allow these individuals to be served outside of managed care settings or by requiring that managed care includes the current level and range of individualized and coordinated services for current and potential future participants.

Every 13 seconds, someone in the United States sustains a TBI. Each year in the U.S.:

  • At least 2.5 million children and adults sustain TBIs
  • 2.2 million are treated in emergency departments for TBI
  • 280,000 are hospitalized for TBI
  • 50,000 die because of TBI
  • At least 5.3 million Americans live with TBI-related disabilities

In New York State alone, TBIs caused by serious falls, assaults, car accidents and other incidents result in an average of 2,279 deaths each year and more than 120,409 emergency room visits; with 19,368 people requiring longer hospitalization for treatment and rehabilitation, resulting in annual hospital and emergency department costs of over $1.2 billion.