When Moving From Connecticut’s ABI Waiver I to ABI Waiver II May Not Be in a Participant’s Best Interest
Understanding the Hidden Impact of Lower Cost Caps, Rising Labor Costs, and Diluted Service Plans
For individuals living with acquired brain injury (ABI), moving from one level of Connecticut’s ABI Waiver program to another may appear to be a routine administrative change. In some circumstances, however, a transition from ABI Waiver I to ABI Waiver II can have significant consequences for the amount and intensity of support that can actually be sustained within a participant’s service plan.
The issue is not that ABI Waiver II is inherently inappropriate. ABI II was established to expand access to waiver services and provides many of the same core community-based supports available through ABI I. The concern is what happens when an individual’s actual service needs remain substantial while the available cost ceiling is lower and the cost of delivering waiver services continues to increase.
For some participants, the result can be a service plan that technically fits within the waiver but does not provide the same intensity, consistency, or rehabilitative value that the individual previously received.
This distinction is especially important for people with acquired brain injury, whose needs may involve executive dysfunction, memory impairment, impaired judgment, behavioral regulation, cognitive fatigue, mobility limitations, medication management, safety awareness, and assistance with activities of daily living.
CT ABI Waiver I vs II
ABI I and ABI II Do Not Have the Same Cost Ceiling
Connecticut's ABI Waiver structure uses individual service-plan cost limits tied to the cost of institutional care. Under the state's current waiver framework, ABI Waiver I permits an individual service plan cost limit of up to 200% of the annualized alternative institutional care cost, while ABI Waiver II uses a 150% limit.
That is a substantial structural difference.
Connecticut describes ABI II as having been implemented in 2014 to increase the number of available waiver slots. The state's Long-Term Care Plan specifically identifies the lower 150% cost cap as one of the principal differences between ABI I and ABI II. ABI II also differs in its covered services, including the addition of ABI Recovery Assistant, ABI Recovery Assistant II, agency-based personal care, adult day health, and consultation services, while Transitional Living Services are not included.
A participant therefore should not view a move from ABI I to ABI II simply as a change in program name. It can change the financial parameters within which the person's entire service plan must be constructed.
The Problem: Service Costs Do Not Stand Still
The cost of providing community-based disability services changes over time.
Connecticut's own ABI II waiver renewal documentation acknowledges that waiver service rates may be adjusted in response to legislatively approved changes and specifically discusses rate increases associated with Connecticut's minimum-wage increases. The document states that services affected by minimum-wage increases have included agency-based personal care assistance, chore/homemaker services, companion services, adult day health, Recovery Assistant services, and other waiver services.
Connecticut's minimum wage increased to $16.94 per hour on January 1, 2026, from $16.35 in 2025. The increase is part of Connecticut's statutory mechanism for annually adjusting the minimum wage based on changes in the federal Employment Cost Index.
This matters because the individual cost ceiling and the provider reimbursement rate are not the same thing.
The waiver establishes a maximum amount that can be spent on an individual's services. The state separately establishes reimbursement rates for the services delivered within that plan. Connecticut's ABI waiver documentation explicitly states that service rates may change based on legislative action and appropriations and that rates do not change unless those changes are approved.
Why this creates a potential mismatch
Consider a participant whose service plan is already close to the maximum amount available under the applicable ABI level.
If the hourly cost of delivering services increases because of wage requirements, staffing costs, benefits, insurance, transportation, training, or other workforce expenses, the same annual service-plan dollar amount will purchase fewer hours of support.
For example, if a service becomes 5% more expensive while the participant's available spending ceiling remains unchanged, the participant cannot receive the same number of hours with the same budget. The mathematical result is a reduction in purchasing capacity of approximately 4.8%.
The participant's disability did not become less significant.
The person's need for support did not necessarily decrease.
The budget simply buys less care.
A Lower Cost Ceiling Can Force Difficult Service-Plan Decisions
The ABI waiver is designed around person-centered planning. Connecticut's waiver documents state that care managers develop individualized service plans through a team process involving the participant, the participant's representative when applicable, and other relevant stakeholders. Plans are intended to address cognitive, physical, and behavioral support needs, and DSS clinical staff review plans for service adequacy and responsiveness to the participant's identified needs.
The waiver also requires DSS to determine that the participant's health and safety needs can be met within the applicable cost limit. ABI II specifically uses four levels of care with different spending caps. If an individual's needs cannot be accommodated within the applicable level of care and cost ceiling, the waiver documentation states that the participant may be reassessed for a different level of care, and if the needs still cannot be accommodated, the participant may face reduction or termination of waiver services.
This creates a critical question:
What happens when the participant's needs remain essentially the same, but the cost of delivering those services has increased?
One potential response is to reduce the number of hours of higher-intensity services and substitute services that cost less.
That may make the service plan fit financially.
But fitting within a budget is not the same thing as adequately meeting a person's needs.
The Risk of “Diluting” a Service Plan
This is where the distinction between skill-building services and direct support services becomes particularly important.
Connecticut defines Independent Living Skills Training (ILST) as a teaching service designed to improve an individual's ability to live independently in the community and implement cognitive or behavioral strategies. ILST can include training related to self-care, medication management, task completion, communication, socialization, mobility, transportation, problem solving, money management, and household management.
Recovery Assistant services, by comparison, provide a different type of support. The ABI II waiver describes Recovery Assistants as supporting participants in the community and notes that, although ADL assistance is not their primary function, they can assist with activities of daily living and medication-related cueing. Recovery Assistant II is intended for participants with more significant safety and supervision needs, including cognitive deficits that can interfere with awareness or create health and safety concerns.
These services are complementary.
They are not interchangeable.
ILST is fundamentally about teaching, training, strategy development, and increasing independence.
RA and related direct-support services can provide hands-on assistance, cueing, supervision, and practical support with carrying out daily activities.
When a participant's budget becomes increasingly constrained, there can be pressure to construct a plan that contains more lower-cost or lower-intensity services simply because they fit within the available financial ceiling.
This is what we mean by service-plan dilution.
A participant may technically continue receiving waiver services, while the overall plan becomes less intensive, less consistent, or less rehabilitative.
Why This Can Be Particularly Problematic for ABI
Acquired brain injury does not always present as an obvious physical disability.
A person may be physically capable of completing a task but unable to consistently initiate it, sequence it, remember it, recognize hazards, regulate emotions, manage competing demands, or understand the consequences of a poor decision.
This creates a unique rehabilitation challenge.
For example, an individual may technically be able to:
prepare a meal but require extensive cueing to remember the steps;
take medication but require reminders and monitoring to do so consistently;
leave the house independently but lack sufficient safety awareness;
manage money but repeatedly make impulsive financial decisions;
complete a household task but become overwhelmed by executive-function demands;
participate in employment but require structured support to maintain routines and compensate for cognitive fatigue.
A lower-intensity service may therefore appear sufficient when viewed only through the lens of whether a physical task can be completed.
The real question is whether the individual can consistently, safely, and independently manage the task in the real-world environment.
That is one reason why maintaining an appropriately intensive rehabilitation and support structure can be so important for people with ABI.
More Hours of a Lower-Level Service Are Not Always Equivalent to Fewer Hours of a Higher-Level Service
An important misconception is that service hours can always be exchanged on a one-to-one basis.
They cannot.
Ten additional hours of a lower-intensity support do not necessarily replace ten hours of a more clinically or functionally intensive service.
The purpose of the service matters.
The qualifications of the provider matter.
The activities being performed matter.
The participant's goals matter.
And, importantly, the outcome expected from the service matters.
A strong person-centered plan should therefore ask:
What service is actually capable of producing the intended outcome?
rather than simply:
What combination of services can be made to fit within the available budget?
ABI II May Be Appropriate — But the Transition Should Be Carefully Evaluated
ABI II was created for a legitimate purpose: to expand access to ABI waiver services to more Connecticut residents. The state reported 249 active ABI II participants as of June 30, 2024.
For some individuals, ABI II may provide an appropriate and sustainable mix of services.
The concern arises when an individual who is already receiving a stable ABI I service plan is moved to ABI II without fully examining the effect of the lower cost ceiling on the individual's actual service intensity.
Before a transition occurs, the participant and their care team should consider:
Will the current services remain available at the same intensity?
A change in waiver category should not be evaluated only by looking at the names of services available under the new program. The team should examine the actual number of hours, frequency, provider qualifications, and functional purpose of each service.
Will increased reimbursement rates reduce the number of hours the budget can support?
As service rates rise, a fixed or comparatively constrained individual budget can purchase fewer hours. The financial impact should therefore be evaluated before the transition is finalized.
Are higher-level rehabilitative services being replaced with lower-level supports?
A plan that appears financially efficient may not be clinically or functionally equivalent if it replaces teaching, rehabilitation, or structured intervention with services designed primarily for supervision or direct assistance.
Will the transition destabilize an established staffing model?
Continuity of staffing can be particularly important for individuals with ABI. Changes in service hours can result in staffing changes, loss of experienced providers, fragmented coverage, or increased reliance on unfamiliar staff. Those consequences should be considered as part of the participant's health and safety assessment.
Does the proposed plan still support the participant's long-term goals?
The purpose of the ABI Waiver is not simply to provide someone with a certain number of service hours. Connecticut describes the program as helping individuals remain in the community rather than entering institutional settings such as nursing homes or hospitals.
A service plan should therefore be evaluated based on whether it supports sustained community living, not merely whether it can be made to fit within a predetermined financial framework.
The Broader Policy Problem: Budgets Must Keep Pace With the Cost of Care
This issue points to a broader policy question for Connecticut's ABI Waiver system.
If provider reimbursement rates increase because the actual cost of employing qualified workers increases, but participant-level service-plan capacity does not increase at a comparable rate, the system can eventually reach a point where participants receive fewer units of service even though the dollar value of the available budget appears unchanged.
This is particularly concerning for ABI services because the workforce delivering them is not interchangeable with a generic labor pool.
Effective ABI support frequently requires staff who understand cognitive rehabilitation, behavioral strategies, executive dysfunction, communication challenges, safety awareness, community integration, and the distinctive consequences of brain injury.
The ABI II waiver itself recognizes this by establishing specific qualifications and training requirements for services such as ILST and Recovery Assistant.
A sustainable waiver system therefore needs to account for both sides of the equation:
The cost of providing the service
and
the amount of service the participant actually needs.
Adjusting only one side can create unintended consequences.
What Families and Participants Should Ask Before an ABI I-to-II Transition
A transition should be approached as a service-planning decision, not simply a waiver-administration decision.
Families and participants can ask:
What is the current annualized value of my ABI I service plan?
What will the maximum available plan amount be under ABI II?
Which services and hours are changing?
What higher-level services are being reduced or eliminated?
Are those services being replaced with a different service, and is that replacement functionally equivalent?
How will the transition affect current staffing and continuity of care?
Will the proposed plan still address my cognitive, physical, behavioral, safety, and community-living needs?
What happens if the current plan no longer fits within the ABI II cost ceiling because provider rates increase?
These are reasonable questions because Connecticut's waiver framework itself requires service plans to be responsive to participants' needs and provides processes for reassessment when an individual's level of care or circumstances change.
A Better Approach to ABI Waiver Transitions
The goal should not be to prevent appropriate transitions between ABI waiver categories.
The goal should be to ensure that a change in waiver category does not unintentionally result in a reduction in the quality, intensity, or effectiveness of care simply because the financial structure of the program has changed.
For a participant whose needs can be appropriately met under ABI II, the transition may be entirely appropriate.
For a participant whose established ABI I plan is already necessary to maintain safety, independence, community participation, and stable staffing, moving to a lower cost ceiling without a corresponding reassessment of actual service capacity may create significant risks.
The participant's needs should drive the plan.
The budget should support the plan.
The budget should not determine the participant's needs.
The Connecticut ABI Waiver Needs a More Dynamic Approach to Service Planning
Connecticut's ABI Waiver was designed to keep people with acquired brain injury living in their communities rather than institutional settings.
That goal depends on more than eligibility.
It depends on whether the system can provide an adequate level of support over time.
As wages increase, provider costs increase.
As provider costs increase, reimbursement rates may need to increase.
As reimbursement rates increase, the same service-plan dollar ceiling may purchase fewer units of care unless the underlying cost limits are also reviewed.
For people with ABI, that can create a cycle in which service plans gradually become less intensive even though the person's disability has not improved.
That is not a sustainable model of rehabilitation.
Connecticut should ensure that ABI Waiver cost ceilings, reimbursement rates, and participant service needs are evaluated together so that transitions between waiver categories do not unintentionally result in diluted care.
At SLG's Connecticut ABI Knowledge Center, our goal is to help individuals and families understand not only how the ABI Waiver works, but also how changes in service planning, reimbursement, level of care, and program structure can affect the real-world supports available to a person living with acquired brain injury.
Sources and Further Reading
Connecticut Department of Social Services, Acquired Brain Injury (ABI) Waiver.
Connecticut Department of Social Services, ABI Waiver I and ABI Waiver II waiver applications and participant service-plan requirements.
State of Connecticut, 2025 Long-Term Care Plan, including the comparison between ABI Waiver I and ABI Waiver II.
Connecticut Department of Social Services, ABI II Waiver Renewal, including service definitions, rate methodology, and minimum-wage-related rate adjustments.
Connecticut Department of Labor / Office of the Governor, 2026 Connecticut Minimum Wage Increase.