N.Y. Comp. Codes R. & Regs. tit. 14 § 630.5
The following policy of OPWDD entitled "Eligibility for OPWDD Services" is hereby inserted into this Part.
New York State Office for People With Developmental Disabilities
ELIGIBILITY FOR OPWDD SERVICES
Important Facts
Revised December, 2008
OPWDD, through its local Developmental Disabilities Services Offices (DDSO), determines whether a person has a developmental disability and is eligible for OPWDD funded services. This fact sheet describes the Three-Step process used by OPWDD to make an eligibility determination of developmental disability.
NOTE: A determination of developmental disability does not mean the person is eligible for all OPWDD funded services. Some OPWDD funded services have additional eligibility criteria. For example, Intermediate Care Facilities, and Home and Community Based (HCBS) waiver programs include an additional level of care determination, and individuals are eligible for HCBS services only when they reside in appropriate living arrangements. These and other additional criteria for eligibility of specific OPWDD services are not reviewed through this process
ELIGIBILITY DETERMINATION PROCESS
Eligibility Request
An OPWDD Transmittal Form must accompany all requests submitted to the DDSO for eligibility determinations. The Transmittal Form includes the name of the person, the name of the person's representative, and relevant contact information. Documentation of the person's developmental disability must also be included as part of the eligibility request
1st Step Review
DDSO staff review the eligibility request for completeness and share the information with other staff designated by the Director, as necessary. After this review, the DDSO notifies the person in writing that:
2nd Step Review
DDSO clinicians designated by the DDSO Director conduct a 2nd Step Review of the eligibility request forwarded by the 1st Step Review, along with any additional documentation provided by the person. If these clinicians require additional medical information, psychological test results, or historical documentation, the person is notified in writing of the type of information needed and the date by which it must be submitted to the DDSO
Following the 2nd Step Review, the DDSO provides the person with written notification of its determination. If the person is found ineligible for OPWDD services because he or she does not have a developmental disability, the letter shall offer the person and his or her representative the opportunity to:
Note that a Notice of Decision informing the person of his or her right to request a Medicaid fair hearing is sent only when the Transmittal Form indicates that the person is interested in receiving Medicaid funded OPWDD services if determined eligible. If the person has not indicated Medicaid funded services, no fair hearing is offered and the decision of the DDSO is final
The person may choose one, two or all three of the above options. If a fair hearing is requested, a 3rd Step Review will automatically be conducted
3rd Step Review
3rd Step Eligibility Determination Committees established by OPWDD in NYC and Albany conduct the 3rd Step Reviews. Committee members include licensed practitioners who are not directly involved in the determinations made at the 1st and 2nd Step Reviews. The Committee reviews the submitted eligibility request and any additional documentation provided by or on behalf of the person. The Committee forwards its recommendations to the DDSO Eligibility Coordinator. The DDSO Director or designated staff person considers the 3rd Step recommendations and informs the person of any change in the DDSO's determination. 3rd Step Reviews will be made prior to any fair hearing date.
N.Y. Comp. Codes R. & Regs. Tit. 14 § 630.5