The Difference Between NHTD and TBI Waiver Programs in New York

Exploring the Foundations of Community-Based Care in New York

New York State offers specialized Medicaid waiver programs designed to support individuals with disabilities and older adults in living independently within the community. Among these, the NHTD and TBI waivers play crucial roles in reducing reliance on nursing homes and promoting personalized, community-centered services. This article delves into the distinctions, eligibility, services, and policy context of both programs, providing a comprehensive overview of their functions and future considerations.

What Are the NHTD and TBI Waiver Programs in New York?

Overview of NHTD and TBI waivers' purpose and administration

The NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waivers are specialized Medicaid programs implemented in New York State. Managed locally through Regional Resource Development Centers (RRDCs), these waivers aim to support individuals with disabilities or seniors who are at risk of institutional care, particularly nursing homes.

Both programs primarily focus on enabling eligible participants to live independently within their communities rather than in treatment facilities. They provide a wide range of services that promote community integration, personal independence, and the prevention of premature or unnecessary institutionalization.

The administration of these waivers is overseen by the New York State Department of Health (NYSDOH). Each regional center is responsible for coordinating services, assessing eligibility, and ensuring that participants' individual needs are met. This decentralized approach allows services to be tailored to the specific needs of local populations.

Historical background and legal framework

The origins of these waivers trace back to federal legislation under the Social Security Act, specifically Section 1915(c). This section authorizes states to create home and community-based services (HCBS) waivers that enable Medicaid funds to be used for services outside of institutional settings.

The TBI waiver was developed in the early 1990s to address the lack of resources for individuals with brain injuries, providing targeted services that help them recover or adapt to their disabilities. Following its success, the NHTD waiver was launched in 2007, leveraging the same federal legal framework but focusing on a broader group—adults with physical disabilities and seniors at risk of nursing home placement.

Both waivers have been integral parts of New York’s broader Medicaid HCBS strategy, aiming to reduce reliance on expensive institutional care while improving quality of life for participants. Over the years, legislative amendments and policy adjustments have refined their scope, eligibility, and services.

Managed locally through Regional Resource Development Centers

The administration of both NHTD and TBI waivers occurs through regional centers situated across New York. These centers serve as the primary local points of contact for participants, family members, healthcare providers, and community agencies.

Regional Resource Development Centers oversee the coordination of services such as personal care, assistive technology, environmental modifications, and community supports. They also facilitate the development of individual service plans tailored to each participant’s needs.

Contact information for these centers varies by region, including dedicated offices in New York City and other counties. Their localized management ensures that services are responsive to community-specific needs and that participants receive comprehensive support.

Program	Target Population	Managed By	Main Services	Purpose
NHTD	Adults 18-64 with disabilities, seniors 65+	Regional Resource Development Centers	Personal care, assistive technology, service coordination, home modifications, community support	Help prevent nursing home placement and promote community living
TBI	Individuals 18-64 with traumatic brain injuries	Regional Resource Development Centers	Behavioral supports, environmental modifications, community integration, outpatient rehab	Support independence and community reintegration

These programs exemplify New York’s commitment to person-centered care, emphasizing individual choice, community participation, and least restrictive environments.

Key Differences Between NHTD and TBI Waivers

What are the main differences between the NHTD and TBI waiver programs in New York?

The main differences between the NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waiver programs in New York primarily relate to their target populations, specific needs they address, and the scope of services offered.

The NHTD program is designed for a broader group that includes individuals aged 18–64 with physical disabilities and seniors over 65 who are at risk of nursing home placement. Its focus is on helping these individuals remain in or transition back into the community through services like housing subsidies, assistive technology, community integration counseling, and transitional support services.

Conversely, the TBI waiver strictly serves individuals aged 18–64 who have sustained a traumatic brain injury. This program emphasizes addressing the unique challenges associated with brain injuries, such as cognitive deficits and safety concerns, through specialized services like brain injury-specific assessments, environmental modifications tailored to brain injury needs, and personal care supports.

While both programs aim to support community living and prevent premature institutionalization, their service focuses differ to meet their clients' specific conditions. The TBI waiver also includes specialized interventions like outpatient rehabilitation, peer mentoring, and substance abuse programs geared toward brain injury recovery and management.

In terms of program scope and demographics, the NHTD covers a wider age range and accommodates individuals with various physical disabilities, including seniors, while the TBI is exclusively dedicated to individuals with brain injury within the 18-64 age bracket.

Ultimately, these distinctions allow each waiver to better target their populations' specific health, safety, and independence needs, providing tailored, effective community-based services.

Eligibility Criteria and Participant Profile

What are the eligibility criteria for the NHTD and TBI waiver programs in New York?

The NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waiver programs are designed to support individuals in living independently within the community. To qualify, applicants must meet specific Medicaid and health-related criteria.

Both programs require that participants are eligible for Medicaid and require nursing home level of care. This means they have significant health or disability needs that could otherwise necessitate residential institutional care. For the NHTD waiver, eligible individuals include those over 18 with physical disabilities or those aged 65 and older. The TBI waiver targets adults between 18 and 64 with a diagnosed traumatic brain injury.

Applicants must demonstrate a desire to live in the community rather than in a nursing home. They should have local supports in place or be capable of developing such supports with help. The programs emphasize personalized support plans, created in collaboration with care providers, to ensure individual needs are met.

The goal is to help participants avoid or transition out of nursing homes by providing services that promote independence, community inclusion, and welfare. Therefore, eligibility also considers whether individuals are willing to participate in developing and following through with their service plans.

In summary, qualifying for the waivers involves a combination of health status, disability level, Medicaid eligibility, community residence preference, and cooperation in planning care. These criteria ensure that services are targeted at those most likely to benefit from community-based supports, helping them maintain independence and improve quality of life.

Services Offered: Core and Specialized Supports

The NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waivers in New York present a comprehensive array of services designed to promote independence, safety, and community participation for individuals with disabilities or age-related needs.

At the core of both programs is service coordination, which involves developing personalized, person-centered plans. These plans are aimed at helping individuals achieve their goals of independent living and community integration. Service coordinators assist with assessing needs, choosing appropriate providers, and advocating for participant preferences.

A vital support component is assistive technology (AT). For NHTD participants, AT includes devices that support daily living, safety, and community access, supplementing standard Medicaid Durable Medical Equipment (DME). The TBI waiver also provides assistive technology, focused on enhancing safety and independence, when directly contributing to these goals.

Environmental modifications (E-mods) are physical adaptations to homes or vehicles intended to improve safety and accessibility. These modifications might include ramps, bathroom fixtures, or door widening, helping individuals to live safely and independently.

Additional services include community transitional services (CTS), which assist with costs related to moving from nursing homes to community residences. These cover expenses like security deposits, furnishings, and moving costs, with specific provisions for each program.

Nutritional counseling and wellness programs, including dietary guidance and health promotion activities, support overall health and prevent complications. Respite services provide scheduled relief for informal caregivers, often delivered in-home, alleviating caregiver burden.

Structured day program services help participants develop or maintain daily living skills and community engagement, delivered in outpatient or community settings to foster independence.

For TBI-specific needs, services extend to substance abuse programs, peer mentoring, respiratory therapy, home visits by medical professionals, and educational supports. These are tailored to address the complex, multifaceted challenges faced by individuals with traumatic brain injuries.

The programs also offer community integration counseling, helping individuals adjust emotionally and socially as they transition back into the community. During emergencies such as the COVID-19 pandemic, service delivery was adapted to include telehealth options, alternative service settings, and flexible oversight, ensuring continued support amidst restrictions.

Overall, the range of services under the NHTD and TBI waivers exemplifies a holistic approach, combining health, social, and environmental supports to enable individuals to lead active, safe, and meaningful lives within their communities.

Program Goals, Functions, and Service Focus

What are the main objectives of each program?

The NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waivers in New York serve distinct but overlapping aims: helping individuals avoid or transition out of nursing home care and promoting community-based living.

The NHTD waiver's primary goal is to prevent unnecessary nursing home admissions by supporting seniors and disabled adults to live safely at home and integrate fully into their communities. It offers services designed to empower individuals with physical disabilities and seniors aged 65 and older, emphasizing personal independence, health, and welfare.

Conversely, the TBI waiver focuses solely on individuals aged 18-64 who have experienced traumatic brain injuries. Its goal is to address the specialized needs of TBI survivors, helping them live independently through tailored services that foster community integration, safety, and productivity.

Both programs aim to reduce reliance on institutional care and improve quality of life, but their specific objectives reflect their target populations' unique needs.

How do the NHTD and TBI Waivers oppose in terms of program goals and functions?

The key difference between the two lies in their target groups and scope.

The NHTD waiver broadly targets adults with physical disabilities and seniors, focusing on community transition and diversion from nursing homes. It provides a comprehensive array of services like environmental modifications, community transportation, and social support aimed at maintaining independence.

The TBI waiver is designed narrowly for individuals with traumatic brain injuries, offering specialized services such as cognitive and behavioral supports, assistive technology, home modifications, and vocational training to address deficits caused by brain injuries.

While both programs promote community living and independence, the NHTD emphasizes transition and diversion services for a wider population, whereas the TBI aims at rehabilitation and support specific to brain injury recovery.

How do these programs promote community integration and independence?

Community integration and independence are central to both waivers' missions.

Through personalized service planning, service coordination, and assistive technology, participants receive support tailored to their individual needs. This includes skills training, therapeutic services, and environmental adaptations that facilitate safe, independent living.

Specific services like community integration counseling help individuals cope with changes and develop strategies for engaging in community activities.

Additionally, services such as community transitional services assist with moving costs and housing setup, easing the transition from institutional care.

By providing these supports, both waivers enable participants to live meaningful lives in their communities rather than in nursing facilities.

What scope of services do these programs cover, and who are their targeted populations?

Both waivers offer a wide array of services aimed at fostering independence and community participation:

Service Type	Description	Target Population
Service Coordination	Assists individuals in creating and implementing personalized plans	All eligible participants
Assistive Technology	Equipment and devices to support independence	All eligible participants
Environmental Modifications	Home and vehicle adaptations	Participants needing safety and accessibility improvements
Community Transition Services	Costs related to moving from facilities to homes	Recently transitioning individuals
Home and Community Support Services	Support for daily living activities	All eligible participants
Respite Services	Temporary relief for informal caregivers	Caregivers and care recipients
Structured Day Programs	Skill development and socialization	Participants aiming to improve independence
Behavioral Interventions	Support for managing behaviors	Participants with behavioral challenges
Transportation	Assistance to access community activities	All eligible participants

Targeted Populations

• NHTD Waiver: Adults aged 18-64 with physical disabilities or seniors 65 and older requiring nursing home level care.
• TBI Waiver: Individuals aged 18-64 with traumatic brain injuries, needing community support services.

Participants must be Medicaid-eligible, prefer to live in the community, and require at least one waiver service per month.

How do the waivers support individuals in transitioning or staying in the community?

Both programs include services specifically designed to ease the transition from nursing facilities back into community settings.

Community Transitional Services support participants with expenses like moving costs, deposits, and furnishings.

Environmental modifications ensure homes and vehicles are adapted for safety and independence, enabling individuals to leave or avoid institutional care.

Ongoing service coordination and community integration counseling provide emotional and practical support, enhancing the individual's ability to live independently.

Respite services allow caregivers to maintain their roles, preventing burnout and ensuring continuous support for the individual.

Together, these services aim to create a supportive environment that encourages community residence, reduces hospitalization, and enhances quality of life.

Overview of service providers and their roles

Service providers under these waivers are responsible for delivering approved services and must comply with federal and state regulations.

They file annual cost reports to ensure transparency and accountability.

Providers collaborate with care coordinators to develop and implement personalized plans.

Regionally, the programs are managed by Resource Development Centers, which oversee service quality and provider compliance.

How do emergency provisions during COVID-19 affect these programs?

During the pandemic, services adapted with emergency modifications such as telehealth, alternative service settings, and suspended face-to-face visit requirements.

These adjustments aimed to safeguard participants while maintaining essential supports.

Provisions included expanded service settings, out-of-state service options, and temporary suspension of some oversight requirements.

Such measures reflect the programs' flexibility in times of crisis, ensuring continuous support for vulnerable populations.

Service Type	Emergency Adaptation	Impact
Telehealth	Expanded delivery of service	Increased access during safety restrictions
Out-of-State Services	Allowed more flexibility	Broader access for participants in remote areas
Service Limits	Temporarily relaxed	Ensured ongoing support despite resource constraints

These adaptations highlight the programs' commitment to safety, continuity, and flexibility during emergencies.

Transition to Managed Care and Policy Context

How do Medicaid managed care and waiver programs like NHTD and TBI interact in New York?

In New York, Medicaid managed care and waiver programs such as the Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) waivers are tightly integrated components of the state's approach to providing community-based supports. These programs aim to help individuals with disabilities or those at risk of nursing home placement live more independently within their communities.

The NHTD and TBI waivers are managed through Regional Resource Development Centers, which coordinate services for eligible participants. Traditionally, these waivers offer a range of supports, including service coordination, assistive technology, environmental modifications, and community transition services. Their goal is to promote independence and prevent unnecessary institutionalization.

Recently, New York has been transitioning these waiver services into Medicaid managed care plans, particularly Medicaid Managed Long Term Care (MLTC) and Medicaid Managed Care (MMC). This move seeks to streamline care delivery, improve care coordination, and increase efficiency. Under managed care, enrollees benefit from a single, integrated plan that covers a broad spectrum of services, including those previously provided through waivers.

Participants are assigned care managers who develop personalized plans of care, focusing on individual goals for community living. This integration helps ensure continuity of services, reduces gaps in care, and fosters better health outcomes. It also simplifies administrative processes for participants, who no longer need to navigate multiple providers or funding streams.

The transition involves a shift from federal-funded waiver services to managed care benefit packages, all within the framework of Medicaid. This allows for more flexible service delivery, innovative supports, and potentially cost-effective models of care.

Despite the benefits, this shift has sparked policy debates, especially concerning how it affects service availability and funding. Some advocates worry that moving waivers into managed care might lead to reduced access to personalized services or less emphasis on community-specific needs. Others argue that managed care can enhance oversight, quality, and accountability.

In summary, Medicaid managed care in New York is becoming the primary modality for delivering community-based services for individuals served by the NHTD and TBI waivers. This integrated approach aims to provide seamless, person-centered care while aligning with broader Medicaid reforms intended to improve the sustainability and effectiveness of long-term supports.

Impact on Services and Funding

The integration of waiver services into managed care plans influences both service delivery and funding dynamics. Under traditional waivers, services are funded separately from Medicaid managed care plans, with providers submitting cost reports and adhering to specific regulations. As services transition into managed care, funding is integrated into capitated payments to the managed care plans, which then coordinate all services for enrollees.

This shift centralizes funding and accountability, potentially leading to more coordinated care but raising concerns about service limitations or provider network adequacy. For example, housing subsidies—an essential component for independent living—may no longer be guaranteed as these are often administered outside managed care plans.

Moreover, the transition could influence provider participation, network composition, and the scope of services offered. While it might promote efficiency and innovation, stakeholders are wary of possible reductions in personalized services and community-based supports, which are crucial for participants’ well-being.

Policy Debates and Legal Considerations

Policy discussions around this transition are intense. Advocates, including the BIANYS (Brain Injury Association of New York State), argue that the waivers should remain separate from Medicaid managed care. They emphasize that waivers like TBI and NHTD have been tailored to address specific needs, including housing, community integration, and specialized services, which might be compromised under managed care.

Legal challenges and class action lawsuits, such as Bagley et al. v. NYS Department of Health, have highlighted concerns about errors and administrative issues in waiver management. These legal actions aim to ensure that vulnerable populations maintain access to essential services during and after the transition.

The state asserts that integrating these programs into managed care will not increase costs and will improve service quality. However, critics worry that the transition might lead to service reductions, increased institutionalization, or loss of personalized supports unless safeguards are maintained.

Overview of Transition and Current Status

The TBI Waiver transition to managed care was originally scheduled to happen earlier but was postponed to January 1, 2022, to address issues and provide further planning. Similarly, the NHTD waiver has experienced delays, with advocates urging that programs be preserved outside of Medicaid managed care.

The administration continues to work with stakeholders to balance operational efficiencies with the needs of individuals served. As the system evolves, ongoing monitoring and advocacy are essential to ensure that the goals of community inclusion, independence, and quality of life are preserved.

Aspect	Details	Additional Notes
Program Type	1915(c) Medicaid waivers transitioning into managed care	Focused on community supports for disabled and elderly populations
Transition Dates	TBI postponed to Jan 2022, NHTD also delayed	Changes implemented gradually to address concerns
Stakeholders	NYS Department of Health, BIANYS, providers, advocates	Diverse parties with different interests
Funding Model	Shift from separate waiver funding to capitated managed care	Aims for integrated, flexible financing
Service Access	Potential risks of reduced personalized services	Emphasized need for ongoing advocacy
Policy Debates	Cost-effectiveness vs. personalized community supports	Public and legal pressures influence policy

Understanding the interaction between Medicaid managed care and the NHTD and TBI waivers is crucial for stakeholders. It shapes how services are delivered, funded, and governed, directly affecting the lives of many individuals with disabilities and seniors in New York.

Future Outlook and Policy Developments

What policy background and future considerations are associated with the NHTD and TBI programs in New York?

The NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waiver programs in New York are deeply embedded in ongoing debates about how community-based care should be managed and funded. Over the years, advocacy groups such as BIANYS have voiced strong concerns about transitioning these programs into Medicaid Managed Care structures. They argue that such a move could jeopardize the personalized, flexible services that residents rely on, especially for those with complex conditions like TBI.

Recent policy efforts aim to integrate these waivers more fully into managed care plans. However, opponents contend that managed care may not sufficiently address the specific needs of individuals with disabilities or brain injuries. This debate is further complicated by legal actions, including class action lawsuits like Bagley et al. v. NYS Department of Health, which seek to challenge administrative barriers and maintain program integrity.

Looking ahead, policy makers are weighing options such as legislative reforms, enhanced service models, and protections for critical supports like affordable housing. These measures are essential to ensure that the programs continue to serve their primary goal: enabling participants to live independently and participate fully in their communities.

What are the current emergency provisions affecting waiver services amid COVID-19?

The COVID-19 pandemic prompted swift emergency responses to ensure ongoing support for waiver participants while minimizing health risks. These provisions include expanding telehealth services, allowing healthcare providers to deliver services virtually, and exploring out-of-state and alternative service settings to reduce exposure.

Service limits were temporarily relaxed to accommodate the increased demand and the need for flexible arrangements. Provider qualifications were also temporarily eased, ensuring that participants continued to receive necessary supports despite staffing challenges.

Procedures around incident reporting and safety monitoring were adapted to account for remote service delivery. Emergency provisions also allowed for the use of telehealth for assessments, counseling, and some therapy services, making care more accessible during public health restrictions.

Many of these emergency measures are under review to determine whether they should become permanent components of the programs. The adaptations have demonstrated the potential for more flexible, resilient service models that could benefit participants in the long-term, beyond the pandemic period.

Operational Development and Oversight

What management and operational details are involved in administering the NHTD and TBI waiver programs in New York?

The NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) waiver programs are crucial components of New York State’s Medicaid services, aimed at enabling community living for individuals with disabilities or seniors at risk of institutionalization. Their effective management relies heavily on the oversight and coordination by the New York State Department of Health (NYSDOH).

One of the fundamental administrative responsibilities involves rigorous financial and operational reporting by participating service providers. These providers are required to submit annual Cost Reports (CR), which offer a detailed account of the costs incurred in delivering services. These reports include a thorough breakdown of wages, fringe benefits, other program support expenses, and specific costs associated with service delivery.

Reporting periods vary depending on the provider’s location. For example, providers based in New York City follow a fiscal year from July 1 through June 30, while those outside NYC report from January 1 through December 31. The CRs must be filed within 120 days after the close of each period, allowing for some flexibility with extensions up to 150 days. This process ensures that the department can monitor financial compliance and maintain program integrity.

For providers operating under federal and state administrative guidance, the requirement to file separate CRs for the NHTD and TBI programs is standard. Those working with multiple state agencies are additionally required to submit a consolidated Fiscal Report (CFR), streamlining oversight and ensuring comprehensive fiscal transparency.

Beyond financial management, operational oversight includes ensuring that providers meet specific qualifications and maintain high standards of service delivery. Regular audits and compliance checks are integral, alongside reviewing provider performance and adherence to Medicaid regulations.

Overall, these management practices foster a well-regulated environment. They help prevent misuse of funds, promote accountability, and support the continuous improvement of service quality. This structured approach ensures that both the NHTD and TBI programs can sustainably serve their populations, adapting to evolving needs and policy changes.

Resources, Education, and Community Awareness

What resources and educational information are available about brain injury and Medicaid waiver programs in New York?

Numerous resources are accessible for individuals seeking to learn about brain injury and the Medicaid waiver programs available in New York. The New York State Department of Health (NYSDOH) maintains comprehensive websites that outline the different programs, including eligibility criteria, covered services, application procedures, and provider details. These online platforms serve as primary sources of official information, helping individuals and families understand how these waivers operate.

The Brain Injury Association of New York State (BIANYS) is a prominent advocacy and educational organization dedicated to improving the lives of people with brain injuries. BIANYS offers a variety of educational materials, including brochures, online resources, and community outreach programs. They focus on raising awareness regarding the availability of services under the NHTD and TBI waivers, emphasizing the programs' roles in fostering independence and community participation.

Additionally, regional resource development centers and provider agencies involved in delivering waiver services provide training sessions and distribute informational brochures. These efforts target both potential participants and care providers to ensure a clear understanding of available supports. Such educational initiatives are vital in enabling individuals with disabilities to make informed choices about their care options.

Participating in community seminars, webinars, and workshops offered by these organizations further enhances awareness. These platforms foster dialogue among service users, families, providers, and policymakers, promoting a community-informed approach to support services.

Overall, access to well-structured educational materials and community engagement efforts ensures that individuals and families are empowered to navigate complex service systems and optimize their quality of life in the community.

How do advocacy groups influence policy regarding these waivers?

Advocacy organizations like BIANYS have a significant impact on shaping policies related to the NHTD and TBI waivers. These groups actively advocate for the continuation and expansion of community-based services, often opposing policies that threaten to shift these programs into Medicaid Managed Care, which could limit access or reduce services.

BIANYS and similar organizations engage in multiple activities to influence policy. They conduct outreach campaigns to educate the public and stakeholders about the importance of the waivers. Participating in public comment periods and consulting with policymakers are key strategies to express concerns and provide expert insights.

These advocacy groups also build relationships with legislators and government agencies, working to ensure that legislation and funding decisions reflect the needs of individuals with brain injuries. Their efforts include mobilizing community voices, organizing grassroots campaigns, and delivering testimonies during policy hearings.

By highlighting the critical role of community supports—such as housing subsidies, assistive technology, and specialized services—these organizations aim to safeguard programs from potentially detrimental policy changes. They emphasize that maintaining these supports is essential for preventing unnecessary institutionalization and promoting independence.

The influence of advocacy groups is crucial in ensuring that policies prioritize personalized, community-based care and that funding levels remain sufficient to meet the complex needs of program participants. Their persistent efforts help shape a policy environment that values dignity, choice, and inclusivity for all individuals with disabilities.

Ensuring Continued Support and Community Integration

The NHTD and TBI waiver programs are vital components of New York's commitment to providing comprehensive, community-based support for vulnerable populations. While each serves distinct populations with tailored services, their shared goal of promoting independence, reducing institutionalization, and fostering community participation remains central. As policy debates and management practices evolve, it is crucial for stakeholders, advocates, and policymakers to ensure these programs continue to offer effective, accessible, and person-centered services. Protecting essential supports like housing subsidies, expanding innovative service models, and safeguarding funding and legal protections will be key to maintaining progress toward inclusive community living for all eligible New Yorkers.

References

• Nursing Home Transition and Diversion (NHTD) Waiver and ...
• TBI NHTD Service Comparison - New York State Department of Health
• BIANYS Issues Statement Calling for a Halt to Transition of TBI and ...
• 2024-2025 Annual Cost Report (CR) Manual
• [PDF] NHTD & TBI Waiver 101
• Medicaid Home-and-Community-Based Waiver Programs in New ...
• [PDF] New York (0444 and 0269) Appendix K Amendment - Medicaid